NICE guidance NG45 ‘Routine preoperative tests for elective surgery’ is recommended for use in preoperative assessment units. As lead clinician for preoperative assessment it is my role to implement this new guidance safely and ensure there is confidence among staff in its use. This example sets out how we implemented all of the guidance in our service.
Aims and objectives
NICE guidance (NG45) and Surgical Outcomes Risk Tool (SORT) use American Society of Anaesthesiologists (ASA) grade for guiding preoperative investigations and shared decision making in preoperative assessment.
ASA grading is subjective and we identified that our preoperative nurses required training to be confident in using the ASA physical status classification system for these purposes.
Reasons for implementing your project
Previous NICE guidance CG3 for preoperative tests for elective surgery included patient's age as a factor and relied less heavily on the use of ASA grade. Age is objective and requires no decision making by preoperative nurses.
In contrast the new guideline relies on ASA grading and surgical grade only and its use requires confidence in ASA grading among preoperative nurses. Our preoperative nursing staff had previously expressed concern regarding ASA grading for calculating SORT scores preoperatively during a departmental governance meeting. We were also aware that the ASA Physical Classification System had been updated in 2014 and from an audit taking place within the department of anaesthesia we had concluded that many local anaesthetists were unaware of this update.
Our baseline assessment included a Plan, Do, Study, Act (PDSA) discussion and one week data collection of the impact of the new NICE guideline on number and type of investigations requested by a single preoperative assessment nurse over a one week period.
How did you implement the project
Preoperative assessment nurses were paired with consultant anaesthetists and asked to score for 10 patients using the ASA Physical Status Classification System. Each staff member was blinded to their colleagues’ results. The lead clinician then reviewed results and requested anecdotal feedback.
We described the exercise and achieved buy in from the preoperative nurses at our departmental governance meeting. We requested participation of the consultant anaesthetists directly by email and each accepted. The exercise was completed during the allocated time of 4 weeks in July 2016.
To ensure there was no delays in progress to surgery for patients secondary to this exercise we selected patients for scoring who did not yet have a date for surgery confirmed. While the exercise was on going and before scoring was complete 7 patients proceeded to surgery and were therefore not included in the results.
Results: 63 patients were assessed in total with an overall 76% agreement between scores. There were no differences in score of more than one ASA grade.
Feedback included that many anaesthetists were unaware that the ASA Physical Classification System, 2014 included BMI and lifestyle factors. Preoperative assessment nurses reported difficulty in grading alcohol intake, requesting definition for the terms ‘minimal’ and ‘social’ alcohol for ASA Grades 1 and 2.
Conclusion: This study raised awareness of the updated ASA Physical Classification System and led to defining the subjective terms ‘minimal’ and ‘social’ alcohol: alcohol intake <14units/week, 14-21U/week, >21U/week or alcohol risk score ≥5 for ASA 1, 2 or 3 respectively.
Following this we compiled a local guidance table for ASA scoring to be used by preoperative nurses covering co-morbidities, BMI and lifestyle factors and after approval by the preoperative assessment nursing manager and an educational session this has been implemented. This exercise has increased confidence and preoperative assessment nurses now use NICE guidance (NG45) for preoperative investigations and SORT to inform risk assessment.
Key learning points
Preoperative assessment is nurse-led in the UK and management shouldn’t assume staff have the required knowledge and confidence to commence ASA scoring when implementing NICE NG45.
Leads within preoperative assessment should assess confidence levels amongst nurses during governance or education sessions. We suggest that a matching exercise between consultant anaesthetists and preoperative nurses using the 2014 ASA Physical Classification System is an appropriate method of identifying which factors staff find challenging within the system.
There should be opportunity for feedback from participants within the exercise. Local guidance can then be added to the system to clarify factors within it with the aim of increasing confidence. In our department the subjectivity of the terms describing alcohol intake required further clarification for our patient demographic and we recommend that departments provide detail to this specific factor locally to increase accuracy.