How one provider is leading the way in pre-operative assessment to both boost the chances of successful surgery and enhance recovery. By HSJ, in association with BMI Healthcare

Ensuring that patients are able to undergo surgery and to return home safely is not only good for them but helps avoid unnecessary costs for healthcare systems - and is therefore important for commissioners.

It can make it less likely that surgery will be cancelled at the last moment as the patient is unfit to go ahead; it can aid admission on the day of the procedure and reduce length of stay; and good, supported, discharge which takes account of the patient’s personal circumstances can make it less likely they are readmitted or end up in A&E.

And from a patient perspective it can make certain that they have given informed consent to the procedure, with the opportunity to address any concerns, and that they know what to expect after the operation.

‘Initial referral letters are all scanned within 24 hours to spot any obvious issues such as high blood pressure’

A good pre-operative assessment process is as important for independent healthcare providers as it is for NHS organisations, including commissioners. BMI Healthcare has been working to improve pre-operative assessment over the last year and ensure that it is done to a consistently high standard in all the group’s hospitals. National physiotherapy lead Sarah Tribe says the aim is to ensure that pre-operative assessment is done to best practice standards, similar to those in the NHS.

Pre-operative assessment is also a vital part of the enhanced recovery programme (ERP) which offers a shorter stay and focused rehabilitation to suitable patients.

Adapting NHS processes

Director of clinical services Bethany Bishop, from the BMI Winterbourne Hospital in Dorset, has chaired a group-wide steering group on pre-operative assessment which is bringing some of the robust processes from the NHS and adapting them to the slightly different environment.

At her hospital, most NHS-funded elective patients will be treated within 11 weeks. “The biggest issue for us is that we don’t want patients breaching,” she says. “We want to ensure our patients are safe to come here and to have surgery and anaesthetic.”

If they are not suitable for treatment - for example, if they have comorbidities which make them high risk - it is important they find that out as soon as possible. This allows either treatment for the underlying problem, allowing them still to have the procedure within a reasonable time, or for them to have the operation in a different hospital with, for example, intensive care facilities.

‘If a patient comes in on the ERP we don’t expect them to stay more than three days if there are no unexpected problems, although of course they won’t be discharged until it is safe for them’

Initial referral letters are all scanned by Ms Bishop and her team within 24 hours to spot any obvious issues such as high blood pressure or cardiac problems. These patients may then be offered an early appointment to establish whether or not they can be safely operated on in the hospital.

When patients have a first appointment with their surgeon and are listed for surgery, they will also have blood checks, an ECG and height and weight checks, as well as undergoing MRSA screening. They will also be given a medical questionnaire to fill in.

Educating the patient

Before they come in for the procedure they will be offered a pre-operative assessment appointment where the patient will be talked through what will happen. This offers an opportunity to educate the patient about the aftermath of their operation and for them to ask any questions.

“If a patient comes in on the ERP we don’t expect them to stay more than three days if there are no unexpected problems, although of course they won’t be discharged until it is safe for them,” says Ms Bishop. Patients and their families need to understand what the ERP will entail - including a physiotherapist expecting them to get out of bed within a few hours of their operation, and sometimes even starting exercises in the recovery room as soon as they come round, and then twice daily physiotherapy support until they are discharged.

Ms Tribe says early discharge has been shown to cut the risk of complications such as deep vein thrombosis, infections and respiratory problems. But the speed with which they are mobilised can still come as a shock to patients - who are told to bring in their own clothes so they can get dressed and that they can only be in bed to rest.

And what happens after discharge is also covered - for example, whether the patient will have someone at home with them, the level of mobility they can expect, and any complications and side effects.

‘We can get more patients through the door but ERP is not about finances,” says Ms Tribe. “It is about what is clinically best for the patient’

Talking to the patient during pre-operative assessment appointments about their home circumstances enables staff to offer tailored advice and also sort out potential problems: checking whether patients will be able to use a toilet and bathroom downstairs, if they are going to struggle to use the stairs, and suggesting they should stock up the freezer if they don’t have someone who can go shopping for them, for example. With some patients social services may need to be involved to sort out simple equipment for the home or a package of support for the first few weeks.

Once discharged, patients get a check call from the hospital but longer term Ms Bishop would like to see patients visited by a discharge team - something which she thinks works well in some NHS hospitals and could reduce post-operative A&E attendances and unnecessary readmissions, which can cost commissioners more. Ms Tribe says patients are also offered group physiotherapy sessions after they are discharged, which are often very popular.

Good pre-operative assessment won’t spot every problem - there will always be the odd patient who is discovered to have a new condition which makes them unsuitable for surgery. But Ms Bishop suggests it can spot the vast majority of issues in advance, allow hospitals to plan better, and help the flow of patients through the system.

Changing the habits of a 66-hospital group is not an easy task, Ms Tribe says. The steering group has been carrying out audits of ERP and pre-operative assessment and working to get staff across the multi-disciplinary teams engaged with pre-operative assessment. Ms Tribe says that historically physiotherapists have been very supportive and aware of the benefits, but some other healthcare professionals have not - so it is important to explain the benefits and get their buy-in.

ERP has, of course, meant shorter stays throughout the group’s hospitals.

“We can get more patients through the door but ERP is not about finances,” says Ms Tribe. “It is about what is clinically best for the patient.”

Mark Ferreira: On pre-operative assessment

In the past, the main function of pre-operative assessments was to ensure the patient was fit for anaesthesia. This process is evolving, and such assessments now play a vital role in a patient’s entire hospital pathway.

The changes in perioperative care which include epidural or regional anaesthesia, minimally invasive techniques, optimal pain control and aggressive postoperative rehabilitation, now extends to the pre-operative management of the surgical patient.

At BMI Healthcare we believe that enhanced pre-operative assessment will be viewed by clinical commissioning groups as increasingly important, mainly due to the impact on patient outcomes.

‘Pre-op assessment will be viewed by CCGs as increasingly important’ to CCGs’

For example, we now know that previously undiagnosed anaemia is common in elective surgical patients. Evidence shows treating even minor degrees of anaemia can reduce the need for blood transfusion, which in turn reduces morbidity, mortality and cost. It has also been shown that patients who are well nourished and hydrated are better able to cope with the peri- and post-operative catabolic state triggered by surgery, and that active nutritional supplementation reduces post-surgical complications.

Our approach to pre-operative assessments prioritises patient education and time to ensure all the patient’s questions are answered and concerns addressed. We know that this improves the patient’s experience of hospital admission and empowers them to participate in their healthcare from the very beginning.

Pre-operative assessments also allow the hospital to be prepared, ensuring they have the right teams and equipment in the right place at the right time. A well prepared patient being received by a well prepared team decreases cancellations on the day of surgery, which are not only an inefficient use of resources but are disruptive for patients and their families.

BMI Healthcare’s pre-operative assessment project focuses on standardisation of evidence based practice across our 66 healthcare facilities, and ensures that everything we do is designed around the patient and their care.

Individualised preparation not only seeks to identify and manage medical conditions that may have a bearing on anaesthesia or surgery but also responds to patients’ needs and preferences.

They are encouraged to make choices in their care that best fit their circumstances, and become active participants in their own recovery, supporting our aims of fewer complications, shorter hospital stays and quicker return to everyday life.

Dr Mark Ferreira is group medical director at BMI Healthcare