5 Pre-admission assessment of the patient and discharge planning
• To explore the underpinning philosophy of pre-admission assessment
• To explore the actual experience of a pre-admission assessment
• To increase awareness of the role that pre-admission assessment plays in patient safety and comfort when admitted to hospital for surgery
• To provide an evidence-based foundation for pre-admission assessment
Introduction
Traditionally and historically, many professionals within the hospital environment have been involved in the assessment of patients going for surgery. These include medical staff, nurses, pharmacists and physiotherapists. Individually, each professional would ‘assess’ the patient from their individual professional perspective (Bassett 2005). As a result, the patient would have to repeat similar information to a number of professionals. The impact of this was that vital information was often lost. Recognition of this and the need to continually improve and streamline patient services has become the result. A major development that we have seen over the last 7–10 years has been in the area of multi-professional assessment services. In particular the learning gained from the early work of day surgery units and the guidelines and practices these adapted to patient selection.
Almost 40 years ago, Crosby et al (1972) researched the benefits of pre-admission assessment on surgical patients and recommended that such assessments should take place. Undoubtedly, for many years, organisations interpreted the aims of pre-admission assessment in different ways and gave such services varying amounts of support (Bassett 2005). It only became apparent how important such a service could be with the reduction in working hours of junior doctors (Department of Health (DH) 1997) as this change resulted in a lack of time to ‘clerk’ patients traditionally. This presented the idea that professionals other than doctors should become involved in the process. Nevertheless, owing to a lack of leadership from key stakeholders anxious to ensure that their professional identity was maintained and anxious not to make recommendations for other professional groups, little was written on the subject until the NHS Modernisation Agency published national guidelines in 2003.
Equally, as the focus of healthcare delivery has shifted from inpatient to ambulatory care and the need to treat greater numbers of patients, healthcare organisations have had to review/develop assessment services which are able to meet these demands.
The recognition of the contribution this model of assessment can offer to organisations and patients has clearly been articulated by the Scottish Executive (2005) in the strategy document Building a Health Service Fit for the Future. A key to successful assessment in a modernising NHS is that:
Key drivers for pre-admission assessment
Pre-admission assessment clinics are now commonplace for surgical specialties. Pre-admission assessment is the process of assessing patients prior to surgery. The key purpose of this assessment is to reduce perioperative morbidity and mortality by identifying patients who may require further assessment, investigation or treatment of co-morbidity prior to surgery (Janke et al 2002).
Provide your own definition of pre-admission assessment.
Consider and write down why pre-admission assessment is necessary for patients prior to coming into hospital.
This definition of pre-operative assessment by NHS Scotland (2008:4) may help you to consider this activity:
Pre-operative assessment establishes that the patient is fully informed and wishes to undergo the procedure. It ensures that the patient is as fit as possible for the surgery and anaesthetic. It minimises the risk of late cancellations by ensuring that all essential resources and discharge requirements are identified and coordinated.
The main driving force behind this change has been the acknowledgement that patient-centred assessment services have become a key means of how the NHS can deliver on national targets (DoH 2001). Nationally, the main drivers for this change were the Labour Government NHS modernisation agenda (pre-2009) and the National Institute for Health and Clinical Excellence (NICE) guidelines for preoperative testing (2003), the aims being to reduce last minute cancellations and to be able to facilitate day of surgery admissions.
Follow this link to obtain evidence of the NHS Modernisation Agency (2002)National Good Practice Guidance on Pre-operative Assessment for Day Surgery:
http://www.generalsurgerybirmingham.co.uk/documents/gen-vasc-guidelines/Microsoft%20Word%20-%20guidance%20copeland%2019.pdf (accessed May 2011).
and the (2003) National Good Practice Guidance on Pre-operative Assessment for In-patient Surgery:
http://uat.qihub.scot.nhs.uk/quality-healthcare-resources/continuous-improvement-in-healthcare/improvement-tools/search-results/improvement-tool.aspx?id=71 (Accessed May 2012).
Read the documents and write out three learning goals that you can achieve if you are in a pre-admission clinic for your clinical placement, e.g. you might consider the informed consent needs of patients from different cultures and learn about the specific cultural needs of one of these groups that will help you plan their care.
These documents are essential reading for this Section of the book and will also help you in Sections 3 and 4.
Historically, within surgery, patients were not always adequately prepared for general anaesthetic due to either inadequate preoperative testing or patients being classified as unfit for surgery. In some cases, this led to operations being cancelled and operating department ineffectiveness. Pre-assessment was performed 1–2 weeks prior to admission resulting in such cancellations because some identified health problems could not always be resolved in the time before surgery and hospital admission.
Following the introduction of the two national good practice guidance documents, single pre-admission assessment clinics were introduced and followed a radically revised care pathway. When a decision for elective surgery is made, within the outpatient department, the patient is immediately taken for anaesthetic assessment. All the necessary preoperative investigations are completed in accordance with the NICE guidelines for preoperative testing (NICE 2003). Objectives of preoperative assessment (NHS Modernisation Agency 2003) prior to inpatient surgery are listed in Box 5.1 and this offers an excellent overview for you to help plan learning outcomes.
Box 5.1 Objectives of preoperative assessment for inpatient surgery
Preoperative assessment should:
Provide the opportunity for further explanation and discussion of the information given by the surgeon. This should minimise any fears or anxieties by ensuring the patient fully understands the proposed procedure.
Assess the patient's fitness for surgery and anaesthesia and provide an assessment of the risks and benefits of the proposed surgery and anaesthesia, and confirm the patient wishes to have the operation in the light of these risks and benefits.
Identify any condition that may require intervention prior to admission and surgery and take appropriate action, e.g. patients taking warfarin, oral contraception, etc.
Refer the patient, if necessary, for optimisation of their health before surgery, e.g. to a primary care and/or a secondary care specialist.
Ensure any necessary investigations are performed, results are available and any necessary action taken. This should reduce any unnecessary duplication of investigations.
Assess the patient's suitability for day surgery, if the operation could be performed as a day surgery procedure (see NHS Modernisation Agency [2002] and DH [2002]).
Identify requirements to aid scheduling of the surgical procedure, including specialist equipment, approximate length of surgery and any special requirements for the postoperative stay, e.g. critical care beds.
Provide information about any specific preoperative instructions, e.g. any fasting instructions.
Provide a contact point for any further queries, or if they want to cancel the operation.
Provide information about the anticipated postoperative recovery, e.g. rate of mobilisation, measures to relieve pain, etc. Videos, information leaflets and picture diaries are effective methods of providing information.
Provide an opportunity to discuss with patients any self-help matters to improve the outcome of their surgery, e.g. stopping smoking, losing weight, etc.
Identify any cultural requirements and any communication or other special needs.
Assess the home support available to the patient post-discharge, and identify any special requirements to facilitate prompt discharge, e.g. coordinating with social services, where appropriate.
(From NHS Modernisation Agency 2003)
Who conducts the pre-admission assessment?
At present it is a registered nurse who completes the nursing assessment and a doctor who completes the medical assessment. As changes are made to the education and training of doctors and with the reduction in working hours of junior doctors (Oakley & Bratchell 2010), nurses are taking on more of the junior doctors' role and, certainly in the UK, there are nurse specialists in this field (DH 2006).
In the case of day surgery/ambulatory surgery, trained nurses undertake the complete assessment. Doctors will see the patient on the day of surgery for medical checks and to obtain consent (see Ch. 6 for issues around informed consent).
The good practice guidelines recommended that preoperative assessment for either day surgery or inpatient surgery should be ‘performed by a trained and competent preoperative assessor’ (NHS Modernisation Agency 2003:6). Each NHS trust or independent hospital will have its own practice guidelines and policies with regards to this, and if you are in a pre-admission placement, it would be good practice to read this and be familiar with the content as patients may ask you: ‘Who is going to see me today? Is it the doctor?’ It requires a multidisciplinary team approach to ensure seamless care for patients.
When a problem is identified, such as a patient having a cold or a chest infection, which may result in a patient's surgery being cancelled or where further advice is required, an anaesthetist is contacted so that decisions can be made regarding the management of the patient either pre- or postoperatively. The anaesthetist may have dedicated pre-admission sessions and be available most days for either patient or notes review. The anaesthetist also sees the patient on the morning of surgery if the patient is for day surgery or ambulatory care surgery. For patients having inpatient surgery or planned surgery, they may see the patient the day before as the majority are admitted at least the day before surgery is to take place (see Ch. 6). The good practice guide also gives an overview of the guidelines used for selecting patients for day surgery, including when day surgery would not be considered, e.g. pain cannot be controlled with oral analgesia and specific physiological contraindications such as poorly controlled asthma or having had a heart attack in the last 6 months.
Identify three other situations where a patient might not be considered suitable for day surgery.
Identify what kind of investigations might be considered for patients during the pre-admission assessment.
Identify at least two investigations where you could visit, with a patient's permission, to understand what these involve.
Depending on the type of surgery a patient is having, other members of the multidisciplinary team may also be involved in the pre-admission assessment process. For example, a physiotherapist might assess a patient's needs and give advice regarding exercise regimes and mobilising in the postoperative period (see section on nursing assessment on admission to hospital in Ch. 6).
Referral to an occupational therapist may be required, who assesses the patient's requirements for discharge home from hospital: for example they may be required not to climb stairs or require raised toilet seats. Patients who are having joint replacements are asked to complete a form, which records the height of chairs, bed and so forth so that any identified requirements are dealt with prior to the patient's discharge home (see Royal National Orthopaedic Hospital leaflet on total hip replacement: http://www.rnoh.nhs.uk/sites/default/files/downloads/10-86_rnoh_pg_thr_web_0.pdf (accessed May 2011)).
A pharmacist may see a patient to address any problems with medications while they are in hospital. For example, a patient may be an insulin-dependent diabetic or taking steroids, both of which will be affected by surgery. For patients coming to hospital for day surgery/ambulatory surgery, the nurse will complete a pharmacy pre-assessment sheet and send it for the attention of the pharmacist.
The consultant surgeon, surgical registrar or surgical care practitioner will ideally be available for the pre-assessment visit to explain the procedure to the patient and get the consent form signed. They would also be able to ensure that any questions that accompanying relatives have can be answered. A useful document to read in relation to patients with learning difficulties who may require surgery is that written specifically for nurses by the Royal College of Nursing (RCN 2006).
Consider the process of assessment that patients in your placement area have undergone in the pre-admission clinic and identify the main health problems that may have been identified.
Re-visit who is involved in the pre-admission assessment and what their role is with regards to patient care.
Consider how information gathered is communicated to other professionals involved with the patient.
Discuss these issues with your mentor as part of your planned learning plan.
Key components of good pre-admission assessment
The major goal of pre-assessment services is to assess the holistic needs of patients and determine their suitability for surgery (Johansson et al 2010). The information obtained enables the team to engage with careful patient selection and plan individual care accordingly.
Read the articles by Beck (2007) and Gilmartin (2004) (see References), related to pre-admission nursing assessments, prior to your surgical placement as background to understanding the nurse's role in this critical area of patient care in the pre-operative period.
The Scottish Executive (2005) noted that failure to assess patients adequately can be responsible for high operating theatre cancellation rates, or unacceptable risks to patients. It further advises that studies in Australia have shown that inadequate assessment is frequently implicated in deaths attributable to anaesthesia (Mackay 2004).
Traditionally, pre-admission assessment services were delivered within the hospital environment. With the modernisation of services along with advances in technology, opportunities exist for pre-admission services to be delivered in more innovative ways (NHS Modernisation Agency 2003:10). Some innovative ways in which pre-admission services are being delivered are the following:
Many advocates of pre-admission assessment services believe there is a place for using information technology in assessment (Macduff et al 2001). In some facilities, information is stored directly on a database and shared between the relevant professionals. In others, patients hold their own records and take them to where they are needed. In both cases, assessment is a good example of the opportunities for sharing information among professionals, and this will only improve with the advent of the electronic patient record (Scottish Executive 2005).
Whatever the method of delivering pre-admission assessment services, it must always be appropriate to the patient and the type of surgery they will undergo.
Consider what aspects of pre-admission assessment are routinely undertaken in preparing patients for surgery/investigation in your clinical placement.
Discuss this with your mentor and consider how you can gain an insight into how a pre-admission clinic or assessment works.
No matter where pre-admission assessment services are delivered, the NHS Modernisation Agency (2003:5) detail key objectives for pre-assessment services as follows:
Confirmation the patient wishes to have the recommended procedure/investigation.
• Assess the patient's suitability to be treated as either an inpatient, day case patient or ambulatory care patient.
• Assess the patient's fitness for the surgery/investigation.
• Ensure the patient fully comprehends what the procedure/investigation will entail and provide additional oral and written information.
• Take the opportunity to minimise any anxiety or fears the patient may have.
• Identify any special requirements the patient may have.
• Provide the opportunity for discussion in relation to self-help matters to improve the outcomes (e.g. smoking cessation, losing weight).
• Identify any cultural requirements.
• Identify problems in advance so that they can be addressed.
• Allow the patient to make suitable arrangements for work, childcare, etc.
• Ensure the patient will be able to go home safely.
• Reduce preventable cancellations on the day of surgery.
• Provide a smooth admission process to avoid delays on the day of surgery.
• Predict and explain risks to patients.
• Assess the home support available to the patient and identify any special requirements to facilitate prompt discharge.
To achieve the above objectives, the following assessments will be required.
The nursing pre-admission assessment process
A careful and detailed history and clinical examination are essential to ensure that important information is not omitted which could have an impact on the pre- and postoperative care of a patient. The aim of the history taking is to obtain and document a complete picture of a patient's present health problems alongside their past medical history, family history and social circumstances. All pre-admission assessment services gather this information via a standard document based upon the NICE (2003) guidelines for preoperative testing: http://www.nice.org.uk/nicemedia/live/10920/29090/29090.pdf (accessed December 2011).
Before continuing with this chapter, read the NMC (2010) Standard related to the requirements of the Essential Skills cluster of care, compassion and communication (Box 5.2). Consider how you will achieve these essential skills by setting yourself objectives while learning about pre-admission assessment. Discuss with your mentor how she/he will assess your skills and competencies to meet both outcomes. An example of what is required can be seen in Box 5.3 (See NMC Standard 6).
Box 5.2 Essential Skills Cluster: Care, Compassion and Communication
People can trust the newly registered graduate nurse to engage therapeutically and actively listen to their needs and concerns, responding using skills that are helpful, providing information that is clear, accurate, meaningful and free from jargon. (NMC, 2010)
The newly qualified graduate nurse should demonstrate the skills and behaviours shown in Box 5.3: they should be used to develop learning outcomes for each progression point and for outcomes to be achieved before entering the register.
Box 5.3 Requirements to achieve NMC Competencies at the three Progression Points to becoming a nurse
Communication with the patient
We can see from the Essential Skills Cluster and NMC (2010) Standard the importance of being able to communicate effectively with patients.
When conducting any assessment with a patient for the first time, it is important always to introduce yourself. It is also important to ask the patient how they would like you to address them (e.g. by their first name or as Mr Smith). Even this may not be appropriate for some cultures (see Holland & Hogg (2010) for cultural names).
Throughout the assessment, it is important to maintain eye contact at all times with the patient, to speak slowly and clearly when asking questions and to allow the patient time to answer questions. For patients whose first language is not English, it is important to ensure that either a family member who does speak English is present or to ensure that an interpreter is available. For patients with hearing or language impairment, many hospital services can provide ‘sign language’ experts to assist. (See http://www.nmhdu.org.uk/our-work/mhep/accessible-mental-health-services/ (accessed December 2011) for information and other links.)
Prior to carrying out the assessment, it is important to ensure that any previous medical records and X-rays are available for you to review as well as being available to the surgeon/anesthetist if required.
Personal details
To set the patient at ease, it is helpful to start with asking simple questions such as to confirm their full name, their date of birth, address, marital status, occupation, contact details for next of kin, religion/spiritual beliefs and ethnic background. If the patient has medical notes then the details provided by the patient should be checked with those held on the medical records.
Existing medical conditions
During pre-admission assessment (which is unlike a nursing assessment normally undertaken on admission to a ward, for example), it is very important to systematically go through each of the body's systems and elicit and document if the patient has any conditions which are being treated. The pre-admission checklists used in pre-admission assessment services will help guide you through this. The most common areas to explore are in relation to the following:
• Cardiac system: do they have angina, hypertension, ischaemic heart disease? Have they ever had coronary artery bypass surgery?
• Respiratory system: respiratory tract infections, chronic obstructive pulmonary disease, asthma, bronchitis.
• Central nervous system: do they have epilepsy? Have they ever had a stroke or transient ischaemic attack (TIA), Parkinson's disease, dementia? Determine if there are any addictions such as alcohol dependence or recreational drug use.
• Renal system: do they have frequent urinary tract infections? Have they ever had renal failure? Do they have diabetes?
• Hepatobiliary system: have they ever had hepatitis, cirrhosis of the liver?
• Gastrointestinal system: Have they ever had oesophageal reflux, anorexia, nausea?
• Reproductive system: if female and of childbearing years, is their menstrual cycle regular?
• Haematological system: do they have anaemia, haemophilia? Do they take anticoagulation or antiplatelet medications.
• Musculoskeletal system: do they have arthritis and/or restricted neck or joint movement.
To learn more about preoperative tests and investigations, access the following document from NICE:
http://www.nice.org.uk/nicemedia/live/10920/29090/29090.pdf (accessed December 2011).
In addition to the above, it is important to ask the patient if they have had contact with anyone or have themselves had methicillin-resistant Staphylococcus aureus (MRSA) recently and been in hospital over the last 3 months. If they answer yes to any of these questions, they may require an MRSA screen. This is particularly necessary for any patient, for example, who is to have a prosthesis inserted, due to the potential risk of postoperative infection.
Medications
It is important to document all medications that the patient is currently on, including medications which have been prescribed. Pay particular attention to the route of administration, dosage and how frequently the medication is taken. It is also important to ask the patient specifically if they are taking any herbal medicines as many herbal medicines can interact with prescribed medications and anaesthetic medications. You should document the name and also how often the patient takes these.
A further area to elicit information on is around the use of recreational drugs. You must document the name, how much they take and the frequency with which they use any recreational drugs. Many recreational drugs like herbal medications can have an adverse reaction with anaesthetic drugs. It is crucial to draw any usage of herbal medications and recreational drugs to the attention of the anaesthetists.
Allergies
Ask about and document any allergies the patient has. It is important to find out not only if they have allergies to any medications but also to any foods, for example peanuts, bananas or kiwi fruits, as these food allergies can be a result of having an undiagnosed allergy to latex rubber. Ask the patient what happens when their allergy is triggered, for example sneezing, vomiting, skin rash (further detailed information is given in Ch. 6). All allergies must be communicated to the anaesthetist directly.
Investigations
There are a number of routine investigations that are carried out on all patients. These usually begin with recording a patient's baseline temperature, pulse and respirations (TPR) and blood pressure (BP). This provides a baseline of the patient's normal parameters.
Recording height and weight then allows the body mass index (BMI) to be calculated. The BMI is a statistical measure that compares a person's weight and height. It is also used to estimate a healthy body weight based on a person's height and this has already been worked out for you on a recognised BMI chart. This is a widely used diagnostic tool and can identify if someone is underweight, overweight or obese. For example, in the UK, a patient with a BMI over 35 is not suitable for day surgery. (See http://www.nhs.uk/Tools/Pages/Healthyweightcalculator.aspx for tools to calculate BMI and links to related health problems. It is also linked to a range of health and wellbeing and weight management resources.)
Using the BMI chart, practice the clinical skill of calculating patients' BMI and recording this on your local care planning documentation. If unsure if you have calculated correctly, check with your mentor. Knowing a patient's normal height and weight measurement on admission to hospital is essential if you are to calculate the patient's BMI. This would not of course be possible in emergency admission to hospital.
Routine urinalysis is carried out primarily to ensure that the patient has no infection or undiagnosised diabetes mellitus. It is particularly important for patients going for joint replacement surgery or having insertion of metal work to be free from infection, as any infection can get into the prosthesis and cause it to fail.
A pregnancy test should be carried out on all female patients of childbearing age who continue to menstruate. It is highly dangerous to a foetus to administer a general anaesthetic.
If you are in a pre-admission clinic placement, under the supervision of your mentor, conduct a pre-admission assessment of one patient. After completing this, make a list of what you felt you did well and areas you feel you require further practice in. Compare your own assessment with the assessment your mentor made. What did you find was different and what knowledge and skills do you need to develop?
If you are not allocated to a pre-admission clinic, ensure that you devise a SMART (Specific, Measurable, Achievable, Realistic and Timely) objective in relation to negotiating an insight learning day or hub and spoke placement.
Additional investigations such as an electrocardiogram (ECG), blood tests and X-rays may be undertaken depending on the patient's medical history. For example, an ECG may be required if the patient has a heart condition. Many pre-admission assessment services have algorithms to help make a decision as to whether a patient requires an ECG.
Anaesthetic history
It is extremely useful to know if a patient has had an anaesthetic in the past and whether they had any problems. If a patient has had a previous anaesthetic and tells you they had a problem with it, it is important to document the exact nature of the problem. The most common problem is severe nausea and vomiting after the anaesthetic. It is important to record any problem voiced by the patient and draw this to the attention of the anaesthetist. Knowing if a patient has had a previous anaesthetic problem allows for planning better postoperative care. There are also conditions which run in families that are extremely dangerous if not managed properly that may manifest when a patient is anaesthetised (e.g. malignant hyperpyrexia).
All of the above mainly relate to the physical fitness of a patient. All patients undergoing a surgical intervention are also assessed in relation to their American Society of Anesthesiologists (ASA) physical status. ASA physical status is a physical fitness tool developed by the ASA and used routinely around the world. It is divided into six levels:
• ASA 1: a normal healthy patient.
• ASA 2: a patient with mild systemic disease – an example of this is a patient that has diabetes mellitus that is controlled by diet only.
• ASA 3: a patient with severe systemic disease – an example of this is a patient with diabetes mellitus who requires insulin but whose blood glucose level is well controlled.
• ASA 4: a patient with severe systemic disease that is a constant threat to life – an example of this is a patient with diabetes mellitus who requires insulin but whose blood glucose level is not well controlled and who has frequent episodes of hypoglycaemia which requires medical attention.
• ASA 5: a moribund patient who is not expected to survive without the operation.
• ASA 6: a declared brain-dead patient whose organs are being removed for donor purposes.
The ASA status of a patient determines whether they will be treated as an inpatient, day case patient or ambulatory patient. Routinely, patients who have an ASA of 1 or 2 can be treated as a day case and patients with an ASA 3 can be treated on an ambulatory basis. Patients who score above ASA 3 are always treated as inpatients as there is an increased risk of requiring either intensive or high-dependency care following surgery.
Anaesthetists have the ultimate authority on a patient's suitability for anaesthesia and there are processes in place to allow nursing staff to communicate findings to anaesthetic staff and to seek guidance from them.
Surgical factors
Any surgical operation causes physiological stress to a patient. The physiological stress becomes greater the more invasive a procedure is. There is no universally agreed and validated scoring system for classifying the ‘stress’ of a procedure. NICE (2003), however, has developed a simple grading scale:
• Grade 1 (minor): examples include the removal of a simple skin lesion or drainage of a breast abscess.
• Grade 2 (intermediate): examples include removal of varicose leg veins, repair of an inguinal hernia.
• Grade 3 (major): examples include total abdominal hysterectomy, thyroidectomy.
• Grade 4 (major +): examples include neurosurgery, cardiac surgery, total joint replacement.
Considerations should be given to the following key factors as part of the assessment process:
• Will the surgery involve significant blood loss or fluid shifts?
• Is the surgery associated with significant nausea and vomiting?
• Is the surgery associated with pain not treatable with simple analgesia?
The above considerations determine whether a patient is admitted as a day case, ambulatory care or as an inpatient.
Social history
When conducting the social history, it is important to be aware that many patients take on a large part of their postoperative care themselves. It is important to find out about patients' social support networks. For example, do they live with someone or do they live alone? Are friends or family available and willing to help support them following discharge from hospital?
The type of housing is also a factor for consideration. For example, does the patient live in a high-rise block of flats where the lift is regularly out of order? For a patient having surgery to their leg, this may make it impossible for them to go home until fully mobile. Another factor to consider is how accessible their toilet is – is it up a flight of stairs? If having surgery that will limit their mobility, this could pose problems on discharge.
It is crucial to ascertain if there is a particular time of year that a patient is not available for admission for surgery. For example, they may be going away on holiday.
Also give consideration to the distance a patient must travel between the facility and home. Whether or not it is appropriate to allow a patient to travel home will also depend on the procedure and anaesthetic involved.
As identified earlier, some patients take on a large part of their postoperative care themselves; therefore it is important to consider the accessibility/availability of a telephone. This is crucial as many studies have found that, following discharge, patients still require advice, support and information in order for them to self-care.
Obtain a copy of one or both of the articles by Caroll and Dowling (2007) and Goodman (2010) (see References). Read and consider the importance of planning for discharge and who needs to be involved in this process. (See Ch. 10 for further information on discharge planning.)
Psychological assessment
A key aim of conducting a psychological assessment is to determine the level of knowledge and understanding patients have of the procedure they are about to have and the potential effects on their life. It is crucial to provide patients with accurate information so that they have realistic expectations about the surgery. For example, the removal of varicose leg veins does not mean that a patient will never have these again, but the patient may have been led to believe that the surgery will solve their problem indefinitely.
It is also important to assess any learning needs patients have and how these can be addressed prior to admission. Also determine which is the best medium to provide patients with further education, for example videos, pictures, leaflets, audio tapes.
All patients going for surgery are naturally anxious and worried. It is important to find out what worries they have and how we can assist to reduce these.
Two articles you will find helpful in understanding more about preoperative anxiety are Pritchard (2009) and Grieve (2002) (see References and also Further Reading). Discuss with your mentor the value of implementing care based on evidence of good practice in anxiety management.
Patient information
During pre-assessment, patients are given information to help them prepare for their admission to hospital. This information includes the following:
• What to bring into hospital including all medications in original packaging.
• What medications to take on the day of surgery and what medications to omit.
• What to expect on the day of surgery.
• Postoperative care and instructions regarding time off work, mobility, etc.
• Information leaflets specific to the surgery they will have.
• Health promotion, e.g. weight reduction, stopping smoking.
Evidence shows that if patients have a clear understanding of postoperative expectations, they recover more quickly and get home more quickly.
Read the articles by Johansson et al (2010) and Smith and Callery (2005) and consider the issues regarding patient information needs.
You may have an individual project to undertake for an assessment during your placement; one project could be to design an evidence-based preoperative admission leaflet for a patient who could be a child, an older person or someone with learning difficulties.
When you are observing your mentor undertaking a preoperative assessment or you are being observed, work out what you wish to learn from the experience. Preparation prior to placement is very helpful in enabling you to engage with patient care in any placement (see Chs 1–4).
Discharge planning
Discharge from hospital is a key element of a patient's stay, therefore planning for discharge must start before admission (Shepperd et al 2010). Much of the information required for efficient discharge planning will have been gathered during the social assessment of the patient. However, dependent on the type of surgery, the involvement of an occupational therapist and possibly social work referral may be required to establish, for example, the following:
• Does the patient's home need to be assessed?
• Will they need a raised toilet seat or hand rails?
• Will they require increased services such as meals on wheels, home help?
• How will they get home from hospital? If there is no friend or family member available, transport arrangements may be required.
(See Ch. 10 and the section on social history, above, for examples of articles that will help you understand the importance of discharge planning.)
Benefits of pre-admission assessment
Much of the literature demonstrates that pre-admission assessment services are beneficial in reducing hospital-led cancellations, patient-led cancellations and patients not attending (DH 2001). Some of the key benefits for both the patient and the service are:
Service
• Prevents cancellation on the day of surgery.
• Allows better utilisation of beds.
• Reduces ‘did not attend’ (DNA) rate.
• Opportunity to give patients necessary information.
When a pre-assessment is complete and the receiving ward is in receipt of this, it is then the responsibility of the ward staff to check the pre-assessment prior to a patient's admission, as very valuable information is contained in the document.
If a patient is pre-assessed for surgery and then has to wait up to 3–6 months for that surgery, it is necessary for the patient to have their details and medical history re-checked, usually by telephone, to ensure that there have been no changes to their medical or social history since the first assessment.
Summary
A pre-admission assessment helps patients focus on their surgery and find out more information on what is going to happen during the whole experience. Assessment of the patient by doctors, nurses and other health professionals is, of course, essential for ensuring an informed experience for the patient. It is also the foundation for the next stage of their surgical journey, that of actually being prepared for surgery and taken to the operating theatre. This is the focus of Chapter 6.
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Beck A. Nurse-led pre-operative assessment for elective surgical patients. Nursing Standard. 2007;21(51):35–38.
Carroll A., Dowling M. Discharge planning: communication, education and patient participation. British Journal of Nursing. 2007;16(14):882–886.
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Department of Health. Junior doctors' hours: the new deal. London: DH; 1997.
Department of Health. National good practice on day surgery preoperative assessment. London: DH; 2001.
Department of Health. Day surgery: operational guide. London: DH; 2002.
Department of Health. The curriculum framework for the surgical care practitioner. London: DH; 2006.
Gilmartin J. Day surgery: patients' perception of a nurse-led preadmission clinical. Journal of Clinical Nursing. 2004;13(2):243–250.
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The NICE website offers national guidance on preoperative tests: http://www.nice.org.uk/Guidance/CG3 (accessed December 2011).
The Association for Perioperative Practice (AfPP) began life as the National Association of Theatre Nurses in 1964. It is a charity providing education and support to theatre nurses, operating department practitioners and all those working in and around operating departments: http://www.afpp.org.uk (accessed December 2011).
A website links directly to the NICE guidelines on the use of preoperative tests for elective surgery: http://www.nice.org.uk/nicemedia/pdf/Preop_Fullguideline.pdf (accessed May 2011).
The NHS Choices website focuses on a preoperative assessment talk for patients by a nurse: http://www.nhs.uk/video/pages/pre-operativeassessments.aspx?searchtype=Tag&searchterm=Liver_Digestion__Bowel_Rectum (accessed December 2011).
The website of the NHS Institute for Innovation and Improvement: http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/discharge_planning.html (accessed December 2011).