VOL: 96, ISSUE: 39, PAGE NO: 42
Paul Ryan, BA, RGN, is clinical nurse specialist (orthopaedics) at Rotherham General Hospital
Longevity is associated with a higher incidence of illness. Many older people require surgical intervention to enhance their quality of life, so orthopaedic surgery is commonly indicated. Despite this, the government’s ‘new NHS’ demands increased efficiency and quality of patient care, while continuing to reduce the hours of junior doctors.
In an attempt to improve patient care and optimise the use of orthopaedic theatre time, a nurse-led orthopaedic preassessment clinic (OPAC) was established at Rotherham General Hospitals NHS Trust (Box 1).
Functions of OPAC
The preadmission clinic is used by all five orthopaedic consultants at the trust. Patients are seen by appointment two to three weeks before their admission. Minor cases are allocated 30-minute appointments; major cases receive 45 minutes.
The clinic is staffed by one full-time registered nurse who assesses patients according to the protocol of each particular consultant. These encompass medical, nursing and social-assessment tools.
Routine observations are also done as part of the assessment process (Box 2). Referrals to other departments are made by the preassessment nurse based on the results of the assessment: for example, Doppler studies and respiratory-function testing. ECGs can be arranged to coincide with the patient’s preassessment appointment.
Patients are given an explanation of routine admission procedures, including surgery, postoperative recovery and the discharge procedure, as well as an opportunity to discuss potential complications.
Information is supported, where possible, with booklets and leaflets that have been compiled by the preassessment nurse and approved by the multidisciplinary team.
This allows patients to begin digesting any new information, which helps them to make informed choices about their surgery and nursing care.
Clerical assistance is provided by a ward clerk, who helps with clinic administration; medical notes and X-rays are provided by the admissions clerk.
All hip and knee arthroplasty patients are seen in the preassessment clinic and have consultations with an occupational therapist and physiotherapist. Other individuals who are thought to require these services can be seen at the request of the preassessment nurse.
This method of consultation means that the patient gets the necessary equipment preoperatively, instead of postoperatively, which, in the past, has been identified as causing delays in discharging patients. It is also at this point that the physiotherapist starts rehabilitation exercises to assist postoperative recovery.
When patients fail to attend their preoperative assessment appointment, inquiries are made by the preassessment nurse. In this way it is possible to ascertain whether or not the patient is well enough for, or intends to go ahead with, surgery.
Patients are given information regarding cancelling or deferring their surgery to ensure that in the event of cancellation all necessary resources, including theatre time, are promptly reallocated to the next suitable patient.
During the five years from June 1995 to March 2000, a total of 5,456 patients were invited to attend for preassessment. Of these, 787 patients (14%) attended.
The figures in Box 3 reveal that 244 (31%) of these patients were medically unfit for surgery. Had these admissions gone ahead without preassessment, it could have resulted in theatre cancellations and time and resources being wasted carrying out admission procedures.
The number of patients who asked for their surgery to be deferred was 192 (24%) (Box 3). Their reasons for deferral varied, some were physical and others were social in origin.
Where possible, other patients were asked to take these places. These patients were also subject to preassessment.
Nearly a fifth of the patients (151) did not wish to have surgery or no longer needed it. These patients were discharged and referred back to their GP by the preassessment nurse.
Fourteen per cent (107) required anaesthetic assessment. This figure may have been affected by the protocol of one of the consultants in post at that time, who routinely requested anaesthetic assessment of all his patients over the age of 80. However, only two patients had surgery cancelled following anaesthetic assessment.
Forty-four patients (6%) were seen by a doctor at the request of the preassessment nurse. These admissions were subsequently cancelled.
Thirty-eight (5%) were identified as needing to be admitted earlier than planned due to a deterioration in orthopaedic condition or because of management of insulin-dependent diabetes.
Eleven patients died while on the waiting list.
It is paramount that the effectiveness of any new service and its impact on patient satisfaction is monitored.
Three patient satisfaction audits have taken place since the preassessment clinic started, each involving 100 patients. The three audits have yielded responses of 57%, 62% and 82% consecutively.
The comments received were generally positive and encouraging, and included ‘prompt attention’, ‘everyone friendly and helpful’, ‘satisfied with everything’, and ‘eased my mind about the operation’.
Many expressed appreciation of the multidisciplinary leaflets they had received.
Comments expressing dislike of one or more areas of the service were either rectified by the nursing staff or referred to the nurse manager for further consideration.
OPAC has proved itself a valuable service, not only to patients but also in ensuring the efficient management of these patients’ care throughout their contact with the hospital.
It has been shown that a registered nurse is able to use this service as a means of identifying a variety of problems that can affect patient admission and use this foresight to alleviate patient concerns, plan to enable early discharge and minimise lost and disrupted theatre times.
This post has since become a regular provision within the orthopaedic service, funded by the trust, and is a routine service provided to all orthopaedic patients due to undergo elective orthopaedic surgery.
In addition, the clinic monitors waiting lists and removes those patients who no longer require or wish to have surgery.
Quality care is provided promptly and efficiently on a one-to-one basis and patients experience minimum disruption due to the centralisation of clinic services.
Nurse-led clinics appear more cost-effective as they employ a senior nurse instead of a consultant or anaesthetist and this is achieved without losing the quality of patient care.
In the new, modern and dependable NHS, nurse-led clinics are the way forward.