Pre-assessment – how we do it: Guy’s and St Thomas’ hospitals

Created - 01.09.2022

Pre-assessment in a tertiary care Interventional Radiology Unit – elective pathway management.

Pre-assessment is a nurse led service designed to prepare patients for their surgery. It is an opportunity to assess their medical fitness and optimise where needed. The benefits of an effective pre-assessment service are to reduce operation day cancellations and delays, patient experience and post-operative outcomes.

Our experience

At our tertiary centre we have a dedicated team of IR pre-assessment nurses that review all elective patients coming for an interventional radiology procedure. Their aim is 3-fold:

1) Determine the appropriate list for scheduling (anaesthetic v non-anaesthetic) and suitability for conscious sedation.

2) Medical optimisation.

3) Prepare patients for the day of their procedure, for example, fasting instructions.

Appropriate List

We have a protocalised assessment to determine suitability for IR led sedation. Patient factors such as significant comorbidities, anticipated difficult airway and moderate to severe respiratory disease are some of the relative contraindications to IR led conscious sedation. Certain procedures may also necessitate anaesthetic support, though the threshold for this need may be determined by the ease of access to an anaesthetic list.

Optimisation

For those patients on an anaesthetic list, it is essential that they are pre-assessed in a similar fashion to all other surgical patients. This encompasses a comprehensive history, appropriate investigations, and use of scoring systems to complete a thorough and individualised assessment, which will guide what form of optimisation is required.

History, should be thorough, going through all the clinical systems. Currently, there are many patient facing, digital patient questionnaires that can be accessed by patients in the comfort of their home. This allows standardisation across all patients. 

Furthermore, scoring systems such as ASA (American Society of Anaesthesiology) grading and STOPBANG score (for obstructive sleep apnoea) can be embedded into the digital software to predict a score for the patient.

Appropriate investigations such as blood tests, ECG and lung function tests must all be part of the pre-assessment nurses remit and an escalation policy in place for abnormal results. There is national guidance on what investigations are needed when and it is important not to over utilise investigations. The aim is to put the history, investigation and scoring systems together to build a picture of the patients’ health and areas for optimisation.

Research and data have demonstrated the impact of poorly controlled co-morbidities on post-operative. One such example is diabetes. There is clear national guidance that elective surgical patients should have reasonably well controlled diabetes, with an HbA1c < 8.5%. Elective patients with poorly controlled diabetes should either be referred to their primary care physician or diabetic team for optimisation. Of course, this must be balanced against the timing and urgency of surgery. Poor diabetic control has been associated with worse outcomes such as increased infection rates and complications. 1

Little research has been specifically done on the interventional radiology cohort of patients with diabetes but with a large proportion of vascular patients suffering with diabetes, it is an issue that will be faced in every IR pre-assessment. Some may argue that the chance of infection at the site of an endovascular intervention may be low, but better diabetic control should limit progression of disease and overall improve outcomes of revascularisation.

Embedding referral pathways for commonly encountered medical conditions helps in the efficient running of the preassessment service. There is a choice to make to run the IR pre-assessment service independent or linked to the centralised pre-assessment service.

Having a linked model of preassessment provides the ability to draw on for example the high-risk anaesthetic clinic. This is an anaesthetic consultant led service accepting referrals of complex patients deemed unsuitable for conscious sedation and considered high-risk from an anaesthetic point of view.

A lot of these guidance’s have been developed for patients having surgery under anaesthesia and it can be challenged if this degree of assessment is needed for the interventional radiology patients. Certainly, for those having their procedure under local anaesthetic, a basic level of preparation may be all that’s needed. Even for those patients having their procedure under local anaesthetic, it is a good opportunity to educate patients on lifestyle modifications and at our hospital we have access to smoking and alcohol cessation services.

Preparation

Finally preparation should include medication advice and fasting instructions and address any issues that may result in on the day cancellation or delays.

The future

There is strong evidence base that perioperative optimisation leads to better outcomes and thus it is essential we use every patient contact as a chance to start and maintain dialogue on improving health.

With IR being called on to provide ever more complex clinical care often in high-risk patients, a robust pre-assessment service is vitally important for the continued provision of an efficient and safe service for our patients. The service needs to have clear protocols for escalation of complex patients that follow national guidelines on preassessment and a governance structure that is able to adopt national guidance locally.

The Centre for PeriOperative Care (CPOC) provide a wealth of information and resource to support pre-assessments services.2

Dr Nazia Khan, Consultant Anaesthetist and President - Society of Anaesthesia and Radiology, Guy’s & St Thomas’ Hospitals

References:

1 www.cpoc.org.uk/sites/cpoc/files/ documents/2021-03/CPOC-Guideline%20 for%20Perioperative%20Care%20 for%20People%20with%20Diabetes%20 Mellitus%20Undergoing%20Elective%20 and%20Emergency%20Surgery.pdf

2 www.cpoc.org.uk