Asking patients to answer a unique set of questions about themselves helps assign them to the right beds from the beginning. Heather Waterman and Cherry Mason detail how a new allocation system has been working
Imagine the disappointment and anger of patients who find their surgery postponed at the last minute because it has been discovered they need additional treatment first.
Imagine also the scene in hospitals across the country - patients with similar histories being admitted for the same surgery but staying for remarkably different lengths of times, each facing different financial and social costs as a consequence. These problems are the result of inefficient and poorly planned surgical management systems.
Stockport and university project
Issues like this were highlighted for Stockport Foundation Trust when it started working on a project with the University of Manchester. It found that 17% of 599 elective surgical patients did not stay for their predicted length of time.
An easy-to-use tool was required so that effective bed use for elective surgical patients could be planned at the first point of contact - on listing. Such a tool could help identify patients who require extra medical input or senior anaesthetic review as early as possible. In order to minimise demands on staff and to encourage patient involvement, the tool was designed to be completed by patients themselves, except for blood pressure and body mass index.
The idea was to produce a tool which would be developed and tested in the hospital but could eventually be used in community settings too, perhaps by primary care teams. This would provide even more support for forward planning around elective surgery.
Results from a survey carried out by the trust, which showed discrepancies between predicted and actual length of stay of elective surgical patients, steered the design. A group consisting of doctors, anaesthetists, nurses, bed managers, out-patients managers and researchers, oversaw the project. The 'mini health screen' (MHS), as it became known, was the brainchild of two members of this group.
After testing the prototype tool on a small group of surgical patients, it was amended and deemed ready for general implementation across four surgical specialities - general surgical, urological, gynaecological, and orthopaedic - to expand the areas to which it could be applied.
Once it was granted.permission from the surgical, anaesthetic and out-patient managers, the MHS was implemented alongside the usual assessment. The researchers set up several training sessions on the MHS with nurses who would be implementing it in the respective out-patient clinics. At this training, it was discussed how they would manage the distribution, completion and collection of the screen.
The mini health screen consists of questions on key medical symptoms, social factors and accepted criteria for day case surgery. Depending on the responses, patients are graded into four bands - A for day case, B for short stay, C for in-patients and D, referral for treatment or investigation prior to listing.
For example, a patient reporting a deep vein thrombosis within the past 12 months would be categorised as Band C - an in-patient. A patient aged 71 but otherwise healthy would be graded as Band B - suitable for short stay.
The MHS that is in use now has no age restriction, so there is no upper age limit for day case admission. The tool is completed by patients or carers, except for body mass index and blood pressure, which are completed by the clinic nurse.
Results and feedback
In patient feedback, many positive comments were made. Reactions included 'very helpful' and 'good idea'. Other observations were about the opportunity provided to ask more questions. For example, one patient said it was 'very useful to have the chance to express any concerns'. However, not all the remarks were positive. One patient stated: 'I would have thought the doctors know best. I cannot understand why you are creating more paperwork.'
A survey of nurses confirmed that as long as that the clinic was not too busy, the MHS could be easily incorporated into the daily routine. In very busy clinics, additional nursing help was required. Nurses also commented that the instructions for the MHS were easy to follow and that the vast majority of patients did not need assistance. Those that did had usually either forgotten to bring glasses or were unable to speak English.
Confidentiality was an issue for a few patients who needed assistance because of the lack of private consulting rooms. There were no disagreements between staff and patient about the type of ward allocated. If there had been, the usual procedure for complaints would have followed.
Following implementation of the screen, it was.found that only 12% of patients varied from the expected admission period. There were some factors lengthening patients' stay which could have been identified before surgery. For example, one patient had a previous stroke and another patient lived alone. Of the 398 patients who completed the MHS, only 2% needed medical attention before surgery.
While the MHS appeared to offer a framework for consistent screening and allocation of type of ward at the time of listing, it drew attention to some intractable problems in the system which needed addressing in the future. The main one was that although some patients were allocated to day case surgery there were too few day case beds, so they were admitted to short stay or in-patient wards inappropriately. Once admitted to a ward, patients were treated and discharged like any other short stay or in-patient.
The project finished in 2005 and the MHS is now in the process of being rolled out across the trust. It has become an essential component of a new initiative called 'clockwork theatre' that aims to increase theatre use, improve the patient experience and maximise income.
Furthermore, the screen has been incorporated into Stockport's local integrated clinical assessment and treatment services scheme, ahead of the introduction of the national scheme for ICATs next year. Patients who are referred from GPs to ICATs will be assessed using the MHS. A tool that has potential for use in the primary care setting and that combines screening of surgical patients with allocation to type of ward has therefore proved to be very useful.
Heather Waterman is professor of.nursing and ophthalmology, University of Manchester, and Cherry Mason, is consultant anaesthetist at Stockport Foundation Trust