Preoperative Assessment & Preparation · Preoperative Assessment & ... • Competencies ... ‘New’ Preoperative Systems:-Conceptual Basis Increasing Complexity

Ross Kerridge

John Hunter Hospital, Newcastle,

[email protected]

Preoperative Assessment &

Preparation

New Horizons in Anaesthesia

Can we foresee the future?

• Communication

• Computers

• Clinical Issues

• Corporate Risk & Benefit

• Conceptual Frameworks

• Competencies

• Consumerism

• Clinical Governance

• Clinical Decision-Making

• Counselling

• Clinical Leadership

Foreseeing the future…..

• Communication

• Computers

• Clinical Issues



• Competencies

• Consumerism



• Counselling


ISBAR

A standard method of communicating for safe clinical care:

I Introduction

S Situation

B Background

A Assessment

R Recommendation

System-based, Standardised Communication


• Communication

• Computers

• Clinical Issues



• Competencies

• Consumerism



• Counselling


PC-EHR

I’m from the

Government, I’m here

to help you


• Communication

• Computers

• Clinical Issues



• Competencies

• Consumerism



• Counselling


Passing to a

new generation

CPET

Coming soon to a Hospital

near you :-

Patient Blood

Management

‘Guidelines’

There may be less

terrifying

alternatives….

So we agree….stop

clopidogrel for five days

New Antithrombotics

No Assay…..

No Monitoring….

No Reversal……

No Therapy…..


• Communication

• Computers

• Clinical Issues



• Competencies

• Consumerism



• Counselling



• Communication

• Computers

• Clinical Issues



• Competencies

• Consumerism



• Counselling


Decision to perform

Procedure

Inform Patient

Plan Procedure

( I.e. Add to Operating List )

Traditional Process

Operate!

Manage the Results

“The Final Check”….“Gatekeeper” …..

“Protecting the Patient from the Surgeon….”

Old System….

‘New’ Preoperative Systems:-

Conceptual Basis

Increasing Complexity surgical procedures more & more specialised;

patients are sicker with more comorbidities,

need to address patient preferences and other patient factors,

the complexity of managing the hospital system requirements,

requires a system integrating all these dimensions

Patient outcomes and efficiency of care are maximised by appropriate (early) preprocedural preparation.

Avoiding adverse outcomes

Avoidance of cancellations

Reducing time in hospital both pre- and post-procedure.

Patient

Health

Factors

Procedure-Specific

Factors

Assessment

Analysis & Integration

• Resolve conflicting requirements

Detailed Planning

• Procedural Plan of Care

• Checklists etc

• Initial post-op care plan

• Provisional discharge plan

Perioperative Process Framework

Hospital/System

Factors

Health

Profile

Patient

Factors

Patient

Issues

Procedure

Issues

Hospital

Issues

•Health Questionnaire

•Telephone Interview

Procedure-specific requirements

• Equipment Requirements

•Emotional Concerns

•Personal Preferences

• Resources

• Priorities

• Waitlists

•Hospital Capabilities

• Staff Skills

• Equipment Availability

• Accommodation

•Transport

•Home Support

Perioperative

Management Plan

Communication & Implementation

• Education/Instruction to Patient & Family

• Communication to Clinical Units & Staff

• Co-ordinate Implementation of Plan of Care

• Surgeon requirements

• Information from RFA

Health

Profile

“Planning the Journey...…”

“Working together…..”

New System….

“Communicating…..”

Gather Information Patient Health; Procedure; Hospital/system; Personal

Collation & Documentation of Information

Review Patient Health Identify potential to improve patient’s health status

Optimise the Patient’s Health as much as realistically achievable in the timeframe available

Analyse/Integrate (four perioperative dimensions)

Assess the risks and benefits associated with planned procedure

Consider alternative perioperative management options and/or procedures.

Decide on perioperative management plan.

Resolve conflicting requirements.

Decide on plan of care

Identify possible undesired events or ‘complications’ that may occur perioperatively

Plan detection and treatment of ‘complications’ if they do occur.

PostProcedural Discharge Planning

Explain/Educate/Implement/Evaluate Communicate plan to patient/proceduralists/theatre staff surgeon

The Key Steps of the PreProcedural Process


• Communication

• Computers

• Clinical Issues



• Competencies

• Consumerism



• Counselling


Hmmm…I need

to order a Stress

Echo and a

Sesatmibi


• Communication

• Computers

• Clinical Issues



• Competencies

• Consumerism



• Counselling


Consumerism in medicine

Consumerism

Medico-Legal Actions are a failure of Consumer Focus

Reengineered systems for patient evaluation

Patient-focussed use of Technology


• Communication

• Computers

• Clinical Issues



• Competencies

• Consumerism



• Counselling


We are engaged in Clinical

Governance– whether we like it or not


• Communication

• Computers

• Clinical Issues



• Competencies

• Consumerism



• Counselling


Clinical Decision Making & Life Expectancy

0

5

10

15

20

25

30

35

40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 100

AGE

Lu

na

r d

ea

ths

We never save a life.

At best, we only

delay death, or

improve quality of

life

Deaths/1000/Month


• Communication

• Computers

• Clinical Issues



• Competencies

• Consumerism



• Counselling


The ‘High-Stakes’ Consultation


• Communication

• Computers

• Clinical Issues



• Competencies

• Consumerism



• Counselling


Preoperative Assessment & Preparation · Preoperative Assessment & ... • Competencies ... ‘New’ Preoperative Systems:-Conceptual Basis Increasing Complexity

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