VOL: 97, ISSUE: 01, PAGE NO: 32
Maureen King, RGN, is ward sister, surgical unit, Papworth Hospital, Cambridge
Georgina Howell, RGN, is perioperative/acute pain nurse, Hinchbrook Hospital, HuntingdonCompared with the extensive services provided for cardiac patients, thoracic surgery is the Cinderella of cardiothoracics. The nursing team in our surgical unit, a 24-bed cardiothoracic surgical ward, felt that establishing a thoracic telephone link line might address this imbalance in resources.
Compared with the extensive services provided for cardiac patients, thoracic surgery is the Cinderella of cardiothoracics. The nursing team in our surgical unit, a 24-bed cardiothoracic surgical ward, felt that establishing a thoracic telephone link line might address this imbalance in resources.
Medical advice hotlines are an established practice in the USA. In the UK, however, telephone helplines are associated predominantly with health promotion: smoking cessation, AIDS, coronary heart disease and breast cancer.
With increasing numbers of early discharges from hospital, and limited time for effective discharge planning, there is the potential for problems to arise in the transition between hospital and home. Not meeting patients' needs following discharge can undo previous progress and may result in a relapse.
Informing and educating patients about their condition improves coping strategies, reduces complications and accelerates recovery. For information and education to be effective they need to be accurately and consistently repeated and reinforced (Ley, 1988).
The primary aim of our thoracic telephone link line was therefore to reinforce the information and advice given to patients before discharge, while also allowing them time to reassess their own needs and prepare further questions.
Developing the project
There was already an established and effective telephone link line for cardiac patients at Papworth Hospital, providing further advice and education following discharge. This was used as the template for setting up the thoracic link line: the cardiac protocol for phoning patients and the audit data collection form were modified to meet the specific needs of this patient group.
The first step in the project was to raise awareness among nurses on the ward. Literature and information on telephone callback systems were made available for all staff to read and their comments and opinions were encouraged. The feedback was then analysed and the project's aims and objectives clarified.
Permission was gained from the two cardiothoracic consultants working on the ward to include their patients in a six-month pilot project. Patients were informed verbally of this service and their permission obtained for the discharging nurse to phone them.
The sample group included all 95 patients discharged from the surgical unit following thoracic and oesophageal investigations and surgery during a five-month period from June to November 1998 (Box 1). The study did not include those patients going to convalescent homes or those transferred to other hospitals.
Staffing the helpline
The skills required for operating the thoracic link line were identified as:
- An extensive knowledge of thoracic disorders and the surgical procedures involved;
- Excellent communication skills, including the ability to assess actual and potential problems;
- The ability to act appropriately on the information gained and a knowledge of the resources available inside and outside the hospital.
The criteria clearly identified the need for senior nurses, of grade E and above, to take responsibility for operating the line. This was undertaken on a rotational basis for one month at a time.
The nurses on the surgical unit did not feel that extra staff were needed for this project, but effective planning of the off-duty rota was essential to facilitate one member of staff making the phone calls on the planned day.
Assistance was sought from the cardiac support nurse and also the Macmillan nurses, who were accustomed to giving help and advice to patients over the telephone.
The data collection form (Box 2) aimed to assess the patient's physical and psychosocial well-being. A list of open and closed questions were included for guidance, and space was included for a written evaluation of the conversation, along with any action taken by the nurse following the call.
A strategically placed patient education board helped to make patients on the ward aware of the function and implementation of the thoracic telephone link line. The discharging nurse informed patients that they would receive one telephone call on the second Thursday following their discharge - the date of the telephone call was written on the patient's copy of their GP's letter.
To help facilitate effective communication between the hospital and the community, GPs were also informed of our intention to phone their patient.
Patients were told the types of questions they would be asked. For example, to assess a patient's nutritional intake and swallowing ability following an oesophagectomy, they would be asked about their appetite, what sort of things they were able eat and what they had eaten the previous day.
Patients were also asked if they were experiencing any discomfort or pain and whether any changes had been made to their analgesia regime. A thoracotomy is one of the most painful surgical procedures, but post-thoracotomy pain syndrome may be modified or even prevented by early detection and adequate treatment in the acute phase (Katz et al, 1996).
Patients were encouraged to write down any questions they might have for staff. It was also important to remind patients and carers that the telephone link line was not an emergency helpline and should not be used to inquire about the results of tests or investigations.
A total of 95 follow-up telephone calls were made by nurses operating the link line during the study. Patients sometimes required only verbal reassurance or simple, practical advice to aid their recovery process.
However, some patients experienced problems that were rectified by liaising with and involving the appropriate member of the multidisciplinary team.
The project revealed that the main areas of concern for patients were pain, constipation, follow-up and wound healing (Box 3).
Some 42 (44%) patients had worries regarding their pain management at seven to 10 days following discharge. The incidence of long-term post-thoracotomy pain is reported to be up to 67% (Matsunaga et al, 1990).
Katz et al (1996) suggest that there may be a relationship between the severity of acute postoperative pain and the development of chronic post-thoracotomy pain.
Unfortunately our data did not clearly identify which patients had the most significant problems with pain. We hope to address this issue by altering the data collection form to include the numerical pain rating score currently in use on the ward.
A high proportion of patients reporting pain a week after discharge had stopped their analgesia prematurely. The main reasons given were constipation and the fear of addiction.
The analgesia regime used on discharge from the surgical unit includes dihydrocodeine, which is a weak opioid and may therefore have caused the constipation. It is now recommended that all patients discharged on dihydrocodeine should be prescribed senna.
Fear of addiction is still one of the greatest barriers to achieving adequate pain relief (Stannard and Booth, 1998).
An unpublished PhD study carried out in the late 1980s in the UK found nurses overestimated the risk of addiction from opioids and that this fear could at times be conveyed to the patient.
Drug addiction is in fact an extremely rare outcome of postoperative analgesia - the overall incidence is only one in 3,000 (Royal College of Surgeons and Royal College of Anaesthetists, 1990). Nurses need to convey the importance of continuing with regular oral analgesia, and a weaning regime is now suggested when giving verbal discharge advice. Our written discharge advice reinforces this information.
Histology results may take up to 10 days and this is an anxious time for patients and their relations. The fact that the link line is not for the notification of results was emphasised to patients before discharge, but patients still required maximum support during this apprehensive time.
We have found that close liaison with the Macmillan services, district nurses and consultant secretarial staff is essential to ensure that patients are seen by the appropriate personnel as quickly as possible.
The project revealed that 20 patients (21%) had concerns about their wound healing. The assessment of verbal information over the telephone can be very subjective, so we feel that to increase the quality and reliability of the data obtained a more structured and focused questionnaire - possibly incorporating the recognised scoring system recommended by the Hospitals Tissue Viability Group (Wilson, 1998) - needs to be included within the data collection sheet.
The telephone link line is a simple and cheap mechanism for providing a link between hospital and home and reinforcing the information and advice given before discharge. The effectiveness of discharge planning can also be monitored. More importantly, it gives patients time to reassess their own needs and provide feedback. This in turn has enabled us to change our practices in response to patients' needs.
At present the thoracic telephone line is still only offered by one surgical ward. The results of this project will help to support the case for the other wards to offer the same service.
A computer database is being developed to enable the information and results to be audited more easily.