A stitch in time to save nine? The role of the Pre-Admission Centres in enhancing quality, safety, and patient centred care

Background
A Pre-Admission Centre (PAC) was established at the study facility in 1996 to provide patient centred care that was accessible, safe, and reliable. The purpose was to reduce the length of stay at the early stages of the hospital admission process by removing the requirement for a pre-operative day for patients. The nursing leadership team was instrumental in establishing the PAC as a nurse-led centre rather than anaesthetist or doctor led. The aim of the research was to understand the role of the PAC in a private tertiary training hospital from a range of stakeholder perspectives namely patients, surgeons, anaesthetists, and registered nurses. From an examination of the literature, it was clear that the focus to date had been on the benefits to the organisation and on patient satisfaction. Previous literature did not research the perceived benefits, to the patients who attend a PAC, the medical and nursing staff who use them and the multidisciplinary team who provide the service.
Methodoloy
The research question asks: What is the role of the Pre-Admission Centre in enhancing quality, safety, and patient centred care? As the research question seeks to understand the experience of the PAC from all stakeholder perspectives an explanatory sequential mixed methods approach was determined to be the most appropriate methodology. A mixed methods approach was used to expand the depth and breadth of the study by using different methods for each component. The research was undertaken in two phases, phase one used primarily quantitative retrospective secondary data from surveys collected by the facility which quantified the characteristics of patients who attended a face-to-face pre-admission appointment or had a telephone admission. Phase two used qualitative methods to achieve a deeper and more insightful understanding of the workings of the PAC from the perspective of all stakeholders. The study consisted of patient surveys, semi-structured interviews, and a focus group to identify the impact of the PAC for elective surgical patients, surgeons, anaesthetists, and registered nurses. The factors that contributed to the success of the PAC as well as any improvements to the existing service was also explored.
Findings
Phase one data outlined the number of patients reviewed by the PAC between 2004 and 2017 and considered these in relation to the total numbers of patients admitted to the study facility for surgery or procedure. In 2004, 4,254 patients were reviewed by PAC staff which increased to 7,537 in 2009 and remained stable until a small decrease in 2017 (6,847). Data were also collected in relation to referrals made to multidisciplinary teams (including clinical nurse consultants, surgeons, anaesthetists, and nurse educators), patients reviewed by the anaesthetist, reported risk variances taken from the risk management system and patient survey data. Descriptive statistics were used to analyse the quantitative data (Cohen, Manion & Morrison 2017). As the information provided from this data did not fully answer the research question exploring the experience and role of the PAC from all stakeholders’ perspectives it was followed by phase two of the study which collected qualitative data. Five themes were identified in phase two, from the 170 patients’ surveys, 15 semi-structured interviews with surgeons, anaesthetists, PAC registered nurses and a focus group with ward area registered nurses. The themes were derived using Braun and Clarke’s six stages of thematic content analysis (Clarke, Braun & Hayfield 2015; Riger & Sigurvinsdottir 2016). The themes derived from the data were 1. Patient safety, contributory sub themes were screening mechanism, early detection of risk, essential part of the hospital, 2. Informing and educating patients, combined informative and pre-operative education 3. Allaying fears and anxiety, reassuring, reduces anxiety, helpful 4. Achieving effectiveness and efficiency, combined the sub themes of excellent, reduced length of stay, reduces cancellations, shortens length of stay, timesaving, and cost 5. Identified problems with the existing service and possible solutions, combined the subthemes anaesthetist not available on the day of the PAC appointment, earlier appointment, duplication of information, not completely electronic, potential for confusion, unnecessary tests, and parking. Findings show that the PAC at the study facility provides a risk screening mechanism for patients providing early detection and communication of risks which allow for appropriate action to be taken in a timely manner. It is perceived as being a time saver for anaesthetists and registered nurses at ward level on the day of surgery and allays fears and anxiety. The PAC may assist in reducing length of stay and reduce cancellations on the day of admission. Problems which were explored identified that patients from a rural area and those living long distances from the study facility had difficulties attending the PAC. Other matters identified involved scheduling with inappropriate timing of anaesthetist appointments, for example an appointment time was convenient for the patient but inconvenient for the anaesthetist and vice versa. Possible over investigation was a consideration, for example attending an electrocardiograph on a person with no cardiac history or unnecessary pathology being taken. The potential for miscommunication such as between the PAC and anaesthetists or surgeons regarding patient medical history or bowel preparation was also seen as problematic. The uniqueness of this study is that the experiences of a range of stakeholders are explored, in contrast to previous research with only a two-perspectives (the patient and organisation perspective) taken into consideration. The PAC was perceived by all stakeholders as an effective way to provide screening and early detection of risks for patients who are having large and complex procedures. The findings identified that a visit to the PAC in conjunction with the multidisciplinary team, surgeons, anaesthetists, and registered nurses can mitigate risk. Registered nurses can provide information and educate patients, which in turn leads to a reassured and less anxious patient.
Limitations
This study was conducted in one facility which may limit its generalisability. The researcher was the Nursing Unit Manager of the PAC during the data collection period and data was collected by two experienced external interviewers to mitigate any possible bias. Retrospective secondary data was used which is potentially limited as it is collected for purposes other than research and may be prone to subjectivity. Despite these limitations the study contributes to and enhances knowledge and understanding of a range of stakeholder perceptions of the PAC.
Conclusion
There is a need to focus on patient safety, quality, experience as well as the sustainability of Pre-Admission Centres. Leadership, quality, and safety along with operational excellence are imperative to the success of Pre-Admission Centres. Further research is required to examine the cost effectiveness of Pre-Admission Centres at a state, national and international level, to ascertain what types of education was most beneficial to patients as well as types of digital health that could be utilised in preparing patients for admission for surgery.