Transcript Challenges & Solutions

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
Anaesthesia Assessment Clinic
is not just
Day Surgery / Same Day Admission PAC
All elective cases
History
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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 free standing ambulatory surgery centres in US
Aims of anaesthesia assessment
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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
Aims (cont)
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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
Benefits of Preoperative Assessment Clinic
(PAC)
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Ideal setting for anaesthetic assessment
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Facilitate SOPD medical consultation
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Decrease of inpatient length of stay (cost, hospitalacquired infection, psychological stress)
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Facilitate operation scheduling
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Ease immediate preoperative preparation
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Reduce cancellation of operation
Essential ingredients
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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
The world trend
70-90% day surgery
Definition of day surgery
9
to 6 pm
8 to 11 pm
23 hours
Round the clock as long as < 24 hours
What is the situation in Hong Kong
90%
20
2
of inpatient services provided by HA
operating theatre suites (230 Operating Rooms)
day centres as there is no inpatient facilities - TWEH, HKEH
Some
have limited number of inpatient beds - AHNH, OLMH,
TSKH, TWH, POH
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centres only deal with high complexity cases - GH/QMH, PWH
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
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
Culture
Hospital
a safer place
Some changes after SARS
Incentives for patient / family
Hospital
New
Old
stay around HK$100 per day all inclusive
case consultation at SOPD - HK$100
case consultation HK$60
Each
drug item HK$10
Consultation
Community
at AED HK$100
Nurse visit HK$44
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)
Misunderstanding / fear
Patient
screening not easy
Post
operative complications attract complaints /
medical legal issues
Hard
to overcome old habits
Respect
tradition
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History of Day Surgery at UCH
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April 1992 - general surgical cases
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Nov 1992 - eye cases
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July 1993 - orthopaedic cases
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Oct 93 - ENT cases
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April 96 - O&G, dental cases
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April 98 - pain cases
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Same Day Admission Programme from July 97
Day Surgery
No. of Day Surgery Cases
Total No. of Cases
6000
5670
5000
4000
2691
3000
2158
2000
1000
2237
1498
504
776
978
0
1992
1993 1994
1995
1996 1997
Year
1998 2008
The UCH model - One stop approach
Surgeon
consultation - anaesthesia assessment all on one day
screening and patient education before anaesthetist’s
assessment
Nurse
Written
Patient
DSC
instruction (with DSC hotline) to take home
to confirm operation within 2 weeks of operation
staff to remind patient the day before
Surgeon
and anaesthetist to review before operation
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
Others
Type
and screened blood / products for every indicated
cases
Bowel
CMS
OR
preparation
enables communication and tracking of actions
Manager to approach all surgeons to promote
benefits of day surgery or SDA
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%)
Nurse
Call patient on day after discharge for
satisfaction score and feedback
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
Physical facilities
Purpose
IT
built Peri-operative Centre
smart environment
Seamless
support
100%