At James Paget University Hospitals, vulnerable patients undergoing elective surgery benefit from extra support from the ‘VIP pathway’ team. This initiative won the Learning Disabilities Nursing category in the 2017 Nursing Times Awards
Adults and children with learning disabilities, or any other physical or mental health problem that makes them more vulnerable than others, may feel particularly anxious or distressed when they need to have a surgical procedure. The anaesthetic phase can be particularly stressful, and it is not unusual for operations to be cancelled at the last minute due to a patient’s anxiety. In 2012, a small team of nurses at James Paget Hospital decided to set up a pathway to provide extra support and reassurance to vulnerable patients and their carers before, during and after elective surgery – the ‘VIP pathway’ was born.
Citation: Crossley R et al (2018) A ‘VIP pathway’ for vulnerable people receiving elective surgery. Nursing Times [online]; 114: 10, 48-49.
Authors: Rebecca Crossley is learning disability liaison nurse; Sarah Hay is dementia care liaison nurse; Joan Pons Laplana is transformation nurse; all at James Paget University Hospitals Foundation Trust.
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- To contact Rebecca Crossley about this project, please email: Rebecca.Crossley@jpaget.nhs.uk
All too often, we read that vulnerable people – whether they have a learning disability, dementia, autism or other – have been victims of serious incidents, had their rights breached or even died when using health services (Heslop et al, 2014; Mencap, 2012). With such reports at the forefront of our minds, we easily miss the beneficial initiatives taken to help these patients in hospitals across England. One such initiative is the ‘VIP pathway’ for vulnerable adults and children undergoing elective surgery at James Paget University Hospitals (JPUH) Foundation Trust – where VIP stands for ‘very important patient’.
Introduced in 2014, the VIP pathway is grounded in the principles of person-centred care and reasonable adjustments. Person-centred care entails:
- Tailoring treatment to individual patients;
- Developing with them a therapeutic relationship built on understanding and trust;
- Respecting their rights as a person (McCormack and McCance, 2011).
As nurses, we have a responsibility to provide all our patients with person-centred care.
With vulnerable patients, person-centred care often includes making reasonable adjustments – that is, taking positive steps to remove barriers people face because they have a disability – thereby ensuring they have equal access to services and receive the same standard of care as anyone else (Turner and Robinson, 2011). There are legal requirements to make reasonable adjustments under the Autism Act 2009, Mental Capacity Act 2005 and Equality Act 2010. Other milestones are the Department of Health’s policy papers, Liberating the NHS (DH, 2012) and Valuing People (DH, 2001).
When it comes to admitting people with learning disabilities, autism or dementia to hospital for surgery, making reasonable adjustments involves:
- Preparing them for their admission and procedure;
- Making their experience less stressful during their stay;
- Supporting their recovery after discharge.
Before the VIP pathway was introduced at JPUH, operations on vulnerable patients were often cancelled at the last minute because patients were overcome by anxiety during the anaesthetic phase. There were also high ‘did not attend’ (DNA) rates. The subsequent delays directly damaged health, cost and efficiency outcomes.
In 2012, a small group of staff started working on a bespoke pathway for vulnerable patients who use the trust’s elective surgery services. Its aims were to:
- Engage with patients, families and carers;
- Reduce health inequalities;
- Adopt reasonable adjustments in key areas;
- Improve efficiency and save costs.
The VIP pathway team comprises a range of condition-specific professionals, supported by the learning disability and/or dementia teams. It ensures that planning, pathway and procedures apply the principles of person-centred care, encompass reasonable adjustments and provide a seamless patient experience. It closely collaborates with patients, relatives and carers (formal and informal), as well as specialist, tertiary and acute care staff, and primary care and community services.
At induction, all JPUH staff receive training in assessing the needs of patients with learning disabilities, autism or dementia. Patients are usually identified as needing reasonable adjustments when they attend an outpatient clinic or go onto the waiting list for surgery.
Every stage of the journey
From that moment, the VIP pathway team starts to plan every stage of their journey, from pre-operative assessment to admission, procedure and discharge.
Relatives, informal carers and/or care home staff are invited, along with patients, to a pre-operative planning meeting where they are introduced to the team and can ask questions. The meeting also enables the team to find out more about patients’ specific needs and what measures may help ease any anxieties they may have.
One such measure is to allow patients’ main carers to be with them during their whole journey in hospital, including during the anaesthetic and recovery phases. Patients are usually given an individual room where their carer or relative can stay with them. The only time when carers cannot be present is during surgery in the operating theatre.
Patients and carers can visit the operating department and see the anaesthetic room, operating theatre and recovery room before admission. They receive a ‘desensitisation kit’ that contains green scrubs, an oxygen mask, cannulas and wristbands – the idea being that patients arrive on the day feeling familiar with the equipment. These have proved hugely successful – some patients even arrive for the procedure wearing the scrubs. The kits also contain a photographic booklet, Theatre Journey, which can be used as an education tool.
According to individual patients’ health needs, they or their carers can speak to a consultant on the phone, or even receive a home visit, so questions arising before surgery are addressed. We have had orthopaedic surgeons, urology staff and anaesthetic staff visiting patients at home pre-operatively. On two occasions, we have even had patients anaesthetised at home due to the severity of their condition and the urgency of the intervention. One of these two home anaesthetics has been cited as an example of good practice by NHS Improvement (2018) in its learning disability improvement standards.
To ensure patient care before, during and after surgery is optimised, and continuity of care is provided after the hospital phase, the team involves primary care staff, including GPs. This is particularly relevant if, for example, blood tests, transfers or other procedures are needed while the patient is under anaesthetic, or if the patient’s care or medication needs to be adjusted at any point in the process.
Impact and feedback
With the VIP pathway, we make sure vulnerable patients receive extra support so they experience as little distress as possible. Patients and carers feel reassured; this not only makes their existing journey easier, but also decreases the chances of them avoiding hospital services in future. Since the pathway was created, the DNA rate and number of theatre cancellations have gone down – cancellations went from 55 in 2011/12 to 41 in 2014/15, which brought year-on-year cost savings.
“Exciting, innovative, replicable, validated, articulated, implemented, embedded, evaluated … Sorted!” (Judges’ feedback)
The trust incurs no extra costs. In many ways, the VIP pathway reduces workload and costs, as several procedures can be done under one anaesthetic; previously a separate anaesthetic would have been needed for each. Despite initially requiring much coordination to ensure everything is in place, in the longer term, the pathway affords more efficient ways of working by reducing the number of procedures needed and avoiding the need to reschedule operations.
The VIP pathway has been publicised throughout the trust and is now well established, with all teams and disciplines on board. It has been adopted by the whole anaesthetic department, and more consultants have become involved as patients with different needs have been treated. The feedback we get consistently indicates that patients feel more settled, family carers more reassured and staff more supported.
We have shared the VIP pathway with other trusts through various forums and many have expressed an interest in adopting similar processes. The idea is to ensure all vulnerable patients can expect the same standards and pathways when they have elective surgery at any acute trust in England.
By embedding the VIP pathway in our practice and culture, we strive to change attitudes towards people with learning disabilities, dementia, autism or any other form of physical or mental health issue that makes them vulnerable. Ultimately, we want the same principles applied to vulnerable patients accessing emergency care.
- Providing person-centred care to patients with a learning disability, autism or dementia requires making reasonable adjustments
- Vulnerable patients waiting for elective surgery need support to be prepared for their admission and procedure
- Patients will often feel reassured if their main carer can stay with them during their admission
- A pathway for vulnerable patients receiving elective surgery can reduce cancellations and rescheduling
- At James Paget Hospital, the ‘VIP pathway’ ensures vulnerable patients undergoing surgery experience as little distress as possible
Department of Health (2012) Liberating the NHS: No Decision About Me, Without Me.
Department of Health (2001) Valuing People: A New Strategy for Learning Disability for the 21st Century.
Heslop P et al (2014) The confidential inquiry into premature deaths of people with intellectual disabilities in the UK: a population-based study. Lancet; 383: 9920, 889-895.
McCormack B, McCance T (2011) Person-Centred Nursing: Theory and Practice. London: Wiley-Blackwell.
NHS Improvement (2018) The Learning Disability Improvement Standards for NHS Trusts.