Hartford Hospital is a high-volume, tertiary hospital that serves as the center for the Hartford Healthcare System in Connecticut. It not only serves patients who live in and around the geographical region but also receives transfer of patients from "feeder hospitals" who can benefit from cutting-edge technology in making a gastroenterology diagnosis and providing treatment. Staff continually face an ever-changing environment, work with medically complicated patients with multiple risk factors, and possess specialty skills in performing high-level procedures.
The Endoscopy Unit at Hartford Hospital has worked to strengthen communication and coordination in patient care using standardized flow and process kaizens in the "Prep," "Procedure," and "Recovery" areas." In addition, the "Pre-Call" area has developed its own approach to creating a quality and efficient process to assess and evaluate patients prior to their arrival. The Pre-Call script is provided in Supplemental Digital Content 1 (available at: http://links.lww.com/GNJ/A59).
Two attempts are made to contact patients up to 1 week prior to their scheduled procedure. This has ensured that a high percentage of patients are reached by phone prior to their endoscopy appointment. The process has helped manage knowledge gaps, enhance an understanding of expectations prior to the procedure, and has facilitated troubleshooting obstacles. Issues resolved have included a lack of knowledge and/or a lack of understanding with regard to the procedure, transportation requirements, location of facility, dietary restrictions, bowel prep when indicated, nothing by mouth (NPO) status, and medication management. In addition, the assessment and evaluation of each patient during the Pre-Call expedites the admission process so that the Prep registered nurse (RN) can quickly validate intake. Pre-Calls in the gastrointestinal (GI) setting pave the way for navigating a successful outcome and patient experience, as well as reduce the number of "no-shows" of up to 33% (Childers, Laird, Newman, & Keyashian, 2016). In addition, the Pre-Call reduces the need for procedures to be cancelled because of not following dietary, medication, or prep instructions, as well as not meeting anesthesia requirements such as abstaining from cocaine for 48 hours.
The standardized Pre-Call begins with confirming the correct spelling of the patient's name, date of birth, attending physician, procedure, and the indication for the procedure. The indication for the procedure may include an abnormal finding, symptoms, and/or history of GI cancer/polyps. Expected time for arrival/procedure is reviewed. The patient's height and weight, with automatic body mass index (BMI) conversion for anesthesia, allergies to medication, food, and latex are obtained. The history continues with an emphasis on body systems including cardiac (coronary artery disease, hypertension, heart murmur, irregular rhythm), pulmonary (asthma, sleep apnea), endocrine (diabetes, thyroid), neuro (seizures, stroke), liver (stones, hepatitis, jaundice, cirrhosis), kidneys (dialysis), cancer/treatment (type, chemo, radiation), and blood/clotting disorders. The history reviews status on smoking, use of alcohol and drugs, including recreational drugs and marijuana. Surgical history completes this section of the intake.
GI Pre-Calls include a review of prescriptions, herbal products, over-the-counter medications, and vitamins. Medication reconciliation creates a single list of the patient's up-to-date medication regimen. Teaching is reinforced for patients who must discontinue specific medications 1 week prior to the procedure per physicians' protocols. Patients who are on anticoagulants receive dosing instructions from the endoscopist. The process requires the endoscopist to contact the prescriber for best care of the patient. Patients taking insulin are instructed to contact the prescribing physician for dosing instructions. Teaching reinforces each patient's unique needs. Patients are also instructed to take essential medications on the day of the procedure. Each is guided in identifying what is an essential medication and may include those for the heart (hypertension regulators, antiarrhythmics), anticonvulsants, anti-rejection medications, inhalers, psychogenics, methadone, proton pump inhibitors (PPIs), anti-reflux medications, and buprenorphine and naloxone, which may be taken with a sip of water. Diuretics are avoided until after the procedure.
Pre-Calls review none per os (NPO) requirements based on the hospital anesthesia policy. The patient's dietary restrictions are reviewed on the basis of procedure and physician protocols. Protocols for procedures including endoscopic submucosal dissection (ESD), peroral endoscopic myotomy (POEM) (E-Poem for achalasia, Z-Poem for Zenker's diverticulum, and G-Poem for gastroparesis), Bravo, and M2A Capsule Preparation for PillCam studies have been developed and are reviewed.
An outpatient profile identifies preferred language and special needs. This can include difficulty with hearing, vision, ambulation, inability to speak, need for oxygen, or Hoyer lift. Patients are instructed regarding the need for a designated driver and are provided with medical transportation information if necessary. As a regional referral facility, patients often travel more than 1 hour for their procedure. Most patients are not familiar with the entryway to the department and require directions and information related to the parking options.
Because of the complex instructions patients must follow and protocols nurses must be familiar with, a booklet has been created that includes comprehensive information for patient teaching. Included are a Pre-Call Cheat Sheet, instructions for use of the Language Line, a HIPPA-approved message for voice mail and call backs, protocol for cancelling cases, protocols for specialty procedures, NPO status, and specialty dietary restrictions. Also included are detailed instructions in the preparation and administration of more than 10 different bowel preps. This has served patients well in their ability to clarify instructions they may have only partially understood.
In this day of a complex and rapidly moving healthcare system, the Pre-Call nurse has evolved into a clinical resource, educator, and patient advocate. This support helps promote compliance and reduces anxiety in what can be a challenging period. This initial contact with the patient establishes a relationship with each patient. Whether anxiety is related to the patient or family, and due to an unknown diagnosis, staging cancer, a previously failed procedure elsewhere, or treating a chronic undiagnosed issue, this relationship sets the foundation for best care and best experience.
ACKNOWLEDGMENTS
The authors would like to thank Hartford Hospital GI Manager, Michelle Day, MSN, RN, CGRN for her support in this project.
REFERENCE