An easy win – taking the pain out of pre-op assessments


The traditional pre-op assessment undertaken by a nurse in a hospital is one obvious procedure that could benefit from a 21st century update. Time- and resource-consuming, in many cases they could be replaced by a more efficient and cost-effective process, as one doctor and one designer suggest.

pre-op assessment

Dr Paul Upton was a consultant anaesthetist in the NHS for over 20 years. In his career he was involved in clinical care, medical education and medical management. Now in his 50s he’s been developing an interest in clinical informatics, not as an informatics expert but in the capacity of a medical professional envisaging how software solutions could improve clinical care. Now his ideas are helping to save resources and money in the NHS by improving the referral time to treatment (RTT) pathway.

Most of us live our lives increasingly online, yet healthcare lags a long way behind. Paul had a particular interest in preoperative assessment having sat on the NICE working group in 2003 that produced the first guidelines on which tests should be undertaken before having an anaesthetic and operation. Before this, patients were admitted the day before their surgery and the preoperative ‘clerking’ and tests were done then. Since becoming an outpatient procedure, pre-ops involve an appointment with a nurse who asks each patient a long set of questions and records their preoperative assessment on a paper form.

The rules were updated last year but still place responsibility in the hands of overworked nursing staff. This had been playing on Paul’s mind but it wasn’t until fate provided a nudge that he started to work on updating this outmoded practice.

A chance meeting of minds

In 2014, on a flight from Gatwick to Newquay, Paul starting talking to the passenger next to him who was reading a magazine about sailing. It turned out that Alan Sanders also lived in Cornwall, liked sailing – and ran an award-winning creative design studio. They swapped business cards and kept in contact as, despite having very different skills sets, they had similar interests and ‘like minds’.

When Paul again questioned was why it was taking 45 minutes for a nurse to ask questions and record answers – with only a small amount of that time being taken to make the relevant clinical decisions and provide further information to the patient – he wondered if partnering with Alan might prove useful. The idea was to get patients to enter their own information online into their own health account. The patient would truly own their own information and decide exactly who to share it with. Alan’s critical input would be to design the user interface.

Paul started testing the idea by writing down examples of the questions that were being asked in pre-operative assessment clinics in a Word document. With a paper record or a simple e-form there were just set of questions with no additional questions asked depending on previous answers. But by using ‘branching Clinical Algorithms’, much more detailed, relevant questions can be triggered from the patient’s initial answers.

Within a day it was clear that a Word document wasn’t the right approach so Paul started writing the questions into a spreadsheet allowing triggered additional questions to be included. By taking examples of the patient questionnaires used in pre-operative assessment in a large number of hospitals (available online) and then building up the questions in the spreadsheet, it was possible to develop a core set of questions that were being used in the majority of hospitals.

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Adding (useful) complexity

The next step was then to build in ‘clinical decision support’. This means suggesting various actions within the Clinical Algorithms depending on the patient’s responses. These actions include suggesting blood tests, doing an ECG and other more complex tests. It also included actions such as referral to other specialist clinicians such as a diabetes nurse if a patient had complex diabetes that would be difficult to control during the operation and recovery period.

Taking a comprehensive medical history is complex and inevitably includes questions about certain symptoms or diseases that not all patients understand. Within the Clinical Algorithms it was possible to build in web links to carefully selected websites that could provide patients with additional information. This would help them complete MyPreOp and also provide access to health education materials about topics like stopping smoking, decreasing alcohol consumption and losing weight. About 140 web links have been built in and are constantly being refined to identify the best information for patients.

Alongside the work on the Clinical Algorithms, Paul and Alan set about the design of the User Interface. If the idea of patients entering their own information was going to work, the interface had to be slick and intuitive. Starting with a ‘story board’ in Alan’s design studio the interface began to develop. It was time to decide, was this just an idea or were we going to develop this further, start up a company and take a product to market.

A small startup grant was obtained alongside personal investment to launch Ultramed Ltd and allow the software to be developed by a third party software house. Ultramed moved into one of the three Innovation Centres in Cornwall providing business startup support as well as office facilities.

Continuing the journey

The Clinical Algorithms that underpin MyPreOp have been further developed into an integrated suite of pre-procedure assessment programs under the tradename of Ultraprep. This allows patients to complete online assessments before having an endoscopy, a cardiac investigation or an interventional radiology procedure. MyEndo, MyCardio and MyIR have joined the exciting range of innovative health technology solutions provided by Ultramed alongside a kid’s version of the pre-op programme and MyPreOpLA , a cut down version of MyPreOp for patients having procedures under local anaesthetic when no anaesthetist is present such as most cataract surgery.

So where are they at? Dr Upton says, ‘We have generated a huge amount of interest and done demos on site for about 60 hospitals in the last two years. Five contracts for trials have been signed but it is still early in our journey. The NHS is a notoriously difficult market to penetrate and is slow to adopt and spread innovation. Despite this, we are making much faster progress than many innovative companies.’ The clear benefits might be the reason for this success. ‘The calculated Return on Investment is £4 saved for every £1 spent,’ he continues. ‘Plus there’s evidence that digital pre-op assessments, where the patients enter their own information, can halve the amount of nursing time that is needed.’

About the author

Journalist and editor Kathryn Reilly has worked in consumer, contract and medical writing for more than 20 years.

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