Computerised CHAT to streamline pre-operative assessments

A trial of over-the-phone consultations and a computerised questionnaire for pre-operative assessments has begun this week at Royal Adelaide Hospital with the aim of reducing unnecessary travel for patients and freeing up session times for surgeons and anaesthetists.

Dubbed Computer Health Assessment by Telephone (CHAT), the trial involves a comprehensive questionnaire that is conducted over the phone by a non-clinical healthcare worker that fully documents the patient's requirements and reduces the need for them to attend outpatients for a face-to-face consultation.

The CHAT pre-screening model is based on previous studies led by the head of acute care medicine at the University of Adelaide, Guy Ludbrook, and his colleague Cliff Grant, as well as WA anaesthetists Tomas Corcoran and Ed O’Loughlin.

Their study of more than 500 patients scheduled for elective surgery found that the quality of assessment provided by a non-clinician telephone interview was comparable to a face-to-face interview by trained anaesthetists, and often more comprehensive.

Professor Ludbrook, also a senior anaesthetist at Royal Adelaide Hospital, said the development of the model was driven by three problems. One is how to ensure that the quality of preoperative work-ups are sound, accurate, robust and consistent, which is a particular challenge with elderly patients.

Another is to help overcome capacity issues in a fiscally tight environment for public healthcare, and the third is how to better deal with access problems for patients who find it difficult to attend hospital.

“What we came up with over time was a really big questionnaire that effectively became a very large pre-operative checklist,” Professor Ludbrook said. “Knowing and understanding the benefits of surgical checklists such as the WHO checklists, we wanted to expand that dramatically and we really needed computers to do that.

“Secondly, we needed a means of interaction that was practical. Just about everyone has a telephone so that allowed us a very easy first contact point. It's often not the last, but it is the first.”

Professor Ludbrook and his team have built up the questionnaire over time through an iterative process, starting with anaesthesia and then bringing in surgery, medicine and pharmacy requirements.

“What we discovered, not surprisingly, is that there is an enormous amount of overlap and redundancy in what we do already. Our craft groups are often working in parallel and that doesn't always make the most efficient sense, so by getting together we discovered that in fact we can reduce the workloads substantially by combining a lot of these questions and answers.”

CHAT was validated through the 500-person trial by comparing those who were assessed through the questionnaire and those who attended outpatients and saw an anaesthetist. “We looked at the comparative error rate, and they were very similar, in fact statistically the same,” Professor Ludbrook said.

The team also sought formal feedback from clinicians and their response was that in many cases it obviated the need to have a face-to-face assessment well in advance of surgery, he said. “It still needs to occur but it can often happen on the day of surgery, as long as all the checks and balances are done.”

The team has built its own software for the questionnaire, as nothing on the market was quite right for CHAT's requirements. Over time, the questionnaire has grown to contain about 500 questions with 1500 fixed responses, and there will be more to come.

A trained receptionist or a nurse conducts the phone interview, which usually takes about 20 minutes, and enters the responses through a touchscreen into a database. Professor Ludbrook said the team did consider fully automating the system – and it definitely has that potential – but the capabilities of the patients has to be taken into account.

“They have to navigate what is a pretty complex questionnaire and it does help to have people take you through it. We are often dealing with the elderly; some are IT friendly but some are not, and some have internet access but some don't. Some have good vision and some don't.

“There are also very complex issues to be dealt with in terms of access, privacy and so on, so we are taking this one step at a time. We don't know whether we'd get the same richness of information if there wasn't someone helping people through it. An 18-year-old would whizz through it but someone who is 80, perhaps not. We feel at this stage that we are going to walk before we run.”

Much of the IT work was done by Mr Grant, who also worked on how to tailor the various reports that each craft group – including nursing, pharmacy, surgery and anaesthesia – will require.

“That information may come from the same pool but we need to give out what's relevant and concise and laid out well. That's actually another IT challenge in itself. We ended up building it ourselves in a draft version and then it had more professional people involved in getting it into better shape, which is good because it has ended up being fit for purpose.”

Various clinicians can access the completed information in PDF form, but it is predominantly distributed to the different clinical groups in old-fashioned paper form, he said.

“We are not a paperless hospital and to be quite frank, having bits of paper is actually quite helpful because we have paper case notes. At the moment with print them out and they go along with the other bits of paper.

“It is accessible electronically and therefore stored but again, we walk before we run. We have the capacity to be electronic and we will have it on our central SA Health servers soon to be able to do that, but we are taking this step by step.

“I understand the benefits of large IT systems and eHealth and so on, but they are complicated and a lot of things are then interdependent. We wanted to fix one thing as part of a whole process redesign, so we have built it fit for purpose.”

The trial began at the Royal Adelaide Hospital this week, with support from the Central Adelaide Local Health Service. Professor Ludbrook said that in addition to reducing travel time for patients, doctors will be able to see more patients in a given session as a lot of the pre-operative work is already done.

Posted in Australian eHealth

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