Evidence-Based Practice Essay

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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…

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