Chapter 1 The evolving role of the preoperative assessment team
This chapter will describe:
• the development of preoperative assessment in the UK
• the development of the preoperative assessment nurse role and benefits of nurse-led POA
• the role of the nurse in preoperative assessment
• the future role of preoperative assessment
• collaboration between POA nurses, anaesthetists and allied healthcare professionals.
This chapter discusses the development of the preoperative assessment team (POA) by reviewing published and unpublished sources and also integrates personal experiences. It discusses studies that compare the work of dedicated preoperative assessment teams, including nurses and doctors, and the importance of a collaborative role with allied healthcare professionals.
The development of preoperative assessment and the role of the nurse
Preoperative assessment in the UK has traditionally been carried out by medical staff. In 1972, nursing staff were identified as having some involvement in POA on a general surgical ward in Cardiff; however, nurses were simply acknowledged as part of the process.1 As the specialty of POA has evolved, the role of the nurse has been enhanced and developed.
This has been reflected in the last 15 years as many health organisations and government departments have produced policies, protocols and guidance advising on how POA services and roles should be developed (see Box 1.1). Since the 1990s, many studies and articles have been published concerning the POA specialty; the majority have the nurse in a pivotal role in the POA process. Some authors describe the nurse’s role as that of a coordinator, liaising between the patient/carers and other healthcare professionals to ensure the patient’s surgical journey is smooth. This is consistent with the developing role of the POA nurse.2,3,4,5
|Box 1.1 Policies, protocols and guidance affecting the POA nurse’s role|
|1991||New Deal for Junior Doctors (Calman-Hine Report) – NHS Management Executive. London: HMSO|
|1992||Scope of Professional Practice – UKCC, London|
|1997||The New NHS: Modern and Dependable – Department of Health. London: HMSO|
|1999||Making a Difference. Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare – Department of Health. London: HMSO|
|2000||NHS Plan – Department of Health. London: HMSO|
|2001||Preoperative assessment: The role of the anaesthetist – Association of Anaesthetists of Great Britain and Ireland|
|2002||Improving Orthopaedic Services: A guide for clinicians, managers and commissioners. NHS Modernisation Agency|
|2002||Functioning as a Team? – The National Confidential Enquiry into Perioperative Deaths|
|2002||National good practice guidance for day surgery – NHS Modernisation Agency|
|2003||National good practice guidance on preoperative assessment for inpatient surgery – NHS Modernisation Agency|
|2003||European Working Time Directive – Council of the European Union (2003/88/EC).|
|2005||Nurse Practitioners: an RCN guide to the nurse practitioner role, competencies and accreditation – RCN|
In the mid-1990s, the registered nurse in POA is described as a coordinator, performing general observations such as blood pressure recordings and urinalysis, giving information to the patient about their forthcoming admission, treatment and further information about any special requirements whilst the senior house officer performs the clerking of the patient and orders tests.6 In Liverpool, Australia, authors describe nurses in the POA and Same Day Admission Unit reviewing patients who do not need medical input, although the role of the nurse was not further specified.7 By 2000, the nurse’s role is described as multifunctional, addressing many factors affecting the patient’s admission to hospital, making appropriate arrangements and referrals to ensure the patient journey is smooth both in and out of hospital.4
The 2002 National Confidential Enquiry into Perioperative Deaths (NCEPOD)8, highlighted the fact that the surgeon was no longer the only consultant involved or responsible for the individual patient’s care, implying a shared care responsibility, which had eroded the continuity previously in place in the UK NHS. An example of fragmented and substandard multi-disciplinary care was reported in 2005 that had resulted in an untimely death. This led to recommendations that the lead clinician role should be revitalised to minimise oversights generated by a growing number of teams and to improve continuity in care.9 Historically, at the author’s hospital, the POA nurse role incorporated the task of monitoring and promoting the ongoing treatment of a caseload of patients deemed unfit for surgery, through case management. This activity ensures that a healthcare professional with medical knowledge and experience oversees the care of an unfit patient who still requires surgery by promoting communication between teams of allied health professionals (AHPs) in primary and secondary care, surgeons, anaesthetists and physicians, to achieve the goal of safe admission. Previously a surgical secretary with limited medical knowledge and limited access to medical advice undertook this aspect of care. However it is clearly more suitable for this practice to be integrated into the national role of the POA nurse.
Gradually, additional clinical focus was attached to the POA nurse role and the valuable input of health promotion was incorporated3,6,10,11 as advised in the core principles of the NHS Plan in 2000. A 1997 paper12 described the results of a study in which 30 surgical patients were advised by POA nurses to stop smoking preoperatively using the method routinely practised and a further 30 were given additional health promotion input. Patients described the approach used by the POA nurse and the leaflet devised for the study as most helpful. This additional input improved the rate of reducing and stopping smoking from 50% of the routine group to 80% of the treatment group. The collaborative role of health promotion in the POA clinic has also been examined in Liverpool, Australia,13 in a study in a POA clinic in which 124 patients were randomly assigned to an experimental group and 86 patients to the routine care pathway in an attempt to improve the standard of smoking cessation information given to patients. A multifaceted intervention was developed which included the use of opinion leaders, consensus processes, computer-delivered cessation care, computer-generated prompts for care provision by clinic staff, staff training and performance feedback. POA nurses were more efficient than the anaesthetists in both groups and it was considered that this was for two reasons. Firstly, the anaesthetists did not receive any performance feedback. Secondly, the anaesthetists may have felt they were offering redundant advice that had been previously given in the POA clinic.
A natural addition to the role of the POA nurse is to act as a central point of contact for the patient, as a named nurse, and as a link between primary and secondary care for patients.3,10 Qualified nurses remain the central figure for the patient in need, are often said to be valuable to patients, are expected to know about individual plans of care, meet needs and be an advocate even though much direct care is being performed by unqualified members of staff.14 It has been reported that patients feel more at ease with a POA nurse than with a doctor, are more relaxed about answering medical questions and feel more able to ask medical questions, although no evidence supporting these assumptions is discussed in the paper.15
As discussed previously, the POA nurse role has been promoted in many NHS policies. Increasing commercial pressure in the NHS has led to the role of the POA nurse expanding to include taking on more clinical interventions and case management. At the author’s hospital the POA nurse has a generalist role, preoperatively assessing in a nurse-led unit for multiple surgical specialties with the support of an Integrated Care Pathway (ICP) and local guidelines and protocols. In other areas of the world, the role of the POA nurse is dedicated to a single surgical specialism, dictated by the size of the local population, hospital or Trust or popularity of the specialism. Box 1.2 shows examples of the variety of POA specialisms although it must be noted that the list of specialties is not exhaustive.
An example of a POA nurse working away from the POA clinic is described at the Good Hope Hospital, Birmingham, where a POA service for emergency surgical patients ensures rapid access to surgery.16 The nurse is able to coordinate the surgical care process from AandE, to the ward then into theatre. The role supports the anaesthetic, surgical and nursing teams by assisting in the prioritisation and optimisation of the patient’s condition and by initiating investigations and prompting further treatment. The development of the POA nurse role in this manner proves that the knowledge and skills are highly adaptable and effective.
Nurse-led POA has been discussed since the 1990s but the lack of POA nurse education programmes leads one to assume that training must be undertaken ‘in-house’.17 A 1996 article written by a POA nurse highlighted the lack of structured training programmes when she described being trained ‘in-house’ for her new POA role18 and others too have discussed ‘in-house’ training programmes16,19 developed to allow a study of the appropriateness of nurse-led preoperative assessment. The development of a competency framework has been recommended, incorporating a range of strategies to evaluate the skills and performance of the POA nurse and assess by observation, witness testimony and self-assessment.17 The use of a competency framework would ensure that consistent standards of education are met locally and nationally, to achieve safe practice in POA. Such a framework would standardise ‘in-house’ POA nurse training programmes but would need to follow a rigorous guideline development process by a group of POA healthcare experts. An example of such a focused preoperative competency framework can be seen in Chapter 20.
University-based POA education is now available in the UK. The POA book and CD Preoperative Assessment: Setting a Standard through Learning20 and on-line ‘e-learning’ modules run by the University of Southampton are evidence of a need for knowledge, skills and theory-based education. A POA lead nurse developed two BSc modules in ‘POA assessment and planning’ and ‘Health assessment and physical examination’ that run at Bournemouth University.21 Other university-based courses are currently available – for example, a module called ‘Principles in pre-assessment’ at De Montfort University in Leicester addresses current developments, management issues, legislative influences and the expanding role of the POA nurse. The module also focuses on practical aspects of POA and critically explores areas such as clinical examination, history taking and anaesthetic practice. Bangor University has recently developed a POA module where students are to be taught physical assessment skills, neck and airway assessment, respiratory assessment, cardiovascular assessment, management of clinical conditions and many other preoperative assessment-related topics. Sadly, the York University ‘Principles of pre-assessment’ module is no longer running.
|Box 1.2 Preoperative assessment specialist areas|
|From The Preoperative Association First National Conference Abstract Book 2004 and The Preoperative Association Second National Conference Abstract Book 2005|
|Lancashire Teaching Hospitals NHS Trust|
|East Birmingham PCT and Birmingham Heartlands and Solihull NHS Trust|
|Manchester Royal Infirmary|
|The Robert Jones and Agnes Hunt Orthopaedic and District Hospital|
|Leeds Teaching Hospitals|
|The Conquest Hospital, St Leonards-on-Sea|
|Hillingdon Hospital, Uxbridge|
|Day Case Surgery|
|Mid Yorkshire NHS Trust|
|Derbyshire Royal Infirmary|
|Hope Hospital, Salford|
|Chelsea and Westminster Hospital, London|
|Radiotherapy, Plastics and Burns|
|St Albans City Hospital, Hertfordshire|
|King’s College Hospital NHS Trust|
|North Cheshire Hospitals NHS Trust|
|Good Hope Hospital, Sutton Coldfield|
|Chelsea and Westminster Hospital, London|
Physical examination skills, including auscultation, are being performed by POA nurses10,22 although there is ongoing debate as to its necessity. Some POA nurses have been trained to Masters level in anatomy, physical examination and test ordering modules.23,24 A small study to compare safety and appropriateness of POA nurses assessing patients, instead of junior doctors, found the nurses to be effective in their practice and superior in their history taking.25 The POA nurses were given 30 hours’ training in history taking and the physical examination skills of inspection, palpation, percussion and auscultation. The Southampton-based team argues that, although the nurses were trained in physical examination and the study found they were effective in their practice, further evidence pertaining to nurses performing these skills should be sought to examine if it can be safely undertaken before allowing it to become common practice. In 1996, POA nurses in the US were performing physical examination.26 Another US paper reports Nurse Practitioners (NP) (qualified nurses educated to a degree level, employed in a NP post) assessing patients preoperatively.27 Part of their role is to perform physical examination skills but the paper does not discuss specific POA training, education or type of documentation used to support the role. The Association of Anaesthetists of Great Britain and Ireland (AAGBI)28 suggests the POA nurse uses a screening questionnaire to identify patients with health problems and, when these patients are identified, that they should be seen by a surgical or anaesthetic house officer who should perform the preliminary clerking and examination of the patient. In a number of studies and geographical locations, robust questionnaires are used in the nurse-led preoperative assessment process which don’t incorporate physical examination skills and this has not been reported as an omission in care provision.15,29–32 At the author’s hospital, auscultation is not performed by the POA nurses as it is thought that history taking skills are effective in assessing any undiagnosed or uncontrolled abnormalities. Local anecdotal evidence supports the view that efficient history taking provides enough information to identify patients with uncontrolled or undiagnosed health conditions.
The preoperative assessment team
Preoperative assessment management involves the coordination of a range of healthcare professionals in the management of care, including medical staff, nurses, and allied healthcare professionals (AHPs). To improve the care provided to patients, POA nurses should be aware of AHPs who can assist and enhance the patient’s surgical journey. In most UK NHS hospitals, POA services actively promote and incorporate interdisciplinary collaboration of AHPs in primary and secondary care, including physiotherapists, occupational therapists, clerical staff and specialist nurses such as stoma care, breast care and diabetic nurses and, predominantly, anaesthetists. In addition, the POA nurse is a member of a team with mixed skills including qualified nurses, clerical coordinators and healthcare assistants, allowing the POA nurse to dedicate their time to clinical duties instead of clerical duties.
A multi-disciplinary and multi-agency approach is essential in POA, drawing on the skills of appropriate health professionals to ensure the patient is fully prepared to undergo elective surgery.32 Occupational therapists and physiotherapists within the multi-disciplinary team work in some POA clinics.33 Even back in 1972 a social worker attended the POA clinic to assist with any ‘difficulties regarding social or domestic commitments’.1 Discharge planning is often mentioned in POA literature and is an integral part of the POA service, involving social services and GP referrals.7 One POA clinic is reported as involving a theatre nurse, occupational therapists, physiotherapists, a social worker and doctors,34 describing the clinical and educational collaboration as very effective and also as enjoyable for its participants. Discharge planning is part of the POA nurse’s responsibility and should be incorporated into the POA integrated care planning approach, an example of which can be found in Chapter 15.
Pharmacists are involved in POA in some areas. For example, in Dudley, UK the POA nurses were reported to accept that collaboration with the pharmacists was vital for the patient.35 In another POA clinic, pharmacists attended a POA clinic to review every patient. The POA nurses and doctors and the ward nurses and doctors identified the completing of discharge documentation as the most valuable service.36
Nurses or junior doctors in the POA specialism?
As previously stated, traditionally POA has been performed by medical staff, supported by nurses.2,6 A number of studies have examined the quality of the POA performed by junior doctors and POA nurses and advantages identified if nurses can be viewed as equals in performing POA: the junior doctors can be freed up to participate in the outpatients department, attend theatre and gain further experience in other areas.37,38 A team from Reading performed a prospective study in which 100 patients were preoperatively assessed by a registered nurse using a proforma and then preoperatively assessed by a junior doctor in the traditional manner.38 The study made direct comparisons of the information collated by both professional groups excluding physical clinical examination information as it wasn’t performed by the nurses. It concluded that the nurse was as accurate as the junior doctor when taking a surgical history. Comparisons of the work of nurses and junior doctors were made in a quantitative study in Southampton, UK, involving 1847 patients from four different surgical sites within the UK.23 The results were comparable between the two groups: overall 15% in the junior doctors’ group made errors possibly affecting management, compared to 13% in the nurses’ group.
Further comparisons were undertaken in Epsom, UK, where the effectiveness of preadmission clerking by both the nurse and doctor was measured.39 The results revealed that the nurses under-ordered investigations and the doctors over-ordered investigations, which identified a need for a protocol. Both groups cancelled a similar number of patients for health reasons, although the nurses were more likely to make valid referrals for further medical opinion. As no patients seen by either the nurses or doctors had their surgery cancelled due to problems unidentified at POA, it was concluded that nurses were as effective as doctors in the pre-clerking role. In another study, at a nurse-led POA clinic at the Royal Hallamshire in Sheffield,25 sets of medical notes were examined and the information gathered by doctors was compared to that gathered by the nurses in a nurse-led POA clinic.31 In their opinion the nurses’ documentation was of more value as it contained information regarding anaesthetic history, allergies, family history and medication. In Newcastle, a qualitative study compared the information gathered by nurses using a structured questionnaire in a nurse-led oral surgery day case clinic, to that of information gathered by clinicians in an outpatients department.15 The review of 57 sets of medical notes highlighted gaps in the information collected by the clinicians, ultimately promoting the use of dedicated time to POA the patient and the use of the questionnaire in the nurse-led clinic. A team from Oxford undertook a quantitative study in which 2726 patients were assessed in a nurseled POA clinic with a view to being admitted to a short stay mixed surgical ward in a hospital without integrated acute services to support them in the event of a medical emergency.40 Using guidelines and policies drawn up in collaboration with anaesthetists and surgeons, the nurses were able to POA patients effectively. The rates for cancellation of surgery were 11% in other areas of the Trust where POA did not occur. The study noted a 3.9% cancellation rate in POA clinic and 5% on day of admission. The POA nurses in Oxford and Newcastle were also able to refer patients accordingly to both anaesthetists and surgeons if the need arose.
A growing number of POA services, nationally and internationally, are nurse-led initiatives which result in greater nurse autonomy and better relations with physicians, leading to a positive impact on multi-disciplinary teamwork.41 They also stated that nurse-led initiatives have been identified in a number of settings and studies suggest better care and patient outcomes, commonly indicating that this may be linked to the nurses’ focus on patient involvement, patient education and the ability to provide psychological support. Nurse-led POA offers a more holistic approach to preoperative screening than the traditional medically orientated approach and enhances the service by integrating other duties into the role such as health promotion and discharge planning as previously discussed in this chapter.11 Following the introduction of nurse-led POA clinics in Grimsby, same day admissions increased from 16% to 60%, which suggests that the initiative may provide major cost benefits for the NHS whilst also enhancing overall patient care.42
Collaboration between POA nurses and anaesthetists
From a US perspective, an anaesthesia-based POA service is described where nurses review the medical records of patients.26 They are also trained to perform physical assessments of patients using standardised protocols and policies and refer patients to the anaesthetists if deemed unfit for surgery. The nurses were trained specifically to assist the anaesthetists following a sharp increase in attendance at the POA centre. A Californian study reports that specially trained nurses are part of an anaesthesia care team.43 In Utrecht, in the Netherlands, a quantitative research study was performed in which 4540 patients were preoperatively assessed on separate occasions by a specially trained nurse and then by an anaesthetist.22 The two professional groups agreed on 87% of the patient assessments. The study proposed that nurses could act as diagnostic filters, identifying patients who need further input from the anaesthetists.
Positive results from POA collaboration were seen at the Cromer hospital in East Anglia where a high number of ‘on the day’ cancellations of day case patients by anaesthetists was noted.44 A consultant anaesthetist collaborated with the POA staff and his colleagues, and reviewed and re-wrote protocols in 2002 that reduced the cancellation rate from 5% to 2.5% by 2005.
Other POA collaborations include POA nurses working with junior surgeons and anaesthetists when the patient was deemed at risk due to medical status.37 A study from 2003 reported POA nurses referring 27% of patients to the anaesthetist and 3.1% to surgeons for further advice regarding preoperative care.40 In 1997, some POA nurses were collecting information from patients and highlighting any potential problems to the consultant surgeon by sending a referral via the secretary.31 In Calderdale and Huddersfield NHS Trust, the POA nurses perform an assessment which is supported by strict protocols and guidelines incorporated within an ICP. In 2006, a retrospective, unpublished audit of the POA nurse-led service provided evidence that approximately 20% of the total number of patients assessed by the POA nurses were referred to the anaesthesia clinic: 10% following the identification of potentially uncontrolled, undiagnosed or complex health problems and 10% due to the nature of the surgery required, for example, major abdominal surgery.
The future of preoperative assessment
POA has become a permanent part of the elective surgical process, performed by qualified nurses, often using a form of documentation that is integrated into the patient’s paper records. However, the Electronic Patient Record (EPR) is the future, when all patients’ records will be accessible on line;45,46 therefore a single IT solution is likely to emerge in the NHS which can link to other aspects of patient care and assessment. There are a number of POA software packages available that advise when preoperative tests are indicated, following the completion of a health questionnaire.47,48,49 This can be done using touch screen technology, used over the phone with voice recognition software or a touch tone phone, or can be completed remotely, e.g. in the patient’s home or GP surgery. These data collection styles have been designed with medical input to ensure valid information is collected. In the US, a study indicated that the use of a computerised POA tool by an anaesthetist increased the number of clinical conditions identified in a set of medical notes, compared to the original process in which trained personnel reviewed medical notes.50 Another US study indicates that the touchtone phone method was liked by patients, they found the system easy to use (similar to other services such as banking via touch tone phones) and the patients indicated that they were ‘likely to be as truthful with their doctor’.48
One of the POA software programs generates a preoperative plan,47 indicating when an anaesthetic assessment is required and could indicate if any additional preoperative tests could be performed before the patient attends the anaesthesia clinic, saving the patient and the hospital valuable time in extra appointments. Risk stratification programs that predict risk according to the patient’s health condition50,51 could be integrated into the program to assist in the filtering of appropriate patients to an anaesthesia clinic, potentially reducing inappropriate referrals (see Chapter 2). Computerised record-keeping data would allow allied health professionals, e.g. physiotherapists and occupational therapists, easy access to a patient’s data away from the POA clinic, thus reducing the amount of time a patient spends in the POA clinic.
Computerised POA health questionnaires, designed for completion by a patient, lead one to consider the effect upon a POA service’s skill mix. Selection criteria for day case patients are already part of the POA process and could be extended within the POA software package to identify patients with complex or uncontrolled health conditions to be reviewed by a POA nurse who could decide if an anaesthesia assessment is required. Otherwise, healthcare assistants (HCAs) or administration assistants could perform more tasks, such as assisting with completion of the questionnaire. For uncomplicated patients, the same staff could follow the generated preoperative plan, performing general observations, swabs for infection control and providing printed pre- and postoperative information as indicated. At Calderdale and Huddersfield NHS Trust, an HCA implements an individual preoperative plan, devised by the POA nurse at the original POA appointment, when undertaking a telephone questionnaire and making admission arrangements for inpatients. A telephone questionnaire allows the HCA to assess whether the patient is still fit for surgery. The introduction of a POA software program would initially be expensive but could change the skill mix in a POA clinic, reducing staffing costs in the long term.
Telemedicine involves the use of communications and information technologies for the delivery of clinical care.52 These are accepted methods of reviewing patients, which are especially useful if patients live long distances from specialist care centres. Often POA is performed over the phone if a patient has dementia or a disability that would make a POA appointment distressing. Occasionally, anaesthetists use the telephone to establish if a referred patient needs to attend the anaesthesia clinic. Used in conjunction with computerised POA programs, telemedicine could reduce the volume of patients attending the POA clinics.
The future make-up of the preoperative assessment team is likely to go through further changes as more technological solutions are applied to patient care in the surgical journey. The whole challenge of delivering new service models is examined in more detail in Chapter 18. However, the role of the nurse in POA will continue, due in part to the patients’ need to share their health story with a healthcare professional who is able to tailor their care package to their individual requirements. The POA team has the ability to identify potential problems with health and social circumstances, act independently and have advanced communication and teaching skills.5 As we have seen from this chapter, in the 1990s the POA nurses’ role was often described in the literature as a ‘clerical’ coordinator who ensured that the patient was reviewed by the surgeons and AHPs attending the POA clinic, but this has changed radically. In the new millennium, in some hospitals, it has developed into that of a dedicated POA nurse competently practising in an advanced role as a ‘clinical’ coordinator. The POA nurse completes a holistic assessment, gives preoperative information, provides a named nurse service, appropriately refers and collaborates with doctors and AHPs, manages a caseload of unfit patients, coordinating care and services in order to improve the patient’s surgical journey. Where the role is performed without direct medical input, e.g. in nurse-led clinics, the POA nurse is an experienced nurse whose autonomous role is supported by policies, documentation, protocols and anaesthetic services. Unfortunately, it has been found that staff working directly with patients are less likely to know about service changes and developments that could benefit patients53 and, as the dedicated POA nurse role has the potential to become isolated, special efforts need to be made by the POA nurses and the managers of all service types to keep up to date regarding service changes and developments. The continuing education of the POA team is necessary and the attainment of professional competencies is essential for POA nurses to further develop their role.17
The already advanced nature of the POA nurse’s role involves increased responsibility, as they often work alone and without direct medical supervision. Some specialist nurses work in primary care areas and integrate POA in their practice.54 Difficulties matching the role of the POA nurse to any of the Agenda for Change job profiles have been identified and the development of a template for a generic POA nurse has been proposed.55 It is anticipated that the development of competencies could help POA nurses to meet the requirements of the Knowledge and Skills Framework.21
The introduction of ‘computerised care’ to POA removes the ideal opportunity for a patient to discuss any anxieties or concerns about pending surgery at a time when some patients feel vulnerable and powerless, whether the surgery is because of a life-threatening disease or not. Computerised care removes the opportunity for a healthcare professional to identify non-verbal cues, to tease out information which a patient had forgotten or was unable to explain within the program’s rigid parameters. The development of a rapport between the nurse and the patient can instil a sense of confidence in the planned surgical journey and maintain the caring touch in modern health-care.
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