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New Procedures, Recovery Care, Patient Education Addressed at Same-Day Surgery Conference
AORN JOURNAL
JUNE 1989, VOL. 49, N O 6
New Procedures, Recovery Care, Patient Education Addressed at Same-Day Surgery Conference
A
dvanced Strategies for Ensuring Success in the 1990s” was the theme of the 10th annual Same-Day Surgery Conference, which was held March 20 to 21 in Chicago. The conference was sponsored by the Same-Day Surgery newsletter. Topics included new same-day surgery procedures, recovery care centers, patient education, and quality assurance.
Hyperopic Radial Thermal Keratoplasty
H
yperopic thermal keratoplasty for farsightedness gives ophthalmologists the surgical tool to eliminate the need for glasses from society, according to Robert H. Marmer, MD, assistant clinical professor of surgery, Morehouse School of Medicine, Atlanta. Dr Marmer was one of the first ophthalmic surgeons in the country to do radial keratotomy surgery for nearsightedness, and now he is one of the first to have been trained in Moscow by Svyatoslav Fyodorov, MD, to perform hyperopic thermal keratoplasty for farsightedness. “It is interesting to have a procedure that everyone will need sometime in their lives,” Dr Marmer said. In hyperopic thermal keratoplasty, heat is used to permanently change the shape of the cornea, which focuses images on the back of the retina. The heat shortens the collagen fibers of the cornea. Preoperatively, antibiotic drops and a topical anesthetic are instilled into the eye. The patient is awake during the procedure. The patient’s corneal thickness is first measured with an ultrasound, and then the heating element is calibrated to a precise depth so that it only penetrates the cornea so far. The heating element is turned to 600 OC, and tiny holes are burned into the cornea. As the cornea heals, it molds to the preoperative corneal curvature, but it does not go all the way back. The cornea has a greater dome size postoperatively, which changes the way
Robert H. Marmer, MD, explains hyperopic thermal keratoplasty for farsightedness.
light is refracted as it enters the eye. Because there is no penetration through the full thickness of the cornea, no infection can enter the cornea, Dr Manner said. Postoperatively there is no severe pain, just some burning and itching. According to Dr Manner, only a few surgeons are able to perform this procedure because the instrumentation is not available in the United States, and only a few surgeons are being taught the procedure in Moscow. In two years, Dr Marmer predicts that ophthalmologists in the United States will develop their own instrumentation and hold their own classes. Dr Marmer bought his heating element from the Soviet Union.
Microsurgeryfor Ruptured Lumbar Discs
H
erbert L. Cares, MD, a neurosurgeon in private practice in the Boston area, presented a workshop on ambulatory microsurgery for 1657
AORN J O U R N A L
JUNE 1989, VOL. 49, NO 6
Herbert L. Cares, MD, presents a workshop on ambulatory microsurgery for ruptured lumbar discs. ruptured lumbar discs. Dr Cares authored the first published report on this procedure. Advances in microsurgical techniques combined with a widening interest in ambulatory surgery led him to investigate ambulatory lumbar discectomy, he said. Dr Cares performs the surgery through a 25mm skin incision. He removes the medial portion of the facets with a high speed diamond-burred air drill and microrongeurs. This allows exposure of the disc with minimal or no root retraction. He then removes any free disc fragments and clears the interspace of loose disc. At the end of the dissection, the operative team can see into the interspace with no retraction of the dura mater or root. “I do a big operation through a little incision, I don’t have to retract the root, there is little bleeding, and both surgeons can see the field,” Dr Cares said. Dr Cares said that his inpatient routine for discectomies did not require intravenous lines, injections, urinals, or bedpans. The hospitalized patients were up in a chair for all meals and discharged in 24 to 48 hours postoperatively without prescriptions. He said he asked himself what he was doing in the hospital that could not be done in an ambulatory surgery facility and at home. 1658
After three years, he has operated on more than
25 patients in ambulatory surgery units. And now, he said, it is routinely done in four community hospitals in Massachusetts, where he practices. According to Dr Cares, none of his patients had to be readmitted to the hospital or had complications, and after three years, all are free of sciatica and would choose ambulatory surgery again. In addition, all of the patients returned to work in less than two weeks, he said. Dr Cares’ patient selection includes standard criteria for any lumbar disc surgery, including sciatica refractory to all conservative measures, objective focal root deficit, and a positive computed axial tomagraphy scan or magnetic resonance image. Patient education begins three days before surgery. Patients are told that postoperatively, the only discomfort may be incisional pain and numbness in the area of their preoperative radicular pain. They also are told that a visiting nurse will see them the night of surgery and the first two postoperative days. Participation in the ambulatory surgery procedure is voluntary. The patients can change their minds at any stage of the process, Dr Cares said. The postanesthesia care step-down unit is the critical component of the ambulatory procedure,
JUNE 1989, VOL. 49, NO 6
AORN JOURNAL
according to Dr Cares. The patient is given clear liquids when awake and progresses to crackers and gelatin. Then the patient sits up in a straightbacked chair with arms, and he or she walks to the bathroom or portable commode. Dr Cares said that before discharge, the patient must void, sit up, walk, take oral nourishment, and be checked by the surgeon. According to Dr Cares, this procedure contributes to the understanding of perioperative pain management, and the trendsetters in this procedure may be the community and not the teaching hospitals. Dr Cares said that if only 5% to 10%of patients choose the option of ambulatory surgery for ruptured lumbar discs, it would mean 10,000 to 20,000 cases per year. Nationally, 90% of patients could be candidates, he said.
Recovery Care Centers
Tony Carr describes The Fresno Surgery and Recovery Care Center.
assage of new recovery care legislation in California in 1986 allows for a new level of health care between acute care and skilled nursing care, said Tony Carr, MS, chief executive, The Fresno Surgery and Recovery Care Center. According to Carr, The Fresno Surgery and Recovery Care Center was the first program in the nation to integrate surgical outpatients and short-stay overnight patients in one facility. The surgery center was started by 76 physicians and opened in 1984. The recovery care center opened in September 1988. Carr said the recovery care center spawned from the concern of orthopedic surgeons. They believed they could eliminate their hospital practice if they had a place for their patients to go for 24 to 48 hours. According to Cam, these surgeons attempted to get a waiver to set up a facility for short-stay surgical patients, but they were not successful. At this point they decided to go through the state legislature to create a new level of care. A bill (SB 1953) was introduced in March 1986 and was signed in September 1986 with some compromises by the physicians. The most restrictive compromise, Carr said, is that the length of stay for any patient cannot be longer than 72 hours. Because of this restriction, he said, many more patients are being hospitalized
that would not need to be if they could have another day in the recovery care center. The typical patients admitted to the recovery care center are those who undergo knee ligament reconstructions, cholecystectomies,hemorrhoidectomies, mastectomies, tonsillectomies, and rotator cuff repairs. According to Carr, 10 urologists recently joined the center and are now doing 10 to 15 renal lithotripsy procedures each month. The surgery center includes five patient cubicles in the preoperative care area, five ORs, 14 postanesthesia care area stations, and eight recliners in the progressive recovery/discharge area. The surgery center serves 20 patients per day. Lunch is provided for the surgery center staff and physicians, and one lounge is used by all (ie, staff and physicians). According to Carr, one lounge is beneficial to the interaction between physicians and staff. The concept behind the recovery care center was to create a hotel with nursing care. It has a friendly, residential atmosphere, not an institutional atmosphere, Carr said. There are 20 beds in the center. The rooms are private and spacious with queen-size sofa beds for visitors (eg, parents with children) and comforters on the beds. There are two telephones, a television, video-
P
1659
JUNE 1989, VOL. 49, NO 6
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center does not itemize. The center has all-RN staffing, primary care nursing, and a minimum of two RNs per 10 patients at all times. Surgery is done on Monday, Tuesday, and Wednesday. The center is closed part of Saturday and all-day Sunday. The center needs to serve 60 patients per month to break even, Carr said. The surgery center is now subsidizing the recovery care center until it serves 100 patients per month. No infections have been reported in the first 350 patients, he said. According to Carr, “what we are seeing here is a further shift of healthy patients out of the hospital. I view hospitals of the future as a place for sick, sick people.”
Patient Education Ardith H. Davis, RN, talks about patient education.
cassette recorder, and mini bar in each room. There also is original art work and custom furnishings. Oxygen and suction systems are camouflaged by paintings on hinges, and medical supplies are camouflaged in wooden cabinets. Other amenities offered in the patient rooms are videocassette libraries, complimentary guest dining, book collections, bathrobes, and hair dryers. According to Carr, illustrated books are provided because studies show that patients waiting for surgery would rather look at pictures than read. Other patient-oriented features include no overhead paging (staff members carry inexpensive beepers the size of a pen that blink when patients need them), flexible meal times, gourmet meals, and a patientlvisitor lounge. Carr listed the top five procedures done in the center as knee ligament reconstructions, acromioplasties, cholecystectomies, hemorrhoidectomies, and mastectomies. The average length of stay for the first 170 patients in the top five categories was 1.8 days, and the average charge was $2,200, he said. The overall bed and breakfast charge for the patient who stays overnight is $300. The only itemized extras are for medications and medication pumps. Carr emphasized that not one insurance company has refused to pay because the 1660
T
he workshop on patient education was presented by Ardith H. Davis, RN, BS, clinical coordinator, Ambulatory SurgiCare, Methodist Medical Center of Illinois, Peoria. More than half of the surgical procedures done at Methodist Medical Center are done in the ambulatory surgery unit, according to Davis. Because of this, preoperative and postoperative teaching techniques, methods, and materials are needed for a variety of patients. With the rise in ambulatory surgery patients, patient education has changed, Davis said. There is a consumer demand for education now; patients want to know what is going to happen to them. Patient education also has become a marketing issue for facilities, she said. Patients see education as caring on the part of the institution. Goals. One of the goals of patient education is to improve the chances for successful surgery and postoperative care. Another goal is to reduce stress and apprehension through understanding the process, surgery, and expectations. Studies have shown that patients suffer less anxiety because of patient teaching, Davis said. Improving interaction, information, and instruction compliance are additionalgoals. There is nothing worse than having surgery cancelled because the patient has not followed his or her preoperative instructions; it upsets the patient, surgeon, anesthesiologis< nurses, and the entire schedule.
JUNE 1989, VOL. 49, NO 6
AORN JOURNAL
Before teaching a child, the nurse should crawl through the OR on hands and knees to see it from the child’s level. Considerations. One consideration for successful patient education is motivation. The patient must want to learn. Another consideration is that the nurse instructor has to have a basic understanding of teaching and learning techniques, Davis said. In the past, with inpatients, nurses had 24 hours before surgery to do teaching; now there is a lack of sufficient time, she said. Because of these time demands, patient education must be a priority of administrators and managers. They have to encourage the nurses to teach and hold them accountable for teaching. Techniques.Perioperative teaching techniques include one-on-one instruction. The nurse should sit down and talk with the patient if possible. For some procedures (eg, dilation and curettage) the nurse may have to give instructions via the telephone. Preoperative tours and interviews are other techniques. Role playing and audiovisual material (eg, preoperative coloring books) are important techniques used in teaching children. Simulation also can be used for teaching. Davis said she saw a nurse have a placebo injection given to her so that a handicapped patient would let an injection be given to him. ChiZdren. Because insurance will not pay for inpatient ear, nose, and throat (ENT) procedures on children, a larger population of pediatric patients are being seen in ambulatory units. Teaching techniques must also be altered for this group of patients, Davis said. Factors that affect teaching techniques for children include the age level and what the child fears. The very young are afraid that their parents will not be there when they return from surgery. Older children are afraid that the procedure will hurt. Adolescents fear exposure of their bodies. Developmental levels also affect learning, according to Davis. Preschool children have a short attention span. School-age children want to
play. Adolescents want more information. Before teaching children, Davis suggests that the nurse get on his or her knees and crawl through the operating room to see the environment from the child’s level. She also said that the nurse should not dwell on unpleasant events, but should be honest. Davis emphasized that children should be allowed to play and touch because they learn and get acquainted by playing and touching. Her hospital has a play pit in the waiting area with toys and a television for watching cartoons before surgery. Preoperative tours are important for children because they allow the child to know what to expect through a hands-on experience. The tours should be given in small groups for short periods of time (eg, 30 minutes). The parents should join the tour and the information should be honest, she said. Also, time should be allowed for questions and answers. EZderZy. In teaching the elderly, nurses must consider that they have more traditional values and are reluctant to change, Davis said. They also have a diminished ability to process information to secondary memory and diminished reaction time, vision, and hearing. Davis said that before surgery, elderly patients should be told only what they need to know. They should be told about the surgery and postoperative care as they progress along in the perioperative experience. The nurse should avoid irrelevant information, and instructions should be reviewed as often as necessary, she said. Elderly patients also need increased lighting to see, and they should keep their glasses on as long as possible before surgery. Printed materials should be written in a larger print with a contrasting background. Teaching the elderly should combine visual and auditory materials. Patients also should be encouraged to leave their hearing aids in as long as possible, if they use them. Instruction should be slower paced and background noise
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JUNE 1989, VOL. 49, NO 6
William F. Card leads a general session on quality assurance.
should be decreased as much as possible, Davis said. Education materials. All education materials must include accurate and up-to-date information. Preoperatively, the most important information should be given first. Combine information patients want to know with information they need to know. The education material must be readable (ie, black on white paper). Davis gave the example that one hospital printed material on tan paper with brown lettering, and none of the patients could read it. Also, jargon and technical terms (eg, NPO) should not be used, and the material should be at an eighth-grade reading level. In conclusion, Davis said education should meet the needs of the patient. The nurse must be sincere and listen. “Enjoy your patients, like them, and enjoy your work,” she said.
Quality Assurance
W
illiam F. Card, MPA, associate director of the accreditation program for ambulatory health care for the Joint Commission on Accreditation of Healthcare Organizations, Chicago, led a general session on quality assurance.
AORN JOURNAL
Ambulatory surgery centers tend to have good, solid quality assurance programs, Card said. The Commission has found the weaknesses to be in scope of care. He suggested that ambulatory centers define the scope of care related to the quality or appropriateness of anesthesia services provided in the facility; identify the important aspects of care; and select indicators of quality. One can judge quality by assessing the number of patients who are unable to leave (x) hours postoperatively, vomit in the postanesthesia care unit (x) number of times, have pain requiring more than (x) doses of narcotics, have a poor understanding of postoperative instructions, have local anesthesia supplemented with general anesthesia, have discrepancies between their preoperative and postoperative diagnoses, are admitted to the hospital, or leave without a designated person. Card believes four elements are necessary for a facility to have a successful quality assurance program. First, the governing body of the facility must require and support a quality assurance program. Second, the facility must have a written plan that reflects the current objectives and scope of the quality assurance program. Third, there must be evidence that action is taken when problems or opportunities to improve patient care have been identified. And fourth, there must be evidence of routine monitoring and evaluation. The key element that the Commission changed in its 1988 standards was in the discharge criteria, Card said. The standards were changed either to allow the “licensed independent practitioner” to discharge patients or to allow the practitioner to develop and approve rigorous discharge criteria that can be used by other designated staff members to discharge patients under the practitioner’sname. This standard was changed in response to “field pressure,” Card said. This change has now caused a turf issue on who is eligible to discharge patients. According to Card, the standard only specifies qualified health care practitioners; state law regulates who may be considered a qualified 1665
AORN JOURNAL
JUNE 1989, VOL. 49, NO 6
health care practitioner. Card gave seven elements that should be considered in criteria for discharging a patient. The patient must be accompanied by a responsible adult, have stable vital signs, not have respiratory depression, be oriented to person, place, and time, have minimal nausea, vomiting, pain, and bleeding, be able to ambulate, and
have been in the facility for (x) hours after intubation. If the practitioner is not present for discharge, he or she must be actively involved in setting the criteria for the other person to follow, and a brief statement about the condition of the patient must be included in the postoperative note, Card said. JUDITH M. MATHIAS,RN, MA CLINICAL EDITOR
Number of Grant Review Cycles Reduced
Vietnam Women’s Memorial Project Conducts Search
The Division of Nursing of the US Department of Health and Human Services has announced changes in the number of grant program reviews for fiscal year (FY) 1990, which begins Oct 1, 1989. Historically, it has conducted three review cycles on a fiscal year basis. As of Oct 1, 1989, the Division of Nursing will conduct two review cycles annually, pending available funds. Deadline dates for applications for FY 1990 are Oct 1, 1989, and April 1, 1990. Applications may be submitted at any time during the year. For the remainder of FY 1989, the deadline for applications is July 1, 1989. For additional information on grant programs administered by the Division of Nursing, write to Jo Eleanor Elliot, director Division of Nursing Bureau of Health Professions Health Resources and Services Administration US Department of Health and Human Services Room 5C-26, Parklawn Building 5600 Fishers Lane Rockville. MD 20857
The Vietnam Women’s Memorial Project is searching for military or civilian nurses and other health care professionals who served during the Vietnam era between 1965 and 1975. Project officials want to hear from those people who were involved either in stateside duty or overseas duty in Vietnam or other sites. The Vietnam Women’s Memorial Project has two goals it wants to achieve. First, the officials extend an invitation to those who served to attend the dedication ceremony of the Vietnam Women’s Memorial statue, which is tentatively scheduled to be in May 1990 in Washington, DC. Second, they want to compile a complete record of nursing service during this time. If you are a nurse or allied health care professional who served during the Vietnam era, or if you know of someone who did, please contact Cathie Solomonson, Vietnam Women’s Memorial Project, PO Box 53351, Washington, DC 20009 the telephone number is (202) 328-7253.
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JUNE 1989, VOL. 49, N O 6
New Procedures, Recovery Care, Patient Education Addressed at Same-Day Surgery Conference
A
dvanced Strategies for Ensuring Success in the 1990s” was the theme of the 10th annual Same-Day Surgery Conference, which was held March 20 to 21 in Chicago. The conference was sponsored by the Same-Day Surgery newsletter. Topics included new same-day surgery procedures, recovery care centers, patient education, and quality assurance.
Hyperopic Radial Thermal Keratoplasty
H
yperopic thermal keratoplasty for farsightedness gives ophthalmologists the surgical tool to eliminate the need for glasses from society, according to Robert H. Marmer, MD, assistant clinical professor of surgery, Morehouse School of Medicine, Atlanta. Dr Marmer was one of the first ophthalmic surgeons in the country to do radial keratotomy surgery for nearsightedness, and now he is one of the first to have been trained in Moscow by Svyatoslav Fyodorov, MD, to perform hyperopic thermal keratoplasty for farsightedness. “It is interesting to have a procedure that everyone will need sometime in their lives,” Dr Marmer said. In hyperopic thermal keratoplasty, heat is used to permanently change the shape of the cornea, which focuses images on the back of the retina. The heat shortens the collagen fibers of the cornea. Preoperatively, antibiotic drops and a topical anesthetic are instilled into the eye. The patient is awake during the procedure. The patient’s corneal thickness is first measured with an ultrasound, and then the heating element is calibrated to a precise depth so that it only penetrates the cornea so far. The heating element is turned to 600 OC, and tiny holes are burned into the cornea. As the cornea heals, it molds to the preoperative corneal curvature, but it does not go all the way back. The cornea has a greater dome size postoperatively, which changes the way
Robert H. Marmer, MD, explains hyperopic thermal keratoplasty for farsightedness.
light is refracted as it enters the eye. Because there is no penetration through the full thickness of the cornea, no infection can enter the cornea, Dr Manner said. Postoperatively there is no severe pain, just some burning and itching. According to Dr Manner, only a few surgeons are able to perform this procedure because the instrumentation is not available in the United States, and only a few surgeons are being taught the procedure in Moscow. In two years, Dr Marmer predicts that ophthalmologists in the United States will develop their own instrumentation and hold their own classes. Dr Marmer bought his heating element from the Soviet Union.
Microsurgeryfor Ruptured Lumbar Discs
H
erbert L. Cares, MD, a neurosurgeon in private practice in the Boston area, presented a workshop on ambulatory microsurgery for 1657
AORN J O U R N A L
JUNE 1989, VOL. 49, NO 6
Herbert L. Cares, MD, presents a workshop on ambulatory microsurgery for ruptured lumbar discs. ruptured lumbar discs. Dr Cares authored the first published report on this procedure. Advances in microsurgical techniques combined with a widening interest in ambulatory surgery led him to investigate ambulatory lumbar discectomy, he said. Dr Cares performs the surgery through a 25mm skin incision. He removes the medial portion of the facets with a high speed diamond-burred air drill and microrongeurs. This allows exposure of the disc with minimal or no root retraction. He then removes any free disc fragments and clears the interspace of loose disc. At the end of the dissection, the operative team can see into the interspace with no retraction of the dura mater or root. “I do a big operation through a little incision, I don’t have to retract the root, there is little bleeding, and both surgeons can see the field,” Dr Cares said. Dr Cares said that his inpatient routine for discectomies did not require intravenous lines, injections, urinals, or bedpans. The hospitalized patients were up in a chair for all meals and discharged in 24 to 48 hours postoperatively without prescriptions. He said he asked himself what he was doing in the hospital that could not be done in an ambulatory surgery facility and at home. 1658
After three years, he has operated on more than
25 patients in ambulatory surgery units. And now, he said, it is routinely done in four community hospitals in Massachusetts, where he practices. According to Dr Cares, none of his patients had to be readmitted to the hospital or had complications, and after three years, all are free of sciatica and would choose ambulatory surgery again. In addition, all of the patients returned to work in less than two weeks, he said. Dr Cares’ patient selection includes standard criteria for any lumbar disc surgery, including sciatica refractory to all conservative measures, objective focal root deficit, and a positive computed axial tomagraphy scan or magnetic resonance image. Patient education begins three days before surgery. Patients are told that postoperatively, the only discomfort may be incisional pain and numbness in the area of their preoperative radicular pain. They also are told that a visiting nurse will see them the night of surgery and the first two postoperative days. Participation in the ambulatory surgery procedure is voluntary. The patients can change their minds at any stage of the process, Dr Cares said. The postanesthesia care step-down unit is the critical component of the ambulatory procedure,
JUNE 1989, VOL. 49, NO 6
AORN JOURNAL
according to Dr Cares. The patient is given clear liquids when awake and progresses to crackers and gelatin. Then the patient sits up in a straightbacked chair with arms, and he or she walks to the bathroom or portable commode. Dr Cares said that before discharge, the patient must void, sit up, walk, take oral nourishment, and be checked by the surgeon. According to Dr Cares, this procedure contributes to the understanding of perioperative pain management, and the trendsetters in this procedure may be the community and not the teaching hospitals. Dr Cares said that if only 5% to 10%of patients choose the option of ambulatory surgery for ruptured lumbar discs, it would mean 10,000 to 20,000 cases per year. Nationally, 90% of patients could be candidates, he said.
Recovery Care Centers
Tony Carr describes The Fresno Surgery and Recovery Care Center.
assage of new recovery care legislation in California in 1986 allows for a new level of health care between acute care and skilled nursing care, said Tony Carr, MS, chief executive, The Fresno Surgery and Recovery Care Center. According to Carr, The Fresno Surgery and Recovery Care Center was the first program in the nation to integrate surgical outpatients and short-stay overnight patients in one facility. The surgery center was started by 76 physicians and opened in 1984. The recovery care center opened in September 1988. Carr said the recovery care center spawned from the concern of orthopedic surgeons. They believed they could eliminate their hospital practice if they had a place for their patients to go for 24 to 48 hours. According to Cam, these surgeons attempted to get a waiver to set up a facility for short-stay surgical patients, but they were not successful. At this point they decided to go through the state legislature to create a new level of care. A bill (SB 1953) was introduced in March 1986 and was signed in September 1986 with some compromises by the physicians. The most restrictive compromise, Carr said, is that the length of stay for any patient cannot be longer than 72 hours. Because of this restriction, he said, many more patients are being hospitalized
that would not need to be if they could have another day in the recovery care center. The typical patients admitted to the recovery care center are those who undergo knee ligament reconstructions, cholecystectomies,hemorrhoidectomies, mastectomies, tonsillectomies, and rotator cuff repairs. According to Carr, 10 urologists recently joined the center and are now doing 10 to 15 renal lithotripsy procedures each month. The surgery center includes five patient cubicles in the preoperative care area, five ORs, 14 postanesthesia care area stations, and eight recliners in the progressive recovery/discharge area. The surgery center serves 20 patients per day. Lunch is provided for the surgery center staff and physicians, and one lounge is used by all (ie, staff and physicians). According to Carr, one lounge is beneficial to the interaction between physicians and staff. The concept behind the recovery care center was to create a hotel with nursing care. It has a friendly, residential atmosphere, not an institutional atmosphere, Carr said. There are 20 beds in the center. The rooms are private and spacious with queen-size sofa beds for visitors (eg, parents with children) and comforters on the beds. There are two telephones, a television, video-
P
1659
JUNE 1989, VOL. 49, NO 6
AORN JOURNAL
center does not itemize. The center has all-RN staffing, primary care nursing, and a minimum of two RNs per 10 patients at all times. Surgery is done on Monday, Tuesday, and Wednesday. The center is closed part of Saturday and all-day Sunday. The center needs to serve 60 patients per month to break even, Carr said. The surgery center is now subsidizing the recovery care center until it serves 100 patients per month. No infections have been reported in the first 350 patients, he said. According to Carr, “what we are seeing here is a further shift of healthy patients out of the hospital. I view hospitals of the future as a place for sick, sick people.”
Patient Education Ardith H. Davis, RN, talks about patient education.
cassette recorder, and mini bar in each room. There also is original art work and custom furnishings. Oxygen and suction systems are camouflaged by paintings on hinges, and medical supplies are camouflaged in wooden cabinets. Other amenities offered in the patient rooms are videocassette libraries, complimentary guest dining, book collections, bathrobes, and hair dryers. According to Carr, illustrated books are provided because studies show that patients waiting for surgery would rather look at pictures than read. Other patient-oriented features include no overhead paging (staff members carry inexpensive beepers the size of a pen that blink when patients need them), flexible meal times, gourmet meals, and a patientlvisitor lounge. Carr listed the top five procedures done in the center as knee ligament reconstructions, acromioplasties, cholecystectomies, hemorrhoidectomies, and mastectomies. The average length of stay for the first 170 patients in the top five categories was 1.8 days, and the average charge was $2,200, he said. The overall bed and breakfast charge for the patient who stays overnight is $300. The only itemized extras are for medications and medication pumps. Carr emphasized that not one insurance company has refused to pay because the 1660
T
he workshop on patient education was presented by Ardith H. Davis, RN, BS, clinical coordinator, Ambulatory SurgiCare, Methodist Medical Center of Illinois, Peoria. More than half of the surgical procedures done at Methodist Medical Center are done in the ambulatory surgery unit, according to Davis. Because of this, preoperative and postoperative teaching techniques, methods, and materials are needed for a variety of patients. With the rise in ambulatory surgery patients, patient education has changed, Davis said. There is a consumer demand for education now; patients want to know what is going to happen to them. Patient education also has become a marketing issue for facilities, she said. Patients see education as caring on the part of the institution. Goals. One of the goals of patient education is to improve the chances for successful surgery and postoperative care. Another goal is to reduce stress and apprehension through understanding the process, surgery, and expectations. Studies have shown that patients suffer less anxiety because of patient teaching, Davis said. Improving interaction, information, and instruction compliance are additionalgoals. There is nothing worse than having surgery cancelled because the patient has not followed his or her preoperative instructions; it upsets the patient, surgeon, anesthesiologis< nurses, and the entire schedule.
JUNE 1989, VOL. 49, NO 6
AORN JOURNAL
Before teaching a child, the nurse should crawl through the OR on hands and knees to see it from the child’s level. Considerations. One consideration for successful patient education is motivation. The patient must want to learn. Another consideration is that the nurse instructor has to have a basic understanding of teaching and learning techniques, Davis said. In the past, with inpatients, nurses had 24 hours before surgery to do teaching; now there is a lack of sufficient time, she said. Because of these time demands, patient education must be a priority of administrators and managers. They have to encourage the nurses to teach and hold them accountable for teaching. Techniques.Perioperative teaching techniques include one-on-one instruction. The nurse should sit down and talk with the patient if possible. For some procedures (eg, dilation and curettage) the nurse may have to give instructions via the telephone. Preoperative tours and interviews are other techniques. Role playing and audiovisual material (eg, preoperative coloring books) are important techniques used in teaching children. Simulation also can be used for teaching. Davis said she saw a nurse have a placebo injection given to her so that a handicapped patient would let an injection be given to him. ChiZdren. Because insurance will not pay for inpatient ear, nose, and throat (ENT) procedures on children, a larger population of pediatric patients are being seen in ambulatory units. Teaching techniques must also be altered for this group of patients, Davis said. Factors that affect teaching techniques for children include the age level and what the child fears. The very young are afraid that their parents will not be there when they return from surgery. Older children are afraid that the procedure will hurt. Adolescents fear exposure of their bodies. Developmental levels also affect learning, according to Davis. Preschool children have a short attention span. School-age children want to
play. Adolescents want more information. Before teaching children, Davis suggests that the nurse get on his or her knees and crawl through the operating room to see the environment from the child’s level. She also said that the nurse should not dwell on unpleasant events, but should be honest. Davis emphasized that children should be allowed to play and touch because they learn and get acquainted by playing and touching. Her hospital has a play pit in the waiting area with toys and a television for watching cartoons before surgery. Preoperative tours are important for children because they allow the child to know what to expect through a hands-on experience. The tours should be given in small groups for short periods of time (eg, 30 minutes). The parents should join the tour and the information should be honest, she said. Also, time should be allowed for questions and answers. EZderZy. In teaching the elderly, nurses must consider that they have more traditional values and are reluctant to change, Davis said. They also have a diminished ability to process information to secondary memory and diminished reaction time, vision, and hearing. Davis said that before surgery, elderly patients should be told only what they need to know. They should be told about the surgery and postoperative care as they progress along in the perioperative experience. The nurse should avoid irrelevant information, and instructions should be reviewed as often as necessary, she said. Elderly patients also need increased lighting to see, and they should keep their glasses on as long as possible before surgery. Printed materials should be written in a larger print with a contrasting background. Teaching the elderly should combine visual and auditory materials. Patients also should be encouraged to leave their hearing aids in as long as possible, if they use them. Instruction should be slower paced and background noise
d1661
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William F. Card leads a general session on quality assurance.
should be decreased as much as possible, Davis said. Education materials. All education materials must include accurate and up-to-date information. Preoperatively, the most important information should be given first. Combine information patients want to know with information they need to know. The education material must be readable (ie, black on white paper). Davis gave the example that one hospital printed material on tan paper with brown lettering, and none of the patients could read it. Also, jargon and technical terms (eg, NPO) should not be used, and the material should be at an eighth-grade reading level. In conclusion, Davis said education should meet the needs of the patient. The nurse must be sincere and listen. “Enjoy your patients, like them, and enjoy your work,” she said.
Quality Assurance
W
illiam F. Card, MPA, associate director of the accreditation program for ambulatory health care for the Joint Commission on Accreditation of Healthcare Organizations, Chicago, led a general session on quality assurance.
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Ambulatory surgery centers tend to have good, solid quality assurance programs, Card said. The Commission has found the weaknesses to be in scope of care. He suggested that ambulatory centers define the scope of care related to the quality or appropriateness of anesthesia services provided in the facility; identify the important aspects of care; and select indicators of quality. One can judge quality by assessing the number of patients who are unable to leave (x) hours postoperatively, vomit in the postanesthesia care unit (x) number of times, have pain requiring more than (x) doses of narcotics, have a poor understanding of postoperative instructions, have local anesthesia supplemented with general anesthesia, have discrepancies between their preoperative and postoperative diagnoses, are admitted to the hospital, or leave without a designated person. Card believes four elements are necessary for a facility to have a successful quality assurance program. First, the governing body of the facility must require and support a quality assurance program. Second, the facility must have a written plan that reflects the current objectives and scope of the quality assurance program. Third, there must be evidence that action is taken when problems or opportunities to improve patient care have been identified. And fourth, there must be evidence of routine monitoring and evaluation. The key element that the Commission changed in its 1988 standards was in the discharge criteria, Card said. The standards were changed either to allow the “licensed independent practitioner” to discharge patients or to allow the practitioner to develop and approve rigorous discharge criteria that can be used by other designated staff members to discharge patients under the practitioner’sname. This standard was changed in response to “field pressure,” Card said. This change has now caused a turf issue on who is eligible to discharge patients. According to Card, the standard only specifies qualified health care practitioners; state law regulates who may be considered a qualified 1665
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health care practitioner. Card gave seven elements that should be considered in criteria for discharging a patient. The patient must be accompanied by a responsible adult, have stable vital signs, not have respiratory depression, be oriented to person, place, and time, have minimal nausea, vomiting, pain, and bleeding, be able to ambulate, and
have been in the facility for (x) hours after intubation. If the practitioner is not present for discharge, he or she must be actively involved in setting the criteria for the other person to follow, and a brief statement about the condition of the patient must be included in the postoperative note, Card said. JUDITH M. MATHIAS,RN, MA CLINICAL EDITOR
Number of Grant Review Cycles Reduced
Vietnam Women’s Memorial Project Conducts Search
The Division of Nursing of the US Department of Health and Human Services has announced changes in the number of grant program reviews for fiscal year (FY) 1990, which begins Oct 1, 1989. Historically, it has conducted three review cycles on a fiscal year basis. As of Oct 1, 1989, the Division of Nursing will conduct two review cycles annually, pending available funds. Deadline dates for applications for FY 1990 are Oct 1, 1989, and April 1, 1990. Applications may be submitted at any time during the year. For the remainder of FY 1989, the deadline for applications is July 1, 1989. For additional information on grant programs administered by the Division of Nursing, write to Jo Eleanor Elliot, director Division of Nursing Bureau of Health Professions Health Resources and Services Administration US Department of Health and Human Services Room 5C-26, Parklawn Building 5600 Fishers Lane Rockville. MD 20857
The Vietnam Women’s Memorial Project is searching for military or civilian nurses and other health care professionals who served during the Vietnam era between 1965 and 1975. Project officials want to hear from those people who were involved either in stateside duty or overseas duty in Vietnam or other sites. The Vietnam Women’s Memorial Project has two goals it wants to achieve. First, the officials extend an invitation to those who served to attend the dedication ceremony of the Vietnam Women’s Memorial statue, which is tentatively scheduled to be in May 1990 in Washington, DC. Second, they want to compile a complete record of nursing service during this time. If you are a nurse or allied health care professional who served during the Vietnam era, or if you know of someone who did, please contact Cathie Solomonson, Vietnam Women’s Memorial Project, PO Box 53351, Washington, DC 20009 the telephone number is (202) 328-7253.
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