Case Studies: Before Surgery
Preoperative assessment initiatives
Trust/Healthboard/Hospital: University Hospitals Bristol
Thoracic pre-operative assessment
The thoracic multidisciplinary team hold a weekly ‘complex case review meeting’ to plan the most appropriate care for high risk patients. Discussion covers the type of surgery required, the patient’s pre-op review and investigations. Morbidity scoring systems are completed. Together, these guide recommendations for prehabilitation and appropriate post-operative care.
Previd incorporates video assessment where patients are videoed introducing themselves, performing the ‘sit-stand test’ and walking a fixed distance. The sit-stand test is analysed as to the quality of the exercise, the number of repetitions and the motivation the patient shows during the test. They are then timed walking down a 20 m slope and back up. The camera is kept running after completion to see how breathless they are. This video is essential as surgeons pool patients, and therefore may not have met face to face; seeing them on screen adds additional information to numbers and scans.
Skype pre-op assessments for patients referred to our tertiary centre from out of region has improved patient experience by preventing journeys to our centre. Baseline investigations are performed at the patient’s referring hospital but the pre-op consultation with a specialist nurse and anaesthetist is done over Skype.
Trust/Healthboard/Hospital: St Richard’s Hospital in Chichester
At St Richard’s Hospital, a one stop pre-operative bariatric clinic assesses patients being considered for bariatric surgery by an inter professional team (Anaesthetist / Surgeon / Preoperative Nurse Specialist / Physician / Dietician / Psychologist) providing advice and appropriate selection of patients for the correct surgical procedure. The patient is booked for surgery only when assessed as “Fit for Surgery”.
Trust/Healthboard/Hospital: St George’s Healthcare Trust
Senior nurses are employed at St George’s to undertake assessments with a pharmacist present in clinic. According to the Preoperative Association, it has been consistently shown that having pharmacy input at pre-operative assessment has significantly reduced medication related admission issues.
Trust/Healthboard/Hospital: Royal Liverpool and Broadgreen Hospitals NHS Trust
An electronic preoperative assessment system (OSCAR) used at Royal Liverpool and Broadgreen University Hospitals NHS Trust has been shown to improve communication and efficiency of preoperative preparation by using algorithm decision protocols to advise nurses, check blood results, print medication advice, track patients, improve communication (Admissions / Theatres / Anaesthetists) and auditing patient outcomes.
Trust/Healthboard/Hospital: South Tees NHS Trust
The vascular team have implemented weekly multidisciplinary meetings (MDT) with consultant representation from surgery, radiology and preoperative assessment enabling all attending patients with AAA disease to be discussed in a team setting, with expedited clinical decision-making. Minor alterations have resulted in high level compliance with national AAAQIP 8-week referral to surgery pathway whilst maintaining good surgical outcomes.
Trust/Healthboard/Hospital: Newcastle upon Tyne NHS Foundation Trust
The Newcastle upon Tyne NHS Foundation Trust established its pre-assessment service in 2004. Over the years it has grown over 3 sites assessing an average of 30,000 patients per year (inclusive of Saturday working) and recently includes a community-based GP site. We provide a local service to all surgical specialties including: Urology, Hepatobiliary, Vascular, Colorectal, Elective Orthopaedics, Ortho-Oncology, general surgery, breast, plastics, gynaecology, intra-abdominal solid organ transplantation, ENT, Head and Neck, Endoscopy and Interventional Radiology. We also provide regional assessment to transplantation and pancreatic surgery.
We have a team of health care assistants, pre assessment nurses, specialist nurses and cardio pulmonary technicians who provide both booked and a one stop service to patients. 70% of the patients go through this nurse led service. We also offer a telephone helpline run by the senior nursing team to aid patients in stopping medications appropriately before surgery.
In addition, there are a team of dedicated Consultant Perioperative Clinicians. Together, we have developed protocol driven pathways to help investigate and optimise high risk patients. These ensure that the patients are managed in collaboration with the GP minimising referral rates to other specialities to avoid unnecessary delay to patient pathways.
We also run a comprehensive cardiopulmonary exercise testing service for patients undergoing major elective surgery to aid in the risk assessment process. This is run by our cardio-pulmonary technicians in conjunction with the medical team and performed over 2000 tests in 2015. This has led to some of the landmark papers in the risk assessment of patients for surgery. We are currently beneficiaries of an NIHR grant (2.5 yrs) to investigate preoperative alcohol cessation before major orthopaedic surgery and developing community based, hospital derived, habilitative exercise programmes.
We are proud to have reduced our surgical cancellation rate described as ‘unfit for surgery due to inappropriate assessment’ from 9% in 2002 to <0.5% despite a significant rise in patient co morbidity, frailty, patient numbers and the addition of multiple directorates. A recent patient satisfaction (2015) carried out on over 250 patients and compared to one in 2011 showed that 98.3% of patients were very satisfied with their overall care which we had maintained despite huge increases in patient numbers.
Trust/Healthboard/Hospital: NHS Grampian Aberdeen
In collaboration with our geriatric colleagues we have promoted the use of the 4AT for the assessment for cognitive impairment and delirium in our preassessment clinics and surgical wards. We have used the HIS -Health Improvement Scotland learning resources- Think Delirium to educate nursing staff and junior doctors as well as information leaflets to support patients’ families.
We have incorporated the rapid 4 AT in our preassessment record, to screen for cognitive impairment in all patients over 65 years of age. Cognitive impairment is a risk factor for delirium and has implications for the consent process for surgery that may necessitate Power of attorney. A score of 1-3 suggests cognitive impairment and these patients are referred back to primary care for further cognitive assessment. In the postoperative period, we follow up with the 4AT combined assessment tool to screen for delirium in these patients. A score of >4 will initiate the TIME bundle.
Trust/Healthboard/Hospital: Colchester General Hospital
Aims and objectives
We have introduced this ‘walk-round’ clinic to streamline and improve our pre-assessment service. All patients who are booked for surgery in clinic proceed directly to the IPA clinic. The two main objectives of the IPA are:
- To identify low risk patients having minor or intermediate surgery on the day they are booked for surgery (‘green’ patients) who can proceed directly to surgery without returning for further appointments pre-operatively
- To identify patients early who are high risk and may need multidisciplinary input in their preparation for surgery and/or optimisation of pre-existing medical conditions.
All patients planned for elective surgery in a surgical outpatient clinic should receive an IPA form at their clinic appointment, which they complete and present to the IPA clinic. Here the IPA nurse will be able to assess them, measure their BMI and observations, and perform MRSA swabs.The IPA nurse will also arrange investigations as appropriate for their medical comorbidities and the type of surgery they are due to have. These might include blood tests and ECGs. The IPA nurse will perform a Rockwood frailty assessment for all patients over 65 years.
On the basis of this assessment, patients will be triaged into red, amber and green groups. ‘Green’ patients can proceed directly to surgery, ‘amber’ patient require a nurse-led pre-assessment appointment and ‘red’ patients will require a nurse-led pre-assessment with notes or face-to-face review by a Consultant Anaesthetist.
In the first 4.5 months we have built up from one to five days per weeks, with the following results:
- 739 patients through IPA
- Total of 71 clinics in 5 months
- Mean 10.4 patients, median 11 seen per day (max 20, min 2)
- Mean wait for patient 10 mins
- Mean appointment time 13 mins (full nurse pre-assessment time in clinic is 45 mins)
Improvements in quality of care
This has meant an improvement in quality of care through referral for optimisation at the earliest opportunity:
- All ‘red’ patients, 73, were identified as needing a Consultant Anaesthetist review (either notes review or face-to-face)
- 33 patients were identified to be hypertensive and were referred to the GP for management of this
- 43 patients were identified to be anaemic and commenced on the anaemia pathway
- 5 patients identified to have poorly controlled diabetes so referred for optimisation of diabetic control
- 6 patients were identified to have a BMI above our CCG’s threshold of 35 for joint replacement so referred back to their GP
- Some referrals of our most frail and elderly patients were made directly to our high risk pre-assessment clinic run jointly with a Consultant Anaesthetist and a Consultant Physician
Improvements in efficiency
For those green patients who now do not require a face-to-face preassessment clinic appointment just over 30mins clinic time is saved per patient. For many of these an additional trip into hospital for pre-assessment is also avoided.
Barriers and Enablers
Our enthusiastic staff with a new band 6 nurse to lead the IPA service have been fundamental to making this new service work.
Challenges include a lack of space in main outpatients to run such a busy clinic. The geography of our clinics is also a challenge; we currently are not providing this service for oral, ENT or ophthalmology as their clinics are in a different building across a road. Staffing and training new staff to run these clinics is an ongoing challenge as our service expands.
However we are optimistic that the excellent results will encourage support for this service going forward.
Redesign of the perioperative pathway enables time for Prehabilitiation
Historically patients requiring colorectal resection for cancer were not referred to the perioperative medicine team until the cancer MDT had taken place and the patient had returned to clinic to discuss results and treatment. Surgery would then be scheduled with the next 2 weeks leaving little or no time for prehabilitation
Our perioperative medicine team worked with the surgeons and clinical nurse specialists to identify an earlier point in the pathway that patients could be referred. It was agreed to start referring patients to the prehabiliiation service following identification of a likely cancer in endoscopy. Although patients did not have a confirmed diagnosis at this point they were aware they were being investigated for a probably cancer and that if this was confirmed surgery was likely to be the first line treatment.
For those patients who required surgery and did not come via endoscopy it was agreed that members of the prehab team would attend the colorectal cancer MDT and take direct referrals from the meeting.
What was the impact?
Early referral of patients to the prehab service via from endoscopy and MDT allowed patients to have an extra 2 weeks of prehab time in their pathway prior to surgery. It was initially thought that patients may find it difficult physically preparing for surgery prior to having a definite diagnosis however none of the patients have reported this to be an issue.
Initially the colorectal team were concerned that patients could potentially have it confirmed they had cancer by someone other than the surgeon or clinical nurse specialist, however this has now been overcome by the prehab nurses working closely with the colorectal cancer nurses regarding communication with patients. This change in practice has worked because the teams have worked together to challenge the traditional order of events in the perioperative period.
Establishing a prehabilitation service with minimal funding
What was the need and what solutions were identified?
In 2017, a review of evidence from Macmillan Cancer Support concluded that prehabilitation should be integrated into routine cancer care to improve the outcomes of those patients undergoing surgery.
Our hospital is situated in a part of England that has above average rates of comorbidities such as obesity and diabetes – all of which can increase perioperative risks and post operative complications. Operations were cancelled or not recommended due to poorly controlled comorbidities which had negative implications for the patients and was also not the best use of resources for the hospital.
If patients understood the implications of such comorbidities with regards to surgical risk, and we were able to guide them and give them tools on how to control comorbidities such as diabetes and obesity, then they may reap benefits in terms of reduced peri and post operative complications. Even if patients did not have comorbidities, by introducing simple measures and exercises to simply increase their baseline functioning may mean they would be better able to withstand the stress of surgery and have an enhanced recovery.
In light of all of these findings, our aim was to set up a prehabilitation unit with the aim of managing comorbidities to optimise patient outcomes during surgery; increasing physiological reserve so that patients are better able to recover after surgery; and to reduce post operative complications and readmissions.
The prehab team at Medway NHS Trust sought to establish a multi-modal prehabilitation programme for our colorectal and urology cancer resection patients. The programme consisted of supervised exercise, nutritional advice, anxiety management strategies and optimisation of patients’ medications and comorbidities such as anaemia.
The purpose of this service was to improve patients’ physiological reserve with the outlook of better withstanding the stress of surgery and to reduce the rate of post-operative complications and hospital re-admissions.
What barriers did you encounter?
As we had no dedicated, ring fenced funding, it wasn’t until October 2018 where we were able to set up a dedicated unit.
To combat this, we applied successfully to charities in order to purchase specialist equipment including exercise bikes. Patient donations and expertise helped procure weights and format patient literature. Clinical internships with Greenwich university helped with supervised exercise delivery. The team intended to deliver this programme as best possible for patients and winning the Chief Executives Scholarships enabled the team to visit the prehabilitation unit at McGill University, Montreal to learn from best practice and implement these into our own unit.
With the use of consultant job planned sessions, the service was set up with no funding or administrative support. Planning and networking in our own time won support and engagement with clinicians, managers and local groups without any local data regarding patient and financial benefit. Patient advocates, multidisciplinary staff and clinicians all gave their time to collaborate and make the service a successful reality.
Presenting our story at regional cancer and GP CME meetings regularly helped us raise awareness of our service.
Despite the many barriers to implementing a new service with a small literature base and initially a lack of senior managerial support, we were able to set up a designated prehabilitation unit, gain invaluable staff that helped deliver the prehabilitation programme, and recruit patients to go through the prehab pathway, all with minimal funding.
Were the solutions supportive of multi-disciplinary working?
Our solutions were not only supportive of multidisciplinary team, our solutions pivoted and revolved around an essential team of doctors, specialist cancer nurses, psychologists, counsellors, physiologists, students and most importantly, the patients themselves.
Doctors and specialist nurses were involved in consultations regarding further management of a patient’s condition with regards to surgical intervention. Doctors were involved with designing a prehabilitation pathway for eligible patients and recruiting them to the prehab service. Doctors were responsible for recruiting physiologists and nurses to help deliver the programme.
Specialist nurses were a crucial part of providing support and being a point of contact for patients. They were vital in providing information about important support groups, organisations, and useful contacts to patients.
Public Health Medway offered ‘hot” smoking cessation and alcohol moderation clinics along with support at patient education meetings.
Physiologists, counsellors, psychologists and students were critical in delivering the prehabilitation programme and being a source of support to patients.
What evidence demonstrates the impact of the programme?
Quantitively, our data shows there has been a 15-20% improvement in functional capacity following prehabilitation, a reduction in HbA1c in 16 patients that were diabetic. We have demonstrated a length of stay reduction in colorectal resections.
Qualitatively, anecdotal patient experiences have been instrumental in gaining support for the service and are regularly fed back to the stakeholders. The nutritional leaflet co designed with our patients has been featured in the Royal College of Anaesthetists’ Bulletin.
As our project progresses, we hope to gain further data to assess to full impact of the programme.
We hope to collect further data on patient reported outcome measures, feedback about the prehab service itself to improve the quality our delivery, and further data about length of hospital stays, 30-day hospital re-admissions and complications.
Were patients engaged and consulted?
The patients' co-designed leaflets aimed at giving patients information about the prehabilitation programme. They were given verbal information about the programme and its potential benefits. Patients were given a choice to attend prehab. The prehab sessions are designed with the patient themselves – it involved an assessment of their current baseline and building the foundations to improve upon that. Peer support is a crucial element of all patient supervised sessions.
Patients were offered other support such as counselling, smoking cessation and diet advice all which was tailored according to their needs.
How does the solution relate to or support wider NHS/government policy in practice?
“Prevention is better than cure”. As a society that is moving more towards preventative medicine, prehabilitation may offer a solution to post operative hospital re-admissions and complications.
The multidisciplinary team that helps deliver the prehabilitation programme is an example of bringing different professionals and organisations together to coordinate and yield better care for patients.
The programme will help tackle major healthcare issues such as diabetes, obesity, smoking and mental health.
We are providing this service with minimal funding and pure commitment from the professionals involved with the service. All of these are principles that are echoed in the Long Term Plan for England. We are already seeing promising data, and further data collection will help demonstrate the virtues of prehabilitation. With this we may be able to expand our services by means of establishing community satellite units and mentoring other sites to initiate their own prehabilitation units with limited resources.
What learning was developed?
Establishing the prehabilitation programme was a learning process in itself. The visit to McGill University’s prehabilitation unit in Montreal was crucial in creating a benchmark and learning from best practice to enable us to implement these lessons into our own unit.
We have partnered with Greenwich University to provide a team who were trained to provide exercise programmes to the patients.
We have, networked and liaised with local groups and shared our lessons and data with clinicians, managers, patient advocates and other members of the multidisciplinary team. This helped promulgate and illustrate the benefits for our programme.
We won the best presentation award at the Enhanced Recovery after Surgery UK society meeting in November 2019 and presenting colorectal data at St Peters Hospital meeting at the Royal Society of Medicine.
We have presented at the regional cancer and GP CME meetings regularly to raise awareness of our service. We have also submitted and displayed abstracts at the World Prehabilitation Conference.
Fit for Surgery
Patients undergoing major abdominal surgery at the Western General Hospital, Edinburgh are being enrolled into a new pilot initiative aimed at reducing perioperative complications and length of hospital stay.
The Fit for Surgery booklet, presented at pre-assessment, details and explains how patients can prepare themselves physically and mentally for recovery from surgery. In addition to pre-optimisation advice, the booklet also details clear targets for post-operative breathing and mobilisation exercises. They are encouraged to practice and rehearse these exercises before their admission.
We believe that through altering the patients’ expectations of their post-operative hospital course, we can positively influence this aspect of their recovery, encouraging patients to take assertive “ownership” of their post-operative recovery. Ongoing audit against baseline data will examine the effect of this new initiative.
A preoperative “Fit 4 Surgery” school was established at University Hospital Southampton in May 2016. The school consists of a two-hour classroom based session covering the benefits of exercise, nutrition, the Enhanced Recovery approach, and lifestyle modification advice regarding smoking and alcohol intake. All patients undergoing elective major colorectal, urological and upper GI resections are invited to attend. The aim of the school is to provide patients with advice and tools to enable behaviour modification and improve fitness prior to major elective surgery.
We have collected feedback from the patients attending school since inception. This has been done using a Likert style satisfaction questionnaire, which patients are asked to complete anonymously at the end of the session. We also asked patients to complete a short lifestyle self-reported questionnaire post-surgery to help identify if they had made any changes to their lifestyle as a result of attending. The responses to the lifestyle questionnaire were compared with those of a similar control group of patients who had not attended school.
We also used the school with the presence of a dietitian, as a screening opportunity for malnutrition. The attending dietitian was able to offer one to one advice to patients identified as at risk while the attended the school.
What was the impact?
During the 2 year data collection period 848 patients were invited to the surgery school with 450 patients attending. 63% of school patients stated they intended to make a lifestyle change as a result of attending. 8% stated that they would recommend the school to a friend having surgery.
The free text aspect of the evaluation form has also been useful in ascertaining acceptability and patient experience of surgery school.
Sessions were regularly described as “useful”, “interesting”, “insightful”, “relevant”, “reassuring”, “above expectation” and “well worth the time”. The staff delivering the presentations were frequently described as “caring”, “supportive”, “friendly”, “approachable” and “welcoming”.
Patients’ described themselves as feeling more confident, inspired to change behaviour, better prepared and less fearful of surgery having attended the session.
Other useful feedback was that patients found it a useful forum to talk to others going through a similar experience, they liked the frequent opportunity to ask questions either openly or on a 1:1 basis, and they felt valued and invested in as service users.
Of those who completed a lifestyle questionnaire postoperatively, 232 had attended school and 182 had not. Improvements in physical activity were higher in school attenders, 46% of patients attending school reported becoming more active compared with 25% who had not attended school. A particularly marked increase in reported activity was seen in those who were not physically active prior to school attendance. There were similar numbers of patients who smoked and drank alcohol in the school and non-school attenders. The proportion of smokers who reduced tobacco consumption was similarly high in both groups (88% and 81%). Similarly reduction of alcohol intake prior to surgery was also seen to be high in both groups (71% vs 67%).
With regard to diet modification, 42% of school patients made positive changes to their diet, compared with 36% of patients who did not attend school.
With regard to the nutrition screening. 27% of the patients screened at surgery school were identified to be at risk of malnutrition. These were offered advice with the dietitian and followed up as necessary. These patients would otherwise have had their malnutrition undetected until preassessment which would have allowed little time for intervention and optimisation.
Barriers / Enablers/ Sustainability
The attendance rate of those who are invited to surgery school remains around 60% of those invited. We currently have no way of reaching out to those who are unable to attend school for whatever reasons. 10% of patients are also referred to late in their surgical pathway to attend the school, due to surgery being within a week of referral date.
This project has been relatively resource intensive as if requires the time of the health professionals involved including a physio, nurse, dietitian and psychologist to deliver the sessions and collect the data.
Cardiopulmonary Exercise Testing
Established in 2014, all vascular aortic aneurysm patients are seen and assessed in the clinic by a consultant anaesthetist with a special interest in perioperative medicine.
The physiological data from the CPET is used to facilitate risk assessment and shared decision making. Opportunities for optimisation are identified and actioned.
In June 2004 a pre-operative risk assessment service for patients being considered for major abdominal surgery was established at York Hospital.
CPET (Cardiopulmonary Exercise Testing) is incorporated into a two hour pre-operative assessment where risk classification takes into account three parameters: anaerobic threshold, ventilatory efficiency and the presence or absence of myocardial dysfunction. This informs decisions on whether the patient should have surgery, any preparation which could improve their outcomes and what care they need following surgery.
In August of 2013 a joint anaesthetic and cardiac physiology clinic was started at Calderdale and Huddersfield NHS Foundation Trust for risk assessing and optimising patients for major gastro-intestinal, vascular & urological surgery. Attendance by a consultant anaesthetist with an interest in perioperative medicine allows for risk stratification, coordinating care with surgical, general practice and cardiology colleagues and discussion with patients and their relatives on what the risks, benefits and aims are for their personalised care.
Patients have a greater opportunity to understand the potential risks and intended benefits of surgery, allowing them more input into all decisions affecting their care and ensuring a better patient experience.
To date the CPET service has tested 160 patients from ages 28 to 96. This has helped plan appropriate critical care across the trust whilst focussing on patient outcomes.
Speciality specific High Risk Anaesthetic (HRA) clinics are supported by an anaesthetic run CPET service. Direct referral pathways exist for certain operations such as oesophagectomy so that patients are tested prior to their HRA clinic appointment, minimising pathway times. Interpretation provides an overall assessment of fitness, based on Peak VO2, Anaerobic threshold and ventilatory efficiency, and advice regarding any specific abnormalities identified. This testing can be especially useful for patients travelling from neighbouring counties for tertiary care.
The service currently tests 140 patients a year including tertiary referral patients and is expanding from 2 to 4 consultant anaesthetists.
Every patient scheduled for major rectal, hepatobiliary, cystectomy or vascular surgery undergoes CPET testing. Results are discussed at multi-disciplinary meetings. They can unveil life-threatening conditions and informs decisions around the treatment of patients. CPET has been associated with increased planned use of high dependency care and a drop in surgery related morbidity.
In 2008, a CPET clinic was started at the University Hospital of Wales in Cardiff, led and run by consultant anaesthetists. Attendance by a consultant anaesthetist with an interest in perioperative medicine and pre-operative optimisation allows pre-operative interventions to be made in addition to CPET being performed.
Such testing has led to interventions in 45% of patients.
All patients undergoing Elective AAA surgery either Open surgery or EVAAR undergo CPET testing and are discussed as part of Vascular Multidisciplinary meeting held every week involving Consultant Anaesthetists, Interventional Radiologists and Vascular Surgeons.
This programme was started in 2007 and has evolved gradually since 2010, making it extremely beneficial for discussion and close co-ordination amongst our teams and thus having a significant impact on the perioperative care provided by our Trust, with significant improvement in our outcomes.
Shared decision making
In addition to the nurse led pre-assessment clinics there are 3 dedicated Consultant led pre-assessment clinics a week at Sandwell and West Birmingham Hospitals. These clinics are run on the ‘shared decision-making model’.
Medical assessment includes objective risk assessment, frailty testing, preoperative exercise testing and preoperative optimization. Objective risk scoring and collaborative decision making with the patient and surgical team is done routinely.
We have detailed discussion with the patients to help them understand the various treatment options and empower them to make ‘informed decisions’ regarding the various treatment choices. This is complemented with detailed letters written to patients.
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