Learning Outcome 1 – Pre-assessment
The ultimate goal of the pre-assessment is to assure that those patients identified as suitable for day surgery are properly identified while those considered unsuitable for a selected procedure are identified early enough in the process to allow for other treatment options (National Health Services, n.d.a, p. 13). Although ultimately it is a joint decision between the surgeon and anaesthetist who make the final determination (National Health Services, n.d.b), the nurse plays a vital role in the process and should be involved in the selection criteria (Royal College of Nursing 2004, p. 1). Pre-assessments of patients scheduled for day surgery are usually performed by an outreach nurse from a day surgery centre, by telephone screening, or by questionnaire (National Health Services, n.d.a, p. 9) or via appointments with day surgery staff or in specialized pre-admission clinics (Joanna Briggs Institute 2004, p.2).
Many institutions are combining pre-assessment interviews with the opportunity to work with the patient in a preoperative education status in order to decrease patient anxiety, assess the needs of the patient and/or family members and to personalise information (Joanna Briggs Institute 2004, p.2). The National Health Services (n.d.a, p. 11) states this is an effective opportunity to also discuss the surgical procedure in greater detail with the patient, note special requirements for admission, surgery and/or discharge and allow the patient to choose their own date for surgery, finalizing and/or setting the appointment.
According to the Royal College of Nurses (2004, p. 3), nurses performing the pre-assessments must have the option of being able to contact the anaesthesiologist of surgeon if a problem is identified that could potentially increase the risk during anaesthetic or surgical intervention.” This is critical; otherwise, there is no apparent reason for the assessment if the nurse cannot raise her concerns.
The National Health Services (n.d.a, p. 9) day surgery guidelines state pre-assessments performed as soon as possible following the surgical consultation can allow for treatment of underlying physical issues that might preclude them from the day surgery procedure, such as high blood pressure and/or arrange for home care. If this is not possible, the National Health Services (n.d.a., p. 13) recommends that patients should then complete a “health-screening questionnaire before leaving the outpatient department.”
According to the National Health Services (n.d.a., p. 11), incorporating the pre-assessment step in the day surgery process has been shown to reduce surgical cancellations and increase communication across the multidisciplinary team.
Based on research, it is important to note that the day surgery pre-assessment is a valuable tool that can help the patient, the perioperative and surgical nursing teams as well as surgeons and anaesthesiologists. The pre-assessment is a way of initiating a comprehensive set of documentation for the entire team.
Learning Outcome 2 – Effective communication
According to the Joanna Briggs Institute (2004, p. 4), caseload can determine the staffing mix required. The staffing mix for a day surgery centre, however, can vary from a group of individuals who work together on a regular basis such as the case in a specialized clinic setting to a group of individuals who rely on departmental shift staffing for perioperative nurses and surgical residents in a busy teaching hospital. No matter what the group mix is, however, the need for communication is critical to patient care in all settings, especially surgical, where according to Cowen et al. (2005) communication is especially challenging for workers in environments that are high stress and time sensitive. Vazirani et al. (2003, p. 72) states that improving the level of collaboration, not just communication, can enhance job satisfaction among medical professionals while increasing the quality of care and patient satisfaction.
While traditional communication techniques such as “active listening, positive voice tone, [and] reiteration to confirm understanding” are desirable goals, in the surgical setting other barriers often compound communication problems, including status and posturing between doctors versus the communication found between doctors and nurses or nurses and nurse practitioners. Vazirani et al. (2003, p. 72) discuss the care nurse practitioners took “not to violate the autonomy of residents or interns… [and] did not admit patients on their own or write orders without the consent of a resident or an intern.”
Essential to a multidisciplinary team is the need for collaboration, where decision-making is a shared event for doctors and nurses and that open communication between the two professionals exists (Vazirani et al. 2003, p. 73). It is important to note that research demonstrates physicians view collaboration differently than nurses, such that physicians believe collaboration implies “cooperation with follow-through” pertaining to following orders rather than sharing in the decision making process (Vazirani et al. 2003, p. 75). Vazirani et al. (2003, p. 76) also cited nurses as not being provided timely or accurate information regarding patient information when physicians autonomously make a change in their normal protocol, stating nurses need the information most as they are the ones at the patient’s bedside.
Communication is a commonly sited problem and is one that, despite all the best suggestions and recommendations, from outlining roles and responsibilities, collaborating as a team or mutual team members each afforded appropriate professional respect (Vazirani et al. 2003) to developing Integrated Care Pathways (ICPs) as outlined by Fisher and McMillan (2004) is difficult to remedy. Ultimately, human emotions and professional pride create unnecessary friction that discourages open communication for fear of reprisal. Cowen et al. (2005) emphasize the need for an accurate flow of information between various disciplines as the most critical aspect in order to assure patient safety.
Learning Outcome 3 – Patient selection criteria
Patient selection criteria primarily focus on three primary factors: surgical, medical and social (National Health Services, n.d.a, p.11; National Health Services, n.d.b.). Surgical criteria assess whether the procedure will leave the patient dependent on others and/or if it has a statistically significant postoperative morbidity level. The National Health Service (n.d.b.) states that the surgical procedure should take less than 1 hour, involve minimal blood loss, be unlikely to produce severe post surgical pain or nausea and be unlikely to result in a loss of physical independence.
When assessing social appropriateness, according to the Association of Anaesthetists of Great Britain and Ireland (cited by Joanna Briggs Institute 2004, p. 2), the pre-screening interview is an opportunity to assess the patient’s willingness to have surgery, the certainty of adult care in the home following surgery, telephone access and taking into consideration the patient’s home situation. For example, are there several young children and toddlers or infants at home requiring constant care; is the only adult available to help the patient an elderly or frail individual, or has the patient stated they feel they are being pressured into having the surgery. These are all reasons that should be presented to the surgeon, anaesthesiologist and the rest of the multidisciplinary team as reasons the patient should be precluded from day surgery. Additionally, patients with a social history of significant levels of alcohol consumption and/or who smoke are indications of potential preclusion or the need for additional counselling prior to surgery (National Health Service n.d.b.). The Royal of College of Nurses (2004) also states that the patient must have the availability of an escort home following surgery and that the travel time home must be within one and a half hours; and if small children are present in the home that a caregiver is available specifically to tend to the children.
Medically, it is important to assess cardiac fitness, assurance of height/weight appropriateness and if they are “physiologically under 70 years of age.” Exclusions are usually automatic if there is uncontrolled hypertension, recent history of cardiac failure, pregnancy, angina, asthma, diabetes or epilepsy. Additional issues that require notification of the appropriate medical personnel include prior difficulties with anaesthesia or current medications that would either preclude day surgery or require either a modification and/or temporary cessation of the pharmaceutical agent, particularly warfarin.
The American Society of Anaesthesiologists’ (ASA) (cited by The Royal College of Nursing 2004) uses three classifications to assess physical status:
Class 1: patient is mentally and physically fit and the surgical procedure is localized without systemic disruption, for example, removal of a uterine fibroid in an otherwise healthy female or the repair of an inguinal hernia in a healthy individual.
Class 2: patient suffers from mild to moderate systemic pathology that is either caused by the pathology to be treated by the day surgery or by other pathology, for example anaemia or mild diabetes or slightly limiting organic heart disease.
Class 3: patient suffers from a severe mental or physical disorder from whatever cause, such as angina pectoris, moderate to severe levels of pulmonary insufficiency, vascular complications from severe diabetes or significantly limiting heart disease.
Criteria used for patient evaluation and assurance of fitness for day surgery as outlined above are focused primarily on the suitability for general anaesthesia without complication. It is essential however, to couple both the individual patient status as provided by the pre-assessment with the type of surgical intervention proposed. The medical professional cannot use the same set of pre-assessment criteria for all patients for all procedures; they must simply be a guide. For example, physiological trauma, anaesthetic requirements and post-operative pain are different for those having arthroscopy as opposed to a laparoscopic cholecystectomy or partial thyroidectomy. All three are considered day surgical procedures by the Royal College of Nurses (2004, p. 2).
Patient selection criteria are important for nurses to understand from many aspects. The nurse has to understand the physician’s reason for suggesting day surgery for their patient, she needs to understand the surgeon’s belief in appropriateness and she has to understand the potential risks that are often overlooked by physicians and surgeons that now become her responsibility to ascertain. Although it is often a delicate position for the nurse to be in, it is essential that she bring to the surgeon or anaesthesiologist’s attention any patient not appropriate for day surgery. This is an issue of legal liability for all professions on the multidisciplinary team and for the clinic or hospital as well as one of ethical concerns for the patient’s overall care and wellbeing.
Learning Outcome 4 – Pain management
According to Lipp and Yap (2005, p. 64) prior to 2003, the responsibility for post-surgical pain was the sole responsibility of the anaesthesiologist and no routine or regular pain assessments were conducted. In 2003, pain management assessments and the nursing role in pain management in the day surgery setting became the standard. The Royal College of Anaesthetists (as cited by Lipp & Yap 2005, p. 64) tell us that following a day surgical procedure, less than five percent of all patients should experience severe pain while up to 85 percent will have mild or no pain following surgery. Beauregard et al. (1998, p. 309) believes that it is not unusual for pain to persist during the entire week following surgery, but that the best predictor of significant post-surgical pain following hospital discharge was inadequate pain control during the first few hours of following surgery. Research has acknowledged that the longer an individual is experiencing pain that is not attended to or interrupted in some way, the more sensitive to painful stimuli the patient becomes (Mukherji & Rudra 2006, p. 355). Ultimately, the goal of effective post-surgical pain management is to be “safe and effective, produce minimal side effects such as nausea.
It was stated that the criteria for patient selection should be individualized based on patient status and type of surgery. Similarly, Mukherji and Rudra (2006, p. 355) state that patients should be identified as potentially at risk based on “age, physical status, presence of pre-existing pain, site and extent of surgery.” Additionally, researchers believe that the amount of postoperative pain a patient experiences is also a factor of the surgeon and surgical techniques used ( Mukherji & Rudra 2006, p. 356; Chung et al. cited by Beauregard et al. 1998, p. 305). Mukherji and Rudra (2006, p. 355) discuss several pain assessment tools: the visual analogue scale (VAS) where pain is rated along a continuum from “no pain at all to the worst pain imaginable” and the Oucher’s scale for children. Many patients themselves downplay post-surgical pain for reasons ranging from believing that pain is part of the natural recovery process and what they are experiencing is normal (Beauregard et al. 1998, p. 209).
Post-operative pain management can take different forms, including pre-emptive analgesia and prophylactic analgesia (Mukherji & Rudra 2006, p. 356). There are also pharmacologic and non-pharmacologic pain management interventions. Pharmacological interventions can be opioid or non-opioids. Opioids are centrally acting and systemic in nature whereas non-opioids are also centrally acting but have a peripheral mode of action, and include codeine, metamizol, paracetamol and non-steroidal anti-inflammatory (NSAIDS) (Mukherji & Rudra 2006, p. 356).
Another problem cited by the Joanna Briggs Institute (2004) is that of inadequate pain management techniques and/or follow-through by the patient place additional burdens on family caretakers and the community at large. For example, Girgis and Sanders (2004, p. 66) tell us that parents generally underestimate and under treat pain; this can be extrapolated to caregivers in the adult community as well. Home caregivers failing to recognize and/or intervene in pain management is often problematic and it is the responsibility of the nurse to assure that proper discharge information is adequately communicated to the patient and/or caregiver/escort, including proper pain management techniques and interventions. To assure there is no confusion, these should be clearly documented and reviewed with the patient and caregiver verbally.
Beauregard, L., Pomp, A. & Choiniere, M., 1998. Severity and impact of pain after day surgery. Canadian Journal of Anesthesia, 45 (4), pp. 304-311.
Fisher, A. & McMillan, R., 2004. Integrated care pathways for day surgery patients. British Association of Day Surgery [Online]. Available from: http://www.bads.co.uk/pdf%20files/IntegratedCarePathways.pdf [cited March 17, 2007].
Girgis, M. & Sanders, D. 2004. Are we giving our children the right dose? The Journal of One-Day Surgery, 14 (3), pp. 65-68.
Joanna Briggs Institute, 2004. Management of the day surgery patient [Online]. Joanna Briggs Institute Best Practices. Available from: http://www.adsna.info/attachments/BPISSup.2004.pdf [cited March 17, 2007].
Lipp, A. & Yap, H, 2005. Is our pain relief protocol effective? The Journal of One-Day Surgery, 15 (3), pp. 64-66.
Mukherji, S. & Rudra, A., 2006. Postoperative pain relief for ambulatory surgery. Indian Journal of Anaesthesia, 50 (5), pp. 355-362.
National Health Services, n.d.a. Day surgery pre-assessment: A brief guide [Online]. Available from www.wise.nhs.uk/surgery/NationalGoodPractice/downloads/14/14d4.doc [cited March 17, 2007].
National Health Services, n.d.b. Day surgery: A good practice guide [Online]. Available from: http://www.wise.nhs.uk/sites/crosscutting/access/Access%20Document%20Library/1/Day%20Surgery/Day%20Surgery%20Guide.pdf [cited March 17, 2007]
Royal College of Nursing, 2004. Day surgery information: Selection criteria and suitable procedures [Online]. Available from: http://rcn.org.uk/publications/pdf/daysurgery_selection.pdf [cited March 17, 2007].
Society of Critical Care Medicine, 2005. Tools for effective communication [Online]. Society of Critical Care Medicine. Available from: http://www.sccm.org/SCCM/Publications/Critical+Communications/Archive/February+2005/communicationsfeb05.htm [cited March 17, 2007].
Vazirani, S., Hays, R. D., Shapiro, M. F. & Cowan, M., 2005. Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. American Journal of Critical Care, 14 (1), pp. 71 – 77.