Pre-admission Clinic Research Articles

Pharmacist E-script transcription service initiated nicotine replacement therapy uptake in pre-admission clinic: A pilot study.

Pharmacist-led smoking cessation programs in pre-admission clinics (PAC) have shown to increase quit attempts and achieve abstinence by the day of surgery (DOS). To evaluate the feasibility of Pharmacist E-script Transcription Service (PETS) initiated nicotine replacement therapy (NRT) in PAC, including smoking cessation on DOS. A single centre, pre and post-intervention pilot study conducted at an Australian public hospital PAC. In a two-month intervention period, PAC nursing staff invited smokers (≥1 cigarette/day) to see a smoking cessation PET pharmacist. Pharmacist-initiated NRT and Quitline© referrals were offered. Cessation outcomes were compared with the preceding two-month control period. feasibility of intervention. DOS smoking abstinence rates and three-months post-surgery. PAC nurses identified 112 smokers over 4 months; 53 during pre-intervention period, and 59 during intervention period. Twenty-two intervention patients (37%) accepted seeing the pharmacist, with 16 subsequent Quitline© referrals (73%) and 11 NRT prescriptions (50%) written. The median nursing smoking status documentation time increased in the intervention period (1 min vs. 4, p < .001). The intervention did not impact pharmacist's workload. Verified abstinence increased from 8.5% (4/47) pre-intervention to 9.4% (5/53) post-intervention, p =1.00. Relapse rates in the intervention period increased (20% vs. 50%) at three-months post-surgery. A PETS-initiated NRT program in PAC is feasible and increased preoperative use of NRT and Quitline© with minimal impact on smoking cessation. SO WHAT?: This study has highlighted the importance of implementing a multidisciplinary smoking cessation program in PAC however, larger studies are needed to determine the true impact of the program on smoking cessations.

Preoperative Anesthesia Virtual Video Consultations in a Preadmission Clinic: Quality Improvement Study.

The preadmission clinic (PAC) is crucial in perioperative care, offering evaluations, education, and patient optimization before surgical procedures. During the COVID-19 pandemic, the PAC adapted by implementing telephone visits due to a lack of infrastructure for video consultations. While the pandemic significantly increased the use of virtual care, including video appointments as an alternative to in-person consultations, our PAC had not used video consultations for preoperative assessments. This study aimed to develop, implement, and integrate preoperative video consultations into the PAC workflow. A prospective quality improvement project was undertaken using the Plan-Do-Study-Act (PDSA) methodology. The project focused on developing, implementing, and integrating virtual video consultations at London Health Sciences Centre and St. Joseph Health Care (London, Ontario, Canada) in the PAC. Data were systematically collected to monitor the number of patients undergoing video consultations, address patient flow concerns, and increase the percentage of video consultations. Communication between the PAC, surgeon offices, and patients was analyzed for continuous improvement. Technological challenges were addressed, and procedures were streamlined to facilitate video calls on appointment days. The PAC team, which includes professionals from medicine, anesthesia, nursing, pharmacy, occupational therapy, and physiotherapy, offers preoperative evaluation and education to surgical patients, conducting approximately 8000 consultations annually across 3 hospital locations. Following the initial PDSA cycles, the interventions consistently improved the video consultation utilization rate to 17%, indicating positive progress. With the onset of PDSA cycle 3, there was a notable surge to a 29% utilization rate in the early phase. This upward trend continued, culminating in a 38% utilization rate of virtual video consultations in the later stages of the cycle. This heightened level was consistently maintained throughout 2023, highlighting the sustained success of our interventions. The quality improvement process significantly enhanced the institution's preoperative video consultation workflow. By understanding the complexities within the PAC, strategic interventions were made to integrate video consultations without compromising efficiency, morale, or safety. This project highlights the potential for transformative improvements in health care delivery through the thoughtful integration of virtual care technologies.

Do patients with osteoarthritis lose weight prior to elective joint replacement?

Obesity is a known risk factor for the development of osteoarthritis and the subsequent need for joint replacement. Weight loss has been shown to reduce pain, disability, and the need for joint replacement, particularly in patients with knee osteoarthritis. The aim of this study was to investigate pre-operative weight change in patients with hip, knee, and shoulder osteoarthritis at a regional, public hospital in Australia, to identify opportunities for pre-operative weight-loss intervention. A retrospective review of patients who underwent elective primary total hip (THR), knee (TKR), and shoulder (TSR) replacement for osteoarthritis was conducted between December 2019 and December 2022. BMI data were collected at three time points: (1) general practitioner (GP) referral; (2) orthopaedic clinic review; and (3) pre-admission clinic (PAC) assessment. A total of 496 patients were included in the study, of which 205 underwent THR, 251 underwent TKR, and 40 underwent TSR. The mean patient age was 67 years, and 46.4% were female. At the time of GP referral, the mean body mass index (BMI) was 31.4 kg/m2. Across the study period, only 2% of patients experienced clinically significant weight loss pre-operatively (≥5% of total body weight). This study has demonstrated that very few patients lose weight prior to undergoing joint replacement in the public sector in Australia. This highlights the need for targeted non-surgical weight loss interventions for patients currently awaiting joint replacement.

Increasing access to cataract surgery in Counties Manukau by optimising the clinical pathway: a quality improvement report.

To streamline the cataract surgery pathway to improve the time from first specialist assessment (FSA) to surgery, while reducing the clinical priority assessment criteria (CPAC) score from 55 to 50. A quality improvement project using Lean Six Sigma tools and the Model for Improvement. Most data were collected from the i.Patient Manager (iPM) system and analysed using statistical process control charts. Change interventions included combining FSA and pre-admission clinics (PAC); post-operative telephone review by non senior medical officers (SMO); and using our own surgeons in private theatres. The standard cataract pathway was reduced from 5 to 3 appointments. This removed 1,514 hours of appointments, released 113 SMO hours and saved patients NZ$156,000 in indirect costs over a year. The average waiting time from FSA to surgery decreased from 90 to 77 days (-13.5%). The number of overdue patients reduced from 127 to 44 (-35%). The average number of patients on the FSA waiting list dropped from 322 to 205 (-40%). There was no change to the proportions of surgeries or appointment attendance rates by ethnicity. Average monthly cataract surgeries increased from 192 to 215 (+12%), and the CPAC score threshold was decreased to 50 in February 2021. Despite significant demand pressures, and the disruptions of COVID-19, we were able to reduce the CPAC score for accessing cataract surgery by optimising the clinical pathway to better utilise staff capacity and maximise value for patients.

Appointment scheduling in surgery pre-admission testing clinics

Pre-admission testing clinics are care units serving outpatients prior to surgical operation and performing procedure-specific tests to prepare them. Patients may need multiple tests, each performed by a specialized operator and delivered in any order. Exam rooms act as renewable resources: rooms are limited, tests are administered to patients inside the rooms, individually, and patients occupy the room until all the required tests are completed.Careful scheduling of patient appointments is essential in clinic management for both the patient and the provider: on the one hand, minimizing patient waiting time improves service quality, on the other hand, minimizing completion time (makespan) improves system efficiency.In this paper, we propose offline policies for the daily scheduling of pre-admission test appointments. As a benchmark, we consider two online scheduling policies widely used in common practice. Each of these offers a different compromise between complexity and resource exploitation.The proposed optimization-based offline booking policy is identified as a new problem in the machine scheduling literature, for which we propose a network-flow model representation. A family of matheuristics based on different variable fixing criteria is provided to circumvent the high computational effort required to solve the mathematical model to optimality on real-size instances. The performance, advantages and disadvantages of each of the online and offline policies are compared in a variety of scenarios based on realistic data.Through this work, decision-makers have a new set of tools they can choose from according to their priorities.

Interrater reliability of the Clinical Frailty Scale in the anesthesia preadmission clinic

PurposeAs many as 30% of patients with frailty die, are discharged to a nursing home, or have a new disability after surgery. The 2010 United Kingdom National Confidential Enquiry into Patient Outcome and Death recommended that frailty assessment be developed and included in the routine risk assessment of older surgical patients. The Clinical Frailty Scale (CFS) is a simple, clinically-assessed frailty measure; however, few studies have investigated interrater reliability of the CFS in the surgical setting. The objective of this study was to determine the interrater reliability of frailty classification between anesthesiologists and perioperative nurses.MethodsWe conducted a cohort study assessing interrater reliability of the CFS between perioperative nurses and anesthesiologists for elective surgical patients aged ≥ 65 yr, admitted to a large regional university-affiliated hospital in Australia between July 2020 and February 2021. Agreement was measured via Cohen’s kappa.ResultsFrailty assessment was conducted on 238 patients with a median [interquartile range] age of 74 [70–80] yr. Agreement was perfect between nursing and medical staff for CFS scores in 112 (47%) patients, with a further 99 (42%) differing by only one point. Interrater kappa was 0.70 (95% confidence interval, 0.63 to 0.77; P < 0.001), suggesting good agreement between anesthesiologists and perioperative nurses.ConclusionThis study suggests that CFS assessment by either anesthesiologists or nursing staff is reliable across a population of patients from a range of surgical specialities, with an acceptable degree of agreement. The CFS measurement should be included in the normal preanesthesia clinic workflow.

Prevalence and predictors of long-term opioid use following orthopaedic surgery in an Australian setting: A multicentre, prospective cohort study.

Opioid analgesics prescribed for the management of acute pain following orthopaedic surgery may lead to unintended long-term opioid use and associated patient harms. This study aimed to examine the prevalence of opioid use at 90 days after elective orthopaedic surgery across major city, regional and rural locations in New South Wales, Australia. We conducted a prospective, observational cohort study of patients undergoing elective orthopaedic surgery at five hospitals from major city, regional, rural, public and private settings between April 2017 and February 2020. Data were collected by patient questionnaire at the pre-admission clinic 2-6 weeks before surgery and by telephone call after 90 days following surgery. Of the 361 participants recruited, 54% (195/361) were women and the mean age was 67.7 years (standard deviation 10.1 years). Opioid use at 90 or more days after orthopaedic surgery was reported by 15.8% (57/361; 95% confidence interval (CI) 12.2-20%) of all participants and ranged from 3.5% (2/57) at a major city location to 37.8% (14/37) at an inner regional location. Predictors of long-term postoperative opioid use in the multivariable analysis were surgery performed at an inner regional location (adjusted odds ratio 12.26; 95% CI 2.2-68.24) and outer regional location (adjusted odds ratio 5.46; 95% CI 1.09-27.50) after adjusting for known covariates. Long-term opioid use was reported in over 15% of patients following orthopaedic surgery and appears to be more prevalent in regional locations in Australia.

Elective day of surgery cancellations: A retrospective observational study

Background Day-of-surgery (DOS) cancellations are a common and frustrating phenomenon for surgical patients globally. They are both costly to health systems and patients, causing inconvenience, decreased productivity, and emotional distress. In Australia, there are only few published literature that have explored DOS cancellations. Aim This study aimed to evaluate the frequency and reasons for DOS cancellations in a South-East Queensland tertiary hospital. Secondly, the study aimed to understand the characteristics of patients who have been cancelled on day of surgery. Methods A retrospective observational design was used to investigate elective day of surgery cancellations over one year, from January to December 2019. Variables collected included patients’ age, gender, ethnicity, socio-demographic status, carer responsibilities, attendance at pre-admission clinic (PAC), American Society of Anaesthesiologists status; surgical specialty; category of surgery; date of placement on elective surgery waitlist; ethnicity; suburb of residence; socio-demographic status derived from postcode, employment status, carer responsibilities for other(s); number of times of failure to attend past appointments; presentation at PAC; referrals to other services such as the pre-anaesthetic assessment nurse, nurse navigator or social worker and indigenous liaison health officer during the surgery planning phase, and reasons for cancellation. Mean and standard deviation were calculated to describe age. Frequencies and percentages were also reported. Findings Over 1 year, 5334 elective surgeries occurred: of these, 412 patients (8%) were affected by DOS cancellations. Hospital-initiated cancellations accounted for 32% (113/412) of total cancellations, including reasons such as patients’ condition, treatment no longer required or surgeons opting not to perform the procedure. The mean age of patients affected by cancellation was 58 years (SD 17.5). Male patients accounted for a greater proportion of cancellations than females (251 versus 161; 61% versus 39%). Almost half of cancellations were patients who were booked as inpatient admissions (47%, 193/412). Cardiothoracic comprised the specialty most affected by DOS cancellations (43%, 177/412 of cancelled patients). Conclusion By identifying the reasons for cancellation, and the characteristics of patients who are prone to being cancelled on the day of surgery, we have highlighted that DOS cancellations may be preventable in some cases. Further, quality improvement projects or root cause analysis are required to investigate and further address preventable DOS cancellation.

Preliminary insights into patient preparedness for knee or hip arthroplasty: a descriptive survey study

ObjectiveKnowledge-based preparedness for surgery is achieved through education. It is unclear which of brief or extended education programs prior to knee or hip arthroplasty provides better patient preparedness. Using the Patient Preparedness for Surgery survey, we investigated whether people awaiting arthroplasty attending a hospital that provided education over multiple visits via a pre-surgery management program (‘Extended’) report superior preparedness compared to those attending a hospital in the same health district that only provides education at the pre-admission clinic assessment (‘Brief’).ResultsA consecutive sample of 128 people (n = 101, ‘Extended’, n = 27 ‘Brief’) completed the anonymized survey. COVID-19 related service disruptions undermined the sample size, reducing statistical power. The pre-specified superiority of the Extended program (a relative 20% more reporting ‘agree’/’strongly agree’) was not observed for ‘Overall preparedness’ [95% (Extended) vs. 89% (Brief), p = 0.36]. Between-group differences exceeding 20% relative superiority were observed for three preparedness sub-domains [‘Alternatives explained’ (52 vs. 33%, p = 0.09); ‘Prepared for home’ (85 vs. 57%, p < 0.01); ‘Recall of complications’ (42 vs 26%, p = 0.14)]. The preliminary findings suggest an extended education program potentially yields better patient-reported preparedness in some preparedness sub-domains, but not all.

Transforming the perioperative medicine care model: The Singapore experience.

More than 300 million surgeries are performed worldwide annually. Established perioperative centres in the UK, USA and Australia have demonstrated the impact of improving perioperative care in reducing costs, increasing patient satisfaction and improving population health. Likewise, the surgical burden of care in Asia is increasing, but with sociocultural, economic and epigenetic differences compared to the west. As Singapore's largest hospital, the Singapore General Hospital pre-admission perioperative clinic sees about 20,000 patients annually. We aim to illustrate Singapore General Hospital's perioperative model of care to contribute to the paucity of literature describing perioperative programme implementation within Asia, and to encourage the cross-sharing of perioperative practices internationally. Our perioperative framework navigates risk assessment, risk counselling, and mitigation of health, medical and functional risks to better patients' perioperative outcomes and population health. We have implemented evidence-based pathways for common conditions such as anaemia and malnutrition, including a multidisciplinary programme for the elderly to tackle frailty and reduce length of stay. We describe how we have enhanced local risk profiling with the Combined Assessment of Risk Encountered in Surgery surgical risk calculator derived locally using a gradient boosting machine learning model. Finally, we report clinical outcomes of these interventions and discuss further challenges and new initiatives at each tier of our perioperative model. Our perioperative care model provides a framework that other centres can adopt to promote value-driven care, while catering for differences in the Asian population, thereby promoting evidence-based improvements in the area of perioperative medicine.

Evaluation of the clinical pharmacist services at a gynaecological oncology preadmission clinic

BackgroundPharmacists working in the multidisciplinary gynaecological oncology pre-admission clinic (PAC) are involved in the perioperative assessment of patients for a comprehensive medication history and information provision regarding withholding of medications before surgery. ObjectiveTo evaluate the current services provided by pharmacists to multidisciplinary staff and patients attending the PAC. MethodsA staff and a patient feedback survey on the value and impact of PAC pharmacy services were distributed within the PAC. The impact of the PAC pharmacist was also assessed by analysing pharmacist interventions and key performance indicators documented. ResultsFifteen staff responses were recorded, 5 nursing staff, 2 midwives and 8 anaesthetists. Eighty-seven percent (n = 13) strongly agreed or agreed that pharmacists at PAC help reduce medication errors on admission. Staff strongly agreed 73% (n = 11) pharmacists obtain a more accurate medication history. Staff reported benefits in having a pharmacist at the clinic to discuss medication related questions with 87% (n = 13) strongly agreeing or agreeing with the statement. A staff overall satisfaction rating of 4.87 out of 5 was recorded. In the patient survey, respondents (n = 6) gave a 4.83 out of 5 rating in confidence in making changes to their medication and their overall satisfaction with the service provided. In reviewing data from January to June 2022, the number of patients seen by the pharmacist were 178 of 681 patients (26.1%) who attended the clinic. The most common medications involved in the pharmacist intervention include those that were advised to be withheld and those that required other changes to therapy prior to their procedure. ConclusionThe role of a PAC pharmacist can be greatly appreciated by the multidisciplinary team and patients. Pharmacist interventions and key performance indicators have demonstrated the important activities of clinical pharmacy services in the PAC in optimising patient care in medication management.

Attendance at anaesthetic or perioperative medicine preadmission clinic and the relationship with unplanned ICU and/or HDU admission Postoperatively

Quality perioperative care not only involves careful preoperative assessment but also identifying the appropriate level of postoperative care. For some patients this involves planned admission to ICU or High Dependency Unit (HDU) postoperatively. With the limited resources and existent bed pressures it is important this postoperative destination is identified in advance. In this study we aimed to assess whether attendance in specialist preadmission clinic, involving an assessment by either an anaesthetic consultant or perioperative medicine physician, was related to unplanned ICU/HDU admissions postoperatively.All patient surgeries conducted at St Vincent's Hospital Melbourne between July-December 2019 were retrospectively collected. Patients were excluded if they were emergency cases, hospital transfers or cardiac cases. Patients were grouped as either being seen in preadmission clinic by an anaesthetist/perioperative medicine physician or not and whether they were later admitted to ICU. Patients were counted as planned ICU admissions if there was a preoperative bed request or a noted plan for ICU ahead of surgery. Of 7712 surgeries conducted, 160 were admitted to ICU (2.07%). Of the ICU admissions, 73 were unplanned (0.9% of all surgeries) and 87 were planned (1.1%). Of the unplanned admissions, 19 were seen in preadmission clinic and 54 were not. This suggests that a preoperative review by a specialist anaesthetic consultant or perioperative medicine physician was associated with a reduction in unplanned ICU/HDU admission at our hospital.

Implementing the "Getting It Right First Time" (GIRFT) Report Recommendations: The Results of Introducing a Shoulder and Elbow Multidisciplinary Team.

ObjectiveIn this study, we aimed to analyse the impact of implementing the “Getting It Right First Time” (GIRFT) recommendations in our shoulder and elbow unit, which included the introduction of a shoulder and elbow multidisciplinary team (MDT) meeting for all patients being considered for surgery.MethodsA retrospective patient case-note review was undertaken to assess the impact of replacing the pre-admission clinic with an MDT meeting. We analysed how many of the proposed management plans were changed as a result of this new MDT, as well as the associated cost savings.ResultsOf note, 118/148 patients who attended the MDT had a provisional operative plan; 24/118 (20%) had their plan changed to non-operative management, 13/118 (11%) had a change of operation, and 6/118 (5%) were recommended further investigations or tertiary referral. This reduced theatre time required by 47 hours, an estimated saving of over £51,000. Significantly, 20/24 patients who had their plan changed from operative to non-operative still had not had an operation after a median follow-up of 39 months.ConclusionThe introduction of a shoulder and elbow MDT for all patients being considered for an operation has improved decision-making, allowed optimisation of non-operative management, and helped prevent patients from having unnecessary operations. This has led to a better patient experience and a more efficient service delivery, which is associated with cost savings.

Barriers and facilitators of following perioperative internal medicine recommendations by surgical teams: a sequential, explanatory mixed-methods study

BackgroundPreoperative medical consultations add expense and burden for patients and the impact of these consults on patient outcomes is conflicting. Previous work suggests that 10–40% of preoperative medical consult recommendations are not followed. This limits measurement of the effect of perioperative medical consultation on patient outcomes and represents a quality gap, given the patient time and healthcare cost associated with consultation. We aimed to measure, characterize, and understand reasons for missed recommendations from preoperative medical consultation.MethodsThis explanatory, sequential mixed-methods study used chart audits followed by semi-structured interviews. Chart audit of consecutive patients seen in preoperative medical clinic were reviewed to measure the proportion and characterize the type of recommendations that were not completed (“missed”). This phase informed the interview participants and questions. The interview guide was developed using the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Template analysis was used to understand drivers and barriers of missed recommendationsResultsChart audit included 255 patients (n=161, 63.1% female) seen in preadmission clinic between April 1 and April 30, 2019. 55.7% of patients had all recommendations followed (n=142). Postoperative anticoagulation management and postoperative cardiac biomarker surveillance recommendations were least commonly followed (50.0%, n=28, and 68.9%, n=82, respectively).Eighteen surgical team members were interviewed. Missed recommendations were both unintentional and intentional, and the key drivers differed by these categories. Unintentionally missed recommendations occurred due to individual-level factors (drivers: knowledge of the consultation note, lack of routine for reviewing the consultation note, and competing demands on time) and systems-level factors (driver: lack of role clarity). Intentionally missed recommendations occurred due to user error due (drivers: lack of knowledge of guidelines or evidence) and appropriate modifications (driver: need to adapt a preoperative plan for a complicated postoperative course).ConclusionsOnly 55.7% of consult notes had all recommendations followed, suggesting a quality gap in perioperative medical care. Qualitative data suggests multiple drivers of missed recommendations that should be targeted to improve the efficiency of care for these patients.

Cardiac Telehealth Pre-Admission Clinic at a Tertiary Hospital – Impact on Patient Journey During the COVID-19 Pandemic

CSANZ guidelines recommend implementing Telehealth clinic appointments [1] to reduce impact of delayed medical treatments during the COVID-19 pandemic [2]. Patient preparation and follow-up can be performed without patient-staff contact [3] which minimises viral transmission risk for both parties [4].

Efficacy and Safety of Repetitive Intravenous Sodium Valproate in Pediatric Patients With Refractory Chronic Headache Disorders: A Retrospective Review

BackgroundChronic headache disorders can cause substantial disability and be treatment refractory. Often, these patients are excluded from clinical trials with leaving little evidence to guide treatment. In adults, divalproex sodium is an effective preventive migraine treatment. MethodsAll pediatric patients admitted for first-time sodium valproate infusions to treat refractory, chronic migraine (CM), new daily persistent headache, or persistent headache attributed to head trauma from January 2017 to October 2020 were identified for review. Each patient underwent a standardized, 4-day protocol. A new preventive was started one week after discharge. Data on headache frequency, severity, and acute medication use were collected through preadmission and postadmission clinic notes. Safety and tolerability were evaluated. Results were evaluated using descriptive statistics and compared with paired t-tests. ResultsForty-five patients were identified for review. Patients with CM had a median of 7 previous preventive trials, and 85% had previously received alternative intravenous treatment for headache. Baseline headache pain significant decreased from 6.9/10 to 5.4/10 by 7-week postadmission follow up, (95% confidence interval = −0.7 to −2.4), P < 0.001. Use of medications for acute headache treatment decreased significantly from 2.1 days/week to 1.5 days/week, (95% confidence interval = −0.3 to −1), P < 0.001. Baseline headache frequency did not significantly change. At postadmission follow-up, 26 of 39 (67%) patients saw improvements in headache frequency, headache intensity, and/or acute pain medication usage. There were no serious adverse events. ConclusionsRepetitive sodium valproate infusions were well tolerated and significantly reduced baseline headache intensity and acute medication usage in pediatric patients with refractory, chronic headache disorders.

Perioperative Satisfaction and Health Economic Questionnaires in Patients Undergoing an Elective Hip and Knee Arthroplasty: A Prospective Observational Cohort Study.

Background:Early hospital discharge shifts the recovery burden toward the patient and can leave patients and their caregivers anxious about the recovery process. Postoperative home care must be broadened to include appropriate and adequate support to address recovery at home. In this prospective study, patient and caregiver perspectives on the level of preparation/satisfaction and cost associated with management of recovery in the postoperative period were evaluated.Methods:We designed this prospective study to measure patient-reported outcomes and to inform the design of a postoperative home monitoring system. Patients undergoing inpatient total hip or knee replacements were recruited from a preadmission clinic at a university hospital. Patients and caregivers completed preoperative, postoperative, and health economic questionnaires. Bivariate analyses were conducted to understand factors associated with satisfaction with care.Results:Of 239 patients and caregivers recruited, preoperative questionnaire was completed by 98.8% of patients, the postoperative follow-up questionnaire was completed by 94.2% of patients, 75% of informal caregivers completed the postoperative follow-up questionnaires, and 93.7% completed the health economic questionnaire. The postoperative satisfaction scores were higher than the preoperative needs/expectation scores for both the overall and individual subscales. Patients undergoing hip arthroplasty reported higher satisfaction scores for postoperative pain management than patients undergoing knee arthroplasty (hip arthroplasty vs. knee arthroplasty: 4.07 ± 1.11 vs. 3.37 ± 1.51; P < 0.001). Patients who underwent knee arthroplasty reported better satisfaction scores with regard to having enough information on how to manage leg stiffness at home compared to patients undergoing hip arthroplasty (knee arthroplasty vs. hip arthroplasty: 3.13 ± 1.35 vs. 2.78 ± 1.30; P = 0.04).Conclusion:Overall, patients are generally satisfied with perioperative care, but they have distinct needs and expectations regarding perioperative medication and postoperative pain management. Virtual postoperative monitoring may be a useful tool during postoperative care to address many of patients’ concerns.

Implementing an Enhanced Recovery After Surgery Joint Replacement Program in a Small Acute Hospital Using a Multi-Disciplinary Approach

<h3>Introduction</h3> The facility began doing elective surgeries in 2017 without a standard joint program to regulate practice. To deliver highest standard of care, the need to systematize the process and develop a program was identified. This can only be done with the support of leadership while using a multi-disciplinary approach, implementing a program using the latest evidenced based practice (EBP) and clinical practice guidelines (CPGS). A joint program was created to initiate an Enhanced Recovery after Surgery (ERAS) program in a small acute care setting. <h3>Identification of the problem</h3> Without the structure of a formal joint program, several orthopedic surgeons were not standardizing their practices when it came to optimization of patients, spinal anesthesia, or ERAS medications. The program identifies these barriers that promote the need for change. <h3>EBP Question/Purpose: PICO question. Databases utilized</h3> In patients undergoing joint surgery, what is the effect of implementing ERAS in reducing length of stay visits, reducing post- operative complications? Research began using EBSCO host to find articles no later than 2010 for ERAS implementation and EBP. Current guidelines referenced from the American Academy of Orthopedic Surgeons, National Association of Orthopaedic Nursing, American Society of PeriAnesthesia Nurses, and the Association of periOperative Registered Nursing were used. Guidelines for the hospital program were created based on research findings. <h3>Methods/Evidence</h3> To initiate the program, EBP and CPGs were first used to support the rationale for the program. Key stakeholders and leadership used a multi-disciplinary approach to develop the program and explain the rationale for the program with each surgeon. Key stakeholders decided to then create a pre-admission testing clinic to screen patients appropriately. Education for hospital-wide staff for joint specific patients was implemented. <h3>Significance of Findings/Outcomes</h3> After three years, of implementing the joint program, the program has had 92% discharges on postoperative day one along with reduction in post-operative complications. <h3>Implications for perianesthesia nurses and future research</h3> Using EBP and CPG to standardize care ensure best practices, in which a majority of the ERAS bundle happens within the perianesthesia department. As ERAS is the gold standard, the next step is Advanced Certification.

Implementation of the telephone montreal cognitive assessment in a telemedicine based pre-admission testing clinic during COVID-19

IntroductionPostoperative delirium (POD) affects 10-70% of patients 60 years or older and has been linked to increasing length of hospitalization, mortality, and morbidity. Pre-existing cognitive impairment is a predictor of POD. COVID-19 restricted use of in-person cognitive screens. The Telephone Montreal Cognitive Assessment (T-MoCA) can screen for cognitive dysfunction remotely. We evaluated the feasibility of administering T-MoCA in a multiethnic population during pre-operative testing televisits. MethodsPatients scheduled for surgery between July 2020 and August 2020 were asked to participate in the T-MoCA at the end of their preadmission testing (PAT) televisit. A retrospective chart review was conducted to collect patient comorbidities and demographics. Patients were stratified by negative (T-MoCA≥19) or positive (T-MoCA<19) for mild cognitive impairment (MCI) and compared using 2-tailed χ2-tests. Univariate logistic regression was used to identify associations between patient characteristics and positive T-MoCA result. ResultsFifty out of 65 (77%) patients who consented to the T-MoCA completed the test. The average time to complete the assessment was 10.5 mins. Twenty two (44%) had a negative score and 28 (56%) had a positive score. Patients who had a positive T-MoCA were older (70.04±7.61 yrs) compared to those with a negative T-MoCA (67.68±4.69 yrs, p=0.007), although the distribution of patients above and below age 65 was not different (p=0.243). The two groups did not vary by gender, race/ethnicity, obesity, surgery type, or medical co-morbidities. When we examined our population for predictors of a positive T-MoCA, we found a trend toward men being less likely to score positive on T-MoCA (OR=0.33, 95% CI: 0.10-1.10, p=0.07) compared to women; and that patients with Hispanic race/ethnicity were more likely to test positive on the T-MoCA (OR=4.13, 95% CI: 0.84-20.28, p=0.08) compared to Non-Hispanic Whites. ConclusionsImplementation of the T-MoCA in a telemedicine-based PAT setting is feasible. In our cohort, most people who consented to the assessment completed it, and more than half scored positively, which may have important implications on the surgical plan and post-operative recovery. There may be limitations in using T-MoCA in certain populations, such as non-English preferred language, hearing difficulties, lack of focus, and use of external aids, which would need to be explored in a larger sample size.

A qualitative study of nurse-patient communication and information provision during surgical pre-admission clinics.

BackgroundHealth‐care service users are often being described as ‘co‐producers’ with an active role in their care. However, there are challenges associated with this approach, including how standardization affects personalized care, and the ability of patients to retain high volumes of information.ObjectiveOur study explores patient and nursing perspectives of information provision in the pre‐admission element of an Enhanced Recovery After Surgery programme, an evidence‐based approach implemented to improve the quality of surgical care. Our analysis has been informed by an evidence‐based model developed by Grande et al Patient Educ Couns. 2014;95:281.Design/Setting and participantsThis was a qualitative study including observations of pre‐admission clinics and semi‐structured interviews across three surgical wards. Patients (n = 21) and registered nurses (n = 21) were purposively selected for interviews.ResultsPatients welcomed the opportunity for active involvement in their care. However, we also identified informational boundaries and how illness and treatment‐related anxieties were barriers to patient engagement with the information provided.DiscussionWe recommend that to support a patient‐centred and individualized approach to patient involvement the ‘information (giving) + activation’ element of Grande et al Patient Educ Couns. 2014;95:281 model be reconfigured to allow for ‘information (giving) + exploration +activation’.ConclusionNurses need to feel empowered to adopt strategies that allow for different informational needs, rather than adopting a one‐size‐fits‐all paternalistic approach.Patient contributionThis study focused on patient involvement and we give thanks to all the patients who took part in interviews and those who allowed us to observe their care.