Pre op assessment
- 1. art & science The synthesis of art and science is lived by the nurse in the tiursing act JDSEPHINE G PATERSON If you would like to contribute to the art and science section contact: Gwen Clarke, art and science editor, Nursing Standard, The Heights, 59-65 Lowlands Road, Harrow-on-the-Hill, Middlesex HAl 3AW. email: gwen.clarke@rcnpublishing.co.uk Nurse-led pre-operative assessment for elective surgical patients Beck A (2007) Nurse-led pre-operative assessment for elective surgical patients. Nursing Standard. 21, 51, 35-38. Date of acceptance: April 5 2007. that patients with uncontrolled medical conditions SumniarY may have had their surgery cancelled on the day Effective pre-operative assessment improves patient outcomes by and valuable theatre time would have been wasted. ensuring that individuals are adequately prepared for anaesthesia, Most hospitals developed pre-operative surgery and the post-operative period. I t can also improve hospital assessment services where nurses and SHOs efficiency by reducing patient v/aiting times and enabling early worked collaboratively to ensure that patients discharge. Nurse-led pre-operative assessment for elective surgery is were prepared physically and psychologically for becoming increasingly recognised as a valuable method of ensuring surgery. The nurses pre-admitted the patients and that patients have a safe and v^^ell-planned hospital stay. This article provided information about the hospital stay. examines the role of the pre-operative assessment nurse v/ithin a The doctor's role was to clerk the patients. nurse-led service for elective surgery at a district general hospital. However, because of demands on the doctor's time Author this method resulted in only a small number of the elective patients being seen in pre-operative Amanda Beck is clinical leader pre-operative assessment, Airedale assessment. It tended to focus on only one area of General Hospital, West Yorkshire. Email: amanda.beck@anhst.nhs.uk treatment, for example, major orthopaedic surgery, Keywords while all other patients were admitted on the day. As pre-operative assessment has developed to Assessment; Patient care; Surgery meet the demands of the service, nurses have been These keywords are based on the subject headings from the British able to improve and adapt their skills to undertake Nursing Index. This article has been subject to double-blind review. some of the work previously done by junior For author and research article guidelines visit the Nursing Standard doctors. Nurses can be trained to perform a home page at www.nursing-standard.co.uk. For related articles systematic review of the patient's medical visit our online archive and search using the keywords. history along with other useful skills such as electrocardiogram (ECG) recording and venepuncture, which allows medical staff to attend PRE-OPERATIVE ASSESSMENT has developed to other duties. Pre-operative assessment becomes in response to the need to treat patients even more effective when centralised as a separate undergoing elective surgery with increased department as large numbers of patients can be efficiency. As waiting times for elective surgery prepared by a small team of nurses, which reduces have decreased, new systems of care are required the number of operations cancelled on the day. to ensure that patients are fully prepared and delays or cancellations are minimised. Pre-operative assessment ^ Surgical patients were originally assessed by the senior house officer (SHO) on the day they were Pre-operative assessment of patients is essential admitted for surgery. The assessment usually to obtain relevant clinical information, highlight involved a review of the cardiac and respiratory any potential areas of concern before surgery and system in addition to any other relevant medical manage potential complications. Effective history. The patient's current medication regimen pre-operative assessment can also reduce the would be noted and a physical examination number of cancelled operations and length of stay performed. This system, known as clerking, meant by planning patients' needs before they are WURSING STANDARD august 29 :: vol 21 no 5 1 : : 2007 35
- 2. equal pre-operative assessment. The systematic art & science surgical nursing approach ensures that nurses undertake a review of the patient's medical history and patient information, a medicines review, and a nursing admitted to hospital. The NHS Modernisation and social assessment. Agency (2002) produced a guide to improving The nursing documentation used is also operating theatre performance. It described how prepared in advance so that it guides the nurse the pre-operative assessment of day case patients through the pre-operative assessment process in and inpatients can influence the use of theatre time. the same way each time. This systematic approach Almost 30% of operations that were cancelled on also benefits the rest ofthe multidisciplinary team the day of surgery could have been avoided if (MDT), which is able to access the same type of effective pre-operative assessment had been carried information written in the same place for each out (NHS Modernisation Agency 2002). patient, thus minimising confusion and improving The main objectives of pre-operative reliability. The assessment process can be divided assessment include (Association of Anaesthetists into four stages: of Great Britain and Ireland 2001): • Stage one: medical history. • Identifying potential anaesthetic difficulties • Stage two: nursing assessment. and existing medical conditions. • Stage three: investigations and clinical scores. • Improving safety by assessing and quantifying risk. • Stage four: information giving. • Enabling post-operative care to be planned. Stage one: medical history On arrival at the clinic • Providing the opportunity for explanation patients are given a health questionnaire that is and discussion, thus allaying fear and anxiety. designed to address each system of the body, including the patient's frailty score, height, weight, Bramhall (2002) stated that the principles of body mass index, neck movement and oxygen pre-operative assessment were to identify the saturations on air. This is not a substitute for the patient's needs before surgery, liaise with others pre-operative interview but acts as a source of involved in discharge planning and ensure more additional information and reduces time spent effective use of hospital resources. While pre- asking basic questions (Garcia-Miguelei 13/2003). operative assessment cannot claim to be the While the patient completes the questionnaire the answer to all of the potential problems faced by nurse reads through the patient's notes checking elective surgical patients, systematic planning for any relevant information. and communication of findings will help to Once the questionnaire has been completed improve the patient's experience. the nurse validates the information given and questions further any areas of potential anaesthetic or surgical risk that have been identified. The The pre-o£ejratij^e assessmentjiurse's role questionnaire is filed in the patient's notes and Pre-operative assessment varies greatly between forms part ofthe nursing documentation. This trusts. Bramhall (2002) noted that there was little can then be accessed by all members of the MDT. national uniformity in pre-operative assessment Adequate training is essential to ensure that and its purpose varied considerably between areas. nursing staff are able to elicit enough information For example, some hospitals include junior doctors about the patient's symptoms to allow the in clinics or have separate clinics for certain anaesthetist to begin to quantify risk. Of particular specialties. Others focus on day case surgery importance is the ability to assess a patient's patients or those having major surgery. Each exercise tolerance or functional capacity. Biccard hospital has its own method of pre-operative (2005) noted that stair climbing capacity has assessment based on the needs of its patients and pre-operative prognostic importance and may even the requirements ofthe anaesthetists and surgeons. predict the risk of complications post-operatively. The author works in a district hospital with a A drug history will also be taken at this stage purpose-built pre-operative assessment unit with and documented on the patient's questionnaire. six private examination rooms. Eive nurses are The information serves to inform the nurse ofthe available to assess approximately 120 patients a patient's current health status and enables any week. Nursing staff are supported by a level three alterations to medication regimens to be made healthcare support worker who is qualified to pre-operatively. The hospital has local policies perform venepuncture and ECG recording as written by anaesthetists that allow nurses to advise well as make basic observations. Nursing staff in the patient to stop taking drugs such as aspirin, the unit are trained to take a systematic approach clopidogrel and metformin in the immediate ensuring that all patients receive a similar and pre-operative period. The policies are specific 36 august 29 :: vol 21 no 51:: 2007
- 3. regarding the circumstances in which members value of pre-operative assessment (NICE 2003). ofthe nursing team arc allowed to provide such This may indicate that pre-operative testing should advice. For example, if the patient has a complex not be carried out without clinical indication and medical history the nurse must seek instruction identifies a need for a skilled and comprehensive from the anaesthetist, surgeon or cardiologist form of pre-operative assessment, involving a before altering any medication regimens. The risk medical history and possible physical examination of continuing to take the drug is carefully assessed to guide the selection of tests required. against that of increased intra-operative risks. As a result of the NICE (2003) pre-operative Stage two: nursing assessment Pre operative testing review a traffic light system was assessment provides the ward nurses and developed as a tool, indicating the necessity of anaesthetist with a baseline ofthe patient's normal testing according to the patient's physical status capabilities. This is usually the first contact that and co-morbidity. The three categories are: nursing staff and the anaesthetist will have with • Definitely test-Green. the patient and is an ideal opportunity to observe the individual's normal physical function, for • Consider testing-Yellow. example, as he or she mobilises or gets changed • Test not required-Red. for the ECG. Problems can be identified at this stage and referred to other members ofthe MDT, The tool has several sections according to the so that any occupational therapy aids or social typeof surgery, for example, minor, intermediate services required can be planned for in advance. or major. Each section has different options The identification of patients' needs during depending on the age and specific co-morbidity prc-opcrative assessment means that most of the patient. For example, a patient with individuals can be discharged as soon as they are cardiovascular disease aged 40-60 years would medically well and with the best possible support be identified on a grid and this would also include at home already in place. The NHS Modernisation an ECG and relevant blood tests. The Agency (2004) indicates that 10% of total bed information on the grid allows a colour guide to days could be released if discharge planning is be identified indicating whether a test is required implemented and a more uniform approach is or not for that particular patient. taken towards length of stay and the percentage This tool is available as a poster or a booklet of patients discharged each day. to assist the choices being made rather than Stage three: investigations and clinicai scores replace professional knowledge and judgement. Investigations Each patient undergoes routine Local guidance has been devised reflecting the observations and investigative procedures such as choices of the anaesthetists and surgeons. It is ECG and blood tests according to local guidelines. designed to allow nurses to make supported More invasive clinical investigations such as decisions regarding the discontinuation of echocardiogram, spirometry, chest or cervical medicines and which patients require further spine X-rays are usually ordered after discussion investigation or referral. with the anaesthetist to ensure they are necessary. Diagnostic testing and obtaining test results Evidence suggests that 60-70% of pre-operative often cause delays for patients waiting to access testing is unnecessary if a proper history and the service and could lead to a delay in scheduled physical examination are carried out (Garcia- operations. To prevent this, tests should be Miguel eta/2003). Although pre-operative requested well in advance, with pre-operative assessment is valuable, a thorough clinical assessment taking place at least one month before assessment ensures that tests requested are based the operation date. This allows requests for ECGs on clinical need, thus reducing unnecessary costs and vitalographs to be made on an urgent basis so (Garcia-Miguel eta/2003). that staff in diagnostic services can plan and book The National Institute for Health and Clinical these without having to sacrifice appointments Excellence (NICE) (2003) produced a guideline for reserved for acutely ill patients. By matching the selection of pre-operative tests based on a demand and capacity in this way patient waiting review ofthe available evidence. NICE (2003) also times can be reduced, enabling early discharge as examined the rationale for, and the value of, pre- well as reducing emergency admissions (NHS operative investigations from the perspective ofthe Modernisation Agency 2004). anaesthetist and the surgeon. Benefits of Clinical scores During stage three nursing staff are pre-operative assessment included an awareness also required to score patients using tools such as of conditions that required treatment before the American Society of Anesthetists Grading surgery or necessitated a change in anaesthetic (Haynes and Lawler 1995) and New York Heart management. The evidence reviewed, however, Association Grading (New York Heart suggested that abnormal test results led to only a Association 1964). An airway assessment small proportion of patients requiring altered is carried out to identify which patients may be clinical management, thereby questioning the difficult to intubate. The gradings used allow the WURSIWG STANOARO august 29 :: vol 21 no 51:: 2007 37
- 4. art & science surgical nursing Changing practice Traditionally pre-operative assessment has been within the remit of the j unior house officer. anaesthetist to assess quickly the risk associated However, with appropriate education and with the planned procedure. Any patients found training nurses are equally capable of to have significant risk factors are referred to the undertaking pre-operative patient preparation. anaesthetist immediately after pre-operative Sherrard (2003) found that pre-operative assessment. The anaesthetist provides written assessments performed by nurses trained to instructions for further investigations or referrals master's level were equivalent in quality to those to other specialists such as the cardiologist or GP. performed by house officers, and resulted in Stage four: information giving Once the fewer unnecessary investigations being ordered. assessment is complete the patient is provided A similar equality of service provision with written information detailing the operation. between nurses and medical staff was found The individual is also given the leaflet You and in other studies (Miles and Primrose 2003, Your Anaesthetic (Royal College of Anaesthetists van Klei etal 2004). Nursing staff should be and the Association of Anaesthetists of Great encouraged and supported in the development Britain and Ireland 2003). This leaflet quantifies of assessment skills. This may include access to the risks of anaesthesia and outlines alternative tools such as the Southampton University methods of anaesthesia such as spinal training package (Janke eta/2003) and ideally anaesthesia, enabling the patient to make an further study in advanced assessment skills at informed decision regarding treatment. degree or master's level. It is important that the patient is given the opportunity to ask questions, which should be Conclusion answered clearly taking care to a void medical jargon. The nurse should also ensure that the Pre-operative assessment provides the MDT with patient understands the proposed operation and is valuable clinical information and ensures that ready to proceed (NHS Modernisation Agency patients are prepared physically, socially and 2002). The patient should receive up-to-date emotionally for anaesthesia, surgery and the information about the procedure and hospital stay post-operative recovery period. Careful follow and accurate discharge advice (Bramhall 2002). If up and reporting of test results combined with the patient has a question that only the surgeon or effective communication between all members of anaesthetist can answer, the pre-operative the team produce positive outcomes for patients. assessment nurse should try to contact him or her Nurses should continually seek to develop their on the patient's behalf. Pre-operative assessment skills to ensure that their knowledge and practice can act as a central contact point by putting all is evidence based, demonstrating excellence in members ofthe MDT in touch with each other. pre-operative assessment nursing NS References Association of Anaesthetists of The Lancet. 362, 9397,1749-1757 (2002) National Good Practice Royal College of Anaesthetists Great Britain and Ireland (2001) Guidance an Pre-operative and the Association of Haynes SR, Lawler PG (1995) Pre-operative Assessment The Role Assessment for In-patient Surgery. 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Great Britain and Ireland, London. between the inability to climb two Pre-operative Assessment: Setting The Stationery Office, London. flights of stairs and outcome after Sherrard H (2003) Preoperative a Standard through Learning. major non-cardiac surgery: National Institute for Clinical assessments by trained nurses were University of Southampton, implications for the pre-operative Excellence (2003) Pre-operative equal in quality to assessments by assessment of functional capacity. Southampton. Tests. The use of Routine preregistration house officers. Anaesthesia. 60, 6, 588-593. Miles K, Primrose J (2003) Preoperative Tests for Elective Evidence-based Nursing. 6, 4,122. Bramhall J (2002) The role of Nurses could be trained to provide Surgery. NICE, London. pre-operative assessment of van Klei WA, Hennis PJ, Moen J, nurses in preoperative assessment New York Heart Association Kalkman CJ, Moons KG (2004) Nursing Times. 98, 40, 34-35. equivalent quality to junior doctors. (1964) Diseases ofthe Heart and The accuracy of trained nurses in Evidence-based Heaithcare. 7, 2, Garcia-Miguel FJ, Serrano- Blood Vessels: Nomenclature and pre-operative health assessment: 60-62. Aguilar PG, Lopez-Bastida J Criteria for Diagnosis. Sixth edition. results of the OPEN study. (2003) Preoperative assessment. NHS Modernisation Agency Churchill Livingstone, London. Anaesthesia 59,10, 971-978. 38 august 29 :: vol 21 no 51:: 2007 WURSING STANDARD