Pre-operative Screening Decision Support

Michael Edmonds

There has recently been considerable interest in improving patient safety since the release of some major reports in the United States of America (USA) [ 1 2 ], the United Kingdom (UK) [ 3-5 ] and Australia [6] . One of the areas that has been identified as associated with significant adverse events is surgery, and pre-operative assessment and management [7] . Decision support systems offer a new approach to reducing adverse events through preventing knowledge- and rules-based errors, and generating patient-specific protocols and recommendations based on the best available evidence.

Adverse Events

Adverse events have been defined as "injury resulting from a medical intervention, not the underlying condition of the patient" [1] . The aetiology of adverse events can be complex, being the culmination of many factors. These factors range from individual human error through to institutional and system errors combining to lead to adverse events [7] . Adverse events in medicine have not been extensively investigated until recently, although it has long been recognised that the practise of medicine has the potential to do more harm than good ("First, do no harm"). Data from the Quality in Australian Health Care Study (QAHCS) showed similar results to those found in the USA and UK[ 8 9 ]. These data suggest that more than 10% of hospital admissions are associated with an adverse event, with at least 2% leading to major disabilities, and 0.5% leading to patient death. Categorisation of these events shows that the 20 most frequent adverse events are predominantly related to surgery, with many of these events potentially preventable with adequate pre-operative management [10] .

Pre-operative Assessment

The aim of pre-operative assessment is to identify the risk of surgery for each patient, and to modify that risk, either by optimising the patient's medical conditions prior to the operation, or by modifying peri-operative management or anaesthetic technique. The recent shift towards day surgery and day-of-surgery admission procedures has seen a change in the process of pre-operative assessment. Previously patients were admitted to hospital at least a day before their operation, to give adequate time to take a full history, perform and investigations required and manage any problems. This has been shifting towards an outpatient-based clinic for day surgery and day-of surgery-admission patients to minimise stay in hospital, with patients ideally seen at least a week in advance of their operation. With the increasing flow through pre-operative assessment less time is available to assess each patient, and the tendency is for patients to be seen up to only the day before their operation, and this fast-tracking through the process leads to incomplete and inadequate assessments being performed, and inadequate time to completely investigate and optimise medical conditions. Patients are at a higher risk of adverse events if their medical conditions are not optimised, and not sufficiently investigated. Late cancellations and subsequent reduction in theatre efficiency are also consequences of inadequately prepared patients.

Inadequate pre-operative assessment and management has been an area of particular focus and interest in recent years as a major factor in preventable peri-operative morbidity and mortality. An analysis of the Australian Incident Monitoring Study (AIMS) data showed that in 1 in 10 adverse events involved inadequate preoperative patient preparation and/or evaluation [11] , and over 3% of all adverse events were clearly related to a deficiency in this area. Of these adverse events, 57% were judged by peers to be 'definitely preventable' and a further 21% were 'possibly preventable'.

Similarly, an Australian triennial report into anaesthetic related perioperative deaths indicated that inadequate preoperative assessment and management was implicated in 53 of 135 deaths attributable to anaesthesia [12] . A recent report from the Victorian Consultative Committee on Anaesthesia-Related Mortality found that similar problems with preoperative assessment were implicated in 18 out of 43 deaths in Victoria , Australia [13] .

The impact of preventable adverse events arising from pre-operative screening is substantial, with 14% of resource use attributed to all adverse events in hospitals consumed by only 5 adverse events arising from pre-operative screening [10] .

The Pre-Operative Assessment Clinic offers an ideal test bed for intervention to prevent adverse events as all patients undergoing day-of-surgery admission operations, and a proportion of day-surgery patients, will be seen in this clinic. This clinic also represents many processes and workflows seen throughout medicine, and can be used as an example when intervention is planned for other areas.

Evidence-Based Decision Support

Evidence-based decision support combines the best available evidence with individual patient information to produce patient-specific recommendations and protocols. Decision support systems have been used in various capacities in medicine, ranging from drug ordering with interaction warning, laboratory test analysis and diagnosis. These systems have been shown to enhance clinical performance in drug dosing, preventive care and other aspects of medical care, but not currently for diagnosis [14] . Decision support systems based on Bayesian decision models use the best available evidence, local population data and specific patient details to determine individual probabilities of outcomes, and the utility of different decisions, allowing the best decisions to be recommended based on expected utility.

There has been significant evidence to show that compliance with new guidelines and protocols is poor using the conventional paper-based process[ 15 16 ]. The inclusion of these same guidelines and protocols into a computerised system within the current workflow may lead to higher compliance as it will effectively force them to be used for each patient.

Project Outline

This project follows on from previous work performed towards my Bachelor of Medical Science (Honours) project. In that project I, with others, developed decision models about some aspects of pre-operative assessment and management. This project is intended to implement these models into an integrated system in the pre-operative assessment clinic.

We intend to implement a computerised system that produces the current paper forms required in the Royal Adelaide Hospital (RAH) pre-operative assessment clinic. This system will also incorporate test ordering and a test result reviewing system. The use of a computerised system will also allow decision support and other risk assessment to be incorporated to produce individualised patient recommendations in terms of test ordering, drug ordering and both pre- and post-operative management.

The effect of these interventions will be evaluated against baseline measurements taken before implementation. These measurements will include workflow and process indicators, as well as clinical practice indicators such as prescribing and test ordering. Clinical and clerical staff satisfaction and compliance will also be evaluated.

Significance

There is currently significant data showing that inadequate pre-operative assessment and planning is a major cause of preventable adverse events leading to major disability and death in hospital. The use of a computerised tool incorporating decision support and the best available evidence has the potential to standardise clinical practice in the pre-operative assessment clinic to reduce the occurrence of these events.

The pre-operative assessment clinic provides an opportunity to intervene in the healthcare of a large number of patients at relatively high risk of adverse events. The clinic also represents many workflows and processes similar to those found throughout medicine, and the potential to intervene in this environment can be used as a basis for modelling further interventions in other aspects of medicine.

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2. Insitute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century . Washington DC: National Academy Press, 2001.

3. National Health Service. An Organisation With a Memory. London: The Stationery Office, 2000.

4. Doing Less Harm. London: Department of Health, 2001.

5. Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984-1995, 2001.

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8. Thomas EJ, Studdert DM, Runciman WB, Webb RK, Sexton EJ, Wilson RM, et al. A comparison of iatrogenic injury studies in Australia and the USA. I: Context, methods, casemix, population, patient and hospital characteristics. Int J Qual Health Care 2000;12(5):371-8.

9. Runciman WB, Webb RK, Helps SC, Thomas EJ, Sexton EJ, Studdert DM, et al. A comparison of iatrogenic injury studies in Australia and the USA. II: Reviewer behaviour and quality of care. Int J Qual Health Care 2000;12(5):379-88.

10. Runciman W, Edmonds M, Pradhan M. Setting Priorities for Patient Safety. Safety and Quality in Healthcare 2001, submitted for publication.

11. Kluger MT, Tham EJ, Coleman NA, Runciman WB, Bullock MF. Inadequate pre-operative evaluation and preparation: a review of 197 reports from the Australian incident monitoring study. Anaesthesia 2000;55(12):1173-8.

12. Davis NJ. Anaesthesia related mortality in Australia 1994-1996. Report of the Committee convened under the auspices of the Australian and New Zealand College of Anaesthetists, 1999.

13. Report of the Victorian Consultative Committee on Anaesthesia-related Morbidity and Mortality, 2000.

14. Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA: Journal of the American Medical Association 1998;280(15):1339-46.

15. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. The Cochrane Effective Practice and Organization of Care Review Group. Bmj 1998;317(7156):465-8.

16. Gibson PG. Implementing evidence-based guidelines. Med J Aust 2001;174(8):377-8.

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