Making Waves October 07 - James Paget University Hospitals

Inside our Preassessment Clinic
Staff will know that the preassessment clinic prepares patients for admission to surgery, as
. inpatients or day cases. Patients normally have an appointment with a preassessment nurse
one to two weeks before their operation. But what does the clinic achieve, and how? Here,
Michael Lundberg Consultant Anaesthetist, Michelle Thompson, Preassessment Sister and
Donna Carrier, Anaesthetic Administrator explain all. They recently made the semi-finals in an
Eastern region Health Care Innovation Contest, and wanted to share what we told them with
Making Waves readers.
Left: The Preassessment Clinic team: left to right: Michael
Lundberg, Consultant Anaesthetist; Debbie Norton, Staff
Nurse; Sharon O’Connor, Sister; Irene Spencer, Admissions
Coordinator and Michelle Thompson, Senior Sister.
So what does Preassessment Do?
The prospect of having even minor surgery can stir up
considerable anxiety in a patient. A good psychological
preparation is essential and has been shown to speed up
recovery. Thus a lot of information is given to clarify what lies
ahead, and ample time is allowed for questions. Many patients
also need bloods taken, X-rays or ECGs done and medications
stopped or modified. The Kardex and other paperwork are
initiated to facilitate the admission process and pre-clerking (ie
examination by a junior doctor) is frequently done at this point.
One of our most important tasks is to identify the patients
at risk of developing complications during or after the
operation. Due to other illnesses patients may lack the
functional reserves to meet the stress imposed by major surgery
which has been compared to running half a marathon. Function
of key organs can be so compromised that anaesthesia is
hazardous. It is essential that these patients are thoroughly
investigated before the operation so that specific risks can be
identified and precautions taken. Such a patient may need
specially tailored anaesthetic technique, monitoring and organ
function support both during and after the operation. They will
also benefit from close monitoring in the high dependency unit
(HDU) for a time after the operation. Studies have shown a clear
decrease in complications if patient risk factors are properly
managed. Fewer complications translate directly into shorter
length of stay and a higher patient turnover.
High-risk patients are traditionally picked up by surgeons.
They communicate with their anaesthetist who then initiate an
investigation of the patient. Some patients slip through the net,
however. When the patient is seen at preassessment one to two
weeks before admission it’s often too late to address serious
health problems and the operation has to be deferred.
Occasionally, these patients are only picked up after admission
and promptly cancelled by the anaesthetist. The patient is
distressed, the surgeon occasionally upset, bed and theatre list
management poor, and the result is sub-optimal use of hospital
resources.
4 October 2007 Making Waves
All about the Well Being Questionnaire (WBQ)
In 2004 Dr Frayssinet (then a JPUH Consultant Anaesthetist)
developed a system to address these short term cancellations.
On decision to operate the patient is asked to fill out a health
questionnaire (WBQ) designed to flag up health problems and
given a slot on the waiting list. A preassessment nurse uses
information from the WBQ to risk grade the patient. BMI (body
mass index), general health score, exercise tolerance and type of
surgery (minor/ intermediate/major) make up a risk index.
Patients who are fit or have well controlled systemic disease
have telephone preassessment or an appointment with a
preassessment nurse. Patients with a high risk score have their
notes reviewed by a consultant anaesthetist, who decides if they
need a clinic appointment or further investigations and plans
the level of postoperative care. No patient has their waiting list
number activated unless they have been “green-lighted” by
dedicated preassessment staff or an anaesthetist.
The gains of the system are that resources are focused on the
high risk patients, who need them most. Waiting time is used to
identify and if possible optimise treatment of co-existing illness
that might affect surgical outcome. Unless exceptional measures
are necessary (such as coronary interventions) no patient loses
their original place on the waiting list.
The WBQ system was launched as a pilot covering general
surgical and urological patients in January 2005. It quickly
proved its worth, as showed by an audit of the first six months
running: short term cancellations for major medical problems
had ceased to be a problem. Gynaecology joined the system
from April 2007.
Part of the
Anaesthetic
administrative
team:
Donna Carrier,
Anaesthetic
Administrator
and Sharon
Peek,
Anaesthetic
WBQ
secretary.
www.jpaget.nhs.uk