Patient-completed, web-based preoperative assessment (POA) electronic questionnaire at Sheffield Teaching Hospitals

Increasing demands on POA services, mean that new and innovative solutions are needed to ensure patients receive timely and appropriate pre-operative assessment.

Situation

As in other NHS Trusts, Sheffield Teaching Hospitals was faced with growing demands on its POA service and  supporting elective activity recovery by using the right capacity at the right time and reducing delays.

Aspiration

• Increase capacity for POA.
• Improve patient flow between surgical clinics and admission as part of the 18 week elective pathway and the RTT (Referral to Treatment waiting Time) 18-week pathway for cancer patients.
• Create an efficient service for pre-operative assessment, including POA on the day of listing.
• Support remote, virtual assessment as well as providing standardisation, efficiency, reliability, and quality.

Solution

Patients referred for POA aged older than 18 years and ASA (American Society of Anesthesiologists) physical classification 1–2 (i.e. relatively fit and healthy and without multiple co-morbidities) are asked to complete an electronic Personal Assessment Questionnaire – Pre-Op (ePAQ-PO)

Step 1: ASA grade 1 or 2 confirmed by surgical team and patient referred to POA.

Step 2: ePAQ-PO voucher and instructions sent electronically to patient by surgical clinic staff or waiting list teams. Contact number for pre-op is provided in case patients require support.

Step 3: Patient completes ePAQ-PO at home on the internet (using smartphone, tablet, home PC); patients are given 5 days to complete, which is monitored on the ePAQ-PO dashboard. Automated electronic reminder issued and follow-up call from POA nurse if not completed.

Step 4: When the patient has completed ePAQ-PO the specialist POA nurse will phone them reviewing and annotating the electronic ePAQ report. The phone call usually lasts 10-15 minutes.

Step 5: Using My Pathway patient portal, POA nurse submits digital patient information PDF to EPR.

Step 6: 30 minute face to face appointment with a support worker for tests: swabs, bloods, vital signs, height and weight. Examination findings are recorded in ePAQ report.

Step 7: ePAQ-PO outcome and other documentation printed by POA nursing staff and filled in paper notes. PDF submitted to POA section of patient’s EPR.

Impact

The benefits realised since introducing ePAQ-PO include:

• reduction in pre-operative assessment nursing time by up to 40% for ASA 1 and 2 patients impacting on patient satisfaction.
• 400 hospital visits per month saved
• £100,000 annual efficiency savings generated
• 20% of POA activity now using ePAQ and continuing to increase and broaden scope and scale.
• 77% of patients reported that the ePAQ ‘helped with communication’, 99% reported that it was ‘easy to use’ and 98% that they would be ‘happy to use again’.

Functionality

Web based software platform, accessible from any networked computer (in-house completion), smartphone, PC or tablet (remote completion) and supports multiple users simultaneously. The system can be hosted on an NHS server by ePAQ Systems Ltd or individual Trusts.

ePAQ comprises separate but integrated questionnaire and management systems, which communicate via secure WCF web services.

There are 2 questionnaire systems available which form the basis of the patient-facing interaction, one hosted on N3 and the other on W3. To ensure patient data security, the information in the questionnaire systems is anonymised and only re-identified when imported to the N3 hosted management system.

The management system gives access to completed questionnaires, summary and detailed reports, along with demographics, outcome reporting tools and the ability to extract data only to registered users and only via NHS networked devices.

Capabilities

• ePAQ provides validated, web-based clinical assessment tools, specifically designed to provide detailed, reliable and meaningful self-reported symptoms & quality of life data from patients.
• The software has different defined user roles to ensure administrative tasks and usage reporting can only be carried out by specifically authorised personnel. Each management system is customisable to suit a particular clinic or hospital and contains a number of different reporting tools.
• ePAQ is not a FHIR based product so PDF documents can be viewed in HTML files, or saved in electronic patient records, or if necessary printed and filed in paper notes.

Scope

The ePAQ platform was initially developed for use in women’s health, urogynaecology and pelvic floor medicine (ePAQ-PF). Subsequently, new questionnaires have been created (e.g. ePAQ-HIV, ePAQ-Menstrual, ePAQ-Cardiac, ePAQ-Vascular) utilising and further developing the technology.

ePAQs are now being used in over 20 NHS hospitals, with a growing evidence-base relating to validity, feasibility, utility, efficiency, quality and outcomes monitoring in a number of clinical areas, including preoperative assessment ePAQ-PO.

Applications for all ePAQs:

• patient assessment and communication
• efficiency and quality of patient assessment
• multi-disciplinary team (MDT)
• specialist and virtual clinics
• research appraisal, revalidation and accreditation

Key learning points

• Having developed and validated the questionnaire itself, the subsequent involvement of the service improvement team at Sheffield Teaching Hospitals was critical to effective implementation.
• Managing change and addressing concerns, doubts and overcoming obstacles took time and effort, in winning hearts and minds of key stakeholders in the pathway, particularly the POA clinical and admin team proved vital to implementation and uptake.
• Wide uptake was gradual over weeks and months; a stepwise approach, specialty by specialty worked well, providing feedback and support to inform and encourage early and late adopters.

Digital equalities

‘ePAQ-PO is helping to ensure that appropriate patients start their pre-operative assessment as soon as possible, in their own time using their own device.  This helps ensure that face to face assessments are used only for those patients who need them, supporting activity recovery by using the right capacity at the right time, reducing delays.’

Kevin Firth, Head of Organisational Development Programmes, Sheffield Teaching Hospitals

Key figures and quotes

• 20,000 patient questionnaires completed using the ePAQ system annually.
• ePAQ questionnaires now in use at more than 20 NHS hospitals in England.

‘ePAQ-PO ensures a seamless transition of the patient through the surgical pathway while reducing the burden of hospital attendance for the patients and the preoperative nursing teams.’

Swati Jha, Consultant Urogynaecologist, Sheffield Teaching Hospitals

‘The ePAQ pathway is now streamlining planned hospital admissions, with convenience to patients submitting information from their own homes.’

Andrew Farkas, Consultant Obstetrician and Gynaecologist, Sheffield Teaching Hospitals

‘ePAQ is a user friendly “light touch” option that allows preoperative assessment to offer proportional appointments or a walk in service for the fitter cohort of patients.  It has allowed our clinic to see significantly more patients, and keep nurse practitioner appointments for those with most need.’

Alexa Mannings, Pre-operative Assessment Nurse, Sheffield Teaching Hospitals

‘ePAQ-PO supports a comprehensive, standardised approach to our preoperative assessment process, which is convenient for patients and enables more efficient use of local resources.’

Hanna Harrison, Specialist Registrar, Sheffield Teaching Hospitals

Find out more

Primary Research: Patient-completed, preoperative web-based anaesthetic assessment questionnaire (electronic Personal Assessment Questionnaire Pre-Operative): Development and validation - PubMed (nih.gov)

Primary Research: Prospective observational study of the impact of an electronic questionnaire (ePAQ-PO) on the duration of nurse-led pre-operative assessment and patient satisfaction

ePAQ website: electronic personal health questionnaires

Key contact

Joanna Ross, Business Manager (Obstetrics, Gynaecology, Neonatology, Medical Imaging and Medical Physics, Sheffield Teaching Hospitals NHS Foundation Trust

joanne.ross10@nhs.net

Sarah Bland, Preoperative Assessment Lead Nurse, Sheffield Teaching Hospitals NHS Foundation Trust

sarah.bland8@nhs.net

Stephen Radley, Managing Director, ePAQ Systems Ltd, Consultant Gynaecologist, Sheffield Teaching Hospitals NHS Foundation Trust               

stephen.radley@nhs.net