Preoperative Assessment Decision Support

S Lake, B Murthy*, A FisherDepartment of Clinical Engineering

* Department of Anaesthesia & Theatres

The Journey BEFORE Pre-opPatient seen by G.P Referred to / seen by surgeon

Lists the patient for an operationGoes on waiting List

Secretary/Clerk sends for the patient (appointment letter)

Patient comes to the hospital the day before or on the day of the operation

Investigations done

Examined by Anaesthetist

Unfit for surgery (D.M, ↑BP) Fit for surgery

Refer back to G.P Goes to operating theatre

Source of all day case cancellations. Aug 01 - Jun 02

Hospital clinical8% (986)

Hospital non-clinical

24% (2980)

Patient68% (8309)

Reasons for day case cancellations on the day & the day before surgery

Aug 01 - Jun 02

23%

(966

)

19%

(803

)

12%

(499

)

8% (3

37)

6% (2

46)

5% (2

34)

5% (2

24)

5% (2

22)

4% (1

87)

4% (1

63)

2% (8

1)

2% (7

9)

1% (6

2)

1% (6

1)

1% (4

9)

1% (3

4)

0.4%

(19)

0

100

200

300

400

500

600

700

800

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1000

1100

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Reason for cancellation

Num

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Reasons for day case cancellations on the day & the day before surgery.

Aug 01 – Jun 02

The Patient’s Journey Now Patient seen by G.P Refer to/seen by surgeon

Lists the patient for operation

Goes on waiting ListPre-op assessment 4 weeks before

surgery, and investigations

Unfit for surgery Fit for surgery

Patient comes to the hospital on the day of

surgery

Goes to theatre Discharge

Refer back to G.P Seen by Anaesthetist

in the clinic

Referred to Specialist (e.g Cardiologist)

Listed for operation once fit for surgery

Electronic Pre-operative Assessment Pathway

• Mile stone • Intranet based

• Present Pathways• Greater Accessibility, Accuracy and • Completeness of clinical information

OSCAR(Optimised Surgery Care and Anaesthesia Record)

Intranet based recording system of: -• Pre-operative anaesthetic assessment, medication

and scoring.• Complete peri-operative anaesthetic chart

including vital signs.• Post-operative monitoring, medication etc...

Now includes: Pre-admission assessment.

Decision Support

• Must predict investigations and provide advice based on: -– Details from patient history– Details about the operation– Local policies & guidelines

Patient History

• What does the prediction routine have to work with: -– The patient suffers from occasional, constant, infrequent

headaches.– Patient has chest pain if she lies on her left side for over

a year.– Skin: somewhat pale but present.– She stated that she had been constipated for most of her

life until 1989 when she got a divorce.

Richard Lederer’s list taken from “The Bride of Anguished English (2000)” where entries were described as real-life doctors’ dictations submitted by the American Association of Medical Transcriptionists.

Pre-operative and anaesthetic assessmentBase Line Observations Temp

Weight(kg) Height(m) BMI (kgm-2) Urinalysis

BP Pulse Respirations Skin integrity

Patient Health Questionnaire

General health Good Poor Elaborate as necessary

Nutrition problem or weight change No Yes

Medication eg –HRT, Oral Contraceptive, Anti-coagulants or steroids (including non prescription drugs)

No Yes Identify on page 4. If HRT or Oral Contraceptive inform medical staff before admission.

Previous steroid therapy No Yes When? Identify on page 4

Have you had an operation or anaesthetic before?

No Yes

Did you/your relatives have any problems associated with the anaesthetic?

No Yes Refer below

Do you smoke? No Yes Amount

Do you drink alcohol? No Yes Units per week

Do you have high blood pressure? No Yes

Do you have any heart problems? No Yes Angina Heart attacks Heart murmur Palpitations Fainting attacks/ blackouts

Do you have any chest problems? No Yes Asthma Bronchitis Emphysema Any other problems

………………… “ ……………………….. … “ ….. … “ .. …………………… “ …………………………

Guidelines for Pre-operative InvestigationsTEST INDICATION

FBC •All patients over 60 years and all menstruating females•Patients undergoing major surgery with likelihood of significant peri-operative blood loss.•H/O blood loss (acute or chronic), anaemia, renal disease, disseminated malignancy, malnutrition.•Patients likely to have regional anaesthesia.

Coagulation screen •Patient taking anticoagulants•Patients with bleeding disorder or chronic hepatobiliary disease or on haemodialysis•Patients likely to have regional anaesthesia•Consumption >21 units alcohol / week.

U&E •H/O cardiovascular disease or renal or hepatic impairment or malignancy.•Any cardiovascular drugs including diuretics.•Diabetes, asthmatics on inhalers, patients on steroids.•All patients over 50 years and in all patients undergoing major surgery

Glucose •All diabetic patients. In patients undergoing peripheral vascular surgery or pancreatic surgery or liver surgery.•In obese patients and patients taking steroids.

HbA1C •All diabetic patients

LFTs •Any patient undergoing major abdominal surgery.•H/O malignancy or chronic liver disease or jaundice or cardiac failure•Consumption >21 units alcohol / week.

………. “ …………… ………………………………… “ ………………………………………………

Arterial blood gases Patients with known respiratory disease who are listed for major surgery like thoracic surgery or oesophageal surgery.

Association• Would the program know that asthma in the

patient history is a respiratory disease, indicated in the guidelines for investigations.

• Or can we predict all occurrences of this now so it can be programmed in.

Solution1. Introduce an intermediary, ‘Fact Code’, that can

be attributed to a patient and used with the guidelines to predict the investigation.

– E.g. Has asthma or On Steroids

2. Three levels of action if fact code present: -• Recommend test : direct evidence in history• Suggest test : indirect evidence in history• Advice : Not a test but administration – e.g. put

patient first on list due to allergy.

Next problem• Anaesthetist wrote guidelines but Pre-op nurses

carry them out. Guidelines need to evolve.• Surgeons have ‘likes’• Flexible way to adjust prediction algorithm

– Defined by rules in a database– Template used to specify questions for history

taking and which rules to apply.

Database Structure

Rule Structure• Each assessment can have one or more rules

• Rule trigger: - Applicable age range

Level of surgery, minor, intermediate, major, major+

Specific operation procedure codes

Type of anaesthetic: GA, LA

Physiological measurement range (Fact Code), e.g. BMI >= 30

Medication (Fact Code), e.g. thyroxine

Condition (Fact Code), e.g. asthma

• Rule output: - Action: Recommend, Suggest, Advise only

Investigation to trigger

Patient information

Rule Application

Pre-Admission Assessment

Management list

Shows which assessments are still waiting for test results. Those past the pre-assigned panic date turn red

Anaesthetic Assessment

Communications

Web Server

Web Browser

(Internet Explorer)

ProgramsWeb Pages

Other systems

Web Page / Scripts

SOAP call (W3C standard)

By splitting the layout of the web page from the programming we can have different web pages calling the same program and even have other systems call the same program without the results being buried inside the web page source.

Database

Benefits

• Encourages a consistent approach to pre-operative assessment.

• Quality of record.• May flag up tests missed by the Nurse.• Highlights missing test results before it becomes a problem.• Anaesthetist is better informed.

• A catalyst to improvement by providing a focus on: -

Optimising Surgery Care