Preoperative Assessment Decision Support S Lake * , B Murthy # , A Fisher

1. Clinical Engineering Royal Liverpool University Hospital Preoperative Assessment Decision Support S Lake*, B Murthy#, A Fisher Depts. of Clinical Engineering and #Anaesthesia & Theatres (*splake@liv.ac.uk) What is OSCAR? Rule Structure • Each assessment can have one or more rules • Each rule may trigger only one investigation • Rule details: - • An intranet based recording system of: - • Pre-operative anaesthetic assessment, medication and scoring. • Complete peri-operative anaesthetic chart including vital signs. • Post-operative monitoring, medication etc... • Now includes: Pre-admission assessment & test result management. • Applicable age range • Level of surgery, minor, intermediate, major, major+ • Specific operation procedure codes • Type of anaesthetic: GA, LA • Physiological measurement range (Fact Code), e.g. BMI >= 30 • Medication (Fact Code), e.g. thyroxine • Condition (Fact Code), e.g. asthma • Action: Recommend, Suggest, Advise only • Investigation to trigger • Patient information Activity 1Pre-Op Assessment • Patient history and vital signs entered during assessment. • Investigations predicted. • Record of which investigations ordered, if TCI date given then panic date assigned. • Scoring may be added. Activity 2Investigation results returning Rule Application • Results entered into assessment record by Nurse, electronically in the future. • System lists all outstanding assessments, those past the panic date go red. Age in range AND surgery grade above or equal to rule value Yes Any of the following: - Physiological measurement in range Activity 3All investigations complete Procedure code match Anaesthesia type match Medication match Condition match • Record now flagged as assessed or cancelled if not going ahead. • If Theatre and TCI date known then record updated and flagged as planned. Recommend investigation, suggest investigation or advise only Add patient information to assessment Database Structure Patient Demographics Fact Code Database e.g. Asthma e.g. Mr Justin Case • Objectives • Electronic record of pre-admission assessment. • Several levels to refine detail, carrying results through (nurse pre-admission, physical exam, anaesthetist pre-op) • Template structure for different assessments (RLBUHT Standard, St Paul’s pre-admission, PRHO examination, anaesthetist pre-op) • Suggest and recommend investigations based on rules (rules to use are specified in template). • Build a knowledge base about the patient before the operation. • Check that investigations have been carried out (daily management list of outstanding assessments). e.g. Respiratory Function Tests Investigation Codes e.g. If Asthma then do Respiratory Function Tests e.g. e.g. Mr Justin Case having elbow surgery Mr Justin Case has Asthma Care Records (Operations) Facts about patients Investigation rules Loaded Updated e.g. Pre-Admission or Pre-Op Anaesthetic Assessment Templates Score on patient Investigation on patient Assessments Copied e.g. Liverpool Elbow Score on Mr Justin Case e.g. Respiratory Function Tests on Mr Justin Case e.g. Pre-Admission on Mr Justin Case There is a database of patients containing demographic details that is connected to a database of operations. The little crows-foot on the end simply means that each patient can have one or more operations. There is a database of ‘facts’, which defines a particular physiological measurement, for example ‘systolic blood pressure’, or it could be a condition like asthma. This database is key to relating an investigation to a result in the patient’s history.At the bottom is the database of assessments and as you can see you can have more than one for each operation. A template is used to control the questions that are asked on the assessment and which rules to apply that trigger investigations. The template is copied across so that any future alterations to the template don’t effect the past assessments. When the assessment is opened, facts about the patient relating to the assessment’s questions are copied in. When the assessment is saved, the answers to the assessment are copied back to the ‘Facts about Patients’ database. The rules assigned to this template are then run against the ‘Facts about Patients’ database and those investigations that are triggered are recorded in the assessment. Two other databases shown here are scoring and the actual investigation results themselves. Benefits • Encourages a consistent approach to pre-operative assessment. • Quality of record. • May flag up tests missed by the Nurse. • Only say may since these highly experienced nurses will do a better job due to the unpredictability of patient health and their ability to make a judgement based on experience. • Highlights missing test results before it becomes a problem. • Anaesthetist is better informed. • A catalyst to improvement by providing a focus on: - • Optimising Surgery Care