Current perioperative care processes at Royal North Shore Hospital (RNSH) present significant challenges, including long wait times, inefficient resource allocation and limited visibility of patient progress prior to surgery. RNSH found that Category 3 surgical patients wait on average 124 days before they are assessed for surgery at preadmission clinic (PAC), leaving on average ten days to implement health optimisation recommendations prior to surgery.
This limited time for optimisation has resulted in clinician’s delivering care that prioritises avoiding surgery cancellations over optimising patient readiness for surgery. 90% of PAC and perioperative staff (nurses, anaesthetists, perceive current PAC processes as inefficient, 50% of the Patient Health Questionnaires (PHQs) submitted are incomplete and 29% of patients seen in PAC did not meet clinical criteria for a PAC appointment. Patients considered medically unfit for surgery spend an average of 90 days awaiting reassessment and follow up to be placed back on surgical waitlist. A time in motion study revealed excessive wait times during PAC appointments with clinicians spending a disproportionate amount of time on administrative tasks rather than patient interaction. RNSH has some of the highest rates of hospital acquired complications among their surgical patient cohort when compared with peers in Health Roundtable data from 2021-2022 and 2022-2023.
Streamlined care for patients on their pre-operative journey
The imPACt project aims to achieve integrated and streamlined care for patients on their pre-operative journey, so that every patient is appropriately assessed and prepared for surgery, receiving quality preoperative care to achieve the best surgical and health outcomes. The project team will achieve this through:
- the digitisation of the perioperative screening process and introduction of tailored optimisation pathway including multiple touch points along the perioperative pathway
- relocation of the preadmission clinic (PAC) from outpatients to surgical short stay unit (SSSU) and surgical admissions area
- changes in the not ready for care (NFRC) process and patient education to reduce the time patients spend on the NRFC wait list
- the re- introduction of a surgical PAC pharmacist and ensuring the accurate capture of activity-based funding and the introduction of continuous PAC performance reporting and review.
NRFC waitlist reduced to 25 days
In September 2023, the imPACt project team introduced a streamlined process to manage NRFC patients using the Perioperative Anaesthetic Registrar (PAR), reducing paperwork, improving patient and staff experience and enhancing efficiency. The PAR oversees this process, ensuring necessary investigations and actions are taken, with clear plans developed in collaboration with patients and their family, GPs and the clinical care teams. Benefits include clinical consistency, efficient resource utilisation, enhanced education for anaesthetic registrars and improved patient understanding through co-designed communication materials. Since the implementation of the changes to the NRFC process, the median number of days patients spend on the NRFC waitlist has reduced from 90 days to 25 days.
The imPACt project team will pilot a digital pre-operative pathway for category 2 & 3 surgical patients on the elective surgery waitlist using Personify Care. A bespoke digital pathway with RNSH anaesthetics and Personify Care will allow both anaesthetic and surgical risk screening (high, medium and low risk) and allow clinicians to automate tailored health optimisation resources that they send to patients (e.g. strength training information sent to all orthopaedic surgery patients). The project team will implement the pilot over an 18-month period at RNSH commencing May 2024.
As the RNSH Perioperative Medicine Service is established, there is an opportunity to strengthen the perioperative approach at RNSH by co-locating the PAC within surgical services on level 4 of the acute services building, and realigning nursing management to the surgical short stay unit.
View this project's poster from the Centre for Healthcare Redesign graduation December 2023.
