Enhancing the utility of virtual surgical pre-assessment

The main purpose of surgical pre-assessment is the risk/benefit evaluation and patient optimisation to minimise surgical and anaesthesia risks, to reduce the length of hospital stay and to enhance patient recovery (Khuri et al, 1995) on a platform of shared decision making (Stiggelbout et al, 2012). This is a major component of perioperative medicine dedicated to enhance surgical outcomes (Grocott and Pearse, 2012).

Traditionally, surgical pre-assessment has involved a focused history and a clinical assessment pertinent to the surgical specialty at a face-to-face meeting. It included a careful evaluation to identify those patients at high risk of complications. Additional investigations were organised when required, specialist opinions were requested in complex situations and the patient's condition optimised within the available timeframe, especially if the surgery was urgent.

Amid the increasing demand for operations and other invasive procedures, organising pre-assessment clinic appointments has become a strenuous burden due to limited hospital resources (Abbott et al, 2017). Therefore, telephone pre-assessment was developed as a tool that could reduce costs while improving patient experience and attendance and relieving overcrowding and patient anxiety at pre-assessment clinics (Lozada et al, 2016). However, little was known about its efficacy in achieving the goals of patient satisfaction (based on patient feedback) and surgical productivity (Yen et al, 2010).

Despite the above uncertainties, telephone pre-operative assessment was widely adopted to replace face-to-face assessment almost overnight during the first COVID-19 pandemic lockdown. This was the only option available to ensure health care could move forward amid the many pressures, restrictions and limitations of the pandemic, but it also presented opportunities for those working in health and social care (Gray and Sanders, 2020). Most anaesthetists and nurse practitioners made every effort to adopt this practice to the best of their ability.

This study was designed to collate the experiences of nurses and anaesthetists directly involved in this process in multiple specialties, including neurosurgery, hepato-biliary surgery, obstetrics, vascular surgery, paediatric surgery, urology, orthopaedics, general surgery, and day surgery in the authors' Trust. The purpose was to identify its limitations and risks and compose suggestions to improve and streamline the service.

Method

All consultant anaesthetists (n=6) and the sister-in-charge in the department (representing the views of the nurses) who were directly involved in telephone pre-assessment during the COVID-19 pandemic, were sent an email inviting them to describe their experiences on an open template. They were asked for their views in relation to the system's feasibility, reliability, weaknesses, patient satisfaction and any measures they adopted to overcome the difficulties required to achieve the best possible outcomes. They were also encouraged to submit criticisms, compliments and comments received from patients, carers and colleagues during their virtual pre-assessment sessions.

The study authors wanted to understand the difficulties they have faced in their telephone pre-assessments. Solutions and processes to resolve the issues they encountered were also sought, with the aim of ensuring patient satisfaction, completion of the process and optimisation of the patient for surgery. A draft document that collated all experiences was circulated among all informants for further clarification, correction or rearrangement. Further telephone conversations were held with informants where necessary to conceptualise the themes. This enabled the authors to construct a summary of the positive and negative aspects of telephone pre-assessment, its limitations and risks and suggestions for improvement through a qualitative contextual (identifying the form and nature of what exists) and diagnostic (examining the reasons for or causes of what exists) analysis of the content (Ritchie et al, 1994).

Findings

There was wide variation in the way pre-assessment was practised across the hospital Trust. It could be categorised into several formats: ‘nurse pre-assessment’, ‘telephone pre-assessment’, ‘notes review’, ‘investigations review’ or ‘none’. The referral pattern was formal and organised in some specialties, whereas in others it was based purely on a ‘private’ email request sent by an individual health professional and not necessarily copied into the patient's notes. Some patients were informed of the exact time and date of an appointment, whereas others were not given such exact information.

All respondents to the study reported that some patients were not able to engage in a valid telephone conversation. Some could not communicate because of their illness, some because they were deaf and using the telephone removed their ability to lip-read, and some had language barriers. Some patients refused to take part without giving a reason. Sometimes the communication was via a third party and this impinged upon the confidentiality and trustworthiness of the conversation. Since there were no other forms of clinical assessment available, for example, visual assessment of a disability by video, home records of blood pressure or blood sugar, records of nursing or home visits, there was no opportunity to pick up clinically covert risks such as untreated hypertension, diabetes, ischaemic heart disease, airway difficulties or obesity. Thus, there was a need to carry out additional tests such as lung function tests and echocardiograms. Blood tests were essential in doubtful cases. These tests were carried out at formal appointments conforming to COVID-19 restrictions, but appointment slots were rare and this added to delays. In effect, some key decisions usually guided by face-to-face interaction had to be based on other methods of evaluation such as additional investigations, or nurse-led clinical parameter recordings.

The sources of referral to telephone pre-assessment included some patients who were due for surgeries off-site owing to collaboration with private hospital surgical facilities for NHS work during the COVID-19 pandemic. This increased the workload for nursing staff, necessitating appropriate workplan adjustments and also, for neurological pre-assessment, for example, creation of additional telephone clinics.

Figure 1 shows the current neurological pre-assessment process. A summary of the contextual and diagnostic analyses and proposed solutions is presented in Table 1.

Figure 1. Current workload and referral pattern for neurological patient pre-assessments per week

Discussion

Telephone pre-assessment is not a new tool. A systematic review in 2012 concluded that it may be a viable option but, overall, evidence in terms of its effectiveness was low, and more rigorous studies were required to examine its outcomes and patient acceptance (Ireland and Kent, 2012). The present authors' study led to a similar conclusion and also outlines the remedies tried individually by consultants to improve the process during the pandemic when there were almost no alternatives. This individual experimentation has led the authors to understand how triage may help, as was also observed in primary care (Gray and Sanders, 2020). The authors' study is a reflection of the interprofessional discussions and collaborative practices that have evolved in a very short space of time to achieve the objectives of pre-operative assessment. The clinical teams had to upskill the use of new technology and ways of working, enabling accurate remote assessment and management of patient needs while also maintaining general data protection regulation (GDPR) requirements (European Parliament and Council of the European Union, 2018; Gray and Sanders, 2020).

Telephone assessments also have benefits. It is suitable when a physical examination is unlikely to be required, and when it is preferred by the patient. Patients reported that they liked the cost-saving aspect of avoiding unnecessary travel, and found it convenient. The average did-not-attend (DNA) rate at the hospital for face-to-face (FTF) clinics was 10-12%, whereas the rate for the obstetric anaesthesia telephone clinic, since April 2020, for example, is 5.6%.

A debate exists about which form of remote consultation is more productive. It is observed that telephone pre-assessment is less useful in paediatrics, especially for children with special needs and those with safeguarding concerns (Ray et al, 2017). Video conferencing bridges this deficit to some extent. This opinion tallied with the paediatric assessors at the authors' hospital. This is mainly because the quality of the assessment becomes less dependent on the information provided by the patient/parent/guardian on the telephone. Some have already found the use of NHS ‘Attend Anywhere’ video consultation software user-friendly and certainly better than the telephone, but thought it does not replace the benefits of face-to-face consultations. Digital poverty, that is limitations due to available software, hardware and connectivity, can be a real issue in some instances.

A study looking at patient preference concluded that patients are satisfied with a telephone interview for their pre-anaesthesia visit; this satisfaction was not affected by complications and it required fewer resources (Lozada et al, 2016). There is, however, another aspect that health professionals at the author's Trust have experienced. Based on the specialty of surgery, some pre-assessments can be concluded within 0.5 hours (for example obstetric anaesthesia, neuro-anaesthesia) but others, such as hepato-biliary surgery and paediatrics may take more than 1 hour. This increased time needed for telephone pre-assessment, together with the added need for additional observations and investigations, may offset the cost-effectiveness of the telephone mode of pre-assessment. This study highlights the need for clear triage protocols to improve the efficacy of the evolving nurse-led pre-admission assessment pathways (Gilmartin, 2008.

Selecting patients remotely who do not need a formal pre-assessment can add to the cost-effectiveness. The Global Outcomes after Surgery study reported a perioperative incidence of complications of approximately 17% and a perioperative death rate of 0.5% (International Surgical Outcomes Study Group, 2016). In a general surgical cohort, Joseph et al reported that 56.3% may be considered as being at low risk and not requiring any further pre-operative investigations (Joseph et al, 2020). Telephone pre-assessment could be a convenient pathway for such patients, adding to the cost-effectiveness. A further 34.1% (at moderate risk) may benefit from a telephonic pre-assessment to arrange specific investigations (such as blood glucose, lung function tests or echocardiography) before the patient's visit to the pre-assessment clinic, making face-to-face clinics more efficient and time-saving (Joseph et al, 2020). Thus, a total of 90.4% of patients could potentially benefit from a telephone pre-assessment service. However, telephonic pre-assessment of the highest risk group (9.5%) was unlikely to be beneficial or appropriate, but could be used to establish rapport with the patient by the specific anaesthetist involved with his or her surgery (Joseph et al, 2020). This is why triage is necessary.

Patients appreciate remote consultation beyond its convenience and value their interactions with health professionals (Elliott et al, 2020). The authors of the present study also noted this. This patient satisfaction was mostly linked to the modality of remote consultation, but patients' views on effectiveness and efficiency are mixed (Kruse et al, 2017). There is a need for the latter to be defined and clarified based on the local circumstances. The authors also identified the need for readjustments based on the surgical speciality's needs.

Since the Trust policy is moving towards establishing nurse-led pre-assessment pathways, creating a ‘triage’ stage seems prudent to maintain the original objective of pre-assessment to enhance patient experience, surgical outcome and minimise risks (Figure 2). It is important that nurse practitioners and anaesthetists work together to achieve the common goal—to optimise the patients to minimise risk at surgery because developing a guideline that suits all has not been easy even at the National Institute for Health and Care Excellence (NICE) level (Dhatariya and Wiles, 2016).

Figure 2. Proposed telephone assessment pathway for neurosurgery

At the end of nurse-led pre-assessment, a specialty-specific set of ‘triage’ questions should filter patients towards a telephone or face-to-face pre-assessment with an anaesthetist if required. Video consultation may be supplementary but is unlikely to replace the triaging by telephone assessment (Greenhalgh et al, 2020). The nurse-led clinic data also helps direct the anaesthetic pre-assessment, reducing delays.

Based on the authors' consultation and literature review, some areas that need attention are summarised in Table 1. It is anticipated that this summary will assist the authors to develop a formal ‘checklist’ that will make telephone pre-assessments more efficient and cost-effective, and conform to the principles of good medical and nursing practice.

Triaging patients at the nursing pre-assessment can avoid unnecessary anaesthetic assessment of low-risk patients. This can release anaesthetist telephone appointments to ensure that high-risk patients are seen earlier to receive the maximum benefit from this service. Besides reducing costs to the hospital, this would also reduce patients' travel and minimise days off work. These telephonic services could also confirm attendance, identify reasons for late cancellations and reinforce pre-operative instructions.

It is the health professional's responsibility to document relevant clinical information in the medical record. In this era of electronic recording, referrals for telephone assessments are not always formalised and may be directed via an email with no record in the patient's clinical notes. Some clinicians have attempted to correct this deficit by temporary means such as retrospectively copying and pasting relevant email dialogues into the electronic patient record (EPR). Using a universal facility via EPR for communication with colleagues for shared care is prudent.

Ethical and confidentiality aspects of patient consultation via telephone is an ongoing issue that has not yet found a perfect resolution (Sokol and Car, 2006; McKinstry et al, 2009). Considering patients' personal security and confidentiality needs, health staff should at least inform patients beforehand that they will be called on a particular date and time, as the information sought is very personal. This will improve answer rates and trust.

There is no standard method for telephone assessment and none of the Trust's staff has undergone any formal training. Development of specialty-specific guidance is required to formalise the process towards a consistent approach. Medical protection societies have already begun discussions on the medicolegal aspects of remote consultation, based on case reports. Health professionals are yet to understand the components of effectiveness and validity, including the cost-effectiveness of this mode. This will require audits of on-the-day surgical cancellations and their relationship to telephone assessment. There is also the need to establish a process to handle patient complaints. A formal policy for the Trust is needed.

Patients need as much information as possible, as early as possible, to make informed judgements (Macfarlane, 2019). This could be verbal or written, but must be evidence based. This is a statutory ‘duty of quality’ for healthcare providers. There is also a need for this process to follow NICE guidance (NICE, 2020).

Some specialties use a comprehensive tool such as a ‘pre-assessment structured letter’, for example, before hepatobiliary surgery, and a surgical outcome risk tool (SORT) risk assessment tool to quote 30-day mortality and discuss the perioperative pathway. Some may use a frailty score, but the validity and quality of any of the risk assessment scores do not exceed that of the American Society of Anesthesiologists (ASA) classification (Owens et al, 1978), which is also considered by NICE (2020) to have low validity and quality. Use of an appropriate score for the surgical specialty or mode of surgery, such as day surgery, may be a useful filtering tool to classify which patients need formal face-to-face assessments. The consent for anaesthesia also needs to be addressed at the pre-operative assessment, in line with recent General Medical Council (GMC) guidance (GMC, 2020).

The expected standards of remote consultations include weighing up whether the patient can be adequately assessed remotely and both doctor and patient are able to reliably identify each other during a remote consultation (Medical Protection Society (MPS), 2021).

Medico-legal risks

There are also inherent risks in telephone assessment that we are learning with time. These need to be addressed and mitigated. Medico-legal risks have been highlighted and explored by doctors' medical indemnity organisations (Medical Defence Union, 2020; MPS, 2021).

Nurse-led pre-assessment and filtering promotes a proportion of patients to surgery without a discussion on anaesthetic choices: anaesthetic technique, postoperative analgesia, side effects and anaesthetic risk. This may incur new medico-legal challenges for the nursing profession.

Conclusion

This mode of clinical management is likely to stay with us in the long term, post-pandemic and be nurse led. Therefore, below is a set of recommendations that may help health professional teams engaged in remote pre-operative assessment work effectively and safely.

Recommendations

Clinic management

• Manage anaesthetic pre-assessments within specific clinics with appropriate time slots
• Patients should be pre-booked preferably 4-6 weeks prior to surgery
• Nurse pre-assessment/triage should be the first stop to filter patients who do and do not need referral for anaesthetist review
• ‘Notes reviews’ or ‘investigation reviews’ without assessment of the patient by telephone or video conference should be discouraged, as they do not serve the objectives of holistic pre-assessment
• Patient referral by private emails should be discouraged. In the event that this is inevitable, any discussions between clinicians conducted via email should be uploaded to the EPR where appropriate.

Clinic type

• The option for face-to-face anaesthetic pre-assessment must be available for all pre-assessment pathways
• To ensure the smooth operation of this pathway, clear definition of locally agreed escalating criteria for telephone, video or face-to-face assessment should be developed.

Governance

• Formal training should be provided for clinicians undertaking remote pre-assessment
• Regular audits of patient satisfaction rates, ‘on the day’ cancellation rates and clinical effectiveness should be in place to monitor the efficacy and quality of the pre-assessment pathway
• The assessments should be structured and standardised where possible
• Professional teams engaged in remote preoperative assessment must work effectively and safely, following local protocols.

KEY POINTS

• Telephone or virtual anaesthesia pre-assessment has been used during the COVID-19 pandemic, has proved useful and will be used in future
• Telephone pre-assessment cannot replace the need for face-to-face assessment in some patients
• Triage is essential to enhance the utility of telephone pre-assessment
• The cost-effectiveness of such pre-assessments needs formal assessment

CPD reflective questions

• Think about the purpose of surgical pre-assessment
• Think about telephone or virtual pre-assessments in your area of work. How have you triaged patients before allocation for virtual pre-assessment?
• How does pre-assessment contribute to improved patient outcomes?
• Should pre-assessment pathways modify according to the needs of different specialties?
• Can you complete an anaesthetic pre-assessment based on clinical notes and investigations alone? Consider why this might not be appropriate