Acute hospital preoperative assessment redesign: streamlining the patient pathway and reducing on-the-day surgery cancellations

Abstract

IntroductionAvoidable surgery cancellations in an acute trust were often attributed to inadequate preoperative assessment. These assessments, undertaken shortly before surgery, were delivered across eight different locations, 60% by a central nursing team and the remainder by other healthcare professionals. There was inconsistency in what and who were assessed, and inadequate time to optimise patients. There was difficulty finding capacity for urgent patient assessment, plus a lack of a pool of ‘ready-assessed’ patients to fill last-minute operating list gaps.MethodsA diagnostic phase using data analysis, root cause analyses and clinic observations identified multiple systemic issues confirming the need for system change.InterventionsOther trusts operating different models were visited and their processes were adapted to create a preassessment model relevant to our trust context. Key features included early preassessment, triage and streaming, in-clinic support from a prescribing pharmacist and consultant anaesthetist, a standardised outcome form documenting specific patient requirements needing action when a surgery date was agreed, surgery dating only on confirmation of patient optimisation, an administrative office (hub) with a tracking database to coordinate follow-up tasks and a patient hotline. A key enabler was a single, bespoke location. Where possible, testing took place in advance of the go-live. However, due to the transformational nature of the new model, some changes could only be tested and refined at scale in the new, single location.ResultsTwo months post implementation, a preliminary audit was positive, but clinic observations indicated that patient clinic flow was suboptimal. Further structural and process modifications were made. Ten months post implementation, a further root cause audit showed a near-elimination of on-the-day surgery cancellations for patients assessed in the redesigned service.ConclusionThe bundle of 17 interlinked interventions proved highly effective in delivering sustained improvements, which could be adopted by other trusts.

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