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Implementation of preoperative visiting for critical care patients

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Preoperative visiting has been around for about 20 years, and involves the nurse responsible for a patient’s care in theatre visiting the patient on the ward before surgery takes place. These visits enable the nurse to assess the patient’s needs and to formulate a plan of care. The nurse can then communicate any relevant information to the theatre team before the patient arrives, thus raising standards of care (Tudor, 1992).


VOL: 99, ISSUE: 41, PAGE NO: 26

Susan Daykin, BSc, RGN, is clinical nurse specialist (acute pain management), Leicester General Hospital, Leicester.


Preoperative visiting has been around for about 20 years, and involves the nurse responsible for a patient’s care in theatre visiting the patient on the ward before surgery takes place. These visits enable the nurse to assess the patient’s needs and to formulate a plan of care. The nurse can then communicate any relevant information to the theatre team before the patient arrives, thus raising standards of care (Tudor, 1992).



Visiting patients in the preoperative period is said to reduce anxiety and aid recovery (Radcliffe, 1993; Copp, 1988). It also enables nurses to talk to patients and prepare them for theatre and a pending stay in an intensive care/high dependency unit (ICU/HDU).



When a patient is critically ill relatives expect to be able to visit them, and it was suggested by staff at Leicester General Hospital that a preoperative visit to the ICU/HDU could be useful in this context to reduce the stress involved for both patients and relatives.



As part of the preoperative consultation patients can also be given the opportunity to visit the ICU/HDU to meet the nurses who will be looking after them. The literature supports this theory.



The evidence for preoperative visiting
According to Dobree (1990), preoperative visiting not only reduces stress but helps patients to become involved in their care and gives them time to voice any fears they may have.



Booth (1991) believes that preoperative visiting could be beneficial within ICUs/HDUs as long as a protocol is followed. Bibbings (1981) highlights that intensive care and high dependency care staff need prior knowledge of their patients because they have little opportunity to meet them before surgery, given the busy nature of their work environment. Patients also need as much information about their care as possible.



It was felt that a preoperative visiting service would benefit patients (and their close relatives) who have a planned admission to the ICU or HDU at the hospital.



This article describes the implementation of the visiting service, which was carried out by the critical care pain nurse, and reports on the outcomes of a patient satisfaction survey, recommendations for changes to practice and re-evaluation of the service.



Implementation of visiting
Discussing preoperative care



The preoperative visit was arranged to take place on the patient’s arrival on the surgical ward. Nursing staff considered that this would enable patients to receive more individualised care.



A protocol was set up to ensure that each patient received the same information from the nurse. This information covered details about theatre and the ICU and/or HDU, including the nil-by-mouth rule and the ‘checklist’ procedure, whereby patients are asked for their name and date of birth before all interventions.



The checklist is necessary for patient safety but being repeatedly asked for their details can make some patients feel insecure.



Having adequate information about the checklist procedure can reassure patients that this is normal practice designed to maintain their safety rather than staff forgetting who they are.



Providing written information
The nurse also provides patients and relatives with written information during preoperative visits. This information includes the following:



- Telephone numbers;



- Visiting times;



- Description of daily procedures;



- Details of pain relief.



Discussing postoperative care
The nurse also discusses element of postoperative care.



These will include:



- Where the patient will wake up after surgery (ICU, HDU or recovery room);



- Infusions;



- Monitors;



- Analgesia, other interventions.



The patients are encouraged to ask questions about their care and are offered an escorted visit to the ICU and HDU to give them the opportunity to become familiar with the surroundings.



Relatives can also visit the units, if appropriate, to give them an idea of what to expect and ensure they know where to go on postoperative visits. They are also shown pictures of the layout of the units.



The nurse fills in a record sheet at the time of the visit. This includes:



- Patient information;



- Any need for glasses or a hearing aid;



- Next of kin details;



- Relative visits;



- Any special requests, for example that a relative be contacted after surgery.



This information is passed to the ICU/HDU staff to ensure the patient’s needs are met after surgery.



Initial evaluation
A satisfaction survey was conducted between September 1998 and September 1999 to ascertain whether patients found the preoperative visits useful.



During this time the critical care pain nurse selected 60 patients for interview at their follow-up visit. This usually took place the day after their patient-controlled analgesia or epidural had been removed and they were back in the surgical ward. The nurse also discussed their overall pain management and postoperative care.



Of the 60 patients selected, five had not needed an intensive care or high dependency care bed, three had been unable to have beds because of lack of availability, one declined surgery and one died while in the intensive care unit. The remaining 50 patients participated in the audit.



Survey questions
Patients were asked to answer yes or no to the following questions:



- Patient information - was the information given at preadmission useful?



- Anxiety - did the information help relieve anxiety?



- Pain - was your pain well controlled?



- Sleep - were you able to sleep while in the ICU/HDU?



- Noise - was the ICU/HDU unit noisy?



- Lighting - did the lighting interfere with your ability to sleep at night?



The first three questions were to help ascertain the effects of preoperative visiting and the provision of information on patients’ pain and anxiety.



The questions about sleep, noise and lighting were to assess patients’ views on current nursing practice in the ICU and HDU. The nurses were keen to get this information because at the time of the audit they had some concerns that their 24-hour working pattern of monitoring those on ventilators was affecting the sleep patterns of patients in the HDU.



Analysis of data
The data was collated and the results are shown as a table (Table 1) and a graph (Box 1). Over 98 per cent of the patients said that the information they received during the visits was useful and the nursing staff think that it has certainly benefited patients who have returned for further surgery.



The fact that 98 per cent of the patients felt less anxious after receiving the information suggests that good information relieves patient anxiety.



The data regarding pain control also suggests this was adequate, as 94 per cent of patients felt their pain had been well controlled.



Nursing staff had been concerned that sleeping difficulties would be a significant problem for these patients. However, sleep, noise and lighting did not seem to be a major concern for patients, although some (12-14 per cent) did not sleep and this issue needs to be addressed on an individual basis.



Changing practice
The survey, although small, showed that patients appreciate receiving information prior to surgery. When questioned, 98 per cent indicated that they found the information that they received during a preoperative visit useful. The patients also seemed to benefit from the link with the critical care pain nurse. This nurse offers valued support for patients on ICU/HDU and then on the surgical wards. When questioned, 94 per cent of patients stated that their pain was well controlled.



These results show that the implementation of preoperative visiting for ICU/HDU is a great success and a benefit for patients from the point of view of anxiety relief and pain control. The findings highlight the benefits that can be obtained from offering and maintaining such a service.



Although sleep, noise and lighting did not seem to be a major concern for patients, there are some recommendations to be made. These include:



- Minimising invasive procedures during the night;



- Dimming lights;



- Offering emotional support to patients who experience problems sleeping.



Three years after the initial audit the patient satisfaction survey was carried out again. This was done in consultation with ICU/HDU staff. This time the patients were asked to complete a questionnaire (containing the same questions that had been asked by the critical care pain nurse) rather than being interviewed.



It was hoped that this approach would remove any pressure patients may feel to respond positively to questions asked by a nurse and would therefore result in more genuine replies and opinions.



However, the answers were surprisingly similar on both occasions. This suggests that the presence of the nurse did not indirectly bias the results at the original data collection.



Following collation of the data (Table 2 and Box 2), the results showed that 100 per cent of patients found the information useful.



The results for anxiety relief and pain control were similar to the last survey (96 per cent and 94 per cent responding positively).



Recommendations to reduce noise and dim lighting had made improvements to responses regarding the issue of sleep but this was not significant.



Future developments
At present, some patients do not receive preoperative visits because their beds are not booked until the day of their surgery. A solution is needed to enable to the critical care pain nurse to gain access to patients being booked into the ICU and HDU via the waiting list office so that arrangements can be made for these patients to be seen. At present, the nurse is only sent information about patients on their admission to the ward. A follow-up visit then takes place when the patient is admitted to the surgical ward. At this visit patients can ask questions and receive any further information.



It is hoped that by continuing to improve this service the quality of patient care and satisfaction will be maintained at the highest possible level. The service is under review and it is hoped to extend it to all patients who are having major surgery so that the pain team can have significant input in the perioperative phase.

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