Challenges & Solutions of setting up an Anaesthesia Assessment Clinic Anne Kwan

1. Challenges & Solutions of setting up an Anaesthesia Assessment Clinic Anne Kwan MBBS FHKCA FHKAM(Anaesthesiology) FANZCA FFPM ANZCA Dip Pain Mgt (HKCA) Dip Acup M Pal Care Chief of Service Department of Anaesthesia, Pain Medicine and Operating Services United Christian Hospital HONG KONG

3. Anaesthesia Assessment Clinic is not just Day Surgery / Same Day Admission PAC All elective cases

4. History • 1909 - Nicole presented to BMA the results of 8988 operations on outpatients performed at the Glasgow Royal Hospital for Sick Children between 1899 and 1909 • 1916 - Waters opened the Down-Town Anaesthesia Clinic in Sioux City, Iowa for minor surgery and dental cases • 1937 - Hertzfelt reported on more than 1000 outpatient paediatric hernia repairs performed with the use of GA • 1962 - a formal ambulatory surgical programme was initiated at the University of California at LA • 1974 - Federated Ambulatory Surgery Association was established • 1989 - 1000 freestanding ambulatory surgery centres in US

5. Aims of anaesthesia assessment • To assess & optimised patient’s medical condition • To explain the different types of anaesthesia which can be used for the operation • To describe the relative risks and complications of the anaesthesia chosen • To briefly explain how the intended anaesthesia is conducted • To explain to patient the available clinical studies • If patient is recruited in a clinical study, adequate explanation must be given and written consent must be obtained • To ally patient’s anxiety by adequate explanation and prescription of premedications

6. Aims (cont) • To remind patient to take premedications if they have been prescribed • To remind patient of fasting time • To select suitable form of postoperative analgesia for the patient • To educate patient in the use of postoperative analgesia • To warn patient of possible postoperative follow up call / visit

7. Benefits of Preoperative Assessment Clinic (PAC) • Ideal setting for anaesthetic assessment • Facilitate SOPD medical consultation • Decrease of inpatient length of stay (cost, hospital-acquired infection, psychological stress) • Facilitate operation scheduling • Ease immediate preoperative preparation • Reduce cancellation of operation

8. Essential ingredients • Anaesthetists • Anaesthetic / PAC nurses • Screening mechanism (patient/operation type, infection) • PAC protocols • Physical set up • Information technology smart • Investigation facilities on site • Fast tract consultation arrangements • Review mechanism streamline • Administrative guidelines • Audit / review

9. The world trend 70-90% day surgery

11. Definition of day surgery 9 to 6 pm 8 to 11 pm 23 hours Round the clock as long as < 24 hours

12. What is the situation in Hong Kong 90% of inpatient services provided by HA 20 operating theatre suites (230 Operating Rooms) 2 day centres as there is no inpatient facilities - TWEH, HKEH Some have limited number of inpatient beds - AHNH, OLMH, TSKH, TWH, POH 2 centres only deal with high complexity cases - GH/QMH, PWH

13. HA has been monitoring day surgery or same day admission cases hoping to have benchmarking for healthcare efficiency The following data are collected regularly and displayed at the MIPO site

17. For those hospitals or sites with suitable cases for day surgery or same day admit, what are the barriers? Barriers: Poor education level Poor home environment Patient staying alone Patient coming from old aged home

18. Culture Hospital a safer place Some changes after SARS

19. Incentives for patient / family Hospital stay around HK$100 per day all inclusive New case consultation at SOPD - HK$100 Old case consultation HK$60 Each drug item HK$10 Consultation at AED HK$100 Community Nurse visit HK$44

20. Incentives for surgeons Funding based on number of inpatient beds Casemix model not encouraging day surgery Hard to streamline patient care path as day cases (admission, consultation, investigation, rescheduling)

21. Misunderstanding / fear Patient screening not easy Post operative complications attract complaints / medical legal issues Hard to overcome old habits Respect tradition

23. History of Day Surgery at UCH • April 1992 - general surgical cases • Nov 1992 - eye cases • July 1993 - orthopaedic cases • Oct 93 - ENT cases • April 96 - O&G, dental cases • April 98 - pain cases • Same Day Admission Programme from July 97

24. Day Surgery No. of Day Surgery Cases Total No. of Cases Year

25. The UCH model - One stop  approach Surgeon consultation - anaesthesia assessment all on one day Nurse screening and patient education before anaesthetist’s assessment Written instruction (with DSC hotline) to take home Patient to confirm operation within 2 weeks of operation DSC staff to remind patient the day before Surgeon and anaesthetist to review before operation

26. Challenges Undiagnosed or unstable medical conditions: IHD, HT, DM, asthma or COAD Anaesthetist as peri-operative physician Fast track consultation Cardiac - IHD - Echocardiography COAD - Resp function test and optimization DM, HT, Asthma - specialist anaesthetist review Team in-charge to follow up patient until ready for operation

27. Others Type and screened blood / products for every indicated cases Bowel preparation CMS enables communication and tracking of actions OR Manager to approach all surgeons to promote benefits of day surgery or SDA

28. KPI Cancellation rate <2% Medical condition - URTI, menstruation; surgical condition changed - lump disappeared Change of mind (not wanting surgery) Social issues (family member was sick, urgent visit to Mainland) Admission rate (<2%) Readmission rate (<0.2%)

29. Nurse Call patient on day after discharge for satisfaction score and feedback

30. Others In houses physician to deal with consultation Anaesthetist or nurse manager to schedule operations (DS, SDA, IP) Casemix funding incentives Pain & symptom relief Case manager to follow patient thru ASA 1/2 Nurse Assessment Clinic

31. Physical facilities Purpose built Peri-operative Centre IT smart environment Seamless support

33. 100%