Improving patient flow and satisfaction: An evidence-based pre-admission clinic and transfer of care pathway for elective surgery patients.


by Jinjing He


The Pre-Admission Clinic (PAC) is an outpatient clinic to ensure that patients are comprehensively prepared for surgery and hospital stay prior to admission. PAC also plays an important role in the planning of post-operative care to facilitate a smooth transfer from hospital to home or other ongoing care facilities.

In Australia, nurse-led PACs have been widely implemented in public and private hospitals for patient assessment and screening. However, each hospital operates the clinic in a different way and there is no standardised practice around PAC services.


We aimed:

  1. To re-design and implement an evidence-based PAC incorporated with a transfer of care pathway for elective surgery patients.
  2. To evaluate the impact of the new PAC process and the care pathway.

We re-designed our Pre-Admission Clinic based on the findings in the literature, hospital interviews and stakeholders’ meetings.

The PAC algorithm starts with a triage process and focuses on earlier patient assessments. Potential risk factors (e.g. surgery type, age, pre-existing co-morbidities and discharge risks) are used to determine whether the patient requires a phone interview, a face-to-face interview or it can safely proceed to surgery.  For complex patients from interstate or rural areas who were unable to attend the PAC, a general practitioner (GP) pre-admission tool was introduced.  Pre-operative tests were conducted with patient’s local GP.  Abnormal results are triggers for further investigations and /or input from a clinical nurse consultant, medical professionals or allied health professionals (See figure 1).


A Transfer of Care Pathway was incorporated to facilitate care continuity from hospital into the community (See figure 2).

Key components of the pathway include:

  1. A Transfer of Patient Care Risk Assessment Tool
  2. An early referral process for comprehensive planning
  3. A discharge checklist for patients and caregivers


The impact of the algorithms was evaluated pre and post-implementation. We collected de-identified data from our hospital electronic medical record system and risk management system.

Outcome measures included:

  1. Cancellations (surgical cancellations & last-minute cancellations)
  2. Length of stay (average length of stay & discharge delays)
  3. Adverse clinical events (DVT/PE, pressure injury, infection, unplanned return to OT, unplanned admission to ICU and readmission rates)
  4. Patient satisfaction was measured by using a survey. A sample of patients completed the survey.



A total of 10,854 eligible cases were extracted from our hospital electronic medical record system. There were 5,716 cases in the pre-implementation period and 5,138 cases in the post-implementation period.

  1. The overall cancellation rate remained relatively stable (14.7% vs 14.6%, p=0.95). The last-minute surgical cancellation rate was reduced (10.8% vs 9.8%, p=0.02).
  2. No difference was observed in average length of stay (2.18 days vs 2.05 days, p=0.39). The percentage of discharge delays was reduced (17.3% vs 15.7%, p=0.03).
  3. The incidence of adverse events was too low to draw statistical conclusion.
  4. A sample of 102 patients completed the survey. The overall satisfaction improved post-implementation (81.4% vs 90.2%, p=0.03).



Results of our study suggest that the algorithms may reduce last-minute surgical cancellations, discharge delays and improve patient satisfaction.

Our paper describes the redesign, implementation and impact of an evidence-based PAC and a transfer of care pathway. Findings from this study have potential positive implications for perioperative practice. The hospital interviews indicated the lack of evaluation processes in place to measure the effectiveness of PAC services.  The algorithms are applicable for elective surgery patients, and can be potentially implemented in private and public hospitals to facilitate the standardisation of care.


He, J., et al. Improving patient flow and satisfaction: An evidence-based pre-admission clinic and transfer of care pathway for elective surgery patients. Collegian (2017),

Bio: Jing Jing He is a research nurse at Macquarie University Hospital and a PhD candidate at the University of Sydney.  Jing graduated with First Class Honours in Nursing from the University of Sydney.  As a nurse, Jing has worked in various specialties include day surgery, cardiology, community nursing and clinical trials.  In 2014, she was appointed by Macquarie University Hospital as the research coordinator for the Pre-Admission Clinic Project (funded by the HCF Research Foundation). She has successfully led the project and implemented a triage system and discharge pathway for elective surgery patients.  Jing has a particular interest in clinical health innovations and using advanced technologies to improve patient outcome and practice efficiency.  Her PhD study focuses on the impact of chemotherapy-induced alopecia and a scalp cooling device on adult oncology patients.