University Hospitals Bristol and Weston (UHBW) prehabilitation service

Prehabilitation is recognised as an important part of optimisation and risk reduction perioperatively and is becoming an integral part of preparation for major cancer surgery in many centres.

The team at UHBW wanted to create a comprehensive prehab service for all patients incorporating integrated digital records and data collection.

Situation

UHBW has been engaged in delivering prehabilitation interventions for many years, but with little uniformity in the screening, patient education, interventions or equity across surgical specialties.

Aspiration

UHBW wanted all patients undergoing major surgery to be referred to a centralised prehabiliation service where their baseline fitness, nutrition, wellbeing, smoking and alcohol status would be assessed and recorded. 

They aimed to improve fitness, patient experience, preparedness for surgery, and reduce post-operative complications. Through delivery of personalised exercise programs, nutrition advice, and support to make positive lifestyle changes.

They wanted assessments and interventions to be documented in an electronic notes system. This reduces admin time in uploading paper notes to an electronic system, allows other health care professionals to quickly access the notes and for outcome data to be automatically taken and reported in a dashboard.

Solution

The UHBW Division of Surgery funded a physiotherapy team 1 whole time equivalent band 6 physiotherapist and 1 whole time equivalent band 4 therapy assistant. Patients are referred to prehabilitation via a Careflow Electronic Patient Record (EPR) service order.

Any healthcare professional can complete this order. The referrals predominantly come from surgical specialist nurses, surgeons and the preoperative assessment clinic. The physio team screen all referrals and phone the appropriate patients to start their prehabilitation assessments.

The physiotherapists also attend some of the surgical clinics where appropriate patients will have their prehabilitation assessment completed face to face.

• During initial assessments the physiotherapists assess current activity levels, nutrition, smoking and alcohol use and psychological wellbeing. They provide personalised exercise plans, support and referrer on to dietetic and psychology services based on MUST (Malnutrition Universal Screening Tool) score and EQ-5D (EuroQol-5Dimentions; validated quality of life questionnaire). The physio team also liaise with the surgeons or POA (Perioperative Assessment) anaesthetists if more medical support or intervention required.
• Follow up and progress with prehab is reviewed in high-risk multidisciplinary planning meetings for thoracic and hepatobiliary patients.

During the initial physio assessment patients can choose if their follow up is via DrDoctor video link, or over the telephone. Due to physical space the team offer face to face follow up only for the most complex patients, who may require a musculoskeletal assessment to facilitate more exercise, or who are unable to use telephone or video for any reason.

UHBW IT services worked with the project team to create a bespoke System C Careflow Electronic Patient Record (ERP) clinical note. All UHBW clinical teams use Careflow EPR, an in-house system.

By developing the prehabilitation workflow on the same system the documentation burden has been reduced for clinicians by enabling linked data fields to cross populate from Preoperative Assessment.

The prehabilitation clinical note can be viewed by the whole perioperative team allowing clarity of advice and interventions given to patients, and their progress with prehab.

To enable ongoing data collection and tracking of progress, IT created a Power BI dashboard to collect accurate live data on referrals, interventions, and patient outcomes.

Impact

• 362 patients have been seen by the prehabilitation service in a 9-month period (June 21 to Feb 22).
• 47% of these patients do not meet the UK Chief Medical Officers’ physical activity guideline (2019) recommendations at the point of referral.
• 77% of cases had an improved 30 Second Sit to Stand Test following prehabilitation interventions with an average improvement of 24%

100% of patients completing feedback said:

• the exercise program and intervention were tailored to them
• they found the activity advice helpful
• the service assisted them with their wellbeing
• 34% of patients preferred the clinical team to send information to them via email instead of in the post.
• Over 90% of the follow up appointment are perform over the telephone vs video or face to face due to patient and therapist preference and available space.
• Patients were asked at the start and end of prehab “On a scale of 1-10 how prepared do you feel for your surgery?”. The team have seen an average increase of 1.2 points on this scale across the patient cohort showing prehabilitation improves perceived preparedness for surgery.

Functionality

The prehab clinical note:

• Is an in-house solution provided by Careflow EPR.
• The note is opened by the prehab team; information from surgical or anaesthetic clinical notes auto populate the prehab note, reducing the need for information transcription.
• The clinical note enables clear documentation of baseline fitness and wellbeing plus nutrition scoring and smoking and alcohol use, and progress with prehab interventions and physio follow up.
• Baseline and follow up outcome measures including grip strength, sit stand in 30 seconds and EQ-5D (standardised measure of health-related quality of life) are recorded directly into the note.
• The note is viewable alongside the preoperative assessment clinical note and forms a clear record of the patient’s involvement in prehab.
• Plans for patients are clearly defined on the clinic note and are visible to the different teams. For patients with tight timelines for surgery, communications about fitness for surgery are easy to find and contribute to preoperative planning.
• The system is live to update with no time delay. Once a clinical note is updated, it is visible to all people caring for that patient. This means for the one stop patients, who see multiple members of the perioperative team in a day, clinical information is immediately available to the next team.
• As an in-house solution, the clinical note is fully integrated with other pathways, something which external providers often struggle to deliver.

The dashboard:

• Draws data directly from the Careflow clinical note.
• Provides an overall view of the patient group and service.
• Pulls data from clearly defined parameters to provide a working view of patients in system
• Ensures constantly updated data is available for planning staff and shows fluctuations in the system, reducing the need for auditing of specific elements and the delays this creates.

Capabilities

The clinical note:

• is accessible to all members of the perioperative team.
• provides a clear vision patient progress (previously the prehab element of care was managed within individual teams so was not available for all to see).
• is immediately uploaded with no time delay to information being available (this was not possible beforehand when multiple emails or other communications would have been needed to find out the status of an individual patient).
• can be rapidly changed by the in-house IT team based on feedback of the users and the quality of data inputted.

The dashboard:

• enables download of data to excel enabling data analysis for clinical audit and quality improvement.
• provides clear visual updates on the demographic and specialty of patients referred into prehab.

Scope

• The clinical note can be used across all hospitals in UHBW (other hospitals in the ICS are also beginning to use Careflow).
• In house data collection will enable service development needs as the service expands.
• Expand Prehab services within ICS.

Key learning points

• A physiotherapy led prehab team can successfully screen patients for prehab needs, and provide bespoke exercise interventions.
• A hybrid model of face to face, online and telephone assessments has been successful and ensures all patients can be recruited to prehab both locally and from referring areas.
• Sit to stand tests are improving as a result of personalised prehab physio input.
• Utilising an in-house clinical note enables rapid changes to digital note keeping are possible, to fit the needs of service users, providers and data analysts.
• When creating an electronic clinical note it is important to think not only about the data you want to be pulled from it but also how practical it is to use. Initially the clinical note didn’t flow for the therapists writing in it so there were sections not completed. This affected the quality of data the team could pull.
• An electronic referral is a good way of centralising referrals however staff need training and education around this. The team found that without this people would still email us referrals; this made it hard to keep track of all referrals and created additional admin tasks.
• A dashboard provides real time data on the service and easy access to data for analysis.
• Regular communication and consistency, via telephone follow up with therapists, improves exercise compliance.

Digital equalities

• Patients are offered telephone, face to face or in person assessments and follow ups to ensure equity of access to the service.
• By attending surgical listing clinics, and the pre assessment clinic, the physio team can enrol patients into prehab without any digital access if necessary.
• Exercises and advice are emailed to the patient, or where they have no access to email will be sent in the post. Patient feedback forms can be completed on paper or electronically through a link sent via email.

Key quotes

"I was far better prepared both physically and mentally",  "my quality of life is much better", "I had a lot more confidence with my body", "before prehab, I had no idea I had any role to play [in my recovery]"

Malcolm, patient

“I have found it very useful to access the updates on clinical notes and have had good communication”

Mrs M Finch Jones, Consultant Hepatobiliary Surgeon

“it is very useful to monitor patient engagement and progress by looking on Careflow” “patients engagement, progress, motivation and goals are known across the team and this helps us provide our patients with additional support as well as helping in decision making”

Rachel Houston Thoracic Clinical Nurse specialist

Key contact

Dr Hannah Wilson Consultant Anaesthetist and Perioperative Medicine Lead, University Hospitals Bristol and Weston NHS Foundation Trust

Hannah.Wilson@uhbw.nhs.uk

Jason Barugh for System C Connected Care, Product Director

jason.barugh@systemc.com