PRE-OPERATIVE ASSESSMENT FOR ADULTS POLICY Version 6 Name of responsible (ratifying) committee Joint CHAT CSC Governance Group Date ratified 10 January 2017 Document Manager (job title) Consultant Anaesthetist Date issued 13 February 2017 Review date 12 February 2019 Electronic location Clinical Policies Related Procedural Documents POA WEB PAGE, Policies and guidelines web page (INTRANET) Key Words (to aid with searching) Competencies Version Tracking Version Date Ratified Brief Summary of Changes Author 6 10/01/2017 Updated clinic flow charts S Lobo E Wood Pre-operative Assessment Policy Version: 6 Issue Date: 13 February 2017 Review date: 12 February 2019 (unless requirements change) Page 1 of 25
Transcript
PRE-OPERATIVE ASSESSMENT FOR ADULTS POLICY
Version 6
Name of responsible (ratifying) committee Joint CHAT CSC Governance Group
4. DEFINITIONS.................................................................................................................................65. DUTIES AND RESPONSIBILITIES................................................................................................6
6. PROCESS......................................................................................................................................97. TRAINING REQUIREMENTS.......................................................................................................10
8. REFERENCES AND ASSOCIATED DOCUMENTATION...........................................................119. EQUALITY IMPACT STATEMENT...............................................................................................13
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS.....................................14Equality Impact Screening Tool...........................................................................................................15
Pre-operative Assessment Policy Version: 6Issue Date: 13 February 2017Review date: 12 February 2019 (unless requirements change) Page 2 of 18
QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural documents.For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.
Patients deemed fit for surgery, admitted as planned on surgery date.
Patients seen either in pre op assessment or highlighted by the surgeon as a high risk for surgery due to complex medical issues.
Once patient has been deemed fit for surgery, patient awaits admission date.
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Waiting List Office arrange pre-op
appointments
Face to Face assesment
Telephone assessment
Anaesthetic review
requested
Patients deemed unfit
at pre-op
Unfit for surgery
Fit for surgery
Patient has admission
date/or awaits one
Patient deemed fit via pre-op
Notes/Pre-op packs sent to ward/ returned
to Medical Records
Patient seen in AA clinic deemed fit
Patients who are unfit for surgery.
Following further investigations via Anaesthetic Assessment clinic.
OR
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Seen in AA Clinic:
deemed unfit for
anaesthetic
Surgeon/GP/Waiting list informed
Await outcome of investigations
Futher investigaions
required
Further investigations
requested by AA
Inform Waiting List office
Fit for surgery admit
Further investigations
Inform Waiting List Office, Surgeon, Patient and GP
Unfit for anaesthetic
1. INTRODUCTIONThe purpose of this policy is to provide a framework for safe and effective practice for all staff working within the Pre-Operative Assessment (POA) service within Portsmouth Hospitals Trust NHS Trust (PHT). It will define the processes, pathways and responsibilities of all concerned, to ensure efficient and effective use of the POA resources
2. PURPOSEFrom 1 April 2010 the NHS Constitution gave patients new legal rights to access services within maximum waiting times, the aim is to ensure that patients waiting for an outpatient appointment, diagnostics, elective or planned admission are managed in line with national waiting list guidance and patient choice. This will ensure patients are treated in a timely and effective manner; supporting the delivery of referral to treatment (RTT) targets and the patient’s rights to access health services under the NHS constitution. The General Practitioner will make referrals to the appropriate specialty via the selected referral system. The purpose of Pre-Operative assessment is to determine patients’ fitness for an Anaesthetic and surgery and to optimize patients prior to elective surgery. Where relevant, this provides a platform for risk assessment of patients with physical and psychological needs in preparation for there surgery. POA will be delivered in designated facilities with standardized procedures, timelines and processes as relevant to individual specialties.
This will ensure that all elective patients are optimized for surgery, thereby reducing cancellations on the day.
3. SCOPE
This document applies to and affects all staff working within POA and those staff whose roles interface with and the users of the POA service and includes the following which is not exhaustive:
POA trained clinical staff POA healthcare assistantsPOA trained operational department practitionersPOA clerical and booking staffJunior doctors involved in POA Consultant Anaesthetist Consultant Surgeons Secretaries and bookers Waiting list management staff Service leads Divisional managers Senior matrons and matrons Outpatient staff General practitioners Referral vetting staff Clinical staff of admitting areasTheatre staff. Infection Control Team
In the event of a major incident, the Trust recognizes that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their managers and all possible action must be taken to maintain ongoing patient and staff safety.
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‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognizes that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’
4. DEFINITIONSTerms stated in full in document.
The Trust, as an employer, will assume ownership of the trust-wide policy with vicarious liability for the actions of non-medical practitioners authorised to work in the pre-assessment clinics providing that they:
* They are deemed competent to undertake the role, by their line manager* The standard practice for pre-assessment is to be followed as set out in this document..
5. DUTIES AND RESPONSIBILITIESA named Consultant Anaesthetist will have overall responsibility for the patients’ Anaesthetic fitness, ensuring the following are in place:
REFERRAL FOR ANAESTHETIC CLINICS:
Referrals are currently being made by clinicians, NPs and anaesthetists using an anaesthetic referral form to anaesthetic secretaries
BOOKING:
Booked onto Plexus.
Anaesthetic secretaries book patients onto clinic –OPD PAS.
Responsible persons for clinic prep- POA admin team
Please use Plexus (Quenda Medic) to call patients in clinic.
CLINICS For Anaesthetics:
Anaesthetic clinics are currently being held 4 mornings and 1 afternoon a week.
5 patients are booked into each clinic (you may be asked to see a sixth in special
circumstances)
Patients should be checked in by a health care assistant and weighed, measured and
obs done. Usually a dedicated HCSW assigned to a clinic.
Patients requiring an ECG may need to have it done in the Consultants room
You may be asked to support POAC nurses with Clinical decision making (murmurs,
ECGs, opinions etc)
You will be expected to review notes, results and the action log and say whether
patients can be put forward for surgery. Please date and initial your comments on the
‘tracker form.’
You will be asked to write prescriptions for those requiring ‘Clexane as bridging therapy’.
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EPRO:
Direct your dictation to Central Medical Transcription on the pull down menu on Winscribe
Highlight the letter as ‘high priority’
Please test your microphone skills by playing back the recording occasionally to ensure it is clear enough for the transcriber to hear.
DOCUMENTATION:
All patients seen by the consultant should ideally have a Pre-assessment record filed in patient’s notes.
A letter should be generated for each patient on EPRO. The letter will be printed off by the POAC team and put in the patient’s notes with the printed EPOA document.
Please endeavour to document latest blood results (Graphnet), ECG results, Echo reports as relevant in your letter.
Emails with cc to relevant personnel for urgent action.
Cc to WL managers for SHCU, HDU, ITU beds
The Surgical Consultant responsible for the patients’ care is ultimately responsible for patient selection for a procedure, and for supporting all health care professionals involved with POA.
REFERRAL For PRE OPERATIVE ASSESSMENT:
Referrals are currently being made by the clinician, when the patient is seen and booked for surgery.
BOOKING:
Booked onto PAS/Plexus.
Appointment sent to patient for pre op assessment
CLINICS For Pre-Operative Assessment:
Pre Operative assessment clinics are currently being held all day starting at 0800hrs finishing at 17.30hrs Mondays to Fridays on Saturdays we have clinics starting at 0800hrs finishing at 1500hrs.
The number of clinics can be 9 to11 clinics most days depending on room availability
Patients are checked in by a health care assistant weighed, height , observations and if required ECGs are recorded.
An electronic proforma is completed by the trained clinical staff.
Pre-Operative Assessment Responsibilities:
5.1 POA Administrative Assistant /Waiting List Office / Medical Records Staff Advise the patient by phone or letter of any cancellations or changes to the POA appointment
made by the department. Request patient medical notes in a timely manner to be available at the time of assessment.
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Ensure a sufficient amount of patient labels are printed and present in the medical notes. Place tracking form in each set of medical notes. Work in conjunction with other POA staff to prepare documentation. Store prepared notes according to clinic date and time of assessment. Receive patients into department on their arrival, complete appropriate entry on PAS/Plexus
patient self check in. Track and forward medical notes and packs to relevant departments on completion of POA
process. Recalling notes that have been required for other patient appointments, to enable completion
of the POA process.
5.2 Registered Practitioners POA staff are responsible for providing patients with procedure specific patient information
leaflets and instruction sheets. liaising with specialties via the link roles to keep the information given current and reliavent.
Trained Pre-Operative assessors are responsible for working within guidelines and competencies agreed locally by anesthetists and surgeons.
Complete the electronic preoperative assessment record and the tracker form (in the event of computer failure-paper version available)
Provide patients with Trust generic and individualized written and verbal information/instruction. http://pht/Departments/preop-assessment/default.aspx
Identify/perform/order investigations/referrals relevant to the POA process. Exceptions to this would be investigations required on admission that cannot be completed within the POA process or are not required by the POA process.
Store medical notes in appropriate areas to await further action. Access/interpret/action and document investigation results. http://pht/Departments/preop-
assessment/default.aspx Refer/liaise to other clinicians/agencies as appropriate/required. Determine suitability and site for surgery (in conjunction with Consultant Anaesthetist if
necessary). Communicate POA outcomes as soon as available with relevant persons. Endeavour to release the medical case notes in a timely manner for those patients who have
a TCI date. Direct patients to specialist practitioners for specific pre and post-operative advice/treatment. Liaise with the patient’s general practitioner/surgery/primary care/patient on issues relating to
the patients admission. Update e.POA with results and action patient’s outcome within 5 working days.
5.3 Healthcare Workers Perform investigations as requested by Registered Nursing Staff, these investigations are
documented by the trained nurse in the Epoa. Liaise with trained staff. Facilitate effective patient flow through the Department/Hospital. Assist Administrative Assistant(s) with medical note preparation as required. Support Registered Nurses in accessing investigation results. Support Registered Nurses in delivery of patient information. Perform tasks that support day to day operation of the Department as instructed by
Departmental Manager/Nurse in Charge. MRSA swabs.
5.4 Volunteers Support the POA Unit as directed by POA staff to include: meeting and greeting of patients, assisting with administrative tasks, assisting patients and relatives/careers. Liaise with other departments and personnel to facilitate patient flow through the department.
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POA staff will endeavor to ensure that all investigations/results ordered by the POA team are documented on the e.POA and tracker form, assessed and plan actioned prior to admission; however there will be circumstances when this is not possible, usually when the time frame between POA and TCI does not conform to these standard operating procedures. If this occurs, POA staff will attempt to identify this clearly in the e.POA documentation. Documentation completed at POA will be enclosed in a clear folder secured in the first inner spine of the patient case notes and will consist of the following core documentation:
Tracker form/ if clinical instructions recorded on this document , this original document needs too be included in the patients notes.
Patient Labels ECG ( according to POA guidelines)/ all ecgs to be scanned onto the pre op g drive Printed abnormal results (Results within normal range should be transcribed into the
appropriate section of the Pre-Operative Assessment Document). E mails (full final print out) Risk assessment ( if identified risk at POA and completed at POA) Additional specialty specific documentation/information
Every effort will be made by POA to ensure the case notes are available to the admitting area prior to admission. If notes are requested for a patient admission prior to the completion of the e.POA process it will be the responsibility of the admitting team to ensure that all investigations/results are Checked / available prior to the patient going to surgery.
6. PROCESS6.1 The Pre-Operative Assessment Appointment
As soon as the patient is added to the waiting list a POA appointment will be made within the following time frames:
Pre-Operative Assessment will be performed ideally between 4-12 weeks prior to anticipated surgical date.
All Patients booked <72 hours before surgery need to be deferred, if the nurse is unsure she will discuss with the duty Anaesthetist
Exceptions: Cancer pathway patients who require an appointment at short notice will be booked into slots, or by direct negotiation with waiting list manager and POA. (See Appendix A)
6.2 Type of Pre-Operative Assessment
Pre-Operative assessments will be performed by either: Telephone assessments – e.POA Face to face – e.POA
6.2.1 Local Anaesthetics questionnaires- triaged using the POA criteria booking guide (See Appendix B)
Clinician Identified on TCI card and PAS as Local Anesthetic - telephone assessed. 6.2.2 Telephone interviews are allocated to day-case/in patients following fixed criteria:
Patients will be assessed by relevant staff. Assessment staff will default patients to face to face assessment if significant issues are
highlighted.
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6.2.3 Face to Face interviews are allocated to in-patients and day case patients following POA booking criteria in line with the NICE guidelines: https://www.nice.org.uk/guidance/ng45/chapter/recommendations pre op guide lines crib cards\ nice guidelines 2016.pdf
Patients will be assessed by trained nursing staff. Assessment staff will default patients to anesthetic note review and/or face to face
anesthetic assessment if needed.
6.2.4 Consultant Anaesthetist referral/note review/face to face interview will be made by: assessment nurse Triaging Anaesthetist
6.3 POA Appointment Booking
Primary booking of POA appointment is to be undertaken whilst the patient is present in outpatients department.
This appointment date is to be confirmed by the patient by telephone or in person. On receipt of the TCI card, Admin Lead for each specialty will include additions to the
waiting list. This will be done on a time scale specific to individual specialty. The waiting list / access team will allocate appointments for patients whose appointment
was not booked in outpatients, selecting the appropriate clinic code. Patients do not need to have a TCI allocated to be offered a POA appointment. Patients wishing to change their appointment should contact the Pre-Operative assessment
unit, these contact details are sent out in appointment letter. Patients wishing to decline their planned surgery should contact the waiting list
manager/respective team who remove the patient from the waiting list.
6.3.1 Patients who do not attend appointments - DNA POA admin team will attempt to contact any patient who DNAs using the contact telephone
number held in the patient records. To respect patient confidentiality messages will not be left on answer phones or with anyone other than the patient.
Daily DNA report generated for the waiting list teams to access- Pre-Operative assessment administrative staff to outcome all clinics on PAS
It is the responsibility of the waiting list team to arrange another appointment in line with local access policy.
As per the local Policy only 1 appointment can be DNA’d. Following this the patient will be referred back to the waiting list team to investigate and gain clinician input regarding the removal of the patient from the waiting list.
6.3.2 Changes to appointments It is the responsibility of the waiting list team to advise the patient by telephone of any
cancellations or changes to the appointment made by the POA clinic; this could be because of staff sickness, adverse weather conditions, accommodating short notice requests for appointments. In adverse weather, the POA team may alter the appointment i.e. face to face to telephones.
7. TRAINING REQUIREMENTSHealth care professionals, who undertake POA, will be able to demonstrate competencies for POA.
Course in physical assessment and history taking. http://pht/Departments/LearningDevelopment/infection/comp_intra_only/reg%202013/HT_physicalexamination_608 032 97942012.pdf
Level one is used as competency. In-house physical assessment and history taking course M&K 5 day course. Competencies in ECG/phlebotomy/INR/BM/Cardiovascular observations
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Annual appraisal during the course of employment will ensure the appropriate levels of competencies are maintained. Employees who fail to meet the required standard of performance due to lack of knowledge, experience, skill, aptitude, ill health or some other reason should be offered support to help them improve to required level within a given time scale. Where an employee has been unable to improve to the required standard, despite training and support their manager should instigate the Capability procedure at the appropriate level.
http://pht/Departments/HR/default.aspx
8. REFERENCES AND ASSOCIATED DOCUMENTATIONAAGBI SAFETY GUIDELINE – Pre-Operative Assessment
NCCAC. Preoperative Tests, the Use of Routine Preoperative Tests for Elective Surgery - Evidence, Methods and Guidance. London: NICE, 2003
Carlisle J, Langham J, Thoms G. Guidelines for routine preoperative testing. Editorial, British Journal of Anesthesia 2004; 93: 495-97.
Munro J, Booth A, Nicholl J. Routine preoperative testing: a systematic review of the evidence. Health Technology Assessment 1997; 11: number 12.
Garcia-Miguel F J, Serrano-Aguilar P G, Lopez-Bastida J, Preoperative Assessment. The Lancet 2003; 362: 1749-57.
American Society of Anesthesiologists Task force on Pre anaesthetic Evaluation. Practice advisory for preanaesthesia evaluation: a report by the American Society of Anaesthesiologists Task Force on Preanaesthesia Evaluation. Anaesthesiology 2002; 96: 485-96.
Pre-operative Assessment – the role of the anaesthetist. AAGBI,London 2001
23 Seeking Patients’ Consent: the Ethical Considerations. GMC, London 1999 www.gmc-
uk.org. Re: C (Refusal of Medical Treatment) [1994] 1 FLR 31.
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:
Respect and dignityQuality of careWorking togetherEfficiency
This policy should be read and implemented with the Trust Values in mind at all times.
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Mitigating Actions(what needs to be done to minimise /
remove the impact)
Responsible Officer
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document: Specialty Governance CommitteeClinical Service Centre Procedural Document: Clinical Service Centre Governance CommitteeCorporate Procedural Document: Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee
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Appendix A
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