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The Preoperative Patient Assessment in an Ambulatory Surgery Center

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According to center policies, all patients deemed appropriate for procedures performed at the center are to be interviewed in order to collect a comprehensive patient history, to include medications, and to identify inherently dangerous patient conditions. Patients are to be counseled and assessed paying particular attention to special needs inherent to the patient's age, prior historical events and underlying health conditions as they impact the proposed surgical and anesthetic event. Vigilance will occur especially in regards to the recognition of risks inherent to surgical procedures relating to potential adverse drug reactions and interactions, potential or anticipated critical events and to the potential for surgical site infections.

During the preoperative interview, whether conducted on-site or through a telephone call, the perioperative staff assess the patient's ASA status, anxiety level, food and drug allergies, skin issues and integrity, any potential airway issues such as those identified due to a history of sleep apnea, previous anesthesia issues/susceptibility to malignant hyperthermia, pending lab/radiographic studies and results, preoperative disease states and those special needs inherent to the patient's age.

Patient education during this preoperative interview is crucial. The time constraints in the ambulatory surgery setting make the collection of comprehensive information and patient education challenging at best. These time constraints do not, however, serve to provide an excuse to erase the performance of the preoperative assessment and education process from the organization's routine activities.

And yet, this seems to be a growing trend, as more and more surgery centers are reporting that staffing constraints have, in fact, negated this activity.

Patient education is one of the primary roles of the perioperative nurse working in ambulatory surgery. Research has proven that patient education plays a huge part in successful and positive patient outcomes and in patient outcomes and satisfaction.

Patient education should start with preoperative brochures either sent to the patient when scheduled, procured by the patient through the organization's website, or provided to the patient during their preoperative physician or ASC interview/visit. This process would be enhanced through on-site tours, group educational meetings, phone calls and education reinforcement conducted on the day of the procedure.

Recently, a licensed risk manager did a trend analysis of patient cancellations in just one of her surgery centers to determine the number of patients being cancelled in the pre-op area on the morning of their scheduled surgical/endoscopic appointment. Of these, many had either eaten or drank something. Several had not taken required medication or followed their plastic surgeons preoperative antibiotic regime. At least two to three per month had inadequate preps with the same number presenting with incomplete lab work.

Three to four each month presented with atrial fibrillation, or pulmonary issues. Top this with a minimum of two to three a month presenting with no care person and you have a large number of cancellations occurring after the patients were admitted, and, frequently, had IVs started. While this number was excessive in this one center, a review of some other centers uncovered similar problems — though not so extensive. In virtually all of the instances identified, none of the patients had received a preoperative phone call from the center, though all had been sent written instructions.

In all centers staff were queried regarding the breakdown in the performance of preoperative phone calls/interviews. New staff members were appalled. Faced with the tight staffing they experienced in the ASC, they could not believe that such a thing would be required of them. They had no understanding, either, of the impact these cancellations had on the organization. Older staff members often recalled a time when pre-op phone calls and/or interviews were done, and that, oftentimes, there was even a preoperative coordinator who performed this duty.

None believed there was adequate time allowed in the schedule for this activity to occur. And yet, this licensed risk manager saw part-time nurses rushing to get out of the center at the end of the schedule, or sitting at the nurses' station or in the lounge for 20 to 30 minutes chatting. This same LRM witnessed staff gossiping and chatting with one another in different parts of the center throughout the day. All of this activity added up to a rejection of the staff's assertion that "there is no time to make these calls."

Further investigation of center's performing as many as 7,000 cases a year found that those centers were being successful in completing 85 to 90 percent of their calls/interviews. A 100 percent goal was rejected due to late "add ons" and failure of patient response/inability to connect with the patient preoperatively. These patients were educated and assessed the morning of their procedure.

Adequate preparation makes a huge difference in the patient's response to his entire procedure. A four-year-old was scheduled for bilateral PE tubes. The grandmother, an OR trained registered nurse living with the family eagerly awaited the child's phone call scheduling a time for the child to come in for her tour and to get her sample anesthesia and/or surgical mask and to play with the stuffed animal surgical patient. No call came, so the grandmother awaited the preoperative phone call to educate the child on what to expect and to gather information in order to best prepare for the care of the child. No call came. The grandmother put all her experience in place and did the teaching for the child.

A trip to the hardware store got a mask and hair cover. The child was told what to expect on arrival, in the preoperative area…. what the OR would look and sound like…. it would be cold…everyone would be dressed the same…. the equipment, the noises, the table/bed…the anesthesia mask. On the day of the procedure, the little girl hopped off the pre-op stretcher taking the OR nurses' hand and walked right down the OR corridor and into the room. The ASC staff did make a postoperative phone call to the family during which she bragged on how brave the child had been and that they had never had a child do that before "without even a whimper."

In another case, a patient, 69 years old, was scheduled for a colonoscopy. During her preoperative visit her physician provided her the packet of information from the surgery center. This particular patient happened to be an ASC registered nurse of nearly 30 years experience. A week prior to the surgical appointment, the nurse opened the packet and discovered that the first piece of literature advised her that the procedure would be performed at one of two centers, but not which one. She waited a day or two for her preoperative call to clarify the issue. None came, so she called her physician the Friday before the surgical appointment to find out where she should go.

A comprehensive preoperative phone call or interview is crucial to patient safety and satisfaction. Needless to say, neither the grandmother in the first example or the RN in the second will frequent those two centers again…. and…rest assured their dissatisfaction has been loudly shared with family and friends who will also, most assuredly, shy away from those two centers.

Conducting a comprehensive preoperative patient assessment and teaching interview, whether onsite or over the phone, need not erode into staff overtime pay. How is it possible to get this very important activity done in the face of "staffing skinny"?

Preoperative assessments can be conducted as near the time the patient is scheduled as possible. Consider setting up a system identifying those patients who are awaiting surgery/awaiting the preoperative assessment and education interview. All preoperative staff should be trained to conduct these interviews and to recognize Red Flags reported during the interview for referral. The "Awaiting" files are checked daily. The goal would be to do the assessment as soon as possible — some may be two weeks out from their surgery date. Staying ahead is a bonus allowing time to get those patients scheduled closer to the date of their procedure interviewed.

Once the history is collected, cultural diversities identified special learning needs addressed and general educational information imparted, the preoperative nurse monitors the receipt of lab, EKG or radiographic reports, the physician's H&P and consents which are all added to the patient's file whether paper or electronic. Anything missing is identified well in advance of the surgery date and collected at that time. Continual monitoring identifies "missings" well ahead of the surgical date thus decreasing those nasty surprises that happen on that date when the H&P, lab work, consents, etc. are missing resulting in case cancellations and/or delays to say nothing of the irate patient and physician.

ASCs pride themselves on patient satisfaction. Cancellations and delays impact patient AND physician satisfaction tremendously to say nothing of the cost incurred by the organization for supplies used in pre-op, staff hours and salaries, supplies opened in the OR and those corresponding staff costs. Add this to the negative experience by both the patient and physician, and the cost is even higher. It could be argued that the organization cannot afford to NOT do the preoperative interview and assessment.

The Joint Commission and CMS urge ASCs to embrace a culture of patient safety. How could this even remotely be possible without a preoperative assessment and educational interview conducted by the ASC?

This article is written by Ann Dean, founder of ADA Group.


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