Preadmission Testing Research Articles

Benefits of Preoperative Education for Adult Elective Surgery Patients

Patient education is a major concern for perioperative nurses in an ambulatory surgery setting. It has proven difficult to develop formal preoperative teaching programs in this environment, but research has shown that preoperative education can improve patient outcomes and satisfaction with the surgical experience. Typical patient education consists of pamphlets that are given to the patient before surgery and verbal instructions from the physicians and nurses on the day of surgery. Ideally, preoperative patient education should begin in the surgeon's office, continue through preadmission testing, and be completed at admission. Having a well-designed preoperative education program enables perioperative nurses in ambulatory surgery centers to provide a thoughtful approach to perioperative teaching in a limited time. AORN J 90 (September 2009) 381-387. (c) AORN, Inc, 2009.

The implementation of evidence-based practice for the prevention/management of post-operative nausea and vomiting

Aim To bring the research evidence for the prevention/management of post-operative nausea and vomiting into clinical practice in the surgical services department of a community hospital. Methods Audit and feedback were used to lead organisational change at the project hospital. A team of key stakeholders was created and helped to bring change to the way post-operative nausea and vomiting was treated and managed at the institution. The Chief of Anesthesia, Assistant Chief Nursing Officer, Nurse Researcher, Director of Surgical Services, operating room manager, post-anaesthesia care unit manager, pre-admission testing nurse and author as team leader made up the change management team. Current compliance with the six criteria set forth as research evidence for the change was derived from a surgical chart audit. Strategies for changes to increase compliance were then developed by the team. For the next several months change management occurred. Results There was a vast improvement in evidence-based practice following change management. Furthermore, post-operative nausea and vomiting decreased from 18% at the start to 5% nausea and 0% vomiting at the end. Conclusion Change management using audit and feedback is effective in changing organisational practice and in improving patient outcomes following surgery.

Effectiveness of nurse-led preoperative assessment services

Effectiveness of nurse-led preoperative assessment services

Ataxia‐Telangiectasia and mechanical ventilation: A word of caution

Ataxia-telangiectasia (A-T) is a rare autosomal recessive multisystem disorder with a short life expectancy. During adoles- cence pulmonary complications are common in A-T patients, and respiratory failure is the most important cause of death. Therefore me- chanical ventilation is often considered in these patients. In this study we retrospectively evaluated the clinical characteristics and ICU course of three consecutive adolescent A-T patients who were mechanically ventilated for respiratory failure. None of these patients had a history of respiratory infection. In all patients volume-pressure ratios indicated severe restrictive lung dysfunction. This was supported by data on pre-admission lung function testing. All three patients died of hypercapnic respiratory failure during ICU admission. The study shows that severe restrictive lung function is a common finding in adolescent A-T patients which may seriously complicate ventilatory treatment. Preadmission lung function testing is essential for the optimal medical management of these patients.

An Investigation of the Effects of Preoperative Interdisciplinary Patient Education on Understanding Postoperative Expectations Following a Total Joint Arthroplasty

This study aimed at evaluating the effect of a preoperative interdisciplinary educational intervention on understanding postoperative expectations following a total joint arthroplasty. The study sample consisted of 156 patients scheduled for elective total joint replacement surgery. The approach for this study was a two-group quasi-experimental design. The treatment group received an additional interdisciplinary educational session whereas the control group did not. Subjects who chose to attend the program were compared with those who received standard outpatient teaching in the preadmission testing center. Subjects who received the interdisciplinary teaching intervention were significantly better at verbalizing and demonstrating postoperative skills, and they rated all aspects of the interdisciplinary educational session as very satisfactory. The study demonstrated that the preoperative interdisciplinary educational program for patients scheduled for total joint replacement surgery had a positive effect on the understanding of postoperative expectations. The educational sessions have continued providing an option that will enhance preoperative education.

Prophylactic Antibiotic Use: Hardwiring of Physician Behavior, Not Education, Leads to Compliance

Surgical wound infections can be significantly reduced by appropriate administration of prophylactic antibiotics (ProAbx). The purpose of this study was to determine the effect of interventions, specifically, forced functions, designed to improve administration of ProAbx in a university hospital setting. We retrospectively reviewed charts from 1,622 consecutive patients, seen between March 2005 and June 2007, for evaluation of ProAbx administration to determine correct choice, appropriate timing of administration, and appropriate postoperative cessation of antibiotics. Processes designed to improve compliance were devising orders to limit ProAbx choice; requiring those orders in preadmission testing; administering ProAbx in the preparation and hold area, subsequently, at the time of the universal timeout; and standardizing postoperative orders in the computerized physician order entry. Specialty-specific standardized orders improved compliance from 76% to 91% (p < 0.001) concerning ProAbx choice. Regarding timing of preoperative administration, a baseline compliance of 55% improved to: 78% (p < 0.001) on requiring orders in the preadmission testing area; 90% (p < 0.008) on administering ProAbx in the preparation and hold area; and 95% (p < 0.07) when ProAbx were administered at the universal timeout. Standardization of postoperative orders in the computerized physician order entry improved compliance with cessation from 60% to 86%, p < 0.001. Despite hospital-wide education, improving compliance with evidence-based recommendations for ProAbx required processes that "forced" physician behavior, specifically: specialty-specific, preprinted physician orders limiting ProAbx choice; linking administration of preoperative ProAbx administration to the universal timeout; and standardization of the postoperative ProAbx order in the computerized physician order entry.

The Preadmission Testing Unit: Patient's First Contact With the Health Care System

Shorter lengths of stay in the hospital decrease costs and the likelihood of hospital-acquired infections. Preadmission units replace the old practice of hospital admissions the day before surgery. This article describes how the preadmission unit at Maine Medical Center meets the need for getting patients thoroughly prepared for their surgical procedures in an outpatient setting.

Budget Impact Analysis of Rapid Screening for Staphylococcus aureus Colonization Among Patients Undergoing Elective Surgery in US Hospitals

To evaluate the economic impact of performing rapid testing for Staphylococcus aureus colonization before admission for all inpatients who are scheduled to undergo elective surgery and providing subsequent decolonization therapy for those patients found to be colonized with S. aureus. A budget impact model that used probabilistic sensitivity analysis to account for the uncertainties in the input variables was developed. Primary input variables included the marginal effect of S. aureus infection on patient outcomes among patients who underwent elective surgery, patient demographic characteristics, the prevalence of nasal carriage of S. aureus, the sensitivity and specificity of the rapid diagnostic test for S. aureus colonization, the efficacy of decolonization therapy for nasal carriage of S. aureus, and cost data. Data sources for the input variables included the 2003 Nationwide Inpatient Sample data and the published literature. In 2003, there were an estimated 7,181,484 patients admitted to US hospitals for elective surgery. Our analysis indicated preadmission testing and subsequent decolonization therapy for patients colonized with S. aureus would have produced a mean annual cost savings to US hospitals of $231,538,400 (95% confidence interval [CI], -$300 million to $1.3 billion). The mean annual number of hospital-days that could have been eliminated was estimated at 364,919 days (95% CI, 67,893-926,983 days), and a mean of 935 in-hospital deaths (95% CI, 88-3,691) could have been avoided per year. Sensitivity analysis indicated a 64.5% probability that there would be cost savings to US hospitals as a result of preadmission testing and subsequent decolonization therapy. The addition of preadmission testing and decolonization therapy to standard care would result in significant cost savings, even after accounting for variations in the model input values.

Development and Initial Testing of the Perianesthesia Safe Practices Instrument: An ASPAN Pilot Study

The perianesthesia environment of care is a unique high-risk health care setting that has a high susceptibility to error because of the vulnerability of patients who are undergoing surgery and anesthesia as well as the high levels of activity in these units. Safe practice in this environment is essential to quality patient care and positive patient outcomes. Consequently, ASPAN conducted a descriptive cross-sectional pilot study to test initial reliability and validity of the Perianesthesia Safe Practices Survey Instrument. The instrument was designed to assess specific safe practices in perianesthesia areas by identifying the following: (1) what are the current perianesthesia safety practices, (2) what are the recommended safety practices that are not in place, and (3) what are the differences in safety practices within areas along the perianesthesia continuum of care. Thirty-six respondents found the instrument to be clear, easy to complete, and containing appropriate content. The alpha coefficients for internal consistency for the unit specific components were preadmission testing (.79), pre-op (.94), Phase I PACU recovery (.92), and Phase II PACU recovery (.90). The results of this pilot study provided information about areas of excellence and areas for improvement for safe clinical practice in the specialty setting, as well as initial reliability and validity for the safe practices questionnaire.

Evaluation of anemia in the elective surgical patient

SUMMARYA national audit demonstrated that 35% of patients scheduled for orthopedic joint replacement surgery have a hemoglobin concentration &lt; 13 g/dL on preadmission testing. Current practice consists of preadmission testing within 72 hours before an elective operative procedure, which precludes the opportunity effectively to evaluate and manage a patient with unexpected anemia. A standardized approach for the detection, evaluation and management of anemia in the preoperative surgical setting was identified as an unmet medical need. A panel of physicians developed a clinical care pathway for anemia management in this setting. Recommendations were that patients undergoing elective surgery should receive a hemoglobin determination up to 30 days before the scheduled surgical procedure. The identification and evaluation of anemia in this setting will assist in expedited diagnosis and treatment of underlying comorbidities, and will improve patient outcomes.

A Multidisciplinary Approach to Total Joint Replacement

A multidisciplinary team was formed to look at consolidating and improving patient education for patients preparing to undergo total knee replacement or total hip replacement. The objective was to encompass disciplines from across the continuum of care, beginning with the surgeon's office through postdischarge rehabilitation. Project goals for the team were to develop the "ideal" pre and postoperative orders for total joint patients, review and revise current clinical and patient pathways for the total knee replacement patient and the total hip replacement patient, add rehabilitation services to clinical pathways, and develop a patient education class and patient education booklet. This article describes how working together with all disciplines involved resulted in a consolidated order set, clinical and patient pathways that reflected actual care and processes, a user-friendly patient education book, and a multidisciplinary patient education class. The end products led to consistency in the quality of care across the continuum from preadmission through postdischarge rehabilitation for total joint replacement patients.

2007 National Patient Safety Goals

THE PURPOSE OF the Joint Commission’s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety. The Goals highlight problematic areas in health care and describe evidence and expert-based solutions to these problems. 1 The Joint Commission2007 National Patient Safety Goals. 2006 Google Scholar The NPSGs focus on system-wide solutions, whenever possible, in an effort to promote the delivery of safe, high-quality health care. Accredited health care organizations are evaluated for continuous compliance with the specific requirements associated with the National Patient Safety Goals, and organizations are permitted to design alternative approaches to meeting goal requirements and to request Joint Commission consideration and approval of such alternatives. The Joint Commission also provides guidance on how to achieve effective compliance with each of the goal’s requirements. 1 The Joint Commission2007 National Patient Safety Goals. 2006 Google Scholar NOTE: JCAHO is now The Joint Commission. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has shortened its name to The Joint Commission. The change was made official in January when The Joint Commission launched a redesigned website. Check out the new website at: http://jointcommission.org and see the new Joint Commission logo as well. NOTE: JCAHO is now The Joint Commission. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has shortened its name to The Joint Commission. The change was made official in January when The Joint Commission launched a redesigned website. Check out the new website at: http://jointcommission.org and see the new Joint Commission logo as well. Nancy M. Saufl, MS, RN, CPAN, CAPA, is a past President of the American Society of PeriAnesthesia Nurses, and the Coordinator of the Preadmission Testing Center at Florida Hospital-Memorial Division, Ormond Beach, FL, USA.

Parental Factors Impacting the Enrollment of Children in Cardiac Critical Care Clinical Trials

Clinical trials are abundant in adult cardiovascular medicine; however, they are rare in pediatric cardiology. Pediatric cardiac trial design may be impacted by the heterogeneous nature of the underlying cardiac defects, as well as by a strong emotional response from parents whose child will undergo a surgical intervention. The purpose of this study was to assess factors that may have an impact on parents considering enrollment of their child in a clinical trial at the time of surgical intervention. A voluntary, self-administered questionnaire (14 questions) was provided to parents of children 16 years of age or younger during the preadmission testing period. Demographic and procedure-related variables were collected for each patient. A total of 119 surveys were analyzed over a 1.5-year period. Only 8% of the parents had their child participate in a clinical trial in the past. Fifty-six percent of the parents preferred that their child's cardiologist or surgeon explain clinical trial details, with 23% preferring the principal investigator and 3% preferring the research coordinator. Fifty percent of the parents were favorably disposed to participate in a clinical trial if the drug or device was currently used by their child's doctor, and 19% were encouraged to participate if the drug or device was approved for use in adults. The majority of parents (64%) preferred to be asked about participating in a trial within 1 month prior to the planned procedure, and 40% preferred to discuss trial details at a remote time in an outpatient location. Sixty-three percent of parents believed that most of the medications currently used in children were already approved by the Food and Drug Administration. Most parents (91%) believed that clinical trials conducted in children will help improve pediatric health care; 74% believed that their child may receive potential benefit from enrolling in a trial. Finally, 43% believed that funding for trials should come from government and health care agencies, as opposed to pharmaceutical companies (24%). This survey reveals the importance of the attending physician and timing in educating parents regarding a cardiac critical care clinical trial. These data may impact the design and successful conduct of future trials.

ECG Tricks

FigureFigureFigureHow an ECG is performed, not necessarily how it is interpreted, can lead to problems. The emergency physician should be aware of such issues so he does not embark on an unnecessary diagnostic or treatment pathway. A case in point: A 58-year-old woman with a history of sarcoidosis is sent to the ED after a visit to the preoperative testing suite. In preparation for elective abdominal surgery (repair and debridement of a chronic inguinal sinus tract), she had an ECG performed, which was deemed abnormal. (See Figure 1.) She was immediately sent to the ED for evaluation and urgent cardiology consultation.Figure 1: Preadmission testing ECG.The patient had no acute complaints, and she denied chest pain, dyspnea, diaphoresis, nausea, weakness, or unusual fatigue. Her medications included bronchodilators and cephalexin. Her vital signs and physical examination were normal. The computer interpretation at the top of her ECG read: “Normal sinus rhythm; possible anterior infarct; age indeterminate; abnormal ECG.” What is your interpretation, and are there any other considerations in this case? See p. 22.

Joint Commission Update

BEGINNING JANUARY 1, 2006, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) implemented “unannounced surveys” for regular accreditation surveys for all programs. 1 Joint Commission on Accreditation of Healthcare Organizations Overview of Unannounced Surveys. Available at: http://www.jcaho.org/accreditationprograms. Accessed March 8, 2006. Google Scholar , 2 Shared Visions-New Pathways. Q&A: Unannounced Survey Process. Available at: http://www.jcaho.org/accreditationprograms/SVNP/qa_uannounced.htm. Accessed March 8, 2006. Google Scholar The term “unannounced” means that organizations receive no advanced notice of their survey dates, thus allowing the organization to focus on preparation for their next patient, not their next survey. 1 Joint Commission on Accreditation of Healthcare Organizations Overview of Unannounced Surveys. Available at: http://www.jcaho.org/accreditationprograms. Accessed March 8, 2006. Google Scholar In addition, accreditation now validates the organization’s continuous systems improvement efforts as opposed to a simple standards compliance exercise at a single point in time. Surveys will provide a more complete and accurate picture of the organization’s actual day-to-day performance. The credibility of the accreditation process will be enhanced by ensuring that surveyors observe performance under normal circumstances. 2 Shared Visions-New Pathways. Q&A: Unannounced Survey Process. Available at: http://www.jcaho.org/accreditationprograms/SVNP/qa_uannounced.htm. Accessed March 8, 2006. Google Scholar Nancy M. Saufl, MS, RN, CPAN, CAPA, is a Past President of the American Society of Perianesthesia Nurses, and Coordinator of the Preadmission Testing and Teaching Department at Florida Hospital Memorial System, Ormond Beach, FL

Blue Ribbon Abstract Award

BACKGROUND/OBJECTIVES: Gram-positive organisms, such as Staphylococcus aureus ( S. aureus ) and Coagulase negative staphylococcus (CNS), are the predominating organisms contributing to prosthetic joint infections. A recent cluster of total hip replacement surgical site infections (SSI) occurred at this hospital in 2004. Four of the six deep SSIs were caused by S. aureus . The patients and OR team members underwent nasal cultures to rule out S. aureus colonization. Several of the patients along with one staff member did have positive nasal cultures as well. Pulse field gel electrophoresis (PFGE) typing determined the strains were genetically distinct and therefore not epidemiologically linked. A protocol was developed at this hospital to identify carriers pre-operatively and treat them with intranasal mupirocin. We hypothesized that pre-operative treatment of patients with positive nasal cultures would decrease the post-operative infection rate. METHODS: At the time of pre-admission testing (PAT), every patient undergoing total joint replacement surgery (including shoulder, hip and knee) was nasally cultured. Between December 2004 and December 2005, a total of 435 patients were nasally cultured. All patients who were culture positive for S. aureus were treated with intranasal mupirocin ointment twice a day for seven (7) days. Additionally, patients identified with methicillin resistant staphylococcus aureus (MRSA) were instructed to undergo a chlorhexidine antiseptic soap shower before surgery, and were given vancomycin for their surgical prophylaxis. MRSA patients were also placed in Contact isolation when admitted to the hospital. All non- MRSA patients received cefazolin or clindamycin as the surgical prophylaxis. RESULTS: Preoperative nasal screening cultures determined a S. aureus carrier rate of 27 % or 119 patients out of 435 patients cultured. MRSA accounted for 16.8% (20/119) of the S. aureus isolates. We observed zero (0) deep S. aureus associated SSI and one superficial SSI over a 12 -month period as compared with the historical rate of 1.64% (p CONCLUSIONS: Identifying and treating S. aureus carriers with a full course of mupirocin does impact the rate of total joint S. aureus surgical site infections. These findings impact hospital length of stays, readmissions, post-op complications, hospital and patient costs, and above all improving patient outcomes.

Detection, Evaluation, and Management of Anemia in the Elective Surgical Patient

The prevalence of anemia in elective surgical patients may be as frequent as 75% in certain populations. A national audit demonstrated that 35% of patients scheduled for joint replacement therapy have a hemoglobin <13 g/dL on preadmission testing. Standard practice currently consists of preadmission testing 3 to 7 days before an elective operative procedure, precluding the opportunity to effectively evaluate and manage a patient with unexpected anemia. Therefore, a standardized approach for the detection, evaluation, and management of anemia in the preoperative surgical setting was identified as an unmet medical need. To address this knowledge gap, we convened a panel of physicians to develop a clinical care pathway for anemia management in this setting. Elective surgery patients should receive a hemoglobin (Hgb) determination a minimum of 30 days before the scheduled surgical procedure. Because the identification and evaluation of anemia in this setting will assist in expedited diagnosis and treatment of underlying comorbidities and will improve patient outcomes, unexplained anemia (Hgb <12 g/dL for females and <13 g/dL for males) should cause elective surgery to be deferred until an evaluation can be performed.

Use of failure mode and effect analysis (FMEA) to improve active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) at a university-affiliated medical center

BACKGROUND: Failure mode effects analysis (FMEA) is a procedure that helps to identify each vulnerable step of a process to determine how these vulnerabilities affect the desired outcome. An FMEA ranks and prioritizes the possible causes of failures and facilitates the development of prevention strategies. As a result of a root cause analysis, our hospital's patient safety committee selected “Early Identification and Timely Isolation of Patients with MRSA” for FMEA. OBJECTIVES: To use FMEA to identify potential failures in the process of admission screening of high-risk patients thus delaying early identification and timely isolation of patients colonized or infected with MRSA. METHODS: Using the hospital's MRSA policy, a multidisciplinary team met to review the admission screening process of patients through all hospital admission sites: pre-admission testing (PAT) for same-day surgical patients, emergency department (ED), and admitting department. High-risk patients, as determined by a positive response to a screening questionnaire, have an automatic “screening alert” message printed on the nursing station printer of the receiving unit. The screening alert results in the entry of an order for a nares culture to rule out MRSA. Upon receiving a positive screening culture result, the patient is placed on contact precautions. RESULTS: The three highest-scoring potential failure modes identified were 1) staff compliance with standard precautions pending positive culture results; 2) delay in screening of patients admitted via the ED; and 3) no reliable process for communication of high-risk or positive MRSA history status by PAT staff to a surgeon, operating room, or infection control (IC) department. Additional potential failure modes included: ED physician-dependent orders for private rooms for isolation patients; delays in obtaining screening cultures for ED holding unit patients; unreliable and inconsistent communication between AD, nursing staff of admitting units, and IC staff; and a 2- to 3-day lag time from culture collection to results availability. CONCLUSIONS: The FMEA process was extremely useful for understanding and analyzing the complex process of screening high-risk admissions for multidrug-resistant pathogens. The process facilitated communication among the various departments that resulted in the identification of creative and sustainable solutions.

Prevention of anesthesia awareness

IN OCTOBER 2004, THE JOINT COMMISSION on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert asking health care organizations to develop policies and procedures on anesthesia awareness. Anesthesia awareness, also called unintended intraoperative awareness, occurs under general anesthesia when a patient becomes cognizant of some or all events during surgery or a procedure and has direct recall of those events. 1 JCAHO: Preventing and managing the impact of anesthesia awareness. Sentinel Event Alert, Issue 32, October 6, 2004. Available at: www.jcaho.org. Accessed October 2004 Google Scholar Because the patient routinely receives neuromuscular blocking agents/paralytics during general anesthesia, they are often unable to communicate with the surgical team if anesthesia awareness occurs. Nancy M. Saufl, MS, RN, CPAN, CAPA, is a Past President of the American Society of PeriAnesthesia Nurses. She is the coordinator of the Preadmission Testing & Teaching Center at Florida Hospital Memorial Division, Ormond Beach, FL.

Preparing the older adult for surgery and anesthesia

Life expectancy in the United States has increased significantly over the past 100 years. It has been suggested that by the year 2050, approximately 20% of the population may be over the age of 65. Many of these older adults will undergo surgery and anesthesia. Preadmission testing nurses need to be able to deal with the various challenges that accompany this group of patients. While many of the elderly are quite active, there are others with multiple disease processes that put them at an increased risk over the general population. It will be to the advantage of all involved if health care providers can develop a better understanding and an increased expertise in caring for the geriatric surgical patient. This article describes the importance of the preanesthetic nursing assessment and evaluation in helping to identify potential problems so that a plan of care to prevent those problems can be formulated and communicated to other members of the health care team.