New Dimensions in Preoperative Assessment

1. New Dimensions in Preoperative Assessment G Ludbrook University of Adelaide & S.A. Health

2. Disclosures and acknowledgements • Grant funds or commercial agreements: • Medibank Private • WA Health (SHRAC) • Medtel Australia • Member, Clinical Governance Committee, RDNS • Customer of O’Brien Glass

4. Business challenges Cost escalation Societal expectations (time) Technology

5. Meeting the challenges of cost and quality Remote, rapid access and communication Information processing Technology

6. Healthcare Conflicting pressures Changing environment Changing society Technology Increased demand Limited resources

7. Australian population projections our patient profile Young population “pyramid” Old population “coffin shaped” Ageing population “middle-aged spread”

8. 112 anaesthesia-related deaths Inadequate preoperative assessment - 28% of cases Inadequate preoperative management - 21% of cases

9. Processes of current preoperative workup Elective surgery

10. Processes of current preoperative workup Windscreen repair / replacement

16. Themes across industries • Process analysis • New technologies • Early triage and streaming to best care pathways • Specific elements • Data exchange / communication • Data management & integration • Data analysis / Decision making • Management pathways Remote communication Early triage and streaming Computer decision support

17. Medication Management via a videophone Virtual HospitalTelehealth Service

18. Drivers for New Service • An aging population • Increased incidence of chronic diseases • Increased pressure on existing health services… • Need to increase client access …. • Maximise workforce efficiencies • New technologies + creative health services • = innovative service delivery

19. Formal evaluation Cost Effectiveness • Time reduction - 7 minutes vs 19 minutes • Cost reduction - 40% decrease Risk and Safety • Vast reduction in reported medication incidents – pharmacy delivery Client satisfaction • Less intrusive for client • Increased client control over medication management

20. Telemedicine versus telephone for remote emergency stroke consultations: a critically appraised topic. Capampangan DJ, Wellik KE, Bobrow BJ, Aguilar MI, Ingall TJ, Kiernan TE, Wingerchuk DM, Demaerschalk BM. To determine the efficacy of telemedicine versus telephone-only consultations for decision making in acute stroke situations. Neurologist. 2009 May;15(3):163-6

21. Neurologist. 2009 May;15(3):163-6.

22. Preoperative call centre pre-screening Remote communication – phone or internet Non-clinician delivered Computer assisted ‘smart’ questionaire

23. Preoperative medical pre-screening 517 patients from two tertiary referral centres Call centre pre-screening before elective surgery Quality of data benchmarked against that collected in OPD 55 anaesthetists involved in assessment Grant, Ludbrook, O’Loughlin, Corcoran et al., unpublished data

24. High quality data collected in 15 minutes Would in theory allow 50-60% of these patients to be seen on DOS Grant, Ludbrook, O’Loughlin, Corcoran et al., unpublished data

25. Data summary and processing Consistency Legibility Areas of concern highlighted

26. Pre-Admission Website: Patients are asked to complete an online assessment.

27. HealthbankPreOpAnaes Tab: If a disease needs further exploration the anaesthetist has a very powerful drilldown tool.

28. Decision making • Evidence-based • Consensus-based • Opinion-based • Eminence-based • Vehemence-based • Eloquence-based • Providence-based • Diffidence-based • Arrogance-based Isaacs and Fitzgerald, BMJ 319 : 1618 1999 Lam BMJ. 2000 July 22; 321(7255): 239

29. Expert consensus on preoperative testing http://www.nice.org.uk/nicemedia/live/10920/29090/29090.pdf

30. http://www.nice.org.uk/nicemedia/live/10920/29090/29090.pdf

31. Determinants of OSAdata modelling Collect data on patient factors which might predict OSA Benchmark against sleep studies Mathematical models which predict likelihood of OSA

32. Model performance Positive Predictive Value Reasonable performance using history alone Improvement adding other factors (eg neck circumference)

33. Preoperative clinical decisions without hard evidence • Obtained opinions from 55 anaesthetists on 517 patients • Identified predictive factors • Built predictive models which identify what the “group” would do for specific cases Determinants of preoperative decisionsdata modelling Grant, Ludbrook, O’Loughlin, Corcoran et al.

34. Decision support: pre-screening Grant, Ludbrook, O’Loughlin, Corcoran et al., submitted to BJA

35. “..... a medical practitioner will not be found negligent if they acted in a manner that was widely accepted in Australia, by a significant number of respected practitioners in the field…..” Value of consensus in decision making Maher and Burke, Medical Journal of Australia, 194(5), 253-255, 2011

36. Processes of current preoperative workup Elective surgery

37. Processes of current preoperative workup Elective surgery

38. Processes of current preoperative workup Elective surgery

39. E-Health will: • •Ensure the right consumer health information is electronically made available to the right person at the right place and time to enable informed care and treatment decisions • •Enable the Australian health sector to more effectively operate as an inter-connected system overcoming the current fragmentation and duplication of service delivery • •Provide consumers with electronic access to the information needed to better manage and control their personal health outcomes • •Enable multi-disciplinary teams to electronically communicate and exchange information and provide better coordinated health care across the continuum of care • •Provide consumers with confidence that their personal health information is managed in a secure, confidential and tightly controlled manner • •Enable electronic access to appropriate health care services for consumers within remote, rural and disadvantaged communities • •Facilitate continuous improvement of the health system through more effective reporting and sharing of health outcome information • •Improve the quality, safety and efficiency of clinical practices by giving care providers better access to consumer health information, clinical evidence and clinical decision support tools • •Support more informed policy, investment and research decisions through access to timely, accurate and comprehensive reporting on Australian health system activities and outcomes. AllscriptEmergisoft Firstnet Healthbank etc National E-Health StrategyDecember 2008

40. New models of care

41. New models of care • Early triage • Call centre-based pre-screening • Computer smart questionnaire • Medicine • Nursing • Computer-generated guidelines • Call centre follow up • Remote lab testing • Data collection • Phone follow up • Informed consent • Streaming to: • Outpatients vs DOSA • Appropriate facility

42. “It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change……”