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Outpatient nursing

The SWLEOC Pre-Assessment (POA) and Outpatients (OPD) Team is a team of Registered Nurses (RNs), Assistant Practitioners (APs)/Nursing Associate (NA) and Healthcare Assistants (HCAs) who pre-assess each patient in advance of their admission to ensure that they are medically optimised and are fit and prepared to undergo their elective orthopaedic surgery at our Centre and that any special requirements are identified in advance of admission.

This also ensures that the patient and appropriate clinicians such as Discharge Nurses, therapies team, ward and PACU teams are aware of any special considerations or requirements to enable a smooth pre-operative, post-operative inpatient and discharge journey. 

Pre-assessment is a very specialised area which requires knowledge of multiple comorbidities, systems, conditions, medications and their potential risks in relation to anaesthetics, surgery, inpatient care and recovery, in addition to having knowledge of the Scheduling and Admin Teams work. The experienced POA Nurse knows when to escalate concerns and who to escalate them to and has knowledge of the many Standard Operating Procedures (SOPs), Pathways and Guidelines within which to work.

The HCAs provide support and chaperoning to the Consultant-led Orthopaedic Clinics.

HCAs run ECG/MRSA Clinics, supported by a Registered Nurse who oversees the Outpatient clinics each day.  

At ECG/MRSA Clinic the patient attends to have their required pre-operative tests such as height, weight, observations (BP, pulse, RR, Temp, SaO2, Peak Flow if appropriate), MRSA swabs (all patients), CPE screening if required, ECG if required, X-rays if needed (these will already have been requested by the Virtual POA Nurse).

  • This is carried out by HCAs supported by the Nurse in Charge (NIC).
  • Any patient who is seen by a Consultant in the OPD and added to the waiting list for surgery is offered the opportunity to have a one-stop appointment where their pre-operative tests can be completed to avoid them having to return for a further visit.
  • If the patient is happy to undergo the one-stop appointment, the reception team will create a Lifebox Account for them immediately, which the patient is asked to activate and complete at home, ideally within 48 hours.
  • If the patient (or a family member or friend who is willing to assist the patient) has an email address and mobile number, they can activate their account and can complete their own health questionnaire to give a full medical history and to record their current health state and social circumstances.
  • If a patient does not have access to an email account or mobile phone number and does not have a family member or friend to assist with this, a Non-Digital Lifebox account is set up for them.
  • The HCA completes a one-stop checklist and a list of medications and any significant medical history (e.g., cancer, organ transplant) is recorded.
  • The one-stop checklist and ECG or other relevant documents e.g., prescription list will be sent to the POA admin team to be scanned and uploaded to Lifebox Patient Files.
  • If the patient is not available to have surgery within the next 90 days (i.e., holidays or other events booked) the patient is not added to the waiting list – this event will then be given an outcome of “patient not ready to list”, and they will be asked to contact their GP to inform the scheduling team to add them to the waiting list when they are ready to proceed.
  • In the event of patient not being ready to proceed in 90 days, the NIC will complete a pre-populated “not ready to list” letter from Bluespier, which is emailed to the Patient’s GP and Orthopaedic Consultant via POA admin support, a copy is given to the patient and a copy is placed in their notes.
  • If the patient is undergoing other medical investigations which need to be completed prior to orthopaedic surgery, or if they are awaiting other surgery, they are therefore not fit to be added to the elective waiting list. The NIC will complete a pre-populated Wait List Cancellation GP letter on Bluespier, which is emailed to the patient’s GP and Orthopaedic Consultant via POA admin support, a copy is given to the patient and a copy is placed in their notes.
  • If the patient can be added to the waiting list, the NIC reviews the HCA’s one-stop checklist and medications list and will request the required blood tests, microbiology swabs and X-rays on ICM, and will indicate whether observations, ECG, and any additional observations are required and inform the HCA. The required tests are dependent upon the patient’s surgery, medical history and based on NICE guideline ‘Routine pre-operative tests for elective surgery’ (NG45) and local guidelines. 
  • The HCA will complete the requested tests and observations with the patient’s consent, following local guidelines and will record observations and actions taken in the patient’s Lifebox episode.
  • The HCA will provide a Patient Journey Book (to hip and knee arthroplasty patients) and Antibacterial Skin Prep pack (Octenisan Wash and Nasal Gel) to patients undergoing arthroplasty and spinal surgery.
  • The HCA will provide an information leaflet regarding bone donation to primary hip arthroplasty patients, and if the patient is willing and suitable to donate their bone during surgery, the NIC will complete formal bone donation consent on behalf of the NHS Blood and Transplant Tissue and Eye Service.
  • If the patient has any questions or concerns regarding the surgery etc, the NIC is available to speak with them if necessary.
  • The HCA advises the patient of the next steps.

In the event of a patient being unable to complete their own Lifebox HQ (e.g., If they do not have access to email or mobile number), a Non-Digital (Non-Dig) Lifebox account will be created for them. 

The patient will then be contacted by the admin booking team, and they will be booked into a 1.5 hour non-digital appointment slot with a Nurse/AP.  This appointment is pre-booked and confirmed with the patient via letter. 

The POA team provide one non-digital Clinic per day, comprising of 5 x 1.5 hour patient slots. 

The records team will have reviewed the virtual POA Clinic lists in advance and prepared a set of SWLEOC notes and should have obtained the Orthopaedic Clinic letter, base hospital notes, base hospital X-rays and/or GP information summary for the patient in advance of this appointment. 

The POA Nurse/AP allocated to each clinic will review the notes in advance of the appointment.

The Nurse/AP will contact the patient at the pre-arranged time.

The Nurse/AP will ensure that the patient’s names, spellings, DOB, address, GP information and Next of Kin (NOK) or emergency contact details are entered to Lifebox and that they are recorded correctly on Bluespier and IPM.  Bluespier details can be altered by the Nurse/AP, but any alterations to IPM will need to be completed by the admin/records/scheduling team.

The Nurse/AP will then complete a full medication history and a full medical history using the Lifebox HQ ‘wheel’ based on the patient’s answers and any available information in BN, GP info, Clinical Manager (ICM) and any available clinic letters.  

As the non-digital appointment is being completed by a clinician, they can also validate the information and question the patient in more depth to obtain an accurate health history and to inform decisions on what further information or investigations are required to ensure the patient is optimised for their surgery. 

  • The HCA team run three daily ECG/MRSA Clinics (Clinic 1, 2, 3) on weekdays, which are each 30-minute appointment slots for all patients, commencing at 8.30am until 3.30pm, with a maximum of 12 patients per clinic per day. On Saturdays the team runs two ECG/MRSA Clinics with the same template.
  • Each patient is pre-booked to attend ECG/MRSA Clinic by the admin booking team, at an agreed date and time and are sent written confirmation via post or email.
  • The POA Nurse (RN or AP) who completes the virtual POA will have completed a checklist of which observations and investigations each patient requires, based on their past medical history, type of surgery and following NICE guideline ‘Routine preoperative tests for elective surgery’ (NG45) and local policies, and they will have completed request forms in advance for the required investigations. The HCA will review their own clinic list at the start of each shift and ensure that they have all the required request forms for each patient. The HCA will cross-check with the Lifebox Clinical Work Plan to ensure that all the required tests have been requested. 
  • The HCA will escalate to the RN in charge if any forms are missing or if there are any queries regarding which tests have been requested.
  • The HCA will ask the patient to identify themselves using their full name and DOB and ensure the correct spelling of all names. This is particularly important as we work from Bluespier (Local SWLEOC system), Trust IPM, Lifebox and the base hospital systems/notes. Any incorrect spellings/information must be corrected before any blood tests are sent to Pathology. 
  • The HCA will undertake tests as required, complying all ANTT guidelines and with correct labelling of samples as per trust policies.
  • The HCA will escalate any concerns to the NIC of OPD/POA clinic at the time if there are any concerns re: observations outside normal parameters; abnormal ECGs; patients with skin issues or if the patient has any further questions. The NIC will advise the patient and refer onwards if appropriate (e.g., to GP to review high BP; to ED in the case of urgent concerns such as newly diagnosed atrial fibrillation with symptoms etc.).
  • The HCA provides the patient with a Patient’s Journey Booklet for Hip and Knee Arthroplasty Patients.
  • The HCA provides an antibacterial skin prep pack and instructions (Octenisan Wash and Nasal Gel) to patients having arthroplasty or spinal surgery, with instructions to commence this treatment protocol three days prior to surgery and continue for five days.
  • The HCA provides an information leaflet on bone donation to primary hip arthroplasty patients. If the patient is happy to donate their bone during the surgery and if they are suitable to do so, the NIC will complete a formal bone donation consent on behalf of the NHS Blood and Transplant Tissue and Eye Services, keeping a log of all consents which have been obtained. 

 

Following completion of all of the above, the patient may require further X-rays prior to surgery (X-rays should usually have been taken within six months of their surgery date, and most Surgeons require a Calibration Ball in the images for measurement purposes for arthroplasty patients). The SWLEOC X-ray department have provided a list of Surgeon’s X-ray requirements for the Nurse to refer to. The patient is then sent to the dedicated outpatients SWLEOC X-ray room, within the same building, to have the images taken before they leave the department.

  • The patient must then activate their Lifebox Account and complete a Health Questionnaire (HQ), ideally within 48 Hours.
  • Completed HQs are triaged by the NIC daily and an outcome added to Bluespier to indicate what type of Nurse POA is required (30-minute virtual clinic (VC); 1 hour VC; 1 hour VC + Anaesthetic Review).
  • The outcome will be reviewed by the admin booking team and the patient will be booked onto the appropriate Virtual Nurse POA telephone appointment; once fit for surgery, the patient will be contacted by the scheduling team to offer a date for surgery.
  • The HCA then discusses with the RN who will review the One Stop checklist and they will ascertain and request any required tests, following the NICE guideline on ‘Routine preoperative tests for elective surgery’ (NG45) and local policies.
  • The HCA will record observations on Lifebox Pre-Assessment software.
  • Patients are allocated a 30 or 60-minute Virtual Nurse POA telephone appointment, depending on the outcome of Nurse Triage of the patient’s Lifebox HQ.
  • Appointments are booked in advance by the admin booking team and are confirmed with the patient via telephone and followed-up in writing via letter or email.
  • Each day the SWLEOC POA Team (RGNs and appropriately trained Band 4 APs runs four virtual clinics from Monday to Friday which commence at 8.30am each day. The team also run one virtual clinic on Saturdays.
  • The clinic templates provide two virtual clinics with seven x 1-hour slots, which finish at 4.30pm. There is one clinic of six x 1-hour slots which finishes at 3.30pm. There is also a clinic with four 1.5-hour slots for non-digital patients. The fifth clinic allows for seven x 30-minute slots in the morning and two x 1-hour slots in the afternoon, finishing at 3.30pm.  
  • All clinics incorporate a 1-hour break from 12.30pm to allow for potential clinic over-runs, lunch and preparing for the afternoon clinic. These clinics reflect that team members work different length shifts.
  • The records team reviews the clinic lists in advance and prepares the notes for each virtual clinic.
  • The information required for the Nurse to complete the Virtual POA Appointment are SWLEOC notes which include ensuring the referral form is available to view on Bluespier, the Orthopaedic Clinic Letter regarding this surgery is available; Base Notes from the patient’s base hospital (if within the SWLEOC group of trusts) are available; a GP information summary (if no Base Notes are available or if the patient attends other hospitals for other medical issues) is available. The records team also request images (X-ray, MRI or CT) from base hospitals which are uploaded to the PACS system and can be accessed by those with permissions (RNs and APs).
  • Prior to the POA appointment, each clinic Nurse will review the above information to have prior knowledge of the patient’s medical history. They will also review the referral form, Orthopaedic Clinic letter and Bluespier record to ensure that the correct surgery is listed, and the correct side of surgery is recorded in all areas.
  • In the Virtual POA telephone appointment, the Nurse will first confirm the patient’s identity, ensure that spellings of names are correct (on all of the systems used – ICM, Bluespier and Lifebox); ensure that the correct address & contact number for the patient is recorded; ensure that the correct contact information for their NOK/person to contact is updated and correct and that the patient is aware of what surgery/which side is planned.
  • The Nurse will ensure that the patient still requires the surgery, is happy to proceed with the planned surgery and can do so within the next 90 days (if unable to proceed within this time, they will be removed from the waiting list as they are “not ready to proceed”). The Nurse will generate a letter from Bluespier to be emailed to the GP Surgery, Orthopaedic Consultant, a copy sent to the patient and a copy retained in the SWLEOC notes.
  • The Nurse will then review all the information provided in the HQ by the patient, section by section.
  • The Nurse will confirm names & doses of medications and update any information if necessary (this is the list of medications which the Anaesthetist will use to complete the Inpatient Prescription for the patient, so it is imperative that it is accurate).
  • Throughout the Lifebox HQ, if the patient has recorded any positive answers to any of the questions, the Nurse can question further to ensure that any relevant supporting information and other required information is recorded accurately, e.g. if the patient is under the care of any other specialities/consultants, why they are under their care, when were they last reviewed, what is their plan and when are they due to be reviewed again?
  • Throughout the appointment, the Nurse/AP will ask the patient about any symptoms associated with other health conditions to build a picture of their current state of health and any areas of concern which may require further assessment.
  • Review of specialist clinic letters, test results such as Echo, Angiogram, CT reports etc) allows the Nurse to identify any areas of particular concern (e.g., patients undergoing active follow-up or treatment for other medical conditions which may have an impact on their suitability to proceed with their elective surgery).
  • If the patient is not medically fit to proceed with the surgery and will not be fit within the following four weeks, the patient will be removed from the waiting list and a Medical Waiting List Cancellation (WLC) is completed. The Nurse will explain this to the patient and generate a letter on Bluespier stating the reason for the WLC, as per the 18-week pathway guidelines and this is emailed to the GP, Surgeon and a copy retained on Bluespier.
  • During the VC, the Nurse will also review patient’s lifestyle information, ensuring that there will be support on discharge – if any concerns regarding discharge are highlighted, these will be forwarded to the discharge team, who will follow-up with a Pre-Admission Discharge Assessment. If a day case patient does not have support on discharge and cannot arrange this, the Nurse will inform the scheduling and ward teams, and an inpatient stay will be arranged.
  • The Nurse will also advise the patient regarding current COVID-19 advice, procedures and testing, based on national and local guidelines.
  • The Nurse will use all available opportunities during the VC to provide health promotion advice e.g., ensuring the patient is aware of good nutrition, smoking cessation, alcohol reduction, maintaining regular exercise and following a Pre-Operative Exercise programme if appropriate, and optimising other health conditions in preparation for surgery.
  • The Nurse will complete other required assessments with the patient – AMTS (for patient’s aged over 75 years or any patient with concerns regarding memory); Mental Capacity Assessment if appropriate; VTE Assessment; STOP Bang Sleep Apnoea risk assessment; Waterlow Score; Falls risk assessment; DASI score; Malnutrition Universal Screening Tool (MUST).
  • The Nurse will allocate an ASA score to the patient based on their current health state.
  • The Nurse will discuss bone donation for primary hip arthroplasty patients, and patients who will be attending for ECG/MRSA Clinic are advised that they will have the opportunity to read a leaflet regarding this and discuss with a Nurse at this appointment, if they are eligible and willing to consider bone donation.
  • The Nurse will review the patient’s images on PACS to ensure the correct images are available and in-date for surgery, as per the Surgeons X-ray preference list provided by SWLEOC X-ray department. If no images are available, but the patient has had recent X-rays at another hospital/clinic, this is recorded, and the Nurse will email the records team to request these images from the specified hospital/clinic.  
  • The Nurse will then formulate a Work Plan, recording on Lifebox what observations, investigations, X-rays (if necessary) are required.
  • The Nurse will inform the patient of the next steps – attending the ECG/MRSA Clinic to have the required tests. Once test results are reviewed, the patient will be contacted if there are any concerns. If there are no concerns and they are fit to proceed with the planned surgery, the scheduling team will contact the patient to offer a surgery date. 
  • If the patient already has a surgery date planned, the Nurse will inform them that this is subject to their results and any other supporting information required being satisfactory and that they will be contacted if there are any concerns.
  • The patient is offered the opportunity to ask any questions, and informed that they will meet a HCA at their face to face (ECG/MRSA) appointment.
  • The Nurse will advise the patient of the Preparing for Surgery Classes, run by SWLEOC via Microsoft Teams, which run each Monday, Tuesday and Wednesday morning for 1.5 hours, and encourage the patient to join one of these. If the patient agrees, the Nurse will email the SWLEOC Lifebox support admin team to book this and they will email the patient with the access information to join. 
  • The Nurse will request any required investigations on ICM, depending on the patient’s medical history, planned surgery and in accordance with local and national guidelines.
  • The Nurse will print the appropriate request forms from ICM and will complete a paper docket to indicate to the HCA in ECG/MRSA Clinic which observations and actions are required: observations, height, weight, MRSA swabs, CPE screen, urinalysis, MSU, bloods, blood Group and Save, blood Group and Crossmatch, Peak Flow, ECG, X-ray, anti-bacterial skin preparation (Octenisan skin wash and nasal gel) pack to be given, Patient Journey Book to be given, bone donation information to be given and any other pertinent information (e.g. If the Patient needs a skin review or a physical assessment to be carried out by the NIC in clinic).
  • The Nurse will document the next steps – if any additional clinical information, letters, or reports are required they will email the POA admin support or records team to request these.
  • The Nurse will email and liaise with discharge team in the case of patients having any discharge concerns.
  • Once the Virtual Pre-Assessment is completed, the POA Nurse will allocate an outcome to this episode. If the patient’s observations, ECG, MRSA and blood results (as required, depending on ASA Grade, patient history and type of surgery) are available from One Stop Clinic, and all the required documentation (Referral form, Orthopaedic Clinic Letter, hospital base notes and/or GP information summary in addition to any other clinical letters from other specialities caring for the patient), the patient may be ‘fitted’ by the Virtual POA Nurse. 
  • If further information is outstanding (MRSA/blood results, ECG, base notes, clinic letters etc, the Virtual POA Nurse will document this on the Lifebox Work Plan, and outcome the patient appropriately on Bluespier. For example, Awaiting ECG/MRSA Clinic; Awaiting GP Info; Awaiting Base Notes (state which Hospital); Awaiting additional Clinical Information; Awaiting Anaesthetic Review. 
  • The notes will then be tracked on Bluespier to the appropriate place: if patient is ‘fit’ the notes will be tracked back to records and the outcome updated as ‘fit for surgery’ or ‘awaiting 72-hour swab’ for patients who require a PCR. If the patient is awaiting further investigations/documentation, the notes will be tracked to the appropriate team and appropriate file within that team’s filing system (e.g., Awaiting Anaesthetic Review; awaiting ECG/MRSA Clinic, Awaiting Echo, Awaiting GP info; Awaiting Orthopaedic Clinic letter; Awaiting Base Notes; Awaiting additional Clinical Information.)

Each team will have at least one allocated member of staff (Band 7, 6, 5 or Band 4 AP) allocated to carry out follow up for their team. 

The daily work plan/task list for the follow up team:

  • Theatre list – aim is to work two weeks in advance to review patients who are on the theatre list but not yet fitted, check what information is outstanding and ensure that this is obtained to ensure the patient is fitted in ample time.
  • Daily ECG/MRSA Clinic – to print and review results from ECG/MRSA Clinics, ideally 2-3 days maximum after the patient has attended. Any abnormal results to be actioned e.g., MRSA positive patients to follow SWLEOC MRSA Protocol; abnormal blood results to be reviewed and any action to be taken e.g., anaemic patients – will oral iron suffice; will they require an Iron Infusion pre-op or do they need to be cancelled for surgery and the cause of their anaemia investigated. ECG abnormalities to be reviewed – does the patient have a history consistent with the abnormalities noted, are there changes compared to any available previous ECGs or does the patient have new, unexplained ECG findings which require further investigations.
  • If unsure about how to proceed, the Nurse will complete an SBAR (situation, background, assessment, recommendation) for review by a Senior Consultant Anaesthetist.
  • To check daily for high-risk clinic in case it was added at the last minute. Review reports and complete any required actions.
  • Any outstanding High Risk Clinic reports to be highlighted to the relevant Anaesthetist.
  • SBARs to be completed to request Anaesthetic advice and review of results etc. Review the outcome of SBARs and action appropriately.
  • Coagulation book – check daily. Any patients who are on anticoagulants and who are fitted for surgery but still awaiting a surgery date will have their details recorded in each team’s Anticoagulation Book. This must be checked regularly to review if patients have been booked for surgery and if so, the patient will be contacted to advise when to discontinue their anticoagulation medication.
  • Echo – Most Patients who are identified as requiring an Echo pre-op will be booked by the scheduling team to have their Echo on the ‘Trust Echo’ day. Once per month, the trust provides an Echo Clinic for 20 SWLEOC Patients so that the Echo can be completed and the results available for review/action.
  • Call backs – patients who require phone calls to update on home BP readings and other outstanding results or updates.
  • Review Base Notes received, update information on Lifebox as required.
  • Review notes awaiting Orthopaedic/additional clinic letters – escalate if there are delays in receiving information/letters.
  • Bridging –any patients who require bridging who have been given a surgery date, ensure that their bridging therapy is prescribed, available from pharmacy and arrange for it to be either collected by or delivered to the patient. Ensure that the anticoagulation/bridging letter is completed with all the patient instructions including the dates and time of administration of the bridging injections.
  • Arrange MDT meetings in conjunction with the POA admin and scheduling teams.
  • Arrange best interest meetings as required, in conjunction with the POA admin support team.
  • Record the number of notes reviewed daily and the number of patients fitted daily.
  • The follow up team Nurse (must have a PIN) will fit the patient for surgery, once all investigations and required information is received and the Nurse is assured that the patient is medically fit to undergo surgery.
  • Ensure the results of all relevant investigations are available and are satisfactory.
  • Review the referral form and Orthopaedic Clinic letter to ensure any further requirements for surgery (e.g., CT for surgical planning) have been completed and images are available.
  • Ensure that if any other specialist reviews or treatment were requested by the Orthopaedic Consultant in advance of surgery (e.g., vascular review; dermatology review etc) have been completed,
  • The appropriate action taken, and documentation is obtained and communicated to the Surgeon.
  • Review the additional clinical information which was requested by the Virtual POA Nurse – has this been received, if so, is it the correct information and does it require any further supporting documentation (e.g., a cardiology letter stating that the patient would undergo an Echo or Coronary Angiogram – ensure the reports of all relevant investigations are obtained to indicate whether there are medical or anaesthetic concerns).
  • Document any significant history, symptoms or comorbidities which require review in high-risk anaesthetic clinic – if in doubt, discuss the patient with a Consultant Anaesthetist for further advice.
  • Ensure patient’s Base Notes and/or GP information has been received and reviewed, and all relevant information recorded and highlighted (e.g., allergies, anaesthetic issues, post-operative complications) and alerted on Bluespier if required.
  • Ensure the patient has had the required X-rays or other images on PACS, they are in-date, and they are the correct views. If not, arrange for a call-back appt for the patient to attend for X-rays (liaise with SWLEOC Radiographers for preferred day/time).
  • Review options for further intervention to optimise the patient’s condition pre-operatively e.g., pre-op antibiotics (contact GP Surgery to arrange prescription); Group and X-match pre-op (arrange call-back appointment for three working days pre-op if patient has blood antibodies); admission on the day before surgery to optimise respiratory function (nebuliser and chest physio); admission early on surgery day to administer platelets etc. If so, liaise with pre-theatre, ward and PACU teams, and inform reception team of early admission.
  • If the patient has all the required information/documentation and is clinically stable, the follow-up Nurse will ‘fit’ the patient for Surgery by updating Lifebox to ‘Ready for Surgery’ and will outcome Bluespier as Fit for Surgery; Fit awaiting 72-hour Swab, Fit High Risk etc.
  • The Nurse fitting the patient will ensure that any alerts regarding treatment are added to Bluespier; confirm that all required preop tests have been undertaken, and that results are available, are satisfactory and have been reviewed by the Anaesthetist or Surgeon, as required.
  • HDU bed will be booked if required.
  • Notes will be tracked back to records.
  • The Pre-Assessment Service was initially set up as an innovative Nurse-Led service when the Centre opened in 2004.
  • It was staffed by Band 7 Nurses. During the development of the Centre, the Nurses underwent study and practical sessions to complete training in Physical Assessment and clinical reasoning training, under the supervision of a Consultant Anaesthetist.
  • Initially the Pre-Assessment service comprised of a group of patients who would attend for a full morning in the Centre when they could have a talk about the surgery, how to prepare themselves for it and then they would be assessed by the HCA team (obs, ECG) and then interviewed by the POA Nurse to complete the Bluespier HQ and Pre-Assessment Questionnaire.
  • The Band 7 Nurses were supported by Band 4 APs who undertook an initial Health Screening Questionnaire to ensure that the patient was fit to proceed with surgery, and to obtain a brief medical history. The patient was then booked into either a 30-minute MRSA/ECG Clinic which was run by the Band 4 APs or a 1-hour face-to-face appointment with the Band 7 Nurse, depending on their clinical complexity and the type of surgery planned. The Band 7s were also supported by a small team of HCAs who would record the patient’s observations prior to seeing the Nurse on the day of their face-to-face appointment.
  • Each of the Band 7 Pre-Assessment Nurses managed their own caseloads, from the initial face-to-face patient Pre-Assessment appointment which included a full physical assessment if required, through to managing their patient’s follow-up and obtaining all the information that was required to support their clinical decision-making in ensuring the patient was fit for surgery. Each Nurse had their own clinical room and retained their own patient files. The Band 7s had access to a Senior Consultant Anaesthetist who would visit the department as required to review any complex patient notes and advise on how to manage these patients. The Band 7s could also request to book the patient into a high-risk anaesthetic clinic with one of the Consultant Anaesthetists, and one Consultant Anaesthetist ran an Echo Clinic where he would perform an Echo on the patient within the Department if necessary.
  • The Band 4 APs were supported by one Band 6 Nurse who would caseload manage the patients who were seen in the ECG/MRSA Clinics and this Nurse would follow-up each patient to ensure they were fit for surgery.
  • The Lifebox Digital Pre-Assessment Tool was introduced in our Centre in 2018/2019. With the intention of allowing the patient to complete their own Health Questionnaire online in the comfort of their own home and allowing the pre-assessment team to identify concerns early. This was to aid in reducing the number of patients who needed to attend in person for pre-assessment and to minimise the time spent face-to-face with the patient, thus increasing through-put.
  • In the post-COVID era, Lifebox now allows most interactions to be undertaken virtually, but most of our patients are required to attend the Centre to undergo observations, MRSA swabs and blood tests. In certain circumstances, these tests can be carried-out remotely by the patient’s own GP/Medical Centre (e.g., prisoners and military patients), but any patient who is having surgery in which blood loss is a concern, must attend in person to have a Group and Save blood test, to ensure there is no risk of a delay in obtaining cross-matched blood in the event of requiring a transfusion.
  • The move from the POA Nurse face-to-face appointment to virtual telephone appointments has resulted in the nursing team moving from clinical rooms to a virtual telephone room, thus freeing up 5 – 6 clinical rooms within the outpatients/pre-assessment department to increase capacity for Consultant or MSK clinics as needed.
  • More recently the POA team have moved from case-load management to adopting a team approach to the follow-up and fitting process. We have three teams (Team 1,2,3), and each patient who is assessed virtually is allocated to a team (patient numbers divided equally between teams each day). Each follow-up team (consisting of at least 1 Band 7, Band 6 and a Band 4 AP) is allocated one team member each day to work in follow-up for that day.  

The POA team interacts with every team within the Centre to ensure a smooth patient journey from pre-assessment to discharge.  The POA team liaise closely with the scheduling team and booking team who arrange the Pre-assessment virtual and ECG/MRSA Clinic appointments.  We liaise in person and via email with the Surgeons and the scheduling team regarding surgery dates or surgery concerns.  The team interacts with the outpatient team if the patient has any concerns regarding their surgery, and a further outpatient appointment can be arranged if necessary. 

Each day the NIC will attend the Centre’s Bed Meeting where the caseload in theatres and the wards is planned, and staffing reviewed.  This encourages collaborative working and any staff shortages on the wards or in outpatients can be highlighted and if appropriate, staff can be moved between wards/departments. 

The POA Nurses liaise with the pre-theatre, wards, PACU, therapies teams and discharge team via email if there are any complex or vulnerable patients who require extra planning for their admission, inpatient stay or discharge. An MDT meeting between all the teams can be arranged if required to discuss and ensure extra measures such as one to one nursing, availability of accessible information, discharge planning, the need for additional equipment on discharge etc. 

The POA team also liaise closely with the Anaesthetists, to discuss complex patients and ensure their optimisation prior to surgery, and to ensure the attending Anaesthetist on the day of surgery is aware of complex patients and that the allocated anaesthetic time is appropriate. 

The POA team take part in many of the multidisciplinary meetings to ensure the smooth-running of the Centre, including Theatre Planning Meetings, Anaesthetic Meetings, Governance Meetings, Performance Meetings and Cancellations Meetings.  This provides opportunities to improve communication and understanding between departments and encourages improvements in practice and learning from incidents.  

The outpatient team works in dedicated clinical rooms within the Outpatient Department and there is a small telephone room/office in this area for use by the NIC.  The Virtual Nurse Clinics take place in a Telephone room on the admin floor, which is set up with a PC and telephone for each Nurse (7 desks), we operate a ‘hot desk’ system to accommodate the different working days/hours for each member of staff.  The follow up team work from a small office on the admin floor, with a three-desk room with notes filing.  The Matron has a dedicated office which can also be used for small meetings. 

  • Bluespier – a stand-alone system for SWLEOC to manage clinics, letters, appointments and waiting lists and track patient’s notes and their journey through the pathway.
  • IPM – trust system to manage clinics, clinical information, letters, referrals.
  • ICM – trust system, within IPM, which enables access to clinical information and pathology system to manage pathology requests & results.
  • Lifebox – digital Pre-Assessment platform to facilitate patients to complete their own Health Questionnaire online, and it also allows for the uploading of patient information videos, which can be accessed by the patient at any time. There is also a facility for the patient to upload documents (e.g., their clinical letters, prescriptions or photographs to be viewed by the POA team) and any documentation required by the POA team can also be uploaded – these can then be viewed by other staff with Lifebox access – e.g., Anaesthetists, ward teams etc.
  • PACS – X-ray/image viewer, which allows access to images which have been added by our Centre, our host trust and the other trusts within our group (St George’s, Croydon, Kingston). If a patient has had an X-ray, CT or MRI performed at a department other than these, the images can be imported and uploaded to PACS by the medical records team so that they are available to view by the Surgeon in advance of and at the time of surgery.
  • Trust Intranet – for trust policies and guidelines.

Think about how you plan to run the service – will it be Nurse-led with the nursing team having additional qualifications and working within their extended scope of practice to make clinical decisions (therefore requiring recruitment of higher grades of Nurses), or will it be Anaesthetist-led, with the Nurses performing history taking and information gathering with a view to the anaesthetic team reviewing all information and making the clinical decisions?

All SOPs and pathways should be produced in advance, to ensure clarity of understanding of roles and limitations for each department/team.

  • Delays in being able to ‘fit’ patients due to the delay in obtaining clinical letters and information from other hospitals;
  • delays between patients attending the One Stop Clinics and having their Virtual Pre-Assessment, which has led to a delay in recognition of issues which could have been optimised or actioned earlier e.g., earlier recognition and management of anaemia or ECG abnormalities;
  • workforce challenges resulting in prioritising the running of planned Virtual POA Clinics, which in turn may affect follow up.
  • The POA Admin Support role has been expanded and the support team has been increased from 1 WTE to 3WTEs as we were able to demonstrate how much Nurses and APs time was being spent in communication with other departments/hospitals/GP Surgeries. This has improved the time taken to obtain this information and has freed-up Nurses time so more patients can be pre-assessed.
  • The admin booking team now aims to book patients for their Virtual Pre-Assessment within 1-2 weeks following their One Stop Appointments. The Virtual POA Nurse will then review the POA results, ECG and any other available clinical information, and may be able to ‘fit’ the patient immediately so this reduces the amount of time spent of follow-up.
  • Utilising senior Nurses from other departments and wards, who received some POA training, and could provide some extra support if needed.
  • Limited number of pre-assessments due to each Nurse requiring a clinical room to perform face-to-face pre-assessments.;
  • difficulties in recruiting suitably trained Nurses to provide physical assessments for patients;
  • increased staff stress-levels due to case-load management, particularly in times of staff illness/absence and handover of patient caseload.
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  • Recruitment and retention of suitably qualified staff and providing sufficient support to enable training and upskilling of more junior and new staff;
  • providing sufficient anaesthetic support to the team to ensure a good working relationship and to understand expectations and limitations of the team;
  • ensuring the integration of the POA team with all other teams in the Centre, and it would be useful for other teams to spend some time working with the POA team to understand the challenges in their role, and vice versa;
  • management teams to be open and transparent about the aims of the service, and to work collaboratively with each team to ensure everyone is working towards the same goal. SOPs and guidelines to be in place in advance to support this;
  • good two-way communication between management and each team, to understand the challenges and work together to overcome them.
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  • Clarity of responsibility: ensure the POA team is aware of their responsibilities in history taking, patient assessment and clinical decision-making. Ensuring that SOPs and guidelines are in place in advance will help to ensure a good understanding of the process.  
  • Good communication and a relationship of trust between teams/management: in an ever-evolving healthcare environment, change is inevitable and to manage this effectively, the teams should be kept informed and involved in the process. Good communication also ensures that each team can identify and improve areas of concern and to be open about what changes need to be made.  
  • Fostering an open and honest environment in the Centre helps to ensure that each team feels safe to report when things go wrong and to seek support in making changes.
  • Empowering staff and ensuring staff feel valued so that they take ownership of their role in the Centre.
  • Develop good communication links with local ICSs/GP Surgeries from the outset to encourage their cooperation in optimising patients underlying medical conditions before initial referral to consultants to consider surgery.

Staff

Staff Member: Clinical Matron (Band 8A x 1 WTE)

  • The Clinical Matron is responsible for the overall management of the POA team.
  • Provide appraisals, one-to-one meetings and return to work interviews for their team;
  • Ensure all team members are up to date with statutory and mandatory training;
  • Support team members in attaining additional training, courses and learning opportunities to enhance their practice. 

Staff Member: Registered Nurse (Band 7 x 2.84 WTE)

Role:

  • deputising for Band 8 in their absence e.g., leave, to attend inter departmental meetings;
  • allocated to NIC role as required;
  • each Band 7 has a small team to manage and support;
  • complete Virtual POA Clinics as allocated;
  • provide support for the team in the clinical management of complex patients;
  • follow-up for complex patients within their team;
  • leadership role in supporting new staff and Student Nurses;
  • clinical decision-making and fitting patients for surgery;
  • liaising with the anaesthetic team regarding complex patient management;
  • attend Best Interest meetings;
  • liaise with other teams regarding complex patients or specific patient needs.

Staff Member: Registered Nurse (Band 6 x 5.2 WTE)

Role:

  • support B7 nurses in providing POA Nurse Assessment Clinics;
  • support Band 5 and Band 4 Nurses;
  • allocated to NICC role as required;
  • management of Band 4 APs and Band 3 HCAs with the support of Band 7 Nurses;
  • complete Virtual POA Clinics as allocated;
  • work in follow-up team as allocated;
  • escalate issues with complex patients to Band 7 Nurses or Anaesthetists if required;
  • fitting patients for surgery;
  • liaise with the MDT within the Centre as required for complex patients;
  • attend Best Interest Meetings.

Staff Member: Assistant Practitioner (Band 4 x 3 WTE)

Role:

  • complete Virtual Nurse Clinics as allocated, seeking support from RGN as required;
  • work in follow-up team as allocated, to obtain results and clinical information and highlight abnormalities to RGN or Anaesthetist, as required;
  • work in ECG/MRSA Clinics as required and support HCAs in running clinics if necessary.

Staff Member: Health Care Assistant (Band 3 x 8 WTE)

Role:

  • run ECG/MRSA, call-back and One Stop Clinics;
  • escalate to NIC any missing request forms or any concerns regarding the requested tests;
  • escalate to NIC any concerns re observations outside normal parameters or any abnormal ECG recordings;
  • oversee and chaperone for Consultant OPD Clinics;
  • support Hand Clinic;
  • report any housekeeping issues to the NIC;
  • report any clinical concerns e.g., ECG or observation abnormalities with ECG/MRSA Clinic patients to the NIC;
  • liaise with reception and transport teams in ensuring smooth running of clinics and minimising delays.