Preadmission clinics for patients awaiting elective procedures or surgery are not a new concept. Over the years, several studies have highlighted the multiple benefits that a well-developed, preadmission clinic can offer. In this commentary, Gemma McCalmont explains how the use of such a clinic—led by nurses—for patients scheduled to undergo transcatheter aortic valve implantation (TAVI) is beneficial for both the patients visiting the clinic and the TAVI service as a whole.
While the original aim of preadmission clinics, in their infancy, was to reduce the number of post admission cancellations, improving the quality—and cost-effectiveness—of day surgery has become a complimentary aim.1 Also, these clinics have now become a pivotal part in enhancing quality of care and ensuring resources are used effectively by highlighting, in advance, when patients are not able to undergo a procedure.2,3
In 2009, when the TAVI service was initially introduced at James Cook University Hospital (Middlesbrough, UK), preadmission assessment quickly became a required standard for all patients referred for TAVI—because of the high-risk nature of this patient cohort, preadmission is now an integral part of the patient journey. This particular clinic is led by an experienced specialist nurse, who holds advanced clinical assessment and prescribing qualifications. In addition to this, they have completed an in-house training competency in TAVI.
All patients are required to be reviewed in the preadmission clinic, and this review takes place between five and 14 days prior to admission for the procedure itself. During the review, the nurse takes a complete history from the patient (including a review of their current medications). Also, the nurse will perform a full clinical examination and a series of tests, which can include blood tests, an ECG, chest X-rays and lung function tests (if clinically indicated). Furthermore, patients are given a detailed explanation of the procedure so they are able to understand their journey during their hospital stay. Barriers to a timely discharge will be highlighted at this stage and a deeper understanding of issues such as frailty and family support (or lack thereof) will be gained. Due to the average age and comorbidities of the typical TAVI patient, understanding and accounting for these social issues is essential.
Identifying, accounting for and planning for any potential issues, in advance, enables a smooth discharge process. This holistic assessment of the patient makes nurses ideally placed to perform the preadmission clinic.
As a natural progression from the assessments and explanation of the procedure, the specialist nurse also takes consent for the procedure. This nurse-led consent process was developed and used initially within cardiology for interventional coronary procedures such as percutaneous coronary intervention (PCI) but has now been adopted into the trust guidelines for consent. As such, this process was integrated into the TAVI preadmission clinic from the outset. Patients are carefully taken through the risks and benefits of the procedure and have the opportunity to ask questions or discuss the procedure further with their consultant if they wish. The specialist nurse will also refer to the consultant if they believe that the patient does not have the capacity to give informed consent.
From the perspective of the TAVI service, up-front identification of issues that may affect the procedure has been a significant benefit. Common issues that arise during the preadmission process can include increasing pulmonary oedema, requiring up-titration of diuretic therapy in advance of the procedure, identification of current infection or the unearthing of other medical conditions or symptoms—all of which may change the timing of the patient’s admission for TAVI. As a result of the clinic, TAVI procedures are rarely cancelled on clinical grounds after a patient has been admitted for the procedure. If a patient’s procedure is cancelled or postponed after review in the preadmission clinic, their “slot” is used for another patient.
Aside from the easily measured and, therefore readily documented, benefits of reduction in patient cancellations and cost savings to the trust, the benefit for the patient about to undergo TAVI should be the driving factor when considering developing this service for patients. Audits of this service to date have demonstrated a high level of patient satisfaction. Patients report feeling suitably prepared for the procedure as well as feeling comforted that they have a point of contact in what can be a protracted “work up phase” prior to TAVI. Enhanced communication between the multidisciplinary team is also a beneficial by-product of a well ran preadmission clinic as the specialist nurse is able to act as a co-ordinator of care between the TAVI team, patient and family.4
References
- Clinch. Journal of Clinical Nursing 1997; 6: 147–51.
- Correll et al. Anesthesiology 2006; 105: 1254–59.
- Foss et al. Current Opinion in Anensthesiology 2001; 14: 559–62.
- Turenen et al. Journal of Clinical Nursing 2016; 1111: 134–48.
Gemma McCalmont is a TAVI Specialist Nurse at James Cook University Hospital (Middlesbrough, UK)
