VOL: 98, ISSUE: 14, PAGE NO: 44
Deborah Patterson, BSc, RN, is practice/professional development nurse, Bradford Hospitals NHS Trust
In 1990, the Audit Office forecast that by 1999 about half of all elective surgery would be done on a day-case basis (Audit Commission, 1990). In collaboration with the Royal College of Surgeons, it identified 20 suitable procedures. The initiative was seen as ‘a way of getting to grips with waiting lists … without placing excessive demands on the taxpayer’ (NHS Management Executive Value for Money Unit, 1991).
In 1999, the British Association of Day Surgery (BADS) proposed its own set of 20 procedures considered suitable for day surgery and another 20 that should be possible for at least half of all patients (Cahill, 1999). All 40 are listed in Tables 1 and 2. However, the expected expansion in day surgery failed to materialise.
The latest figures from BADS (2000) show a wide variation in provision with the proportion of inguinal hernias repaired as day cases ranging from 5-80%, breast lumps from 3-80% and varicose veins from 10-90%. This lack of progress in day surgery in the UK has been blamed on organisational and staff attitudes (Watts, 2001), and the inappropriate management of postoperative morbidity (Fortier et al, 1998).
Health secretary Alan Milburn’s latest campaign to promote the expansion of day surgery (Department of Health, 2002) presents a challenge to health care professionals, but the obstacles are not insurmountable. Nurses, who play a leading role at all stages of the patient’s hospital journey, are ideally placed to implement the necessary changes.
The patient’s journey usually starts with a preadmission assessment, which benefits the patient mentally and physically (Smith and Rudd, 1998). Hospitals also benefit as this assessment identifies patients who are not suitable for day surgery, reducing the number of cancellations (Jones et al, 2000). In addition, non-attendance at the preadmission stage has been shown to indicate patients who are likely not to attend on the day of surgery (Newton, 1996). Any reduction in the number of cancellations results in more effective use of theatre time.
In many hospitals, preassessment clinics are led by nurses who work closely with the anaesthetics department. Staff work to protocols which ensure that diagnostic tests are not ordered unnecessarily and that problems are dealt with before admission (Jones et al, 2000). They also provide the patient with written and verbal information on what to expect before, during and after the operation. Future developments are likely to include telephone assessment for suitable (fit and healthy) patients and an opportunity to deliver information by post or via the internet.
The average day-surgery practice is a busy environment in which staff shortages are as common as they are elsewhere in the health service. It is essential that patients feel cared for and know that the nurses have time for them, which can be daunting given that nurses may be admitting patients to four theatre lists while others are attending for ward-based procedures, such as bladder chemotherapy or lithotripsy.
Core skills are crucial in day surgery. Nurses need to be able to make decisions and act on them immediately. Quick thinking ensures that they keep track of the large numbers of patients passing through the unit every day. Being able to build relationships with patients and carers in a short space of time is also crucial, as are excellent communication skills.
Working with patients from numerous specialties who attend for countless different procedures presents certain problems, which can lead to dissatisfaction and confusion. One way to ensure all patients receive the same high standard of care is to introduce procedure-specific care pathways (Campbell et al, 1998).
Care pathways are perfect for day surgery: patients are usually healthy, the procedures are relatively straightforward and recovery in the unit is fairly predictable. The development and ongoing review of evidence-based pathways is another challenge for day-surgery nurses.
Inguinal hernia care pathway
The first day-surgery care pathway to be developed at Bradford Hospitals NHS Trust was for inguinal hernia repair. The pathway starts with preadmission assessment about two weeks before surgery and then moves to the day of surgery. The admission outcomes ensure that the patient is physically, mentally and socially prepared for the procedure. A number of the required patient outcomes are listed and summarised in Tables 3, 4 and 5.
A risk assessment for antiembolic prophylaxis is included in the pathway, although Jenkins (1998) suggests that the early mobilisation of day-surgery patients may protect against thrombolytic complications. Hospital admission is avoided if possible, and day-surgery patients are encouraged to mobilise and go home within a couple of hours, taking responsibility for their own recovery.
However, when they get home they may wish to adopt the ‘sick role’ to ensure that they are given time to recover from surgery and general anaesthetic. This term was developed by sociologist Talcott Parsons to explain sickness behaviour (Annandale, 1998). Mobile patients who adopt this role may go home and confine themselves to bed, with health professionals having no control over the length of time they stay there. Recognising this, Huber et al (1992) recommend that short-stay minor surgical patients may benefit from prolonging the use of antiembolic stockings. Thrombolytic prophylaxis should therefore be considered for all day-surgery patients and they should be given information on the risks involved and preventive methods, such as leg exercises and mobilisation.
A moving-and-handling assessment is also carried out on admission, on return from theatre and when the patient is ready to be discharged.
After admission, patients may have to wait a few hours before going to theatre. They change into a gown just before going to theatre and walk rather than being taken by trolley. This enables patients to feel in control for as long as possible. A ward-based nurse accompanies the patient to the anaesthetic room and stays with the patient until he or she is asleep. The patient is collected from the recovery area when ready to return to the ward.
The nature of day-surgery procedures means that patients do not spend long in theatre or recovery. This length of time is decreasing, with some units using a fast-track system whereby suitable patients bypass the recovery room and recover on the main ward or unit (Mamaril, 2000).
Postoperative (second-stage recovery) care
When patients return to the ward they are assessed against recovery outcomes. A number of required outcomes are listed and summarised in Table 4. Pain and nausea are evaluated and postoperative observations are recorded according to protocol. An audit of 200 patients showed that there was no need to recheck blood pressure and pulse in asymptomatic patients, provided that both readings taken in the recovery area were normal. These patients have their observations checked before discharge. Patients with a history of cardiovascular problems, postoperative morbidity (pain, nausea or vomiting), or abnormal readings in recovery will have their observations checked on return to the ward and then as necessary.
Refreshments are offered at this stage, although eating and drinking is not a discharge criteria as the evidence suggests that this increases the risk of postoperative nausea or vomiting (Jin et al, 1998). Once patients have been back on the ward for 60-90 minutes, they may be ready for discharge.
Discharge and post-discharge care
Discharge is usually nurse-led and is based on a number of procedure-specific criteria, including an ability to mobilise independently, pain and nausea scores that are acceptable to the nurse and patient, and no bleeding or visible swelling. The rest of the discharge process ensures that patients and their carers are prepared for recovery at home (see Table 5). The care of day-surgery patients does not end when they leave the ward and a telephone helpline provides support for patients and carers. Carers are crucial to the success of day surgery and are encouraged, with the patient’s permission, to be present when discharge advice is discussed.
Once the patient has been discharged the nurse completes an audit form, listing variances from the care pathway. These sheets are kept on the ward for analysis and are an excellent source of data relating to the clinical effectiveness of the nursing and medical care provided. Developing mechanisms to evaluate care through audit and nursing research can illuminate all stages of the patient experience and should be an integral part of the overall day-surgery service.
Describing key aspects of a typical patient pathway highlights some of the challenges faced in day surgery. It is an exciting, innovative and dynamic specialty that should be considered by all nurses looking for an interesting, challenging career in an innovative field of practice.