Pre-admission Clinic Research Articles

Effect of an e-Learning Tool on Expectations and Satisfaction Following Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundOrthopedic surgeons recognize patient expectations of total knee arthroplasty (TKA) can be managed through education. E-learning is the application of educational technology. The objective of this study was to evaluate whether an e-learning tool could affect whether patients’ expectations were met and they were satisfied 1 year following TKA. MethodsPatients with osteoarthritis from the London Health Sciences Centre, Canada, were randomly assigned to either a control group (n = 207) receiving standard patient education or an intervention group (n = 209) using the e-learning tool in addition to the standard. We used a web-based system with permuted block sizes, stratified by surgeon and first or second TKA. Preoperative measures were completed following the patients' preadmission clinic visit. Postoperative patient-reported outcome measures were completed at 6 weeks, 3 months, and 1 year after TKA. One year after TKA, risk difference was used to determine between-group differences for patient satisfaction and expectations being met. ResultsOne year postoperatively, the risk that expectations of patients were not met was 21.8% in the control group and 21.4% in the intervention group for an adjusted risk difference of 1.3% (95% confidence interval, −7.8% to 10.4%, P = .78). The proportion of patients satisfied with their TKA at 1 year postoperative was 78.6% in the intervention and 78.2% in the control groups. ConclusionThere was no between-group difference at 1 year between intervention and control groups for either the risk that expectations of patients were not met or the proportion of patients who were dissatisfied with their TKA.

Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial

ObjectiveTo assess the efficacy of a single preoperative physiotherapy session to reduce postoperative pulmonary complications (PPCs) after upper abdominal surgery.DesignProspective, pragmatic, multicentre, patient and assessor blinded, parallel group, randomised placebo...

Ultrasound Identification of Diaphragm by Novices Using ABCDE Technique.

In this study, we examined the consistency, rapidity, and reproducibility of the ABCDE technique for diaphragm identification. Operators using this method place the probe at the Anterior axillary line, watch for Breathing (lung sliding), and then move the probe Caudally to identify the Diaphragm for Examination. A convenience sample of 100 patients was recruited from the preadmission clinic. Two novice operators each scanned the diaphragm using a linear ultrasound transducer in B-mode. Both operators completed the examination on all participants using the ABCDE technique, their times were averaged, and clinical success was defined as identification of the diaphragm in less than 2 minutes. An average of 33.7 seconds was taken to scan and identify the right hemidiaphragm (RD) (median, 25 seconds; 95% confidence interval, 28.8-38.5 seconds) with a 98% clinical success ratio, and an average of 46.9 seconds was taken to identify the left hemidiaphragm (LD) (median, 39.5 seconds; 95% confidence interval, 40.2-53.6 seconds) with a 97% clinical success ratio. In patients with a body mass index (BMI) of less than 30 kg/m, a 100% success ratio was seen when scanning the RD and 97% when scanning the LD. For those with a BMI of 30 kg/m or greater, a 94% success rate was seen when scanning the RD and 97% when scanning the LD. No clinically significant differences were found between the times required for scanning either side of the diaphragm, regardless of the BMI. The ABCDE technique demonstrates a fast, reliable, and simple method in which ultrasound can be used to visualize the diaphragm.

Prevalence and causes of preoperative anaemia in elective major surgery patients.

Preoperative anaemia is associated with increased morbidity and mortality in surgical patients. Recent national patient blood management guideline recommended screening surgical patients for anaemia, particularly iron deficiency anaemia, without reference to the prevalence of anaemia or iron deficiency anaemia in this patient population. To establish the prevalence and cause of preoperative anaemia in elective major surgery patients. Patients attending the anaesthetic pre-admission clinics from 1 July 2013 to 30 June 2014 prior to their major elective surgery in our institution were screened for anaemia and iron deficiency by measuring full blood count, iron studies and C-reactive protein. Patients who were anaemic were either further assessed in the haematology clinic or had their medical records reviewed to ascertain the cause of the anaemia. Of 1494 patients, 208 (13.9%) were anaemic, with a male predominance (70.7%); 57 (27.4%) of them had iron deficiency anaemia. Other common causes of anaemia include underlying malignancy (18.3%), end-stage renal failure (11.5%) and other chronic diseases (7.2%). In 53 patients (25.5%), the cause was unknown. Anaemia was most commonly found in patients scheduled for gastrointestinal surgery. Preoperative anaemia affects 13.9% of patients undergoing elective major surgery. The most common causes are iron deficiency and chronic diseases. The cause was unexplained in 25.5% of patients with anaemia. The prevalence of anaemia in different surgical specialties may have implications on the approach to screening, particularly in resource-limited areas.

Prevalence and predictors of persistent post-surgical opioid use: a prospective observational cohort study.

Post-surgical opioid prescribing intended for the short-term management of acute pain may lead to long-term opioid use. This study was undertaken to determine the prevalence of persistent post-surgical opioid use and patient-related factors associated with post-surgical opioid use. One thousand and thirteen opioid-naïve patients awaiting elective surgery in a tertiary private hospital in Sydney were enrolled. Preoperatively, patients completed a questionnaire comprising potential predictors of persistent post-surgical opioid use. Patients underwent surgery with routine perioperative care, and were followed up at 90 to 120 days after surgery to determine opioid use. Factors associated with opioid use were assessed with logistic regression. We had an overall response rate of 95.8% (n=970) of patients, of whom 10.5% (n=102) continued to use opioids at >90 days after surgery. On surgical subtype analysis, the prevalence of persistent opioid use was 23.6% after spinal surgery, and 13.7% after orthopaedic surgery. Four factors were independently associated with persistent post-surgical opioid use in a multivariate model: having orthopaedic (odds ratio [OR] 4.6, 95% confidence interval [CI] 2.0 to 10.8, <i>P</i> <0.001) or spinal surgery (OR 4.0, 95% CI 1.7 to 9.2, <i>P</i> <0.001), anxiety (OR 2.1, 95% CI 1.1 to 4.1, <i>P</i>=0.03), attending pre-admission clinic (OR 3.7, 95% CI 1.6 to 8.6, <i>P</i>=0.002), and higher self-reported pain score at >90 days after surgery (<i>P </i> <0.001). More than 10% of opioid-naïve patients undergoing elective surgery experience persistent post-surgical opioid use. Identification of factors associated with persistent post-surgical opioid use may allow development of a risk stratification tool to predict those at highest risk.

Rates, Causes, and Reduction of 30-Day Readmissions of Otolaryngology-Head and Neck Surgical Cases.

ObjectivesThe aim of this study was to determine risk factors associated with 30-day readmission for patients undergoing inpatient otolaryngologic head and neck surgery.Study DesignRetrospective cohort study analysis.SettingStudy at 2 tertiary hospitals.MethodsA 10-year retrospective cohort analysis was performed for 30-day readmissions of otolaryngology surgical cases between July 1, 2006, and June 30, 2016, at Assir Central Hospital and Abha Private Hospital. Data included total number of patients, type of surgical procedure, number of and reasons for readmissions, and length of hospital stay.ResultsThere were 32,662 discharges for otolaryngology operations over the 10-year period of the study, of which 364 patients were readmitted, giving a rate of 11.14 readmissions per 1000 operative procedures (95% CI, 10.1-12.3). The male:female ratio was 1.4:1. Period of postoperative stay ranged from 1 to 3 days and, after readmission, 2 to 5 days. The main reasons for readmission were bleeding in otolaryngologic cases and wound hematoma in head and neck surgical cases. Overall readmission rates dropped significantly from 12.72 per 1000 operative procedures in the first 5 years to 10.16 in the second 5 years.ConclusionsThis study helped to establish special policies and procedures to prevent readmission by utilizing best practices, including addressing quality care, using preadmission clinics, preventing surgical site infection, and improving communication with community physicians. Plans based on these results also include the development of national model for predicting readmission within 30 days of discharge.

Knowledge of and willingness to try acupuncture for postoperative nausea and vomiting: an Australian survey of surgical patients.

Level 1 evidence supports the use of acupuncture as a safe and effective treatment for postoperative nausea and vomiting (PONV). However, to date, very few hospitals in Western countries have incorporated this technique into their management strategies. To conduct a survey to establish patients' knowledge and opinions of acupuncture as a treatment option for the management of PONV in a large Western teaching hospital that did not offer acupuncture. Over a 4-week period, a self-completed, anonymous questionnaire survey was distributed to 171 consecutive patients attending the preadmission clinic pending surgery. Overall, 161 participants met the selection criteria and completed the survey (100%). The majority of them had a European background (88.8%) and were over 40 years old (87.6%). Seventy-eight participants (48%) had a history of nausea and vomiting and 39 (24%) had suffered from PONV. One hundred and four (65%) and 110 (68%) patients, respectively, stated that they would be willing to try acupuncture in hospital or at home following surgery to prevent or reduce PONV. Only 25 (15.5%) participants knew that acupuncture could be used to treat nausea and vomiting; however, 140 (87%) indicated that they would be willing to try the therapy after being informed of the potential benefit of acupuncture for PONV prevention/reduction. Those with previous experience of acupuncture were ~3.9 times more likely to be willing to use acupuncture for PONV than those without. Patients attending an Australian tertiary hospital showed an overwhelming interest in acupuncture to manage PONV. This provides strong support for the potential implementation of acupuncture in an acute hospital setting.

Pharmacist charting in the preadmission clinic of a Sydney teaching hospital: a pilot study

AbstractAimTo trial a pharmacist charting service, comprising medication charting, in the preadmission clinic (PAC) at a Sydney teaching hospital.MethodsA prospective pre/post‐trial was conducted comprising a 1‐month baseline audit and a 1‐month trial of pharmacist charting (i.e. pharmacists' preparation of patients' medication charts during routine consultations). Purpose‐designed data collection forms were used to document: pharmacist and doctor consultation times, time taken by pharmacists to prepare medication charts, and completeness and accuracy of the prescribed medication charts. A semi‐structured survey was used to elicit feedback from PAC staff regarding the pharmacist charting service; the data were thematically analysed using manual, inductive coding.ResultsSeventy‐two medication charts were completed by PAC pharmacists during the 1‐month trial. Completeness of charts improved post‐intervention (5.4 vs 80.6%, p &lt; 0.001), as did the accuracy of charts (proportion of charts with inaccuracies: 41.1 vs 1.4%, p &lt; 0.001); only one (1.4%) pharmacist‐prescribed medication chart was identified as having an inaccuracy. The changes in mean consultation times per patient for doctors and pharmacists, respectively, changed from pre‐ to post‐intervention as follows: pharmacists 18.9 ± 6.5 min to 20.6 ± 8.3 min (p = NS); and doctors 25.0 ± 9.6 min to 19.0 ± 6.4 min (p &lt; 0.001). A statistically significant relationship was found between pharmacist consultation time and patients' numbers of medications (p &lt; 0.001) and age group (p = 0.004).ConclusionPharmacist charting in the PAC has been shown to improve medication chart completeness and accuracy, helping to ensure medication safety in the hospital setting. A further, long‐term trial will help confirm the clinical benefits of such a service.

Physiotherapy education and training prior to upper abdominal surgery is memorable and has high treatment fidelity: a nested mixed-methods randomised-controlled study

ObjectivesTo (1) assess memorability and treatment fidelity of pre-operative physiotherapy education prior to elective upper abdominal surgery and, (2) to explore patient opinions on pre-operative education. DesignMixed-methods analysis of a convenience sample within a larger parallel-group, double-blinded, randomised controlled trial with concealed allocation and intention-to-treat analysis. SettingTertiary Australian hospital. ParticipantsTwenty-nine patients having upper abdominal surgery attending pre-admission clinic within six-weeks of surgery. InterventionThe control group received an information booklet about preventing pulmonary complications with early ambulation and breathing exercises. The experimental group received an additional face-to-face 30-minute physiotherapy education and training session on pulmonary complications, early ambulation, and breathing exercises. Outcome measuresPrimary outcome was proportion of participants who remembered the taught breathing exercises following surgery. Secondary outcomes were recall of information sub-items and attainment of early ambulation goals. These were measured using standardised scoring of a semi-scripted digitally-recorded interview on the 5th postoperative day, and the attainment of early ambulation goals over the first two postoperative days. ResultsExperimental group participants were six-times more likely to remember the breathing exercises (95%CI 1.7 to 22) and 11-times more likely (95%CI 1.6 to 70) to report physiotherapy as the most memorable part of pre-admission clinic. Participants reported physiotherapy education content to be detailed, interesting, and of high value. Some participants reported not reading the booklet and professed a preference for face-to-face information delivery. ConclusionFace-to-face pre-operative physiotherapy education and training prior to upper abdominal surgery is memorable and has high treatment fidelity.Trial Registration: ACTRN-12613000664741.

Do Patients Understand the Role of Resident Physicians in the Operating Room? A Survey of Gynaecology Patients

ObjectiveStudies from disciplines outside gynaecology have found that most patients do not understand the clinical responsibilities allocated to physicians-in-training. No research on this topic has been published in gynaecology, despite litigation against gynaecological surgeons regarding the role of residents in surgery. The goal of this research was to explore what gynaecological surgery patients understand about the role of resident doctors. MethodsA questionnaire was distributed to female patients in gynaecological surgery pre-admission clinics in Edmonton, Alberta. Surveys included knowledge and opinion statements about residents' duties. Anonymous responses were entered into a secure database. Descriptive statistics were used to characterize the results. ResultsOf 108 participants, 83% understood that residents had a higher level of training than medical students, yet 40% were unsure whether residents were doctors. Almost one half (43%) of participants were uncertain whether residents required supervision, including while operating (20%). Most (92%) believed it was important to know their physician's level of training, yet only 63% reported knowing this information. Only 50% of participants would be comfortable with residents operating on them under supervision. A considerable number (56%) wanted to learn more about residents' roles. ConclusionPatients do not fully understand the role of residents, and many are uncomfortable with trainees operating on them under supervision. Considering the significant role of residents in patient care, educating patients is essential to improve their comfort and the overall consent process.

P613Nurse-led pre-admission clinics for percutaneous coronary intervention (PCI) patients are beneficial and are positively evaluated by patients

P613Nurse-led pre-admission clinics for percutaneous coronary intervention (PCI) patients are beneficial and are positively evaluated by patients

Long-term effectiveness of the preoperative smoking cessation programme at Western Health.

Smoking is associated with adverse effects in the perioperative period, including elevated risk of death. The perioperative period provides an opportunity to engage with patients who are smokers to encourage smoking cessation, often referred to as a 'teachable moment'. We developed a smoking intervention model for the pre-admission clinic (PAC) at Western Health, Victoria, Australia. This case series aimed to assess the impact of the smoking intervention model, which is standard of care, on the participant's smoking habits over four time points. We enrolled 50 consecutive participants for elective surgery who were smokers and had attended PAC at Western Health, Footscray. All smokers were offered a standard intervention package to address their smoking. Participants underwent a brief interview to elicit their current smoking behaviour on their day of surgery, 3 and 12 months post-operatively. We found a reduction at each time point post-intervention in the average number of cigarettes smoked per day by all participants with a 43% reduction at 12 months compared with PAC. We found that the number of participants who had quit increased at each time point, with 29% abstinent at 12 months post-operatively. At 12 months, we found 71% of participants had either quit or reduced the number of cigarettes smoked compared with the amount reported at PAC. This study adds to the evidence that a simple intervention preoperatively can contribute to long-term changes in smoking behaviour.

P819Outcome of a streamlined care pathway for patients with previously undetected atrial fibrillation (AF) in surgical pre admission clinics (PAC) with dedicated cardiac rhythm management

P819Outcome of a streamlined care pathway for patients with previously undetected atrial fibrillation (AF) in surgical pre admission clinics (PAC) with dedicated cardiac rhythm management

Improving patient flow and satisfaction: An evidence-based pre-admission clinic and transfer of care pathway for elective surgery patients

AimsTo redesign, implement and evaluate a Pre-Admission Clinic incorporated with a Transfer of Care Pathway for elective surgery patients. MethodsAn evidence-based approach was used to redesign the Pre-Admission Clinic and the Transfer of Care Pathway. The impact of the pre-admission clinic and the care pathway was evaluated. De-identified data containing patient outcomes was collected from the hospital electronic medical record system from May 2014 to March 2015. Outcome measures included surgical cancellations, last-minute cancellations, average length of stay, discharge delays, and adverse events that were compared pre and post-implementation. Patient satisfaction was measured pre and post-implementation by using a modified version of Best Practice hospital survey. ResultsA total of 10,854 eligible cases were included (5716 in the pre-implementation period and 5138 in the post-implementation period). The overall cancellation rate remained relatively stable (p=0.95), however, the last-minute cancellation rate was reduced post-implementation (p=0.02). Although no difference was observed in average length of stay (p=0.39), the percentage of discharge delays was reduced (p=0.027). The incidence of adverse events was too low to draw statistical conclusion. A sample of 102 patients completed the patient satisfaction survey. The overall satisfaction improved post-implementation (p=0.03). ConclusionsThe evidence-based Pre-Admission Clinic and the Transfer of Care Pathway had a positive impact on last-minute surgical cancellations, discharge delays and patient satisfaction.

The Role of Residents in the Gynecologic Operating Room – What Do Patients Understand? [5O

INTRODUCTION: Studies in emergency medicine show that patients believe it is important to know the training level of their doctor, but most do not understand the responsibilities of physicians-in-training. No research on this topic has been published in gynecology, even though gynecological surgeons have been sued by patients alleging they did not understand the role of residents in their surgery. The goal of this research was to explore what gynecological surgery patients understand about the role of resident doctors. METHODS: A questionnaire was distributed to female patients in pre-admission clinics awaiting gynecological surgery in Edmonton. Surveys included knowledge and opinion-based questions about resident duties. Anonymous responses were entered into a REDCap database. Descriptive statistics were used to characterize the results. RESULTS: Of 108 participants, 83% understood that residents had a higher level of training than medical students, yet 40% were unsure if residents were doctors. Almost half (43%) were uncertain if residents required supervision, including while operating (20%). The majority (92%) felt it was important to know their physician's level of training, yet only 63% reported actually knowing this information. Only half of participants would be comfortable with residents operating on them under supervision. A considerable number (56%) wanted to learn more about residents' roles. CONCLUSION: Patients do not fully understand the role of residents and many are uncomfortable with trainees operating on them under supervision. Considering the significant role of residents in patient care, educating patients is essential to improve their comfort and the overall consent process.

Low pre-operative heart rate variability and complexity are associated with hypotension after anesthesia induction in major abdominal surgery.

Significant hypotension after induction of general anesthesia is common and has the potential for serious complications. This study aimed to determine if pre-operative heart rate variability (HRV) was associated with post-induction hypotension in patients undergoing major abdominal surgery. Patients undergoing semi-elective major abdominal surgery were consecutively recruited during pre-admission clinic assessment. Exclusion criteria included cardiac conduction disease, arrhythmias or severe liver or renal disease. Ten minutes of electrocardiogram at 1024Hz were recorded a median of 3 days pre-operatively. Pre-operative HRV parameters were compared in patients who experienced significant hypotension (fall in systolic and mean arterial pressure (MAP) >30% baseline and MAP ≤60mmHg) versus those who remained haemodynamically stable after induction of general anesthesia with propofol and fentanyl. Patients who experienced hypotension after general anesthesia induction had significantly lower pre-operative HRV (SDNN 16 vs. 37ms, p < 0.001), reduced spectral power (total power 262 vs. 1236 ms2, p = 0.002) and reduced correlation dimension, a measure of signal complexity (0.11 vs. 2.13, p < 0.001). Hypotension occurred relatively frequently in our cohort and was associated with a higher ASA grade (36 vs. 6% ASA 3, p = 0.036), hence post-induction hypotension and lower HRV may be associated with severity of illness or poor physiological reserve. Pre-operative HRV was a useful screening tool in identifying patients undergoing major abdominal surgery who were at risk of haemodynamic instability after anesthesia induction.

Use of the Montreal Cognitive Assessment Test to Investigate the Prevalence of Mild Cognitive Impairment in the Elderly Elective Surgical Population

Postoperative cognitive disorders are common in elderly patients. Pre-existing cognitive impairment including mild cognitive impairment may be an important risk factor for developing postoperative cognitive dysfunction and may not be detected in a standard preoperative interview, yet is not routinely sought. Our primary aim was to estimate the prevalence of mild cognitive impairment among elderly patients presenting to our hospital for elective surgery using a simple established screening tool: the Montreal Cognitive Assessment test. Secondarily, we wished to determine the proportion of patients with mild cognitive impairment who presented with this information available, the effect of increasing age on the prevalence of mild cognitive impairment and whether the timing and location of testing influenced results. We used the Montreal Cognitive Assessment test to screen preoperative patients aged 65 years and over. Our results suggested a potential prevalence of mild cognitive impairment of 56%, with prevalence increasing with age. No patients in the sample had a recorded diagnosis of mild cognitive impairment. Testing in either the preadmission clinic or on admission on the day of surgery yielded similar results. We found the Montreal Cognitive Assessment test to be a simple screening tool that was easily administered during the pre-admission visit.

Use of the Montreal Cognitive Assessment test to investigate the prevalence of mild cognitive impairment in the elderly elective surgical population.

Postoperative cognitive disorders are common in elderly patients. Pre-existing cognitive impairment including mild cognitive impairment may be an important risk factor for developing postoperative cognitive dysfunction and may not be detected in a standard preoperative interview, yet is not routinely sought. Our primary aim was to estimate the prevalence of mild cognitive impairment among elderly patients presenting to our hospital for elective surgery using a simple established screening tool: the Montreal Cognitive Assessment test. Secondarily, we wished to determine the proportion of patients with mild cognitive impairment who presented with this information available, the effect of increasing age on the prevalence of mild cognitive impairment and whether the timing and location of testing influenced results. We used the Montreal Cognitive Assessment test to screen preoperative patients aged 65 years and over. Our results suggested a potential prevalence of mild cognitive impairment of 56%, with prevalence increasing with age. No patients in the sample had a recorded diagnosis of mild cognitive impairment. Testing in either the preadmission clinic or on admission on the day of surgery yielded similar results. We found the Montreal Cognitive Assessment test to be a simple screening tool that was easily administered during the pre-admission visit.

A Pilot Study to Assess the Appropriateness of Prescribing From a Collaborative Pharmacist Prescribing Study in a Surgical Pre Admission Clinic

Background: Current evidence to support non-medical prescribing is predominantly qualitative, with little evaluation of appropriateness. This study aims to evaluate the appropriateness of prescribing, and significance of omissions, from a doctor pharmacist collaborative prescribing model in an elective surgery pre admission clinic (PAC). Method: A modified version of the Medication Appropriate Index (MAI) was developed, piloted and subsequently used by an expert panel, comprised of a surgeon, anaesthetist, clinical pharmacologist, pharmacist, resident medical officer (RMO) and clinical nurse. The tool was used to rate the appropriateness of prescribing of medications, and the significance of omissions in a 5% sample (N=19) of the total cohort from a randomised, controlled two arm trial of doctor-pharmacist collaborative prescribing. Results: When reviewer assessments were combined, 32 out of 294 (10.9%) medications assessed for appropriateness in the control arm were classed as inappropriate, compared to 13 of 266 (4.9%) in the intervention arm. Out of 89 regular medications in the control arm, 25 (28%) were omitted from the medication charts, compared to 1 out of 55 (2%) in the intervention arm (p<0.001, fishers exact) On average, 52% of omissions in the control arm were judged to have potential for patient harm or ward inconvenience. Conclusion: For the appropriateness of prescribing, overall results were similar between arms, as judged by individual panel members. Medication charts in the control arm contained significantly more omissions than in the intervention arm, a number of which were rated by the panel members as having the potential for patient harm or ward inconvenience.

Improving Quality and Safety through Positive Patient Identification.

The World Health Organization recognizes that patient misidentification can contribute to medication, surgical and charting errors. Accreditation Canada has set national standards and the Joint Commission on Accreditation of Healthcare Organizations has listed patient identification as a national patient safety goal. A qualitative and observational evaluation of patient identification practices in the Pre-Admission Clinic, Admitting Department and the Perioperative Care Center uncovered confusion, with 90% (n = 55) of patient verification occurrences not matching current policies. These discrepancies identify an opportunity to reassess and standardize workflow, clarify what identification methods are acceptable and determine additional appropriate identification verification practices with ID bracelets and patient charts.