Digital preoperative assessment triage

The Nuffield Orthopaedic Centre (NOC), Oxford University Hospitals NHS Foundation Trust (OUH) provides a range of orthopaedic services, ranging from high volume low complexity joint replacement procedures to quaternary bone infection services in the internationally renowned Bone Infection Unit.

As the volume of elective surgery increases, a common limiting factor in increasing elective capacity and addressing the unprecedented backlog is capacity within the preoperative assessment process.

Insufficient patients were fit for surgery to populate theatre lists. Inefficiencies include multiple face-to-face visits to the preoperative assessment clinic and complex pathway workflow prior to being declared fit for surgery. Pre-preoperative assessment operative assessment appointments were performed face-to-face approximately 4-6 weeks prior to surgery.

Situation

Limitations of pre-existing approach included:

• Insufficient patients fit for surgery to utilise theatre capacity.
• Inefficiency from repeat ‘fit/unfit’ face-to-face assessments without the option for a personalised patient condition service.
• Postponed surgery due to patients requiring further investigation too late in the pathway.
• Difficult to allocate the appropriate level of resource/grade, with no differentiation between high and low complexity cases.
• Urgent need to address unprecedented surgical waiting lists by increasing elective capacity.

Aspiration

• Prioritise face-to-face assessment for patients with conditions that need it.
• Commence preoperative patient optimisation earlier in the clinical pathway.
• Increase the pool of patients declared fit for surgery to assist elective recovery.
• Improve compliance with personalised assessment planning.
• Reduce the administration burden on specialist preoperative nursing staff.
• To reduce outpatient footfall and unnecessary patient travel.

Digital collection of health screening data completed by patients when listed for surgery, intelligently identifying required preoperative investigations following NICE guidance.

Virtual preoperative assessment prevents further unneeded visits.

Patients who require investigation or treatment prior to surgery, such as those who have anaemia, are identified early in the patient pathway to prevent subsequent postponement.

Solution

PRO-MAPP solution platform runs on iPads in the clinic which is used to securely collect patient information at the time they are listed for surgery.

It collects information for Occupational Therapy, mandatory Patient Reported Outcome Measures, and National Joint Registry Consent when appropriate.

The responses clearly guide staff as to which investigations are required prior to patients leaving clinics such as an ECG and specific blood tests.

Prior to patients leaving the clinic, patients confirm a date and time for a telephone consultation. The platform also identifies patients who are medically complex or require a preoperative orthogeriatrician or anaesthetist assessment, where a face-to-face preoperative assessment appointment is booked instead.

At the telephone appointment, a specialist preoperative assessment nurse reviews the patient history and results of investigations on the platform to determine whether a patient is fit for surgery or requires further assessment.

Data is uploaded to the EPR. If a patient provides consent, PRO-MAPP can then continue with a personalised digital engagement and monitoring pathway.

The project will work synergistically with the introduction of digital consent, which further reduces the need for face-to-face appointments.

There is also a collaboration with the NIHR-funded Blood and Transplant Research Unit for Data-Driven Transfusion Practice for the clinical translation of research to ensure accurate patient selection.

Impact

• After PRO-MAPP was introduced in April 2022 the proportion of patients who did not attend their preoperative assessment fell from 8% (November 2021 to March 2022) to 0.8% (April- August 2022).
• Two-thirds of patients listed for orthopaedic surgery do not require a further face-to-face appointment prior to surgery.
• The carbon savings are 9,059 miles or 14,579 km of travel saved. This equates to 2,493 kg of CO2 saved (2.5 tonnes of CO2) and is equivalent of 25 return flights from London to Paris.
• Conditions that require optimisation are identified and treated early, preventing postponement of procedures later in the pathway as well as improving patient outcomes.
• A considerable proportion of patients on the waiting list are fit for surgery allowing Covid recovery operating lists to be populated at short notice.
• Interim health economic evaluation shows that the PRO-MAPP pathway saves £1,200 per patient annually.

Functionality

• Web-based application
• Device agnostic
• Securely cloud-based
• Data rich capture including photos, Barcodes, QR codes, document scanning
• Integration with existing EPR platform

Capabilities

• Supports elective recovery
• Increases preoperative assessment capacity
• Increases the pool of patients who are fit for surgery
• Commences patient optimisation when first listed for surgery
• Digitises pathway and patient care
• Reduces hospital visit footfall and reduces the carbon footprint for the patient journey

Scope

• Patients use the platform in the clinic and at home to complete questionnaires reducing patient stress and burden at the time of listing.
• Staff can use the platform on any device securely tracking outstanding patient investigations or appointments and whether a patient is fit for surgery (in conjunction with EPR software).
• Multi-level real-time dashboards allow constant service review and efficiency tuning.
• The OUH team is exploring whether PRO-MAPP can be implemented in other specialities and across the Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System.
• Digital consent is currently being introduced to complement the pathway.

Key learning points

• It was essential that the platform was flexible and tailorable to work synergistically with EPR.
• Introducing the preoperative assessment triage influenced every stage of the patient pathway.
• Reallocation of resources was required including outpatient rooms and staff.
• It was important to engage all stakeholders at an early stage.

Digital equalities

Dedicated staff are available in the clinic to assist patients to complete digital capture. The clear interface and instructions for patient self-use ensure an easy and accurate patient data collection process.

Patients who decline to use the iPad can complete all the appropriate questionnaires on paper ensuring inclusivity.

Key quotes

“Our new clinical pathway has enabled us to increase preoperative assessment capacity and commence patient optimisation as soon as individuals are listed for surgery. It has also allowed us to digitise the pathway, reduce hospital visits, and improve carbon footprint.”

Antony Palmer, Consultant Orthopaedic Surgeon Clinical Lead for NOC Preoperative Assessment, OUH

“The PACT project has transformed the way we provide pre-assessment care for patients. It is a fantastic example of digital enhancement of a clinical pathway improving patient experience.”

Professor Andrew Price, Trauma and Orthopaedic Surgery Clinical Director, OUH

“Triaging patients earlier in their surgical pathway has improved the optimisation and management of their complex long-term conditions. This allows the follow-up of patients to be arranged in a timely manner and to reduce unnecessary visits to the hospital.”

Natasha Brand, Specialist nurse practitioner, Pre-Assessment clinic, OUH

Find out more

A news article on Oxford Academic Health Science Network

Key contact

Antony Palmer, Consultant Orthopaedic Surgeon Clinical Lead for NOC Preoperative Assessment

Antony.Palmer@ouh.nhs.uk

Michael Phillips, Founder, Director

Michael.Phillips@PRO-MAPP.com

Flora Gleave, Project Manager, Oxford Academic Health Science Network

flora.gleave@oxfordahsn.org