1. New Dimensions in Preoperative Assessment G Ludbrook University of Adelaide & S.A. Health

2. Disclosures and acknowledgements Grant funds or commercial agreements: Medibank Private WA Health (SHRAC) Medtel Australia Member, Clinical Governance Committee, RDNS Customer of O’Brien Glass

4. Cost escalation Societal expectations (time) Technology Business challenges

5. Meeting the challenges of cost and quality Remote, rapid access and communication Information processing Technology

6. Conflicting pressures Increased demand Limited resources Changing environment Changing society Technology Healthcare

7. Australian population projections our patient profile Ageing population “middle-aged spread” Old population “coffin shaped” Young population “pyramid”

8. 112 anaesthesia-related deaths Inadequate preoperative assessment - 28% of cases Inadequate preoperative management - 21% of cases

9. Anaesthetic OPD / RoomsProcessesDSU / DOSA Surgeon decides on operation Patient comes to clinic Input from multiple clinicians Nursing Anaesthetist Pharmacist Surgical intern Further testing +/- specialist referral off site Possible repeat clinic visit Exchange of data History Examination Testing Data integration and analysis Management decisions Surgeon decides on operation Some work up may occur Seen on DOS by anaesthetist Processes of current preoperative workup Elective surgery Resource expensive Time expensive – staff/patient High quality Efficient? Resource inexpensive Time inexpensive Quality? Efficient? Fit 17 yr old girl Dental work Mother and daughter lost a day off work 70 yr old repeat colonoscopy Defibrillating pacemaker inserted since last ‘scope

10. Processes of current preoperative workup Windscreen repair / replacement

16. Themes across industries Process analysis New technologies Early triage and streaming to best care pathways Specific elements Data exchange / communication Data management & integration Data analysis / Decision making Management pathways Remote communication Early triage and streaming Computer decision support

17. Virtual Hospital Telehealth Service Medication Management via a videophone

18. Drivers for New Service An aging population Increased incidence of chronic diseases Increased pressure on existing health services… Need to increase client access …. Maximise workforce efficiencies New technologies + creative health services = innovative service delivery

19. Cost Effectiveness o Time reduction - 7 minutes vs 19 minutes o Cost reduction - 40% decrease Risk and Safety o Less intrusive for client o Increased client control over medication management Client satisfaction o Vast reduction in reported medication incidents – pharmacy delivery Formal evaluation

20. Telemedicine versus telephone for remote emergency stroke consultations: a critically appraised topic. Capampangan DJ, Wellik KE, Bobrow BJ, Aguilar MI, Ingall TJ, Kiernan TE, Wingerchuk DM, Demaerschalk BM. To determine the efficacy of telemedicine versus telephone-only consultations for decision making in acute stroke situations. Neurologist. 2009 May;15(3):163-6

21. Neurologist. 2009 May;15(3):163-6. Audio-visual (videoconference) Telephone only Correct acute stroke treatment decisions 98% (NNT 6) 82% Specificity98%92% Sensitivity100%58% Thrombolysis eligibility PPV NPV 94% 100% 76% 84%

22. Preoperative call centre pre-screening Remote communication – phone or internet Non-clinician delivered Computer assisted ‘smart’ questionaire

23. Grant, Ludbrook, O’Loughlin, Corcoran et al., unpublished data Preoperative medical pre-screening 517 patients from two tertiary referral centres Call centre pre-screening before elective surgery Quality of data benchmarked against that collected in OPD 55 anaesthetists involved in assessment

24. Grant, Ludbrook, O’Loughlin, Corcoran et al., unpublished data High quality data collected in 15 minutes Would in theory allow 50-60% of these patients to be seen on DOS

25. Data summary and processing Consistency Legibility Areas of concern highlighted

26. Pre-Admission Website: Patients are asked to complete an online assessment.

27. Healthbank PreOp Anaes Tab: If a disease needs further exploration the anaesthetist has a very powerful drilldown tool.

28. Decision making Isaacs and Fitzgerald, BMJ 319 : 1618 1999 Lam BMJ. 2000 July 22; 321(7255): 239 Evidence-based Consensus-based Opinion-based Eminence-based Vehemence-based Eloquence-based Providence-based Diffidence-based Arrogance-based

29. Expert consensus on preoperative testing http://www.nice.org.uk/nicemedia/live/10920/29090/29090.pdf

31. { Collect data on patient factors which might predict OSA Benchmark against sleep studies Mathematical models which predict likelihood of OSA Determinants of OSA data modelling

32. { Reasonable performance using history alone Improvement adding other factors (eg neck circumference) Model performance Positive Predictive Value

33. Grant, Ludbrook, O’Loughlin, Corcoran et al. Preoperative clinical decisions without hard evidence Obtained opinions from 55 anaesthetists on 517 patients Identified predictive factors Built predictive models which identify what the “group” would do for specific cases Determinants of preoperative decisions data modelling

34. Grant, Ludbrook, O’Loughlin, Corcoran et al., submitted to BJA Probability Model ROC AUC CBP 0.828 MBA 0.861 Coags 0.709 ECG 0.903 ICU 0.876 OPD 0.852 Lumbar discectomy 65 yr old male BMI 35 Treated hypertension Previous CVA 93% 9%99%67%90% Decision support: pre-screening

35. “..... a medical practitioner will not be found negligent if they acted in a manner that was widely accepted in Australia, by a significant number of respected practitioners in the field…..” Value of consensus in decision making Maher and Burke, Medical Journal of Australia, 194(5), 253-255, 2011

36. Anaesthetic OPD / RoomsProcessesDSU / DOSA Surgeon decides on operation Patient comes to clinic Input from multiple clinicians Nursing Anaesthetist Pharmacist Surgical intern Further testing +/- specialist referral off site Possible repeat clinic visit Exchange of data History Examination Testing Data integration and analysis Management decisions Surgeon decides on operation Some work up may occur Seen on DOS by anaesthetist Processes of current preoperative workup Elective surgery

37. Anaesthetic OPD / RoomsProcessesDSU / DOSA Surgeon decides on operation Patient comes to clinic Input from multiple clinicians Nursing Anaesthetist Pharmacist Surgical intern Further testing +/- specialist referral off site Possible repeat clinic visit Exchange of data History Examination Testing Data integration and analysis Management decisions Surgeon decides on operation Some work up may occur Seen on DOS by anaesthetist Processes of current preoperative workup Elective surgery

38. Anaesthetic OPD / RoomsProcessesDSU / DOSA Surgeon decides on operation Patient comes to clinic Input from multiple clinicians Nursing Anaesthetist Pharmacist Surgical intern Further testing +/- specialist referral off site Possible repeat clinic visit Exchange of data History Examination Testing Data integration and analysis Management decisions Surgeon decides on operation Some work up may occur Seen on DOS by anaesthetist Processes of current preoperative workup Elective surgery

39. National E-Health Strategy December 2008 E-Health will: Ensure the right consumer health information is electronically made available to the right person at the right place and time to enable informed care and treatment decisions  Enable the Australian health sector to more effectively operate as an inter-connected system overcoming the current fragmentation and duplication of service delivery  Provide consumers with electronic access to the information needed to better manage and control their personal health outcomes  Enable multi-disciplinary teams to electronically communicate and exchange information and provide better coordinated health care across the continuum of care  Provide consumers with confidence that their personal health information is managed in a secure, confidential and tightly controlled manner  Enable electronic access to appropriate health care services for consumers within remote, rural and disadvantaged communities  Facilitate continuous improvement of the health system through more effective reporting and sharing of health outcome information  Improve the quality, safety and efficiency of clinical practices by giving care providers better access to consumer health information, clinical evidence and clinical decision support tools  Support more informed policy, investment and research decisions through access to timely, accurate and comprehensive reporting on Australian health system activities and outcomes. Allscript Emergisoft Firstnet Healthbank etc

40. OPD / RoomsProcessesDSU / DOSA Surgeon decides on operation Patient comes to clinic for workup Input from multiple clinicians Nursing Anaesthetist Pharmacist Surgical intern Further testing +/- specialist referral off site Possible repeat clinic visit Exchange of information Inspection and auscultation Testing Decision making Management Surgeon decides on operation Some work up may occur Seen on DOS by anaesthetist New models of care

41. Early triage Call centre-based pre-screening Computer smart questionnaire Medicine Nursing Computer-generated guidelines Call centre follow up Remote lab testing Data collection Phone follow up Informed consent Streaming to: Outpatients vs DOSA Appropriate facility

42. “It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change……”