For a recent HTN Now webinar on the topic of digital pre-op assessments, we were joined by panellists including Abi Burrows, pre-op, prehab & NCSEM matron, ambulatory care at Nottingham University Hospitals (NUH); Dr Katie Misselbrook, consultant paediatric anaesthetist at Alder Hey Children’s Hospital; and Dr Lara Mason, director of product at Isla Health.
The session focused on ways in which digital can support pre-op assessments, and how a digital first process supports waiting times in line with NHS elective recovery goals, and streamlines pre-operative triage across a patient caseload.
Kicking off the introductions, Abi shared a few details about her work as part of a team of centralised pre-operative assessment staff who are “continuing to work through those solutions to implement the NHSE Pre-Screening and Optimisation mandate”. Abi also told us how NUH has a centralised pre-operative assessment service which receives around 2,000 referrals per month, as well as an elective orthopaedic major joint replacement pre-op service, and “a few very small siloes of pre-op services across the hospital”.
Abi shared how they “have been working with Isla to create a patient-facing pre-screening arm of the current pre-op assessment,” she noted, “in order to help us work towards identifying the individual needs of patients”. That work has included the creation of “a bespoke pre-screening questionnaire and RAG rating criteria”, Abi continued, “which flags to the team patients who may require earlier investigations, which is important, because we wouldn’t previously have known anything about them”.
Katie also offered an introduction to her role at Alder Hey, in a paediatric service “which delivers general anaesthesia for approximately 20,000 children per year, across around 16 specialities”. The paediatric pre-op assessment “is about a decade behind what would have been adult pre-op assessment services”, she told us, “but since our service was established in 2017 we’ve rapidly progressed, with expansion to all specialties and a massive increase in volume of patients”.
The key thing with paediatrics is the early identification of “patients who might need input, investigations and additional support on the day”, according to Katie, “and given the complexity of the surgeries we do, we have a lot of sub-specialty pathways that we need to filter these children into”. Whilst initially the service was based on telephone triages, its expansion prompted the trust to consider moving to “a new digital-facing platform”, and the team have now designed a bespoke e-health questionnaire with Isla which allows the team to send a text message “the minute surgeons identify that a patient is going to have surgery”.
The questionnaire collects information from parents about a child’s medical history which allows them to be triaged effectively, and identifies any children or families requiring additional support. “It’s given us a much greater degree of visibility about patients sitting on our waiting list”, Katie said, “as well as helping us avoid cancellations, improve the quality of care and support we can offer, and identify any issues earlier. Because most of our surgeries are day cases, there are often higher rates of cancellation compared with adult services, like common coughs and colds that might cause surgeries to be cancelled, and we’ve got robust systems in place to manage short-notice cancellation, so it’s improving theatre utilisation on the shop floor.”
And we heard from Lara, who introduced herself and offered a brief background to her role with the product team at Isla, saying, “we’re responsible for what we build and how we build it, so we spend a lot of time speaking with users to understand pain points, pathways, and how we could be implementing Isla’s digital solution in digital practice”. Whilst Isla is “quite well embedded across perioperative pathways” for things like remote monitoring of patients following surgery, Lara shared how the team has recently been focused on how to bring those benefits to the pre-operative side of things, “because we saw an opportunity for a scalable and efficient digital pathway that can support clinical and operational teams, but also patients”.
The team at Isla has been particularly interested in the potential benefits of standardising the approach to pre-op care, Lara told us, “and having patients automatically contacted from the moment they’re on the waiting list, and then periodically to check in, satisfies that NHSE requirement for contacting patients regularly, doing that waiting list validation, and understanding which patients no longer require surgery.” From a patient’s perspective, she shared that the solution can facilitate engagement, ensuring patients are kept up to date, allowing the sharing of resources and guidance, and helping them to prepare for their surgery.
Identifying patients for pre-op optimisation and streamlining pathways at NUH
Sharing that the system has been running as a pilot at NUH since June, Abi talked us through the decision to implement for newly listed laparoscopic cholecystectomies, and to send questionnaires out to patients “listed day forward”, also doing a “look back” to feed patients into the system to include all patients on the pathway using a staggered approach. “The questionnaire initially asks whether patients still want the surgery,” she said, “and for patients who were listed a while ago, we did receive some responses saying it was no longer required, so it has helped us do a bit of a data cleanse”.
To date, 1,354 questionnaires have been sent out to 736 patients, including three- and six-month follow ups, with a response rate of 84.5 percent which Abi says the team have been “quite surprised about”. The service has also been rolled out to all newly listed gynaecology patients from the 24 July, and all HPB and endocrine patients “just this week”, she shared. One challenge has been around splitting patients between those having general anaesthetic and those having local anaesthetic, Abi went on, “and we’re continuing to work on that, so we’re not sending one group information which might not be relevant to them”.
Sharing a few other statistics on the impact of Isla to date, Abi told us how it has identified 21 patients no longer requiring surgery, with 38 patients referred for medical optimisation, 120 patients referred for lifestyle optimisation, and 10 “low risk fit” patients identified in the last two weeks. “Being able to send messages to and from patients has been really helpful,” she said, “because we can send them information by text message, so if they’re at work and can’t answer the phone, they still receive that”.
Digital pre-op in paediatrics at Alder Hey
Katie next took us through the use of digital pre-op with paediatric patients at Alder Hey, saying that when a child is booked for theatre they automatically get placed onto a pre-op work list, which the nurses work through to do things like telephone triage. Due to the number of patients, the team found that “about 20 percent of the time phone calls went unanswered, perhaps because parents are working, so we had another whole work list created of people we had to try and contact again the next day, which wasn’t a great use of nurse time.”
The use of the electronic questionnaire means it can be completed by parents in their own time to be reviewed by nursing staff, she told us, “after which patients might be deemed fit to proceed, which means no further intervention, and the form is automatically sent from our Isla online dashboard to our EPR, so on the day of the operation the anaesthetist can look at the PDF nursing summary we designed to go at the end of the report, and know it’s all been signed off, so there’s safety in place there.”
Although Alder Hey is set to go live with Isla across all services, it has been trialled in dental services, with the questionnaire being sent out to 261 patients when it was launched two months ago. “Out of those 261 patients,” Katie told us, “over 100 of those questionnaires were completed within three hours. The impact meant we were overwhelmed with the fact that it was genuinely working – parents found it very easy to complete, too.” 147 patients were identified as requiring a further telephone call, and only one child needed a face-to-face appointment. The effect of this, according to Katie, was that “suddenly, the dental service had this bank of patients who we have said are good to have surgery, 184 of whom also said they’d be happy to accept a short-notice date, so that’s a great efficiency improvement.”
In terms of managing short notice surgeries, Katie told us how once a patient has said that they’re happy to be contacted on short notice, their details will be available from the hospital’s dashboards, so dental nurses can pull up the list to bring patients in. “Hopefully those sorts of things will be able to be administrative-led, rather than clinician-led”, she added.
Having the questionnaire in place also helped identify patients with additional needs or parents requiring further support, Katie said, “and it means we’re able to have a two-way conversation with families before they’ve even got their date for surgery”. Even though this trial has been “very small”, Katie highlighted that her team has been “overwhelmed with the impact” it has had, “and nursing staff have found that even if they are having to have a telephone call with a patient, they’re doing it in a much more targeted way, rather than going through an entire load of questions on our current pre-op triage and having to document it all”. Once the solution goes live across all specialities, Katie also anticipates that “we’ll be able to triage our entire waiting list of patients within a few weeks”.
Triaging patients and caseloads with the Isla solution
The panel moved on to discuss Isla’s value in triaging patients and caseloads, as well as some of the customisation on offer for different specialties. “Streamlining is something we’re really focused on,” Lara said, “so that includes gathering information from patients whilst they’re still at home, reducing bottlenecks, reducing unnecessary appointments, and working in integrations.” Once patients are placed on a waiting list, they’re sent a text with a link to complete the questionnaire, which “doesn’t require them to log in or create an account”, she went on, “just to verify with their date of birth”.
The bespoke nature of the questionnaires means “they can be really configured to the pathway”, and the solution can triage based on the specialty or “even the procedure”, allowing tweaks to be made where there might be something specific to a pathway, Lara shared. “It’s all automated, so from that first text sent out with the questionnaire, to reminders if they haven’t completed it, there’s no manual need to contact patients, and there’s also visibility of those patients who haven’t submitted, and who might need a different approach.”
Once the questionnaire has been submitted, Isla also has automations which “pick out answers which might be relevant”, according to Lara, “so for example if they have diabetes, or if they smoke a certain number of cigarettes per day, we can build work lists based around those”. Having that dashboard with that visibility makes it easier for teams working through the list, she said, “so they can see that cohort view, rather than having to work through looking at individual patients”.
Looking at how the solution can work to reduce bottlenecks has also been important to the Isla team, Lara said. “It’s about identifying issues as early as possible, and one of the things we’ve been working on with NUH has been sending a message back into their systems when a patient might be the right fit for lifestyle optimisations, for example if a patient has consented to being referred for smoking cessation, that can be sent automatically.”
For RAG rating, Lara pointed to the way the solution works to identify patients who are eligible for a “reduced” appointment, or a telephone appointment, “and having this information and these clinically-led algorithms to identify that risk status can really help both teams and patients to prepare for their surgeries”.
Referring to the process around implementing the solution, Lara talked us through how Isla offers “bulk upload” functionality, “which allows us to go live straight away, without having to rely on a feed”. Instead of having to wait for integrations, patients can be uploaded into Isla and sent off onto their automatic pathway straight away”, she said.
“We’ve intentionally built the platform to be very configurable”, Lara told us, “and we’re very proud of that”. Ultimately, “it’s one core platform that can be used in a number of different ways”, she continued, “and we do that because there’s so much digital fragmentation in healthcare and we want to reduce that as much as possible”. On working with NUH and Alder Hey, she said, “both sites are similar but quite specific, so the fact our questionnaires can be completely customised means they can be tweaked depending on the pathway to fit the need”.
Our panellists next moved on to take questions from our live webinar audience. We’d like to thank all of our panellists for their time in sharing these insights with us.
