Pre-Anaesthesia CompuTerized Health Assessment
Condition: Anesthesia; Computer, Attitude to
Study type: Interventional

Summary: 
      Pre-anaesthesia assessment is an important component of preoperative care of surgical
      patients. With the increasing prevalence of same-day-admission and ambulatory surgery,
      patients no longer undergo preanaesthesia assessment as an inpatient in traditional "premed
      rounds". Currently, a nurse-administered paper-based health screening questionnaire is used
      at the Preadmission Service to identify patients who require outpatient evaluation by
      anaesthetists prior to elective surgery. In this study, the investigators aim to re-design
      and convert the current paper-based, nurse-administered health screening questionnaire into a
      reliable patient self-administered digital tool- Pre-Anaesthesia CompuTerized
      Health-assessment (PATCH). The electronic questionnaires will be validated by comparison of
      responses from digital self-administration against that obtained from a nurse interview
      structured to the same format. The investigators hypothesize that the responses obtained
      using PATCH will have at least 95% agreement with responses obtained in a nurse-led
      structured interview. Finally, the use of PATCH would be compared with standard nurse-led
      paper-based interview in a non-blinded, randomised controlled trial with regard to time taken
      for nurse processing of the patient at the clinic.
    

Detailed description: 
      Pre-anaesthesia assessment is an important component of preoperative care of surgical
      patients. Early engagement of medically-complex patients is critical to allow ample time for
      risk evaluation, discussion of anaesthetic plan and medical optimization. Timely and optimal
      preparation of patients before elective surgery could reduce morbidity and mortality, and
      day-of-surgery case cancellations. Due to the implementation of same-day-admission and
      ambulatory surgeries, medically complex patients would require preanaesthesia evaluation at
      an appropriate time interval prior to their elective surgery, in an outpatient facility.
      Currently, a nurse-administered, paper-based health screening questionnaire is used at the
      Preadmission Service to determine the need for outpatient specialized assessment by an
      anaesthetist prior to elective surgery. This process is labour-intensive and time-consuming
      for both patients and nurses.

      The need for efficient and cost-saving processes are driving healthcare practice.
      Computer-assisted history-taking systems have been shown to assist clinicians in the accurate
      eliciting of information from patients. Increasing evidence supports the use of such systems
      to triage patients and determine the timing of specialist-led anaesthetic review. Low-risk
      patients could be evaluated by an anaesthetist on the day of surgery while high-risk patients
      could be channeled into appropriate pathways for evaluation and optimisation prior to day of
      elective surgery.

      This study is planned to be conducted in several phases:

      In the first phase, the investigators aim to re-design and convert the current paper-based,
      nurse-administered health screening questionnaire into a reliable patient self-administered
      digitized tool - Pre-Anaesthesia CompuTerized Health-assessment (PATCH). The feasibility of
      introducing a digital pre-anaesthesia health assessment screening tool will first be assessed
      by conducting two discrete anonymized surveys on healthcare providers and elective surgical
      patients to explore their needs, attitudes and acceptability towards having a digitized tool.
      Next, a new paper-based preanaesthesia health screening questionnaire will be designed after
      extensive literature review of published, validated preanaesthesia screening questionnaires
      and a focus group evaluation by clinicians of the anaesthesia department.

      Using the draft self-administered paper questionnaire, a pilot study of about 100 patients
      would be conducted after obtaining written informed consent. Feedback would be sought through
      a short structured interview that focuses on patient's perception of language, relevance of
      content and ease of completion. Patients would then be processed, as per standard of care,
      through a nurse-led interview using the paper-based tool. Validity of each assessment
      question is determined by percentage agreement method. Percentage agreement of 95% or higher
      is considered as good criterion validity. Analysis would also include measurement of
      identical, contradictory and non-contradictory response rates.

      In the second phase, the paper-based questionnaire will be converted to a digitized tool on
      an iOS platform and accessible via a tablet, called Pre-Aneshtesia CompuTerized Health
      assessment (PATCH). PATCH and its server would be developed using a JavaScript framework.
      Patient responses using self-administration of PATCH would be validated against the responses
      obtained by a nurse using the same platform. After written informed consent, participating
      patients (n=250) will complete the health screening questionnaires on a tablet without help,
      after which a nurse who is blinded to the patient's responses, would conduct the health
      screening using the same platform . Responses for each screening question will be compared
      for agreement and percentage agreement of 95% or higher will be considered good criterion
      validity.

      In the final phase, a two-arm, non-blinded randomized trial would be conducted at the
      Preadmission Service after written informed consent, comparing duration of nurse assessment
      in patients who have completed the self-administration of preanaesthesia health assessment
      using a tablet vs those undergoing standard care nurse-led interview. Based on an expected
      difference in means of 3 minutes and standard deviation of 3.5 minutes at 80% power and a
      level of significance of 5%, the total sample size for power of analysis is 44. To account
      for drop-outs, the investigators aim to recruit 52 patients in this phase. Duration of nurse
      assessment ("service time") will be measured by the "1Q 1Payment" system and is defined from
      the moment the nurse clicks on the queue system to call for the patient, to completion of the
      nurse assessment.

      Primary aim(s):

      To convert a paper-based preanaesthesia health screening questionnaire into an electronic
      tool, with at least 95% concordance of responses from patients

      To compare the duration of nurse assessment at the Preadmission Service in patients
      randomized to self-administration of digital preanaesthesia health assessment vs those
      undergoing standard nurse interview

      Primary hypotheses:

      The conversion of a paper-based preanaesthesia health screening questionnaire can be
      converted into an electronic tool, with at least 95% concordance of responses from patients.

      Self-administration of a digital preanaesthesia health assessment tool does not prolong nurse
      assessment at the Preadmission Service, compared with standard care nurse interview.

      As a secondary aim, the patients' perceptions and experience in using PATCH will be
      evaluated.
    

Intervention name(s): Self-administered electronic health screening
Intervention type(s): Procedure
Intervention description(s): Health assessment using an electronic device
Allocation: Randomized
Intervention model: Crossover Assignment
Intervention model description: Participating patients performs self-administered preanaesthesia health screening on an electronic tablet, before receiving nurse-administered health screening by nurses blinded to their electronic responses. This cross over study design aims to validate the electronic patient responses. In another phase, a randomized controlled trial design will be adopted to compare nurse processing time between patients who are assessed by self-administration of PATCH vs patients who undergo standard nurse-led health assessment interview.
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: Preanaesthesia health assessment; Computerized health assessment