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At your convenience: preoperative assessment by telephone.


Preoperative assessment clinics for elective surgical patients are not a new concept. As early as the mid 1980s in Britain the clinics became recognised as having potential benefits for improving the quality of the service delivered to patients (Sabin 1985, Pring et al 1987). The early literature concentrated on patient outcomes as the benefits of hospitals providing preoperative assessment clinics (or preadmission clinics as they were more commonly referred to at that time), for example increased levels of patient satisfaction and reduced levels of anxiety (Sabin 1985, Haines & Viellion 1990, Le-Noble 1991, Bruce 1993). Over time the emphasis and drive to continue with preoperative assessment came with the realisation that effective preoperative assessment could also have a number of organisational benefits: fewer cancelled operations due to patients being unfit for surgery; reduced lengths of stay; and reductions in junior doctors' working hours (Macpherson & Lofgren 1994, Whitely et al 1997, Keenan et al 1998).

As part of the booked admissions programme, preoperative assessment was identified as an essential part of the patient pathway to facilitate booking and effective theatre scheduling and utilisation. The National Patients Access Team set up a preoperative assessment project (later it became part of the National Theatre Project under the auspices of the Modernisation Agency) to facilitate the expansion and standardisation of pre assessment and to develop good practice guidelines for day, and subsequently inpatient stays (NHS Modernisation Agency 2002, 2003).


Around this time at Bolton Hospitals NHS Trust, preoperative assessment was being increased to cover more specialities in order to facilitate the implementation of the booked admissions programme. A specialist nurse was appointed to further develop the service, increase capacity and standardise practices across all surgical specialities. It soon became apparent that there was not enough capacity in terms of staffing and space to enable all patients to be preoperatively assessed. At the same time, staff working in the Booked Admissions Project Team made a visit to the local NHS Direct to view its call centre and realised that telephone assessment might be one way to address the shortfall.

Further discussion with NHS Direct led to its agreement to develop telephone preoperative assessment with us. A successful joint service proposal was included in a bid for further funding from the Booked Admissions Project and a twelve month pilot undertaken.

Why NHS Direct?

One of the most frequently asked questions during the pilot study and indeed since has been why we chose as a Trust to develop this service with NHS Direct as opposed to going it alone. There were several reasons for this:

* NHS Direct employed a large number of highly trained and experienced staff, many of whom not only worked but lived in Bolton

* local knowledge of the staff (in many cases they had worked within the Bolton Hospitals)

* staff were available at key times such as evenings and weekends

* the already established call centre offered security and confidentiality

* staff were familiar with working on the telephone in a call centre with protocols

* NHS Direct could offer additional services if required.

All of the above ensured that the Trust's set up costs were kept to a minimum allowing us to use the resources available to directly impact upon patient care.

Developing the service

A team was set up to manage the project. Suitable operative procedures for patients to have a telephone assessment were identified. The pilot began with day case patients from the specialities of Gynaecology and General Surgery and soon expanded to include Orthopaedics and Oral Surgery.

The Trust's nursing staff along with the consultant anaesthetist lead for preoperative assessment developed guidelines and protocols for assessment. These were the same as those used for a face to face assessment and are based upon best available evidence. They are regularly reviewed and updated as new information becomes available (AAGBI 2001, NICE 2003).

A screening tool was developed to identify suitable patients for the service. To be offered the service patients were required to have:

* a diastolic blood pressure of <95

* a body mass index of <35

* be aged over 16 and under 60 (for the pilot phase only)

* have no obvious medical conditions.

The screening tool was expanded to include the patient's consent to be assessed over the phone. To ensure NHS Direct nurses were speaking to the correct patient on contact, unique patient determined identifiers were included on the consent form, for example, mother's maiden name or place of birth.

To inform patients about this new service information leaflets were designed by Trust staff while NHS Direct arranged for posters and flyers describing the service to be produced. These were available in all of the outpatient areas that patients might access the telephone preoperative assessment service from.

The most difficult parts of setting up the service were issues surrounding information technology (IT). There were concerns about the sending of information electronically and how this could be encrypted. There was the need to set up firewalls to protect the information stored and IT experts from both organisations worked together in developing a safe and secure system that would support the delivery of the service. Initially, assessments were completed and emailed between the two organisations. The database created with all the patients' details stored on it had to be sent between the two organisations. This meant that only one could access it at any one time. As the service has developed the IT systems used have enabled the creation of a database that allows both organisations to access and work upon it simultaneously. Evaluation from both patients and staff ensured the continuation of the service after the initial pilot.

The service in 2007

Telephone preoperative assessment delivered by NHS Direct is an integral part of the day case patient pathway at the Royal Bolton Hospital. This section of the article describes the current process. The project team now forms the steering group that meets bi-monthly to ensure the service meets the needs of patients and both organisations. The team consists of practitioners and senior managers from the Trust and NHS Direct, IT support as required from both organisations and other key stakeholders including registration and data quality, information and clerical staff. The plan is to invite a patient representative in the near future to give true meaning to the notion of our patient-centred service.

The aims of the service

These remain largely unchanged from our initial thoughts during the pilot study and are:

* to ensure that patients are physically and psychologically prepared for the procedure they are to undergo and have the appropriate social circumstances to be discharged timely and safely

* to ensure that all patients have equal access to quality preoperative assessment that is managed around agreed clinical protocols

* to provide a preoperative assessment service to a high volume of patients with the facility to refer back to secondary care for a face to face assessment when required

* to provide a timely service in a way that patients find easy and convenient to access

* to provide an opportunity for patients to ask further questions about the procedure which they are attending for.

The process (see Figure 1)

Table 1 identifies the possible patient outcomes following assessment. The actual outcome is recorded on the pro forma which is returned to the hospital and the patient is informed of the next steps as detailed.


One of the major benefits realised by patients with the introduction of this service was that they did not have to attend hospital for a further visit prior to their day case surgery as they had previously. For many this reduced the need to take more time off work and struggle with car parking at the hospital. Assessments are completed at the convenience of the patient at times specified by them.


Other developments within the organisation have since reduced the effect of this, as many day case patients now have access to one stop preoperative assessment clinics at the outpatients on the day of decision to operate. Telephone preoperative assessment, however, is still offered and, indeed, accepted by the majority as it means they do not have to wait to be assessed. This has resulted in a smoother flow within the outpatient department as the potential for one stop pre-assessment bottlenecks and subsequent waiting is lessened.

Service evaluation has demonstrated that DNA rates are reduced as a result of patients having telephone preoperative assessment, therefore improving theatre utilisation.

At the first evaluation in 2003 all patients assessed as suitable for day case surgery by NHS Direct (50-80 patients per month) attended on the day of surgery while those who had a face to face attendance returned a DNA rate of 3%. At the second evaluation in 2005 as the numbers of patients assessed by telephone increased, (100-150 per month) DNA rates continued to be fewer for those patients assessed by NHS Direct (1.4%) compared to face to face assessment which remains fairly constant at 2.9%. Further evaluation is planned for 2007.

Telephone assessment is presently completed for approximately 250 patients per month with the opportunity to increase up to 330 within the present service level agreement. This has freed up capacity within the Hospital preoperative assessment teams to enable them to assess a greater number of patients with more complex medical and social care needs, facilitating improved discharge planning and shorter lengths of stay.

Working in partnership with NHS Direct has proved a very positive experience and the strong relationship between the two organisations has allowed us to look creatively at other ways they may be able to support secondary care services. We are further strengthening our partnership working by developing a service whereby NHS Direct preoperative assessment staff undertake postoperative telephone follow up of day case and short stay surgery patients whom had previously been scheduled for an outpatient follow up appointment at the hospital. The NHS direct assessment team work to protocols which allow them to discharge patients back to their general practitioner's care or arrange for further secondary care follow up. This service development is at the pilot phase but early indicators are that this scheme is successful and is set to expand further.

Patient feedback

To evaluate the service from a user's perspective, regular patient feedback has been collected. Periodically, questionnaires are sent out to patients after they have had surgery to monitor the service, highlight what is going well and areas that need improvement. Encouraging patients to give us their views and suggestions ensures that the service remains appropriate to their needs. Feedback has been very positive. Patients report that they are being contacted by NHS Direct at a convenient time and comments such as: 'Phoned at night which is what I asked for', and, 'Phoned on a Saturday morning - which was actually very reassuring, because I felt the nurse had made an extra effort to contact me out of hours'. Positive comments were also offered when the contact was not at a convenient time: 'Excellent. Contacted me on my mobile which wasn't convenient, but rang me back on my home number within 20 minutes as arranged'.

Most patients surveyed felt comfortable answering questions about their health over the phone and have said that the, 'nurse put me at ease', and, 'very comfortable, better than going to the Hospital', and, 'I was very worried at first but the relaxed discussion with the nurse about what to expect put me at ease'.

Patients felt that they have the opportunity to ask questions and have commented that, 'the nurse answered every question so I understood and felt better'. However, some patients do worry more after the assessment and one said: 'Only because she was very thorough and honest and explained everything - which was a good thing because I knew what to expect, but worried slightly more.' Patient feedback will once again be sought as we evaluate the service again during 2007.

Future plans

One of the keys to success of this service development has been the continuation of the steering group. Regular meetings have allowed us to iron out any issues before they become problems and it has also encouraged us to continually look to how we might move the service forward. Future plans currently under discussion include the following:

* the invitation of a patients' representative to sit on the steering group

* expansion of the service to include more short stay elective procedures

* completion of the telephone postoperative follow up pilot and expansion of this service

* further evaluation is planned, both local as before and independently commissioned by NHS Direct in conjunction with Imperial College London.


As the drive to reduce the numbers of beds in hospitals increases and the basket of procedures for day surgery has expanded, high quality, standardised, preoperative assessment is more important than ever. It is an essential stage in the elective surgical day case patient pathway and is integral to delivery of an 18 week patient journey. Preoperative assessment has to be fit for purpose. In Bolton we feel we have developed a service with local partners in the health community that meets the needs of our day surgery patients, which truly is their choice and at their convenience.


The author would like to thank the other original members of the project development team, without whose drive and enthusiasm this service would not have been realised: Kathy Agrebi, NHS Direct, Regional Head of Business Development North West; Tricia Robinson, Service Delivery Manager, NHS Direct, North West Region; Annette Thorpe, Sister, Bolton Hospitals NHS Trust; Vicky Welsby, Matron, Bolton Hospitals NHS Trust; Joanne Ellis, Former Booked Admissions Programme Manager, Bolton Hospital NHS Trust.


Bruce P 1993 Off site preadmission unit supports hospital ambulatory surgical unit Journal of Post Anesthesia Nursing 8 (4) 262-269

Haines N, Viellion G 1990 A successful combination: Pre-admission testing and preoperative education Orthopaedic Nurse 9 (2) 53-57

Keenan J, Henderson M H, Riches G 1998 Orthopaedic preoperative assessment: A two year experience in 5,000 patients Annals of the Royal College of Surgeons England 80 (4) 174-176

Le-Noble E 1991 Pre-admission possible Canadian Nurse 87 (2) 18-20

Macpherson DS, Lofgren RP 1994 Outpatient internal medicine preoperative evaluation: a randomized clinical trial Medical Care 32 (5) 498-507

National Institute for Clinical Excellence 2003 Preoperative tests. The use of routine preoperative tests for elective surgery Clinical Guideline 3 Available from: [Accessed 16 May 2007]

NHS Modernisation Agency Operating Theatre and Preoperative Assessment Programme 2002 National Good Practice Guidance on Preoperative Assessment for Day Surgery Department of Health Available from: cmsWISE/Cross+Cutting+Themes/access/elective/documents/documents.htm [Accessed 16 May 2007]

NHS Modernisation Agency Operating Theatre and Preoperative Assessment Programme 2003 National Good Practice Guidance on Preoperative Assessment for In-patient Surgery Department of Health Available from: +Themes/access/elective/documents/documents.htm [Accessed 16 May 2007]

Pring DJ, Naidu A, Burdett-Smith P, England JP 1987 An assessment of orthopaedic preadmission clinic Journal of the Royal College of Surgeons Edinburgh 32 (4) 221-222

Sabin N 1985 Dedicated preadmission testing centre cuts costs LOS Hospitals 59 (6) 66 & 70

The Association of Anaesthetists of Great Britain and Ireland 2001 Preoperative Assessment--The Role of the Anaesthetist Available from: [Accessed 16 May 2007]

Whitely MS, Wilmott K, Offland RB 1997 A Specialist Nurse can replace pre-registration House Officers in Surgical pre-admission clinic Annals of the Royal College of Surgeons England 79 (6) 257-260

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Marie Digner

RGN, BSc (Hons), MSc

Professional Practice (Development and Evaluation) Matron/Clinical Lead Outpatient Services, Bolton Hospitals NHS Trust
Table 1 Possible assessment outcomes

Outcome A    Patient is to attend for booked surgery as planned
Outcome B1   Patient requires further input before decision taken
              about suitability for surgery. The patient is referred
              back to the Trust for a face to face assessment
Outcome B2   Patient is unable to be contacted. The patient is
              referred back to the trust two weeks before the
              procedure date to enable the arrangement of a face
              to face pre-assessment/postponement of surgery
Outcome C    Patient assessed as unsuitable to undergo surgery/
              procedure. The patient is referred back to the trust
              with advice to cancel the procedure indicated on the
              document template
Outcome D    Patient requires ECG/Blood tests prior to admission. NHS
              Direct nurse arranges relevant investigations and
              patients attends appointment for these at the trust
Outcome E    Procedure no longer required. Patient has already had/no
              longer wants procedure. NHS Direct complete relevant
              section with advice to cancel the procedure indicated on
              the document template
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Article Details
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Author:Digner, Marie
Publication:Journal of Perioperative Practice
Article Type:Report
Geographic Code:4EUUK
Date:Jul 1, 2007
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