Development of an NP-Managed Preoperative Orthopedic Clinic
Development of an NP-Managed Preoperative Orthopedic Clinic
A comprehensive electronic database search was performed to further examine PECs. The Medical Literature Analysis and Retrieval System Online (Medline) with Full Text, Health Source: Nursing Academic, ProQuest Nursing and Allied Health Source, Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, and the Cochrane Database of Systematic Reviews were utilized. Key search terms included: preoperative evaluation; preoperative evaluation clinic; preoperative assessment; and preoperative assessment clinic. Inclusion criteria were research studies with a primary focus on high-quality, consistent, and patient-oriented clinical evidence utilizing the Strength of Recommendation Taxonomy framework. Search-limiting phrases included the English language. Exclusion criteria were selected to ensure that the literature search would provide high-quality evidence that could be interpreted in the English language. Finally, bibliographies from the identified studies provided additional relevant articles for review.
Emanuel and MacPherson conducted a retrospective, cross-sectional, descriptive study to examine the effectiveness of a preadmission assessment clinic (PAC) in determining whether patients were medically cleared for surgery while further analyzing the reasons why surgical procedures were cancelled. Specifically, researchers examined the number of surgical procedures that were cancelled due to anesthetic reasons after being cleared for surgery by the PAC. Over a 4-year period, 12,537 patients attended the PAC, of which 58 (0.46%) were cancelled on the day of surgery due to anesthesia reasons. Anesthesia reasons included: (16) patient or system error (inadequate fasting, medication issues, and abnormal laboratory levels); (7) misadventure (respiratory infection, otherwise unwell, and other causes); (6) clinical deterioration (asthma/respiratory and cardiovascular); (15) clinical disagreement (cardiovascular, asthma, and other); and (5) undetermined. The most common cause of nonpreventable surgical cancellation was acute respiratory tract infections (33%) and the second most common cause was patient or facility error, defined as inadequate fasting, medication-related concerns, and abnormal laboratory results (28%). Clinical disagreement between the attending anesthesia provider and the PAC assessment was also low (21%). Researchers concluded that the number of surgeries cancelled for anesthesia reasons represented a small percentage of surgical cancellations and that PACs are effective at minimizing surgical cancellations.
Another study examined the effectiveness of a PAC on elective surgical cancellation rates. In this retrospective descriptive study, surgical cases were reviewed before and after implementation of a PAC, 1,421 and 1,405 cases, respectively. Cancellation rates for each group were statistically analyzed and revealed a 12.7% increase in the number of elective surgical cases (815 versus 723) after PAC implementation, although this was not statistically significant (P > .05). The PAC did, however, significantly reduce the number of surgical cancellations (114 versus 256, P < .001). Further statistical analyses revealed that cancellation rates for medical reasons decreased after implementation of the PAC (P = .013). Researchers therefore concluded that PACs are effective in reducing the number of surgical cancellations, particularly those due to medical reasons.
Hariharan et al. prospectively examined the utilization of 2 preanesthesia assessment clinics and their impact on surgical cancellation rates in a large university teaching hospital in the West Indies. Over a 12-week period, 424 patients scheduled to undergo elective surgery were enrolled in the study. Data collection included patients' demographics, admitting diagnoses, proposed surgical procedures, and whether or not patients were evaluated in the preanesthesia clinic preoperatively. Researchers found a statistically significant difference in the surgical cancellation rates between those who did and did not attend the preanesthetic clinic (P = .004). Patients were 52% more likely to have their surgery cancelled if they did not attend the clinic; therefore, the widespread utilization of preanesthesia clinics was recommended.
Although the impact of PACs on surgical cancellation rates has been well described in the literature, it is also important to consider the quality of PAC care. A retrospective case analysis of 100 patients was performed within a gynecology preoperative clinic to examine the effectiveness and quality of care provided by an NP utilizing standardized protocols. Researchers concluded that the NPs' documentation was exemplary, serious medical issues were not overlooked, and surgical procedures were not cancelled on the day of surgery for medical-related issues. Integrating an NP into PACs can therefore maintain, if not improve, the quality of preoperative care.
In 2006, researchers examined the impact of an NP-assisted preoperative evaluation (NPAPE) program with more than 1,500 pediatric patients in a prospective, observational, longitudinal study. The researchers reviewed the incidence of respiratory complications and patient preoperative preparation time and found no significant change in either after the NPAPE program implementation. They also found that preoperative clinic nurse and parent satisfaction increased after initiating the NPAPE. Researchers concluded that the NPAPE maintained patient safety, parent and staff satisfaction, and timeliness, and as a result could offer operational advantages without compromising care.
A retrospective analysis of 1,147 hip and knee arthroplasty patients was performed to determine whether a PAC was effective in reducing mortality after complex orthopedic surgery. Researchers found a statistically significant reduction (P = .001) in the number of admissions to the postanesthesia care unit by 12% and a reduction in mortality rates by 4.9%. In addition, there was a statistically significant reduction (P = .01) in unplanned critical care admissions with a reduction in critical care length of stay from 2.3 to 1.9 days, with a yearly cost savings of approximately 50,000 British pounds. The results of this study support the use of PACs before complex orthopedic surgery.
Nicholson et al. conducted a systematic review of nurse-led versus physician-led preoperative assessments for elective surgical candidates requiring regional or general anesthesia. They examined a total of 2,469 patient charts and determined there was insufficient evidence available to conclude that nurse-led preoperative assessments led to an increase or decrease in perioperative complications or in the knowledge or satisfaction among surgical candidates. Researchers suggested that a diagnostic accuracy review could provide more useful information for future research.
An examination of the current literature from 2006 until present highlighted the advantages of PACs, including reductions in surgical cancellation rates and providing quality preoperative care. There were no randomized, controlled trials, or meta-analyses that examined the effectiveness of PACs. In addition, there were no research studies examining PACs within a freestanding orthopedic practice. This clinical practice inquiry project added to the body of knowledge supporting the effectiveness of PACs and NP-led preoperative care in a multidisciplinary orthopedic practice.
Review of the Literature
A comprehensive electronic database search was performed to further examine PECs. The Medical Literature Analysis and Retrieval System Online (Medline) with Full Text, Health Source: Nursing Academic, ProQuest Nursing and Allied Health Source, Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, and the Cochrane Database of Systematic Reviews were utilized. Key search terms included: preoperative evaluation; preoperative evaluation clinic; preoperative assessment; and preoperative assessment clinic. Inclusion criteria were research studies with a primary focus on high-quality, consistent, and patient-oriented clinical evidence utilizing the Strength of Recommendation Taxonomy framework. Search-limiting phrases included the English language. Exclusion criteria were selected to ensure that the literature search would provide high-quality evidence that could be interpreted in the English language. Finally, bibliographies from the identified studies provided additional relevant articles for review.
Emanuel and MacPherson conducted a retrospective, cross-sectional, descriptive study to examine the effectiveness of a preadmission assessment clinic (PAC) in determining whether patients were medically cleared for surgery while further analyzing the reasons why surgical procedures were cancelled. Specifically, researchers examined the number of surgical procedures that were cancelled due to anesthetic reasons after being cleared for surgery by the PAC. Over a 4-year period, 12,537 patients attended the PAC, of which 58 (0.46%) were cancelled on the day of surgery due to anesthesia reasons. Anesthesia reasons included: (16) patient or system error (inadequate fasting, medication issues, and abnormal laboratory levels); (7) misadventure (respiratory infection, otherwise unwell, and other causes); (6) clinical deterioration (asthma/respiratory and cardiovascular); (15) clinical disagreement (cardiovascular, asthma, and other); and (5) undetermined. The most common cause of nonpreventable surgical cancellation was acute respiratory tract infections (33%) and the second most common cause was patient or facility error, defined as inadequate fasting, medication-related concerns, and abnormal laboratory results (28%). Clinical disagreement between the attending anesthesia provider and the PAC assessment was also low (21%). Researchers concluded that the number of surgeries cancelled for anesthesia reasons represented a small percentage of surgical cancellations and that PACs are effective at minimizing surgical cancellations.
Another study examined the effectiveness of a PAC on elective surgical cancellation rates. In this retrospective descriptive study, surgical cases were reviewed before and after implementation of a PAC, 1,421 and 1,405 cases, respectively. Cancellation rates for each group were statistically analyzed and revealed a 12.7% increase in the number of elective surgical cases (815 versus 723) after PAC implementation, although this was not statistically significant (P > .05). The PAC did, however, significantly reduce the number of surgical cancellations (114 versus 256, P < .001). Further statistical analyses revealed that cancellation rates for medical reasons decreased after implementation of the PAC (P = .013). Researchers therefore concluded that PACs are effective in reducing the number of surgical cancellations, particularly those due to medical reasons.
Hariharan et al. prospectively examined the utilization of 2 preanesthesia assessment clinics and their impact on surgical cancellation rates in a large university teaching hospital in the West Indies. Over a 12-week period, 424 patients scheduled to undergo elective surgery were enrolled in the study. Data collection included patients' demographics, admitting diagnoses, proposed surgical procedures, and whether or not patients were evaluated in the preanesthesia clinic preoperatively. Researchers found a statistically significant difference in the surgical cancellation rates between those who did and did not attend the preanesthetic clinic (P = .004). Patients were 52% more likely to have their surgery cancelled if they did not attend the clinic; therefore, the widespread utilization of preanesthesia clinics was recommended.
Although the impact of PACs on surgical cancellation rates has been well described in the literature, it is also important to consider the quality of PAC care. A retrospective case analysis of 100 patients was performed within a gynecology preoperative clinic to examine the effectiveness and quality of care provided by an NP utilizing standardized protocols. Researchers concluded that the NPs' documentation was exemplary, serious medical issues were not overlooked, and surgical procedures were not cancelled on the day of surgery for medical-related issues. Integrating an NP into PACs can therefore maintain, if not improve, the quality of preoperative care.
In 2006, researchers examined the impact of an NP-assisted preoperative evaluation (NPAPE) program with more than 1,500 pediatric patients in a prospective, observational, longitudinal study. The researchers reviewed the incidence of respiratory complications and patient preoperative preparation time and found no significant change in either after the NPAPE program implementation. They also found that preoperative clinic nurse and parent satisfaction increased after initiating the NPAPE. Researchers concluded that the NPAPE maintained patient safety, parent and staff satisfaction, and timeliness, and as a result could offer operational advantages without compromising care.
A retrospective analysis of 1,147 hip and knee arthroplasty patients was performed to determine whether a PAC was effective in reducing mortality after complex orthopedic surgery. Researchers found a statistically significant reduction (P = .001) in the number of admissions to the postanesthesia care unit by 12% and a reduction in mortality rates by 4.9%. In addition, there was a statistically significant reduction (P = .01) in unplanned critical care admissions with a reduction in critical care length of stay from 2.3 to 1.9 days, with a yearly cost savings of approximately 50,000 British pounds. The results of this study support the use of PACs before complex orthopedic surgery.
Nicholson et al. conducted a systematic review of nurse-led versus physician-led preoperative assessments for elective surgical candidates requiring regional or general anesthesia. They examined a total of 2,469 patient charts and determined there was insufficient evidence available to conclude that nurse-led preoperative assessments led to an increase or decrease in perioperative complications or in the knowledge or satisfaction among surgical candidates. Researchers suggested that a diagnostic accuracy review could provide more useful information for future research.
An examination of the current literature from 2006 until present highlighted the advantages of PACs, including reductions in surgical cancellation rates and providing quality preoperative care. There were no randomized, controlled trials, or meta-analyses that examined the effectiveness of PACs. In addition, there were no research studies examining PACs within a freestanding orthopedic practice. This clinical practice inquiry project added to the body of knowledge supporting the effectiveness of PACs and NP-led preoperative care in a multidisciplinary orthopedic practice.