Centre conducting the review
The Hong Kong Centre for Evidence Based Nursing
The Nethersole School of Nursing
The Chinese University of Hong Kong, Hong Kong
Chan Sau-Man Conny, RN, BN, MN, Doctoral Nursing Student
Professional Consultant, The Nethersole School of Nursing, The Chinese University of Hong Kong
Phone: (852) 3943 4432
Fax: (852) 2603 5269
Poon Chung Leung Henry, RN, BN, MN, Doctoral Nursing Student
Advanced Practice Nurse, Nursing Services Division, United Christian Hospital, Hong Kong
Phone: (852) 3513 4395
Fax: (852) 3513 5529
Commencement date: August 2011
Expected completion date: July 2012
Hong Kong Centre for Evidence Based Nursing: a Collaborating Centre of the Joanna Briggs Institute
8/F, Esther Lee Building, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong.
The specific review objectives are:
To synthesize the evidence on the impact of nurse-led pre-operative assessment clinic for elective orthopaedic patients on health service outcomes, including cancellation or delay of surgery, length of hospital stay and waiting time for pre-operative assessment and surgery.
To examine the effectiveness of nurse-led pre-operative assessment clinic on orthopaedic patient outcomes such as levels of satisfaction with the process of pre-operative assessment, incidence of post-operative complications, post-operative recovery, as well as levels of fear and anxiety before surgery.
Traditionally, the practice of elective surgery admission is that patient will be admitted to the ward on the day before surgery after the medical consultation from the outpatient clinic. Usually the date of admission to the operative unit will be planned quite in advance for ward admission. While the patient is admitted to the surgical unit, the medical or physiological condition may be changed. Research findings showed that patients are often not fit for surgery on the scheduled time due to the change of their medical or physical condition. Such practice results in high rates of cancellation of the operative procedure or the surgery will have to be postponed.1,2,3,4,5,6,7,8 Moreover, cancellation of surgery contributed a negative impact on patient's anxiety as well as the waste of hospital resources and preparation. 4
It has been noted that pre-operative assessment can inform health professionals the update health condition of the patients and thus the cancellation rate of surgery can be avoided. National Health Service Modernization Agency9 produced a guide and described how the pre-operative assessment of inpatients can influence and improve the performance of operating theatre time. It further stated that almost 30% of operations that were cancelled on the day of surgery could have been prevented if effective pre-operative assessment had been carried out. According to the NHS Modernization Agency (2003) of the National Good Practice Guidance on Pre-operative Assessment for Inpatient Surgery9, pre-operative assessment is to establish that the patient is fully informed and wish to undergo the procedure. ‘It ensures that the patient is as fit as possible for the surgery and anaesthetic. It minimizes the risk of late cancellations by ensuring that all essential resources and discharge requirements are identified and coordinated’ (p.2). 9
Nurse-led pre-operative assessment clinics (POAC) have been advocated as one of the effective health care agency to conduct the pre-operative assessment in order to prepare the patients for surgery.6,10,11,12,13,14,15,16,17,18,19,20 The comprehensive and multifunctional roles of nurses in nurse-led POAC assess patients for the preparation before anesthesia and impending surgery. The clinic was designed to optimize the medical condition of the patient before surgery. The post-operative complications and pain management options, current medication, peri-operative cardiovascular, respiratory disease and thrombo-embolic morbidity, postoperative infection, and the hematological result could also be revealed. 11,13,21,22,23,24,25,26 Several research studies also indicated that the rate of cancellation of surgery was reduced after the implementation of the nurse-led POAC. 6,7,10,14
Traditionally, pre-operative assessment has been within the remit of the junior medical doctor. Several studies reviewed that nurses can play a pivotal role in the pre-operative assessment centre and they performed as good as doctors and thus reduced the hospital cost.27,28,29 Whilst, a range of research studies also identified that pre-operative assessment had a positive economic impact to a hospital budget.5,15,19,30 Pollard et al5 and Pollard et al30 reported savings continue to be attributable to fewer and shorter hospitalizations that saved an average of 4.76 days and 4.5 days of hospitalization per patient who attended the preoperative evaluation clinic for outpatients. Also, Fischer15 demonstrated that a hospital cost-reduction of 59.3% or US$1,112.09 per patient which accounted the potential cost-reduction to the hospital of US$1.01 million per year. Furthermore, Newton19 stated that the average stay for primary total hip and knee replacements has been reduced by 2 days since the nurse-led orthopaedic pre-admission clinic was established.
Whilst the surgery cancellation rate can be minimized by the appropriate screening of patients in the POAC clinic and in turn reduce hospital cost with the implementation of the nurse-led pre-operative assessment clinic, some research literatures also reiterated the satisfaction of patients in receiving the service of POAC.12,17,18,20,21,31,32 Patients usually have a very high rating of satisfaction level with the service provided by the nurses. Studies found that the services provided by nurses were efficient and also reduced the waiting time to attend the pre-operative assessment clinic.
On the other hand, it is also noteworthy that the number of orthopaedic surgery is in an increasing trend. According to the Centers for Disease Control and Prevention National Center for Health statistics reports33, there were 46 million procedures performed on inpatients during the year of 2006. The number of surgery of reduction of fracture is 672,000, total knee replacement is 542,000 and the total hip replacement is 231,000 respectively. However, the rate of knee replacements for those aged 65 years and over increased from 60.1 per 10,000 population in 2000 to 88.0 per 10,000 population in 2006. Whereas the rate doubled among those aged 45-64 years old during the same time period from 13.1 per 10,000 population in 2000 to 27.3 per 10,000 population in 2006. Moreover, Rutkow34 stated that the orthopaedic surgery procedure of arthroscopy of knee demonstrated enormous growth (153%) and was the United States of America(US)'s seventh most frequent operation in 1994.
While with an increasing trend in the orthopaedic surgery worldwide, the role of nurse-led pre-operative clinic may offer an efficient and effective means of providing patients with valuable information for their impending surgery, especially for the older orthopaedic patients who are at high risk of peri-operative morbidity and mortality. The orthopaedic patients with chronic or co-existing disease should be assessed and have their medical condition stabilized before surgery.22,35,36 Some studies indicated that the high-risk orthopaedic patients who had paid visit to the nurse-led POAC had lower cancellation rate for surgery on the scheduled day.10,14
Although there is a significant increase in the number of orthopaedic surgeries and the likelihood of the occurrence of co-morbidity of advanced age in elderly orthopaedic patients, the evidence on the role of nurse-led clinics in the pre-operative assessment for the orthopaedic patients has not been well established. Also, there is no systematic review has been identified and published previously on the effectiveness of nurse-led POAC for patients receiving elective orthopaedic surgery in the preliminary search on Cochrane Library and JBI library. Therefore, a systematic review will be drawn on the effectiveness of nurse-led pre-operative assessment clinics for patients receiving elective orthopaedic surgery. The aim of this systematic review is to summarize and identify the best available research evidence in order to better inform the current clinical practice and to guide health-care decisions.
Types of participants:
This review will consider all studies that included adult patients who were 18 years old or above, required elective orthopaedic surgeries e.g. total knee replacement, total hip replacement, reduction of fracture or procedure of arthroscopy etc in hospitals or day surgery centers, and had attended a nurse-led POAC. Adult elective orthopaedic surgical patients within the American Society of Anesthesiologist (ASA) Physical Status Classification of 1 or 2 will be eligible for inclusion in the review. ASA classification 1 patients are considered to be healthy and normal, and ASA classification 2 patients are patients with mild systemic disease such as mild asthma, well-controlled hypertension, or well-controlled diabetes.37
Studies will be excluded:
- if the participants had received emergency orthropaedic surgery.
- if they were primitively related to preoperative teaching or education.
Types of interventions:
The review will consider studies that evaluate the effectiveness of attending a nurse-led POAC for elective orthopaedic surgery. A POAC is defined as a clinic that provides a general medical and anaesthetic pre-operative assessment includes history taking, health assessment and physical examination. Routine investigations such as laboratory and blood tests may be carried out. Referral to specialists before surgery work-up and health education will also be provided. Patients would attend a POAC 2 to 4 weeks prior to the scheduled elective orthopaedic surgery. The nurse-led POAC could be solely run by nurses, or nurses worked collaboratively with physicians.
Foreseen comparisons include:
- Comparison between two or more of the types of interventions: for example, POAC vs standard or routine care vs. no additional care.
- Comparison between providers of interventions: for example, nurse vs. physicians; or nurses vs other allied health providers.
Types of outcomes:
The review will consider the following primary and secondary outcomes:
Primary outcome measures are related to patients' health and well-being. This includes:
- self-reported measures of pre-operative anxiety e.g. State-Trait Anxiety Inventory (STAI).
- self-reported measures of patient satisfaction and experience with the process of pre-operative assessment e.g. patient's satisfaction questionnaire.
- the incidence of patients' post-operative complications e.g. the perioperative blood transfusion, the post-operative wound infection and thrombo-embolic morbidity.
- Post-operative recovery
Secondary outcomes measures includes:
- the rate of surgery cancellation or delay
- patient waiting time for pre-operative assessment and surgery
- the length of hospital stay
Types of studies:
The review will include Randomized control trials (RCT), Pseudo-randomized controlled trial, quasi-experimental studies, cohort studies and case-control studies will be eligible for inclusion.
The search strategy aims to find all published and unpublished studies in English and Chinese of studies capturing an extensive review of current literature relating to the topic of the effectiveness of nurse-led POAC for elective orthropaedic surgery. A three-step approach will be employed. Firstly, a limited search of MEDLINE (Appendix I) and CINAHL Plus will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. Secondary, a more extensive search using all the identified keywords and index terms will then be conducted across all included databases. Thirdly, a search to identify unpublished studies will be undertaken by scanning the unpublished dissertation and Index of Thesis. A hand searching of other sources of studies, including a manual search of relevant conference proceedings and journals, postgraduate and doctoral dissertations, online database search and websites such as Goggle Scholar, will be performed to identify additional materials, such as local reports, that are not located through the Search strategies. Personal contact will be made with first authors of key studies to gather further evidence on unpublished work or work in progress. Lastly, the reference list of all identified reports and articles will be searched for additional studies. Identified article published from 1990 to 2011 will be included in this review.
The databases to be searched include:
- Academic Search Premise (1975 to 2011)
- British Nursing Index and achieve (1985 to 2011)
- Campbell Collaboration Library
- CINAHL Plus (1985 to 2011)
- Clinical Evidence
- Clinical Trials
- DARE (Database of Abstracts of Reviews of Effectiveness)
- EBM Reviews: Cochrane Database of systematic reviews
- EMBASE (1980 to 2011)
- MEDLINE (1966 to 2011)
- PsychINFO (1985 to 2011)
- ProQuest 5000 (1985 to 2011)
Electronic databases to be searched for primary publications written in Chinese include:
Wan Fang Data, China Journal Net, Chinese Biomedical Literature Database, Chinese Medical Current Contents, Hong Kong Index to Chinese Periodical Literature, Chinese Electronic Periodical Services, Chinese Electronic Theses & Dissertations Service, and Taiwan Electronic Periodical Services. The Chinese search terms will be based on the terminology used in Taiwan and China.
The search for unpublished studies will include:
Agency for Healthcare Research and Quality, Current Controlled Trials, Clinical Study Results, Digital Dissertation Consortium, OpenSIGLE, MEDNAR, National Institute of Clinical Studies (NHMRC), New York Academy of Medicine Library Grey Literature Report, Science.gov, ProQuest Dissertation and Thesis, The Networked Digital Library of Theses and Dissertations.
Initial keywords to be used will include:
admission process, ambulatory setting*, advance practice nurse*, cancellation, costs of peri-operative care, changing roles, elective surgery, elective surgical patient, efficacy and financial benefit, inpatient surgery, length of stay, nursing effectiveness, nursing outcomes, nursing efficacy, nurse practitioner*, nurse specialist*, nurse consultant*, nurse-led clinic*, nurse-led model*, nurse managed clinic*, nurse managed health cent*, nurse-led pre-operative assessment clinic, orthop#edic nurse practitioner, outpatient preoperative evaluation, operating room cancellation* and delay*, patient education, patient perceptions / perspective, patient satisfaction, pre-anesthesia evaluation, pre-admission clinic, pre-admission assessment clinic, pre-admission service, pre-operative clinic visit, pre-operative evaluation clinic, pre-operative assessment and management, postoperative outcomes, change management, waiting time. Whereas the initial Chinese searching terms will be SymbolSymbolSymbolSymbolSymbol.
Assessment of eligibility
All potential studies will be assessed for relevance based on the title and abstract of the study. Additional relevant studies will be assessed for relevance based on the title of study from reference list of each identified relevant study. The first and second reviewers will independently assess all identified abstracts using the Study Eligibility Verification Form (Appendix II). If the title and abstract are not conclusive, full text of the study will be obtained for further analysis. Two reviewers will make decision using the inclusion and exclusion criteria regarding the types of studies, participants, interventions and outcome measures of the studies. Any discrepancies between them will be resolved by discussion and consultation with the third reviewer. Eligible studies will be entered into a bibliographic software package (RefWorks). Full text will be obtained for all included studies for critical appraisal and data synthesis. Duplicated studies will be included once only.
Assessment of methodological quality
All studies identified as meeting the inclusion criteria set out in the reviews eligibility form will be assessed for methodological quality by two independent reviewers (a primary and a secondary reviewer). The quantitative papers selected will be reviewed using critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) for quantitative studies (Appendix III).
Details of the included studies will be extracted and summarized independently by one reviewer using the standardized version of the JBI-MAStARI data extraction form (Appendix IV). A second reviewer will independently check for its accuracy. A meeting will be held with co-reviewers to resolve any discrepancies and obtain consensus. Any unresolved disagreement will be referred to a third reviewer for discussion. The data extraction form will be piloted by two independent reviewers prior to use. This will extract information on study design, methods, setting, study population, inclusion and exclusion criteria, type of intervention, clinical characteristics, significance of outcomes measures to the review objectives and the number and reasons for withdrawals and dropouts. In order to minimize the risk of errors during data entry, all results will be subject to double data entry.
The process of synthesis brings together the evidence extracted from included studies and how the results of the studies can be synthesized. The reviewers have to determine the degree of heterogeneity or homogeneity in the included studies.38 The included studies will be categorized according to the types of intervention being conducted. Quantitative data, where possible, will be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). For continuous data that are collected using the same scale, the mean differences and 95% confidence interval will be calculated for each included study and used as the summary measure of effect; while for continuous data collected using different scales, the standardized mean differences and their 95% confidence interval will be calculated. For dichotomous data, relative risks, odds ratios and their 95% confidence interval will be calculated and used as a summary measure of effect. The studies will be assessed for clinical heterogeneity by considering the settings, populations, interventions and outcomes. The statistical heterogeneity of the combined studies will be tested using the I2. A fixed effects model will be applied for pooling if there is no clinical or statistical heterogeneity; while a random effects model will be used in the absence of clinical heterogeneity but with the presence of statistical heterogeneity. If statistical pooling of results of the included studies is not appropriate or possible, the findings will be reported in narrative form.
1. Cantlay, K. L., Baker, S., Parry, A., & Danjoux, G. (2006). The impact of a consultant anaesthetist led pre-operative assessment clinic on patients undergoing major vascular surgery. Anaesthesia, 61
2. Craig, S. E. (2005). Does nurse-led pre-operative assessment reduce the cancellation rate of elective surgical in-patient procedures?: A systematic review of the research literature. British Journal of Anaesthetic and Recovery Nursing, 6
3. Ferschl, M. B., Tung, A., Sweitzer, B., Huo, D., Glick, D. (2005). Preoperative clinic visits reduce operating room cancellations and delays. Anesthesiology, 103
4. Knox, M., Myers, E., Wilson, I., & Hurley, M. (2009). The impact of pre-operative assessment clinics on elective surgical case cancellations. The Surgeon: Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland, 7
5. Pollard, J. B., Zboray, A. L., & Mazze, R. I.(1996). Economic benefits attributed to opening a preoperative evaluation clinic for outpatients. Anesthesia and Analgesia, 83
6. Rai, M. R., & Pandit, J. J. (2003). Day of surgery cancellations after nurse-led pre-assessment in an elective surgical centre: The first 2 years. Anaesthesia, 58
Reed, M., Wright, S., & Armitage, F. (1997). Nurse-led general surgical pre-operative assessment clinic. Journal of the Royal College of Surgeons of Edinburgh, 42
8. van Klei, W. A., Moons, K. G. M., Rutten, C. L. G., Schuurhuis, A., Knape, J. T. A., Kalkman, C. J., & Grobbee, D. E. (2002). The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesthesia and Analgesia, 94
9. NHS Modernisation Agency's Operating Thratre and Pre-operative Assessment Programme. (2003). National Good Practice Guidance on Pre-operative Assessment for Inpatient Surgery.
Department of Health.
10. Barnes, P. K., Emerson, P. A., Hajnal, S., Radford, W. J. P., & Congleton, J. (2000). Influence of an anaesthetist on nurse-led, computer-based, pre-operative assessment. Anaesthesia, 55
11. Beck, A. (2007). Nurse-led pre-operative assessment for elective surgical patients. Nursing Standard, 21
12. Bhutta, M., Boutchier, B., & Latif, M. (2008). Nurse-led adult ENT pre-operative assessment. Clinical Otolaryngology, 33
13. Casey, D., & Ormrod, G. (2003). The effectiveness of nurse-led surgical pre-assessment clinics. Professional Nurse, 18
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15. Fischer, S.P. (1996). Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology, 85
16. Flowers, M., & Wright, S. (2003). The development of a nurse-led outpatient orthopaedic clinic. Nursing Times, 99
17. Flynn, S. (2005). Nursing effectiveness: An evaluation of patient satisfaction with a nurse led orthopaedic joint replacement review clinic. Journal of Orthopaedic Nursing, 9
18. Hepner, D. L., Bader, A. M., Hurwitz, S., Gustafson, M., & Tsen, L. C. (2004). Patient satisfaction with preoperative assessment in a preoperative assessment testing clinic. Anesthesia and Analgesia, 98
19. Newton, V. (1996). Care in pre-admission clinics. Nursing Times
, 92(1), 27-28.
20. Walsgrove, H. (2004). Piloting a nurse-led gynaecology preoperative-assessment clinic. Nursing Times, 100
21. Malkin, K. F. (2000). Patient's perceptions of a pre-admission clinic. Patient's perceptions of a pre-admission clinic, 8
22. Fellows, H., Lucas, B., Burgess, L., Abbott, D., Clare, A., & Barton, K. (1999). Orthopaedic pre-admission assessment clinics: Part 2. Journal of Orthopaedic Nursing, 3
23. Wadsworth, L., Smith, A., & Waterman, H. (2002). The nurse practitioner's role in day case pre-operative assessment. Nursing Standard, 16
24. Ryan, P. (2000). The benefits of a nurse-led preoperative assessment clinic. Nursing Times, 96
25. Truscott, J. M., Townsend, J. M., & Arnold, E. P. (2007). A successful nurse-led model in the elective orthopaedic admissions process. Journal of the New Zealand Medical Association
, 120, 1265.
26. Lucas, B. (2009). The emergence of specialist orthopaedic nurses and nurse-led pre-operative assessment in the 1990s. Journal of Orthopaedic Nursing, 13
27. Kinley, H., Czoski-Murray, C., George, S., McCabe, C., Primrose, J., Reilly, C., … Thomas, E. (2002). Effectiveness of appropriately trained nurses in preoperative assessment: Randomised controlled equivalence/non-inferiority trial. British Medical Journal, 325
28. Rushforth, H, Bliss, A., Burge, D. & Glasper, E. A. (2000) Nurse-led pre-operative assessment: A study of appropriateness. Paediatric Nursing, 12
29. Rushforth, H., Burge, D., Mullee, M., Jones, S., McDonald, H., & Glasper, E. A. (2006). Nurse-led paediatric pre operative assessment: An equivalence study. Paediatric Nursing, 18
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33. Centers for Disease Control and Prevention National Center for Health Statistics (2008). 2006 National hospital discharge survey
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34. Rutkow, I. M. (1997). Surgical operations in the united states: Then (1983) and now (1994). Archives of Surgery, 132
35. Lucas, B. (2002). Developing the role of the nurse in the orthopaedic outpatient and pre-admission assessment settings: A change management project. Journal of Orthopaedic Nursing, 6
36. Grant-Casey, J., & Madgwick, K. (2010). Anaemia, blood transfusion, hip replacement surgery, pre-operative assessment. Nursing Standard, 24
37. Ellis, P., & Howatson-Jones, L. (2008). Outpatient, day surgery and ambulatory care
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Appendix I - MEDLINE (Ovid) search strategy
- exp Ambulatory Surgical Procedures/
- exp Ambulatory Care/
- exp General Surgery/
- exp Surgical Procedures, Elective/
- exp Surgical Procedures, Operative/
- exp Preoperative Care/
- pre-operative assessment.mp.
- pre-operative evaluation.mp.
- pre admission clinic.mp.
- 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
- exp Orthopedics/
- exp Orthopedic Procedures/
- orthopedic elective surgery.mp.
- exp Traumatology/
- 11 or 12 or 13 or 14
- exp Advanced Practice Nursing/
- exp Nurse Practitioners/
- exp Nurse Clinicians/
- nurse led clinic.mp.
- nurse-led pre-operative assessment.mp.
- nursing effectiveness.mp.
- nurse consultant.mp.
- nurse specialist.mp.
- advanced nurse practitioners.mp.
- nurse led model.mp.
- nurse managed clinic.mp.
- orthop?edic nurse practitioner.mp.
- 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27
- exp Patient Participation/
- exp Patient Satisfaction/
- exp Practice Guideline/
- exp Length of Stay/
- 29 or 30 or 31 or 32
- delay surgery.mp.
- exp Health Care Costs/
- financial benefit.mp.
- postoperative outcomes.mp.
- changing roles.mp.
- nursing outcomes.mp.
- change management.mp.
- waiting time.mp.
- surgery waiting time.mp.
- 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43
- 10 AND 15 AND 28 AND 35 AND 44
Appendix II: Study Eligibility Verification Form
The effectiveness of nurse-led pre-operative assessment clinics or services for patients receiving elective orthropaedic surgery
Appendix III: JBI Critical Appraisal Checklist for Randomised and Pseudo-randomised studies
Appendix IV: Data Extraction Form
The effectiveness of nurse-led pre-operative assessment clinics or services for patients receiving elective orthropaedic surgery