Improving Surgical Outcomes Using the Perioperative Dialogue Model
The estimated $8.5 to $17 billion lost to surgical errors in 1999 was not primarily due to individual incompetence, but to the failure of perioperative systems to operate seamlessly (reviewed by Plasters, Seagull, and Xiao, 2003). The successful management of an operating-room depends heavily on effective communications, but in the absence of a foolproof system for keeping abreast of changes in patient status or surgery schedules, miscommunication is not as rare as it should be.
An important component of the perioperative surgical team is the duties performed by the perioperative nurse (PN), who typically functions as a patient advocate before and during surgery (reviewed by Lee, Kerridge, Chui, Chiu, and Gin, 2011). In Sweden, surgical nursing care has begun to emphasize the importance of a perioperative dialogue between the patient and the PN (Reviewed by Lindwall and von Post, 2008). Under the perioperative dialogue model, the goal is to go beyond the patient advocate role to one focused on establishing a trusting relationship between the patient and a single PN. The dialogue thus created remains intact throughout the perioperative process. Everyone is expected to benefit from this dialogue, including the patient, surgical team, and healthcare administrators concerned about the bottom line.
Implications for a Perioperative Dialogue-Focused Practice
The continuum of care during perioperative procedures depends heavily on a variety of communication methods, including the surgical white board maintained by the charge nurse, patient medical records and admissions information, pagers, phones, face-to-face discussions, and paying attention to the activities taking place on the floor of the surgical department (Plasters, Seagull, and Xiao, 2003). However, the personnel responsible for preoperative care may not be the same individuals in the OR, or who administer postoperative care. The continuum of care in the United States therefore depends on various forms of communication between members of the perioperative team, forms of communication that have been shown to fail too frequently. It could be argued that failures of communications among surgical team members represent a major weakness in U.S. perioperative systems.
Should perioperative care in the U.S. revise the role of the PN to include initiating and maintaining frequent dialogue with the patient throughout the perioperative period, the PN could function as a surgical liaison between the patient and all members of the perioperative team. Breakdowns in communication, and by extension medical errors, could potentially be avoided by making the PN the primary contact for surgical team members.
Advantages of new Approach
The more a patient is informed about the perioperative process, the better the surgical outcome (reviewed by Kehlet and Wilmore, 2002, p. 631). Less analgesia is needed and recovery times may be shortened for well-informed patients. In a more recent study of 5 to 11-year-old children undergoing surgery, perioperative dialogue with the same PN lowered salivary cortisol levels significantly (p = 0.003) during recovery when compared to control patients (Wennstrom, Tornhage, Nasic, Hedelin, and Bergh, 2011). In addition, the children who received perioperative dialogue as part of their care required less morphine to achieve the same level of comfort as control patients (p = 0.014).
The perioperative dialogue model could have a significant impact on the incidence of surgical complications, since most occur during surgery and the early post-operative period (reviewed by Kehlet and Wilmore, 2002, p. 637). As Kehlet and Wilmore (2002) suggest, when everything that can be done medically is being done, improvements in attending to the medical and psychological needs of the patient may represent the best source of reducing adverse outcomes.
Interviews of patients who received perioperative dialogue reported feeling as though the PN had ‘made time’ for them and their concerns (reviewed by Lindwall and von Post, 2008). Another common experience reported by patients is the absence of a feeling of abandonment immediately prior to induction; children reported that they would have felt ‘let down’ if the anesthesia had been administered by someone other than the PN. Patients also reported experiencing more comfort with the process of abandoning the care of their bodies to the PN prior to induction, one of the more stressful situations for surgical patients.
From the PN’s perspective, the perioperative dialogue model offers the opportunity to establish an uninterrupted caregiver relationship with a patient (reviewed by Lindwall and von Post, 2008). In addition to the fulfillment conferred by this relationship, PN’s report feeling that their ability to manage the perioperative process is enhanced through frequent dialogue with the patient. PN’s also reported feeling a greater sense of responsibility for patient outcomes and accordingly, began to feel more like a nursing professional who had more to learn about being a nurse. The perioperative dialogue model therefore challenges nurses to care more deeply about the patients they care for and improve their skill set.
Involving Key Stakeholders
Successful management of a surgery clinic depends on the ability to coordinate the availability of multidisciplinary stakeholders (reviewed by Plasters, Seagull, and Xiao, 2003, p. 525). The availability of an anesthetist, surgeon, patient, equipment, operating-room, and nursing support has to be synchronized for a surgical procedure to commence on time. Should this coordination effort fail, the clinic tends to bear any extra costs that rescheduling requires. Based on the study by Plasters, Seagull, and Xiao (2003), changing or missing information routinely caused surgery schedules to be reorganized in a level 1 trauma center. The impact of a single piece of missing information, such as patient status, frequently caused a rescheduling ripple-effect throughout the rest of the day for a busy trauma center.
Implementing a perioperative dialogue model would provide a single information source regarding patient status. The charge nurse’s ability to stay informed would be improved by staying in contact with a patient’s PN, thereby minimizing rescheduling events caused by inaccurate or missing information concerning patient status. The anesthetist’s and surgeon’s ability to improve patient outcomes would likely be enhanced, by having access to information the PN has accumulated during dialogues with the patient. There may also be a direct positive impact on patient outcomes through the reduction of anxiety levels during the postoperative period. Implementing a perioperative dialogue model would therefore likely benefit all stakeholders, including clinic administrators concerned about the costs incurred by frequent surgery rescheduling.
Overcoming Barriers to Change
Lee and colleagues (2011) briefly discuss the evidence for barriers to change for implementing perioperative system changes. The primary barrier is the lack of a ‘change agent’, which for a perioperative team can be anesthetist or surgeon, or at least require their cooperation. A change agent can also come in the form of a highly motivated team and/or strong and consistent material support by clinic administrators. Unfortunately, the reverse is also true; staffing and other shortages will undermine attempts to improve patient outcomes. Lee and colleagues (2011) mention that preoperative assessments by an anesthesiologist can be a weak point in care quality if there are staffing shortages or time spent doing an assessment is not compensated. A PN trained in anesthesiology would help to eliminate this weak point.
Lindwall and von Post (2008), both advocates of the perioperative dialogue model, report that nursing staff can be a significant barrier to change. At institutions where nurses are given little decision making responsibility, nurse initiatives to improve care quality can be muted. Low nurse morale and intransigence were mentioned as other barriers to change. However, these authors also described nurse reactions to implementation of the perioperative dialogue model, which were generally positive. Nurses felt challenged professionally and more fulfilled. In addition, the perioperative dialogue model tended to empower nursing staff by conferring a greater sense of responsibility for surgical outcomes. Based on these comments, implementing the perioperative dialogue model may encourage nursing staff to reconsider their unwillingness to change, and improve their morale and sense of professionalism.
Implementing a perioperative dialogue model would probably be viewed initially as an unjustified expense to uninformed clinic administrators. Implementation of this model would increase salary and benefits costs if additional nurses are hired and/or reassigned, costs which may not be viewed favorably by budget-constrained clinics. However, the potential for improved patient outcomes, fewer surgical errors, and reduced costs associated with rescheduling a day of procedures, might be a strong enough argument to motivate cash-strapped administrators to agree to at least a trial period. The promise of reduced litigation costs can be very enticing and could potentially cover the costs of increased staffing.
References
Kehlet, Henrik and Wilmore, Douglas W. (2002). Multimodal strategies to improve surgical outcome. American Journal of Surgery, 183, 630-641.
Lee, Anna, Kerridge, Ross K., Chui, Po Tong, Chiu, Chun Hung, and Gin, Tony. (2011). Perioperative systems as a quality model of perioperative medicine and surgical care. Health Policy, 102, 214-222.
Lindwall, Lillemor and von Post, Irene. (2009). Continuity created by nurses in the perioperative dialogue — a literature review. Scandinavian Journal of Caring Sciences, 23, 395-401.
Plasters, Cheryl L., Seagull, F. Jacob, and Xiao, Yan. (2003). Coordination challenges in operating-room management: An in-depth field study. AMIA Annual Symposium Proceedings, 524-528.
Wennstrom, Berith, Tornhage, Carl-Johan, Nasic, Salmir, Hedelin, Hans, and Bergh, Ingrid. (2011). The perioperative dialogue reduces postoperative stress in children undergoing day surgery as confirmed by salivary cortisol. Pediatric Anesthesia, 21, 1058-1065.
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