The systematic review of the effectiveness and meaningfulness of telephone pre-operative assessment for adults.

Abstract

REVIEW OBJECTIVES/QUESTIONS: This review aims to answer two specific questions: Is telephone preoperative assessment as effective as face-to-face preadmission clinic visits in terms of preparing the patient for elective surgery? What are the perioperative experiences of adult patients who have received telephone based preoperative preparation prior to elective surgery? BACKGROUND: The preparation of the patient for any surgery is an extremely important part of the perioperative process. Although elective surgery is a non-emergency procedure, it may fall into different categories of urgency (urgent, semi-urgent and non-urgent) which will determine the time frame in which a person should be operated on1. This creates variability in the amount of time available to preoperatively prepare the patient (physically, mentally and socially) to maximise opportunities for achieving an optimal state of preparedness for their surgical procedure. Elective surgery can be performed as day surgery, where the patient and procedure meet specific criteria to allow for procedure and discharge on the same day2, or inpatient surgery, which is where the patient is admitted to hospital for a stay that is greater than 24 hours3. Elective surgery is a key focus of activity for health providers worldwide; in Australia alone, elective surgery admissions were estimated to be around 1.8 million in 2008-9,4 and worldwide there was an estimated 281 million surgical operations in 2004 in 56 countries5. Traditionally all patients were admitted to hospital the night before surgery. This was resource intensive, with the requirement for hospital beds to be available for surgical lists the night before surgery. Preadmission (preoperative assessment) clinics were established in the early 1990s to achieve optimal patient preparation for surgery prior to being admitted on the day of surgery while also providing significant organizational benefits, such as fewer cancelled operations on the day of surgery, more effective booking procedures and theatre scheduling and utilization, and reduced lengths of stay6. The preadmission appointment (which may be face-to-face, via the telephone or take other formats) allows the patient to be reviewed by nursing staff and, where applicable, a member of the anaesthesia medical team, to ensure that the patient is in an optimal state of health prior to their surgery and that they are also psychologically and socially (such as work and family arrangements) prepared. This consultation should be timely and take into account the patient's comorbidities, the surgery and anaesthetic to be performed, and inform the facility's ability to manage the patient postoperatively 7-8. Nurses undertake a nursing assessment of patient's needs and provide education regarding fasting procedures, any other preparatory procedures such as antimicrobial showering and bowel preparations, medications to be administered prior to surgery, postoperative exercises and discuss postoperative expectations such as postoperative nausea and vomiting and pain management. They also check the correct side and site of surgery and that a valid consent is in place. It is also important to discuss the patient's expectations and perceptions about their procedure and postoperatively to address any concerns that they might have 9. Anxiety and fear regarding surgery are common, and nursing staff provide psychosocial support to allay these emotions 10. It has been demonstrated that there are key factors to patient satisfaction in their hospital experience11. Some of these factors include consideration, privacy and respect, effective communication, staff that patients can trust, successful pain control, fast access to advice, involvement in decision making, information that is clear and understandable, emotional support, relief of anxiety, involvement of significant family or friends and smooth transitions between care 11. With increasing numbers of elective surgical patients worldwide, there have been alternate systems trialled and put in place to address ways to manage the preadmission of patients without compromising their safety. A system that is commonly used is to send a paper based questionnaire out, or give it to the patient at the time they see their surgeon, with a request that the patient completes and return it to the hospital. These questionnaires are then reviewed by preadmission nurses who determine if any further assessment by telephone or face-to-face interview, or no further verbal contact is required 6, 12. Instructions to patients are often mailed out to confirm fasting schedules, time of arrival to the facility, medication management and other relevant information for the patient 12. There have been significant advances in communication technologies since the 1990s. In regard to preadmission preparation for surgery, there has been an exploration of the use of new technologies to aid in the preoperative management of patients. The use of touchtone telephone 13 and computerbased questionnaires 14 are two forms of different methods of assessment that have been implemented into practice. For the education of the patient there are a number of different formats such as written, audio-visual and computer-assisted instructions and learning packages to facilitate increased knowledge and the ability to perform postoperative activities 15. Telephone based preoperative preparation is becoming more prevalent worldwide, as a means of managing large numbers of preoperative patients in an efficient manner. With the utilisation of this service there is less physical space required and different staffing models can be developed to enhance efficiency, such as that used by the UK's National Health Service 6. In this system, those patients that are selected for telephone assessment are screened to determine those who meet set criteria such as specific age range, blood pressure, body mass index and general health status, and who are, thus, perceived as low risk 6, 12, 16. A structured protocol devised by individual health services may be used to conduct the assessment and ensures that all health service and patient needs are met 6.Telephone based preoperative evaluation is seen as being highly valuable for the rural population who may have to travel lengthy distances to attend clinics 17. It has also been noted that this format of assessment can also alleviate hospital parking problems, allows the patient the convenience of being in their own home, and to have contact at a time that is suitable for them 6. In the event that a patient is assessed with risk factors by the telephone assessment process they are then referred to the face-to-face clinic 6, 12. Despite the amount of work that has been undertaken validating the use of telephone in the evaluation of the preoperative patient 6, 16, 18, there have been concerns expressed by nurses that some aspects of communication are lost 19. These include the observation and interpretation of nonverbal behaviours that indicate lack of understanding, anxiety and fear surrounding the patient's impending surgery. There is also concern about the preparedness of patients for theatre in regard to compliance with preadmission procedures and postoperative activities, the level of knowledge demonstrated regarding their procedure and consent for anaesthesia (informed consent), pain management and patient expectations regarding discharge planning. Systematic reviews have been conducted into the effectiveness and best practice in regard to preadmission for day surgery 20, routine preoperative testing 21, knowledge retention from preoperative patient information 15, the use of telephone consultation and triage in an Emergency Department context 22, telemedicine (in chronic disease) versus face to face patient care 23 and nurseled preadmission 24. However, there is currently no evidence synthesis comparing the impact of telephone with face-to-face consultations for preadmission assessment for surgery. OBJECTIVES This review will examine the best available evidence in regard to preoperative telephone patient assessment and preparation to determine the impact of this intervention on patient knowledge and expectations of their surgery and anaesthesia, compliance with preoperative and postoperative preparations, their levels of fear and anxiety, reduction in cancellations on day of surgery in comparison to face-to-face assessment. This review will also examine the patient experiences and satisfaction with this method of assessment. Thus both the evidence related to effectiveness and meaningfulness of telephone preoperative preparation on patient preparedness for elective surgery will be explored and synthesized. This will include a comparison of telephone assessment with face to face consultation in the preoperative preparation of the adult patient in day of surgery admission patients. GLOSSARY Preoperative assessment: A process to determine whether a patient is suitable for surgery and anaesthesia, and by which the patient is informed about their surgical procedure. Elective surgery: Surgical non-emergency procedure required by patients and planned at least 24 hours in advance of the procedure time. Emergency admission: A not booked or planned patient admission to hospital, usually through an emergency department or casualty. Day surgery: It refers to that process by which patients are admitted for planned surgery on the day of the procedure and in which the discharge is scheduled for the same day. Inpatient: A patient admitted to hospital that stays at least one night in a hospital facility before being discharged. INCLUSION CRITERIA: Types of Participants: For both the quantitative and qualitative components this review will consider studies that include adult (> 18 years) patients having elective day or inpatient surgery in a hospital setting who have had a telephone preoperative consultation or face-to-face preadmission clinic visit. Emergency surgery is to be excluded. Phenomena of interest: The qualitative component of this review will focus on the experiences of patients who have utilised telephone based preoperative assessment. The quantitative component will focus on the comparison of effect of telephone-based patient preparation for elective surgery with face-to-face preparation. Type of outcome: The quantitative component of the review will consider studies that include the following outcome measures related to the patient preparation for surgery including: patient understanding and expectations of postoperative pain, nausea, anxiety, medication management and discharge planning knowledge of procedure and anaesthetic, and informed consent informed consent anxiety pain management medication management patient understanding and compliance with preoperative and postoperative activities Types of studies: The quantitative component of the review will consider any randomised controlled trials (RCTs); in the absence of RCTs, other research designs, such as non-randomised controlled trials and before and after studies, will be considered for inclusion in a narrative summary where applicable to enable the identification of current best evidence regarding telephone based preoperative assessment. The qualitative component of the review will consider interpretive studies that draw on the experiences of adult elective ambulatory and inpatient surgery patients including, but not limited to, designs such as phenomenology, grounded theory, ethnography and action research. SEARCH STRATEGY The search strategy aims to find both published and unpublished English-language studies. The search will be limited to 2000 to present. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: AIHW Bandolier BestBETS Campbell Collaboration Library (CENTRAL) (The Cochrane Library) CINAHL Clinical Evidence Clinical Trials DARE EBM Reviews EMBASE HTA JBI Library of Systematic Reviews MEDLINE PsychINFO TRIP Web of Science Mednar The search for unpublished studies will include: Current Controlled Trials Postgraduate theses New York Academy of Medicine Library Grey Literature Report TRoPHI Clinicaltrials.gov Government documents, relevant organisational documents such as NICE/ANZCA/ ACORN/ RACS/ NHS/ AAGBI/ AORNNational Institute for Health Research Australian New Zealand Clinical Trials Registry (ANZCTR) Review the reference lists of all studies to search for additional studies Initial keywords to be used will be: (Preoperative OR preadmission) AND (Assessment OR prescreening OR workup) (Preoperative OR Perioperative) AND (care OR nursing OR preparation OR teaching OR procedures) Day of surgery admission Adult patient assessment tools Nursing assessment Surgery preparation Ambulatory care Preoperative phone calls Information resources (Telephone OR face-to-face OR alternative methods) AND (assessment OR prescreening) Telenursing/ telehealth Clinical competence Perioperative pain management Perioperative patient knowledge Perioperative anxiety Informed consent Inpatient care Key outcomes (pain etc) Patient admission Patient education/ preparation/ training Patient management Patient acceptance Patient attitudes Patient experience Patient perspective Patient satisfaction Postoperative Discharge planning ASSESSMENT OF METHODOLOGICAL QUALITY Quantitative and qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) for quantitative studies (Appendix I) and the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix II). DATA EXTRACTION: Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to the inclusion in the review using the standardised critical appraisal instruments from the Joanna Briggs Institute. Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix III). Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument JBIQARI (Appendix IV). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. DATA SYNTHESIS: Quantitative papers will, where possible, be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Qualitative research findings will, where possible, be pooled using the Qualitative Assessment and Review Instrument (JBI-QARI). This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rates according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a metasynthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidencebased practice. Where textual pooling is not possible the findings will be presented in narrative form. CONFLICTS OF INTEREST: None known.