Major changes occurred in hospitals in the 1980s. Driven by improvements in anaesthetic drugs and monitoring capabilities, we realised that not every patient needed to be admitted to hospital the night before surgery nor to stay until the following day. The development of day case surgery, also known as ambulatory surgery in the United States, meant that patients could come in and go home the same day which reduced costs, reduced infection and improved patient satisfaction.


There was also political pressure to increase the amount of day case surgery but it was soon realised that many patients were being cancelled or delayed due to poor preparation and in the 1990s St Bartholomew’s Hospital was one of the first to consider the concept of preparing and assessing patients before the day of admission: so-called preassessment.


We have come a long way since those early days of seeing patients in a clinic and along the way strange terms such as nursing preassessment and anaesthetic preassessment have come and gone. Today the UK leads the world in universal preassessment


Preassessment has a number of aims:

obtaining the patient’s medical history to identify any concomitant disease which can then be assessed, measured and optimised for the operation

identifying any anaesthetic issues with past operations or any inherited issues with anaesthetic drugs

obtaining the patient’s medical notes so that they are available on the day of surgery

adjusting drug treatment such as insulin for the perioperative period

undertaking blood tests and x-rays to eliminate abnormalities

identifying patients with infection so that they can be isolated to protect other patients

providing information to the patient about the pathway

assessing the home situation to identify those that cannot be sent home the same day

ensuring specific equipment, drugs and blood is available if needed

planning for intensive care or pain management postoperatively


Preassessment should be provided to all patients and the mechanism should be the same for all operations, although some larger operations may need additional investigations or management.


Preassessment has been shown to have a number of benefits:

It reduces both mortality and morbidity

It reduces the number of operations delayed or cancelled on the day of surgery

It avoids patients being kept overnight when not clinically indicated

It improves patient satisfaction and convalescence

and it saves money


Many hospital providers still ask patient to come to a clinic. This is suboptimal because it means taking time off work or arranging child care. Even the most efficient clinics take the best part of a half day. It is impractical for an anaesthetist to see every patient, so some patients have to return to have a second consultation with an anaesthetist. And if investigations are required they may have to be done on a separate day.


Other providers have tried telephone calls, and these do suit a minority of patients. However they are time consuming and the call often happens at a time inconvenient for the patient. As with clinics they are expensive


I have been using an on line preassessment service for the best part of a decade and it is now in universal use at the Weymouth Street Hospital. It is designed to be simple, easy for both patient and assessment nurse, and to facilitate rapid work up – often we have less than 24 hours to prepare urgent cases.


The patient receives an encrypted email – the encryption is required by GDPR but we now have it such that simply means clicking a link. The email can provide vital information such as when to stop eating and drinking, or indeed anything else. It explains we are asking the patient to complete a questionnaire and why. One more click opens a 27 question on line form that takes about 5 minutes to complete if the patient has no other issues. Each question is conditional ie if the patient answers ‘yes’ it opens further questions to get more information on that issue and to give a free text field so the patient can type in whatever they wish.


On clicking ‘send’ the questionnaire immediately appears on the preassessment nurse’s screen. The nurse has a series of protocols she can follow; for example we use the Association of Anaesthetists of Great Britain and Ireland protocol for diabetes, and the King’s College protocol for anaemia. So the nurse can set in place both investigations and instructions. She can also obtain old notes and summaries from other physicians


These are added to the questionnaire which is sent electronically to the relevant anaesthetist. He can ask for further interventions or information or can ask the nurse to arrange for him to see the patient in our consulting rooms. A copy remains securely encrypted on his system.


The nurse can communicate with the patient and the patient can come back to ask for further information.


On the day of admission the questionnaire, all the results, and any old medical notes are in the patient’s folder ready for the anaesthetist to carry out his consultation and examination.


We have repeatedly audited this system. 93% of patients are preassessed. Considering some patients are travelling before their admission, some do not speak English, and others are ‘booked’ only hours before admission we think this is excellent. Patients too like the system; they find it simple and they can do it when they have time as opposed to a clinic or telephone calls where they often complain. Importantly the number of avoidable cancellations is effectively zero.


In the future we hope to offer additional languages and to offer video consultations, especially for providing information about the hospital and the patient pathway.