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Mary Short is the Clinical Nurse Specialist Preadmission Clinics, at St. Vincent's Hospital Sydney. Kate Egglington is the Nursing Unit Manager of the Cardiothoracic Surgical Unit (CW 16) at St Vincent's Hospital Sydney. Christine Conn is the Clinical Coordinator working in CW 16 All three are involved in the Cardiothoracic Surgical Preoperative Clinic. |
The Cardiothoracic Surgical Preoperative clinic was commenced in March 1993 to enhance the admission and discharge process for patients undergoing cardiothoracic surgery. The aims of the clinic were:
A questionnaire was used to evaluate the clinic's operation from March 1993 to August 1993.
Results
Conclusions:
Overall, the aims of the clinic were met. The services noted for improvement were found to be autologous blood donation, social work intervention and collection of statistics for on-going evaluation. These concerns have been addressed and the currently run (May 1995) clinic has incorporated these changes.
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In March 1993, a cardiothoracic preoperative clinic was commenced at St. Vincent's Hospital Sydney, to provide a comprehensive outpatient service for those patients undergoing cardiothoracic surgery. The service was designed to provide full medical assessment, physiotherapy assessment and education, nursing education, and social work/discharge planning assessment.
Prior to establishing the clinic, a review of cardiothoracic preoperative clinics at the Royal North Shore Hospital and Royal Prince Alfred Hospital was made. Building on aspects of these programs, the St. Vincent's Hospital preoperative clinic was organised to allow a well-structured program with designated times for medical, nursing and physiotherapy sessions. The clinic ran between 0800 and 1300 hours on Tuesday, Wednesday and Thursday.
One of the aims of the clinic was to enhance the admission process; thereby, reducing the time spent in hospital preoperatively. Patients were sent a package of information to enable them to understand the purpose of the clinic and to have routine, preoperative investigations performed by their general practitioner before attending the clinic. Patients were asked to bring the test results to the clinic. At the clinic, the resident medical officer reviewed the patient's test results, completed the full admission or when indicated, organised further investigations prior to admission. The process reduced the incidence of last minute cancellations due to a patient's current health status or comorbidity.
Another aim of the clinic was to improve postoperative regimen compliance by preoperative education; thereby, helping to reduce postoperative complications. The clinic assessment of the discharge plan was designed to reduce postoperative length of stay, by assessing the patient's social supports and addressing any inadequacies.
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In 1993, an evaluation of the preoperative clinic was undertaken between March and August to ascertain the level of patient satisfaction with the preadmission clinic. The evaluation took the form of a patient survey using a questionnaire, with questions designed to assess the different components of the clinic. One hundred questionnaires were distributed to patients attending the clinic.
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The response rate was 65%.
Purpose of the Clinic and Clinical Staff
Patients were asked if they understood the purpose of the clinic. Ninety-eight per cent replied that they had a good understanding of the clinic's purpose. Information regarding the reason for attending the clinic was given by the bed allocations office at the time the clinic appointment was made. Written material was also sent to the patients. Specific information about the day's activities was given to the patient on arrival at the clinic.
The majority of patients found the staff very helpful (92%). Three per cent found the staff helpful, while 5% did not answer the question.
Distance Travelled and Catchment Area
Sixty-five per cent of respondents were from the metropolitan area, 14% attended from a distance of less than 200 kilometres, 16% were from a distance greater than 200 kilometres and 5% did not answer the question. Figure 1. illustrates these results.
Figure 1.
Patients who lived at a distance greater than 200 kilometres from the hospital had their admission organised for the same day as their clinic appointment. Unless the admission day coincided with the preoperative clinic appointment, country patients were not required to attend the clinic.
When questioned on the degree of difficulty experienced in attending the clinic, 84% responded that they had not experienced any difficulty. The appointment times were satisfactory for 88% of the respondents. The results demonstrated the importance of allocating appointment times in relation to the distance the patient has to travel.
All patients were provided with information regarding autologous blood collection in the package they received before attending the clinic. However, only 28% of the patients were autologous blood donors. Half of these patients had been able to link their autologous blood donation with a clinic appointment.
A number of reasons may explain the low number of patients donating blood, and more particularly, donating blood on the same day as the preoperative clinic attendance:
Social Work/Discharge Planning
Patients received a social work/discharge planning questionnaire as part of the package. They were asked to complete this and submit it on arrival at need the clinic. Those patients who indicated the to see a social worker should have had this arranged at the clinic. The need for a social work assessment was identified by 19% of the respondents. Consultation with the social worker on the day of the clinic was arranged for 83% of those patients expressing the need. Eighty per cent of patients who saw the social worker believed that they had sufficient information about accommodation, transport and financial options. All of the patients who were seen by the social worker reported having received sufficient information about community services available on discharge.
The nursing staff conducted a program that consisted of a tape-slide presentation followed by discussion and question time.
The patients were encouraged to bring to the session the person who would be their primary carer during the postoperative period. Eighty-seven per cent of the patients found this session very helpful, 10% thought it helpful, and 3% were not helped by the session. Figure 2. illustrates these results.
Figure 2.
The education session was complemented by the distribution of the 'Cardiothoracic Surgery Patient Handbook'. Patients also received instruction on preoperative skin preparation and were given a bottle of antiseptic soap.
The physiotherapy component of the clinic assessed each patient's respiratory and musculo-skeletal status, and educated patients on postoperative physiotherapy and early mobilisation. Spirometry was performed and breathing and secretion clearing techniques were taught. A written copy of the exercises was also provided. Ninety per cent of the patients responded that they found the information, given to them by the physiotherapists, adequate. The time allowed for the physiotherapy education was considered sufficient by 86% of respondents.
The overall evaluation of the preoperative clinic was positive, with 98% of the patients reporting that they understood what to expect during their hospital stay. Discharge expectations were also well understood by 97% of the respondents.
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The evaluation of the clinic was positive with no major problems indicated. Several improvements have been made to the services of the clinic subsequent to this evaluation:
Changes have also been made due to the increased number of patients attending the clinic. The increase is attributable to the referral of country patients for preoperative assessment and education immediately after having coronary angiography, before returning home. These patients are fully investigated at the clinic and their results are checked prior to their admission.
Overall, the aims of the clinic are being met. The majority of patients who have attended the preoperative clinic are admitted one day preoperatively. The admission process is more streamlined, with patients well prepared for surgery on admission to hospital.
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