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Clinical nurse specialist Shelley McMahon reflects on the ongoing development of Northland’s Nurse-Led Preoperative Assessment Clinic.

In late 2006 Northland took its first fledgling steps towards a fully Nurse-Led Preoperative Assessment Clinic (NLPAC).

The result of this initiative was well documented in a report in 2008 by fellow clinical nurse specialist Zoe Pathan and anaesthetist Rod Harpin. This was a very exciting time for the Northland District Health Board (NDHB) clinic, but as we settled into our new roles we knew that we had to constantly revise and review the high standards originally set. Over the last five years, the earlier success of the clinic has been built upon to improve the service and ensure its sustainability.

Hatchett in 2003 defined nurse-led Clinics as “a clinic where the nurse has his or her own patient caseload…involves an increase in the autonomy of the nursing role…to refer onto more appropriate healthcare colleagues”.

Northland’s Nurse Led Preoperative Assessment Clinic began with just three nurses but the clinic’s staff has since doubled. Now there is a clinical nurse specialist and four specialty clinical nurses working in Whangarei and one specialty clinical nurse working in Kaitaia. All preoperative assessment clinic (PAC) nurses have successfully undertaken the DHB’s core clinical competencies and completed University of Auckland’s Advanced Assessment and Clinical Reasoning paper. Postgraduate education over the last five years has seen all PAC nurses gain postgraduate qualifications ranging from a postgraduate certificate to a masters degree in nursing.

The Kaitaia clinic began in February 2008, with two nurses travelling once a month to Kaitaia for two days. This was to capture patients whose first specialist appointment (FSA) was undertaken in the Far North and to ensure equity of access to our service. In 2011 Kaitaia gained its own preoperative assessment clinic.

New patient-centred criteria
Much of the clinic criteria were dictated by age. For example, all patients over 50-years-old had an ECG performed and required routine blood tests. This has recently been reviewed by the anaesthetic department and the PAC. To expect a patient to attend the PAC because of their age and not their co-morbidities is not patient-centred care. Patient safety is paramount. Asessments are underpinned by clinical competence and the ability to interpret health information and fitness for anaesthetic.

Age is not now a major factor in our decision to see a patient. Patients are assessed by phone when possible and brought into clinic if a physical assessment is required. Our decision-making skills are challenged on a regular basis, but with peer support and an open door policy with the anaesthetists, positive outcomes are achieved.

In 2010 referral to the clinic was adapted to allow us to take ownership of the whole PAC process. Prior to this each service’s booking clerk would book patients independently into the clinic. This was on a ‘first come first served’ basis and did not take into account the urgency of the surgery or staffing levels.

Upsurge in demand
The increase in elective surgery completed in Northland is reflected across the rest of New Zealand. In the first nine months of 2007 2,174 patients were seen in PAC, of these 423 were seen by the anaesthetist. This represents 19.4% of patients seen in clinic by the PAC nurse. Approximately 1,550 patients were fast-tracked (assessed by post, phone etc.). Of the patients seen in clinic 65 were cancelled as “unfit” on the day of surgery. This represents 2.9% of all patients seen in PAC.

By contrast, patients seen in PAC up until the end of September 2012, numbered 2,755. 705 of these patients required an anaesthetic assessment. This represents 25.5% of all patients seen in the PAC. Fast-tracked patients totalled 1,959. 80 patients, who were seen in PAC by the nurse and/or the anaesthetist, were cancelled as “unfit” on the day of surgery. This represents 1.1% of all patients seen in clinic.

A really exciting piece of news is that the preoperative assessment clinic held its first combined cardiology/anaesthetic clinic in December. This is a new innovation for PAC and is working really well. Previously patients were referred to the medical outpatient department to wait their turn for an appointment. They did not go onto the surgical booking list until all of their preoperative tests had been completed and their health optimised. This could mean a wait of up to six months for surgery on top of the optimisation period. By co-ordinating our service with cardiology to review preoperative patients, we hope to reduce the wait for surgical optimisation and promote a more patient centred service.

To summarise, over the last five years the service has grown in size and complexity. The PAC staff case-manage more and more complex patients. The work is exciting and attracts dynamic, motivated staff. Northland DHB are also justly proud that the Nurse Led Pre-operative Assessment Clinic was also chosen by the Ministry of Health to be a Demonstration Site for 2012.