Innovative perioperative role improves patient and organisational outcomes in minimal invasive surgery.
Abstract: The drive to improve clinical care and productivity in the NHS has required an innovative approach in the use of the resources and skills of the workforce. With rapidly evolving technology, surgical and anaesthetic techniques, concentration is increasingly being placed on improving patient focused pathways, aiming to return patients back to normal activities as soon as possible. The article highlights the exciting new perioperative role developed at University Hospitals Coventry and Warwickshire (UHCW) NHS Trust in the care of patients undergoing laparoscopic cholecystectomy. It includes the history and development of the post and its current impact in improving the care of patients.

KEYWORDS Advanced laparoscopic nurse / Clinical outcome / Effectiveness / Laparoscopic cholecystectomy
Subject: Perioperative care (Analysis)
Surgery (Health aspects)
Treatment outcome (Health aspects)
Treatment outcome (Analysis)
Author: Abraham, Jenny
Pub Date: 05/01/2011
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: May, 2011 Source Volume: 21 Source Issue: 5
Product: Product Code: 8000410 Surgical Procedures NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 272168016
Full Text: Background

Given the current economic climate within the UK, the NHS, as with many organisations, faces increasingly challenging financial and structural changes. During the past decade the government has endeavoured to reform and modernise healthcare (DH 2000) to improve productivity and efficiencies. Crucially the Lord Darzi report (DH 2008) and Quality Innovation Productivity and Prevention (QIPP) (DH 2010a) have firmly shifted the focus to improving the quality of patient care and experiences. Therefore health professionals and management teams are working hard to improve both the quality and productivity of patient services.

This renewed focus on quality has created local innovations, many led by nurses and allied health professionals (AHPs), to support patients and organisations in achieving a safe, effective quality service. Innovation in clinical practice, developing care pathways and enhancing the patient experience will ultimately improve effectiveness, thus providing value for money alongside quality of care (DH 2006a). This has allowed a range of innovative new perioperative roles to be developed, fulfilling the operational and clinical priorities set by these agendas (Kneebone & Darzi 2005).

Cholecystectomy surgery has routinely been performed using minimal invasive techniques since the early 1990s. Minimally invasive surgery (MIS) offers many advantages for patients such as a quicker recovery, a reduction in postoperative complications, less time off work and reduced hospital stay (Cushieri 1991). The British Association of Day Surgery (BADS) has identified laparoscopic cholecystectomy surgery as a safe and suitable procedure, which could be performed as a day case or 23 hour stay (Cahill 1999, BADS 2009a).

Recent studies in the UK (Gurusamy et al 2008, Briggs et al 2009) and Ireland (Ahmed et al 2008) confirm that laparoscopic cholecystectomy procedures performed as day surgery continue to be both safe and acceptable to patients. However, according to the Department of Health (DH 2006a) the percentage of laparoscopic cholecystectomy patients treated as day cases varies from 5 to 60%, with a national average of approximately 13%. The NHS Institute for Innovation and Improvement (DH 2006a) suggests that targets of 70% are achievable, whereas BADS recommends that approximately 50 to 60% of laparoscopic cholecystectomy procedures should be treated as day surgery. Factors that influence day surgery discharge vary. They include organisational reasons, patient co-morbidities and associated complication risks, discharging processes, follow-up and readmission facilities (Blatt & Chen 2003).

Advanced nurse role

Advanced nurse practitioners and AHPs are well positioned to enhance this type of service, being an integral part of a multidisciplinary team and the patient journey. These professionals are experienced, skilled and knowledgeable having the ability to manage patient expectations, and coordinate patient optimisation alongside service requirements (Scott 2005). Their roles are extremely patient focused, enabling a holistic caring approach through a therapeutic patient relationship, a relationship which is key to producing high levels of patient satisfaction (Mottram 2009).

Advanced practitioner roles are derived from a variety of backgrounds and create an array of different titles such as advanced nurse practitioners (ANPs) and clinical nurse specialists (CNSs). More recently two new roles: perioperative specialist practitioners (PSPs) and surgical care practitioners (SCPs) have evolved, primarily due to the introduction of the European Working Time Directive (DH 2003) and the New Ways of Working agenda (DH 2007). Non-medically qualified practitioners working within these roles undertake many functions traditionally associated with doctors' roles (Kneebone & Darzi 2005). This has proved controversial, particularly within the medical profession (Beckwith 2005, Dehn 2005), but also from within nursing (Edwards 1996, Bernthal 1999, Scott 2004, Dimond 2008), possibly because it challenges traditional boundaries and the status quo. However, many see these new roles working to benefit both patients and organisations (McWhinnie 2005, Kingsnorth 2005, Martin et al 2007). In modernising healthcare today nurses and organisations alike should see this as an opportunity to challenge these boundaries to improve patient care. However, competence will be the determining factor both from a professional perspective (RCN 2008), but also legally and ethically (Quick 2010). Advance practice roles have established a clear validated, educational pathway at graduate and masters level (DH 2006b). Currently no advance practice register exists for nurses or AHPs, although, consultation has taken place within the nursing profession (Wilson & Bunnell 2007).

Local context

UHCW NHS trust was instrumental in piloting the new perioperative specialist practitioner (PSP) in 2004 within breast surgery, as part of the New Ways of Working agenda (DH 2007), adding to the advanced roles within the Trust. Since 2004 the trust has reconfigured services and extended PSPs to other specialities including cardiac and orthopaedics. These roles proved popular and influential in improving patient care and developing services, each being uniquely integrated within the contexts of their speciality teams. The perioperative specialist laparoscopic nurse post was appointed in mid August 2009. The aim of its role was to:

1. reduce the length of laparoscopic cholecystectomy patient stay by improving the same-day-discharge

2. improve the quality of patient care.

Within UHCW trust the majority of laparoscopic cholecystectomy patients are operated within the main operating theatre complex on all-day lists, due to the lack of available general surgical day surgery sessions. Therefore, patients are restricted to morning or early afternoon operations to enable same-day-discharge to be achieved. Evidence suggests that many laparoscopic cholecystectomy patients require between 4 and 6 hours to recover sufficiently for safe discharge (BADS 2010, Huang et al 2000).

Role of the perioperative nurse within the patient pathway

Clinical performance will be discussed and measured using the Quality Innovation Productivity and Prevention scale (DH 2010a). Figure 1 details the involvement of the perioperative nurse throughout the patient's journey. The innovations, developments and involvement of the perioperative nurse's role are discussed preoperatively (Table1), intra-operatively and postoperatively (Table 2).

Preoperatively

Preoperative assessment is performed on the same day as the OPD visit, to ensure timely patient optimisation (Beck 2007, BADS 2010, AAGBI 2010). Optimisation of physiological and psychological (Anderson et al 2003, Awad & Chung 2006) aspects of care facilitates self-recovery (Bramhall 2002, AAGBI 2010). According to Suhonen and Leino-Kilpi (2006) it is crucial that this preparation is individually tailored; therefore a varied resource strategy is required (Blay & Donoghue 2006). However, in practice this holistic approach rarely occurs (Mitchell 2010), possibly due to staffing levels and time restraints. Many patients fear postoperative pain and postoperative nausea and vomiting (PONV) (Walling 2006) and it is imperative that these complications are effectively managed since they both affect same-day-discharge (Chung 2006,

BADS 2010). Management includes psychological (Mitchell 2002), pharmacological (Skilton 2003) and nonpharmacological approaches by reviewing the patient's previous experience of pain and surgery, and their coping strategies such as positioning, breathing and preferred analgesic and antiemetic requirements. Providing patients with regular paracetamol and non-steroidal anti-inflammatory drugs enhances patient recovery thus facilitating same-day discharge (BADS 2010).

Examples of the perioperative nurse's improvements and developments are shown in Table 1 with associated patient and organisation outcomes. Organisationally this provides additional efficiencies (NHS Modernisation Agency 2002, Beck 2007).

Intra-operatively

The perioperative nurse acts as camera holder, infiltrates local anaesthetic to the wounds incisions and undertakes wound closure. This skilled assistance can help in reducing the operative time (McWhinnie 2005) and it is reported that reducing the operative time to less than 45 minutes improves postoperative recovery (BADS 2010). Subcuticular infiltration of local anaesthetic occurs prior to the insertion of the ports (Raeder 2006, BADS 2010) and intra-peritoneal injection/spraying over the liver and gall bladder bed assists in reducing the requirement of analgesia postoperatively, as well as reducing shoulder tip pain (Boddy et al 2006) caused by the insufflation of carbon dioxide gas. The perioperative nurse continually encourages, monitors and requests the use of these techniques as appropriate for each individual patient. Venous thromboembolism (VTE) prophylaxis is managed in accordance with the patient assessment (NICE 2010); unless contraindicated mechanical devices are routinely applied.

Postoperatively

Mitchell (2007) suggests that nurses need to support and motivate patient recovery. To assist with this a poster and staff information booklet were developed. This prompted staff in assessment, review and measurement of the patient's recovery by identifying milestones/targets. These targets are required to be met before discharge and can be used as an indicator in reducing adverse events by recognising deterioration (DH 2010a, NPSA 2010).

[FIGURE 1 OMITTED]

The perioperative nurse reviews the day case patients postoperatively which facilitates nurse-led discharge. The nurse ensures that pre-packed analgesia is available and that sick notes are completed. Nurse-led discharge has been used within day surgery for many years and facilitates safe and efficient patient discharge (BADS 2009b).

Fallis and Scurrah (2001) suggest that telephone follow-up is an acceptable support mechanism, and this has been positively evaluated by patients (Flanagan 2009). The perioperative nurse telephones patients the working day after their surgery to review their health status, pain relief, PONV and wound management. This also provides reassurance and confidence to the patient and carers. This service can highlight postoperative complications and readmission can be expedited. Anecdotally many patients have highlighted the value of this service.

These innovations have improved the quality of care to both the patient and the organisation (Table 2).

Measuring the impact of the role

In delivering quality improvements it is important that new developments are robustly audited and evaluated to understand their impact. Although measuring improvements in service quality can be difficult and creates a challenge, quality is closely associated with prevention and safety during patient care. Clinical outcome can be measured by length of stay, readmission and complication rates. Therefore, a program of clinical and operational audit was introduced to identify the key areas of impact for the role.

Auditing the service

The perioperative nurse role was measured against the existing data prior to commencement of the role and targets published by BADS and the Department of Health. Data were collected regarding the length of stay, categorising patients into same-day-discharge (day case), 23 hour stay, and inpatient stay (greater than 24 hours).

Pre-commencement of perioperative nurse role

To see whether the introduction of the perioperative nurse's role had made an impact on the service, performance data were analysed from July 2008 to August 2009, which was before the introduction of the role in mid August 2009. For this period 551 patients were reported as having had a laparoscopic cholecystectomy procedure performed at UHCW Trust; 19% of these were admitted as a day case (same-day-discharge).

Post-commencement of laparoscopic nurse role

Data from May 2009 to April 2010 were collected to provide a baseline for comparison against new developments (Figure 2). The graph indicates the benchmark targets from BADS and the Department of Health and has been illustrated as percentages. Twenty-three hour stay data from before September 2009 is poorly documented and therefore was not included.

Following the introduction of the role, analysis of the data shows a significant increase in same-day and 23 hour discharge. On average 38% laparoscopic cholecystectomy patients were sent home on the same day. Although this increase is still below the national recommended target, the trend continued during the first 12 months of the role with the percentages increasing to between 40 and 50%, see Figure 3.

UHCW have found it difficult to move above the 50% same-day-discharge, primarily due to laparoscopic cholecystectomy patients being performed within main theatre, as previously discussed.

Organisationally where same-day-discharge is not possible, there are additional benefits in converting elective inpatients to 23 hour stay. This reduces the length of stay and if the patients are discharged promptly the next morning, releases bed capacity for next day elective admissions. The perioperative nurse proactively discharges the day cases and the day surgery unit 23 hour stay patients at 7.30am. Currently UHCW Trust discharges over 70% of patients as combined day case and 23 hour. With further developments such as nurse-led discharge and the supply of pre-packed discharge medication from the main wards, this rate could be further increased.

Prevention:

Readmissions/complications

From a patient, an organisational and a national (NPSA 2010) perspective, patient safety is paramount. Many aspects of prevention and safety have been discussed during the section on the preoperative role of the perioperative nurse, such as assessment, consenting, information, and VTE assessment. However analysing readmission and complication rates can provide a measure to a quality service.

Nationally elective readmission rates vary from 1 to 12% (DH 2008). BADS (2010) suggests that readmission rates tend to rise with increased same-day-discharge, possibly due to health professionals erring on the side of causation. However UHCW Trust readmissions were equally represented in both elective in-patient (8%) and day case procedures (9%). All patients are provided with verbal and written details of when and how to contact the hospital if complications arise after discharge. The majority of readmissions were patient self-referral.

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

Readmissions were analysed between May 2009 and April 2010. A total of 51 patients were readmitted within 28 days of the initial operation. The majority of these were for minor complications (Table 3).

A few were more serious complications such as bile leaks (0.1%) and stone retention (1%), however these were considered to be within normal parameters.

Success factors

There were a number of factors, which assisted in the successful introduction of this role.

* Review of patient information, introduction of patient journey leaflet and wall poster. This assisted in aligning both the patients and staff expectations of the process ahead.

* A clinical trigger tool and pocket guide was designed for ward staff with expected patient achievement milestones, to assist with identifying preoperative investigations and postoperative complications, recovery progress and discharge process.

* Staff training sessions were provided for the perioperative staff - to assist in the correct use and trouble shooting of the equipment.

* Involvement of the perioperative nurse in pre-booking day surgery beds and organising operating list reduced patient transfer between wards and enabled the release of inpatient beds, which improved bed capacity.

* The perioperative nurse was central in a team approach enabling the implementation of changes whilst creating holistic patient-centred patient care.

* Nurse-led discharge reduced the length of patient stay, whilst generating additional income.

Barriers

As with all new roles barriers were encountered. The main barrier was a cultural shift from in-patient to day surgery both from staff and patients, alongside the need to streamline some parts of the service. Since the role was not linked specifically to one or two consultant led teams, there were a number of individuals to consult with and seek agreement from. Inevitably in some areas there were issues, such as the need for Patient Group Directive and consultant preferences. Although there was the potential for conflict from the junior medical staff, this did not emerge as a problem. In reality a successful working relationship emerged through respect, understanding and good communication. On an organisation level difficulties remain in securing morning day surgery theatre sessions, this is mainly due to the complexity of consultant job plans.

Costs

Significant cost improvements have been made by converting elective in-patients to 23 hour stay (one-night), as well as increasing the numbers of same-day admissions. The additional financial incentive of approximately 300 [pounds sterling] per same day-discharge (DH 2010b) from April 2010 has covered the nurse's salary and also generated income; this income has supported the supply of the additional discharge medications.

Developments

An integrated care pathway is being developed to streamline patient care within the hospital. Clinical pathways can both clinically and economically benefit patient care and organisations (Muller et al 2009) and are seen as a high-quality tool in reducing adverse events (NPSA 2010). The Enhanced Recovery Programme (DH 2010c) also supports their use in reducing the length of stay, reducing repetition and improving communication.

A research proposal has been submitted to evaluate the service from a patient's perspective, including the value and involvement of the perioperative specialist laparoscopic nurse within their care pathway.

Conclusion

The perioperative specialist laparoscopic nurse has coordinated and assisted in leading the service by developing and delivering different strategies to improve the quality and efficiency of laparoscopic cholecystectomy care. A vital element of the role is psychological support provided to patients to motivate, encourage and support their recovery to an early, safe discharge. Improvements made by reviewing the patient journey, improving patient information, educating staff, measuring productivity and patient outcomes have shown the nurse's role to have a positive effect. Remodelling the delivery of laparoscopic cholecystectomy patient care to same-day-discharge has benefited the organisation by improved bed capacity, increasing productivity, costs and positivism within the workforce. However, further research, streamlining and organisational developments are required to create additional improvements to support the sustainability of this service.

Acknowledgement:

Prof Mark Radford (Divisional Director of NursingSurgical Services, UHCW hosp) for constant encouragement to submit article proofing, and feedback given.

No competing interests declared

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication February 2011.

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Correspondence address: Jenny Abraham, Surgical Division, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX. Email: jenny.abraham@uhcw.nhs.uk

About the author

Jenny Abraham

RGN, BSc (hons), PgCert HE, SCP

Perioperative Specialist Laparoscopic Nurse Practitioner, University Hospitals Coventry & Warwickshire NHS Trust
Table 1 Role of the perioperative nurse in preoperative care,
identifying benefits to the patient and the organisation

Perioperative nurse        Patient outcome         Organisational
role                                               outcome

Information                Improved expectations   Reduced length of
Patient journey                                    stay
poster and                 Informed patients and   Productive service
leaflet                    carers
Information booklet        Motivated               Less complaints
Staff information poster   Empowered               Staff education
                           Streamlined care

Assessment                 Optimisation            Reduced DNA and
Physiological              Reduced risks           cancellation rates
Psychological              Individualised care     Reduced infection
                           planning                risk
Pharmacological            Patient concordance     Improved theatre
(paracetamol, codeine,                             capacity
ibuprofen/diclofenac)      Coping strategies       Reduced adverse
                           reviewed                events
                           Medication discussed
                           Discharge planning

Pre-booked postoperative   Reduced risk of         Improved bed
DSU beds                   cancellation due to     capacity
                           no bed                  Reduced on the day
                           Discharge medication    cancellation
                           available
                           Family aware of
                           postoperative ward

Risk reduction             Risks explained,        Efficient service
Consent                    Risks reduced           Reduced adverse
Thromboprophylaxis                                 events

Table 2 Role of the perioperative nurse in postoperative care,
identifying benefits to the patient and the organisation

Perioperative         Patient outcome          Organisational outcome
nurse role

Assessment            Motivational             Quality service
                      Individualised care      delivery
                      Early detection of       Reduced adverse
                      deterioration/           events
                      complications
Nurse-led discharge   Continuity of care       Reduced readmission
* Medication          Pain relief              rates
* Sick note           Timely discharge         Staff education &
                                               support
                                               Productive service
Telephone follow-up   Continuity of care       Improved hospital to
service               Support following        home communication
                      discharge
                      Increased patient        Reduced adverse events
                      confidence
                      Opportunity to discuss   Improved readmission
                      concerns                 process
                      Prompt readmission
                      process

Table 3 Minor complications linked to improvements in practice

Minor complications   Improvements in practice
Pain                  Increased pre/packed TTO (to
                      take out/home medication)
                      analgesia from 3 to 5 days'
                      (BADS 2010) (Paracetamol,
                      codeine, ibuprofen/
                      diclofenac)

Constipation          Senna as TTO, advised on
                      increasing fluid intake

Nausea and vomiting   Nausea is a common side effect
                      of anaesthetic and medication.
                      Use of local PONV guidence,
                      including perioperative
                      hydration

                      Readmission if 2 or more
                      episodes of vomiting in 24
                      hours

Wound heamatoma       Changed timing of Enoxaparin
                      administration At least 2
                      hours postoperatively,
                      normally given at 18.00hrs
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