It s not just Obs and Swabs! Developing a pre-operative assessment service in a complex tertiary referral centre a multidisciplinary approach Emma McCone- Lead Pre op Sister Healthcare at its very best - with a personal touch
The Geordies! Healthcare at its very best - with a personal touch
Welcome to our Pre assessment Team
Our daily problems! Healthcare at its very best - with a personal touch
The good old MRSA swab! Healthcare at its very best - with a personal touch
Pre-operative surgical patient All patients admitted night before surgery No idea what tests to do - everyone got everything or nothing No risk assessment, no discussion with patients No idea how to manage anticoagulation, diabetes, COPD or what to do if something was wrong
13 yrs ago BC (Before clinic) 2004 9/10 % cancellations (Unfit for surgery) Isolated Pre-assessment Units all around the trust Various health professionals completing it! Assessed late in surgical pathway Patient disappointment /inconvenience No chance for change Postponement Wasted theatre time No/minimal DOSA
Whats been happening? Population getting older (cant be ageist) Chronic disease on the increase (Diabetes) Patient Choice New and innovative surgical techniques Targets. Targets. Targets! Healthcare at its very best - with a personal touch
Pre-assessment 2016 One of the largest, leading PA service in the UK 30,000 patients each year (3 sites including community based) Largest UK Cardiopulmonary Exercise Testing Facility biggest nurse/ ODP led service in the UK ran by ODP (hes amazing!) < 1% Cancellation Rate yearly audited 90% Patients come in on Day of Surgery (DOSA) Integrated Cross Trust Units (14 disciplines 140 surgeons!) Targeted Investigations (NICE) Healthy Perioperative Income generation
How did we do it? Our 3 biggest achievements! 1. Satisfying our service users: Our patients! Consultant surgeons (and they are hard to please!) Business/ Directorate Managers
How are we doing? What our patients told us about the pre-assessment clinic In Summer 2015 we undertook a survey to look at the satisfaction of patients using the pre-assessment service The survey was offered to all patients coming to the clinic during a week long period in June 2015 The questions covered a number of different areas including the clinic environment, waiting times, the staff, and overall impressions In total 249 surveys were completed. RESPECT AND DIGNITY 100% of patients were given enough privacy for discussion of their condition or treatment 100% of patients were given enough privacy when being examined or treated 100% of patients felt they were treated with respect and dignity 100% of patients stated the care they received at the clinic was excellent or very good WAITING TIMES 67% were seen within 5 minutes of arrival at the clinic, and 93% within 15 minutes Only 2% of patients waited longer than 30 minutes OVERALL SATISFACTION 98.3% stated their main reason for attending the clinic was dealt with to their complete satisfaction HELLO MY NAME IS.. Our patients said that the clinic staff introduced themselves on 99% of occasions CLEANLINESS 100% of patients found the clinic very clean or fairly clean CONFIDENCE AND TRUST 100% of patients had confidence and trust in the nurse 100% of patients stated the nurse explained things in a way they could understand 90.7% stated that the nurse definitely dealt well with their anxiety SOME COMMENTS FROM PATIENTS Very obliging and pleasant All staff friendly, clean and well presented Nurse very understanding of my anxiety regarding anaesthesia The efficiency moving through the assessment no waiting time Nurse had empathy for my condition Every time I come into the hospital I have been very pleased with any treatments and the staff have been great We value your feedback, thank you
Meet Mr French Consultant HPB surgeon I am frequently impressed by team s efficiency, attention to detail and communication with both patients and clinicians. They are flexible, have shown initiative, are extremely hard working and it is clear have developed a very positive departmental culture. It really is a pleasure to work with them
Meet Hannah Powell DM for neuro surgery I just wanted to drop you a quick line to say that I attended the surgeon s meeting yesterday and the feedback re: new PAC was all positive. So, you seem to be pleasing the patients, the surgeons and the anaesthetists well done!!
2. Training and Believing in our staff Preoperative Education Team Led by our nursing and medical teams across 3 sites Meet James, Rhona, Chris and Emma
Outpatients nurse Flexible working: 9-5 Going for an easy life Older Redeployed Retired and returning Lazy How hard can it be to tick a box No one really knows what we actually do! Perception of the PAC assessor
Meet katie Confused by Guidelines Robotic Confused by Anaesthetists Frustrated No Confidence Confused by Surgeons Administrator
Guidelines why so confusing? NICE updated 2016 Consider seeking advice from a senior anaesthetist Consider if no ECG results available from past 12 months Consider in people at risk of AKI No set protocols No definitive answers Have to use Clinical Judgement????? AAGBI Jan 2016 Pre-operative assessment clinics need not measure the blood pressure of patients being prepared for elective surgery whose systolic and diastolic blood pressures are documented below 160/100 mmhg in the referral letter from primary care What!! No blood pressure?? Reliance of referral letters aren t always there Always worried we are held accountable we hate that!
Anaesthetists! Getting better but still a huge variation in what happens in different clinics everywhere in UK but with same stories!! Which colleague let him through!!!? I would have liked the charts from 1954 for the GA at the Netherlands if at all possible? Yep. Happy
Surgeons A surgeon is someone who likes to operate; an anaesthetist is someone who doesn't like to give anaesthetics. David M. Dent Perceived by patients as the fixer - surgery can be done- I ll refer you to PAC PAC have taken away decision making process for many surgeons as victims of their own success Rotational surgeons mean an unfamiliarity with PAC processes To be fair, limited out patient time to discuss/ explore patient risks and definitely not consistent (diagnosis/ treatment options/ medical history/ medication/ patient choice its just not doable!)
What Katie Wants To liaise with GPs To be inspired To work within Structured protocols To learn and be educated To work Consistently To use her clinical skills
Meet Gerry Receptionist HCA Assistant Practitioner HOW? (Band 4) Competency based training Good Leadership from a supportive MDT structure Structured education around protocols Support through University
Meet Alison PAC nurse Nurse Specialist CPeT Practitioner Consult 231 15% CPeT Volumes 2008-15 Senior Nurse 314 21% Not reviewed 953 64% 3000 2000 1000 0 2008 2009 2010 2011 2012 2013 2014 2015
What can we achieve with the right High Risk (10%) - Consultant Overall Risk Assessment Patient Consultation (including SDM) CPeT Interpretation Appropriate Specialist Referral Ordering of complex tests Communication with surgeons/ cardiologists guidance? Intermediate Risk (20%) Nurse/ODP Practitioner Chest Auscultation Arterial Blood Gases ECG Review Appropriate Anaesthetic Referral Low Risk (70%) - Nurse led (HCA/AP/Nurse) Bloods, Pulmonary Function Tests Behavioural intervention Non invasive Testing (ECHO) CPET GP referrals (BP management)
Day Care Protocols QUESTIONS YES NO Suitable for DC surgery Absence of any chest pain No previous problems with anaesthesia or family and anaesthesia <2 medications Absence of any co morbidities (asthma/ihd/epilepsy) BP <185/110 METS > 5(can walk up 2 flights of stairs without stopping) Age<50 BMI >16<35 Adult available for 24 hours post anaesthetic Lives< 1 hour from hospital
Smoker >20 day Alcohol >14units/ week (women) >21 units (man) oral contraceptive pill Diabetic medication (including insulin) Anticoagulants/ antiplatelets YES NO VTE assessment MRSA screen MSU
3. Optimising our patients for surgery and Life our biggest challenge! Alcohol intervention National research study Respiratory optimisation 1) Smoking cessation Public health 2) COPD management Primary Care/Pfizer Optimisation for fitness before surgery Anaemia optimisation Comprehensive Geriatric Assessment Curing diabetes!!!!! please visit fixing dad
Perioperative medicine 5 yr plan Identifying co morbidities early Peri operative Clinicians Shared Decision making Initiating clinical testing without need to refer Improving lifestyle and fitness pre and post op
CQC highlight perioperative medicine service at the Freeman as an area of outstanding practice The Dedicated Peri operative TEAM.have not only embraced the RCoA 5 year vision.. We are already there as national leaders The perioperative care team at the Freeman were national leaders in pre-operative assessment, cardiopulmonary exercise testing and outcome prediction after major intra-abdominal surgery (including shared decision making in the pre-operative counselling process CQC 2016