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Dissertation - Do pre-admission clinics alter the pre-operative course of patients awaiting major (cardiac) surgery?

Dissertation - Do pre-admission clinics alter the pre-operative course of patients awaiting major (cardiac) surgery?



This systematic review examines the role pre-admission clinics (PACs) in the preparation of patients for surgery and whether there is an optimal skill-mix profile of nurses, doctors or professions ...

This systematic review examines the role pre-admission clinics (PACs) in the preparation of patients for surgery and whether there is an optimal skill-mix profile of nurses, doctors or professions allied to medicine (PAMs) for them. The stage pre-operatively which patients are assessed for admission is considered and the length of time patients can be expected to spend at PACs. The format of documentation offering optimal communication between PAC and ward/operating theatre is evaluated together with whether this alters repeat investigations ordered before surgery. Finally whether patients benefit from the information given at PACs and if this results in improved discharge-planning for the patient.



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    Dissertation - Do pre-admission clinics alter the pre-operative course of patients awaiting major (cardiac) surgery? Dissertation - Do pre-admission clinics alter the pre-operative course of patients awaiting major (cardiac) surgery? Document Transcript

    • Do pre-admission clinics alter the pre-operative course of patients awaiting major (cardiac) surgery? Zachary Charles WHITEWOOD-MOORES Dissertation submitted in partial fulfilment of the MSc in Advanced Nursing Practice, Department of Health Sciences (School of Nursing and Midwifery), City University, London. Submission Date: 5th October 2001
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? TABLE OF CONTENTS TABLE OF CONTENTS.................................................................................................. 1 DECLARATION .............................................................................................................. 3 ACKNOWLEDGEMENTS .............................................................................................. 4 GLOSSARY ..................................................................................................................... 5 ABSTRACT...................................................................................................................... 7 BACKGROUND .............................................................................................................. 8 QUESTIONS ADDRESSED BY THE REVIEW .......................................................... 10 REVIEW METHODS..................................................................................................... 11 DETAILS OF INCLUDED AND EXCLUDED STUDIES........................................... 13 RESULTS OF THE REVIEW ........................................................................................ 15 What role do pre-admission/assessment clinics perform in preparing patients for surgery?.......................................................................................... 15 Is there an optimal staffing profile for PACs? ...................................................... 19 Do patients benefit from information giving at PACs? ......................................... 27 At what stage pre-operatively should patients be assessed for admission and what period of time can patients expect to spend in PACs? ............................................................................................................... 31 What format of documentation offers the best communication between PAC and ward/operating theatre? ....................................................... 32 Do PACs alter the investigations ordered before surgery? ................................... 33 Does the PAC alter discharge planning of the patient? ......................................... 35 DISCUSSION ................................................................................................................. 36 CONCLUSIONS ............................................................................................................ 45 CONFLICT OF INTEREST ........................................................................................... 48 REFERENCES ............................................................................................................... 49 APPENDIX 1 – REPORTING AND DISSEMINATION ............................................. 56 APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC PRE-ADMISSION CLINIC ........................................................................ 57 1
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? APPENDIX 3 – PRESENTATION FOR CSPAC NURSE ........................................... 71 APPENDIX 4 – TIMING OF PRE-ADMISSION CLINICS ......................................... 81 APPENDIX 5 – COMPARISON OF NURSES AND DOCTORS ................................ 84 APPENDIX 6 – EXCLUDED STUDIES ....................................................................... 85 2
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? DECLARATION I grant powers of discretion to the Department of Health Sciences (City University) to allow this dissertation to be copied in whole or in part without any further reference to me. This permission covers only single copies made for study purposes, subject to the normal conditions of acknowledgement. Zachary Charles WHITEWOOD-MOORES 3
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? ACKNOWLEDGEMENTS Thanks are extended to the following people for their assistance during the course and towards the completion of this dissertation. Dr Carol Ball Tracy Whitewood-Moores Maree Barnett Rachael Whitewood-Moores Carol Flowers Nicholas Whitewood-Moores Patricia McCarville 4
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? GLOSSARY ACNP Acute Care Nurse Practitioner (a term used widely in North America for hospital based Nurse Practitioners). ANP Advanced Nurse Practitioner/Practice (see notes in introduction). CABG Coronary Artery Bypass Graft CSPAC Cardiac Surgery Pre-admission Clinic. CSPAC Nurse PAC Nurse (see below) working in cardiac surgery. DoH Department of Health. DRG Diagnostically Related Groups. HCA Health Care Assistant. HCSW Health Care Support Worker. Hospital 1 Hospital in central area of capital city. Hospital 2 Hospital in outskirts of capital city. ITU Intensive Therapy Unit (in the context of this systematic review it refers to all units caring for ventilated patients, e.g. Intensive Care Units and Cardiac Recovery Units). North America USA and Canada. NP Nurse Practitioner. NSF-CHD National Service Framework for Coronary Heart Disease. PAC Pre-admission/Pre-assessment Clinic. PAC Nurse A nurse working in the pre-admission/pre-assessment clinic of either gender, irrespective of title (e.g. Sister, Charge Nurse, Nurse Practitioner, Advanced Nurse Practitioner, Acute Care Nurse Practitioner). 5
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? PAMs Professions Allied to Medicine (e.g. Physiotherapists, Pharmacists, Occupational Therapists etc.). Pre-admission clinics Usually see a patient in the 28 days before admission for operation; to conduct nursing/medical assessments, laboratory tests, x-rays if appropriate and any other tests as indicated by the operation or co-morbidity. Pre-assessment clinics Can be at any stage and are normally conducted to evaluate whether a patient is suitable for a particular method of treatment, e.g. day care surgery, and thus may be completed as the patient is put onto the waiting list, as different waiting lists are often used for differing treatment options to enable advance theatre list planning. PRHO Pre-registration House Officer. RCN Royal College of Nursing. SHO Senior House Officer TCI To come in (planned date of admission). The Trust The Trust in which the author works. UK United Kingdom. UKCC United Kingdom Central Council for Nurses, Midwives and Health Visitors. USA United States of America. 6
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? ABSTRACT This systematic review examines the role pre-admission clinics (PACs) in the preparation of patients for surgery and whether there is an optimal skill-mix profile of nurses, doctors or professions allied to medicine (PAMs) for them. The stage pre- operatively which patients are assessed for admission is considered and the length of time patients can be expected to spend at PACs. The format of documentation offering optimal communication between PAC and ward/operating theatre is evaluated together with whether this alters repeat investigations ordered before surgery. Finally whether patients benefit from the information given at PACs and if this results in improved discharge-planning for the patient. The original aim of most PACs appear to have been to achieve a reduction in post- admission cancellations of surgery; however, this single aim appears lost amongst the advantages of quality improvements offered to patients and the potential financial savings if day of admission surgery is implemented. PACs have become an essential part of quality surgical care, to admit a patient without knowing they are fit to proceed for surgery is wasteful of both human time and financial resources. Nursing appears to offer the most holistic option, particularly with nurses who practise advanced assessment skills within evidence-based protocols appear in other respects to be as effective as the doctors with whom they work. The ideal time for the pre-admission assessment is between one and three weeks pre- operatively; however, this does not coincide with the optimal time for patient education and behaviour modification (smoking etc.) which should be at least six weeks prior to surgery. Multidisciplinary documentation offers significant advantages in terms of cross professional communication however traditional boundaries remain and implementation of integrated care plan’s can meet obstruction from some individuals. The investigations requested pre-operatively may be slightly higher in nurse-led PACs however they conform more closely to evidence based protocols. Patients are better prepared for discharge with a combination of education and assessment prior to surgery. 7
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? BACKGROUND The development of Cardiac Surgery Pre-admission Clinics (CSPACs) have evolved alongside other pre-assessment/admission clinics (PACs) in the United Kingdom (UK) with varying degrees of nursing input. The training and suitability of staff to undertake various roles has been questioned with some authors comparing doctors with nurses (e.g. Jones et al, 2000; Toogood et al, 1998; Whiteley et al, 1997). The advanced nurse practitioner’s (ANP) role expands and may enhance the responsibilities of PAC nurses and therefore the attributes of advanced/higher level practice are also examined. Current waiting periods for cardiac surgery are universally considered to be unacceptably long; the National Service Framework for Coronary Heart Disease (NSF- CHD) has outlined targets to reduce waiting times for heart surgery to less than three months. Significant changes to existing practices and expansion in services will be required to achieve these ambitious but important standards from the current waiting times which are sometimes in excess of eighteen months (Department of Health, 2000a). The principal aim of many PACs appears to be the reduction of cancellations for medical reasons together with the length of time the patient is admitted pre- operatively. Medical problems discovered in the immediate pre-operative period were identified as a key reason for wasted surgical time due to the cancellation of operations (McCarville, 1999; Newton, 1996). It is hoped that by avoiding cancelled surgery and increasing capacity generally, that approximately 500 needless deaths on the waiting list can be avoided. The formidable target of a 40% reduction in cardiac deaths by 2010 has been presented as one of the principle roles of the newly established ‘Heart Czar’ Dr Roger Boyle (Hope, 2000). There is also evidence of significant anxiety experienced by patients awaiting cardiac surgery, which may be relieved by effective nursing intervention (Fitzsimons et al, 2000). The nurses conducting PACs/CSPACs will be referred to as PAC/CSPAC Nurse(s) throughout this text as this refers to nurses of either gender, although not their many different titles (see glossary). It is argued that some of these roles fulfil many of the widely discussed attributes of nurses undertaking Higher Level Practice (further analysed within the systematic review). The Trust in which the author works, currently conducts cardiac surgery on two sites, Hospital 1 and the Hospital 2, although there are Department of Health (DoH)/Trust plans to consolidate cardiac services at Hospital 1 in 8
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? the long-term (Department of Health, 1997b). The CSPAC Nurses’ role is a novel approach within the author’s Trust to optimise the pre-operative preparation of patients for cardiac surgery. To meet the aims of evidence-based practice, this has required comprehensive review and audit of patients is required to ensure that optimisation of the preoperative period is occurring in the way intended. It appears that although some PAC Nurses have been in post for some considerable time, little in the way of substantive research has been generated in this area. It is postulated that factors, which may have influenced this, include the difficulties of obtaining funding for nursing research and the lack of conclusive data, which is generated from this research. Any differences found between two groups of patients in nursing research may be as much to do with individual personalities of nurses as the way in which they practice. The quantifiable differences between sample and control groups may also be influenced by the many actions out of the control of the researcher and thus the data may be unreliable. This systematic review is set in this context and hopefully will generate interest in more widespread primary research in this area. 9
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? QUESTIONS ADDRESSED BY THE REVIEW What role do PACs perform in preparing patients for surgery? Is there an optimal staffing profile for PACs? Do patients benefit from information giving at PACs? At what stage pre-operatively should patients be assessed for admission and what period of time can patients expect to spend in PACs? What format of documentation offers the best communication between PAC and ward/operating theatre? Do PACs alter the investigations ordered before surgery? Does the PAC alter discharge planning of the patient? 10
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? REVIEW METHODS Involving patients in research must aim to improve outcome for the patient population, not be simply a means to academic qualification; this improvement normally involves a significant dedication of time to the process and cannot be done alongside other responsibilities (Wagstaff & Gould, 1998). This systematic review has been conducted as part of an MSc programme in Advanced Nursing Practice; during this time, the author has also been jointly responsible for the establishment of the new cardiac surgery pre-admission service on two sites within the Trust, which has limited the time available to complete this systematic review. A patient satisfaction survey was initially considered; however, ethical issues and the expense involved in conducting a postal survey of a significant sample of patients made this unsuitable. Writing to patients whose outcome is unknown raises the possibilities of increased anxiety amongst the families of those patients who did not survive surgery or who died later at home. The ethics, practicalities and expense of writing to or telephoning general practitioners to ascertain that the patient remains alive and well to conduct a retrospective study were considered unviable. It is therefore proposed that this should be conducted prospectively at the patient’s outpatient appointment as part of quality audit, rather than as an academic paper. The use of comparative quantative data to demonstrate whether a difference in cancellation rates exists in the authors Trust, between those patients who have been pre- assessed and those who are not was considered. However, the detailed audit highlighting the reasons for cancellation of surgery have only been collected in the current financial year, during which time the CSPAC has been running concurrently. In the early stages, only limited numbers of patients could be seen meaning patients were selected for clinic, concentrating on those thought most likely to have outstanding problems, e.g. ‘long-waiters’ and those with known co-morbidity. To make a comparison with more traditional forms of preparation would thus produce unreliable results due to selection bias compromising internal validity (Polit & Hungler, 1999: 227-233; LoBiondo-Wood & Haber, 1998:164-169). To ensure that this work would be relevant to practice, a systematic review was chosen, investigating whether pre-admission services altered the course of patients in the pre- operative period. The review was conducted in accordance with the NHS Centre for 11
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? Reviews and Dissemination (University of York, 2001) guidelines; a summary of their suggested structure is shown in Appendix 1. A single researcher undertook the search using the search terms identified in the search facilities shown in Table 1 (below) The numbers in brackets relate to the number of ‘hits’ from each group of resources and the search facility shown in Table 1. Manual searches of the referenced articles also widened the scope of literature identified. ADVANCED NURSING (8361/3212/663/6294/35/6726) CARDIAC PRE-ADMISSION CLINIC (8021/862/223/24/05/06) CARDIAC PRE-ASSESSMENT CLINIC (6621/952/213/04/05/06) CARDIAC SURGERY (9871/3642/423/60094/395/4076) PRE-ADMISSION (10261/2622/383/2724/45/1426) PRE-ADMISSION CLINIC (2271/1722/413/404/05/296) PRE-ADMISSION NURSE (9161/1712/203/24/05/06) PRE-ASSESSMENT (7231/2652/203/344/15/446) PRE-ASSESSMENT CLINIC (5831/2112/303/14/05/146) PRE-ASSESSMENT NURSE (6481/782/203/04/05/16) PRE-OPERATIVE CARE (9651/662/433/84/15/166) Table 1 – Search Facilities Utilised Search Facility utilised Search Engines Altavista GoTo AOL.com HotBot Compuserve LookSmart Direct Hit Lycos 1. “The Web” grouping of EuroSeek Mamma.com Copernic Plus 2001 Excite MSN Web Search FAST Search Netscape Netcenter FindWhat Open Directory Project Google Yahoo AltaVista UK Lycos UK Espotting Mirago Euroseek NBCi Excite UK Searchengine.com 2. “The Web – UK” grouping Fast Search Snoopa of Copernic Plus 2001 Find Once UK Directory Go To United Kingdom UK Plus Hot Bot UK Search King Lineone UK Max Look Smart Yahoo UK AHealthyMe Mayo Clinic Health Oasis AMA MedExplorer Ask Dr. Weil MedicineNet.com drkoop.com MediConsult.com 3. “Health” grouping of DrugInfoNet MEDLINEplus Copernic Plus 2001 HealthAnswers OnHealth HealthAtoZ The Thrive Health Library Healthfinder WebMD InteliHealth YourHealth.com 4. OVID Technologies Inc MEDLINE CINAHL 5. OVID Technologies Inc Cochrane Database DARE 6. OVID Technologies Inc Nursing Full Text Nursing Collection 2 12
    • Despite apparently high yields, particularly from Internet resources, the vast majority were of no relevance, poor quality or simply patient information as to location of the clinics etc. In addition because of multiple search engine listings, the same resource may be listed many times within the same database and duplicated across different databases. In addition some referred to sites which were no longer functioning. MEDLINE, CINAHL and OVID were the most useful databases, perhaps because they are specifically designed for searching relevant professional journals; however, there is the limitation that results are restricted to the major published journals. Despite advances in recent years, many journals do not have a full-text archive available on-line, although the majority have recent years accessible to subscribers. The use of abstracts as the sole source of information is a hazardous pursuit, as it is impossible to analyze the author’s conclusion based on the minimal data available. Therefore full-texts were sought using the British Library, University Libraries and Welcome Library resources together with personal communications with authors where contact details were available. Two people, the researcher and a nurse working in general surgery at a provincial District General Hospital reviewed the papers to assess their suitability for inclusion in the systematic review. The use of journal articles alone causes publication bias, which is thus termed due to the influence of the publishing journal, affecting the style of writing. If an author wishes to publish their work in a particular journal, this may alter the methodology chosen and the comprehensiveness of the study due to word limitations (Polit & Hungler, 1999: 268). There is also a tendency for researchers to publish ‘successful’ findings only, and success may be gauged by vested interest involved in the project. Sadly in common with many other papers, the author failed to identify or obtain significant numbers of unpublished works for several reasons including financial resources and the logistical difficulties in searching for unpublished works. There were no previously conducted systematic reviews listed within the Cochrane and DARE listings, which would offer the best levels of evidence. This emphasised the need to conduct a systematic review assessing the efficacy of pre-admission assessment prior to cardiac surgery. Few randomised, controlled trials were found and it is noted also that the literature lacks pure research based on the quantitive paradigm in this area; for this reason many papers utilised are qualitive and many lack empirical basis. Respected authors with significant experience and professional intuition (e.g.
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? Castledine) were also included; as although lacking scientific data, omitting opinions based on experiential learning would deny Nursing’s key attribute. In scientific and academic terms though, these formulate the lowest level of ‘acceptable’ evidence. 12
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? DETAILS OF INCLUDED AND EXCLUDED STUDIES The articles utilised are restricted to those published since 1989, except where their relevance to the study is sufficiently strong, or where considered classic works. This date was chosen to allow for papers since the Bevan Report (1989), which expressed the growing need for pre-admission, particularly with pressure for shortened length of hospital stay. This time also led up to the publication of the Scope of Professional Practice document (UKCC, 1992), before which the developments of nurses’ roles were severely limited. The date of 1989 also corresponded approximately with the guidance for research projects of ten years (Krainovich-Miller, 1998: 120). The data collected was of variable quality and few used similar, let alone identical methodologies for a comprehensive collation of data. The disparity of results between different systematic reviews has been widely recognised, even amongst authors with identical questions and search criteria. The poor retrieval of documents in some studies has been attributed to the sole use of electronic search medium, which are said to vary in reliability between 20% and 87% of eligible studies found. This is said to be dependant on the skills of the user, database used and retrieval means, i.e. CD-ROM or Internet. Internet searches tend to be more comprehensive where appropriate search terms/engines are used (Sindhu, 1998: 94-95; Jadad et al, 1997). It was considered necessary to limit searches to a wide range of computer-resources together with manual searches of the referenced articles, as these have been available on CINAHL since 1982 and MEDLINE since 1966 To limit searches to the United Kingdom only would have severely restricted the quantity of pertinent research, as there are relatively few cardiac centres in this country. In the initial search, it was restricted to cardiac pre-admission; however, this gleaned relatively few relevant papers so this was extended to major surgery which could be considered comparable in terms of length of stay (Department of Health, 2000c). Day and short stay surgery papers were excluded in the main, except where the content was generalisable to hospital patients as a whole, e.g. reducing anxiety contributes to reduced analgesic requirements in the post-operative period (Miller & Shada, 1978). Due to the difficulty in obtaining accurate translations, English language versions of publications and websites were used exclusively. 13
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? The financial resources of the author have limited this study as no commercial or grant funding was available; however, this has minimised external influences on the methodology and results. Publication bias may influence the overall outcome of this review, emphasising positive effects as authors have a tendency to avoid publishing their failures (Sindhu, 1998: 98; Polit & Hungler, 1999: 268). However, there have been attempts to source unpublished information with a limited amount of success, although it would be incorrect to suggest this was as comprehensive as the searches of published data. Studies, which were excluded from the study, can be found in Appendix 6. The publication and English language biases will have had a tendency to show positive results more favourably, and readers should take this into account. One trial, which should offer significant new evidence when completed, is the work being undertaken at Oxford as part of a randomised controlled trial of 600 patients comparing assessments by House Officers with that of Nurse Practitioners. The results have not yet been published and therefore despite the excellent methodology and relevance to the systematic review, it had to be excluded (Hodgson et al, 1999). Advanced/higher-level nursing practice has been considered as part of this review; however, the focus is entirely on the doctor – nurse substitution debate, with particular regard to pre-admission assessment of patients. Excluded papers on advanced/higher- level nursing have not been individually listed; this is an area, which is being extensively debated by several eminent authors as well as the United Kingdom regulatory bodies (e.g. Ball, 1997; Castledine, 1995/1998/2000; Rolfe & Fulbrook, 1998; UKCC, 1998). A comprehensive list of excluded studies/resources would be impractical to compile, thus only those, which were considered ‘borderline’, have been listed individually. Internet resources have a tendency to be transient in some cases and therefore any search list will be outdated before this systematic review is completed. The included literature was limited to primary research, government and professional bodies policy documents and work undertaken by seminal or widely quoted authors that related specifically to the questions set by this systematic review. Studies were excluded primarily because despite keyword recognition within search facilities there was no direct relevance to the questions identified within this systematic review. A number of articles failed to meet the quality criteria despite relevance to the questions and these are identified in Appendix 6. 14
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? RESULTS OF THE REVIEW What role do pre-admission/assessment clinics perform in preparing patients for surgery? Although pre-admission and pre-assessment clinics have been considered together, some differences in definition are evident and many clinics would fall within both definitions (see glossary). In some hospitals PACs are now considered an essential part of pre-operative preparation of patients; however, in view of a significant number with sub-optimal or no PAC service, a review of their purpose was considered necessary. Sadly there is little evidence surrounding CSPACs specifically so research examining PACs also has been extrapolated where appropriate to extend the knowledge base available. Early identification of factors which impact on resource requirements can allow the planning of operative time to balance the list with high/low risk procedures, thus preventing the ‘blocking’ of all beds with patients needing longer recovery times (Smith et al, 1997; Cohn et al, 1997). The optimisation of bed usage allows more patients to be treated per bed and is reliant on good standards of patient information being available before planning of ‘to come in’ (TCI) dates. The ability of hospitals to maintain workload levels and reduce bed numbers is an aim most managers would relish; however, in the UK under capacity of hospitals over the past few years, means the aim would be to treat increased numbers of patients and therefore reduce waiting lists. One Canadian unit managed to decrease their cardiac surgical ward bed numbers from 35 to 27; however, in this time they also introduced a surgical step down unit with unchanged numbers of surgical intensive therapy unit (ITU) beds. The allocation of ITU and step down beds for cardiothoracic patients is not clearly stated; however, it is likely that some of the surgical step down beds were then utilised for cardiothoracic patients. The reduced bed numbers were largely due to the reduced length of stay for patients, for coronary artery bypass grafts (CABG) this has reduced from a mean of 2.7 pre-op days and 8.9 post-op days to 1.1 and 7.7 days respectively (Plett et al, 1998). In terms of the patient satisfaction with the service, this was reported as outstanding at 96% in the ‘satisfied’ group of responses. Interestingly the responses from patients who travelled a distance to the clinic were similar to local patients, although particular effort was made to schedule appointments in co-ordination with other clinics/consultants. The 15
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? ‘fast tracking’ (F/T) of patients has been demonstrated to improve outcomes and reduce hospital stays by 2 days less than ‘traditional care’ (T/C), with readmissions within six- months virtually identical between the two groups. Peri-operative mortality was 3.7% (F/T) compared to 4.0% (T/C) and post-discharge mortality 2.0% (F/T) compare to 3.6% (T/C). F/T protocols reduced the time ventilated from 20 hours to 13 hours, which meant stays in ITU, were reduced by an average of 24 hours. The reduction in intubated time may also account for the reduced weight gain, which was attributed to fluid and inflammatory response, 1.6 kg (F/T) compared to 2.7 kg (T/C). Sadly, the results did not reach statistical significance; however, they are encouraging never the less (Cotton, 1993). Loop et al (1983) selected a sequential sample of 25 patients with >35% ejection fraction and 3-vessel disease with 50% stenosis or greater was selected in 1981. This was compared to randomly selected control samples of 25 patients with the same criteria from each of the years from 1977 to 1981, and cost adjustments to allow for inflation. Loop et al (1983) reported that utilising outpatient testing before cardiac surgery together with better utilisation of hospital beds showed a 10% reduction in episode costs for the TCI group compared to the control group. To achieve this reduction, patients were admitted on the day of surgery, with the night before operation spent in a hotel adjacent to the hospital. Despite the need to pay their own hotel bills in this study, the patients preferred to stay with their families on the evening before admission. The apparent level of patient confidence in PACs indicated in Plett et al’s (1998) study is encouraging; however, the conclusions drawn are unlikely to be generalisable due to a number of limitations of the study. They highlight the relatively poor response rate of 38% despite being a multi-lingual study; although the responders/non-responders had similar demographics and thus the sample may remain representative. More concerning, however, is the questionnaire itself, which refers to ‘1-poor’ and ‘2-fair’ as ‘satisfactory’ and ‘3-good’ and ‘4-excellent’ as ‘unsatisfactory’. If this was actually the form that was sent out as opposed to a printing error in publication, it may account for the poor response rate and render the data unreliable. A patient satisfaction questionnaire is a vital audit tool to improve the user friendliness of any service; however, internal validity must be established before putting the tool to use, if the research is to be constructive (Polit & Hungler, 1999). 16
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? Disadvantages, which have been noted in the literature, include the additional journeys by patients, many of whom are elderly or infirm, who may have to travel many miles (e.g. up to 85 miles in the case of the author’s Trust). Some authors have commented that it was not possible for all the members of the multidisciplinary team to see patients at the clinics, or alternatively that patients spend all day seeing the various practitioners involved (McCarville, 1999; Bond & Barton, 1994; Hotel Dieu Hospital, 2001; Toogood et al, 1998). There are centres that appear notably efficient in the handling of patient information; however, it may be questionable whether patients gain as much emotional support and information in 45 minutes as they might in slightly less rushed encounters. The use of multiple stations at which the patient calls in any order involve the patients entering their own histories via an interactive computer database, answering between 15 and 500 questions depending on whether their history is straight forward or complex (University of Missouri Hospital, 2001). There is inconsistency with regard to length of hospital stay; which has been attributed to the lack of specific financial incentive for reductions in costs, particularly within the private sector. The repetition of diagnostic tests due to inadequate communication of results has been identified as one disadvantage of PAC testing. It is reported that this problem is related to the initial stages where inadequate attention is applied to making systems ‘foolproof’, and that integrated documentation is the best solution to this potential problem. Relying on internal mailing systems for results also presents considerable challenges, and the use of computer terminals improves communication of investigations and lessens repetition of tests (LeNoble, 1991). The Royal Hallamshire Hospital found a fall in post-admission cancellation of surgery from 6% to just 1%, as approximately 20% had abnormalities identified at PAC allowing time for correction or investigation before surgery (Reed et al, 1997). The need for clear communication of findings is highlighted by the 18% of tests that were needlessly repeated in this study, and a third of results were not reviewed before the patient’s admission. The long-term aim to reduce overall waiting times for surgery and therefore mortality is unlikely to be in time for a number of patients, therefore an interim measure to prioritise patients may need to be established in a similar manner to the New Zealand scoring system. However, these systems are being questioned because they may fail to account for the detrimental effects on the patient who is ‘downgraded’ by their score. The 17
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? relative mortality risk may exceed that of the more seriously ill patient who ‘jumps the queue’ due to their priority weighting and hence earlier surgery (Sherlaw-Johnson, 1999; Seddon et al, 1999; Hadorn et al, 1997). The development of more complex scoring systems, which accurately assess the degree of priority; not just at the point the patient is put on or removed from the list, but as every patient is added/removed to the list or their individual situation changes. This can only be done with a live database of all patients as they are referred from the first point of healthcare contact until completion of definitive treatment; electronic patient records (EPR) should offer this possibility if integrated effectively across the country. The initial impetus for pre-admission/assessment from many hospital management and funding authorities appears to have been largely related to cost-containment, directly or indirectly. Reduced hospital stay, reduced cancellations, increased throughput of patients and reductions in junior doctors hours have all been effected by the introduction of pre-admission/assessment clinics. It appears that many of the consultations that patients have in outpatient clinics are too short to be sufficiently comprehensive to identify factors other than their primary condition that may be relevant to their admission. It is clear that where well run PACs co-ordinate the patient’s pre-operative investigations to ensure that on admission the patient proceeds to surgery as planned, this is likely to improve satisfaction with the service as a whole. However there are other issues which appear to be a valuable bonus to the quality of the patient’s experience, this is far more difficult to quantify in measurable terms. The element of caring within nursing appears to be present in the PAC where frequently it is now lacking within the ward areas due to the frenetic activity, staff shortages and use of transient agency staff. The assessment of patients for cardiac surgery needs to start at the initial referral point with the existing professional’s comprehensive letter of referral enabling the Tertiary centre to prioritise the patient’s initial and subsequent appointments. This needs to be updated with each appointment to ensure that the patient does not endlessly slip down the waiting list due to emergency referrals which may lead to the unacceptable position of deaths on the waiting list. PACs should ensure that when a patient is admitted they are fit to proceed to surgery and that suitable arrangements have been made for discharge to avoid the beds being blocked by patients fit for discharge in normal circumstances. Therefore from the healthcare provider perspective savings of both wasted surgical slots and extended bed stays should be avoided. Some patients may be 18
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? inconvenienced by additional journeys to hospital, however most seem to value the contribution to quality care made by the well co-ordinated PAC. Is there an optimal staffing profile for PACs? There are wide disparities in the professionals involved in patient assessments between different PACs with many involving multiple professional groups with each patient’s appointment. Some units have moved towards single practitioner PACs in an attempt to reduce delays to the patient’s time at the clinic and associated departments, the costs of employing additional staff and the fragmentation or repetition of information provided by patients. Preliminary work within the Trust presented data gathered from a number of prominent UK cardiothoracic centres, vital in the establishment of a business case for the CSPAC (Appendix 2) (McCarville, 1999). All centres studied used multiple professionals in the clinic, and some seemed to have an ad hoc arrangement as to whether patients were seen by particular practitioners (especially medical staff). There appears to be little congruence of management within the units examined; in the way clinics are administered, and by whom. The depth of information in the study was limited, possibly due to a degree of reluctance to share information between ‘competing’ centres. A secrecy culture built up since the introduction of healthcare trusts in 1992 and tendering for contracts remains despite the insistence that the professions share information about ‘best practice’ (NHS Executive, 1998). Coventry and Warwickshire initially used junior doctors to examine orthopaedic patients awaiting surgery, although laboratory tests and x-rays were done prior to admission, they were rarely reviewed. Documentation was missing when the patients were admitted and significant number needlessly occupied beds as they were unfit to proceed to surgery. In 1996, this approach was recognised as inefficient, leading to the appointment of a nurse conducting holistic assessments and relieving anxiety by providing patients with information of good quality. The medical staff retained aspects of assessment, such as auscultation of the chest to confirm fitness for anaesthetic and consenting the patient. The potential conflict of intentions between management and nursing staff was highlighted, with their Trust seeing the reduction in cancellation of operations paramount, whereas nurses saw the patients’ psychological preparation for surgery equally as important to physical fitness. The rotation of ward nurses rather than 19
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? dedicated PAC staff allowed greater continuity of care, allowing the same nurse to assess the patient and become their named nurse on admission (Smith, 1998). The use of named nurses in the PAC studied by Smith (1998), suggests that this orthopaedic unit is fortunate in having experienced staff with low turnover rates, some wards have relatively inexperienced staff who would be unsuitable to safely and effectively conduct pre-assessments. The use of medical staff to conduct small parts of the clinic’s role could fragment the service and cause delays, however due to the location on the orthopaedic ward this threat is minimised. The use of primary/associate nurses to assess patients was favoured in the BUPA Hospital, Portsmouth following the trial phase of their pre-admission service. The rollout of the service coincided with the introduction of primary nursing and the splitting of nursing teams into diagnostically related groups (DRGs). This followed a period of training nurses and adjustments to the documentation, learning from the experience of the trial (Holloway & Hall, 1992). These two studies suggest that experienced ward staff can offer a more holistic option than independent PAC nurses can; however, this is reliant on skilled and experienced nurses working in the ward areas. ANPs are “specially prepared nurses who are working in roles which demand a lot of nursing experience, education at Masters Degree level, and nursing skills that contribute to meeting the complex needs of vulnerable people and the need to be continuously questioning the fundamentals and boundaries of nursing” (UKCC, 1994). Autonomy is lacking from the UKCC’s definition despite consensus amongst most authors opinion that this is a key component of the ANP’s standing (Ball, 1997; Castledine, 1998; Reveley, 1999: 275-277). This is not to say that there is not co-ordination of the patient’s care in partnership with the consultant; however, this is a collaborative relationship between fellow professionals and across ‘bricks and mortar’ boundaries (Ball, 1997; Castledine, 1998). This link between the patient’s community, primary, secondary and tertiary treatment leads all professionals to aim towards holistic care (Castledine, 1998). Several pieces of research have found specialist nurses to perform equally well or to exceed the standards of the medical staff who would formerly have conducted assessments in different environments (Whiteley et al, 1997; Hicks, 1998; Nursing Management, 1995). There appears to be increasing favour for nurse led clinics with medical staff continuing to consent patients, and nurses practicing advanced assessment 20
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? skills (McCarville, 1999). It is only from the consistent pre-operative assessment that the information required for admission will be available and research and audit enables the development and optimisation of future services. This consistency is most likely to occur if ANPs take on the pre-admission assessment role. The CSPAC Nurses at the author’s Trust conduct all of the history and physical examination with the patient being consented by a surgeon on admission; thus, development of advanced physical assessment and history taking skills were vital in the evolution of this role. The CSPAC Nurses act on this information (e.g. carotid bruit) to determine further investigations that may be necessary (e.g. carotid Doppler studies) and discuss with senior surgical staff any alterations to planned surgery that may be required. This role is currently poorly evaluated in the literature due to its novel nature which presents practitioners with particular challenges when attempting to ensure their practice is evidence-based. In orthopaedic surgery, two differing PACs are compared in a small-scale qualitative study evaluating the pre-operative assessment of patients at two London teaching hospitals. In hospital A, a senior house officer (SHO) ran the PAC and an occupational therapist (OT) visited the patients at home. In hospital B, a multidisciplinary PAC was jointly run by a nurse and SHO; however, the OT was not involved until the post- operative period (Lucas, 1998). The sample of 16 patients was split equally between the two hospitals; however, despite this, the multiple variables made accurate comparison impossible. The multidisciplinary team differed in more than one respect, the OT home visit being evaluated against the ‘traditional handmaiden’ style of nursing in two different hospitals. It would have been easy to dismiss the negative comments by some of the patients (e.g. difficulty locating departments and lack of information regarding what to expect at the clinic), as isolated; however, these are effectively considered in the recommendations. Key areas highlighted in the study, were the importance to communicate in invitation letters/leaflets the purpose of the PAC and what can be expected during the patients time at the appointment. The role of the nurse is central to the success of the clinic, both as an advocate and to co-ordinate care within a protocol driven service, adapting to the patient’s individual needs. The patient’s time at the PAC must be used effectively and hospital systems should be modified to meet patient needs; suggestions include location of the clinic adjacent to phlebotomy, x-ray and other services frequently used, together with appropriate scheduling of appointments to minimise the waiting time for patients. 21
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? Interviews can develop the researchers understanding of the interviewees’ feelings in a richer and more meaningful way than questionnaires ever could, the researcher being left to find common themes amongst responses (Waterman, 1998). The meaningful information gleaned in Lucas’s (1998) study may be at risk of significant bias by the use of convenience samples, as the populations studied could not be considered homogenous. This weakness in sampling method is reported as very common in nursing research due to poor levels of investment (Polit & Hungler, 1999). The only constants in the two sample groups appeared to be type of surgery (major joint replacement), the presence of the SHO in a hospital-based clinic, and the patients’ proximity to their hospital (3-4 miles). The limitations on the distance to be travelled by patients in the sample groups may or may not be comparable to the patient population as a whole; it can be extrapolated that patients who have a longer distance to travel may find it more inconvenient to attend, although this would need to be tested. Lucas (1998) omitted the median in the interpretation of the statistics, which may have presented a more accurate impression of the true values, due to the skewed data from the intervening extraneous variables, i.e. two patients who had to wait a half-day to see their consultant (Bello, 1998: 358). The threats to non-participant observation of PAC and OT visit were recognised by the researcher, and care was taken to avoid data contamination. Despite the areas of the study which Lucas (1998) recognised could not be generalised without further research, some potential weaknesses of methodology and sample size/distribution, the study highlights several very important points, partly due to the skilled and comprehensive review of the literature. In a prospective study of 300 elective patients undergoing vascular surgery, nurses or pre-registration house officer (PRHO) clerked the patients according to selection criteria, groups were not randomised and assumptions regarding suitability for attendance were made, e.g. age and diagnosis (Toogood et al, 1998). This makes it difficult to assess whether the findings were due to inherent selection bias or differences in the way the two professional groups assessed patients and any difficulties for the patients’ attendance at the PAC were gauged. There appears little congruence of practice between orthopaedic PACs in British hospitals, although a number of common themes have emerged, co- ordination/management, information giving and assessment (Lucas & Sample, 2001). The co-ordination and management of the patient appointment appears to be one of the central themes to the pre-admission nurses’ role, despite this being a largely 22
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? administrative function (89%). However, the significant minority who do not always record a nursing assessment are more concerning than the nursing time being spent on non-nursing activities (15%). It was not evident, whether these respondents were part of the group who always recorded a medical assessment (48%), as a multidisciplinary assessment did not appear to be an option. The majority did not conduct physical assessments of their patients (70%) despite this being an area which can be safely be taken on by appropriately trained nurses (Greenhalgh & Company, 1994; Jones et al, 2000). Recording of observations appears to be an area, which many nurses continue to undertake despite being a straightforward task which health care assistants (HCAs) could perform, releasing nursing time for patient teaching (74%). The conclusion highlights these areas of practice which require further development in line with government plans for clinical effectiveness and the need for appropriate financial backing to PAC development, which is frequently inadequate to maximise efficiency (Lucas & Sample, 2001). In a retrospective audit by Jones et al, 2000, 127 urology patients invited to a PAC over a 4-month period, 16 patients were excluded, as they had not attended, leaving 111 patients in the study. Of the 59 seen by the nurse specialists, 14% of investigations were missed, whereas of the 52 seen by the PRHO, 4% of investigations were missed. There were three patients in the nurse-assessed group who subsequently developed post- operative complications; however, none had symptoms or signs indicating further referral was needed at the time. Conversely, there were eight patients in the PRHO group who subsequently developed complications; three had symptoms warranting referral, including the one who died following a CVA who had a history of chest pain and hypertension. The authors concluded that more effective communication was needed between different members of the multidisciplinary team, and a single document for recording the PAC nurse clerking and medical assessment on admission with an investigation checklist would improve continuity. Specialist nurses working in surgical PACs are also compared to PRHO in a study conducted at the Royal Berkshire Hospital in Reading (Whiteley et al, 1997). One area, in which the nurse was not evaluated, included the physical examination of patients and areas of apparently poorer performance included the recording of allergies, drug doses, social, alcohol and smoking histories. It was discovered that this might have been due to poor proforma design, suggesting that the nurse might be working through the form rather that having training in the skills of medical history taking and physical 23
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? assessment. This appears to be confirmed by the decision to keep physical assessment as one of the doctor’s roles on admission rather than incorporate it into the PAC nurse’s job profile (Whiteley et al, 1997). The use of evidence-based practice rather than routine care has demonstrated improvements in the outcomes of nursing (Heater et al, 1988). The ANP is more adaptable due to their education and experience, and thus able to develop new procedures and policies responding to the ever-changing needs of healthcare provision (Wallace & Gough, 1995). The diversity with which ANPs and nursing have adapted to the needs of service has drawn criticism that they are merely extending their role of ‘handmaiden’ to medical staff. It is argued that nursing is actually pushing healthcare forward with its increased academic preparation throughout the nurse’s career, presenting medicine with new challenges and with audit examining everyone’s practice (Brown, 1995). Patients appear to welcome the practitioner who takes time to explain the expected clinical course in terms they understand, but who has comprehensive knowledge to be able to answer their questions, not just to give a pre-prepared answer to standard questions. There is considerable effort within nursing (let alone advanced nursing practice) to establish a research basis for the profession; however, because of nursing’s multifaceted nature, it has been difficult to identify unique attributes and thus there has been a sharing of theory with other professions, especially medicine (Clarke, 1986). The UKCC is yet to issue definitive guidelines on higher-level practice, however they proposed in a consultation document that for practitioners to enter the assessment process, they should meet the following prerequisites (UKCC, 1998): 1. To have current first level registration with the UKCC. 2. To spend the majority of their practice planning and organising, carrying out and evaluating work related to improving health and well-being; 3. To hold a UK degree or equivalent in nursing, midwifery, health visiting or health related subject or hold a UK degree or equivalent in any other subject together with the successful completion of a post-registration education programme in their area of practice. 4. To have practised for a specified minimum period of time in their chosen area of practice; it is anticipated that practitioners will need to have at least 5000 hours - the equivalent of three years full time in order to collect the required evidence. 24
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? This criteria is fairly conservative by international standards, at least five years experience in a specialty is normally necessary to be considered an ‘expert’ (Benner, 1985). There are further suggestions that there is a sixth and higher level of practice, advanced practice taking expertise into intuition together with the ability to disperse this experiential knowledge effectively to colleagues (Rolfe, 1997). The perceptual awareness of the expert nurse is described by Benner (1985) as intuitive and resulting from a multitude of interpretations, which differ from those of the inexperienced nurse. The expert is said to find it difficult (or impossible) to communicate the cognitive process involved drawing particular conclusions. English (1993) suggests that Benner is ambiguous in her definition of intuition as an aspect of the expert’s practice, however other authors seem to have derived significant inspiration from Benner’s work. True intuition is more than the synthesis and deduction from complex pieces of data; it is decision making with incomplete and inadequate information to accurately implement the necessary intervention (Rew & Barrow, 1987). Intuition has developed as Nursing’s unique and most effective feature, this is the art of nursing; however it is the area which nurses find most difficulty articulating to other professional groups (Rolfe, 1997; Rew & Barrow, 1987). There are enormous pressures within cardiothoracic centres to care for more patients, in a shorter time and with fewer resources. In addition, moves towards increased clinical activity in an ever more litigious society, the attention to detail and committal of optimal resources is essential. The year 2000 saw a 50% increase in complaints lodged with the General Medical Council against doctors over the previous year. The number of complaints registered were 4470 compared with just 1000 in 1995, an increase of 447% in just 6 years. The Patients Association who saw daily complaints rise by 250% in 3 years from approximately 20 in 1998 to around 50 in the year 2000 corroborates these figures. The complaints are thought to be largely trivial with much more readily known procedures following high profile trials such as the Bristol Cardiac Centre and Shipman cases. These complaints are set in the context of much improved services and life expectancy than ever before, with higher expectations from patients initiated by legislation and the media (Charter, 2001). There has been a need for health care workers to redefine working practices, and for professionals to take on new roles, which were traditionally undertaken by another professional group. This continual evolution, by definition, involves change together 25
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? with the introduction of new skills in the workplace. Adequate training is essential to avoid tragedy or lesser misfortune leading to human suffering, complaints and litigation. Theoretically, nurses should embrace change brought about because of ‘evidence based’ practice; however, nurses are human and people have varying degrees of acceptance and adaptation to new practices or change in particular circumstances. The impetus for these changes has partly been the ‘New Deal’ for junior doctors, which aims to limit their working hours and night-time commitments considerably (NHSME, 1991). The acute care nurse practitioner (ACNP) has been judged able to provide the necessary experience and coordination to optimise the care process throughout the hospital stay and the associated outpatient care. It is suggested that nurses are more effective in this liaison role between medical, surgical and paramedical staff and patients/relatives, than the ‘junior’ surgeons who formerly undertook the role are. This conclusion is drawn from the experience described by one of the surgeons working within a team of ten acute care nurse practitioners at the Rochester Medical Centre’s Division of Cardiothoracic Surgery (Hicks, 1998). Acting intuitively and conceptualising with reflection in practice, gives the ability to articulate the decision- making theory behind their practice. Many assume roles that were formerly undertaken by medical staff; however, it is usually argued that they are the most skilled and appropriate professionals involved. The theory base is often as great, with more experience than most of the doctors who previously undertook the role, caring for the patient as a whole to integrate all aspects of their care to optimise the client’s clinical and personal outcomes. Patients give nurses an overwhelming vote of confidence, with 96% expressing that the nurse was appropriate to do pre-assessments (Org et al, 1997). However, despite Org et al (1997) obtaining study data by interview, it appears to be largely quantitative information and therefore a larger sample would be expected. Additionally, the means to approach the original 137 patients is not stated, and therefore selection bias may have been introduced. However, it is suggested that the largest possible sample provides the most accurate results and as questionnaire based, a postal survey of all those willing to participate, may have provided both a more cost-effective and accurate study (LoBiondo-Wood & Haber, 1998). There are nurses now working in many aspects of care, whose posts were originally created with the hope to reduce junior doctors hours. The progress in areas such as 26
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? ANPs and minor injuries appear to have taken longer than expected. One of the major factors appears to be the waiting time for training in technical skills; it has been suggested that it might be appropriate for many of these training tasks might be delegated to appropriately trained nurses. In a Trent region study of 59 post holders in 16 specialities, PACs have been the most successful of all groups in achieving their aims in extended role positions (Nursing Management, 1995). The move of healthcare providers, purchasers and stakeholders to treat patients as clients and customers may change the way systems are organised; however, there appears to be a key element missing from this philosophy of consumerism, the human being within. ‘Being cared for’ was one of the central themes discussed by all patients in an inductive study of experiences at an orthopaedic PAC informed by grounded theory. The warmth of greeting at the PAC, establishes trust not just at the clinic, but also the patient’s expectations for the clinical episode as a whole. This caring side of nursing seems to go beyond the professionalism of nurses; it is to do with the human emotions of the nurse-patient relationship (Malkin, 2000). It remains difficult to conclusively say which practitioners are the most appropriate to conduct assessments, although experience in the speciality appears to be more important than the professional group to which the practitioner belongs. Holistic assessments by ANPs appear to offer the most cost-effective and least fragmented option and adhere to evidence-based practice more closely than other options. However direct access to senior staff from other professional groups is vital to ensure that appropriate decisions are made quickly where the patient is found to have results deviating from the norm. Do patients benefit from information giving at PACs? The paternalistic approach towards patients has long been considered unacceptable and informed consent is now considered an essential process before surgery. The information giving is not solely the responsibility of practitioner who actually asks the patient to sign the consent form although they are ultimately accountable for ensuring the patient understands the operation to be undertaken. The PAC often encompasses information giving with an information gathering opportunity and thus consideration as to whether this is the optimal time is essential. The importance of preparation from a psychological and educative perspective cannot be underestimated, especially in the patient who has not undergone surgery previously. The patient’s psychological preparation may be considered superficial in terms of the 27
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? success of surgery; however, an increasing body of evidence is demonstrating much improved recovery amongst patients who are adequately prepared (Lucas & Sample, 2001; Miller & Shada, 1978; Suls & Wan, 1989; Shuldham, 1999). Therefore, the PAC interview must not simply be information gathering in terms that are quantifiable; it must also establish the trust, knowledge and support the patient requires, preparing them for their surgery. The timing of the presentation of this information is not universally in favour of the PAC as the most appropriate place. It is thought that education at this stage, may contribute to improved comprehension of information presented whilst in hospital in the immediate pre-operative period (Holloway & Hall, 1992; Bysshe, 1988; Alcock, 1986). Patients are said to desire detailed information regarding the sensations experienced in the period before and after surgery. A significant minority of patients experience depression particularly on the third and fourth post-operative day (Miller & Shada, 1978). However, in this study only nineteen patients were interviewed, so only small numbers would appear significant in statistical terms, i.e. p<0.05 (LoBiondo-Wood & Haber, 1998: 384). The mechanism for inclusion in the study threatened both internal and external validity through selection bias as subjects were purposefully selected and do not appear representative of the patient population as a whole (15 men and 4 women). Patients were excluded if they had complications or co-morbidity and had to have normal hearing, be literate and without confusion, leaving a predominance of Caucasian, protestant males, married with children and aged around 55 years. The sampling bias reduces the chance of establishing reproducible findings (generalisability) and therefore lacking reliability and external validity, meaning one must be cautious when interpreting findings as without reliability research cannot be considered valid (Robson, 1993:67). Ethnicity can be a significant factor in certain geographical areas, and perhaps greater steps could have been taken to consider this in the sample. Anxiety in the immediate pre-operative period is considered a barrier to learning by some authors, which may lead to poor retention of material presented (Bond & Barton, 1994; Haines & Viellion, 1990). Some research in the field of cardiac surgery has found statistically non-significant differences between those who were given information on admission and those who receive it the week before at the PAC. The inclusion of significant others in that preparation has been considered important; although the authors concluded that, despite the research failing to achieve statistical significance in relation to the effectiveness of including relatives in information giving 28
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? (Lepczyk et al, 1990; Raleigh et al, 1990; McGaughey & Harrisson, 1994). In the planning of information giving, these authors present no demonstrable difference in efficacy between pre-admission and post-admission timings. Teaching in the pre- admission phase is purported to be more economical and logistically more feasible to hospitals. The increasing pressures to reduce length of stay fortunately appears to be in congruence with patient preference, if work conducted with regard to minor surgery can be considered transferable (Wallace, 1985). One aspect of unnecessary levels of anxiety is the associated pain, which may require greater use of analgesics and delay mobility in the post-operative period. This has been widely documented over the last 35 years, which has been one of the driving forces to the much wider information giving to patients and away from the paternalist approach to medicine of the past (Bysshe, 1988; Haywood, 1975; Egbert et al, 1964). The type of information given should concentrate on the sensations that are likely to be experienced by the patient, rather than simply the procedures to be undertaken; this lessens anxiety when encountered and thus the pain is reduced. A certain amount of procedural information may be helpful to coach the patient as to when to expect certain types of discomfort (Johnson, 1983; Suls & Wan, 1989; Miller & Shada, 1978). Taking the psychological preparation a step further, by the use of guided imagery improves outcome and reduces opiate analgesic use by approximately 43% less than that of the control group (median). A random sample was utilised in a selection of 130 patients undergoing major abdominal surgery, 65 to the guided imagery group and 65 to a control group that received routine care. The guided imagery group were encouraged to use cassette tapes in the 3 days before and 6 days after surgery and most complied fully in the study. The cassette tapes gave guidance on imagery, using relaxation and distraction; in the pre-operative phase, they are encouraged to relate the surgical episode to a pleasant experience such as lying on a tropical beach. In the peri-operative and post-operative period, the patients are encouraged to imagine themselves back on the tropical beach (or other pleasant thoughts). Since the study, the hospital has started to make the guided imagery available to most patients, showing a descriptive video in the outpatient waiting room and giving complementary tapes to patients who request them. The programme is not covered by the patients’ insurance; however, it appears to be cost effective, saving much time for ward staff previously spent on reassurance and pain control (Tusek et al, 1997). 29
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? Tooth et al (1998) studied 130 patients (65 experimental, 65 control) to determine whether a pre-admission education/counselling program had a positive effect on risk factor modification amongst patients undergoing coronary angioplasty. The two groups were compared pre-procedure and at follow-up clinic and both groups demonstrated an extremely significant improvement in both knowledge and physical activity levels (p=0.00). The improvement in total cholesterol was greater amongst the experimental group (p=0.02); however, it is not clear whether this could be due to the greater period of time elapsed since the pre-admission clinic. The patient’s knowledge and activity improvements in both groups are attributed to the high standards of care and education in both groups. The study also raises concerns about the efficacy of education programmes without follow-up and rehabilitation is considered to be a longitudinal process rather than a single event. It is evident from some studies that the PAC impacts on the patient’s understanding of their general health (50%) as well as the specific operation planned (64%) (Ong et al, 1997). The sample was randomised from a larger group (137 patients) who agreed to participate; the final sample had 50 participants with equal gender distribution. The effect on general health status can also be seen in the PAC nurse’s role to assist with smoking cessation, using a combination of health promotion advice, leaflets and a diary (Haddock & Burrows, 1997). In patients who intended to stop smoking pre-operatively, 88% in the treatment group and 81% of the control group succeeded in stopping or reducing smoking, indicating the importance of the patient’s intentions to their success. There were quite dramatic effects amongst those who did not intend to stop or reduce their smoking, 75% of the treatment group compared to just 14% of the control group. The overall effects of treatment (80%) were significantly higher than the control group (50%), indicating a very positive effect from the nursing intervention on the patients’ long-term health. There is growing evidence that information giving and health promotion are as important elements as physical preparation for surgery and information gathering in terms of medical history etc. The timing of this information is less conclusive; however, in practical terms, smoking cessation should be at least six-weeks before an anaesthetic (Haddock & Burrows, 1997). Thus the PAC does not appear to be the most appropriate place for the majority of health promotion activity, it could be suggested that a group education day offers the patients the best opportunities to make lifestyle changes and this should be when the patient is initially placed on the waiting list. The 30
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? specific practitioners involved in education giving does not appear to have been fully evaluated; however, it does appears that the group of patients who benefit most from therapeutic intervention are those who had not intended to make lifestyle changes. The optimal time for PAC (see following question) is not the most appropriate time for behaviour modifications (e.g. smoking cessation) which should be made at an earlier stage in the patient’s pre-operative preparation. However, it is an ideal time to reinforce behaviour changes and to emphasise the need to continue with the healthier lifestyle post-operatively. Patients invariably have additional questions that need to be addressed at the PAC; however the majority should be covered in a pre-operative education day earlier in their time on the waiting list. At what stage pre-operatively should patients be assessed for admission and what period of time can patients expect to spend in PACs? There appears to be considerable differences between hospitals as to the timing of the PAC in relation to surgery; however, these nearly all range between 1 and 30 days of operation (see Appendix 4 for a summary of these results). The aim of most units is to see patients at an average of 14 days before the day of operation, which may also be the day of admission in some units. The period of time which patients are expected to spend at the clinic ranges from 45 minutes to a full day, with a mean average of approximately 3 hours 5 minutes. The figures appear to be representative of experience within the Trust; however, they are based on incomplete statistics, which appear to be the planned timings of most units, rather than audited times. Despite the majority of patients (74%) receiving less than one weeks notice, all but 4% considered the appointment convenient in a sample of 50 interviewees (Ong et al, 1997). Unlike some other types of surgery, many patients with cardiac disease are unable to work or have already retired and most seem content to spend as much time as is necessary to undertake investigations at the CSPAC; however, where this differs from the expected schedule, the communication of reasons with revised and realistic timings is central to maintain patient satisfaction. Taking control of patients as they arrive is vital to attain and maintain their confidence, a warm and friendly greeting followed by a resume of the plans for them whilst at the clinic, do much to quickly establish trust and avoid complaints about any difficulties experienced (Edmondson, 1996: 37-61). The use of PACs can save time when the patient is admitted to hospital; however, the longer the time period that has elapsed since the date of the PAC, the more information 31
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? gathering and investigations that will need repeating. The ideal time frame from this perspective appears to be 1-2 weeks prior to admission for surgery, any longer than a month and most medical staff seem to consider the investigations and information to be ‘out of date’. This reiterates the need for a separate information giving day, rather than combining the two processes into a complete day as found in a few centres. A period of 2-3 hours at the hospital appears to be acceptable to most patients, this time should be utilised effectively however, and waiting should be considered an exception rather than the norm. If the patient’s time is considered valuable too, then patients who fail to keep appointments can be fairly but firmly treated in terms of their waste of hospital resources, in most cases involving removal from the waiting list. What format of documentation offers the best communication between PAC and ward/operating theatre? Effective communication between the PAC and the staff involved in the admission episode is essential and thus the method involved must be both comprehensive and concise is likely to be a historical rather than an actively used document. The Society of Cardiothoracic Surgeons of Great Britain and Ireland (1998) suggests that “the hospital Trust should provide the hardware, software and personnel to allow patient orientated data collection for risk stratification and down loading of data into the Society’s National Cardiac and Thoracic Surgical Databases”. These systems of effective audit are vital to avoid some of the criticism levelled during the recent enquiry into the Oxford & Bristol cardiac centres. The ICP (which identifies common practice guidelines), is one of the key ways which the commitment to team working is demonstrated within the author’s Trust (NHS Executive, 2000; Bristol Inquiry Unit, 1999). ICPs are enabling healthcare to move towards a more effective way to manage information. Initially, these have developed in a paper format; however, this simple, ‘variance from the norm’ recording of care and improved computer technology at lower costs is allowing the move towards EPR. EPR allows multiple users to view the same records, and minimises the effects of mislaid paper records, while they remain in use (Johns, 1997). The rationale for the introduction of ICPs have been conceptualised into four different models; to ensure continuity of care, for clinical effectiveness, cost control/effectiveness and patient focus (de Luc, 2000). The recording of ‘variances’ rather than every aspect of care make more efficient use of time as around 75% of 32
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? patients follow a predictable clinical path. The successful implementation of ICPs require a clinically based co-ordination, it is said that to use a management appointment increases the likelihood of failure. The absence of a dedicated co-ordinator makes communication between all members of the multidisciplinary team difficult; even where there is initial motivation for ICP introduction, without effective project management the inertia tends to be lost (Riches et al, 1994). The use of PACs should simplify the process of admission for patients by offering ‘one- stop shopping’ for their pre-operative needs. The co-ordination of hospital departments in PACs brings the service to the patient, rather than the patient to multiple departments as part of the admission process. It is vital that the documentation is also brought together in this way, at least 24 hours before the surgery (Bailes, 1998). The information collected at the PAC has little value if it is not communicated effectively to the teams responsible for their inpatient care. The ideal documentation follows the patient through the entire episode from first appointment, PAC, their admission episode and follow-up consultation. The multidisciplinary ICP offers the most comprehensive ‘template’ for care and facilitates cross-professional communication. Do PACs alter the investigations ordered before surgery? There is a need to liase carefully with other departments before the establishment of a pre-admission service to ensure they are aware of the changes in arrangements for patients in the pre-operative period. It has been reported that some PAC nurses initially considered that the pre-admission service would simply shift the timings of clinical investigations; however, in reality a slight increase in ordering has occurred for a number of reasons (Le Noble, 1991). If a patient’s admission is delayed, laboratory (and other) investigations may need to be repeated on admission. Repeat laboratory investigations where found to be abnormal at the PAC. Additional investigations ordered, it is postulated that this may be due to PAC nurses more strictly adhering to protocols or more comprehensive investigations due to a trend towards stricter use of evidence-based medicine generally. 33
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? The risks of cerebral vascular accident (CVA) during/following surgery are fortunately relatively small, in the region of 2%; however, this can increase to approximately 9% in patients with co-existing carotid artery occlusion. Carotid endarterectomy is potentially hazardous in itself, with myocardial infarction in around 18% of patients, the relative benefits being seen in those patients with occlusion of 70-80% or greater (Hornick & Taylor, 1995; Warlow et al, 1998). Patients are especially at risk with a history of neurological symptoms, particularly in the first three months following a Transient Ischemic Attack (TIA), for this reason patients with symptoms are now screened by fast-track carotid Doppler studies in some centres (Bhatti et al, 1999; Warlow et al, 1998). In relation to cardiac surgery, it is postulated that the clinical signs of carotid bruit are checked pre-operatively by the referring physician, at surgical outpatients or the CSPAC rather than on admission allowing investigations to be completed before proceeding with admission and surgery. This has been demonstrated to reduce pre- operative days in hospital, freeing up beds for increased numbers of patients to be treated or to reduce bed numbers whilst maintaining the service to patients (Plett et al, 1998). Initial concerns about the additional costs of investigations at PAC were highlighted by one insurance policy, which would only cover these costs if the surgery proceeded within seven days; however, it is interesting to see that later policies do not include this clause (American College Student Association, 1999). There is evidence from orthopaedics that the cost savings from reduced cancellations are considerable, this is stated as over £1300 per patient, which is much less expensive than cardiothoracic surgery (Fellows et al, 1998). The common theme amongst the articles describing pre- admission/assessment services across specialities is that they minimise patient risk, reduce cancellations, improve patient satisfaction, reduce anxiety, and optimise the care process and therefore reduce costs (Stokes-Roberts, 1999; Fellows et al, 1998; Lucas, 1998; Smith, 1998; Newton, 1996; Bond & Barton, 1994). Notice of the patient’s current condition before admission, also allows clinicians to decide the patients who may benefit more from conservative treatment, where the risks of surgery outweigh the potential benefit. The Smith (1998) study appears to be of good quality, with quantative data, e.g. reduced length of stay and cancellations triangulated with more qualitative data, e.g. patient satisfaction with information provided and reduction in anxiety. There are many examples of investigations being repeated on admission, despite valid results being on file or available to staff via computer systems. However, it would 34
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? appear that many staff believe that by ordering an investigation, they are fulfilling their medico-legal obligations. It is postulated that a number of investigations are not examined in any depth or acted upon, judging by the number of repeated tests in some studies. Some studies have demonstrated nurses investigating higher numbers of patients in greater depth; however, the specificity of these to protocols/evidence-based healthcare appears closer than by medical staff. Thus it would appear that despite higher levels of investigation requesting amongst nurses, this is due to stricter adherence to protocols and guidelines, which should result in improved detection of undiagnosed co-morbidity. Does the PAC alter discharge planning of the patient? The blocking of acute surgical beds by patients who are clinically fit for discharge but are unable to be discharged for social reasons have led to the consideration of discharge arrangements at a far earlier stage than was traditionally the case. In order to provide for ongoing health needs after the patient’s discharge, planning in many hospitals (including the Trust) now commences before the patient is even admitted. Some authors suggest it is the ANP exclusively, who involves the family in the assessment of the patient’s health status, to optimise post-discharge health; however, it is argued that all nurses should be achieving this (Castledine, 1998). It is evident that the PAC Nurses are ideally placed to accomplish this, with holistic incorporation of a full nursing, medical and social assessment. The patient and their loved ones need forward planning to ensure that they are able to cope effectively upon discharge, and the comprehensive assessment is central to optimising these arrangements (Bridge & Nelson, 1994; Department of Health, 1989). The PAC nurse may improve the information available to the patient before surgery, however it is difficult to ascertain from existing research whether this is different from that of group education sessions. It would appear that both offer value in a complementary way, one dealing with the majority of general information whereas the PAC nurse is able to tailor information to the patient in a way that may be inappropriate in a group setting where issues of confidentiality may be infringed upon. Informed patients should be able to make necessary preparations for discharge, preventing unnecessary delays to discharge from hospital. 35
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? DISCUSSION There appears to be a lack of published research in the UK regarding the development of CSPACs; searches of North American literature also seem to have scant regard to the effectiveness of CSPACs, despite being longer established; however risk factor assessment in general seems better covered. For this reason PACs have been considered alongside CSPACs. Information and research regarding pre- admission/assessment for day, orthopaedic and general surgery seem to be in greater supply, probably due to the greater ‘competition’ in these fields. Even in our non-profit NHS there is increasing emphasis on ‘league tables’ comparing different centres, however where these are distant from each other, patients/clients have little choice but to accept their regional cardiothoracic centre. It is postulated that the lack of published literature in this field is due to complacency amongst these centres in a virtual monopoly. It is important to view with caution the results from relatively small studies, as it can be difficult to generalise them to the wider patient population. The reluctance appears to be in sharing information before completion of a project or establishment of supporting data, perhaps so that a centre can publish a more dramatic statement with sole credit for its development. Indeed the Cochrane collaboration only includes completed and not ongoing research currently, which may contribute to the time lag in the thorough evaluation of newer areas of practice. Sadly networking between professionals in the same trust, quite apart from between trusts, is dependent largely on personal contacts, informal arrangements and self-funded conference attendance. The most effective teams are judged on the performance of the whole team/organisation, rather than each individual task/person (Handy, 1993: 270). One cannot imagine an industrial corporation surviving without the periodic conferences of key staff from different areas meeting to compare performance, discuss strategies and prepare for the future. This view is not held universally, Foy (1980) states in her work on organisations that ‘the effectiveness of a network is inversely proportional to its formality’. Perhaps we are utilising the most effective means of communication already; however, this does rely on both the motivation and movement of people throughout the organisation (NHS) to build up contacts. A culture remains within the NHS of establishing new services (whether pilot projects or permanent departments) without specific allocation of resources, even where cost 36
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? savings are expected elsewhere. It is perhaps because these establishment costs are so poorly audited, as few clinics have budgets from the outset that anticipated resource requirements are difficult to quantify. It is apparent that supportive resources such as administrative assistance and medical records, x-ray and phlebotomy departments are as important to the efficient running of the PAC as proficient and appropriately trained professional staff. The development of the CSPAC in the author’s Trust was slower than the schedule presented for appointment as a CSPAC Nurse (Appendix 3), largely because of the lack of administrative staff in the initial phase, which is a predicament widely reflected in the literature (e.g. Lucas & Sample, 1998). The Royal Navy’s use of ‘The Team Works’ as their logo is doubtless very appropriate; however, team work should apply across every type of industry. Everyone from top to bottom is vital to the effective working of an organisation, if they are not they have no place within it (Royal Navy, 2001). There appears to be a preference through the literature for pre-admission to be split into diagnostic related groups, utilising specialist nurses to conduct all, or part of the patient assessment. There are a significant number, which utilise a central PAC, covering multiple specialties; however there is no clear-cut evidence, which is preferable to either patients or healthcare providers. Assuming experienced practitioners from the relevant speciality are appointed to diagnostically related PACs; they are able to concentrate on the most pertinent parts of the assessment and impart information that is more specific to the patient’s condition. It is not clear from the literature whether the centres utilising a centrally organised PAC, split sessions or staffing into diagnostic related groups; however, they may offer some advantages to both patient and healthcare provider. There are elements of the pre-admission process, which are common to many specialities, e.g. pre-operative Chest (or other) X-rays, ECGs and blood testing. The sharing of facilities between specialities allows dedicated allocation of time/resources thus reducing delays caused by sharing facilities with acute services. A number of papers have compared the effectiveness of nurses to the junior doctors who formerly had complete responsibility for the physical assessment of patients before surgery (Whiteley et al, 1997; Hicks, 1998; Nursing Management, 1995). It would appear that nurses who have appropriate training are as effective in pre-operative assessment of patients and follow investigation protocols more accurately. The use of multidisciplinary teams appears to frequently lead to fragmentation and delays due to 37
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? the involvement of multiple team members; the use of nurses practicing advanced assessment skills or ANPs seem to offer a more holistic option. It can be argued whether it is possible to actually use a ‘wholistic’ model due to the complexity of the human species, the brain will segment the person into needs, systems, problems etc., forming a composite picture. The philosophy should be to aim to view a person holistically, as the whole is greater than the sum of its parts (Levine, 1971). The overlap of different healthcare groups’ professional skills is now being acknowledged as more roles are being undertaken by more than one profession. This is most apparent in the doctor – nurse substitution that has occurred since the early 1990’s. This has led to professions broadening the philosophies on which they are based, nursing has become more scientific and analytical, using protocols for the basis of treatment, and medicine has acknowledged the major role experience and social factors must have in the decision making process (Luker et al, 1998). The framework for Clinical Governance formalised the radical changes in management style within the NHS. Clinical staff have been given the responsibility to use evidence-based practice, maintaining excellence and facilitating research and life-long learning in novel techniques (Department of Health, 1997a). The establishment of committees to evaluate current practice, suggest changes where appropriate and implement change with ongoing audit, is already an integral part of the management plans of the Trust (Department of Health, 1998). It is postulated that nurses apply knowledge from a unique perspective, the assimilation of theory from many disciplines being its greatest strength rather than unique (Luker, 1988; McKenna, 1993). The only hospital studied by McCarville (1999) that used nurses to conduct all the assessments was the John Radcliffe at Oxford, which used a ward nurse to go through ‘nursing’ assessment followed by the nurse practitioner conducting the ‘medical’ and physical assessments. It is suggested that these nurses were thus acting as physicians assistants rather than ANPs, particularly as they reported to individual consultant teams. Sadly, the Oxford Heart Centre has recently become the subject of a NHS Executive (Regional Office) inquiry due to reducing numbers of patients treated and concerns over the management in the Trust, to the extent that the RCN are considering industrial action in some areas of the hospital (Daly, 2001; NHS Executive, 2000; Daly, 2000; Meikle, 2000). It is possible that the reduced efficiency is related to the falling numbers of nurse practitioners (NP) during this time and the withdrawal of teaching status from the unit effecting recruitment and retention of staff. Nursing colleagues may have felt 38
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? abandoned by the NPs due to their almost complete allegiance to the surgical teams rather than a nursing structure. A more holistic approach to the assessment may have made the work more interesting and encouraged greater support from other nurses. In contrast to ANPs these ‘nurses’ were acting as ‘mini doctors’ rather than ‘maxi nurses’ and had been carrying out the doctors’ role rather than providing a holistic health provision as intended by expansions/extension of practice (Castledine, 1995). The assessment process being split between the NP and the nurses may have contributed to the reduction in efficiency. The area of practice, which was most questionable amongst some of the nurse practitioners, was consenting of patients, which should be undertaken by an appropriately qualified surgeon. Although this frees surgeons, to spend time operating; current opinion on consent for surgery is that it should be taken by a person capable of carrying out the particular surgical procedure described, i.e. not a junior grade doctor (Bristol Inquiry Unit, 1999). “Successful professional partnerships between doctors and nurses are characterised by the presence of teamwork, and the possession of shared, common and clear objectives, that focus on the safe provision of effective care and treatment. Members of such teams demonstrate an appreciation of each other’s role and constraints; mutual trust and respect; open, honest and good communication” (BMA and RCN, 1993). Research, practice development and education have assisted nursing to adapt its priorities, with greater accountability, increased professionalism and narrowing the imbalance of power and knowledge between medicine and nursing (Poulton et al, 1997). The central reason behind the breakdown of services at Oxford was the deterioration of collaborative practice and trust between professional groups (NHS Executive, 2000). Inter- professional teamwork and responsibilities are developing with each practitioner accountable for their own practice, together with a degree of professional autonomy working towards the team goals of quality health care. Significant barriers have been identified towards these goals of team working, including differences of culture, history, professional terminology, tradition, schedules, education, accountability and differences in salary/benefits between the professions. The use of reward, financial or otherwise has been found to be a very strong motivating factor, leading to improved patient care (Benner, 1985; Carr-Hill et al, 1995). The major concern, which remains in all professionals minds, is how to determine responsibility in a team when events go wrong, particularly in the case of omissions where all could be said to be accountable (Headrick et al, 1998). 39
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? Nursing has not been a particularly strong force traditionally due to the relative power of medicine, factors such as clinical governance, evidence-based practice and budgetary control have worked towards redressing some of the balance. However, this may also create anxiety and antagonism amongst some medical/surgical colleagues who may be fearful at their reduction in control, especially when our own regulatory body has not finalised its own position on advanced or higher-level practice. In an attempt to cope with the change process and to be proactive in the method, nurses have had to understand change theory so that the experience may be both positive and beneficial. The recent introduction of ‘nurse consultants’ running their own clinics is said to be a way of providing more equity between the nursing and medical professions and thus improving the career prospects and remuneration of nurses (BMJ, 1998). However, despite increasing numbers of proclamations regarding inter-professional team working and joint training programs, there has been little real progress towards core programs. Universities claim they have had difficulties establishing modules due to vastly different entry requirements and disparity between different regulatory bodies for both content and length of courses (Finch, 2000). It is suggested that until nurses will not have equivalent professional status to doctors until they are paid as equals, from April 2001 Nurses at the top of Nurse Consultant scale will earn £45,050, whereas a Medical Consultant can earn up to 286% more, i.e. £128,935 (Milburn, 2000). The way in which advanced practitioners will ultimately become recognised is by extending the boundaries of new knowledge through publication and conference presentation of their work (Castledine, 1998; Gedwill et al, 1997: 148-149). Patients appear to need to separate their expectations of the nurse and doctor’s roles; however, there also seems to be a place for a practitioner who takes the middle ground. Patients want nurses who show compassion and warmth, taking time to listen to their concerns and to teach them about their condition (Webb & Hope, 1995). It is suggested that a more ‘traditional’ concept of nursing is required to befriend the patient through the rapid course of their technological care, rather than this being passed to someone with a more basic understanding of their needs (Wright, 1995). The essence of professional nursing care should be to guide their own development rather than performing tasks or roles which medical staff or management wish to direct at nursing as a cost containment exercise. In practice the patients and their loved ones frequently ask, “Will we see you again” both with regard to their period of admission and following discharge. It appears that there would be a patient encouragement towards pre-admission assessment 40
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? becoming part of the ANPs comprehensive responsibility, throughout the clinical episode. It is questionable how autonomous any health care professional can be in the light of recent standards, guidelines and performance targets from government (Department of Health, 2000a; Department of Health, 2000b; Reveley, 1999: 275-277). Most of these documents are an assimilation of best practice from various centres, however with such stringent targets to meet it is likely this will thwart individual consultants from maverick practices. This should have good short to medium term effects in establishing more equal provision of care, with standard setting and assisted by organisations such as the National Institute for Clinical Excellence (NICE) and Commission for Health Improvement (CHI) thus avoiding the postcode lottery (Shrimsley, 1999; Department of Health, 2000b; Department of Health, 1998). However it could be argued that in the long-term this may slow the development of new and innovative practice in a similar way to formulary committees, which have been found to delay the introduction of novel medicines (ABPI, 1999). The nature of health care provision has become multi-disciplinary with many specialist roles due to increasing medical knowledge and use of technology, which would be difficult for generalist practitioners to deliver. This specialisation creates a culture of referral amongst nurses in general areas, which once were considered basic nursing care. In some circumstances, this has led to unacceptable deferment of intervention to the extent of neglect where arrival of the specialist has been delayed (Castledine, 2000). The use of advanced skills in some PACs and associated research, demonstrates that nurses are implementing new research and quality assurance through clinical audit of their practice in an aim to optimise patient care and service delivery systems, which can be compared to the role of the ANP (Castledine, 1998: UKCC, 1994). A comprehensive health assessment is undertaken; stretching far beyond the nursing considerations, which allows the planning of care (both nursing and medical), to effectively implement strategies towards health improvements (Castledine, 1998). More nurses are becoming involved in multi-disciplinary assessment and this is now not exclusively the realm of ANPs with the advent of Night Nurse Practitioners, Advanced Life Support Teams and Nurse-Led thrombolysis etc. (Quinn, 1995). The advanced skills of medical and nursing staff are recognised and appreciated by patients; however they criticise the deterioration in communication skills and lack of 41
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? warmth in the professional relationship. There is a desperate need for nursing to regain its care of patients, not just fulfilment of tasks (Castledine, 1999). The pre-admission nurse must do this, viewing the patient as a person first, analysing what needs to be done and carrying it through providing holistic care. The ANP may possess advanced skills (indeed some can be vital depending on the area of practice); however they are viewed as a small component of the total care package they deliver (Fulbrook, 1998). There is an expectation that ANPs will lead nursing forward through education and acting as consultants for other multi-disciplinary staff in their field. The implementation of effective working systems for the healthcare team is not only their place; all staff have a responsibility to take nursing (and healthcare provision) forward though research and development (Castledine, 1998). There is consensus in the literature that ANPs have comparable levels of knowledge and skills to the specialist and expert practitioners. However the ANP’s more comprehensive view of the client, surpasses either of these other professional groups, with the ability to view and plan the patient’s care in the context of the holistic nature of their humanity, rather than in the narrow context of the specialty in which they practice (Sutton & Smith, 1995). It appears that there is no clear-cut evidence, whether education at the PAC is more effective than teaching once the patient is admitted. Some studies show that during the week before admission, anxiety may prove a barrier to learning (Bond & Barton, 1994; Haines & Viellion, 1990). The PAC is rather late for smoking cessation, although this is not an excuse to omit firm advice that continuing to smoke is hazardous to both the patient’s short and long term prognosis. The outstanding success of appropriate smoking cessation advice and support means that this should be given a high priority soon after their diagnosis or referral for surgery (Haddock & Burrows, 1997). If multidisciplinary education is given at this early stage, the patient’s health should be improved by the time of operation; e.g., it is too late for the optimal benefits from the pharmacist’s session about cardiac medicines, a few weeks before admission, especially when many drugs may be discontinued following surgery. It is therefore suggested that the concentration of effort towards secondary prevention should be in the early part of the time on the waiting list, with reinforcement at pre-admission and during hospitalisation. Some patients have also commented that they would appreciate more support in the weeks following surgery, although the type and quantifiable benefit of this would need to be properly evaluated. It would appear that the ANP is ideally suited to this role, caring for the patient throughout their clinical episode; however, to be 42
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? effective and holistic in their approach, it is vital to ensure there are sufficient members of staff available, to cope with the numbers of patients involved. It is suggested that the reduction in nurse practitioner numbers may have contributed towards the lack of holistic assessment and the failures of efficiency at Oxford (NHS Executive, 2000; McCarville, 1999). The importance of effective administrative support cannot be understated for PACs, as the key to success is the accurate collation of information from multiple sources, before admission to hospital. X-rays, medical records, other investigation results and the information gained during their pre-admission appointment must be available both in the clinic and on the day of admission/surgery (Audit Commission, 1995; Edmondson, 1996). It would appear from the literature that 14 days prior to surgery is the optimal time for the PAC to occur, meaning that investigations are still considered valid and the patient is likely to retain some pre-operative information. Less time is needed for interactions with staff on admission when patients have attended PACs; although this includes patient education, the opportunity for reinforcement on admission remains important. This time also allows additional investigations to be requested, based on the findings at the clinic; preferably without deferral of the patient’s date of surgery, e.g. carotid doppler studies, renal or other ultrasounds, CT scans etc. There are many cardiologists who practice excellent standards in their referrals, with the results of investigations required before surgery and detailed descriptions of co-morbidity, risk factors etc. The use of a referral form for cardiologists might improve information from those who provide less detail, with particulars of carotid bruit, Doppler’s, blood results, and co- morbidity would assist cardiac centres to arrange investigations in advance. Nurses have been found to be more accurate in following hospital protocols for investigations, than pre-registration house officers (Whiteley et al, 1997); however, the conclusion that this was a ‘safe’ way to replace the pre-registration house officer may have some weaknesses. It is suggested that there is insufficient data to draw this conclusion, given that important information to a surgical episode (e.g. allergies) were omitted, this may have been partly due to poor proforma design, but one which could reasonably be expected to be considered. The training of the nurse for this role was perhaps insufficiently thorough to enable an unscripted history to be taken in the way that medical staff are expected to, in addition the proforma development team could 43
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? reasonably be expected to include this on the form. It would appear however, that the nurse follows hospital policy/guidelines/protocols more accurately than the pre- registration house officer does; it could be suggested then that these may need to be distributed more effectively amongst medical staff as well as nurses. This attention to detail by nursing staff may be attributable to the way in which role extensions/expansions have been sanctioned both before and since the Scope of Professional Practice document (UKCC, 1992). To use electronic history taking (e.g. University of Missouri Hospital, 2001) may suit the younger patients in some specialties; it is questionable however, how many patients’ would have the confidence to use this method in the United Kingdom, given the degree of ‘techno phobia’ that exists even within the professions. It is suggested that those who were born since 1970 would have no problems with computerisation of services (BBC News, 1997). Illiteracy amongst adults in the Britain stands at around 23%, which combined with only 30% of household connected to the Internet compared to 56% in the USA demonstrates significantly lower levels of experience with interactive computer interfaces (Lightfoot, 1999; PC Advisor, 2001). It is suggested that the first step towards this type of live data entry will be the widespread introduction of EPR. Unless the development is handled carefully, with full consultation with the healthcare professionals involved to ensure EPR meets the needs of end users, it is likely that financial and human resources will be drained by information technology (computer) departments with little or no improvements in efficiency. If handled properly the introduction of EPR will result in one of the most useful contributions to communication in medicine, since the birth of language itself. The concentration on the professionals involved and their roles is deliberate as it is these people who make the difference to any service. The effectiveness of the CSPAC/PAC may be effected by other considerations; however, without the appropriate people, the service will collapse. It is vital that the pre-admission service has direct communication with waiting list managers to achieve admission between 7 and 14 days post PAC appointment unless the patient’s surgery needs to be deferred for further investigations. Computer based documentation offers the most reliable format of ensuring available information is transferred between departments but has to be built on an effective and reliable network. 44
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? CONCLUSIONS The effectiveness of CSPACs in the preparation and assessment of patients is relatively poorly evaluated by published research. It would appear that they are highly effective in reducing post-admission cancellations of surgery where good communication takes place between the PAC and surgical/ward staff. It is possible that the literature is biased towards the success of PACs, because they offer a more cost-effective option for healthcare providers, than the alternative of early hospital admission for investigations before surgery (Smith et al, 1997; Cohn et al, 1997; Plett et al, 1998). In addition, most studies with a research basis have compared their preferred choice with a control group, rather than different variations to find the optimal format for pre-operative care. Unpublished data is much more difficult to gain access to, with many Trusts limiting access to their own staff, especially where potentially damaging information may be contained within the data released. There is sufficient evidence to indicate that PACs are an essential part of quality surgical care, not an add-on luxury to please patients (although they seem to). To admit a patient without knowing they are fit to proceed to surgery is wasteful of both human time and financial resources. Thus, the questions that remain are with regard to how PACs should be introduced and function optimally, rather than whether they are effective. The utilisation of specifically trained nurses, rather than a multidisciplinary team to perform assessments appears poorly evaluated by many areas of the literature. This review has identified areas of research, which suggest that a nurse-led service is as effective, at lower cost, based on findings from other disciplines. Further research is required, particularly in cardiac surgery; it is suggested that a randomised large-scale study using a triangulated methodology, co-ordinated audit data, questionnaires and interview strategies is needed. It would appear that where multiple professions are involved, this usually leads to delays for the patient, although not universally so. The only cost-effective way to have patients see multiple professional groups without significant delays appears to be a centralised PAC service where the patient works on a ‘merry-go-round’ (University of Missouri Hospital, 2001); however, this appears to be a more fragmented service than that offered by a single practitioner. Nursing appears to offer the most holistic option, especially with ANPs or nurses practicing advanced assessment skills with effective protocols appear as effective as the doctors they replace. 45
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? Doctors working alone do not appear to consider social aspects of care, although when working as a team with nurses, their assessments appear more comprehensive (Lucas, 1998). Thus, it appears that nurses could satisfactorily work alone; however, doctors need to be part of a team to effectively conduct the global assessment of the patient required in modern healthcare. The personnel involved should be evaluated with a large-scale study covering multiple centres and specialities using an objective methodology, to ensure that it is not just the enthusiasm for cost savings and role expansion that is driving change, but is a strive towards quality care for patients. There appears to be patient acceptance for ANPs or nurses with advanced skills conducting assessments, however they also seem to desire a degree of continuity and further contact with the nurse who pre-assesses them. The ANP who follows the patient through their episode from pre-admission to post- discharge follow up appointment would seem to offer this holistic quality care to patients. Nurses appear to adhere to hospital or national protocols with greater diligence than medical staff, although they appear more reliant on documentation to prompt their patient records. It is likely that this is the traditional culture showing through, of doctors using a blank page for clerking and nurses using a care plan with headings. The use of integrated care pathways develop the culture of thinking in terms of ‘variance from the norm’, rather than the activity of the day, in terms of recording the patient episode. Although EPR offer significantly more effective use of both space and information than paper based records, it is likely to become very slow and clumsy if every aspect of routine care is recorded. The recording of variances is quicker and more efficient, and when reading the patient record, it is easier to find any difficulties the patient may have had, as details are not lost amongst routine care. PAC nurses, as with all professional groups, base their decisions on broad concepts (Theories), applying to individual circumstances, knowledge gained from scientific, experiential and personal learning. The purpose of theory is to describe, explain, predict and control; thus guiding practice in a prescriptive manner (Walker & Avant, 1988: 11; Meleis, 1997; Rolfe, 1998). The unique and major component of nursing being the Art of Nursing which goes far beyond the mere application of the sciences. “Nursing… as a learned profession is both a science and an art. A science may be defined as an organised body of abstract knowledge arrived at by scientific research and logical 46
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? analysis. The art of nursing is the imaginative and creative use of this knowledge in human service” (Rogers, 1989: 182). It is suggested that this is how the patient gains from nurses using advanced practice in a nurse-led PAC; this would rarely be the case with a multidisciplinary clinic. The healthcare provider gains by the more efficient use of hospital beds and lower costs than would be the case with multiple professional involvements. There are significant savings on care costs available, especially where hospitals utilise the practice of admission on day of surgery. The use of hotel rooms rather than hospital beds on the night before operation may facilitate this where patients have long distances to travel, which is frequently the case in regional specialties such as cardiac surgery (Plett et al, 1998). The reason for the introduction of most PACs from the management perspective appears to be for the reduction in cancellations of surgery after admission; however, this single aim appears lost amongst the advantages of quality improvements offered to patients and the potential financial savings if same day admission is utilised. The improved preparation of patients should result in better outcomes for all involved; patients, loved ones and healthcare providers. The professions must now examine the process further to ensure that we do not accept a better service than before, but the best available with the resources allocated to the NHS. 47
    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? CONFLICT OF INTEREST The role of the author as a Senior Charge Nurse in a CSPAC could be seen as a potential conflict of interest, in that the future existence and expansion of such roles is dependent on this being backed up by the professions and literature. However, it is hoped that a balanced view has been presented, allowing the reader to reach their own conclusions as to whether there is a positive effect from the assessment of patients in the pre-operative phase. It is acknowledged that complete objectivity is unrealistic as the lived experience contributes much to ones personal knowledge and professional care. The CSPAC at the author’s Trust uses nurses practicing advanced skills who are studying towards a MSc in Advanced Nursing Practice, partly because this has developed as the most practical option in the Trust. The comparison with other centres presents a (hopefully) balanced view of multidisciplinary team working; however, based on the experiences of the author and the literature a preference for a holistic advanced nursing assessment remains. It is possible that the literature is biased towards the success of PACs, because it offers a more cost-effective option for healthcare providers, than early admission for investigations before surgery. In addition, most studies with a research basis have compared their preferred choice with a control group, rather than different options to find the optimal format for pre-operative care. 48
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    • DO PRE-ADMISSION CLINICS ALTER THE PRE-OPERATIVE COURSE OF PATIENTS AWAITING MAJOR (CARDIAC) SURGERY? APPENDIX 1 – REPORTING AND DISSEMINATION Suggested structure of a systematic review report (University of York, 2001) Title Executive summary or structured abstract Context Objectives Methods (data sources, study selection, quality assessment and data extraction) Results (data synthesis) Conclusions Main text Background Questions addressed by the review (hypotheses tested) Review methods (how the research was conducted) Data sources and search strategy Study selection (inclusion and exclusion criteria) Study quality assessment Data extraction Data synthesis Details of the included and excluded studies Results of the review Findings of the review Robustness of the results (sensitivity analyses) Discussion (interpretation of results) Conclusions Recommendations for health care Implications for further research Acknowledgements Conflict of interest References Appendices 56
    • APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC SURGERY PRE-ADMISSION CLINIC (McCarville, 1999) APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC PRE-ADMISSION CLINIC Patricia McCarville (February 1999) Contents 1.0 Introduction 2.0 Overview 3.0 Purpose of the clinics 4.0 Potential problems 5.0 Proposed locations 5.1 St Bartholomew’s Hospital 5.2 London Chest Hospital 6.0 Multi disciplinary approach 6.1 Kings College Hospital 6.2 Papworth Hospital 6.3 John Radcliffe Hospital 7.0 Admission letter 7.1 Letter style 1 7.2 Letter style 2 8.0 Patient survey 9.0 Process flow chart 10.0 Job description 1.0 Introduction Pre-admission clinics are being introduced into the cardiac services, following an operational review. The key aim of the services is to provide support and health education to the patient and their carers. Pre-admission clinics are used throughout the country for patients who are being admitted for a variety of elective surgical procedures. Cochran (1984) maintained that surgical patients who are given emotional support and information about the procedure generally have a smoother post-operative recovery and show greater compliance with treatment.
    • APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC SURGERY PRE-ADMISSION CLINIC (McCarville, 1999) 2.0 Overview A number or centre that perform cardiac surgery, invite their patients to clinic one to two weeks prior to admission, Cupples (1991) has suggested that this is the ideal time for teaching patients. There are many different types of clinic that maybe held: Those run by medical staff Those run by nurses And clinics, which have a multidisciplinary team approach. There is however, common element in all types of pre admission clinics. All routine investigation are carried out, for e.g. EGG, Chest X-Rays and blood tests. All clinics give information about the hospital stay. Ideally, the cardiac services would see the clinic as being nurse lead, by someone who has undertaken the MSc in Nursing and is able to undertake the extended role in clerking and physical assessment of the patients. However this is a two-year module and is currently only in year one, therefore the clinic will have to be multi-disciplinary during the initial period. 3.0 Purpose of the clinics There are a number of key reasons for establishing this type of clinic, and some of the primary reasons are identified below: To prevent surgery form being postponed or cancelled once the patients is admitted due to medical problem that requires further investigation. If a medical problem is identified at clinic, the appropriate investigation can be arranged if the patient surgery needs to be postponed there is time to find another suitable patient to fill that slot. MRSA swabs can be done at the clinic. This allows appropriate action to be taken if they are positive, i.e. implement isolation on admission and start treatment if there is time To prepare patients physically and psychologically for surgery. 58
    • APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC SURGERY PRE-ADMISSION CLINIC (McCarville, 1999) Any potential problems with discharge arrangement can be picked up sooner and relevant services contacted. 4.0 Potential problems A number of potential problems have been identified, that may be removed from the process following the introduction of the clinic service, some of which are shown below: If the patients who attended the clinic have their operation postponed. This means that, the tests will have to be repeated on admission due to the time delay between clinic and surgery. Test may be, initially repeated because everyone is not aware that the clinic existed. If the numbers of patients that are attending the clinic is small, this makes it a poor use of time for those involved. At times the SHO’s may not be available because of the workload on the ward or in the theatres. 5.0 Proposed locations This report seeks to identify potential locations from which the clinic service can operate, and are detailed below: 5.1 St Bartholomew’s Hospital The clinics are to be held daily on alternative site Clinical to be held on Vicary ward. In the teaching rooms and sisters office. This is the ward that the patients will be admitted to, thus enabling the patients to become familiar to their surroundings prior to admission. All other cardiac departments are in this area i.e. ITU and HIDU. The X-ray department is in the same building. The doctors are located in this area. 5.2 London Chest Hospital The clinics to be held in the outpatients department. 59
    • APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC SURGERY PRE-ADMISSION CLINIC (McCarville, 1999) Because there is no spare room on the ward. All departments are located in the same building. 6.0 Multi-disciplinary approach As stated earlier, there is the need in the early stages of the clinics operation, for a multi disciplinary approach to the service. Detailed below are three sample locations that operate on this basis. 6.1 King College Hospital pre-admission clinic Patients are seen two to four weeks prior to admission The clinic nurse will explain about the day and give a talk about heart disease in general The ward and ITU nurses who explain the procedure, expected pattern of recovery and hospital stay see them. The physiotherapist will explain their role in the post-operative phase. They are seen by the pharmacist who explains about their medication. They are given a talk by the dietician. They are shown around ITU. This will take most of the morning. After lunch they are seen in the outpatients department. They are seen and examined by the doctors. Consent forms are then signed They have a ECG Chest X-ray Blood tests 6.2 Papworth Hospital Seen two weeks before admission in the cardiac department All patients have the usual bloods test, chest X ray and ECG 60
    • APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC SURGERY PRE-ADMISSION CLINIC (McCarville, 1999) The clinic nurse will see the patients individually and commence nursing documentation, (ICP). They may take a brief medical history. No observations are taken They are seen individually by the pharmacists who will make a record of their medication. As a group they are seen by the physiotherapist, who will explain the post operative care The ITU nurse sees them who explain the procedure, expected pattern of recovery and hospital stay. If there is a doctor available, he will examine and consent the patients. They are shown around the ITU. 6.3 John Radcliffe Hospital, Oxford Seen two weeks before admission in the cardiac outpatients department. These clinics are nurse lead The nurse will explain the procedure, expected pattern of recovery and hospital stay Completes some elements of the nursing history taking Commence nursing documentation (ICP) Show the patients around the ITU They are then seen by the nurse practitioner, who are assigned to a consultant. They follow the patients through out their stay, until the patient is discharge from the consultant care The nurse practitioner will complete the physical examination and clerk the patients. If necessary, they can request Dental work Neuro assessment Blood tests 61
    • APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC SURGERY PRE-ADMISSION CLINIC (McCarville, 1999) ECG Chest X ray Repeat Angio Some will do consenting. 62
    • APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC SURGERY PRE-ADMISSION CLINIC (McCarville, 1999) 7.0 Admission letter 7.1 Letter style 1 Dear I am writing to invite you to attend a Pre-admission clinic on …… in the out patients department at St Bartholomew’s hospital / London chest hospital, as it may be up to a year or more since you have been seen in clinic. This attendance is important to ensure there are no problems which could interfere with or delay your surgery. At the clinic you will see a doctor and nurse. An up to date ECG, blood test and chest X-ray will be taken. Other tests may be carried out depending on your individual medical condition. This attendance is also an opportunity for you to discuss any concerns that you may have regarding the surgery, and you may therefore wish to bring your partner or friend with you. It would be helpful if you could bring with you a list of your current medication, details of your next of kin and of your doctor. If you are having valve surgery, you will need a letter from your dentist stating that your dental health is satisfactory for surgery. Please confirm your attendance by calling me on…… Ext….. Between 08.30am .... and 4.30pm Monday to Friday. I look forward to hearing from you soon. Yours sincerely, 63
    • APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC SURGERY PRE-ADMISSION CLINIC (McCarville, 1999) 7.2 Letter style 2 Dear I am writing to invite you to attend a Pre-admission clinic on….. at St Bartholomew’s Hospital / London Chest Hospital. The purpose of this clinic is to ensure that you have received all the necessary tests and investigations that are required for your surgery. It is important that you are in the best possible health to ensure that you make a good recovery and to avoid cancellation of surgery because of other medical problem, which we could identify and start treatment for, in advance of the surgery. This clinic session is an opportunity for you and your family to ask questions about the operation and hospital stay, and will enable you to plan for going home and returning to work. This service will provide you with a named contact if you have any questions prior to admission. There will be approx 4 other people attending the clinic. It would be helpful if you could bring with you a list of your medication, detail of your next of kin and the name of your GP. I look forward to hearing from you soon. Yours sincerely, 8.0 CARDIOTHORACIC CENTRE PRE-ADMISSION CLINIC PATIENT SATISFACTION SURVEY Today you attended the Cardiothoracic Pre-admission Clinic. We would like to improve the quality of 64
    • APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC SURGERY PRE-ADMISSION CLINIC (McCarville, 1999) service we offer our patients and to do this we need your help. By completing this questionnaire it will tell us a little about your views of the service we offer and how it can be improved. This questionnaire is totally anonymous and your answers will not affect your care in any way so please be totally honest in your answers. A FREEPOST envelope is attached for your reply. 1) Your sex Male Female 2) Your age 3) How far did you have to travel to this hospital? Less than 5 miles 5 to 10 miles 11 to 25 miles 26 to 50 miles Over 50 miles 4a) How much notice did you receive before your appointment to attend the pre-admission clinic? less than 7 days 7 to 13 days 14 days or more I can’t remember 4b) Was this enough time For you to plan for your journey to the hospital? Yes No 4c) If No, what problem did you have? 5a) Did you have to ask your GP arrange transport for you? Yes No 5b) If yes, did you have any problems: Yes No 5c) What problems did you have? 5d) Did the pre-admission clinic help out with your problems? Yes No 6a) Before you arrived for your appointment, at the pre-admission clinic, did you understand why you were attending? Yes No 6b) How did your appointment differ from what you expected? 7a) Would you have found it beneficial to have been given a leaflet about the pre-admission clinic before you came for your appointment? Yes No 7b) If Yes, what information would you like it to include? 8) Whilst at the pre-admission clinic did you see the - a) Cardiac Nurse Yes No b) Doctor Yes No 65
    • APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC SURGERY PRE-ADMISSION CLINIC (McCarville, 1999) 9) Did you have the following tests done whilst at the pre-admission clinic? a) Blood tests Yes No b) ECG Yes No c) X-rays Yes No 10a) If extra tests were required were they done on the same day as the pre-admission clinic? Yes No 10b) If No, when were they done? 10c) What extra tests did you have done: (please list) 11a) Do you feel better prepared for your surgery now you have attended the pre-admission clinic? Yes No 11b) If No, please give reason: 12) In total, approximately, how long did your appointment at the pre-admission clinic take? 13) Please feel free to make any other comments, especially if you feel we can improve the service provided 66
    • APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC SURGERY PRE-ADMISSION CLINIC (McCarville, 1999) PROPOSED PROCESS Waiting list notification Patient receives letter advising them they are on the Cardiac Surgical Waiting List and details of how to contact the community liaison nurse Admission notification Approximately 6 weeks prior to their surgery the patient receives a letter from the Patient Activity Manager indicating their admission is imminent, admission information leaflet and details of the pre-assessment clinic (date of attendance to follow) Patients will be a sent a letter by the ‘pre-assessment’ nurse 3/4 weeks prior to their planned admission inviting them and their carer (s) to attend the pre-admission clinic which will be held approximately two weeks prior to their admission Attendance at the pre-admissions clinic Notes will need to be pulled as per normal clinic attendance Clinics will be held daily on alternate sites, approximately 5 patients a day (25 = approximately 50% of activity) The nurse will: Explain the procedure, expected pattern of recovery/hospital stay Commence nursing documentation, (ICP) and discharge planning process Record basic observations i.e. blood pressure, pulse, temperature, height. weight etc. Complete details/history on medical checklist and contact named doctor if outside boundaries set. This may include clinical parameters and the need to re-catheter or arrange other tests e.g. neuro assessment, dental work etc. Arrange routine investigations i.e. CXR, ECG, bloods. A doctor will attend, consent the patient and complete the physical assessment. (The nurses role would be developed to enable them to undertake physical assessment with appropriate training, consultant medical supervision and nursing professional support). 68
    • APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC SURGERY PRE-ADMISSION CLINIC (McCarville, 1999) 10.0 Job description K983 CARDIAC CLINICAL GROUP NURSE LED CARDIAC SURGICAL PRE-ASSESSMENT Introduction The Cardiac Clinical Group will carry out approximately 1694 cardiac operations in 1998/1999. This represents 78% of operations performed within the Cardiac Group. There is a well developed infrastructure to support these patients, their family and carers. However, the operation cancellation rate is high. This is due to a multitude of reasons, some of which involve poor operating list planning and review/preparation of patients pre-operatively. The purpose of this post will be to develop a pre-assessment framework for patients prior to their admission which will minimise cancellations by ensuring better planmng and optimising the patients physical and psychological well being. Key Aims of the Service To provide support and health education to the patient and their carers in conjunction with the Rehabilitation Team and Community Liaison Sister. To co-ordinate the pre-assessment of patients admitted from the routine waiting list and liase with the Patient Activity Manager and clinical teams to plan effectively for the patients admission and subsequent care. Post Holder Specifications Grade: F/G, dependant on experience/expansion of the role. Accountable to. Activity Co-ordinator (PAM) Responsible to: Managerial: Operations Manager. Professional: Lead Nurse. Minimum Requirements Essential Desirable First Level Registration ENB l00, 249/254 or relevant post basic course A recognised teaching qualification Experience of/or training in counselling skills Experience of health promotion Cardiac health promotion course or equivalent Three years cardiac experience at which two years at E-grade First degree Experience of working with a multidisciplinary team Able to demonstrate effective communication at all levels Computer skills Knowledge of PAS MSc in nursing (to include physical assessment/history taking skills) 69
    • APPENDIX 2 - INITIAL REPORT ON THE INTRODUCTION OF A CARDIAC SURGERY PRE-ADMISSION CLINIC (McCarville, 1999) Key Objectives All patients to reach admission physically and psychologically prepared for surgery hence reducing risk of cancellation and enhance post-operative recovery. Pre-empt any problems associated with the patients admission e.g. social/medical problems, ensuring appropriate and well managed hospital admission and low risk of patient cancellation. Increased quality of patient care by improving psycho-social and clinical support service to patients, their family/carers. Liase with acute and primary HealthCare groups to help provide seamless care. Effective discharge planning, linking with providers of ongoing care/treatment, community and support services. Provide a named contact person for the patient, their carer and the multidisciplinary team associated with the patients care/treatment. In conjunction with the community liaison sister and rehabilitation team co- ordinate support and advice to patients, their carers and community interface. Benefits Improved quality of patient care. Increased communication between all parties. Pre-empt problems complaints about level of service offered. Increasing efficiency and reducing numbers of people re-admitted because of poorly co-ordinated patient admission and/or discharge. 70
    • APPENDIX 3 – PRESENTATION FOR CSPAC NURSE (Whitewood-Moores, 1999) APPENDIX 3 – PRESENTATION FOR CSPAC NURSE Whitewood-Moores (1999) 71
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    • DOES THE PRE-ASSESSMENT OF PATIENTS ALTER THE PREOPERATIVE COURSE WHILST AWAITING MAJOR (CARDIAC) SURGERY? APPENDIX 4 – TIMING OF PRE-ADMISSION CLINICS DAYS PRIOR DURATION CENTRE & SOURCE OF INFORMATION SPECIALTY TO SURGERY OF CLINIC Elective Arnot Ogden Medical Centre (1999) ? 1-2 hours Surgery Royal Infirmary of Edinburgh (University of Cardiac 1-3 days ? Edinburgh, 2000). surgery Cardiac Barts & the London NHS Trust (N/A) 3-30 days 2-3 hours surgery Elective Ottowa Civic Hospital (Kitts, 1996) 7-21 days ? surgery Compatibility Transfusion Medicine Update (1999) <14 days N/A testing Royal Surrey County Hospital, Guildford Orthopaedics 14-21 days 1-3 hours (Asimakopoulos et al, 1998). Christiana Hospital (Christina Care Health Elective <30 days ? System, 2001) surgery Cardiac St George Private Hospital, Sydney (2001) 7-11 days ? surgery Lord Mayor Treloar Hospital, Alton (Bond & 28-42 initially Orthopaedics 1-5 hours Barton, 1994). 10-14 on review Elective 2-3 hours Surgery Hotel Dieu Hospital, Ontario (2001) > 14 days Cardiac & Up to full day orthopaedics Elective Saskatoon District Health, Canada (2001) 1-30 days 3-4 hours surgery Sir Charles Gairdner Hospital (Health Elective 1 day-unspecified ? Department of Western Australia, 1997) surgery number of weeks Elective University of Missouri Hospital (2001) >30 days 45-90 minutes surgery Elective St Boniface General Hospital, Winnipeg, surgery ~14 days <4 hours Canada (Plett et al, 1998). (including cardiac) King’s College Hospital, London (McCarville, Cardiac 14-28 days Full day 1999) surgery Papworth Hospital, Cambridge (McCarville, Cardiac 14 days ? 1999) surgery John Radcliffe Hospital, Oxford (McCarville, Cardiac 14 days ? 1999) surgery Royal Hallamshire Hospital, Sheffield, UK General Following OPA ? (Reed et al, 1997) Surgery or 14 days Exploratory Study of British Pre-admission Orthopaedics 7-21 days ? Clinics (Lucas & Sample, 2001) Aberdeen Royal Infirmary (2001) Orthopaedics ‘A few weeks’ 4 hours 81
    • DOES THE PRE-ASSESSMENT OF PATIENTS ALTER THE PREOPERATIVE COURSE WHILST AWAITING MAJOR (CARDIAC) SURGERY? London Health Sciences Centre, Ontario, Non-cardiac 7-14 days ? Canada (Badner et al, 1998). surgery Cardiac Tierney (2000) < 4 hours Surgery Epsom General Hospital, Surrey, UK (Jones et Urology 10-14 days ? al, 2000) Initially Royal Columbian Hospital, New Westminster, Cardiothoracic, 6-11 days ? BC, Canada (LeNoble, 1991). later most elective 155-240 minutes Orthopaedics 168 minutes Hospital A (mean) Lucas (1998) Implies 7-21 days 115-367 minutes Orthopaedics 174 minutes Hospital B (mean) STATISTICAL SUMMARY OF AVAILABLE DATA DAYS PRIOR TO SURGERY DURATION OF CLINIC Minimum 1 45 minutes Maximum 42 7 hours 30 mins Mean 13.8 3 hours 5 mins Standard 10.1 1 hour 53 mins Deviation Median 14 3 hours Mode 14 3 hours The considerable variance in the data collection methods, missing values and the general quality of data available from the studies in the literature, means that a number of assumptions had to be made in the calculation of statistics, which are outlined below. 1. Where the days before surgery are given a maximum, but no minimum value in the literature, the minimum has been set at 1 day. 2. Where the days before surgery are given a minimum, but no maximum value in the literature, the maximum value is omitted from the data set. 3. The duration of clinic was calculated in minutes and converted to hours for readability of the data. 4. A half-day was considered to be 4 hours. 5. A full day was considered to be 7 hours 30 minutes. 6. Where the duration of clinic is given a maximum, but no minimum value in the literature, the minimum value is omitted from the data set. 82
    • DOES THE PRE-ASSESSMENT OF PATIENTS ALTER THE PREOPERATIVE COURSE WHILST AWAITING MAJOR (CARDIAC) SURGERY? 7. Where the duration of clinic is given a minimum, but no maximum value in the literature, the maximum value is omitted from the data set. 8. Where no data is available, or it is unspecified, the value is omitted from the data set. 9. Where statistics are provided their mean value is utilised for the mean of the summary provided; however, the minimum/maximum are used to derive the mode and median. 83
    • DOES THE PRE-ASSESSMENT OF PATIENTS ALTER THE PREOPERATIVE COURSE WHILST AWAITING MAJOR (CARDIAC) SURGERY? APPENDIX 5 – COMPARISON OF NURSES AND DOCTORS EVALUATED NURSE DOCTOR STUDY ACTIONS NUMBER OF PATIENTS NUMBER CORRECT NUMBER INCORRECT OVER ORDERING NUMBER OF PATIENTS NUMBER CORRECT NUMBER INCORRECT OVER ORDERING Investigations at PAC 59 282 48 11 52 296 14 25 Repeated Investigations O/A (S/B by Dr at PAC) 52 0 14 22 Repeated Investigations Jones et al, 2000 O/A (S/B by N at PAC) 59 11 37 60 Post-op complications and whether appropriately 3 3 0 8 5 3 assessed at PAC Requiring referral for further opinion 18 11 7 15 6 9 Important Current Medical Problems 68 91 12 62 79 13 Important Past Medical Problems 156 11 162 9 Whiteley et al, 1997 Allergies (not specifically requested on proforma) 100 82 18 100 99 1 Blood Pressure 100 97 3 100 65 35 Lucas, 1998 8 0 8 (Hospital A) Social Circumstances Lucas, 1998 8 7 1 8 5 3 (Hospital A) Totals 356 729 100 11 464 728 146 107 Percentage of total investigations 88% 12% 83% 17% Percentage of the number of patients 19% 66% on which statistics are available Data not available Not applicable 84
    • DOES THE PRE-ASSESSMENT OF PATIENTS ALTER THE PREOPERATIVE COURSE WHILST AWAITING MAJOR (CARDIAC) SURGERY? APPENDIX 6 – EXCLUDED STUDIES Hodgson, W; Welstand, J; Booth, J & Stables, R Paper describes methodology in (1999) The study of nursing intervention in practice. significant detail, however although it Nursing Standard 13(48): 32-34 states approximately 25% of the sample size had been randomised at the date written, it gives no initial details of findings. Dodds, F (1993) Access to the coping strategies. Journal article without primary research Managing anxiety in elective surgical patients. or systematic review basis. Professional Nurse 9(1): 45-46,48,50,52 Mitchell, M (2000) Nursing intervention for pre- Journal article without primary research operative anxiety. Nursing Standard 14(37):40-43 or systematic review basis. Brooten, D & Naylor, MD (1995) Nurses’ effect on Journal article without primary research changing patient outcomes. Image – the Journal of or systematic review basis. Nursing Scholarship 27(2): 95-99 The Scarborough Hospital (2001) Patient services: Basic patient information only, no useful surgical pre-admission. data. http://www.tsh.to/services/surgicalpreadmission.html Swindale, JE (1989) The nurse’s role in giving pre- Journal article without primary research operative information to reduce anxiety in patients or systematic review basis. Focuses on admitted to hospital for elective minor surgery. Journal of Advanced Nursing 14(11): 899-905 the requirements of patients undergoing minor surgery. Davies, N (2000) Patients’ and carers’ perceptions of Pre-operative anxiety level not evaluated factors influencing recovery after cardiac surgery. in the study’s methodology. Journal of Advanced Nursing 2: 318-326 85