Preoperative Assessment Decision Support

1
Preoperative Assessment Decision Support S
Lake, B Murthy, A Fisher Depts. of Clinical
Engineering and Anaesthesia Theatres
(splake_at_liv.ac.uk)
What is OSCAR?
Rule Structure

• Each assessment can have one or more rules
• Each rule may trigger only one investigation
• Rule details -

• An intranet based recording system of -
• Pre-operative anaesthetic assessment, medication
  and scoring.
• Complete peri-operative anaesthetic chart
  including vital signs.
• Post-operative monitoring, medication etc...
• Now includes Pre-admission assessment test
  result management.

• Applicable age range
• Level of surgery, minor, intermediate, major,
  major
• Specific operation procedure codes
• Type of anaesthetic GA, LA
• Physiological measurement range (Fact Code),
  e.g. BMI gt 30
• Medication (Fact Code), e.g. thyroxine
• Condition (Fact Code), e.g. asthma
• Action Recommend, Suggest, Advise only
• Investigation to trigger
• Patient information

Activity 1Pre-Op Assessment

• Patient history and vital signs entered during
  assessment.
• Investigations predicted.
• Record of which investigations ordered, if TCI
  date given then panic date assigned.
• Scoring may be added.

Activity 2Investigation results returning
Rule Application

• Results entered into assessment record by Nurse,
  electronically in the future.
• System lists all outstanding assessments, those
  past the panic date go red.

Age in range AND surgery grade above or equal to
rule value
Yes
Any of the following -
Physiological measurement in range
Activity 3All investigations complete
Procedure code match
Anaesthesia type match
Medication match
Condition match

• Record now flagged as assessed or cancelled if
  not going ahead.
• If Theatre and TCI date known then record updated
  and flagged as planned.

Recommend investigation, suggest investigation or
advise only Add patient information to assessment
Database Structure
Patient Demographics
Fact Code Database
e.g. Asthma
e.g. Mr Justin Case

• Objectives
• Electronic record of pre-admission assessment.
• Several levels to refine detail, carrying results
  through (nurse pre-admission, physical exam,
  anaesthetist pre-op)
• Template structure for different assessments
  (RLBUHT Standard, St Pauls pre-admission, PRHO
  examination, anaesthetist pre-op)
• Suggest and recommend investigations based on
  rules (rules to use are specified in template).
• Build a knowledge base about the patient before
  the operation.
• Check that investigations have been carried out
  (daily management list of outstanding
  assessments).

e.g. Respiratory Function Tests
Investigation Codes
e.g. If Asthma then do Respiratory Function Tests
e.g.
e.g. Mr Justin Case having elbow surgery
Mr Justin Case has Asthma
Care Records (Operations)
Facts about patients
Investigation rules
Loaded
Updated
e.g. Pre-Admission or Pre-Op Anaesthetic
Assessment Templates
Score on patient
Investigation on patient
Assessments
Copied
e.g. Liverpool Elbow Score on Mr Justin Case
e.g. Respiratory Function Tests on Mr Justin Case
e.g. Pre-Admission on Mr Justin Case
There is a database of patients containing
demographic details that is connected to a
database of operations. The little crows-foot on
the end simply means that each patient can have
one or more operations. There is a database of
facts, which defines a particular physiological
measurement, for example systolic blood
pressure, or it could be a condition like
asthma. This database is key to relating an
investigation to a result in the patients
history.At the bottom is the database of
assessments and as you can see you can have more
than one for each operation. A template is used
to control the questions that are asked on the
assessment and which rules to apply that trigger
investigations. The template is copied across so
that any future alterations to the template dont
effect the past assessments. When the assessment
is opened, facts about the patient relating to
the assessments questions are copied in. When
the assessment is saved, the answers to the
assessment are copied back to the Facts about
Patients database. The rules assigned to this
template are then run against the Facts about
Patients database and those investigations that
are triggered are recorded in the assessment. Two
other databases shown here are scoring and the
actual investigation results themselves.
Benefits

• Encourages a consistent approach to pre-operative
  assessment.
• Quality of record.
• May flag up tests missed by the Nurse.
• Only say may since these highly experienced
  nurses will do a better job due to the
  unpredictability of patient health and their
  ability to make a judgement based on experience.
• Highlights missing test results before it becomes
  a problem.
• Anaesthetist is better informed.
• A catalyst to improvement by providing a focus
  on -
• Optimising Surgery Care