VOL: 97, ISSUE: 41, PAGE NO: 30
Liz Allen, RN, is lead nurse, the Easi-Book and preassessment service, Walsall Hospitals NHS TrustThe government is committed to reducing the number of patients waiting for an operation and the length of time they wait, and to improving the quality of the service they receive throughout the entire process.
The government is committed to reducing the number of patients waiting for an operation and the length of time they wait, and to improving the quality of the service they receive throughout the entire process.
With this in mind, Walsall Hospitals NHS Trust decided to improve the service it provides to patients who need operations. It has initiated a booked admissions programme that encompasses flexibility and patient choice while ensuring optimum use of the resources available.
The Easi-Book system, as it is called, is an 18-month pilot project. It aims to ensure that patients who attend an outpatient clinic and are offered treatment will be able to book a provisional date for surgery and be preassessed for their operation before leaving the department (if they have the time to do so and feel that this is the best time for them). In this way, patients will have the convenience of a one-stop appointment.
The project has assumed the emblem of an aeroplane, which reflects the ease of booking through a central reservation system - similar to the way you would book a flight. The project office regularly distributes an information flyer to GPs, primary care groups, health centres and throughout the trust so that everybody is kept up to date on how the project is progressing and what will be happening next.
The project has been divided into four stages (Box 1) and the trust is currently in stage two. This article examines the Easi-Book service and the role of the nurse in providing it.
Referral to the Easi-Book suite
After the patient's consultation with a doctor in the outpatients' department, where a need for treatment has been identified and discussed, the patient is shown to the Easi-Book suite with his or her notes and a completed Easi-Book consultant form. The doctor referring the patient is required to complete all the details on the form before it can be processed.
On arrival at the Easi-Book suite, the clerk who greets the patient enquires whether he or she has the time to stay and book the impending operation and undergo a preoperative assessment. This assessment generally takes between 25-40 minutes for patients who will undergo a general anaesthetic and 10-20 minutes for patients who require local anaesthetic. Patients are advised of these timescales before committing themselves.
If patients decide that it is not convenient to stay and wish to return to the Easi-Book suite at a later date, they select a day and time that is convenient for them and the relevant appointment is made.
Some patients prefer to go home with a list of available dates so that they can check their diaries and then telephone the Easi-Book suite to book a provisional operation date and preassessment. A letter is then sent to the patient confirming the date and time of each appointment.
Booking the patient onto a theatre list
The provisional operation date is confirmed once the patient has been preassessed. They are booked straight onto a theatre list using Res - Q OR, a theatre booking system that reserves the relevant equipment needed for the operation and allocates the time required to carry out the procedure.
To enable a booking to an operation theatre list, the clerk is required to input the patient's personal, hospital and consultant details and the theatre to be used. A description of the operation is also required, and whether it is to be carried out under local or general anaesthetic.
The consultants and theatres have access to these lists via the Res - Q OR system, enabling them to keep up to date and see their lists at a glance.
What happens during preassessment? The nurse's role involves:
- Completing a full nursing assessment - physical, psychological and social (not required for patients undergoing a local anaesthetic);
- Completing a comprehensive anaesthetic assessment, including an airway assessment (not required for patients undergoing a local anaesthetic).
Every Thursday a combined clinic is held in which a nurse and anaesthetist can discuss any problems identified with patients, such as an abnormal electrocardiograph or difficult airway assessments. Patients who are worried about the anaesthetic are invited to talk to an anaesthetist about their fears before admission;
- Autonomously carrying out blood tests and investigations following guidelines and protocols (not required for patients undergoing a local anaesthetic);
- Preparing patients psychologically by providing them with both written and verbal information on their impending operations and discharge needs. Patients can also be directly referred to specialist nurses or a dietitian, as appropriate;
- Ensuring that the patient leaves the Easi-Book suite that day with a helpline telephone number and contact name in case they have any further queries;
- Identifying abnormalities in tests and investigations or identifying that the patient is not suitable for treatment in the surgical day unit.
Where abnormalities are identified, the nurse is responsible for referring the patient to the appropriate people so that the problems highlighted are either rectified before admission or the patient's operation is deferred until the problem has been addressed. This involves liaising with GPs and practice nurses to ensure that relevant treatment is initiated.
Where the patient does not meet the surgical day unit criteria, the nurse liaises with the consultant and his or her secretary and the patient is moved to an inpatient theatre list. Patients are given a full explanation of the reasons why they do not meet the criteria. An estimated date for inpatient treatment is then provided. (In stage three of the project the patient will be able to choose a date for inpatient day-case treatment.)
The GP is contacted regarding the patient's unsuitability for surgical day-unit treatment and his or her addition to an inpatient day-case list. If the reason for this is unsuitability to undergo general anaesthetic and the consultant decides that it is possible to perform the operation under local anaesthetic, the patient is given this option. If the patient wishes to continue, a date for the operation is booked. All information is forwarded to the GP.
In cases where treatment needs to be deferred, theatre time is reallocated to another patient to ensure optimum use of theatre time and resources. Any abnormalities identified are discussed with the relevant consultant and the information is forwarded to the patient's GP.
Patients are asked to return to the Easi-Book suite at a date and time that is convenient to them to discuss the abnormal findings and relevant treatment or an appointment is made for them to return to their GP.
Patients are also asked to contact the Easi-Book suite if they develop a cold, cough or flu in the week before their operation so that their suitability for the impending surgery can be reassessed. If they are deemed unsuitable to undergo surgery, their theatre time is reallocated to another patient and they are given a later date once their cough, cold or flu has cleared up.
How are GPs kept up to date?
At the end of each clinic, patients' notes and details of their provisional operation dates and treatments are sent to the consultant's secretary to be forwarded to the relevant GPs. If dates are changed or patients decide that they no longer want the operation, their GP is informed by letter.
Do GPs have access to Easi-Book?
The Easi-Book system is starting to take direct referrals from 'accredited' GPs who can book their patients directly onto a day-case theatre list. GPs are invited to join this process by the hospital consultants and hence gain 'accreditation' status. Designated consultants forward referrals from GPs straight to the Easi-Book suite.
The patient is then informed of the provisional operation date and preassessment appointment, which are negotiated with them. Once patients have passed their preassessment, a letter or e-mail confirming the details is sent to the GP.
Because patients are being booked onto theatre lists directly from GP referrals, they do not necessarily see a consultant or attend as an outpatient before their operation. Patients are asked if they wish to see a consultant and an appointment is arranged if necessary.
Where possible, patients who have direct GP referrals attend their preassessment appointment on the day the consultant performing the operation is carrying out his normal outpatient clinic. If any queries or concerns are raised at the preassessment appointment, the nurse can liaise with the consultant or registrar. This clinic is close to the Easi-Book suite.
What do patients think of Easi-Book?
- Patients love it. They cannot believe the flexibility of the system and the amount of choice they are given;
- They like having someone to talk to on a one-to-one basis who has the time to listen to and answer their questions, no matter how trivial;
- They like being given the option:
a) Of booking their date and being preassessed there and then or
b) Being given the chance to go away and think about what the doctor has said, to consider their forthcoming commitments and then contact us to book a provisional date for their operation and preassessment appointment;
- They like knowing that there is someone they can get in touch with if they need more information;
- They like the friendliness of the system and the relaxed atmosphere;
- They like receiving written as well as verbal information.
What has Easi-Book done for the trust?
The Easi-Book system has had many positive effects on the trust. It has:
- Reduced the rate of non-attendance;
- Filtered out patients who are not suitable for day surgery, ensuring optimum use of resources;
- Provided patients with a quality service that is flexible and gives them more choice;
- Provided a better communication network with local GPs as well as within the multidisciplinary team;
- Provided a nurse-led service, encouraging autonomy;
- Ensured that patients are better informed before surgery;
- Provided patients with a dedicated helpline, which is used by a quarter of them.
Using stage two of the project as a foundation, the trust is about to embark on the third stage, where the Easi-Book system will book day cases for inpatient beds. Hopefully, the project's success and popularity will continue.