Referral to Treatment Targets

Preoperative preparation should focus on all aspects of the patient journey commencing in primary care, transferring to secondary care and finally going back to primary care once the patient has been discharged from hospital. Current NHS referral to treatment target guidelines (Department of Health UK 2012) recommend investigation/treatment should be commenced within 2 weeks for cancer referrals and 18 weeks for non-cancer surgery. The ‘clock’ can be stopped if the patient has co-morbidities requiring optimisation.

Patient-Focussed Care

The service should be patient-led, appropriate to the patient requirements as well as to the requirements of the healthcare provider. There needs be clear documentation, in paper or electronic format, that will form the base for the ongoing patient optimisation/treatment and be accessible by the full inter-professional team. Appropriate assessment tailored to the individual patient requirements will provide patients with the information they require to make an informed choice, involve as necessary the appropriate members of the inter-professional team and put mechanisms in place to optimise health and to minimise patient cancellations on the day of surgery. This can be achieved only through effective training and competency assessments of nurses that meet an agreed standard of care. The Preoperative Association (www.pre-op.org) is committed to identifying the standard of care that patients and staff should expect and have published an Excel sheet and PowerPoint presentation detailing the tasks associated with each band of nursing staff.

Nurse-Run Service

While preoperative assessment is commonly a nurse-run service, the service should be patient focussed, ensuring that timing and skills of the staff meet the requirements of the patient groups attending.

Patients should have the opportunity to discuss their concerns and to receive appropriate examination, investigation and advice by individuals who are appropriately skilled with the knowledge and experience that ensure a standard of care that is of the highest level, and that patients receive sufficient and accurate information that informed consent can be safely given. With the patients having had time to think through the outpatient advice and pending surgery, arrival at POA will often result in the assessor receiving patient queries regarding the anaesthetic and surgery, also of social requirements, during the perioperative period. It is common practice for patients to arrive at the POA appointment with Internet searches on their pending procedure and multiple questions that require direction.

The nurse in POA may become a contact point for patients during the preoperative phase of patient care, often coordinating any patient preparation prior to admission, requesting investigations, taking action on results and checking on optimisation pre-surgery, as well as liaison with the support for the individual from within both the primary and secondary care.

Any POA service should meet the Care Quality Commission 2015 (CQC) expectations, and the managerial team should ask themselves these CQC questions.

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  Is your POA service safe?

  
  
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  Is it effective?

  
  
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  Is the service caring?

  
  
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  Is the service responsive to people’s needs?

  
  
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  Is the service well-led?

The role of the nursing team within POA is varied. Tasks associated with the role will enhance patients’ progress during their surgical pathway and ensure clear documentation on all co-morbidities, patient investigations and optimisation completed prior to admission. This will maximise admission on the day of surgery and minimise operation cancellations on the day of surgery.

The tasks undertaken by the RN, supported by the non-RN (healthcare assistant and/or assistant practitioner), are varied and will differ according to the experience and training of the team, as well as the patient requirements (www.pre-op.org).

Potential tasks associated for the nursing team in POA:

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  Identify and confirm patient demographics and ensure notes/waiting list details are accurate.

  
  
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  Identify patient status and offer information regarding general health, smoking cessation and healthy eating.

  
  
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  Identify procedure and provide information of procedure.

  
  
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  Identify social requirements to minimise delayed discharge.

  
  
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  Identify past medical, surgical and anaesthetic history, exploring history and current status as appropriate.

  
  
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  Complete baseline observations, including manual radial pulse.

  
  
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  Complete ECG and spirometry as required.

  
  
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  Complete chest auscultation as required, sufficient to identify normal/abnormal and when to refer to anaesthetist.

  
  
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  Request investigations according to an agreed policy.

  
  
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  Determine those patients fit for admission and those requiring anaesthetic opinion.

  
  
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  Refer as appropriate e.g. to anticoagulation team for patients requiring anticoagulation bridging therapy.

Patient Tracking System

An effective tracking system (electronic or paper) is essential to keep the flow and to ensure the patient is not ‘lost’ in the preoperative preparation process. A tracking system should be used to track the progress of the patient along the perioperative pathway when referred to specialists for assessment and optimisation, to collate investigations and to summarise patients’ preoperative records for planning the patients’ surgical journey. An electronic preoperative assessment reporting/tracking system – perhaps using an EXCEL spreadsheet – has the additional advantages of recommending what investigations should be ordered, collating investigation results, providing medication advice for patients and recommending a perioperative plan according to patients’ co-morbidities and surgical procedure. Viewing the electronic record prior to patient admission by anaesthetists, theatres, HDU or an admissions clerk will allow patients’ surgical plans to be implemented and sharing of essential information for safe care.

Francis Report

A well-run preoperative assessment service will tick all the boxes in terms of the Francis recommendations and Care Quality Commission expectations.

Ideally the service of POA should be co-located within the outpatient department to enable patients to walk from their OPD, but a stand-alone clinic can be equally fully functional.

Extracted summary from the Francis report (2013):

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  Leadership and management need to focus on the provision of good patient care.

  
  
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  All should be responsible and accountable for their actions/inactions.

  
  
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  Inter-professional teamwork should be encouraged.

  
  
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  Openness – admitting areas of poor care/areas for improvement as well as areas of achievement.

  
  
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  Clinical governance is one means of monitoring agreed standards of care.

  
  
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  Policies should meet national levels of acceptability, with processes in place to ensure local compliance.

  
  
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  Staff should be appropriately trained to undertake their duties, ensuring ongoing training and competence assessments.

  
  
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  Performance should be measured against agreed policies.

  
  
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  Audit should be continually undertaken.

  
  
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  Actions should be taken on findings e.g. from audits, complaints.

Meeting the points as raised in the Francis recommendations and the CQC expectations requires clear policy for the POA service, a policy that the nursing and anaesthetic team have agreed and will apply consistently to ensure patient safety is maintained. Appropriate training and competency to apply the policy is required, together with audit of the outcomes of patient assessment. This will highlight potential areas for further training, and, where appropriate, the policy will be updated and cascaded through the inter-professional team at clinical governance sessions to ensure practice is updated as and when required.

Who Should Perform Preoperative Assessment?

POA requirement and provision of service varies according to the local area requirements.

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  Day and/or inpatient assessments

  
  
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  Complexity of patients

  
  
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  Speciality of surgical care

  
  
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  Local hospital catchment/specialism

  
  
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  Is the POA to be an interview face-to-face/telephone assessment/patient self-assessment?

POA teams may comprise nursing – registered and non-registered, and medical staff – foundation doctors, consultant anaesthetists, surgeons, occupational therapists, physiotherapists and pharmacists. In addition, adequate secretarial and administration support is required for the preoperative service to run efficiently.

The Guidelines for Provision of Anaesthetic Services published by the Royal College of Anaesthetists recommend the following staffing requirements for preoperative assessment based on 1000 inpatients passing through a preoperative preparation clinic.

Anaesthetists

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   – Reviews/consultations one session per week (1.25 PAs)

   
   
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   – High-risk clinics one session per week (1.25 PAs)

   
   
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   – Clinical leadership for service one session per week (1.25 PAs)

Nurses

Grade and experience of preoperative assessment are determined by local policies. Specially trained RNs, assistant practitioners and healthcare assistants will be efficient and effective in undertaking the tasks associated with patient preparation.

Per 1000 patients

0.6 RN and 0.3 HCA

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   – Staffing ratio based on 80 per cent of patients as day cases and 20 per cent as inpatients.

   
   
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   – Assumes nurse assessments for day-case patients have 30-minute assessments and inpatients have 45-minute assessments.

The majority of preoperative assessment in the UK is now undertaken by nurses in the preoperative assessment clinic. Nursing staff working in this specialist field undertake a varied number of tasks depending on their nurse banding levels. The Preoperative Association has published a framework of nursing skills for different band levels in preoperative assessment. The team of nurses will vary in the requirements of their skills and experiences required depending on the complexity of patients to be assessed. It is important to ensure that nurses are given the appropriate training and competency assessments to ensure that they have the skills to accurately and safely undertake the task, and that policy or protocol documentation clearly defines their role. It is unlikely that any one POA service will have a full range of Band 2–8b.

The presence of a pharmacist in the preoperative assessment clinic will reduce the nurses’ workload, reduce drug errors and provide information to patients regarding what medications should be stopped or continued on the day of surgery.

Patients attending ‘joint clinics’ in preparation for hip or knee replacement surgery benefit from having an anaesthetist/surgeon/physiotherapist/occupation therapist/nurse present at the communal session as the information provided to patients is reinforced by all members of the inter-professional team. Similarly, a ‘bariatric clinic’ may have an anaesthetist/surgeon/physician/dietician/psychologist present to discuss the appropriate treatment and management of patients being considered for bariatric surgery. Similar clinics would be effective for cataract surgery to allay any concerns of patients, relatives or carers.