Aim
The primary aim of the project was to develop and evaluate a high-risk medication-based referral criteria to:
- increase the number of patients on high-risk medications seen in the pre-admission clinic
- reduce the number of theatre cancellations due to medication misadventure.
The secondary aim was to demonstrate the potential increase in activity-based funding that could be generated through optimisation of the PAC pharmacy service.
Outcomes
The additional patients that were referred to the pharmacist by PAC nursing staff and the additional Activity Based Funding (ABF) funding that was created as a result of this project.
Once the screening tool was finalised, education was provided to the PAC nursing staff by the PAC nurse unit manager and PAC pharmacist. Nursing staff were educated on how to use the screening tool within their current workflows. Following education, the sprint trial was then implemented over a two-month period. During this time, nursing staff referred the high-risk patients to the PAC pharmacists. Importantly, low risk patients were still reviewed by the pharmacist.
The positive outcomes of the project resulted in additional funding that was granted by the Executive to continue the service. This will help collect further data that will support publication in the future.
Background
The Princess Alexandra Hospital (PAH) performs approximately 15,000 elective surgeries per year and local data estimate s there is a 50% cancellation rate.
The last-minute cancellations of theatre cases are disruptive to staff, leave theatres vacant, frustrating to patients, and costly to the hospital. Pre-admission clinics (PAC) are designed to review the patients early (i.e. a week or more before theatre) to prepare the patient and streamline their journey and recovery. Many patients require dose adjustments or temporary cessation of their medications so that surgical complications are reduced. Classic examples include anticoagulants (to prevent excessive bleeding) and insulin (as patients are often fasting).
Unfortunately, there is a lack of resources to pre-emptively see all high-risk patients. Pharmacists are medication experts and there is much evidence they improve medication management in the PAC setting; however, their workload must be prioritised to the high-risk patients. An audit of all 2022 surgical bookings at the PAH found that 66 surgeries were cancelled (at the last minute) for medication-related reasons, equating to lost revenue of over $700K. The majority of the cancellations were for patients who were not reviewed by a pharmacist in the PAC.
Prior to this improvement initiative the screening of patients for a clinic appointment was based on an anaesthetic referral criteria. Those who met the anaesthetic referral criteria attended PAC either in person or via a telephone appointment and were reviewed by PAC pharmacists regardless of medication type. Patients who did not meet the criteria were reviewed by PAC nursing staff only. If any medication adjustments were required, nursing staff referred these patients back to the surgical team for perioperative medication plans. A limitation to this system was that the PAC pharmacists did not review all patients on high-risk medications prior to surgery, subsequently leading to patients being cancelled on their day of surgery. This not only resulted in lost revenue for the hospital, but more importantly, led to sub-optimal patient outcomes and care.
