Introduction

Traditionally and historically, many professionals within the hospital environment have been involved in the assessment of patients going for surgery. These include medical staff, nurses, pharmacists and physiotherapists. Individually, each professional would ‘assess’ the patient from their individual professional perspective (Bassett 2005). As a result, the patient would have to repeat similar information to a number of professionals. The impact of this was that vital information was often lost. Recognition of this and the need to continually improve and streamline patient services has become the result. A major development that we have seen over the last 7–10 years has been in the area of multi-professional assessment services. In particular the learning gained from the early work of day surgery units and the guidelines and practices these adapted to patient selection.

Almost 40 years ago, Crosby et al (1972) researched the benefits of pre-admission assessment on surgical patients and recommended that such assessments should take place. Undoubtedly, for many years, organisations interpreted the aims of pre-admission assessment in different ways and gave such services varying amounts of support (Bassett 2005). It only became apparent how important such a service could be with the reduction in working hours of junior doctors (Department of Health (DH) 1997) as this change resulted in a lack of time to ‘clerk’ patients traditionally. This presented the idea that professionals other than doctors should become involved in the process. Nevertheless, owing to a lack of leadership from key stakeholders anxious to ensure that their professional identity was maintained and anxious not to make recommendations for other professional groups, little was written on the subject until the NHS Modernisation Agency published national guidelines in 2003.

Equally, as the focus of healthcare delivery has shifted from inpatient to ambulatory care and the need to treat greater numbers of patients, healthcare organisations have had to review/develop assessment services which are able to meet these demands.

The recognition of the contribution this model of assessment can offer to organisations and patients has clearly been articulated by the Scottish Executive (2005) in the strategy document Building a Health Service Fit for the Future. A key to successful assessment in a modernising NHS is that:

Key drivers for pre-admission assessment

Pre-admission assessment clinics are now commonplace for surgical specialties. Pre-admission assessment is the process of assessing patients prior to surgery. The key purpose of this assessment is to reduce perioperative morbidity and mortality by identifying patients who may require further assessment, investigation or treatment of co-morbidity prior to surgery (Janke et al 2002).

This definition of pre-operative assessment by NHS Scotland (2008:4) may help you to consider this activity:

The main driving force behind this change has been the acknowledgement that patient-centred assessment services have become a key means of how the NHS can deliver on national targets (DoH 2001). Nationally, the main drivers for this change were the Labour Government NHS modernisation agenda (pre-2009) and the National Institute for Health and Clinical Excellence (NICE) guidelines for preoperative testing (2003), the aims being to reduce last minute cancellations and to be able to facilitate day of surgery admissions.

Historically, within surgery, patients were not always adequately prepared for general anaesthetic due to either inadequate preoperative testing or patients being classified as unfit for surgery. In some cases, this led to operations being cancelled and operating department ineffectiveness. Pre-assessment was performed 1–2 weeks prior to admission resulting in such cancellations because some identified health problems could not always be resolved in the time before surgery and hospital admission.

Following the introduction of the two national good practice guidance documents, single pre-admission assessment clinics were introduced and followed a radically revised care pathway. When a decision for elective surgery is made, within the outpatient department, the patient is immediately taken for anaesthetic assessment. All the necessary preoperative investigations are completed in accordance with the NICE guidelines for preoperative testing (NICE 2003). Objectives of preoperative assessment (NHS Modernisation Agency 2003) prior to inpatient surgery are listed in Box 5.1 and this offers an excellent overview for you to help plan learning outcomes.

Who conducts the pre-admission assessment?

At present it is a registered nurse who completes the nursing assessment and a doctor who completes the medical assessment. As changes are made to the education and training of doctors and with the reduction in working hours of junior doctors (Oakley & Bratchell 2010), nurses are taking on more of the junior doctors’ role and, certainly in the UK, there are nurse specialists in this field (DH 2006).

In the case of day surgery/ambulatory surgery, trained nurses undertake the complete assessment. Doctors will see the patient on the day of surgery for medical checks and to obtain consent (see Ch. 6 for issues around informed consent).

The good practice guidelines recommended that preoperative assessment for either day surgery or inpatient surgery should be ‘performed by a trained and competent preoperative assessor’ (NHS Modernisation Agency 2003:6). Each NHS trust or independent hospital will have its own practice guidelines and policies with regards to this, and if you are in a pre-admission placement, it would be good practice to read this and be familiar with the content as patients may ask you: ‘Who is going to see me today? Is it the doctor?’ It requires a multidisciplinary team approach to ensure seamless care for patients.

When a problem is identified, such as a patient having a cold or a chest infection, which may result in a patient’s surgery being cancelled or where further advice is required, an anaesthetist is contacted so that decisions can be made regarding the management of the patient either pre- or postoperatively. The anaesthetist may have dedicated pre-admission sessions and be available most days for either patient or notes review. The anaesthetist also sees the patient on the morning of surgery if the patient is for day surgery or ambulatory care surgery. For patients having inpatient surgery or planned surgery, they may see the patient the day before as the majority are admitted at least the day before surgery is to take place (see Ch. 6). The good practice guide also gives an overview of the guidelines used for selecting patients for day surgery, including when day surgery would not be considered, e.g. pain cannot be controlled with oral analgesia and specific physiological contraindications such as poorly controlled asthma or having had a heart attack in the last 6 months.

Depending on the type of surgery a patient is having, other members of the multidisciplinary team may also be involved in the pre-admission assessment process. For example, a physiotherapist might assess a patient’s needs and give advice regarding exercise regimes and mobilising in the postoperative period (see section on nursing assessment on admission to hospital in Ch. 6).

Referral to an occupational therapist may be required, who assesses the patient’s requirements for discharge home from hospital: for example they may be required not to climb stairs or require raised toilet seats. Patients who are having joint replacements are asked to complete a form, which records the height of chairs, bed and so forth so that any identified requirements are dealt with prior to the patient’s discharge home (see Royal National Orthopaedic Hospital leaflet on total hip replacement: http://www.rnoh.nhs.uk/sites/default/files/downloads/10-86_rnoh_pg_thr_web_0.pdf (accessed May 2011)).

A pharmacist may see a patient to address any problems with medications while they are in hospital. For example, a patient may be an insulin-dependent diabetic or taking steroids, both of which will be affected by surgery. For patients coming to hospital for day surgery/ambulatory surgery, the nurse will complete a pharmacy pre-assessment sheet and send it for the attention of the pharmacist.

The consultant surgeon, surgical registrar or surgical care practitioner will ideally be available for the pre-assessment visit to explain the procedure to the patient and get the consent form signed. They would also be able to ensure that any questions that accompanying relatives have can be answered. A useful document to read in relation to patients with learning difficulties who may require surgery is that written specifically for nurses by the Royal College of Nursing (RCN 2006).

Key components of good pre-admission assessment

The major goal of pre-assessment services is to assess the holistic needs of patients and determine their suitability for surgery (Johansson et al 2010). The information obtained enables the team to engage with careful patient selection and plan individual care accordingly.

The Scottish Executive (2005) noted that failure to assess patients adequately can be responsible for high operating theatre cancellation rates, or unacceptable risks to patients. It further advises that studies in Australia have shown that inadequate assessment is frequently implicated in deaths attributable to anaesthesia (Mackay 2004).

Traditionally, pre-admission assessment services were delivered within the hospital environment. With the modernisation of services along with advances in technology, opportunities exist for pre-admission services to be delivered in more innovative ways (NHS Modernisation Agency 2003:10). Some innovative ways in which pre-admission services are being delivered are the following:

Many advocates of pre-admission assessment services believe there is a place for using information technology in assessment (Macduff et al 2001). In some facilities, information is stored directly on a database and shared between the relevant professionals. In others, patients hold their own records and take them to where they are needed. In both cases, assessment is a good example of the opportunities for sharing information among professionals, and this will only improve with the advent of the electronic patient record (Scottish Executive 2005).

Whatever the method of delivering pre-admission assessment services, it must always be appropriate to the patient and the type of surgery they will undergo.

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