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Preoperative Assessment Decision Support

An electronic pre-operative assessment pathway to enhance the accuracy, completeness, and accessibility of clinical information, and provide decision support for preoperative investigations. Includes patient history, guidelines for investigations, and rule-based algorithms.

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Preoperative Assessment Decision Support

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  1. Preoperative Assessment Decision Support S Lake, B Murthy*, A FisherDepartment of Clinical Engineering* Department of Anaesthesia & Theatres

  2. The Journey BEFORE Pre-op Patient seen by G.P Referred to / seen by surgeon Goes on waiting List Lists the patient for an operation Secretary/Clerk sends for the patient (appointment letter) Patient comes to the hospital the day before or on the day of the operation Investigations done Examined by Anaesthetist Unfit for surgery (D.M, ↑BP) Fit for surgery Refer back to G.P Goes to operating theatre

  3. Reasons for day case cancellations on the day & the day before surgery. Aug 01 – Jun 02

  4. The Patient’s Journey Now Patient seen by G.P Refer to/seen by surgeon Lists the patient for operation Pre-op assessment 4 weeks before surgery, and investigations Goes on waiting List Unfit for surgery Fit for surgery Refer back to G.P Seen by Anaesthetist in the clinic Patient comes to the hospital on the day of surgery Referred to Specialist (e.g Cardiologist) Listed for operation once fit for surgery Goes to theatre Discharge

  5. Electronic Pre-operative Assessment Pathway • Mile stone • Intranet based • Present Pathways • Greater Accessibility, Accuracy and • Completeness of clinical information

  6. OSCAR(Optimised Surgery Care and Anaesthesia Record) 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.

  7. Decision Support • Must predict investigations and provide advice based on: - • Details from patient history • Details about the operation • Local policies & guidelines

  8. Patient History • What does the prediction routine have to work with: - • The patient suffers from occasional, constant, infrequent headaches. • Patient has chest pain if she lies on her left side for over a year. • Skin: somewhat pale but present. • She stated that she had been constipated for most of her life until 1989 when she got a divorce. Richard Lederer’s list taken from “The Bride of Anguished English (2000)” where entries were described as real-life doctors’ dictations submitted by the American Association of Medical Transcriptionists.

  9. Pre-operative and anaesthetic assessment Patient Health Questionnaire

  10. Guidelines for Pre-operative Investigations

  11. Association • Would the program know that asthma in the patient history is a respiratory disease, indicated in the guidelines for investigations. • Or can we predict all occurrences of this now so it can be programmed in.

  12. Solution • Introduce an intermediary, ‘Fact Code’, that can be attributed to a patient and used with the guidelines to predict the investigation. • E.g. Has asthma or On Steroids • Three levels of action if fact code present: - • Recommend test : direct evidence in history • Suggest test : indirect evidence in history • Advice : Not a test but administration – e.g. put patient first on list due to allergy.

  13. Next problem • Anaesthetist wrote guidelines but Pre-op nurses carry them out. Guidelines need to evolve. • Surgeons have ‘likes’ • Flexible way to adjust prediction algorithm • Defined by rules in a database • Template used to specify questions for history taking and which rules to apply.

  14. Database Structure

  15. Rule Structure • Each assessment can have one or more rules • Rule trigger: - • 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 • Rule output: - • Action: Recommend, Suggest, Advise only • Investigation to trigger • Patient information

  16. Rule Application

  17. Pre-Admission Assessment

  18. Management list Shows which assessments are still waiting for test results. Those past the pre-assigned panic date turn red

  19. Anaesthetic Assessment

  20. Communications Database Web Pages Programs By splitting the layout of the web page from the programming we can have different web pages calling the same program and even have other systems call the same program without the results being buried inside the web page source. Web Server SOAP call (W3C standard) Web Browser (Internet Explorer) Web Page / Scripts Other systems

  21. Benefits • Encourages a consistent approach to pre-operative assessment. • Quality of record. • May flag up tests missed by the Nurse. • 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

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