Authors Philip Walters, RN, is nurse specialist; Emma Peters, RN, is nurse specialist; Karen McKinnon, RN, is specialist staff nurse, all in the cardiac homecare team, Royal Brompton Hospital, London.
In 1996 we established the first post-operative home-care service for patients who had received cardiac surgery. This was in response to requests from patients to shorten their stay in hospital. Inpatient stay is reduced by up to 30% by continuing post-operative care at home.
Over the years the short-stay service has been extended to encompass a pre-operative screening scheme known as Fit for Surgery. Together, these programmes constitute the Royal Brompton’s cardiac homecare service, which was developed by nursing staff, provides new and effective ways of working and has excellent potential to be implemented at local, regional and national levels.
AIMS OF THE INITIATIVE
The short-stay service was established to reduce the length of time patients needed to remain in hospital after undergoing heart surgery. In addition to its obvious cost benefits to the trust, the service offers patients the convenience of receiving care in their own home.
The Fit for Surgery programme was developed to screen patients at home before they were admitted for surgery, enabling us to identify abnormalities that could cause delays or cancellations to their surgery. We also wanted to use the waiting time to address risk-factor management with patients and support both them and their families through this stressful period.
Research undertaken among patients who were cared for on the short-stay programme revealed that they had fewer post-operative complications as a result of early discharge from hospital. Fewer cancellations of surgery have occurred among those receiving care as part of the Fit for Surgery service. The most recent research was undertaken two years ago.
We audit our service annually and the results have guided its development. The service is constantly being developed to meet both patient need and government initiatives, including targets such as the
18-week wait for surgery.
We developed a nurse-led initiative to address anaemia and low ferritin levels pre-operatively. Patients who are low in iron are started on ferrous sulphate and given advice and support on improving their diet. Anaemia is investigated and the cause treated to prevent post-operative complications and the need for blood transfusion. The British Blood Transfusion Society heard of our work in this area and asked us to present our strategy at one of its professional workshops. As a direct result of our work, the society has produced an NHS-wide information leaflet to advise patients on how to prevent anaemia.
We have devised a manual, entitled Fit for Surgery, Fit for Life, for patients awaiting coronary artery bypass surgery. This helps them to understand their illness, advises them on risk-factor management and encourages lifestyle change that improves their preparation for surgery. We evaluated the usefulness of the manual and patient response was extremely positive – one patient described it as ‘his heart bible’.
The service offers a combined approach that benefits both the patients and their relatives. The home visits mean patients
are seen in an environment where they feel they have greater control and are, generally, more comfortable asking questions about their condition, surgery and care. It is particularly useful for patients who have an underlying condition, such as hypercholesterolaemia, as both they and their relatives can be counselled and referred to a surveillance service that is
also run by the trust.
Patients are delighted that the service is brought to them with minimal disruption to their daily routine and appreciate the benefits of a personalised service. The Royal Brompton’s homecare service was mentioned twice in the Department of Health document, Now I Feel Tall: What a Patient-led NHS Feels Like. Both the Short Stay and the Fit for Surgery programmes were described as innovative and beneficial to patients.
The pre-operative visits also provide a platform to support patients in both losing weight and giving up smoking prior to surgery. This not only provides long-term health benefits but also reduces the risk of post-operative complications. We also address poorly controlled diabetes and advocate better care for these patients in primary care. We monitor their blood glucose and HbA1c levels to optimise them for surgery and provide dietary and lifestyle advice to manage their diabetes.
As a result of our work other specialties in the hospital have established similar pre-procedure screening programmes. We have demonstrated that better pre-operative preparation can reduce both cancellation of surgery and inpatient stay. We plan to expand the services we provide by setting up pre-admission screening programmes within our referring hospitals.