Dentistry Pilots Clinic to Prepare Parents, Patients for Surgery

from Caring For Our Future, Spring 2006

By Terri Eldridge, MS, RN, CPNP, Nurse Practitioner, Preoperative Services

In August of 2004, The Children’s Hospital’s Dental Clinic and Perioperative Services Department developed and implemented a pilot program for a Pre-Admission Testing (PAT) clinic. The goal of the PAT clinic was to facilitate orientation, management and preparation for smooth intake and transition to the operating room on the day of surgery for Children’s dental patients scheduled for elective surgery. Dentists at Children’s perform more than 2,000 dental surgeries a year.

Prior to the implementation of the pilot program, the cancellation and “no show” rate was approximately 20 percent for Children’s dental-clinic surgeries. The primary causes for these cancellations on the day of surgery were illness, exposure to infectious disease, consent issues and inappropriate ingestion of fluids or food. Dr. Stephen Wilson, the former director of Children’s dental clinic, Dr. Desmond Henry, director of anesthesia, Nanci Royal, the former clinical director of nursing perioperative services, and the advanced practice nurses (APNs) in the perioperative services department met and discussed ways to decrease the cancellation rate and provide better service to dental surgery patients. They decided to pilot a preoperative clinic that would do pre-admission testing and preparation.

The initial goals of the PAT were to:

• Decrease the cancellation rate of patients scheduled for elective dental surgery.
• Facilitate the efficiency of preparation for care in the operating room on the day of surgery.
• Increase the communication among professionals providing care to ensure the patient assessment, testing and delivery of care would be complete, efficient and individualized.
• Provide increased patient and staff satisfaction.

PAT clinic patients were scheduled by the dental clinic scheduler for one of three half-days in the surgical specialties clinic. The perioperative APNs performed chart reviews prior to the patient’s appointment. On the day of their preoperative clinic appointment, the APN completed a focused preoperative history and physical examination, obtained consultations, lab, or other preoperative testing as needed, and prepared the family by completing preoperative teaching.

Increased efficiency on the day of surgery was accomplished by discussing:

• Instructions on what (or what not) to eat or drink prior to surgery (NPO)
• Potential consent issues
• Patient medication management (including dose and timing on the day of surgery)
• Necessary tests or labs prior to surgery (EKGs, blood clotting labs, etc.)
• Referrals from other areas such as cardiology or pulmonology
• Scheduling an interpreter
• Issues that had the potential for a delay or cancellation such as illness or exposure to infectious diseases
• Providing the children with a positive experience in a less threatening environment prior to surgery

The preoperative teaching for parents included: NPO guidelines, arrival time, approximate discharge time, and bringing a comfort item or special items such as feeding tube supplies, medications or a glucometer for the child. Parents also were instructed to call the surgeon’s office if the child developed upper-respiratory symptoms, flu, rashes, or if the child had exposure to contagious diseases such as chicken pox or influenza.

Staff reviewed a Surgical Preparation Booklet with families and gave them information about parking, location for admission, a preoperative tour, and phone numbers to call if a parent had questions. The families also were advised of the anesthesia process, side effects and reasons for NPO guidelines. Parents were provided with suggestions for preparing their child for surgery based on the child’s developmental age and special needs. Parents indicated they felt better prepared for the surgery and less stressed on the day of surgery.

The cancellation and no-show rate decreased to 11 percent. Many of the cancellations for illness or exposure to infectious diseases were done far enough in advance to schedule a patient on the waiting list for the vacated surgical time. Some of the patients seen in the PAT clinic were canceled until further testing or consultation could be completed or until they met the appropriate criteria for anesthesia. Those who were canceled and rescheduled did complete their surgeries at a later date. At the end of the six-month pilot study, 91 percent of the patients seen in the PAT clinic successfully completed their surgery. Parents and patients verbalized satisfaction with the clinic and the preoperative teaching they received. Nursing and anesthesia staff also indicated increased satisfaction as an outcome of the PAT clinic.

The PAT clinic has been able to address issues that often delay or slow the admission process. Interpreters are scheduled ahead of time, anesthesiologists are aware of potential issues and co-morbidities that impact anesthesia, and infectious-disease issues are resolved prior to the day of surgery, resulting in a decrease in delays and cancellations. By preparing parents in advance about what to expect on the day of surgery, they are less stressed and better informed. Patients seen in the PAT clinic are also able to arrive half an hour later than patients not seen in the preoperative clinic. Children with special needs have many issues that can be addressed prior to the day of surgery, and often their arrival time and NPO status can be adjusted to accommodate for this.

Special preparations in the operating room can be planned in advance. Patients seen in the PAT clinic have a much smoother admission on the day of surgery, and the nursing staff in the admission/discharge area find that they have to do less teaching and that parents are more prepared with fewer questions and concerns. This provides the nurse with the opportunity to spend more time with the families who have not attended the PAT clinic and with the post-operative patients. Due to the success of the pilot study, the PAT clinic has plans to expand. Other options for preparation and screening are also being explored for families who live out of town or who have difficulty scheduling an additional appointment.