A nurse-led pre-admission clinic for elective surgical patients was opened at Harrogate District Hospital in November 1997.
It is staffed by three nurses appointed to work with one consultant general surgeon, who has organised training in heart and chest examination, electrocardiogram interpretation and phlebotomy with other consultant medical staff.
The nurses are trained to perform a complete medical, nursing and social assessment, ensuring that all patients admitted for surgery are prepared both mentally and physically for their operation. The clinic, which is situated near outpatients, operates all day on Mondays and assessments generally last an hour.
The numbers of patients attending each clinic varies between two and 15. The age range is from 18 to over 90. Patients are seen approximately one week before their operation in a relaxed, informal atmosphere and have the opportunity to discuss all aspects of their planned stay in hospital.
All information is recorded in a care pathway document which is then used by all the healthcare professionals involved during the patient's stay in hospital. Decisions regarding the patient's fitness for anaesthetic are made by the pre-admission nurse using guidelines agreed by both surgical and anaesthetic departments.
A recent audit compared patient information from the first six months of the clinic's operation to the same six-month period in 1996. A comparison was difficult to make as operations performed by general surgeons range from major cases, which can take all day, to simple investigative procedures, lasting minutes. However, the results were significant.
Pre-admission assessment benefited the hospital greatly by increasing the number of patients who could be admitted on the same day as their operation. Patients for some types of major surgery may still need to be admitted on the day before their surgery, but patients for other types of major surgery, such as cholecystectomy, can increasingly be admitted on the day of surgery (see figure 1).
The fact that all investigations and assessments have been performed in a pre-admission clinic significantly reduces the time it takes to admit the patient to the ward and prepare them for theatre.
The percentage of all patients admitted on the day of surgery increased from 30 per cent to 38 per cent. After a pre-operative assessment the pre-admission nurse can identify patients who, although listed to come in the day before surgery, can be admitted on the morning of their operation.
The effect of the pre-admission process on the patients was pleasing. The number of patients who cancelled operations on their admission date was reduced from 33 to four.
Patients who did not attend for pre-operative assessment were immediately replaced on the operating list, thus preventing the wastage of a bed and a theatre slot.
There was also a significant fall in the number of patients whose operation was cancelled because they were unfit on admission. This was due to the time lapse between pre-admission assessment and admission.
Patients who were on the routine waiting list (ie for non-urgent surgery) who presented with a relatively minor complication, such as hypertension, were referred back to their GP for control and replaced on the operating list. The audit did not reflect the patients on the priority waiting list who presented as unfit for anaesthetic. These patients could not be cancelled, but the pre-admission process gave medical staff more than a week to improve the patient's level of fitness before surgery. This significantly improved their chances of recovering from major surgery.
One hundred questionnaires were sent out at random to patients who had been pre-operatively assessed by the pre-admission nurse. A total of 65 replies were received.
Patients were asked questions about how the assessment was conducted, how long they were expected to wait, how friendly and helpful they had found the staff and how much they felt that the process had benefited them.
More than two-thirds (69 per cent) of patients said they were reassured after the assessment. Many patients expressed their thanks for the way they felt the assessment was centred on them and not the needs of the hospital.
Asked who they would want to see if they came into hospital again - the pre-admission nurse, a junior doctor, or to simply arrive on the ward the day before their operation - more than 70 per cent opted for a pre- admission assessment (see figure 2).
Only 3 per cent of patients wished to see their consultant in the pre- admission clinic, and these were all private patients.
The views of the medical staff
All surgical and anaesthetic staff expressed a high level of satisfaction with the pre-admission assessment process. The anaesthetist is particularly happy with the fact that he gets valuable information about patients who are poorly well before admission, which gives him the opportunity to ask for specific consultations or treatments well in advance of surgery.
In the past he would not receive this information until the day before surgery. Both the consultant anaesthetist and the consultant surgeon have said that the process helps them because they know they can rely on the system.
The two house officers who worked for the participating consultant surgeon during the trial period said that the process saved them up to six hours' ward work a week. They also commented that the pre-admission system ensured that they could document the work they had to do quickly and easily. This gave good levels of job satisfaction as they knew that they had done exactly what was required for each patient. There was no difficulty ascertaining what the surgeon's requirements were for each specific type of surgery - a problem that several of their colleagues had encountered.
Pre-admission assessment of patients benefits medical staff, hospital and patient. The process has reduced the amount of wasted time patients spend on the ward and their anxiety before the operation. It has also improved communication between specialties. We intend to extend the clinic to all other surgical consultants, appointing pre-admission nurses with experience in each specialty.