Quality improvement project to improve the process of pre-operative assessment of elective vascular surgery patients incorporating a new POPS (perioperative care for the older patient undergoing surgery) service

Background:

St George’s hospital is the hub for the South West London vascular network admitting approximately 1400 elective patients yearly. A robust pre-operative assessment can identify areas requiring optimisation avoiding cancellation on the day of surgery which is costly to the hospital and patient. 

Introduction:

Formerly, the pre-operative assessment involved three separate reviews by a clinical nurse specialist (CNS), physician associate (PA) and pharmacist. Patients reported poor satisfaction due to time spent and repetition. Anaesthetists reported inconsistent assessments and we observed avoidable medical cancellations on the day of surgery. 

In 2023, a vascular POPS consultant was appointed to support the pre-operative pathway. 

Methods: 

Initially, the POPS consultant met weekly with the CNS team to discuss their assessments and identify patients needing optimisation or discussion with the surgical team. 

We then created a new proforma for our preoperative clinic to help take a consistent medical history and examination and identify issues that need optimisation. These assessments were performed fully by the CNS with pharmacist support to provide written medication instructions.  

We reviewed the number of and reasons for cancellations on the day of surgery as a measure of effectiveness of the pre-operative assessment. Iterative improvements to the process were designed to address themes that arose. 

We also sought patient and colleague feedback. 

Results:

Patient feedback improved significantly and anaesthetic feedback was universally positive.

Avoidable cancellations have remained variable but reasons have changed over time as identifying themes has led to successful interventions. 

Increasingly, cancellations relate to patients bypassing  the pathway, for example due to urgent admission through the new Same Day Emergency Care (SDEC) service. 

Conclusion: 

Streamlining of the pre-operative pathway has led to significant patient and staff satisfaction and better use of staffing resource. Review of avoidable cancellations on the day of surgery has been an effective outcome measure and enabled some problems to be addressed.

Patients not assessed using this process are more likely to be cancelled on the day further demonstrating it’s effectiveness.