Nurses can enhance the pre-operative assessment process: nurse-led pre-assessment clinics can offer a more holistic approach to pre-operative preparation. Patients involved in a trial at Whakatane Hospital expressed satisfaction with the model.

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Pre-operative screening of patients is esential to ensure their safety. It is also an important toot in minimising late cancellations and disruptions to operating lists. Assessing patients in advance presents a valuable opportunity to provide information, educate and investigate the patient. This has been shown to have a positive impact on improving the quality of the service and the patient's experience with the health system. (1)

Nurse-Led pre-assessment (NLPA) involves taking a comprehensive medical history, a nursing assessment, physical examination, airway assessment, ordering appropriate investigations and carefully documenting the process and results. More valuably, it provides an opportunity for the patient to participate in planning their care. NLPA has been described as an essential feature of modern day surgery, contributing significantly to greater patient safety during anaesthesia/surgery. (2) Patient perceptions of NLPA have been explored in various studies and results indicate satisfaction. (3) The trend internationally has escalated, though few NLPA clinics are operating in New Zealand.

Pre-operative assessment has been defined as: "establishing that the patient is fully informed and wishes to undergo the procedure. It ensures that the patient is as fit as possible for the surgery and anaesthesia. It minimises the risk of Late cancellations by ensuring that all essential resources and discharge requirements are identified." (4)

In 2004, Whakatane Hospital's anaesthesiology, theatre, clinical operations, outpatients, pre-assessment/day stay unit (DSU) and administration departments began looking at the pre-assessment service. There was a desire to short circuit delays and congestion in existing pre-assessment clinics, streamline the pre-assessment process and reduce the number of patient visits to hospital. Reducing cancellations of surgery (often on the day of surgery) and "did not appear" (DNA) numbers were also objectives.

A small pilot involving an eight-day trial was completed. However, this was not successful due to reduced patient numbers, staff shortages and geographical/environmental reasons.

Last year, staff involved in the consultation determined that pre-assessment would best be delivered in outpatients as an NLPA clinic. The Ministry of Health agreed to fund the initiative over six months, beginning in August 2005.

The objectives of the clinic were to:

* decrease waiting times between appointments;

* reduce the number of visits to hospital for patients;

* reduce costs by using nurses instead of house officers;

* decrease call time on anaesthetist/specialist;

* early identification and intervention of preoperative problems, which may prevent surgery and therefore minimise cancellations;

* create a link from pre-operative assessment to post-operative service;

* reduce DNA rates on day of surgery; and

* decrease surgery cancellations, thus increasing theatre utilisation.

Primarily, NLPA was implemented to pre-assess a patient defined within ASA1 and ASA11 criteria (see figure 1). This would reduce the traditional three-tier system of nurse, house officer or anaesthetist, to a two-tier system of nurse or anaesthetist clinic. This resulted in widening the boundaries for both clinics.

Figure 1: The American Society of Anaesthesiologists classification
of patients

ASA 1: There is no organic, physiological, biochemical or
psychiatric disturbance. The pathological process for which the
operation is to be performed is localised and not conductive to
systemic disturbance These patients are usually assessed by nurses.

ASA 11: Mild to moderate systemic disturbance caused either by the
condition to be treated surgically or by other pathophysiologic
processes These patients traditionally are seen in house officer
clinics.

ASA 111: Severe systemic disturbance. These patients are usually
seen in anaesthetist clinics.

Following the clinic's implementation, it quickly became apparent that, to accurately categorise patients for the appropriate clinic, all patients facing surgery should attend pre-assessment. Before entering the clinic room, patients were asked to complete two forms--the patient details and health questionnaire forms. Following introductions, the patient was invited to the clinic room where the nurse did a number of assessments. These included calculating body mass index; taking blood pressure, pulse, blood oxygen saturation and blood sugar levels prn; chest auscultation and heart sounds; clarification of and understanding of the surgery; discussion and clarification of completed health questionnaire; taking a comprehensive medical history; assessing airway; discussing pre-operative and post-operative analgesia, safe discharge and possible follow-on anaesthetist appointment; ordering/completing investigations, eg bloods and electocardiograms; and using the opportunity as appropriate for information and health education and general wellbeing.

Over the six-month trial, 373 patients attended NLPA; 178 patients required anaesthetist review before surgery, and 198 could proceed directly to surgery following NLPA.

Patients requiring major joint and ear, nose and throat (ENT) surgery were excluded from the service. The majority of ENT patients have their surgery at Tauranga Hospital, with only ENT day surgery performed at Whakatane Hospital. The six-month contract defined patients as those who had their surgery at Whakatane Hospital. Statistical data requested over two distinct time tines (the six-months prior to NLPA and the six-months during NLPA) was presented in a comparative form. However, this was inaccurate due to a number of inconsistencies. Patients who attended within the timeframes had not yet been entered on the system, and, in some instances, specific data was not recorded. Prior to October 2005, there was no data entry for those patients who attended anaesthetist clinic. Over the four months data was collected for the anaesthetist clinic, 380 patients attended. Forty-two of these patients DNA, an 11 percent DNA rate. In the six-month trial, 114 of these patients were seen in NLPA clinics. Of these, two patients DNA their follow-on anaesthetist review, representing 1.7 percent. A further reduction was demonstrated with surgery DNA rates, which decreased by 17.5 percent after the advent of the NLPA clinic.

Through NLPA, pre-operative problems were identified early, resulting in early and effective intervention. Early intervention allowed patients to be referred back to their GP with the intention of optimising their health so their surgery would not be delayed. It has been noted that patients often volunteer more details of their medical history and lifestyle to nurses than to clinicians. (2) This was often confirmed during the trial and NLPA was able to identify the need for intervention, eg a day-stay admission requiring a change to overnight admission or a patient requiring admission the day before surgery because it was more appropriate to that patient's needs, safety and recovery. The importance of patient suitability for day surgery and the importance of social and psychologicaL concerns, as welt as physical aspects, have been identified. (1)

Those patients who were anaesthetic category ASA 1/ASA 11 had their hospital visits reduced. They attended NLPA directly following consent for surgery and, if assessed fit for surgery, were able to proceed straight to admission on a date agreeable to the patient and the surgeon. An added benefit was the formation of a "pool of well people." These patients were identified in NLPA as fit for surgery/anaesthesia and available for short notice admission. This could be seen as a contributing factor to increased theatre utilisation over the six months compared to the previous six months.

Reduction in hospital visits could also be achieved if ASA111 patients were included, provided the pre-assessor had access to an on-call anaesthetist when it was necessary to have the patient assessed thoroughly in one visit. This would be appropriate for patients who face lengthy travelling times to the hospital, whose surgery was within 14 days and who had work commitments. The flow-on effect of this would be a decrease in waiting times, with no further appointment or assessment needed prior to surgery, and increased patient satisfaction.

During this trial an anonymous postal survey was posted to all 128 patients who attended an NLPA clinic during a given time period. Seventy patients (54 percent) responded and those results were collated. The feedback was very positive. Patients identified their satisfaction with the reduction in visits, a comfortable and friendly environment, information and education received on the pre-operative and postoperative experience, and safe discharge. They also valued advice on analgesia and specific health concerns.

Little evidence could be sourced on cost analysis of NLPA clinics internationally. Over the six months the pilot operated, it continued to develop. Problems with data retrieval were experienced, including inaccurate data entry and nil entry of specific data needed to make comparisons. If the clinic is to continue after the pilot, a standard audit toot will have to be developed.

Recommendations following the six-month trial included:

* implementation of NLPA clinics as effective components of pre-operative services within clinical management;

* follow-up phone calls to clarify/confirm health status before booking wait-listed patients;

* NLPA to follow up investigations and referrals, to ensure patient remains in pre-assessment team;

* NLPA to continue to liaise actively with anaesthetic department;

* NLPA to take responsibility for communication with the patient throughout their pre-assessment journey; and

* compilation and implementation of an appropriate audit toot.

Pre-operative management has been identified in many reports as a key focus in improving patient outcomes following surgery. In this trial, it was repeatedly evident that when a patient is informed, prepared and able to participate and organise themselves for their journey through the health system, the outcome and follow-on effects are far more positive for both the patient and the hospital.

NLPA has been shown to be the foundation for forming a rapport with the patient. It enables the patient to reveal their health history, participate in their care and helps them achieve a quality experience in the health system, white pre-operatively assessing them for surgery and anaesthesia. (5)

In February this year, the Ministry of Health evaluated the pilot as successful, noting it showed a positive effect on elective services. It hoped the organisation would fund a continued service. Unfortunately, this has not yet happened, though there has been some recent renewed interest in the clinics. However, plans have been disrupted by restructuring at the hospital, with governance matters now handled regionally. There is also some interest in starting NLPA clinics there.

References

(1) Gilmartin, J. (2004) Day surgery: patient's perceptions of a nurse-led preadmission clinic. Journal of Clinical Nursing; 13, 243-250.

(2) Thompson, P.J., Fletcher, I.R. & Downie, C. (2004) Nurses versus clinicians--who's best at pre-operative assessment? Journal of Ambulatory Surgery; 11, 33-36.

(3) Clinch, C.A. (1997) Nurses achieve quality with pre-assessment clinics. Journal of Clinical Nursing; 6, 147-151.

(4) NHS Modernisation Agency. (2005) Definition of pre-operative assessment. National Good Practice Guidance on Pre-operative Assessment for Inpatient Surgery; 2-31. www.modern.nhs.uk/theatreprogramme/preop. Retrieved 20/10/05.

(5) Travelbee, J. (1966) Interpersonal Aspects of Nursing. 2nd Ed. Phildelphia: F.A. Davis.

This article was reviewed by Kai Tiaki Nursing New Zealand's editorial review committee in May 2006.

Mereana Hunt, BN, Postgrad Cert, works the outpatients department of Whakatane Hospital.