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

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

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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

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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

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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

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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).

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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.

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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.

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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

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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.

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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?

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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

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Reviews and Dissemination (University of York, 2001) guidelines; a summary of their
suggested structure is shown in Appendix 1.

A single researcher undertook the search using the search terms identified in the search
facilities shown in Table 1 (below) The numbers in brackets relate to the number of
‘hits’ from each group of resources and the search facility shown in Table 1. Manual
searches of the referenced articles also widened the scope of literature identified.

ADVANCED NURSING (8361/3212/663/6294/35/6726)
CARDIAC PRE-ADMISSION CLINIC (8021/862/223/24/05/06)
CARDIAC PRE-ASSESSMENT CLINIC (6621/952/213/04/05/06)
CARDIAC SURGERY (9871/3642/423/60094/395/4076)
PRE-ADMISSION (10261/2622/383/2724/45/1426)
PRE-ADMISSION CLINIC (2271/1722/413/404/05/296)
PRE-ADMISSION NURSE (9161/1712/203/24/05/06)
PRE-ASSESSMENT (7231/2652/203/344/15/446)
PRE-ASSESSMENT CLINIC (5831/2112/303/14/05/146)
PRE-ASSESSMENT NURSE (6481/782/203/04/05/16)
PRE-OPERATIVE CARE (9651/662/433/84/15/166)

Table 1 – Search Facilities Utilised
Search Facility utilised Search Engines
Altavista GoTo
AOL.com HotBot
Compuserve LookSmart
Direct Hit Lycos
1. “The Web” grouping of
EuroSeek Mamma.com
Copernic Plus 2001 Excite MSN Web Search
FAST Search Netscape Netcenter
FindWhat Open Directory Project
Google Yahoo
AltaVista UK Lycos UK
Espotting Mirago
Euroseek NBCi
Excite UK Searchengine.com
2. “The Web – UK” grouping Fast Search Snoopa
of Copernic Plus 2001 Find Once UK Directory
Go To United Kingdom UK Plus
Hot Bot UK Search King
Lineone UK Max
Look Smart Yahoo UK
AHealthyMe Mayo Clinic Health Oasis
AMA MedExplorer
Ask Dr. Weil MedicineNet.com
drkoop.com MediConsult.com
3. “Health” grouping of
DrugInfoNet MEDLINEplus
Copernic Plus 2001 HealthAnswers OnHealth
HealthAtoZ The Thrive Health Library
Healthfinder WebMD
InteliHealth YourHealth.com
4. OVID Technologies Inc MEDLINE CINAHL
5. OVID Technologies Inc Cochrane Database DARE
6. OVID Technologies Inc Nursing Full Text Nursing Collection 2

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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.

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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.

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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.

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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

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‘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).

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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

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

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

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