When nurses at Royal Brompton Hospital responded to patients’ requests to leave hospital early after cardiac surgery, they barely realised the size and scope of the service they were about to set up, as Kathy Oxtoby finds out.
‘Lost, frightened and in no-man’s land.’ That, says Philip Walters, a nurse specialist in cardiac surgery homecare, is how many of his patients seem when he first visits them.
‘Imagine the fear of waiting for the day of your heart surgery operation. You sit at home, worrying, unsure of what will happen, unsure if you will even survive.’
But after the home visit, Philip or another member of the Royal Brompton Hospital’s cardiac surgery homecare team in London will have tried to allay those fears while helping to ensure their patients will be fitter and better prepared for what lies ahead.
For others recovering from routine coronary artery bypass grafting (CABG) surgery, there is the reassurance of a visit from one of the nursing team.
Post-operative home visits mean these patients can leave hospital three days earlier than the normal seven-day stay to recuperate at home.
The cardiac challenge
The patient-centred approach of these nurse-led services – the first of their kind in the UK – won the team the Excellence or Innovation in Cardiac Intervention or Surgery category at the Cardiac Nursing Awards in April 2007.
All of the team – Philip, Emma Peters, nurse specialist in cardiac surgery homecare and Karen McKinnon, specialist staff nurse in cardiac surgery homecare – came from an intensive care background before moving into cardiac care.
‘Cardiac care is an enormous health challenge for our nation,’ says Philip. ‘The UK has the highest rate of heart disease in Europe.
‘And the associated causes also bring their own challenges, such as obesity, diabetes, high blood pressure and high cholesterol.
‘These are the problems cardiac nurses are facing, and our team really wants to play a part in helping to address them,’ he said.
Setting up the service
It was the frequent requests from adult patients wanting to leave hospital early following routine heart surgery that prompted the team to set up the post-operative cardiac homecare service in 1996.
‘The patients were asking if they could leave early, so Emma approached the surgeons at the hospital to see if there was a way we could look after them at home,’ Philip recalls.
‘Professor John Pepper, a specialist in adult cardiac surgery, liked the idea and agreed to a pilot study of suitable patients.’
The patients are chosen pre-operatively based on strict criteria.
For example, they must be first-time CABG patients with no history of respiratory problems, no renal impairment, they must live no more than one hour’s drive from the hospital and they must have a carer at home.
A member of the specialist team gives the required daily care to patients in their own homes for up to five days.
This may include pain management, dietary advice, wound care and advice and support for the carer.
A research trial conducted by the hospital compared early discharge patients cared for at home to those who had had a conventional hospital stay.
The research showed the homecare patients ate and slept better, had fewer constipation problems and were less at risk of contracting wound infections.
Following these results the team formalised their approach by developing a five-day care pathway which included the daily recording of blood pressure, temperature, pain management – in fact everything that would normally be done for them in hospital.
The nurses needed to be highly skilled so they received physical assessment training and acquired phlebotomy skills.
They then developed a unique patient group directive that allows them to prescribe drugs to an identified group of post-operative patients.
The directive has a series of algorithms for such areas as heart rate, pain or nausea to help identify potential problems.
If, during the course of a visit, the team finds the patient is unstable in any way they will be readmitted to hospital.
Five years ago, following the success of the short-stay programme, it became apparent that more could be done for patients prior to surgery.
‘Patients were telling us they would have liked more support at home during the stressful months that they were waiting for their operation.
So we thought: “What can we do to improve things for them?”’
The team set up Fit for Surgery, a personalised service for patients at home that involves physical and psychological assessments.
‘We know about patients’ heart problems but we need to know if they are fit for surgery in other ways, so we give them a full clinical assessment.
This includes checking for anaemia and we’ve set up a nurse-led haematology referral system so we can refer anaemic patients to a haematologist at the hospital who will advise on treatment.’
The months that patients wait for surgery are a useful time to examine their lifestyle and other factors likely to cause heart disease.
‘We use a technique called motivational interviewing which helps patients to look within themselves and make decisions to change their lifestyle.
‘We’re not saying you must give up smoking – we ask them why they smoke and what would help them to stop.’
Some 200 to 300 patients a year benefit from the scheme.
Suitable patients within an hour’s drive from the hospital are identified from the cardiac surgery waiting lists and invited to make an appointment.
‘Patients come to hospital fitter and better prepared to face surgery because we’ve been able to spot any medical problems and we have a series of algorithms to address them based on national best practice and treatment guidelines.
‘Again, this is a nurse-led service that previously would have been carried out by doctors.’
The programmes have been so successful that, as well as their recent award, the nurses’ achievements have been recognised by the British Blood Transfusion Society and the Department of Health.
The team has also designed a manual for patients awaiting coronary bypass surgery: Fit for Surgery, Fit for Life, to help them understand their illness and offer advice on how to prepare for surgery.
Recognition of the value of these services has not always been forthcoming – Philip acknowledges there have been obstacles as well as accolades along the way.
‘Because of the turnover of nursing and medical staff we have to educate new people about the value of what we do, which in some cases involves needing to win their trust and confidence.’
The nurses hope to win the trust of more staff and patients in the future.
The Royal Brompton Hospital is a national referral centre so the team is looking to expand its services nationwide and to helping other nurses run their own cardiac homecare programmes.
‘We’re thrilled our work has been recognised and that it has given us the opportunity to share our experiences with other nurses.
We hope they will adopt some of our ideas and set up similar services elsewhere.’
One personal patient experience Philip shares sums up just how powerful the impact of these services has been and why this is his ‘perfect job’.
‘During one home visit a patient said to me that since she’d been diagnosed with heart disease she hadn’t been able to share her fears with anyone because she didn’t want them to know how frightened she was.
‘I held her hand as she cried for the first time. As I left she said I was her ‘guardian angel’.
She later wrote to thank me for giving her back her life. It’s wonderful to be doing a job like this.’
How to establish a home-based service for patients awaiting cardiac surgery
• Have a clear vision of what you want to do and make sure it is measurable and achievable
• Gain support from your consultant cardiac surgeons and nurse manager
• Communicate what you are trying to achieve to the multidisciplinary team and be prepared to persuade them that you have the ability to do this
• Organise appropriate staff, training, equipment and transport
• Design cardiac care pathways and cardiac care algorithms
• Carry out a pilot study first so you can learn from your experiences