Preoperative Preparation of the Surgical Patient: Providing the Foundation
By Patricia A. Menges, RN, CNOR, MBA/HCM
Having celebrated my 35th anniversary as a perioperative nurse, I reflect on the changes in healthcare. Advances in technology and innovative techniques employed to diagnose and treat disease have been dramatic, but so is the radical revolution in how services are delivered to patients needing surgery and other invasive treatments. No changes have been more sweeping than those imposed on healthcare in preprocedure preparation of patients.
In the 1960s and 1970s, surgical patients were admitted the day before surgery to receive the obligatory preoperative "shave prep" and other delights like "enemas until clear." Many times, abnormal test results were not reported until surgery was ready to start, X-ray films could not be found or patients were fed by accident. Surgery was delayed or cancelled and patients, physicians and hospital staff were frustrated and angry.
Radical changes came for hospitals in 1983 when the federal government adopted diagnostic related groupings (DRGs) to control Medicare costs. Inpatient days, outpatient surgery and same-day surgery became a necessity imposed by new reimbursement structures. Observation status programs created a shift from inpatient to outpatient utilization, thereby reducing length of stay. Hospitals report 85 percent of surgical patients now arrive on the day of surgery.
Hospitals created preoperative holding areas where patients often had tests performed, including EKGs and chest X-rays, immediately before scheduled surgery. Patients were anxious and surgery was at great risk to be cancelled due to abnormal test results and the need for additional patient work-up. Lab results and orders did not always arrive at the destination, films still got lost, patients were poorly instructed or did not comply with preoperative instructions for NPO, resulting again in delays and cancellations. The system was still flawed.
The burden is on hospitals to find innovative means to coordinate care for patients in absentia, preoperatively.
Good Samaritan Regional Medical Center in Phoenix employed a team approach in the development of a Pre-admission Utilization Management Services Department (PAUM) to coordinate and manage surgical patients in the prehospital phase of preoperative preparation. The PAUM department works with surgery scheduling, patient services, the nursing staff in the preoperative area and the physician's office to ensure the patient's surgical event is coordinated. The PAUM department receives demographic information on the patient at the time surgery is scheduled. Insurance authorization, appropriate level of care, and financial counseling can be accomplished in advance so there are no surprises for the patient on the day of surgery. The PAUM department is staffed with a registered nurse who calls patients and performs preoperative teaching before admission. A mailout provides instructions, maps and hospital information for patients and family members. Patients also receive a form to complete and return so pertinent medical history can be reviewed prior to admission, saving time on admission day and allaying many anxious moments before surgery.
The program provides value to patients and members of the healthcare team. Some organizations have gone beyond this model to establish centers that see patients well in advance of surgery and provide comprehensive services including an anesthetic evaluation and work-up, history and physical, required pre-op testing, patient education and even nutrition and exercise counseling to affect optimum outcomes. The objectives for preoperative programs are:
- To optimize efficiency and bed utilization preoperatively
- To avoid delays and cancellations resulting in lost operating room time
- To proactively coordinate patient care
- To provide high-quality, safe patient care
- To improve satisfaction
- To set the foundation for optimum outcomes for the surgical patient
Many standards and principles of good patient care have been constant, while healthcare and hospitals reinvented themselves in order to survive change. The dilemmas and opportunities posed by advances in technology, the constraints of regulation, cost containment and working with government and managed care will continue to keep a career in perioperative nursing stimulating.
Patricia A. Menges, RN, CNOR, MBA/HCM, is the service line director of general surgery at Good Samaritan Regional Medical Center in Phoenix.