VOL: 98, ISSUE: 40, PAGE NO: 34
Jenny Bramhall, MSc, RGN, is nurse consultant, preoperative assessment, Birmingham Heartlands and Solihull NHS Trust
Nurse-led clinics have been highly effective for a number of years in many specialties.
However, preoperative assessment of elective inpatients is a growing concern and this article identifies the vital role that the nurse working in a preoperative assessment service has within the field of elective patient care.
As health professionals in elective care, nurses are in the forefront of health care delivery and must seize every opportunity to make an impact on the quality, effectiveness and efficiency of the patient’s journey through the maze of service delivery.
The government’s view of patient care delivery
Patients may be the most important people in the health service, but it does not always appear that way. Too many of them feel they are talked at, rather than listened to, as noted in the The NHS Plan, (2000) and this has to change.
Health care must be tailored for the convenience and concerns of patients. To bring this about, patients must have more say in treatment and more influence over the way the NHS works. They should be able to make choices about their health care, such as being able to choose a GP or a date that is convenient for them to undergo elective procedures (Department of Health, 2000).
The NHS Plan (2000) sets out the government’s intentions to invest in and reform the NHS. As a result of public consultations, the plan now reflects the views of the public and of NHS staff. It aims to reduce waiting times and ensure quality patient-centred care. Chapter 10 of The NHS Plan, ‘Changes for Patients’, sets out new rights and roles for patients in the NHS.
Greater information is available to empower patients from an increasing range of sources available on the internet to NHS Direct and clinical guidelines from the National Institute for Clinical Excellence, which use jargon-free language.
There is also better protection for patients through the introduction of new quality-assurance systems aimed at raising standards in the NHS, such as ensuring that the professional bodies representing doctors, nurses and other health care professionals have in place much tighter regulations to guarantee that their members are competent to practise.
The principles of preoperative assessment
Preoperative assessment is not a new service - it has been around for many years and is very successful in day surgery. However, elective inpatient preoperative assessment has a long way to go. While it is successful in some trusts, there is little national uniformity and its purpose varies considerably from area to area.
The principles of preoperative assessment are:
- To identify before surgery a patient’s medical, physical, psychological and spiritual needs;
- To liaise, where appropriate, with external agencies to implement discharge planning;
- To ensure a more effective use of hospital resources such as theatre time and bed occupancy by reducing the number of patients who do not attend scheduled surgery, the number of cancelled operations, and the length of time patients spend in hospital, thereby having a positive impact on waiting lists.
Preoperative assessment is essentially a clinical risk assessment where the health of a patient is appraised to ascertain that the person is fit to undergo the anaesthetic for a planned operation. The optimum time frame for this assessment to take place is three to four weeks before the surgery.
The assessment is divided into three parts. The first involves taking a full medical history, with particular attention to any complications following previous operations/anaesthetics. When indicated, appropriate tests will be performed such as bloods, X-ray and electrocardiogram. Blanket routine investigations are inefficient, expensive and unnecessary (Association of Anaesthetists, 2001).
If any abnormalities are detected, these can be addressed before surgery, discussed with the anaesthetist and, if necessary, surgery can be deferred until the patient has reached optimum health.
A three-to-four week period in the run-up to surgery will enable any tests to be carried out and, if necessary, allow another patient to be assessed and prepared for surgery. This will ensure that resources such as theatre time and ward beds are appropriately used, and that the number of cancelled operations, patients who do not attend for surgery and time spent in hospital will be reduced as a result.
The use of medications and herbal preparations before surgery
The pharmacist plays an important role in the first part of the assessment, by giving advice on changing treatments or stopping medications, such as the contraceptive pill, aspirin and warfarin, which need special consideration before a patient has scheduled surgery.
A patient’s use of herbal preparations must also be assessed. Herbal preparations are widely accepted and may be used alongside conventional medication. They are often taken with the knowledge of the patient’s GP.
As a rule, such preparations do not provoke drug interactions, although this will need to be checked in each individual case. It is important to consider carefully the continuing use of certain herbal remedies.
For example garlic inhibits platelet aggregation, which may increase the risk of bleeding after surgery (Ang-Lee et al, 2001). The patient needs to be told that any garlic supplements should be discontinued at least seven days before the date of the scheduled surgery.
If the patient is taking an echinacea preparation, which is used primarily as an immunostimulant, this must be discontinued as far in advance of surgery as possible. It may lead to an allergic reaction, the reduction of the effectiveness of immunosuppressant drugs, and subsequent poor wound healing, which could result in an increased risk of infection (Ang-Lee et al, 2001).
The second part of the assessment concerns the social aspects of the patient’s well-being and factors that may affect his or her discharge from hospital, such as transport, the involvement of social services, a physiotherapist, an occupational therapist, or any community care that is being provided for the patient.
The preoperative assessment is a prime opportunity to prepare the discharge arrangements that are necessary to ensure the smooth return of the patient to the community. All too frequently avoidable delays occur in discharging patients following surgery.
In many cases where patients are medically fit for discharge, it is discovered that they live alone and require care that only a social worker is able to set up. Or it may be found that the patient requires a commode/bath rails as a direct result of the surgery, resulting in delays until these can be ordered, delivered and fitted. Such delays, in turn, increase the length of a patient’s hospital stay, which is inappropriate for both the patient and the trust.
The third part of the assessment is the information exchange that takes place preoperatively between the staff and the patient/carer. The value of this cannot be overestimated. It offers an ideal opportunity to establish that the patient still wants the operation to go ahead and that he or she fully understands why they are having the procedure; the benefits and disadvantages of having the surgery; what will happen in hospital in terms of any drips, drains or pain control they may need; and details of the surgical procedure.
Written information about the operation/hospital stay is given to the patient and any carers. If patients require a blood transfusion as part of their surgery, autologous blood donation can be discussed if this service is available. If not, the NHS booklet, Receiving a Blood Transfusion (Department of Health, 2001) will need to be discussed with the patient.
The length of the hospital stay and the proposed date of discharge gives preoperative assessment staff the chance to discuss transport arrangements with the patient. There will be exceptions, however. As this is a planned episode in hospital, the majority of patients will be expected to arrange their own transport to and from the hospital.
A systematic approach
Preoperative assessment, although nurse-led in many areas, is not the exclusive province of nurses. A multidisciplinary, multiagency approach is fundamental. It draws on the skills of the appropriate health care professional at the appropriate time and ensures that the patient is fully prepared to undergo their elective stay in hospital.
Whatever approach is taken in setting up a preoperative assessment service, careful consideration of the skills and knowledge of the staff working in this specialist area is vital. Staff members must be able to disseminate accurate up-to-date information about the operation and the hospital stay and provide appropriate discharge advice.
It is imperative that there is a coordinated approach in the provision of elective inpatient care and that preoperative assessment is not seen merely as an add-on service. A systematic approach is needed to identify the whole inpatient elective care journey, from GP referral to hospital stay and back to primary care.
Preoperative assessment is ideally suited to commence in the primary care setting and I believe this is the future of this growing service.
Evaluation of the service
Evaluation is a crucial part of any service, and it will enable the process of preoperative assessment to be mapped out accurately at regular intervals. This will identify any problems such as unnecessary duplication of labour.
The information that is obtained can then be used to further refine the service in order to meet the needs of each patient coming in for surgery.
A preoperative assessment service is a valuable and important part of the care of patients having elective surgery. The care is carefully planned and offers nurses the opportunity to ensure that patients will be as comfortable as possible.
The effective introduction of a preoperative assessment service not only increases patient satisfaction, reduces regional and local differences in practice, and minimises non-attendance for surgery, but it also reduces hospital-led cancellations and improves organisational satisfaction (NHS Modernisation Agency, 2001).