By Patricia A. Menges, RN, CNOR, MBA/HCM
Havingcelebrated my 35th anniversary as a perioperative nurse, I reflect on thechanges in healthcare. Advances in technology and innovative techniques employedto diagnose and treat disease have been dramatic, but so is the radicalrevolution in how services are delivered to patients needing surgery and otherinvasive treatments. No changes have been more sweeping than those imposed onhealthcare in preprocedure preparation of patients.
In the 1960s and 1970s, surgical patients were admitted the day beforesurgery to receive the obligatory preoperative "shave prep" and otherdelights like "enemas until clear." Many times, abnormal test resultswere not reported until surgery was ready to start, X-ray films could not befound or patients were fed by accident. Surgery was delayed or cancelled andpatients, physicians and hospital staff were frustrated and angry.
Radical changes came for hospitals in 1983 when the federal governmentadopted diagnostic related groupings (DRGs) to control Medicare costs. Inpatientdays, outpatient surgery and same-day surgery became a necessity imposed by newreimbursement structures. Observation status programs created a shift frominpatient to outpatient utilization, thereby reducing length of stay. Hospitalsreport 85 percent of surgical patients now arrive on the day of surgery.
Hospitals created preoperative holding areas where patients often had testsperformed, including EKGs and chest X-rays, immediately before scheduledsurgery. Patients were anxious and surgery was at great risk to be cancelled dueto abnormal test results and the need for additional patient work-up. Labresults and orders did not always arrive at the destination, films still gotlost, patients were poorly instructed or did not comply with preoperativeinstructions for NPO, resulting again in delays and cancellations. The systemwas still flawed.
The burden is on hospitals to find innovative means to coordinate care forpatients in absentia, preoperatively.
Good Samaritan Regional Medical Center in Phoenix employed a team approach inthe development of a Pre-admission Utilization Management Services Department (PAUM)to coordinate and manage surgical patients in the prehospital phase ofpreoperative preparation. The PAUM department works with surgery scheduling,patient services, the nursing staff in the preoperative area and the physician'soffice to ensure the patient's surgical event is coordinated. The PAUMdepartment receives demographic information on the patient at the time surgeryis scheduled. Insurance authorization, appropriate level of care, and financialcounseling can be accomplished in advance so there are no surprises for thepatient on the day of surgery. The PAUM department is staffed with a registerednurse who calls patients and performs preoperative teaching before admission. Amailout provides instructions, maps and hospital information for patients andfamily members. Patients also receive a form to complete and return so pertinentmedical history can be reviewed prior to admission, saving time on admission dayand 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 seepatients well in advance of surgery and provide comprehensive services includingan anesthetic evaluation and work-up, history and physical, required pre-optesting, patient education and even nutrition and exercise counseling to affectoptimum outcomes. The objectives for preoperative programs are:
Many standards and principles of good patient care have been constant, whilehealthcare and hospitals reinvented themselves in order to survive change. Thedilemmas and opportunities posed by advances in technology, the constraints ofregulation, cost containment and working with government and managed care willcontinue to keep a career in perioperative nursing stimulating.
Patricia A. Menges, RN, CNOR, MBA/HCM, is the service line director ofgeneral surgery at Good Samaritan Regional Medical Center in Phoenix.