Open heart surgery is considered to be a major event for patients, their families, and hospitals. Delays in surgery cause emotional distress for the patient and their family and are costly to the hospital. For these reasons, it is beneficial for all organizations providing open heart surgery services to review their processes that prepare the patient for open heart surgery. Investing the time to detail the patient flow processes involved in the preoperative preparation will assist in eliminating process gaps and identify opportunities to improve organizational communication, patient care and satisfaction. This can be accomplished by instituting a task force/ committee to assist in this area.
It is advisable to include departments involved with patient entry points into the open heart process. These departments are usually the inpatient medical cardiac units, registration area, cardiovascular surgeon office, and cardiac cath lab. Development of standardized preoperative open heart surgery orders help to create common practice routines that can reduce errors, improve the staff education, and reduce organizational costs by eliminating unnecessary tests and improving staff efficiencies. These benefits outweigh the challenge of standardizing preoperative physician orders.
The orders set should be approved by the appropriate organizational committees, explained to the staff, and then distributive to appropriate departments for implementation. Included in these order sets should be preoperative lab tests, patient testing (CXR, EKG), medications, consults including anesthesia, and surgical prep. Input from the medical staff is essential to this process. The administrative leader should be well versed on latest clinical techniques and cardiovascular research ensuring best practices are addressed and not overlooked.
Some of the most common causes of delays are from inaccurate completion of blood bank procedures, long turnaround times for patient reports, a lack of the chest film or lateral view, scheduling delays for patient testing, and lost pieces of the patient’s medical record. Addressing these topics during patient flow planning is essential in expediting the presurgery process. Once process gaps are identified it is important to develop a workable solution and education plan. Ongoing continuous quality management can evaluate the effectiveness of the changes and identify any additional needed areas of improvement.
The outpatient preadmission process should be flow charted to facilitate a smooth patient transition through the appointment schedule. This is the patient’s introduction to your heart program and efforts should be directed at providing the patient with a good first impression.
The following issues should be addresses in the planning sessions for the preadmission appointment:
• What time of day is best to schedule preadmission appointments
• Where should the patient report
• Who will educate the patient on post operative care, incentive spirometer, skin prep, family waiting, and discharge needs
• Who will be involved in the preadmission process
Due to the need for a number of tests and significant clinical education it is recommended to schedule the preadmission appointment prior to the day of surgery. This provides the time to review the test results and provide comprehensive education for the patient. The preadmission process can be accommodated in a same day surgical appointment but more opportunities are present for process delays. Frequently included with the diagnostic testing are a listing of consults for anesthesia and other services, an insurance assessment, and completion of history and physical by a physician assistant /certified nurse practitioner if this has not been provided by physician office.
A standardized patient education session is a major component to patient surgical preparation. One of the first steps should be to determine who will be involved in the education process. Cardiac care coordinator, clinical nurse specialist, or cardiovascular unit staff nurses are good choices to provide the postoperative education. When multiple patient care providers are providing patient education it is recommended to script the education ensuring all topics are consistently presented. Many hospital heart programs are now offering preoperative cardiovascular patient education online through their website. This is another educational opportunity that compliments the individualized approach. The patient education session should be brief as to not frighten the patient, but should review the major care components such as monitoring, invasive lines, tubes, and alarms. Most patients are interested in knowing when the lines and tubes are inserted and how long they remain. Ambulation protocol should be explained so they can anticipate getting out of bed shortly after they awake from surgery. Skin prep and other medications such as Bactroban (if they are a part of the night before prep) should be provided with written instructions and explanation for use. The educational session is also a good time to review specific discharge issues like the expected length of stay and need for someone to stay with them the first few days following discharge. A tour of the post op recovery unit allows the patient and their family to visualize the high level of care that will be provided. The committee should plan for how the sequence of appointments will flow to reduce wait times for the patients and all disciplines involved. This attention given to improving the preadmission process can increase the level of confidence the patient and family has in your program. It starts their surgical experience off on a favorable note.
For all open heart surgery patients test results should be reviewed with abnormal results provided to the surgeon as quickly as possible. If the patient is a diabetic, the anesthesiologist usually prefers to be informed of the morning blood sugar. Latest research correlates blood sugar levels with wound healing therefore; strict regulation of blood sugar levels is now common practice and can be a key to improved patient outcomes. Any preoperative indication of infection warrants physician notification such as an elevated temperature and abnormal blood or bacteria counts in the urinalysis.
Carotid studies should be anticipated for patients that presents with clinical symptoms or at a specific age (commonly >65). Open heart surgery will be delayed if the patient has a significant carotid stenosis. This condition will likely require treatment before open heart surgery can be preformed. Chest x-ray report along with the films for posterior anterior and lateral views is another frequent source of open heart surgery delay. The films are needed and reviewed in the surgical suite helping the physician determine the depth of the incision. A lateral view is essential for all redo open heart surgery patients since adhesions may be present. The chest views enables the surgeon to determine the heart size, pulmonary vascular and possibility of calcification of the aorta.
A comprehensive preadmission process for open heart surgery patients sets the stage for preventing post operative complications and improving patient outcomes. Due to the complexity of open heart surgery and the expensive to perform it is prudent for the organization to ensure that the candidates are adequately assessed, well educated and prepared both clinically and psychologically for the event. These efforts help to achieve program goals and outcomes. Good patient outcomes are vital to open heart programs since they are monitored by most insurance providers, federal agencies, and available to consumers. Poor patient outcomes place the whole open heart surgery program in jeopardy. An efficient preadmission process can reduce costly delays and improve patient and family satisfaction. For these reasons it is of value to the organization to invest the time to guarantee the preadmission processes are smooth and efficient.