Case Studies: Perioperative Pathways and Team Working

Perioperative Pathways and Team Working

Clear pathways and clinical team working are key components of perioperative care and have significant impact on patient experiences.

General perioperative pathways

 A Role for the Perioperative Pharmacist

Local audit identified poor accuracy of drug history recording in pre-op assessment, prescribing errors on drug charts and poor communication regarding medicines to take or withhold on the day of surgery. 55% of our patients’ drug history was recorded inaccurately, 30% of drug charts contained prescribing errors. Potential perioperative optimisation issues were identified for 86% of patietns including anticholinergic and polypharmacy review, drug interactions, immunosupresive drugs and more.

It was identified that Pharmacy intervention at the pre-operative assessment phase of the patient journey could help prevent potential prescribing errors and drug interactions and the formation of a perioperative medicines plan for pre, intra and post-op periods could have a positive impact.

COVID enabled the service  to explore remote means oh pharmacy review in a cohort of major surgical patients having surgery during May-August 2020. The interventions were patient centered and involved pharmacy reviews delivered remotely through telephone clinics. 

47 patients were included in the pilot. 83% of patients required amendment to the medication recording history performed at pre-op assessment thus avoiding drug errors in these patients. A perioperative medicines plan was recorded for all patients in the electronic patient record which included withholding medicines pre-operatively and post-operatively if no longer required. Plans for alternative deliver of drugs in patietns who were NBM post-operatively. Individualised medicines optimisation involving patient education and shared decision making was employed in 93% of cases. MDT discussions took place with plans put in place for perioperative infusions of steroids and Octreotide. Communication was improved by alerting the MDT team of potential pharmacy issues.
Prescribing safety was improved as well as communication between staff groups. Patient education was improved including counselling about risk of delirium and other side effects. Two patients had their surgery delayed for optimisation following issues uncovered by the Pharmacist (acute thyrotoxicosis and drug toxicity). The Pharmacist also delivered smoking cessation advise and support.
 

Since 2007, preoperative assessment at the Blackpool Victoria Hospital has been integrated and streamlined to a uniform and coherent process rolled out by degree level qualified Nurse Practitioners. NP's take ownership of their caseload resulting in a single point of contact for individual patients and resulting in a streamlining of the process and a drive towards single visit assessment. Major surgery assessment is complemented by CPEx testing delivered and fed back by 4 Consultants Anaesthetists in real time, allowing these patients to also experience one stop assessment.

In 2012 we further benefited from a rebuild to our surgical services resulting in all elective patients not only being admitted on the day of surgery but only being required to walk a few yards from admission lounge to anaesthetic room. Our postoperative management of major surgery across the Trust is coordinated by anaesthetic and surgical champions led on the ground by a dedicated nursing lead for ERAS.

Novel Perioperative Anaesthetist and multi-disciplinary ward round - care model for high risk patients

We have a dedicated ‘perioperative anaesthetist’ who plays a key role in the management of high risk patients.  There are 4 level 1 beds, where high risk patients undergoing major surgery are admitted based on objective risk scoring criteria.  This area is outside the remit of critical care and is managed by the surgeons and anaesthetists.

The perioperative anaesthetist is a key part of the ‘Perioperative multidisciplinary ward round’ which is done 5 days a week (with plans to extend to 7 days a week).  This MDT ward round brings together various team members including the surgeon, a dedicated anaesthetist, pain team, physiotherapy, nutrition and nursing team to enable collaborative decision making.  This is a formal structured ward round which addresses all aspects of perioperative care including enhanced recovery using a unique model of care called: PREPARE (Acronym for Physiology optimization, Remove catheters & drains, Emotive support, Pain & Physiotherapy, Activities, Ready for discharge and Eat). This is aimed at expediting early patient recovery and rehabilitation.

The Peri-operative Enhanced Surgical Medicines Optimisation Service (ESMOS)

The Enhanced Surgical medicines optimisation service (ESMOS) was introduced at Manchester University Hospitals Foundation Trust, a large 1200 bedded tertiary hospital within hepatopancreato-biliary (HPB), upper gastro-intestinal (GI), lower GI and vascular specialities. ESMOS is a novel model of care which has shown to improve patient outcomes in those undergoing major surgery by active and dedicated pharmacist involvement throughout the patient’s surgical journey. All pharmacists providing the service are prescribers. 

The goals of the service are aligned with the national enhanced recovery programme. The objectives are to identify high risk surgical patients once they are listed for surgery and get them in the best possible state in the pre-operative period by focusing on optimising their pre-existing co-morbidities such as hypertension and diabetes control. The ESMOS service also addresses any pre-operative anaemia. All eligible patients have their anaemia corrected pre-operatively voiding any adverse outcomes related to low haemoglobin levels.  

Patients are reviewed virtually in the pre-operative period mainly over the phone. These patients may also be reviewed by face to face contact when they attend the hospital for one of their other appointments e.g. pre-op appointment in a nurse-led clinic or attendance at surgery school. Surgery school is a multidisciplinary initiative set up to provide education to patients on what to expect during their admission for surgery and the steps patients can take to optimise their general fitness prior to surgery. 

Once high risk patients are identified, the relevant specialist ESMOS pharmacist contacts the patient by telephone to discuss: a) Current medication the patient is taking and any problems the patient may have such as compliance, adverse effects etc. b) Management of existing medical conditions to be able to identify areas for medicines optimisation c) Peri-operative drug management and provide advice on stopping drugs in this period. 

The patient’s medication is also prescribed pre-operatively reducing the incidence of missed doses post-operatively. Following admission, patients are subsequently followed up and monitored closely after their surgery with the focus on medicines optimisation to minimise the incidence of any post-operative complications. Complications such as post-operative pain, nausea and vomiting, electrolyte disturbances etc. are addressed pro-actively at the point of need with patient-centred care with patients involved in discussions around any pharmacological management. 


Any challenges experienced and how these have been overcome?

Some of the key challenges experienced include:
1.    Identifying patients pre-operatively once they were listed for surgery. This required engaging the admission coordinators and consultant secretaries who had their own workload to deal with
2.    Engaging other key stakeholders within the trust to include the anaesthetists, surgeons and specialist nurses. As a result, we set up an electronic referral system to receive referrals from the stakeholders which worked well. 

Outcomes and evaluation

A retrospective cohort study was undertaken between September 2017 and September 2018. Adult patients undergoing elective major general surgical procedures were included and stratified into four sub‐specialties, including HPB, upper GI, lower GI and vascular surgery. Patients undergoing emergency and day case procedures or with missing outcome data were excluded from this study. Patients' demographics, baseline co‐morbidities, high‐risk medications, ASA physical status classification, surgical procedure, post‐operative complications, length of stay and nature of pharmacist interventions were collected and reported by descriptive statistics. Length of stay was compared with the corresponding expected length of stay by the national standard. A total of 246 patients were included in the four general sub‐specialties: HPB (n = 82), upper GI (n = 17), lower GI (n = 87) and vascular (n = 60). There was a significant reduction in the median length of stay in three surgical specialties, compared with the national standard: lower GI (median reduction: −2; IQR: −4, 1.8; P = .038), HPB (median reduction: −4.5; IQR: −7, −1; P = .001) and vascular (median reduction: −2; IQR: −4, 0; P = .043). The median actual length of stay was longer than the median expected length of stay in the upper GI specialty (median reduction: 5; IQR: −3, 17; P = .055), although it was not significant. This could be due to the small number of patients in this group.
 

Enhanced Recovery Pathways

Enhanced recovery in elective colorectal surgery has been running for the last 7 years with dedicated nurse led preoperative assessment and most of the patients are admitted on the day rather than earlier and the compliance has been really good. We are on the top of the list for sigmoid colectomy.

For elective joint replacement surgery the enhanced recovery pathway has been running for the last 4 years. We have a dedicated drug chart for the protocoled regime which has made us compliant with the pathway more than 90% of the time. We are now moving to rapid recovery for these procedures; trying to reduce the length of stay even further and looking at the feasibility of day case knee replacement in select group of patients.

Elective Caesarean Section Patients in The Jessop Wing Obstetric Unit

After implementation of the enhanced recovery initiative for patients having an elective caesarean in this unit, the proportion of patients discharged on the first postoperative day rose from 1.6% in the first quarter of 2012 to 25.2% in the first quarter of 2014.

Many other units across the UK have contacted Sheffield for advice on implementation.

ERAS at the University Hospital of North Midlands started in 2009 covering Colo-Rectal surgery initally, then expanded to include Oesophago-gastric, Hepato-biliary, Urology, Obstetrics, thoracic surgery, Trauma/orthopaedic and bariatric.

Each pathway is tailor made to the specific surgeries it deals with. 

For each of these above surgeries, there is a team of Enhanced Recovery nurses. Their roles are: Meet and greet the patients at the earliest opportunity - here the patients are counselled on lifestyle choices such as smoking cessation, alcohol habits etc. Referrals are made to the appropriate team to optimise fitness for surgery.

 The patients are counselled on their surgical journey and manage the patient's expectations. They are educated on the importance of early mobilisation, informing ward staff of pain / nausea, expected length of stay etc. The ERAS team dispense the carbohydrate loading drinks and discuss with the patients optimisation strategies (daily activity, eating well, rest etc.)

All potential oesophagectomy and major vascular procedure patients undergo a CPEX test to assess fitness for surgery. Those that are borderline are given an exercise regimen to improve their fitness. The ERAS nurse keeps in contact with them during this time to ensure the patient is compliant with the regimen or provide words of advice / motivation for those that are struggling to undertake the exercises daily. The patients are then reassessed at a later date.

 

The ER nurses then meet the patients the morning of surgery to re-iterate the important messages around early mobilisation, teach deep breathing exercises post op, give the patient the opportunity to address any concerns.

Any inpatient referrals are then made here - i.e. mobility physio for those already identified with mobility issues, or chest physio and dieticians for all oesophago-gastric patients, liaise with the discharge facilitators regarding any pre-assessed issues which may extend the length of stay.

All patients are also seen on the first post op day. Patients are mobilised daily (by the ER nurses) and the ER team identify how to keep the patient on their pathway, look for variations away from the pathway and ensure these issues are addressed in a timely manner to prevent unnecessary delays. 

They assist the ward nurses to keep the patient on the pathway - i.e. remove drains, initiate enteral analgesia, patient education to ensure the patient is confident prior to discharge etc.

Once discharged home the ERAS nursing team telephone the patients on a regular basis to ensure they are progressing well at home and reduce readmissions. 

There is also a helpline for patients to call should they have any issues and are unsure who to speak to or how to manage it. If related to surgery the ERAS nurses will liaise with their surgeons to organise a surgical review (either in surgical clinic or in Surgical Ambulatory Care Unit)

If not related to surgery the ERAS team will signpost the patient to the appropriate area (chemist, GP etc) to reduce unnecessary hospital attendances.

Once the patient is reviewed in surgical clinic, following surgery, the ERAS team discharge the patient from their care.

Virtual Clinics

Barnet Hospital, Royal Free Trust- Transformation of high risk ante-natal anaesthetic clinics from face to face to virtual clinics in a busy DGH

What was the problem/issue?

High risk obstetric patients requiring anaesthetic pre assessment during pandemic, with the need to offer an alternative from face to face appointments.


How did you know there was a problem?

  • Speed of pandemic and need to limit patients coming into hospital unnecessarily to reduce patient risk
  • Some patients who would benefit from pre assessment were not recieiving it until in active labour

The number of patients affected?
8-10% on background of 5.5-6,000 deliveries.
With approx. 70% women receiving anaesthetic care during their delivery. So a small proportion of women are referred.

What solutions were identified?

  1. Utilising digital technology (telephone calls and video calls) during pandemic to ensure good, effective and seamless anaesthetic peri-operative assessment of obstetric patients
  2. Collaborative working amongst health care professionals and patients using different technology applications. Ensuring feedback was gained throughout in order to make positive tweaks and changes to the virtual clinics for a successful outcome
  3. We have implemented an e-learning which covers how staff should use the platform to connect with patients. As this is new territory for a lot of staff there isn’t training in place for staff on how to get the best out of a video appointment in respect to consultation technique. We have worked closely with the undergrpointments.
  4. Every medical school in the country is now teaching about remote consulting.  It’s also important to bear in mind that we are still in an 'emergency operating mode' of teaching, having had two national lockdowns and both national and local restrictions that have caused huge and rapid changes in the way that medical school teaching is delivered - to enable students to continue to learn under these circumstances - at the same time as considerable upheaval in health service delivery.  
  5. Telemedicine is not new, particularly for some countries, and medical schools across the UK have been collaborating to share ideas and learn from each other over the past eight to nine months.  
  6. New subjects and domains of professional behaviour are added to the curriculum all the time and incorporated into assessments - this isn’t an unusual situation in that regard; evaluation and reflection are part of the course,aduate programme leads to ensure there is a clear process in place for students to join in on video ap

Why were these solutions chosen?

  • Digital technology widely utilised amongst anaesthetists and obstetric patient cohort (patient cohort tends to be young, have smart phones and are technology savvy)
  • National recommendations to perform virtual clinics and avoid unecessary patient footfall within hospitals
  • Several digital platforms to use that were NHS ‘safe.’
  • Prior to pandemic, NHS plan to use technology to develop stronger relationships between care givers and service users, and to develop better-integrated, team-based services and to deliver holistic, whole-person rather than narrowly bio-medical care
  • Individual services are responsible for the quality of their consultations/training in the same way they would be for a face to face clinic. There shouldn’t be a distinction between the 2 because they are just as important. In the event that a video or telephone consultation is insufficient staff always have the open to use face to face clinics to complete the consultation.

What were the barriers?

  • Change behaviour always takes time to create a uniform and seamless process
  • Digitial technology and data warehousing in the NHS (success of digital innovation often depends on what might appear to be small details such as how long it takes for health care staff or patients to log on or how hard it is to rectify a small inputting error.)
  • Non face-to-face clinics can help reduce unnecessary visits to hospitals, but are still a relatively new model of care. Guidance in the current climate is changing at a rapid pace
  • Small percentage of patient cohort will find using the technology difficult
  • Work space: finding appropriate rooms to undertake videocalls that met appropriate social distancing requirements
  • Key challenges are around equipment and internet connection largely on the Trust side as well as having a place for patients to contact much like you would have in a physical clinic.  IT are working extremely hard to upgrade the infrastructure to deal with the rapid shift to remote working.  We have implemented a virtual receptionist which greets patients and checks them in . They are also a point of contact should the patient have issues joining.

What were the enablers?

  • Enthusiastic and committed staff
  • Digital savvy users (Clinicians and patients)
  • Able to use translator service during virtual clinic
  • Less admin required compared to face to face clinics
  • Overall NHS trend to move from face to face clinics to virtual clinics
  • Less resources required- fewer rooms required, digital applications can be downloaded on personal mobile phones, clinic can be carried out whilst working from home
  • National mandate on virtual clinics to be offered

Which disciplines were involved?     
 Anaesthetics, admin anaesthetic staff, midwives, obstetricians, managers, patients

What evidence (qualitative or quantitative) is there to demonstrate impact (either positive or negative) on:

  • morbidity/mortality
  • patient record outcomes
  • patient experience
  • process measures (e.g. reduction in referral times, hospital bed days, readmissions, cancellations etc.

Positives
Positive staff feedback and informal patient feedback
Reduced wait times by patients
Flexibility within system to allow last minute additional appointments to be booked
Less inconvenience for patients when attending virtual appointment (no need for travel, childcare, time of work)
Records are electronic- minimises risk of some records being on paper and some being recorded electronically.

Negatives
Patient DNAs still remain
Unable to physically examine patient

Dr Yohinee Rajendran (ST7 Anaesthetic registrar North Central London Deanery)
Dr Sonia Brocklesby (Consultant Anaesthetist, Deputy Regional Advisor)
Dr Sanjana Singh (Consultant Anaesthetist, Lead for Obstetric Anaesthesia)

Electronic systems

Implementation of an integrated preoperative care pathway and regional electronic clinical portal for preoperative assessment

NHS Greater Glasgow and Clyde has implemented an electronic preoperative integrated care pathway (eForm) allowing all hospitals to access a comprehensive patient medical history via a clinical portal on the health-board intranet.

In January 2013, more than 90,000 patient preoperative assessments had been completed via the electronic portal. Two complementary strategic efforts were instrumental in the successful deployment of the preoperative eForm.  At the local health-board level: the PCIP led to the rationalisation of surgical pre-assessment clinics and the standardisation of preoperative processes. At the national level: the eHealth programme selected portal technology as an iterative strategic technology solution towards a virtual electronic patient record. Our study has highlighted clear synergies between these two standardisation efforts.

The electronic clinical portal allows the collection and sharing of detailed patient information across the various clinical teams involved in the care of a patient across the perioperative pathway, from referral to discharge.

Our study focuses on the implementation of both the integrated care pathway and the clinical portal which supports it.

Based on an extract from Bouamrane and Mair BMC Medical Informatics and DecisionMaking 2014, 14:93

http://www.biomedcentral.com/1472-6947/14/93

Electronic alert on theatre booking system for anaemia and high HBA1C

A Consultant Anaesthetist (David Nunn) designed the electronic record fpr the preoperative assessment service with a link to the ICE system.  This searches for blood results within last 3 months and identifies haemoglobin less than 130 and HBA1C greater than 69mmol/mol.  When a patients records are opened in the theatre booking system( ORSOS) the user is alerted to the presence of anaemia or poorly controlled diabetes.

We have prepared standard letter templates to inform other medical staff including the patients GP, of presence of either anaemia or diabetes.  These letters state whether surgery can proceed, depending on urgency of procedure and advice GP what steps need to be taken to either investigate and treat anaemia or improve diabetes control. 

The alert has enabled early, consistent identification of both anaemia and poorly controlled diabetes; The letter templates enable any member of the pre op team to action the abnormal results quickly and ensure consistent management and clear communication to all involved in patient care.

 

Improving Communication and Education between Primary and Secondary care

Woodend Hospital is Aberdeen’s elective orthopaedic hospital. Over 300 patients per month attend the preassessment clinic from the Orthopaedic clinic once Decision to Operate has been made. Time to Treatment Guarantee (TTG) in Scotland is twelve weeks. Patients are kept on this waiting list if they are referred back to Primary care for further medical management but removed if they are referred to a Secondary care speciality.

We aimed to expedite the deferred patient pathway between Primary care and Secondary care by improving communication and education between general practice and preassessment.

To start this two way process, the voice of GPs in Grampian-the GP Subcommittee was approached to discuss several key areas. Namely how our electronic preassessment letters were received and acted upon, BMA advice of Duty of care regarding communication of investigation results, AAGBI Guidelines:  management of adult blood pressure and management of hypertension before elective surgery 2016 and Peri-operative management of the surgical patient with diabetes 2015,

Primary care and secondary care work to different treatment thresholds and our letters could be more directional and emphasise the abnormal result, specify the effects of the abnormality and explain the level of improvement expected to reduce patient complications.

GPs directly receive our electronic letters via ECCI system with the enclosed relevant abnormal results. The handover of responsibility for ensuring that these results are acted upon has to be a consensus decision between the hospital team and the GP and if the GP hasn’t accepted that role, the person requesting the test must retain responsibility.

A recorded blood pressure in the previous 12 months in primary care should be accepted by secondary care to prevent spurious hypertensive measurements and an attempt to diagnose hypertension at preassessment clinic in patients who are normotensive in primary care. BP measurements in primary care require workforce planning and are not routinely done in patients who are referred to secondary care for consideration of surgery. Also our standard SCI gateway referral letter from primary care to secondary care currently does not upload BP values and therefore we have to amend this section to a mandatory one. To aid the perioperative management of the patient with diabetes, referral from primary care should include usual management of diabetes and HbA1c check within 3 months. HbA1c levels are taken less frequently than 3 months in primary care and often time to referral is breached exceeding this 3-month period.  Preop targets of HbA1c for elective surgery aim to reduce morbidity, mortality and length of stay. At preassessmnet clinic if a review of patients HbA1c is greater than the target values, these patients are referred back to the GP to review treatment thus delaying surgery. Sharing of these guidelines will promote a better pathway of care for all diabetic patients.

This is our local initiative to improve health and clinical outcomes in our elective orthopaedic patients in Grampian by the collaboration of primary and secondary care with anaesthetists working more closely with GPs. This model of care has the potential for transference as several colleagues in the UK are enthusiastic to promote some of these methods in their preassessment clinics.

Do you have an example of great perioperative care?
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