Patient Pathways
The SWLEOC patient pathway is divided into three stages: pre-admission, inpatient and post-discharge. This pathway has evolved over the past 20 years since the centre opened. When SWLEOC opened in January 2004, all referrals for treatment were received by the scheduling team from outpatient clinics in the five base hospitals. All patients attended SWLEOC preoperatively for a pre-admission assessment and attended a group, joint-school, education session to help set their expectations for their inpatient treatment and aftercare.
Pre-admission
The patient’s first visit to SWLEOC was to attend a pre-admission assessment appointment with an Advanced Nurse Practitioner. In most cases, the Advanced Nurse Practitioner was able to clear the patient for the schedulers to provide a date for surgery. When cases with complex medical co-morbidities were identified, the patients were seen, during their assessment visit, by one of the centre’s in-house Anaesthetists or Intensive Care Specialists, as appropriate. The intensivists were able to undertake echocardiograms and every effort was made to create an ethos that a single pre-admission visit should result in a treatment plan that would allow the patient’s operation to be undertaken safely. Also, that the SWLEOC team would have the clinical expertise to minimise the need for other external specialist opinions.
While patients continue to be listed for surgery by the base hospitals; a significant proportion of patients are now seen in a SWLEOC clinic, by a SWLEOC employed surgeon or surgeon from one of the base hospitals. The outpatient facility has a dedicated X-ray suite, so that radiographs can be undertaken without delay or compromise to the inpatient pathway. The majority of SWLEOC listed patients also see a SWLEOC pre-admission assessment Nurse, on the day of their outpatient appointment. This provides a one-stop service that avoids any need for a second visit. All patients complete a virtual health questionnaire that is validated by the preoperative assessment (POA) nursing team.
Group, joint-school education classes have been superseded by online education resources and ‘Preparing for Surgery‘ videos that the patients can review, at home, with their families and carers.
In-patient
From the outset, inpatient treatment has been designed as a “one-way” pathway from reception to pre-theatre, on to the operating theatre, then to the post anaesthetic care unit (PACU) (where they may b e discharged as a day case) and finally to the ward for mobilisation and discharge.
Robust pre-admission assessment, surgical and anaesthetic planning combined with telephone calls from the pre-admission Nurses minimises the number of day-of-surgery cancellations. The layout of the centre means that patients can be transferred easily and rapidly from pre-theatre to the operating theatre by members of the theatre team. Following surgery, patients are transferred to the PACU. This is staffed by Nurses trained in high dependency patient care and an on-site Consultant Intensivist. The patients stay on the PACU until they are metabolically stable and are then transferred to one of the two wards for mobilisation, rehab and discharge. Patients suitable for same day discharge following joint replacement are discharged directly from PACU once their discharge criteria are met.
Twice daily safety huddles and once-daily ward rounds are undertaken by the on-site Consultant Intensivist, a Ward Nurse, a Physiotherapist and a Pharmacist. This ensures that any patient who is failing to progress or developing medical problems is rapidly identified and if deterioration is observed, the patient is seen quickly by a senior clinician. If necessary, the patient can be transferred back to PACU for high dependency care. The SWLEOC intensivist-led, post-surgical care pathway is proven to provide optimal medical support and shown to be a cost-effective strategy to provide the centre with appropriate 24-hour, inpatient medical care.
Post-discharge
Discharge planning starts prior to admission. Patient expectation is the most significant factor in driving length of stay after surgery and this is set by the consultant, the pre-assessment nurses, the information patients are given, and the pre-theatre staff. Patients transfer from PACU to the ward when they are medically fit to start their mobilisation and rehab for discharge. Patients suitable for same day discharge following joint replacement are discharged directly from PACU once their discharge criteria are met. The inpatient X-ray suite is located close to the wards so that post-operative X-rays can be obtained without delay. The ward team includes dedicated discharge co-ordinating staff.
Following discharge patients are monitored through the centre’s therapy programme with pathways tailored to the patients’ home circumstances, medical co-morbidities and aspirations. Patients encountering problems or complications in the early post-discharge period can be seen at the centre for a rapid assessment and the incidence of unnecessary readmissions is minimised.
Through the Recovery Diary Pathway, patients are remotely monitored by the SWLEOC Recovery Diary team. Not only does this enable regular 2-way interaction between the patient and an experienced clinician, it also provides continuity in care, reassurance and reduction in patient anxiety. Clinical teams can identify post-op issues early on which can be assessed and escalated to the right clinician on the same day. Patients receive answers to their questions or concerns in real time which improves their confidence to continue their recovery without having to leave the comfort of their home environment.
If outpatient clinic review is required, this is arranged either at the patient’s base hospital or in one of SWLEOC’s clinics. These are provided both by the therapy team and Surgeons operating at the centre.
