Preadmission testing in a children's facility

AORN Journal,  Oct, 2003  by Kathleen Sexton,  Michelle Redfearn

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Children's Mercy Hospitals and Clinics (CMHC), Kansas City, Mo, is a pediatric facility that provides patients and their family members with child-focused care. Patients undergoing outpatient or inpatient surgical procedures at CMHC often have complex medical histories. The same day surgery (SDS) unit at CMHC is the portal for all children scheduled for surgery who also stay overnight or for several days in a surgical unit or the pediatric intensive care unit.

The culture of the SDS unit, since its development in the early 1980s, was based on the concept that a patient and his or her family members make only one trip to the hospital for surgery. This process was no longer functional after he hospital became a tertiary referral center. As the referral area grew, so did the population of chronically ill children being treated at this facility. The time needed to solve complex medical and social problems exceeded the 90-minute period from patient arrival to the scheduled initiation of the procedure. As a result, delays and cancellations ensued. The SDS nurses at CMHC had a quality improvement idea to change the patient preparation and admitting process.

THE TEAM PROCESS

The nurses identified a way to increase efficiency at the main campus by starting preparation for surgery at least one week before the surgery date. The SDS nurse manager encouraged these nurses to form a quality team to convince administrators, surgeons, and anesthesia care providers to support a preadmission testing (PAT) visit to prepare patients for surgery.

Nurses at CMHC use the TEAM approach to quality improvement. The TEAM model, implemented by the director of quality and her staff members, is an adaptation of the Juran Institute's process for quality improvement. (1) The TEAM model simplifies the Juran model, using four major steps instead of six. These steps include

* T--think of an improvement idea,

* E--establish a project,

* A--analyze the problem, and

* M--make recommendations and changes.

All CMHC departments now initiate quality projects using this process model to ensure consistency throughout the organization. (2) The quality team assembled for this project consisted of staff nurses, a project coordinator, the SDS and OR nurse managers, and the vice chief of anesthesiology.

DATA COLLECTION

Team members conducted a literature review, but they were frustrated by the lack of pediatric PAT data in the literature. One team member called other pediatric hospitals for information and drew on the expertise of two staff nurses who previously had worked in adult facilities that used PAT.

Team members collected data and compared indicators with similar facilities in a benchmarking process. Data determined that CMHC had the highest cost per procedure associated with typical pediatric procedures and was the only facility in the cohort without a PAT program. Patient satisfaction information for a 10-year period illustrated two reasons for parent dissatisfaction: lack of information about arrival time until the day before surgery and lack of information about delays. Operating room start time delays ranged from 30 minutes to three hours.

Team members studied SDS data collected during a two-week period on the number of canceled and delayed cases by specialty and by surgeon. Reasons for delays and cancellations were identified, including

* family member decision,

* lack of preoperative preparation,

* late arrival of the surgeon,

* patient illness, and

* scheduling error.

These data were retrievable via an online documentation and report-writing program. Team members also constructed flow charts to visually demonstrate the cumbersome preoperative process (Figure 1). In addition, team members designed a streamlined process to decrease delays and cancellations and increase family member and staff member satisfaction (Figure 2).

[FIGURE 1-2 OMITTED]

Team members made a site visit to another children's hospital--a facility from the benchmarking group that is similar to CMHC in size, number of inpatient beds, number of OR suites, patient population served, and demographics. The other hospital's PAT program, which had been in place for three years, was endorsed by staff members and received high scores for patient satisfaction on satisfaction surveys. Delays and cancellations decreased after the initiation of PAT at this facility. The CMHC team members toured the SDS unit, where preadmission takes place for approximately 80% of preoperative patients. Nurse practitioners complete patient histories and perform physical examinations to determine readiness for the scheduled procedure, complete preoperative teaching, and coordinate any test results from medical specialties and social services. The anesthesia care provider conducts the preanesthesia assessment, and a child life specialist is available for teaching and support.

Team members learned key information from the site visit.

* Same day surgery patients and PAT patients could be seen in the same physical space without confusion about which patient was present for which purpose.