Making digital preoperative assessment (POA) the default at South West London Elective Orthopaedic Centre (SWLEOC)

Traditionally the POA is paper-based. It has many forms, documents and leaflets telling patients about their procedure.

Administrating the POA process is demanding and time-consuming for both patients and staff.

Situation

A study found that SWLEOC patients spent 3 hours 12 minutes for each POA appointment. Nurses spent 1 hour 30 minutes for each appointment.

In 2018, this equated to 16,320 hours of patient’s time and 7,650 hours of clinician time.

Aspiration

Digital solutions would enable patients to enter data from home. This would reduce the administrative burden on staff during face-to-face appointments.

SWLEOC wanted to streamline the POA process by sending and receiving key information earlier in the pathway. This included:

• receiving patient health information
• delivering health and procedure information

Solution

The POA service was redesigned to increase efficiency for patients and staff.

Patients have a face-to-face appointment with a surgeon. They then visit a drop-in POA for essential tests. At this point, it’s identified if the patient needs help with the digital questionnaire.

Patients receive a LifeBox login to complete the health screening questionnaire.

They can watch informative videos related to the questionnaire at home and can submit questions if they need more information.

The LifeBox dashboard and comorbidities questionnaire support clinical decisions.

Patients are allocated face-to-face or telephone appointments with a POA nurse and anaesthetist if required.

If a patient has not completed the questionnaire or watched the videos, they receive a prompt. When patients watch a video, LifeBox creates a record.

Videos are in English and patients who need translation can attend a face-to-face appointment with an interpreter.

Telephone appointments last an average of 13 minutes and face-to-face appointments last an average of 30 to 40 minutes.

Up to 3 POA clinic nurses work on patient follow-up each day. They review test results and optimise patients promptly.

The LifeBox dashboard informs daily POA safety huddles and Friday progress report meetings.

Impact

• Completed POAs increased by 800 patients per month.
• Previously, only 33% of patients attended a preoperative information group. Now 100% of patients receive the same information through videos.
• 7.8% of patients need help with the digital POA and attend a 15 minute face-to-face appointment with a nursing associate. The information is then validated by a registered nurse. The nurse also supports patients when they watch the information videos and can answer questions.
• Printing and postal costs for patient information have reduced by roughly £11,000.
• Before COVID-19, the system reduced face-to-face outpatient appointments by over 3,000. It saved the unit over £96,000 for every 5,000 patients.
• Following COVID-19, all 7,000 appointments are virtual with no face-to-face outpatient appointments. This has reduced costs and CO2 emissions.

Functionality

• Interoperability and integration via FHIR HL7 APIs.
• Clinical coding information is more efficiently generated.
• The service is cloud-based and hosted on Amazon Web Services.
• The service follows the NHS’ Internet First policy.
• Assessment, education and outcomes are delivered remotely.
• Patient information videos on procedure and consent are linked by procedure code. Each time they are accessed by a patient, LifeBox creates a record.
• There is a secure two-way transfer of information.

Capabilities

• Clinicians can access their patients' assessment to prepare for their hospital visit in advance.
• Smart dashboards help improve elective pathways in hospitals.
• The service caters to both consent conditioning information and digital consent.
• Patients can be assessed and educated remotely.
• Patient responses can be validated based on best practice.
• Questionnaires can be personalised.
• Secure virtual clinics allow hospital staff to transfer information to the patient and from the patient back to the hospital.
• Recovery platform allows hospitals to monitor patients’ progress after discharge.
• Outcome assessments are collected for patient reported outcome measures and research.

Scope

Patients complete pre-assessment when and where they are most comfortable. This is done using a browser on a smartphone, tablet or computer.

Half of all patients at SWLEOC access the system on a mobile device and the digital assist programme helps prevent health inequalities.

Key learning points

This was a challenging change for nursing. Redesigning the pathway workflows with nurses was key to success and managing expectations.

Up to 3 registered nurses now cover the follow-up caseload every day, allowing other nurses to focus on patient telephone assessments. This approach has made follow-ups more efficient and the clinics rarely over run.

The system is more flexible. Staff sickness no longer leads to cancelled patients as a ‘follow-up nurse’ covers the new patient telephone assessment clinic.

Nursing associates and assistant practitioners are vital for efficiency and supporting patients who need digital assistance.

Champions from all disciplines meet regularly and provide an approach for improvement.

Key quotes

"We have been using LifeBox ePOA at SWLEOC now for around 2 years. The app is easy to use and gives me the live access I need to see my patients ahead of any proposed surgery.

The feature of remotely accessing patients’ history, observation and some investigations are very convenient. Selecting the anaesthetic review option saves us a lot of time going through the full set of notes.

The built-in risk scores and the ability for me to leave comments for my clinicians to read and act upon has allowed us to redesign our POA processes and workflows.

The support from the LifeBox team has made a big contribution - they have accommodated our needs and have acted upon our feedback to streamline and fully utilize the services of the app."

Dr Burhan Shawki, Consultant Anaesthetist FCARCSI, Clinical Lead for Anaesthetics SWLEOC, Epsom and St Helier Hospitals University Hospitals NHS Trust

"This comprehensive pre-assessment tool enables us to see all patient details including their MRSA, blood and COVID-19 test results and it also flags up if there is a need for an anaesthetic review."

Mary Richardson, Managing Director, SWLEOC

Key contact

Emma Flynn, Associate Director of Nursing, SWLEOC

emma.flynn2@nhs.net

Sandeep Chauhan, Orthopaedic Surgeon, Founder LifeBox, Definition Health

sandeep@lifeboxhealth.com