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PORTSMOUTH HOSPITALS NHS TRUST

Section 3.24 Section 3.13

CLINICAL POLICIES

TITLE REFERENCE NUMBER MANAGER / COMMITTEE RESPONSIBLE DATE ISSUED VERSION REVIEW DATE AUTHOR RATIFIED BY

PREOPERATIVE ASSESSMENT POLICY

3.24

TRUST PREOPERATIVE ASSESSMENT POLICY GROUP 16.11.2007 4 MARCH 2008 TRUST PREOPERATIVE ASSESSMENT POLICY GROUP CHAIR: PROFESSIONAL ADVISORY COMMITTEE. 13.11.2007

AMENDMENTS RECORD: The policy has been reviewed via consultation. There were no changes other than an extension of the review date to March 2008. CONTENTS: 1. INTRODUCTION / BACKGROUND 2. STATUS 3. PURPOSE 4. DEFINITIONS 5. PROCESS: EVIDENCE BASED GUIDELINES FOR PRACTICE 6. DUTIES AND RESPONSIBILITIES 7. TRAINING 8. ASSOCIATED DOCUMENTATION APPENDICES: 1. PRE-OPERATIVE ASSESSMENT PATHWAY 2. COMPETENCY STATEMENT

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1. INTRODUCTION / BACKGROUND This policy was developed as a consequence of national guidelines and changes in practice to encourage patient involvement and choice. The National Direct Bookings project, changes in the consent procedure and expansion of nurses` roles have all contributed to the development of POA. Local aims to reduce last minute cancellations, DNA`s and unplanned inpatient stays have been key triggers. 2. STATUS Clinical policy 3. PURPOSE Currently within Portsmouth Hospitals NHS Trust, there are many different pathways involved in the pre-operative assessment (POA) of surgical patients. Patient selection and assessment involves a number of health care professionals. This policy supports the development of a single pathway for patients to follow prior to an operation. 4. DEFINITIONS Pre-operative assessment is the process that ensures a patient is fully prepared, both physically and emotionally for planned surgery and anaesthesia. Risk factors are identified and are eliminated, minimised or accommodated.
5.

PROCESS: EVIDENCE BASED GUIDELINES FOR PRACTICE RATIONALE To ensure patients are fit for surgery, and added to appropriate waiting list or referred using POA pathway To minimise the risks from surgery / anaesthesia and provide informed consent. Minimise risks EVIDENCE Best Practice Local expert opinion National guidelines 1,2

ACTION A health-screening tool will be undertaken in outpatients to establish patient suitability for adding to day surgery / inpatient waiting list.

Patients will be appropriately assessed investigated and fully prepared and informed prior to their procedure. Ongoing medical problems

Anaesthetic department guidelines for pre-operative investigations. Speciality specific guidelines. Current procedure specific information leaflets. Anaesthetic assessment
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CLINICAL POLICIES will be appropriately investigated and optimised, working with general practitioners or specialist referral. Adequate space for appropriately equipped interview/examination rooms, with facilities for or access to basic investigations-blood testing, ecg`s, needs to be identified. Patients will have access to high quality information leaflets.

Ensure appropriate use of specialist resources. Avoid cancellations on day of surgery. Appropriate facilities to provide and match patients pre-assessment needs. Patients have informed consent

clinic referral criteria. Selection criteria Medical protocols

Benchmarking of existing suitable equipped areas for POA.

Speciality specific information leaflets are approved by the patient experience council and are regularly updated. EVIDENCE References PHT competencies for preoperative assessment. Clear channels of communication using appropriate methods of documentation.

ACTION Trained competent preoperative assessment health care professionals will undertake preoperative assessment. Administrative support to facilitate the pre-operative assessment process.

RATIONALE Skilled staff are able to prepare patients safely for surgery. Ensure a seamless process with clear documentation of patient clinical details and communication between health care professionals.

AUDIT STANDARDS / AUDIT TOOL ASPECT OF CARE/OUTCOMES Informed consent Reduction in clinical cancellations. Reduction in DNA`s for surgery EXPECTED STANDARD/TARGET 100% reduction 10% reduction 10% SOURCE OF DATA COLLECTION Audit department Patient Administrative Systems Patient Administrative Systems
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CLINICAL POLICIES Staff knowledge of preoperative investigations

100%

Staff audit

6. DUTIES AND RESPONSIBILITIES A named consultant anaesthetist will have overall responsibility for the patients anaesthetic fitness ensuring that the following are in place: Selection criteria, guidelines for pre-operative investigations and a clear mechanism for referral of abnormal test results, or patients requiring a more detailed assessment by an anaesthetist. The Consultant responsible for the patients care is ultimately responsible for patient selection for a procedure, and for supporting all health care professionals involved with POA. Surgical CDs for individual specialities have responsibility for procedure specific patient information leaflets and instruction sheets. Trained pre-operative assessors are responsible for working to guidelines and competencies (see appendix) agreed by local anaesthetists and surgeons. Representatives from the PCT`s and HA will be invited to the ongoing review and development of the policy.

7. TRAINING Health Care Professionals who undertake pre-operative assessment, will be able to demonstrate competencies for pre-operative assessment. (appendix 2). National training tools, including an interactive CD has recently been developed and should be incorporated into local training programmes.

8. ASSOCIATED DOCUMENTATION 1. Modernisation Agency (2002) National Good Practice Guidance on Preoperative Assessment for Day Surgery. 2. Modernisation Agency (2003)National Good Practice Guidance on PreOperative Assessment for Inpatients having Surgery. 3. Health Screening Tool. 4. Patient Pathway for pre-assessment. 5. Jones. A (2000) Pre-admission clerking of urology patients by nurses, Professional Nurse, vol 15, 4. 6. Bramhall.J (2002) The role of nurses in preoperative assessment, Nursing Times, vol 98, 40. 7. McCarter.D & Neal.P (2001) Telephone pre-operative assessment. 8. Kinley.H et al (2001) Extended scope of nursing practice: a multicentre randomised controlled trial of appropriately trained nurses and preregistration house officers in pre-operative assessment in elective general
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Section 3.13 CLINICAL POLICIES surgery, Health Technology Assessment, vol 5, 20. 9. Barnes.P (2000) The nurse clinician in surgical services, Professional Nurse, vol 15, 4. 10. Rushforth.H et al (2000) Nurse-led pre-operative assessment: a study of appropriateness, Paediatric Nursing, vol 12, 5. 11. Lucas.B (2002) Developing the role of the nurse in the orthopaedic outpatient and pre-admission assessment setting: a change management project, Journal of Orthopaedic Nursing, 6, p153-160. 12. Barnes.P et al (2000) Influence of an anaesthetist on nurse-led, computer-based, pre-operative assessment, Anaesthesia, 55, p576-589. 13. Hilditch.W et al (2003) Pre-operative screening: Criteria for referring to anaesthetists, Anaesthesia, 58, p117-124. 14. Sutcliffe.A et al (2002) Multidisciplinary pre-admission clinics for orthopaedic patients, Nursing Standard, vol 16, 21. 15. Clinch.C (1997) Nurses achieve quality with pre-assessment clinics, Journal of Clinical Nursing, 6, p147-151. 16. Ryan.P (2000) The benefits of a nurse-led pre-operative assessment clinic, Nursing Times, vol 96, 39. 17. Knape.J (1999) Nurses` accountability in relation to nurse-led services, British Journal Of Nursing, vol 8, 22. 18. Chapple.A & Macdonald.W (1999) A nurse-led pilot scheme, Primary Health Care, vol 9, 4. 19. Knowles.J (1997) Pre-assessment of the day surgery patient, British Journal of Theatre Nursing, vol 7, 4. 20. Alerson.P (1995) Consent to surgery: the role of the nurse, Nursing Standard, vol 9, 35. 21. Scott.PA et al (2003) Autonomy, privacy and informed consent 4: surgical perspective, British Journal of Nursing, vol 12, 5. 22. Read.S (1999) Nurse-led care: The importance of management support, NT Research, vol 4, 6.

APPENDIX 1: PRE-OPERATIVE ASSESSMENT PATHWAY

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CLINICAL POLICIES APPENDIX 2: COMPETENCY STATEMENT: UNDERTAKING PATIENT HISTORIES AND CLINICAL EXAMINATION.
Competency Indicators st 1 Level
After obtaining consent from the patient 1.Correctly obtain patient demographic details 2.Correctly undertake initial assessment of: -Vital signs (TPR, BP & MEWS) -Conscious level (AVPU) -Comfort (Pain score) 3.Using a systems approach undertake a full patient history 4.Interpret information from assessment and identify risk factors 5.Report significant changes and refer to relevant health care professional

Competency Indicators 2nd Level


After obtaining consent from the patient 1.Correctly undertake full patient physical examination 2.Compare information with previous medical history to confirm/refute identified risk or developing diagnosis 3.Plan ongoing monitoring requirements 4.Communicate patient status and plan patient specific requirements with ward team 5.Refer to other healthcare professionals recognising personal/professional limitations in practice as appropriate 6.Delegate patient specific monitoring to a member of the ward team (if required) 7.Accurately record full assessment in patient records and further assessment and interventions required 8.Inform patient and relatives of the need for ongoing assessment and monitoring

Competency Indicators rd 3 Level


After obtaining consent from the patient 1. Correctly undertake full patient assessment (level 1& 2) 2.Manage and lead assessment process, instigate more indepth monitoring and investigations, utilising specialised medical equipment

Competency Indicators 4th Level


After obtaining consent from the patient 1.Direct health care team and utilise specialist indepth monitoring, investigation and assessment techniques 2.Utilise expert judgement to facilitate the timely referral to critical care or specialist practitioners to improve patient outcome

4.Able to present case history of patient to other health care professionals 5.Inform patient and relatives of any outcomes of assessment

3.Act as an expert resource advising, teaching and supporting members of the healthcare team, patient and relatives 4.Act as an assessor in ensuring the nurse-led development of patient histories and clinical examinations

6.Accurately record comprehensive patient assessment in patients notes 7.Plan further assessment required for patient and reprioritise workload accordingly 8.Inform other health care workers within the team of change in patients condition 9.Involve patient and relatives, informing them of assessment and potential outcomes

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Education resources to support your development History Taking and Physical Examination Course Southampton University CD rom `Setting a Standard Through Learning` Management and leadership course. Pre-Operative Assessment and Planning Bournemouth University In-house physical examination course/preassessment.

Teaching and assessing qualification.

COMPETENCY STATEMENT: ASSESS THE FITNESS OF PATIENTS REQUIRING ELECTIVE SURGERY MINIMUM LEVEL 3
Competency Indicators 1st Level
1.Can demonstrate knowledge of patient selection criterias for day/inpatient surgical admissions

Competency Indicators 2nd Level


1.Is able to assess individual patient needs and plan patient care accordingly

Competency Indicators 3rd Level


1.Understands the risks/benefits for proposed surgery and acts as the patients advocate for informed consent

Competency Indicators 4th Level


1.Is able to present a comprehensive history of the patient to a multidisciplinar y team

Competency Indicators -5th Level


1.Is able to teach and assess others on assessment of elective surgical patient

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2. Is able to communicate fully with patients giving and receiving all relevant information re proposed surgical procedure 2.Demonstrates good communication with the multidisciplinary team 2. Can demonstra te competenc y at ordering/p erforming preoperative investigati ons in accordanc e with anaestheti c/specialty specific guidelines / policies 3.Ensures any specific risks are referred for Anaesthetic Opinion or Anaesthetic Assessment Clinic 4.Is able to liase with the community team and make referrals to ensure minimal delayed discharges 2.Is able to review documentation and make recommendatio ns for change 2.Regularily present case historys of patients to other professional colleagues

3. Documents all findings from assessment accurately

3.Can provide evidence of knowledge of the trusts policy/guidelines relating to informed consent

4. Able to perform basic investigations to record patients vital signs

4.Is able to make basic interpretation of any pre-operative investigations and takes appropriate action

3.Can demonstrate competency in taking formal consent, in accordance with trust and speciality policy / guidelines 4.Demonstrates knowledge of national guidelines/curre nt research and can apply to practice 5.Regularily reviews data/audits and changes practice in the light of any results 6.Attends trust/team meetings to develop the pre-assessment service 7.Can demonstrate competency in physical examination in accordance with trust/speciality policy / guidelines

3.Acts as a clinical lead/expert at trust/regional/ national groups

5. Able to identify any risk factors relating to surgery

6. Can identify issues, which may lead to delayed discharges

5.Demonstrates knowledge of necessary pre-operative investigations in accordance with anaesthetic/specialty specific guidelines / policies 6.Is able to recognise any specific risks and has knowledge of the process for referral for Anaesthetic Opinion or Anaesthetic Assessment Clinic 7.Is able to promote healthy living and advise appropriately

5.Completes data/audits on the effectiveness of the pre-operative assessment

4.Using feedback from audits/service users is able to design methods for measuring the effectiveness of the preassessment service 5.Can assess others on the physical examination of elective surgical patients

6.Demonstrates knowledge of national guidelines/current research related to pre-assessment

Education resources to support your development


Basic induction. CD rom `Setting a Expanded skills History taking / Teaching/assessin

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Standard Through Learning` Policy/ Guidelines on `Informed Consent` Legal implications re expanded roles, informed consent courses in ECG / venepunture. Guidelines for referral to anaesthetic clinic/ pre-operative investigations physical examination course. Inhouse physical examination, pre-assessment course. Policy/guideline s on PreAssessment of Surgical Patients

Time spent in anaesthetics/theatre / recovery as appropriate

g course. Service development courses, e.g. audit, patient satisfaction surveys

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