Dissertation - Do pre-admission clinics alter the pre-operative course of patients awaiting major...

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


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


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


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


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


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


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


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


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


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


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


12

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 (9651/662/433/84/15/16 ) 6

Table 1 – Search Facilities Utilised Search Facility utilised Search Engines

1. “The Web” grouping of Copernic Plus 2001

Altavista AOL.com Compuserve Direct Hit EuroSeek Excite FAST Search FindWhat Google

GoTo HotBot LookSmart Lycos Mamma.com MSN Web Search Netscape Netcenter Open Directory Project Yahoo

2. “The Web – UK” grouping of Copernic Plus 2001

AltaVista UK Espotting Euroseek Excite UK Fast Search Find Once Go To United Kingdom Hot Bot Lineone Look Smart

Lycos UK Mirago NBCi Searchengine.com Snoopa UK Directory UK Plus UK Search King UK Max Yahoo UK

3. “Health” grouping of Copernic Plus 2001

AHealthyMe AMA Ask Dr. Weil drkoop.com DrugInfoNet HealthAnswers HealthAtoZ Healthfinder InteliHealth

Mayo Clinic Health Oasis MedExplorer MedicineNet.com MediConsult.com MEDLINEplus OnHealth The Thrive Health Library WebMD 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

http://www.copernic.com/



http://www.ovid.com/



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.


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


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


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


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


‘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


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


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


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


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


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


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


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


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


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


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


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


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


(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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


REFERENCES

Aberdeen Royal Infirmary (2001) Clinical services – orthopaedics http://www.show.scot.nhs.uk/guh/clinical/clinical_directorates/clinicalservicesb/orthopaedics/orthopaedics.htm

ABPI (1999) NICE and medicines. The Association of British Pharmaceutical Industry, London

Alcock, P (1986) Pre-operative information and visits promote recovery of patients. NATNews 23(7): 17-18

American College Student Association (1999) Student injury & sickness insurance plan - pre-admission tests. http://www.asca.com/99StudentInsurance/pre_admission_tests.htm

Arnot Ogden Medical Center (1999) The preadmission center. http://www.aomc.org/pac.html

Asimakopoulos, G; Harrison, R & Magnussen, PA (1998) Pre-admission clinic in an orthopaedic department: evaluation over a 6-month period. Journal of the Royal College of Surgeons of Edinburgh 43(3): 178-181

Audit Commission (1995) Setting the records straight. Audit Commission, Abington, UK http://www.audit-commission.gov.uk/ac2/NR/Health/ebnh0695.htm

Badner, NH; Craen, RA; Paul, TL & Doyle, JA (1998) Anaesthesia preadmission assessment: a new approach through use of a screening questionnaire. Canadian Journal Anaesthesia 45(6): 87-92

Bailes, BK (1998) Pre-admission: efficient operation and customer satisfaction. AORN Journal 67(6): 11595

Ball, C (1997) Planning for the future: advanced nursing practice in critical care. Intensive and Critical Care Nursing 13(1): 17-25

BBC News (1997) Special report – is technology taking over the world? 25/12/1997 http://news1.thdo.bbc.co.uk/hi/english/special_report/for_christmas/_new_year/technophobia/newsid_41000/41853.stm

Bello, A (1998) Descriptive data analysis. In LoBiondo-Wood, G & Haber, J (1998) Nursing research: methods, critical appraisal and utilization (4th Edition). Mosby Inc., Missouri, USA pp 351-368

Benner, P. (1985) From novice to expert: excellence and power in clinical nursing practice. Menlo Park, California, Addison-Wesley

Bevan Report (1989) Staffing and utilisation of operating theatres. HMSO, London

Bhatti, TS; Harradine, K; Davies, B; Heather, BP & Earnshaw, JJ (1999) First year of a fast track carotid duplex service. Journal of the Royal College of Surgeons of Edinburgh 44:307-309

BMA & RCN (1993) Intravenous drug therapy: a statement from the BMA and RCN. London, British Medical Association & Royal College of Nursing

BMJ (1998) News – in brief. British Medical Journal 317(7160): 698

Bond, D & Barton, K (1994) Patient assessment before surgery. Nursing Standard 8(28): 23-28

Bridge C & Nelson S (1994) A deficit in care: the educational needs of thoracic patients (Nurses' roles in providing postoperative patient education). Professional Nurse 10(1): 8-13.

Bristol Inquiry Unit (1999) Bristol Royal Infirmary Inquiry (Phase 2) – Service: Empowering the public in the health care process. Bristol Inquiry Unit, Bristol, UK

Brooten, D & Naylor, MD (1995) Nurses’ effect on changing patient outcomes. Image – the Journal of Nursing Scholarship 27(2): 95-99

Brown, RA (1995) The politics of specialist/advanced practice: conflict or confusion. British Journal of Nursing 4(16): 944-948

Bysshe, JE (1988) The effect of giving information to patients before surgery. Nursing 3(30): 36-39

Carr-Hill, RA; Dixon, P; Griffiths, M; Higgins, M; McCaughan, D; Rice, N & Wright, K (1985) The impact of nursing grade on the quality and outcome of nursing care. Health Economics 4(1): 57-72

49

http://www.show.scot.nhs.uk/guh/clinical/clinical_directorates/clinicalservicesb/orthopaedics/orthopaedics.htm

http://www.show.scot.nhs.uk/guh/clinical/clinical_directorates/clinicalservicesb/orthopaedics/orthopaedics.htm

http://www.asca.com/99StudentInsurance/pre_admission_tests.htm

http://www.aomc.org/pac.html

http://www.audit-commission.gov.uk/ac2/NR/Health/ebnh0695.htm

http://news1.thdo.bbc.co.uk/hi/english/special_report/for_christmas/_new_year/technophobia/newsid_41000/41853.stm

http://news1.thdo.bbc.co.uk/hi/english/special_report/for_christmas/_new_year/technophobia/newsid_41000/41853.stm


Castledine, G (1995) Will the nurse practitioner be a mini doctor or a maxi nurse? British Journal of Nursing 4(16): 938-939

Castledine, G (1998) Developments in the role of advanced nurse practitioner: a personal perspective. In Rolfe, G & Fulbrook, P (1998) Advanced Nursing Practice. Butterworth-Heinemann, Oxford pp 3-7

Castledine, G (1999) The NHS is loosing its personal touch with clients. British Journal of Nursing 8(16): 1114

Castledine, G (2000) Are specialist nurses deskilling general nurses. British Journal of Nursing 9(11): 738

Charter, D (2001) Doctors in crisis as complaints soar. The Times No:67063 15/2/2001: 1

Christiana Care Health System (2001) A guide to prepare you for your surgical procedure at Christiana or Wilmington Hospital. http://www.ezorganizer.com/patient_care/patient_care_pre_admin.cfm

Clarke, M (1986) Action and reflection: practice and theory in nursing. Journal of Advanced Nursing 11(1): 3-11

Cohn LH; Rosborough D & Fernandez J (1997) Reducing costs and length of stay and improving efficiency and quality of care in cardiac surgery. Annals of Thoracic Surgery 64(6 Suppl): S58-60

Cotton, P (1993) Fast-track improves CABG outcomes. JAMA 270(17): 2023

Daly, N (2000) Nursing head criticised at Oxford Heart Centre. Nursing Times Net 15/11/2000 http://www.nursingtimes.net/news/nipage.asp?story=NT001115N3&gutter=news_index_gutter

Daly, N (2001) Strike action planned for John Radcliffe Hospital Oxford. Nursing Times Net 1/3/2001 http://www.nursingtimes.net/news/nipage.asp?story=NT010301N3&gutter=news_index_gutter

Davies, N (2000) Patients’ and carers’ perceptions of factors influencing recovery after cardiac surgery. Journal of Advanced Nursing 2: 318-326

De Luc, K (2000) Are different models of care pathways being developed? International Journal of Health Care Quality Assurance 13(2): 80-86

Department of Health (1989) Discharge of patients from hospital – Circular HC/89/5. Department of Health, London

Department of Health (1997a) IHSM report on clinical governance - Clinical governance: Clinician heal thyself? http://www.ihsm.co.uk/clin_rep.htm

Department of Health (1997b) Health services in London – a strategic review. Department of Health, London

Department of Health (1998) A first class service: quality in the new NHS. Department of Health, London

Department of Health (2000a) National Service Framework for Coronary Heart Disease. Department of Health, London

Department of Health (2000b) The NHS plan: a plan for investment, a plan for reform. Department of Health, London

Department of Health (2000c) Hospital in-patient data: based on hospital episode statistics (HES). http://www.doh.gov.uk/hes/standard_data/available_tables/main_operations/tb00599a.pdf

Dodds, F (1993) Access to the coping strategies. Managing anxiety in elective surgical patients. Professional Nurse 9(1): 45-46,48,50,52

Edmondson, M (1996) Pre-assessment for day care. In Penn, S; Davenport, HT; Carrington, S & Edmondson, M (1996) Principles of day surgery nursing. Blackwell Science, Oxford, UK

Egbert, LD; Battit, GE; Welch, CE & Bartlett, MK (1964) Reduction in post-operative pain by encouragement and instruction of patients. New England Journal of Medicine 270: 825-827

English, I. (1993) Intuition as a function of the expert nurse: a critique of Benner’s novice to expert model. Journal of Advanced Nursing 18(3): 387-393

Fellows, H; Lucas, B; Burgess, L; Abbott, D; Clare, A & Barton, K (1998) Orthopaedic pre-admission assessment clinics: Part 1. Journal of Orthopaedic Nursing 2(4): 209-218

50

http://www.ezorganizer.com/patient_care/patient_care_pre_admin.cfm

http://www.nursingtimes.net/news/nipage.asp?story=NT001115N3&gutter=news_index_gutter

http://www.nursingtimes.net/news/nipage.asp?story=NT010301N3&gutter=news_index_gutter

http://www.ihsm.co.uk/clin_rep.htm

http://www.doh.gov.uk/hes/standard_data/available_tables/main_operations/tb00599a.pdf


Finch, J (2000) Interprofessional education and teamworking: a view from the education providers. British Medical Journal 321: 1138–40

Fitzsimmons, D; Parahoo, K & Stringer, M (2000) Waiting for coronary artery bypass surgery: a qualitative analysis. Journal of Advanced Nursing 32(5):1243-1252

Foy, N (1980) The yin and yang of organisations. Morrow, New York, USA

Fulbrook, P (1998) Advanced practice: the ‘advanced practitioner’ perspective. In Rolfe, G & Fulbrook, P (1998) Advanced Nursing Practice. Butterworth-Heinemann, Oxford pp 87-102

Gedwill, A; Mack, S; Mlakar, D & Vanek, RK (1997) Actulization of the ACNP role: the experience of university hospitals of Cleveland. In Daly, BJ (1997) The acute care nurse practitioner. Springer Publishing Company Inc, New York, USA

Greenhalgh & Company (1994) The Greenhalgh Report: the interface between junior doctors and nurses (executive summary). Greenhalgh & Company, Macclesfield, UK

Haddock, J & Burrows, C (1997) The role of the nurse in health promotion: an evaluation of a smoking cessation programme in surgical pre-admission clinics. Journal of Advanced Nursing 26: 1098-1110

Hadorn, DC & Homes, AC (1997) The New Zealand priority criteria project, Part 2: coronary artery bypass surgery. British Medical Journal 314: 135-138

Haines, N Viellion, G (1990) A successful combination of pre-admission testing and pre-operative education. Orthopaedic Nursing9(2): 53-57

Handy, C (1993) Understanding organisations (4th edition). Penguin Books, London, UK

Hayward, J (1975) Information – a prescription against pain. Royal College of Nursing, London, UK

Headrick, LA; Wilcock, PM & Batalden, PB (1998) Interprofessional working and continuing medical education. British Medical Journal 316(7133): 771-774

Health Department of Western Australia (1997) Overnight wait for surgery goes in new pre-admission clinic. http://www.health.wa.gov.au/healthv/spring97/973_51.html

Heater, BS; Becker, AM; Olson, RK (1988) Nursing interventions and patient outcomes. A meta-analysis of studies. Nursing Research 37: 303-307

Hicks, GL (1998) Cardiac surgery and the acute care nurse practitioner – “the perfect link”. Heart & Lung 27(5): 283-284

Hodgson, W; Welstand, J; Booth, J & Stables, R (1999) The study of nursing intervention in practice. Nursing Standard 13(48): 32-34

Holloway, B & Hall, J (1992) Planning for a more comfortable stay: setting up a pre-admission visiting service. Professional Nurse 7(6): 372-374

Hope, J (2000) Big fall in heart surgery – doctors http://www.thisislondon.com/dynamic/news/top_story.html?in_review_id=264098&in_review_text_id=210859 Associated Newspapers Ltd., 14 March 2000

Hornick, P & Taylor, KM (1995) A difficult case: Perform carotid endarterectomy and coronary artery bypass surgery as a single procedure. British Medical Journal 310: 1451-1452

Hotel Dieu Hospital (2001) Pre-admission service. http://www.hoteldieu.com/preadm.htm

http://www.tsh.to/services/surgicalpreadmission.html

Jadad, AR; Cook, DJ & Browman, GP (1997) A guide to interpreting discordant systematic reviews. Canadian Medical Association Journal 156(10): 1411-1416

Johns, PM (1997) Integrating information systems and health care. Logistics Information Management 10(4): 140-145

Johnson, JE (1983) Psychological interventions and coping with surgery. In Baum, A; Taylor, SE & Singer, JE (editors) (1983) Handbook of psychology and health Volume 4. Erlbaum, Hillsdale, NJ, USA

Jones, A; Penfold, P; Bailey, M; Charig, C; Choolun, D & Rollin, A-M (2000) Pre-admission clerking of urology patients by nurses. Professional Nurse 15(4): 261-266

51

http://www.health.wa.gov.au/healthv/spring97/973_51.html

http://www.thisislondon.com/dynamic/news/top_story.html?in_review_id=264098&in_review_text_id=210859

http://www.thisislondon.com/dynamic/news/top_story.html?in_review_id=264098&in_review_text_id=210859

http://www.hoteldieu.com/preadm.htm



Kitts, JB (1996) Pre-admission clinic: new territory for the anaesthetist. http://www.anesthesia.org/winterlude/wl96/wl96_1.html University of Ottawa (Department of Anesthesiology), Ottawa, Canada

Krainovich-Miller, B (1998) Literature review. In LoBiondo-Wood, G & Haber, J (1998) Nursing research: methods, critical appraisal, and utilisation (4th edition). Mosby Inc., Missouri, USA

LeNoble, E (1991) Pre-admission possible. The Canadian Nurse February: 18-20

Lepczyk, M; Raleigh, EH & Rowley, C (1990) Timing of pre-operative patient teaching. Journal of Advanced Nursing 15: 300-306

Levine, ME (1971) Holistic nursing. Nursing Clinics of North America 6:253

Lightfoot, L (1999) One in four Britons baffled by the change from their shopping http://www.telegraph.co.uk/et?ac=004667707714096&rtmo=3Sx3ASKM&atmo=rrrrrrrq&pg=/et/99/3/26/nshop26.html Daily Telegraph Issue 1400 - Friday 26 March 1999

LoBiondo-Wood, G & Haber, J (1998) Nursing research: methods, critical appraisal and utilization (4th Edition). Mosby Inc., Missouri, USA

Loop, FD; Christiansen, EK; Lester, JL; Cosgrove, DM; Franco, I & Golding, LR (1983) A strategy for cost containment in coronary surgery. JAMA 250: 63-66

Lucas, B & Sample, V (2001) A survey of registered nurses’ activities in British orthopaedic pre-operative assessment clinics. Journal of Orthopaedic Nursing 5:30-36

Lucas, B (1998) Orthopaedic patients’ experiences and perceptions of pre-admission assessment clinics. Journal of Orthopaedic Nursing 2(4): 202-208

Luker, K.A. (1988) cited by McKenna, G. (1993) Unique theory – is it essential in the development of a science of Nursing? Nurse Education Today 13(2): 121-127

Luker, K.A., Hogg, C., Austin, L., Ferguson, B. & Smith, K. (1998) Decision making: the context of nurse prescribing. Journal of Advanced Nursing 27(3): 657-665

Malkin, KF (2000) Patients’ perceptions of a pre-admission clinic. Journal of Nursing Management 8: 107-113

McCarville, P (1999) Initial report on the introduction of a Cardiac Pre Admission Clinic. Cardiac Clinical Group, Royal Hospitals NHS Trust, London, UK (unpublished)

McCaugherty, D (1991) The use of a teaching model to promote reflection and the experimental in first-year student nurses: an action research study. Journal of Advanced Nursing 16: 534-543

McGaughey, J & Harrisson (1994) Understanding the pre-operative information needs of patients and their relatives in intensive care units. Intensive and Critical Care Nursing10(3): 186-194

McKenna, G. (1993) Unique theory – is it essential in the development of a science of Nursing? Nurse Education Today 13(2): 121-127

Meikle, J (2000) Bleak future for heart centre ‘riven by conflict’ Guardian Unlimited 16/11/2000 http://www.guardian.co.uk/Archive/Article/0,4273,4091852,00.html

Meleis, AI (1997) Theoretical nursing: development and progress (3rd edition. Lippincott-Raven Publishers, Philadelphia

Milburn, A (2000) "We're determined to do right by frontline NHS staff": 70,000 senior nurses targeted for biggest pay rises Chief Executive Bulletin - 18 December 2000. Department of Health, London, UK http://www.doh.gov.uk/cebulletin/pr0746.htm

Miller, P & Shada, EA (1978) Pre-operative information and recovery of open-heart surgery patients. Heart & Lung 7(3): 486-493

Mitchell, M (2000) Nursing intervention for pre-operative anxiety. Nursing Standard 14(37):40-43

Newton, V (1996) Care in pre-admission clinics. Nursing Times 92(1): 27-28

NHS Executive (1998) Integrating theory and practice in nursing. NHS Executive, Leeds, UK

NHS Executive (2000) Report of the external review into Oxford cardiac services. NHS Executive, South-East Regional Office

NHSME (1991) Junior doctors – the new deal. HMSO, London

52

http://www.anesthesia.org/winterlude/wl96/wl96_1.html

http://www.telegraph.co.uk/et?ac=004667707714096&rtmo=3Sx3ASKM&atmo=rrrrrrrq&pg=/et/99/3/26/nshop26.html

http://www.telegraph.co.uk/et?ac=004667707714096&rtmo=3Sx3ASKM&atmo=rrrrrrrq&pg=/et/99/3/26/nshop26.html

http://www.guardian.co.uk/Archive/Article/0,4273,4091852,00.html

http://www.doh.gov.uk/cebulletin/pr0746.htm


Nursing Management (1995) Nurses fail to cut junior doctors’ hours – yet (news). Nursing Management 1(10): 5

Org, BN; Jordan, K; Dunn, G; Parry, M; Newell, J; Moulton, H & Cade, D (1997) Patients approve of pre-operative assessments. Nursing Times 93(40): 57-59

PC Advisor (2001) UK lags US in number of connected homes. PC Advisor 68: 34

Plett, P; Kress, J; Friesen, RM & Hudson, RJ (1998) The pre-admission assessment clinic: patient impression and impact on length of stay. Today’s Surgical Nurse 2094): 14-19

Polit, DF & Hungler, BP (1999) Nursing research: principles and methods (6th edition). Lippincott, Philadelphia, PA, USA

Poulton, B, Gough, P & Wright, S (1997) Forward thinking Nursing Standard 11(44): 25

Quinn, T (1995) The changing role of the nurse. Care of the Critically Ill 11(2): 48-49

Raleigh, EH; Lepczyk, M & Rowley, C (1990) Significant others benefit from pre-operative information. Journal of Advanced Nursing 15: 941-945

Reed, M; Wright, S; & Armitage (1997) Nurse-led general surgical pre-operative assessment clinic. Journal of the Royal College of Surgeons of Edinburgh 42: 310-313

Reveley, S (1999) The professional and legal framework for the nurse practitioner. In Walsh, M; Crumbie, A & Reveley, S (1999) Nurse practitioners: clinical skills and professional issues. Butterworth Heinemann, Oxford, UK

Rew, L. & Barrow, E.M. (1987) Intuition: a neglected hallmark of nursing knowledge. Advances in Nursing Science 10(1): 49-62

Riches, T; Stead, L & Espie, C (1994) Introducing anticipated recovery pathways: a teaching hospital experience. International Journal of Health Care Quality Assurance7(5): 21-24

Robson, C (1993) Real world research. Blackwell Publishers

Rogers, M.E. (1989) Nursing a science of unitary human beings. In Riehl-Sisca, I. (editor) (1989) Conceptual models for nursing practice (3rd edition). Appleton and Lange, Englewood Cliffs

Rolfe, G (1997) Beyond expertise: theory, practice and the reflexive practitioner. Journal of Clinical Nursing 6(2): 93-97

Rolfe, G (1998) Advanced practice and the reflective nurse: developing knowledge out of practice. In Rolfe, G & Fulbrook, P (1998) Advanced nursing practice. Butterworth Heinemann, Oxford, UK pp 219-228

Rolfe, G. & Fulbrook, P. (1998) Advanced nursing practice. Butterworth Heinemann, Oxford

Royal Infirmary of Edinburgh - University of Edinburgh (2000) Preoperative management. http://www.ed.ac.uk/anaesthetics/cardiac/preop.htm

Royal Navy (2001) The team works – website. http://www.royal-navy.mod.uk

Saskatoon District Health (2001) Pre-admission clinic. http://sdh.sk.ca/access/ptadmit/defPAC.htm

Seddon, ME; French, JK; Amos, DJ et al (1999) Waiting times and prioritisation for coronary artery bypass surgery in New Zealand. Heart 81: 593-597

Sherlaw-Johnson, C (1999) Managing waiting lists for surgery. Heart 81: 586-92

Shrimsley, R (1999) Dobson will stop ‘NHS postcode lotteries’. Daily Telegraph Issue 1352: 6/2/1999

Shuldham, C (1999) A review of the impact of pre-operative education on recovery from surgery. International Journal of Nursing Studies 36(2): 171-177

Sindhu, F (1998) Meta-analyses and systematic reviews of the literature. In Roe, B & Webb, C (1998) Research and development in clinical nursing practice. Whurr Publishers Ltd., London, UK pp 84-111

Smith PK; Smith LR & Muhlbaier LH (1997) Risk stratification for adverse economic outcomes in cardiac surgery. Annals of Thoracic Surgery 64(6 Suppl.): S61-3

Smith, J (1998) Streamlining pre-operative assessment in orthopaedics. Nursing Standard 13(1): 45-47

Society of Cardiothoracic Surgeons of Great Britain and Ireland (1998) National Adult Cardiac Surgical Database Report. Society of Cardiothoracic Surgeons of Great Britain and Ireland

53

http://www.ed.ac.uk/anaesthetics/cardiac/preop.htm

http://www.royal-navy.mod.uk/

http://sdh.sk.ca/access/ptadmit/defPAC.htm


St George Private Hospital (2001) Services – Cardiac Surgery Preadmission Clinic http://www.hcoa.com.au/stgeorge/servicesbody.htm

Stokes-Roberts, A (1999) Smooth operators. Health Service Journal (7 Jan): 22-23

Suls, J & Wan, CK (1989) Effects of sensory and procedural information on coping with stressful medical procedures and pain: a meta-analysis. Journal of Consulting and Clinical Psychology 57: 372-379

Sutton, F & Smith, C (1995) Advanced nursing practice: new ideas and new perspectives. Journal of Advanced Nursing 21: 1037-1043

Swindale, JE (1989) The nurse’s role in giving pre-operative information to reduce anxiety in patients admitted to hospital for elective minor surgery. Journal of Advanced Nursing 14(11): 899-905

The Scarborough Hospital (2001) Patient services: surgical pre-admission.

Tierney, M (2000) Pre-assessment clinic for pre-operative cardiac surgery patients http://www.aacn.org/__882569e6006c80d5.nsf/0/10BDDB0D0A3642AA882568F3005A85F8?OpenDocument (Bulletin Board)

Toogood, GJ; Wilmott, K; Jones, L; Magee, TR & Galland, RB (1998) Feasibility of pre-admission nurse clerking of patients with vascular disease. Journal of the Royal College of Surgeons of Edinburgh 43: 246-247

Tooth, LR; McKenna, KT & Maas, F (1998) Pre-admission education/counseling for patients undergoing coronary angioplasty: impact on knowledge and risk factors. Australian & New Zealand Journal of Public Health22(5): 583-588

Transfusion Medicine Update (1999) Elective surgery pre-admission testing and the transfusion service. http://www.itxm.org/TMU1998/tmu10-99.htm

Tusek, D; Church, JM & Fazio, VW (1997) Guided imagery as a coping strategy for perioperative patients. AORNJournal 66(4): 644-649

UKCC (1992) The scope of professional practice. London, UKCC

UKCC (1994) The future of professional practice, the Council’s standards for education and practice following registration. United Kingdom Central Council for Nursing, Midwifery and Health Visiting, London, UK

UKCC (1998) A Higher Level of Practice (Consultation Document). United Kingdom Central Council for Nursing, Midwifery and Health Visiting, London, UK

University of Missouri Hospital (2001) Convenience and ease: pre-op clinic improves pre-surgery process. http://www.hsc.missouri.edu/~anest/preop.htm

University of York (2001) Undertaking Systematic Reviews of Research on Effectiveness: CRD's Guidance for those Carrying Out or Commissioning Reviews - CRD Report Number 4 (2nd Edition). NHS Centre for Reviews and Dissemination, University of York, UK http://www.york.ac.uk/inst/crd/report4.htm

Wagstaff, P & Gould, D (1998) Research in the clinical area: the ethical issues. Nursing Standard 12(28): 33-36

Walker, LO & Avant, KC (1988) Strategies for theory construction in nursing (2nd edition). Appleton & Lange, East Norwalk, Connecticut

Wallace, LM (1985) Surgical patients’ preferences for preoperative information. Patient Education and Counselling 7: 377-387

Wallace, M & Gough P (1995) The UKCC’s criteria for specialist and advanced practice. British Journal of Nursing 4(16): 939-944

Warlow, C; Farrell, B; Fraser, A; Sandercock, P & Slattery, J (Writing Committee) (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). The Lancet 351: 1379-1387

Waterman, H (1998) Data collection in qualitative research. In Roe, B & Webb, C (editors) (1998) Research and development in clinical nursing practice. Whurr Publishers

Web, C & Hope, K (1995) What kind of nurses do patient’s want? Journal of Clinical Nursing 4(2): 101-108

54

http://www.hcoa.com.au/stgeorge/servicesbody.htm

http://www.aacn.org/__882569e6006c80d5.nsf/0/10BDDB0D0A3642AA882568F3005A85F8?OpenDocument

http://www.aacn.org/__882569e6006c80d5.nsf/0/10BDDB0D0A3642AA882568F3005A85F8?OpenDocument

http://www.itxm.org/TMU1998/tmu10-99.htm

http://www.hsc.missouri.edu/%7Eanest/preop.htm

http://www.york.ac.uk/inst/crd/report4.htm


Whiteley, MS; Wilmott, K & Galland, RB (1997) A specialist nurse can replace pre-registration house officers in the surgical pre-admission clinic. Annuls of the Royal College of Surgeons of England (Supplement) 79:257-260

Whitewood-Moores, ZC (1999) My views and understanding of the critical aspects for successful development of the Cardiac Pre-admission Charge Nurse. Presentation to Barts and the London NHS Trust – Cardiac Directorate Managers

Wright, SG (1995) The role of the nurse: expanded or extended? Nursing Standard 9(33): 25-29

55


56

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

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.


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


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


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


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


ECG

Chest X ray

Repeat Angio

Some will do consenting.

62


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


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


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


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


9.0 Process flow chart PROPOSED PROCESS Surgery –1 year

WAITING LIST NOTIFICATION

Surgery –6 weeks

ADMISSION NOTIFICATION

Surgery –3 weeks

PRE-ADMISSION LETTER

ATTEND CLINIC

Surgery –2 weeks

67


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


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


70

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.

APPENDIX 3 – PRESENTATION FOR CSPAC NURSE (Whitewood-Moores, 1999)

APPENDIX 3 – PRESENTATION FOR CSPAC NURSE

Whitewood-Moores (1999)

71


72


73


74


75


76


77


78


79


80

DOES THE PRE-ASSESSMENT OF PATIENTS ALTER THE PREOPERATIVE COURSE WHILST AWAITING MAJOR (CARDIAC) SURGERY?

APPENDIX 4 – TIMING OF PRE-ADMISSION CLINICS

CENTRE & SOURCE OF INFORMATION SPECIALTY DAYS PRIOR TO SURGERY

DURATION OF CLINIC

Arnot Ogden Medical Centre (1999) Elective Surgery ? 1-2 hours

Royal Infirmary of Edinburgh (University of Edinburgh, 2000).

Cardiac surgery 1-3 days ?

Barts & the London NHS Trust (N/A) Cardiac surgery 3-30 days 2-3 hours

Ottowa Civic Hospital (Kitts, 1996) Elective surgery 7-21 days ?

Transfusion Medicine Update (1999) Compatibility testing <14 days N/A

Royal Surrey County Hospital, Guildford (Asimakopoulos et al, 1998). Orthopaedics 14-21 days 1-3 hours

Christiana Hospital (Christina Care Health System, 2001)

Elective surgery <30 days ?

St George Private Hospital, Sydney (2001) Cardiac surgery 7-11 days ?

Lord Mayor Treloar Hospital, Alton (Bond & Barton, 1994). Orthopaedics 28-42 initially

10-14 on review 1-5 hours

Hotel Dieu Hospital, Ontario (2001)

Elective Surgery

> 14 days 2-3 hours

Cardiac & orthopaedics Up to full day

Saskatoon District Health, Canada (2001) Elective surgery 1-30 days 3-4 hours

Sir Charles Gairdner Hospital (Health Department of Western Australia, 1997)

Elective surgery

1 day-unspecified number of weeks ?

University of Missouri Hospital (2001) Elective surgery >30 days 45-90 minutes

St Boniface General Hospital, Winnipeg, Canada (Plett et al, 1998).

Elective surgery

(including cardiac)

~14 days <4 hours

King’s College Hospital, London (McCarville, 1999)

Cardiac surgery 14-28 days Full day

Papworth Hospital, Cambridge (McCarville, 1999)

Cardiac surgery 14 days ?

John Radcliffe Hospital, Oxford (McCarville, 1999)

Cardiac surgery 14 days ?

Royal Hallamshire Hospital, Sheffield, UK (Reed et al, 1997)

General Surgery

Following OPA or 14 days ?

Exploratory Study of British Pre-admission Clinics (Lucas & Sample, 2001) Orthopaedics 7-21 days ?

Aberdeen Royal Infirmary (2001) Orthopaedics ‘A few weeks’ 4 hours

81


London Health Sciences Centre, Ontario, Canada (Badner et al, 1998).

Non-cardiac surgery 7-14 days ?

Tierney (2000) Cardiac Surgery < 4 hours

Epsom General Hospital, Surrey, UK (Jones et al, 2000) Urology 10-14 days ?

Royal Columbian Hospital, New Westminster, BC, Canada (LeNoble, 1991).

Initially Cardiothoracic,

later most elective

6-11 days ?

Lucas (1998)

Orthopaedics Hospital A

Implies 7-21 days

155-240 minutes 168 minutes

(mean)

Orthopaedics Hospital B

115-367 minutes 174 minutes

(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 Deviation 10.1 1 hour 53 mins

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


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


APPENDIX 5 – COMPARISON OF NURSES AND DOCTORS

STUDY EVALUATED ACTIONS

NURSE DOCTOR NUMBER OF PATIENTS

NUMBER CORRECT

NUMBER INCORRECT

OVER ORDERING

NUMBER OF

PATIENTS

NUMBER CORRECT

NUMBER INCORRECT

OVER ORDERING

Jones et al, 2000

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 O/A (S/B by N at PAC) 59 11 37 60

Post-op complications and whether appropriately

assessed at PAC 3 3 0 8 5 3

Requiring referral for further opinion 18 11 7 15 6 9

Whiteley et al, 1997

Important Current Medical Problems 68 91 12 62 79 13

Important Past Medical Problems 156 11 162 9

Allergies (not specifically requested on proforma) 100 82 18 100 99 1

Blood Pressure 100 97 3 100 65 35

Lucas, 1998 (Hospital A) Social

Circumstances

8 0 8

Lucas, 1998 (Hospital A) 8 7 1 8 5 3

Totals 356 729 100 11 464 728 146 107

Percentage of total investigations 88% 12% 83% 17%

Percentage of the number of patients on which statistics are available 19% 66%

Data not available

Not applicable

84


85

APPENDIX 6 – EXCLUDED STUDIES

Hodgson, W; Welstand, J; Booth, J & Stables, R (1999) The study of nursing intervention in practice. Nursing Standard 13(48): 32-34

Paper describes methodology in significant detail, however although it 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. Managing anxiety in elective surgical patients. Professional Nurse 9(1): 45-46,48,50,52

Journal article without primary research or systematic review basis.

Mitchell, M (2000) Nursing intervention for pre-operative anxiety. Nursing Standard 14(37):40-43


Brooten, D & Naylor, MD (1995) Nurses’ effect on changing patient outcomes. Image – the Journal of Nursing Scholarship 27(2): 95-99


The Scarborough Hospital (2001) Patient services: surgical pre-admission. http://www.tsh.to/services/surgicalpreadmission.html

Basic patient information only, no useful data.

Swindale, JE (1989) The nurse’s role in giving pre-operative information to reduce anxiety in patients admitted to hospital for elective minor surgery. Journal of Advanced Nursing 14(11): 899-905

Journal article without primary research or systematic review basis. Focuses on the requirements of patients undergoing minor surgery.

Davies, N (2000) Patients’ and carers’ perceptions of factors influencing recovery after cardiac surgery. Journal of Advanced Nursing 2: 318-326

Pre-operative anxiety level not evaluated in the study’s methodology.


Dissertation - Do pre-admission clinics alter the pre-operative course of patients awaiting major...

Documents

Transcript of Dissertation - Do pre-admission clinics alter the pre-operative course of patients awaiting major...