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Journal of the New Zealand Medical Association, 09-November-2007, Vol 120 No 1265

A successful nurse-led model in the elective orthopaedic admissions process

Jennifer M Truscott, Joanne M Townsend, Edwin P Arnold

Abstract

Aim To document a nurse-led admissions process for same day orthopaedic surgery, on relatively fit patients under 70 years of age.

Methods Patients undergoing minor surgery, under 70 years of age, and with a body mass index (BMI) of <35, were selected from the total of patients being admitted for elective orthopaedic surgery under the Accident Compensation Commission (ACC) contract. The nurse-led project relied primarily on an admission questionnaire, on physician consultation notes, and on previous clinical records.

Results During the 6-month study, 331 patients with a median age of 38 years were categorised into 3 streams. 252 patients (76%) underwent a nursing-admission process without the need for further consultation with a junior medical officer or an anaesthetist. The remaining patients not included in the study were admitted and clerked by a house officer. No safety issues arose and the surgeons and anaesthetists were satisfied with the process. The junior medical officers described improved job satisfaction by being able to attend theatre, other educational opportunities, and working more closely with the consultant.

Summary The process was safe; it improved the patient journey and job satisfaction among house surgeons; and it extended the skill base and job satisfaction of the nurses. It also allowed the hospital to cope better with the reduced number of house surgeons available. The process has now been incorporated into elective orthopaedic admissions at Burwood Hospital.

The Surgical Orthopaedic Unit (SOU) at Burwood Hospital (Canterbury District Health Board [CDHB], Christchurch) has a capacity of 29 beds with 13 beds in the Admitting Unit (AU). Annually, over 2000 procedures are carried out at Burwood Hospital, including 670 primary hip and knee joint replacements, in the 2005–2006 financial year.

The orthopaedic medical team consists of 16 orthopaedic surgeons, 5 registrars, and 3 house surgeons in the ward plus a 0.2 full time equivalent (FTE) house surgeon for pre-admitting in the Orthopaedic Outpatient Department.

As part of an exercise in process-mapping that followed the elective orthopaedic patient journey from GP referral to discharge after surgery, several issues were identified that could provide opportunities for improvement in the journey.

One of the ‘bottlenecks’ in the patient journey was the admission phase of the process. A suggested option to unblock the bottleneck was the development of Nurse Led Admission (NLA) practices in the SOU.

Historically, the house surgeon’s role in the admission process on the day of surgery admission (DOSA) was to record the patient’s clinical details in the case notes.

During 2005, the number of house surgeons (junior medical staff) available for the orthopaedic run was frequently reduced (as a result of a CDHB-wide shortage of house officers) from the normal three down to two and sometimes only one house surgeon. This problem was most acute in winter. Consequently, this compromised the delivery of elective orthopaedic surgery and resulted in expressions of job dissatisfaction for a variety of staff.

In the UK, in 1991, the NHS Management Executive introduced the Junior Doctors: the New Deal document which resulted in a reduction in junior doctors’ hours and the subsequent re-allocation of some routine medical duties to nursing staff.1 Following its publication, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) facilitated the expansion of nursing roles within their own and organisational capabilities with the dissemination of the document The Scope of Professional Practice (UKCC, 1992).2

Harvey and Gaudoin (2005) identified a reduction in patient waiting-time and an increase of 25% of patient throughput in nurse-led clinics.3 Nurse-led clinics also resulted in a 40% financial saving for the health service provider. Indeed, the increasing role in day surgery units has led to increased patient satisfaction and improvements in cost-effectiveness.4

House surgeons at Burwood Hospital have experienced frustration when they were often needed in the admissions area, operating theatre, and outpatients at the same time. This led to insufficient experiential learning (i.e. learning through action) throughout the elective orthopaedic run.

These difficulties led to the proposal to do a pilot study on nurse-led admissions, along lines similar to those followed in the private sector.

Methods

Working party—A working party responsible for the governance of the project was established led by the medical advisor. The working party included the Director of Nursing, Clinical Charge Nurses (CCNs) of the Surgical Orthopaedic Unit, Orthopaedic Outpatients, the Post Anaesthetic Care Unit, Operating Suite, and the Anaesthetic Nurse Co-ordinator.

Consultations were held with the Anaesthetists; Clinical Directors of Orthopaedics, Health Care of the Elderly, and the Burwood Spinal Unit; and The Resident Medical Officer (RMO) Unit.

A house surgeon representative, on behalf of the Resident Doctors Association (RDA), attended meetings in the development phase and informed the central RDA of the process of the pilot study.

Patient selection—All patients being admitted to Burwood Hospital under the ACC Orthopaedic Contract were included (800 patients/year). The triaging into categories described below was undertaken by the experienced anaesthetic clinical nurse specialist.

These patients tend to be younger, relatively fit, and usually require a short time in hospital either as day surgery cases, or for a stay of only 1–2 nights.

The patients were allotted to one of three categories, on the following basis. If there were any doubts in a particular case concerning the triaging, nurses could consult with a house surgeon or an anaesthetist.

Category A	Any patient having major surgery These include those having major joint replacements, spinal fusions, and revision surgery. Clinical assessment recorded in the case notes by the house surgeon in the standard way.
Category B	Patients having minor surgery but who also had significant comorbidity, or who were over 70 years of age, or who had a BMI>35*. Clinical assessment recorded in the case notes by the house surgeon in the standard way.
Category C	Patients having minor surgery and who were relatively young and fit. These included those having removal of orthopaedic internal fixation, surgery on the hand, shoulder, knee, ankle and foot, and spinal decompressions. About 30% had day surgery but the remainder were in hospital for 1 night. The majority of patients were considered by the anaesthetists to be in ASA categories 1 or 2. These patients were included in the nurse-led admission process.

*BMI information—Evidence showing that obese patient is more prone to respiratory problems and other anaesthetic hazards is not well substantiated in the literature. However to assist nursing staff triaging, our anaesthetists advised <35 BMI as an arbitrary cut-off point.

Admission process and documentation—The admission documentation, was based on what is currently used in the private sector, so the anaesthetists. And surgeons were familiar with it, and confident in the process. This documentation included a patient medical history questionnaire, and a health assessment form completed by the registered nurse. ECGs, and any blood tests organised by the surgeon, were included in the case record along with any other test report arranged by the surgeon preoperatively.

The type of anaesthesia was decided by the attending anaesthetist; mostly (70% ) it was general anaesthetic and the remainder was by local or regional block.

The CDHB Corporate Solicitor confirmed there was no legal requirement that it should be a medical officer who records the admission details. The audit of the process was undertaken with the advice of the Clinical Audit Facilitator at Burwood Hospital. The areas audited included:

Pre-admission nursing staff.
Anaesthetists.
Orthopaedic surgeons.
Operating theatre nurses.
Recovery room staff.
House surgeons.

Patients were also asked in a survey if they thought their clinical evaluation was adequate, whether they felt well prepared for surgery, and whether they had any comments on how things could have been done differently. .

The pilot study commenced in July 2005. After the first 3 months it was decided to continue the NLA process for ACC cases but also to include all CDHB elective admissions, for a further 3 months.

The results of the audit were analysed under the following headings:

Demographic details.
Compliance with completion of documentation.
Stakeholders’ satisfaction (including doctors, nurses, and patients).
Retrospective clinical record review

Results

Demographic details

During the 6-month period of the pilot study, 348 patients (i.e. 317 ACC and 31 DHB contract patients) were scheduled for operations; 17 patients had their operations cancelled for a variety of reasons during the pilot study, thus leaving 331 for categorisation in the current process.

Categorisation

Category A	9 (3%)
Category B	70 (21%)

Twenty-one of the 70 Category B patients had a BMI >35.

Those in categories A and B were not included in the study.

Category C

252 (76%)

These formed the basis of this current NLA study.

The median age of the patients was 38, and the age distribution is demonstrated in Figure 1.

Figure 1. Distribution of patients’ ages

Compliance with completion of documentation

By the time the patient arrived for admission on the day of surgery, the surgeon’s clinic note was present in 208/242 (86%) (10 forms were never returned out of the total of 252 cases). The pre-anaesthetic questionnaire was available in 178/242 (74%), and the signed consent form in 168/242 (70%). The remaining forms were completed before the procedure by the surgeon concerned.

Stakeholders’ satisfaction (including doctors, nurses, and patients)

Stakeholder satisfaction was assessed qualitatively. Each group was asked if there were issues identified that meant in their view that clinical examination and notes by a house-surgeon would have been better than the forms completed by the admitting nurse.

Stakeholders included admitting nurses, anaesthetists, orthopaedic surgeons, theatre and recovery nurses, and the house surgeons dealing with the patients in the ward post-op. Patients were also asked to make comments on the fact they did not see a house surgeon before theatre.

Nursing pre-admission process and triaging: nurse competency—Apart from one case (who subsequently was found to have a BMI of 40), all patients were categorised by the nursing staff without need for further consultation with the house surgeon or anaesthetist.

Nurses relied primarily on the questionnaire and to some degree on previous clinical records—or if a previous operation had been done, then on that anaesthetist’s comments.

Anaesthetist perception of the nurse-clerking—Of 242 cases, the anaesthetist made no comments in 205 (85%) cases, and in a further 35 (14.5%) cases indicated positively that in their view if the records had been made by a house surgeon this would not have been additionally helpful. Therefore the anaesthetist considered that the processes were considered quite satisfactory in 240 out of 242 cases.

For the other two patients (0.8%), the anaesthetist considered it might “possibly” have been preferable for a house surgeon admission process to have been followed. One of these patients was a known diabetic (NIDDM), but the oral medication doses were not recorded in the notes, and she had not had a blood sugar checked on the morning of surgery. This was rectified by the anaesthetist.

The second patient had had a full medical assessment at the Cardiology Department at Christchurch Hospital because of atrial ectopics. A copy had not been filed for the hospital record. Both the surgeon and the anaesthetist had seen a copy of the opinion previously, and were happy to proceed with the operation.

Both patients had uneventful upper limb surgery.

As the nurse-led procedure was congruent with procedures undertaken in the private hospital, the anaesthetists were satisfied with these arrangements.

Orthopaedic surgeons, operating theatre nurses, and recovery staff—No adverse comments were received from the surgeons. The surgeons and anaesthetists had already worked out an effective process for themselves in the private sector without using house surgeons. The process instituted here reflected what applied in the private sector.

Theatre nurses made some suggestions on the layout of the forms and on completeness of the data. Although most anaesthetists complied with the charting of post-op medications, house surgeons were required to do this in the Recovery Ward in some instances.

Patient opinion—A patient satisfaction survey form was provided to each patient but only 44 (17.5%) out of 252 were completed. There were no adverse comments and their tone was very positive.

House surgeon opinion—Several comments mentioned the reduction in workload, and that the process was helpful. Nine house surgeons felt that when called postoperatively to see a nurse-clerked patient, it did not mean more work for them, compared to what would have been necessary if they had been clerked by a house surgeon.

Retrospective clinical record review

103 records were reviewed during first 3-month audit period. Although not part of this pilot study, it was interesting that orthopaedic protocols (standing orders) were used by the nursing staff on 84 (82%) occasions. Nurses’ involvement in clinical decision-making was enhanced by the NLA process; indeed it had a positive impact on the patient journey from admission to postoperatively and through to discharge, and it also enfranchised job satisfaction among the nurses involved.

The 19 (18%) instances where the house surgeon was called postoperatively to discuss management issues were mainly for prescribing drugs or intravenous ( IV) fluids.

Discussion

Collaboration between nurses and doctors in patient care has increased in recent years and has been well received and beneficial.4,5

The nurse-led admission process for elective orthopaedic patients worked well and proved to be effective and efficient. The process now includes all ACC cases and CDHB cases not pre-admitted. The patient was seen preoperatively by a registered nurse and a consultant anaesthetist—there was no house surgeon involvement pre-surgery. This streamlined the patient journey.

There has been a financial saving as one house surgeon FTE (0.2) previously dedicated to the pre-admission clinic was no longer required.

Initial concerns regarding the process of NLA before the study were unfounded, as shown by the following positive outcomes:

Legal opinion reassured us that there was no necessity for a medical employee to write in the case records before surgery.
Anaesthetists were accustomed to the process in the private sector and had no concerns in following similar processes in public at Burwood Hospital.
Orthopaedic surgeons were unconcerned, as they too were familiar with the processes. Their own medical notes were available to them.
Patients. Only 17% of the patients responded (to the survey), but they were enthusiastic and positively accepted the process. No negative comments were received. Indeed, nurse-led clinics are usually received positively by patients.6
Nurses noted an increase in workload but were able to accommodate this additional workload without the need for any increased staffing. Their comments were generally very favourable to the extent that the process has been used now for a range of patients on the standard DHB waiting list, as well as continuing with the ACC cases.

The nurses have benefited by increasing their skill levels, having greater autonomy, and enjoying increased respect from clinical colleagues.2 It has also resulted in a respect for the different roles that are needed for completion of the elective orthopaedic surgical procedure. Effective utilisation of nursing time has resulted in no increase in the nursing resource during the trial and this situation still remains.

The house surgeons considered that the lack of a house surgeon’s note did not result in any increased effort in evaluating adverse events in patients to whom they were called postoperatively. There has been increased job satisfaction, especially from the house surgeons working on the elective orthopaedic run. There is not the early morning rush to admit patients but more time to focus on ward patients.

The favourable outcomes listed above have led to the nurse-led process being incorporated into hospital routines at Burwood Hospital. The process should also be applicable to other clinical service units.

(Further detail of the questionnaires and documentation used can be obtained from the lead author, Jennifer Truscott.)

Competing interests: None.

Author information: Jennifer M Truscott, Preoperative Clinical Nurse Specialist and Co-ordinator Anaesthetics Department; Joanne M Townsend, Clinical Charge Nurse, Surgical Orthopaedic Unit; Edwin P Arnold, Medical Advisor to General Manager, Older Persons’ Health and Rehabilitation; Burwood Hospital, Christchurch

Correspondence: Dr E Arnold, Older Persons’ Health and Rehabilitation, PO Box 4708, Burwood Hospital, Mairehau Road, Christchurch

References:

NHS Management Executive. Junior Doctors: The New Deal. London: NHS Management Executive; 1991.
United Kingdom Council for Nursing, Midwifery, and Health Visiting. The Scope of Professional Practice. London: UKCC; 1992.
Harvey N, Gaudoin M. Effectiveness of a nurse-led pregnancy termination clinic. Nursing Times. 2005;101(17):34–6.
Gilmartin J, Wright K. The nurse’s role in day surgery: a literature review. International Nursing Review. 2007;54:183–90.
Thomson S. Nurse-physician collaboration: a comparison of the attitudes of nurses and physicians in the medical-surgical patient care setting. Medsurg Nurs. 2007;16:87–91.
Miles K, Penny N, Power R, Mercey D. Comparing doctor- and nurse-led care in a sexual health clinic: patient satisfaction questionnaire. J Adv Nurs. 2003;42(1):64–72.