Art & science |
The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
EVALUATING A SPECIALIST NURSE’S ROLE IN A GENERAL PAEDIATRIC SURGICAL TEAM The outcome of an audit to assess an interprofessional general surgical team showed that the surgical care practitioners’ role improves continuity and enhances the care of children and their families, as Julie Quick explains Correspondence julie.quick@ walsallhealthcare.nhs.uk Julie Quick is a surgical care practitioner for Walsall Healthcare NHS Trust, Walsall Date of submission February 2 2014 Date of acceptance June 5 2014 Peer review This article has been subject to open peer review and checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ ncyp-author-guidelines
Abstract A surgical care practitioner (SCP) is a registered nurse or allied health professional who, following specific education and competency training, carries out pre- and post-operative treatment and some surgical interventions under the supervision of a consultant surgeon, contributing to the maintenance of surgical services and the enhancement of patient care. With a cohesive approach, the SCP can do much to ensure continuity of care and mutual understanding and concordance between staff, child and family. Costs can be reduced and the surgical training of junior doctors supported. The results of this audit show that, with the inclusion of an SCP, higher quality general children’s surgery can be provided at a medium-sized district general hospital, so that patients can be seen locally. Keywords Children’s nursing, general paediatric surgery, surgical care practitioner, surgical outcomes
(Department of Health (DH) 1999, 2000a, 2000b, 2004, 2007). A number of posts have been established, that have enabled nurses to cross former disciplinary boundaries. It is 25 years since the introduction of the first formally trained surgical care practitioner (SCP) to a cardiothoracic surgical team, and now evaluation of the work of paediatric SCPs is emerging. The SCP is a registered nurse or allied health professional who, following robust academic education and competency training, carries out pre- and post-operative care and some surgical interventions under the supervision of a consultant surgeon (Royal College of Surgeons of England (RCSE) 2014). SCPs now work alongside surgical teams in a number of specialties, including paediatrics (Knight 2009). This article aims to describe the development of the SCP role in paediatric surgery at one NHS trust in the UK by formal evaluation between 2011 and 2013, to identify its effect on the holistic care of children and their families.
The role
Surgical care practitioner Julie Quick (right) and colleagues carry out a surgical intervention at Walsall Healthcare NHS Trust, Walsall
IN THE UK, new health policies, a changing medical workforce and an ever-more demanding health service have led to the development of a number of innovative peri-operative roles to maintain surgical provision and enhance patient care at reduced cost. The potential of nurses, and more recently of allied health professionals (AHPs), has been maximised now for many years
16 October 2014 | Volume 26 | Number 8
Local context Walsall Healthcare NHS Trust is a medium-sized acute healthcare provider for the population of Walsall and the surrounding area. The NHS trust offers elective day-case and emergency inpatient paediatric surgery in a number of specialties included in general surgery. This is supported by paediatric anaesthetic and medical teams and has close ties with regional providers. NURSING CHILDREN AND YOUNG PEOPLE
Nursing Children and Young People 2014.26:16-20. Downloaded from journals.rcni.com by FLINDERS UNIVERSITY on 12/05/15. For personal use only.
Tim George
NURSING CHILDREN AND YOUNG PEOPLE
October 2014 | Volume 26 | Number 8 17
Nursing Children and Young People 2014.26:16-20. Downloaded from journals.rcni.com by FLINDERS UNIVERSITY on 12/05/15. For personal use only.
Art & science | audit acute care Since 2011, the current general paediatric surgical (GPS) consultant-led service has been carried out by one named consultant surgeon (vascular, general and paediatric surgery) and one SCP. In the UK, surgical trainees participate in general paediatric theatre sessions only on an impromptu basis (RCSE 2010). In the absence of junior hospital doctors, the addition of an SCP to the GPS team has made available a knowledgeable surgical assistant who is a competent operator and who can assist while they train (Quick 2013). The SCP in this study – the author – is a registered nurse with a peri-operative background that includes paediatrics, who has completed the national two-year educational training programme for SCPs. She is a non-medical prescriber, has attained an MSc in professional studies in healthcare, and has undertaken local training in safeguarding and in children’s intermediate life support. Benefits The addition of an SCP as a permanent member of the GPS team, to increase its potential, has been shown to confer benefits, including the maintenance of surgical services and enhancing patient care (Box 1) (Quick 2013). With a cohesive approach, the SCP can do much to ensure mutual understanding and concordance between staff, child and family, therefore improving their experience (Quick 2013). Costs can be reduced and the surgical training of junior doctors supported (Abraham 2011, Quick 2013). Box 1 Benefits of including a surgical care practitioner in a general paediatric surgical team ■ Provides a knowledgeable surgical assistant and competent operator. ■ Improves the child’s and family’s experience. ■ Supports surgical training. ■ Provides continuity of care. ■ Maintains service provision. (Quick 2013)
Box 2 Surgical outcome criteria for general surgery Outcomes used as measurements include unplanned readmissions, re-operation and/or reintervention at 28 days for children who underwent any of the following procedures: ■ Medical circumcision. ■ One-stage orchidopexy. ■ Hydrocele repair. ■ Umbilical hernia repair. ■ Inguinal herniotomy. (British Association of Paediatric Surgeons 2011)
18 October 2014 | Volume 26 | Number 8
Safety and efficacy Senior clinicians in the UK had previously raised concerns about the value and safety of nurses and AHPs extending their skills to include those previously associated with doctors (Scott 2004, Aning 2006, Freudmann 2006). Studies have, however, found that SCPs can be suitably qualified and trained to safely assist with and perform surgery in adults and children (Hickey and Cooper 2009, Hall 2011, Quick 2013). The national curriculum framework for SCPs, recently revised, incorporates general and specialist knowledge and skills acquisition in various surgical specialties including paediatric surgery (RCSE 2014). Completion of the curriculum promotes safety and high standards among practitioners in the role. This demonstrates that the SCP job description adheres to professional regulatory standards (Nursing and Midwifery Council (NMC) 2008) to ensure the best patient care and reduce the risk of harm. Findings have suggested that SCPs are also able to recognise situations outside their scope of practice when assessing children and adults (Newey et al 2006, Quick 2013).
Audit At the NHS trust, the GPS team assesses and treats neonates and children up to the age of 15 years for a variety of congenital and acquired general conditions; this includes ankyloglossia (tongue tie), phimosis (unusually tight foreskin), inguinal hernia and undescended testes. There are four children’s outpatient clinic sessions and two dedicated GPS operating sessions each month. The SCP works alongside the consultant surgeon at two clinic sessions, and undertakes consultations with new and follow-up referrals, and specified operative procedures – including freehand circumcision, tongue-tie release and foreskin stretch – as well as providing general surgical assistance during each theatre session. Measuring practice Audit allows healthcare professionals the opportunity to evaluate the care they provide (Sinclair and Bridgewater 2007). Analysis of readmission and complication rates can provide a measure of service quality offered by SCPs (Abraham 2011). The service provided by the interprofessional GPS team was therefore measured against criteria issued by the British Association of Paediatric Surgeons (BAPS) (2011) (Box 2). Data were collected retrospectively by the SCP from the NHS trust’s patient management systems for 24 months, starting June 2011, relating to children aged 0-15 years who underwent any of the specified procedures under the care of the GPS team. NURSING CHILDREN AND YOUNG PEOPLE
Nursing Children and Young People 2014.26:16-20. Downloaded from journals.rcni.com by FLINDERS UNIVERSITY on 12/05/15. For personal use only.
Information was then collated to identify children discharged by the GPS team who: ■ Underwent subsequent readmission or a repeated operation under the care of the same GPS team. ■ Were readmitted as an emergency under any on-call consultant general surgeon. ■ Attended the ward under the GPS consultant or other consultant surgeon or paediatrician. The medical records of these children were then examined by the author to determine diagnosis and reintervention. Pre-established exclusion criteria eliminated three children who had been readmitted for an unrelated diagnosis and one who was readmitted and treated for complications of general anaesthesia. Results Of 250 children who underwent elective day-case procedures performed by the GPS team over the two years, 147 were treated with a surgical procedure specified in the BAPS criteria. One child had bilateral orchidopexy and this was classed as two separate procedures in the data. The age range was 1-15 years, and 139 of the children were boys (93.8%). The operation was performed by the consultant surgeon for 121 (81.8%) of these children and the SCP operated for 27 (18.2%). As shown in Figure 1, the 148 procedures consisted of: ■ Circumcision (either Plastibell, a less invasive technique, or freehand). ■ One-stage orchidopexy. ■ Inguinal herniotomy. ■ Umbilical hernia repair. ■ Hydrocele repair. No child underwent a repeated operation within 28 days of the initial procedure. There were three ward attenders, all of whom had undergone circumcision; no reintervention or readmission was required, and they were reassessed and discharged by the consultant general paediatric surgeon. Two children had unplanned readmissions within 28 days; both had their initial operation performed by the consultant paediatric surgeon. Of these, one two-year-old child was readmitted under the care of the GPS team four days after a right orchidopexy with a wound infection. The other child, aged ten years, was readmitted with a urinary tract infection eight days after undergoing a circumcision. Both were discharged after receiving oral antibiotics. For the consultant general paediatric surgeon, these figures are comparable to outcomes published in the literature (Hutton and Sau 2007, Weiss et al 2010). The zero rate of complications experienced by children undergoing medical circumcision by the SCP is considerably less than that documented in the literature (14%). Unlike the provision of circumcisions NURSING CHILDREN AND YOUNG PEOPLE
Figure 1 Procedures undertaken (n=148) 3% (5) 7% (11) 10% (14)
14% (21) 66% (97)
Key: Circumcision Orchidopexy Inguinal herniotomy
Hydrocele repair Umbilical hernia repair
performed by unsupervised non-medical providers in community settings reported by Weiss et al (2010), this result is likely to be due to a number of factors, including the experience and competency of the nurse, the supervision by the consultant paediatric surgeon and the performance of the procedures in a sterile hospital environment.
Discussion The SCP post is well established at the NHS trust. Despite a number of studies identifying the benefits that the work of the SCP has on surgical outcomes, few studies have explored the role of the SCP in children’s services. The 2011 census revealed that Walsall, with a medium-sized district general hospital, has a greater proportion of 0-15 year olds in the population than nationally (Census Report 2011). RCSE (2013) stipulates that children who require surgery should be treated in a suitably equipped and safe environment close to their homes by suitably trained healthcare professionals. In this context, smaller district general hospitals can experience difficulties in providing timely, safe and high quality local services for children and their families (RCSE 2007), although outcomes comparable with those of regional paediatric centres have been reported (Hart Prieto and Jones 2011). The results of this audit suggest that surgical outcomes among children who undergo specified elective day-case procedures provided by the interprofessional surgical team are within or below national figures for readmission, repeated October 2014 | Volume 26 | Number 8 19
Nursing Children and Young People 2014.26:16-20. Downloaded from journals.rcni.com by FLINDERS UNIVERSITY on 12/05/15. For personal use only.
Art & science | audit operations or reintervention at 20 days post procedure for any of the procedures listed in Box 2. This supports the premise that a high quality GPS service can be provided by a medium-sized district general hospital, since acceptable outcomes for children undergoing elective day-case procedures have been demonstrated (RCSE 2010). The results also show that post-operative complications were within or below national limits for surgical outcomes performed by non-medical providers when the SCP performed operative procedures or assisted during day-case elective GPS. This is comparable with the findings of other surgical teams that include an SCP (Alex et al 2003, Newey et al 2006, Hickey and Cooper 2009) and establishes that the SCP role is safe and effective in GPS. In addition, since acceptable outcomes are demonstrated, these findings support the nurse and consultant surgeon in the demonstration of professional revalidation (BAPS 2011, NMC 2011). The addition of a specialist nurse to the surgical team has been found to be beneficial for ensuring continuity of care for adults, children and their families, while maintaining and improving services (Abraham 2011, Kumar et al 2013, Quick 2013). This is confirmed by the present evaluation and supports the premise that high quality GPS can be provided by a medium-sized district general hospital, so clients can be seen locally and in a timely fashion. More children live in Walsall than any other borough in the UK, and improvement enables a greater number of them
to receive treatment close to home, as specified by national paediatric surgical standards (RCSE 2013). Limitations This audit did not include children who may have been readmitted, had a repeated operation or underwent a reintervention under the care of an alternative healthcare provider. Nor does it evaluate post-operative complications assessed and treated in primary care. It was outside the scope of this audit to examine the long-term complications of any procedure. All these are areas for future evaluations.
Conclusion Children need to be cared for holistically, with the child’s needs considered alongside those of the parents and family. Unplanned readmission or ward attendance may have a significant effect on the family unit. The presence of an SCP as part of the GPS team has positive effects on children’s and families’ experiences, surgical outcomes and continuity of holistic care. The SCP enhances interprofessional interactions with clients and their carers, while contributing to the safe performance of surgical interventions and to the experience of junior doctors, by exposing them to a GPS in a non-regional centre. The unit’s readmission and post-operative complication rates are within or below national averages, with the SCP’s personal figures for these parameters lower. This benefits children, their families and the employing hospital.
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
References Abraham J (2011) Innovative perioperative role improves patient and organisational outcomes in minimal invasive surgery. Journal of Perioperative Practice. 21, 5, 158-164. Alex J et al (2003) Surgical nurse assistants in cardiac surgery: a UK trainee’s perspective. European Journal of Cardiothoracic Surgery. 25, 1, 111-115. Aning J (2006) Surgical care practitioners: The case against. British Medical Journal Careers. careers.bmj.com/careers (Last accessed: September 5 2014.) British Association of Paediatric Surgeons (2011) Using Outcomes Information for Revalidation in Paediatric Surgery. tinyurl. com/baps-revalidation-guide (Last accessed: September 10 2014.). Census Report (2011) Key Statistics for Walsall: Borough Summary. tinyurl. com/walsall-census-2011 (Last accessed: September 10 2014.) Department of Health (1999) Making a Difference: Strengthening the Contribution of Nurses, Midwives and Health Visitors to Health and Healthcare. The Stationery Office, London.
Department of Health (2000a) A Health Service for all Talents; Developing the NHS Workforce. The Stationery Office, London. Department of Health (2000b) The NHS Plan: A Plan for Investment, a Plan for Reform. The Stationery Office, London. Department of Health (2004) Modernising Medical Careers: the Next Steps. The Stationery Office, London. Department of Health (2007) New Ways of Working for Everyone: A Best Practice Guide. The Stationery Office, London. Freudmann M (2006) Surgical care practitioners are having a detrimental effect on surgical training. British Medical Journal Careers. careers. bmj.com/careers (Last accessed: July 21 2014.) Hall S (2011) Steadfast Hands with Experience. MSc dissertation. University of Leicester, UK. Hart Prieto MC, Jones PA (2011) Are general paediatric surgery outcomes comparable between district general hospital and regional referral centres? Annals of the Royal College of Surgeons of England. 93, 7, 548-550. Hickey N, Cooper K (2009) Varicose vein surgery performed by a surgical care practitioner. Phlebology. 24, 1, 43-45.
20 October 2014 | Volume 26 | Number 8
Hutton KAR, Sau I (2007) Section F: genitalia. In Wilcox DT et al (Eds) Pediatric Urology: Surgical Complications and Management. Blackwell Publishing, Oxford.
Royal College of Surgeons of England (2007) Surgery for Children: Delivering a First Class Service. tinyurl.com/rcs-surgery-children (Last accessed: September 10 2014.)
Knight J (2009) Crossing boundaries: developing the surgical practitioner role. Paediatric Nursing. 21, 9, 16-19.
Royal College of Surgeons of England (2010) General Paediatric Surgery: Survey of Service Provision in District General Hospitals in England. RCSE, London.
Kumar R et al (2013) The general surgical care practitioner improves surgical outpatient streamlining and the delivery of elective surgical care. Journal of Perioperative Practice. 23, 6, 139-141. Newey M et al (2006) Nurse-led management of carpal tunnel syndrome: an audit of outcomes and impact on waiting times. Annals of the Royal College of Surgeons of England. 88, 4, 399-401. Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London. Nursing and Midwifery Council (2011) The Prep Handbook. NMC, London. Quick J (2013) The role of the surgical care practitioner within the surgical team. British Journal of Nursing. 22, 13, 759-764.
Royal College of Surgeons of England (2013) Standards for Children’s Surgery. RCSE, London. Royal College of Surgeons of England (2014) The Curriculum Framework for the Surgical Care Practitioner. RCSE, London. Scott H (2004) RCN warns that the nursing profession is in danger. British Journal of Nursing. 13, 20, 1166. Sinclair A, Bridgewater B (2007) Section A: principles of surgical audit. In Wilcox DT et al (Eds) Pediatric Urology: Surgical Complications and Management. Blackwell, Oxford. Weiss HA et al (2010) Complications of circumcision in male neonates, infants and children: a systematic review. BMC Urology. 10, 2. doi:10.1186/1471-2490-10-2.
NURSING CHILDREN AND YOUNG PEOPLE
Nursing Children and Young People 2014.26:16-20. Downloaded from journals.rcni.com by FLINDERS UNIVERSITY on 12/05/15. For personal use only.
The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
EVALUATING A SPECIALIST NURSE’S ROLE IN A GENERAL PAEDIATRIC SURGICAL TEAM The outcome of an audit to assess an interprofessional general surgical team showed that the surgical care practitioners’ role improves continuity and enhances the care of children and their families, as Julie Quick explains Correspondence julie.quick@ walsallhealthcare.nhs.uk Julie Quick is a surgical care practitioner for Walsall Healthcare NHS Trust, Walsall Date of submission February 2 2014 Date of acceptance June 5 2014 Peer review This article has been subject to open peer review and checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ ncyp-author-guidelines
Abstract A surgical care practitioner (SCP) is a registered nurse or allied health professional who, following specific education and competency training, carries out pre- and post-operative treatment and some surgical interventions under the supervision of a consultant surgeon, contributing to the maintenance of surgical services and the enhancement of patient care. With a cohesive approach, the SCP can do much to ensure continuity of care and mutual understanding and concordance between staff, child and family. Costs can be reduced and the surgical training of junior doctors supported. The results of this audit show that, with the inclusion of an SCP, higher quality general children’s surgery can be provided at a medium-sized district general hospital, so that patients can be seen locally. Keywords Children’s nursing, general paediatric surgery, surgical care practitioner, surgical outcomes
(Department of Health (DH) 1999, 2000a, 2000b, 2004, 2007). A number of posts have been established, that have enabled nurses to cross former disciplinary boundaries. It is 25 years since the introduction of the first formally trained surgical care practitioner (SCP) to a cardiothoracic surgical team, and now evaluation of the work of paediatric SCPs is emerging. The SCP is a registered nurse or allied health professional who, following robust academic education and competency training, carries out pre- and post-operative care and some surgical interventions under the supervision of a consultant surgeon (Royal College of Surgeons of England (RCSE) 2014). SCPs now work alongside surgical teams in a number of specialties, including paediatrics (Knight 2009). This article aims to describe the development of the SCP role in paediatric surgery at one NHS trust in the UK by formal evaluation between 2011 and 2013, to identify its effect on the holistic care of children and their families.
The role
Surgical care practitioner Julie Quick (right) and colleagues carry out a surgical intervention at Walsall Healthcare NHS Trust, Walsall
IN THE UK, new health policies, a changing medical workforce and an ever-more demanding health service have led to the development of a number of innovative peri-operative roles to maintain surgical provision and enhance patient care at reduced cost. The potential of nurses, and more recently of allied health professionals (AHPs), has been maximised now for many years
16 October 2014 | Volume 26 | Number 8
Local context Walsall Healthcare NHS Trust is a medium-sized acute healthcare provider for the population of Walsall and the surrounding area. The NHS trust offers elective day-case and emergency inpatient paediatric surgery in a number of specialties included in general surgery. This is supported by paediatric anaesthetic and medical teams and has close ties with regional providers. NURSING CHILDREN AND YOUNG PEOPLE
Nursing Children and Young People 2014.26:16-20. Downloaded from journals.rcni.com by FLINDERS UNIVERSITY on 12/05/15. For personal use only.
Tim George
NURSING CHILDREN AND YOUNG PEOPLE
October 2014 | Volume 26 | Number 8 17
Nursing Children and Young People 2014.26:16-20. Downloaded from journals.rcni.com by FLINDERS UNIVERSITY on 12/05/15. For personal use only.
Art & science | audit acute care Since 2011, the current general paediatric surgical (GPS) consultant-led service has been carried out by one named consultant surgeon (vascular, general and paediatric surgery) and one SCP. In the UK, surgical trainees participate in general paediatric theatre sessions only on an impromptu basis (RCSE 2010). In the absence of junior hospital doctors, the addition of an SCP to the GPS team has made available a knowledgeable surgical assistant who is a competent operator and who can assist while they train (Quick 2013). The SCP in this study – the author – is a registered nurse with a peri-operative background that includes paediatrics, who has completed the national two-year educational training programme for SCPs. She is a non-medical prescriber, has attained an MSc in professional studies in healthcare, and has undertaken local training in safeguarding and in children’s intermediate life support. Benefits The addition of an SCP as a permanent member of the GPS team, to increase its potential, has been shown to confer benefits, including the maintenance of surgical services and enhancing patient care (Box 1) (Quick 2013). With a cohesive approach, the SCP can do much to ensure mutual understanding and concordance between staff, child and family, therefore improving their experience (Quick 2013). Costs can be reduced and the surgical training of junior doctors supported (Abraham 2011, Quick 2013). Box 1 Benefits of including a surgical care practitioner in a general paediatric surgical team ■ Provides a knowledgeable surgical assistant and competent operator. ■ Improves the child’s and family’s experience. ■ Supports surgical training. ■ Provides continuity of care. ■ Maintains service provision. (Quick 2013)
Box 2 Surgical outcome criteria for general surgery Outcomes used as measurements include unplanned readmissions, re-operation and/or reintervention at 28 days for children who underwent any of the following procedures: ■ Medical circumcision. ■ One-stage orchidopexy. ■ Hydrocele repair. ■ Umbilical hernia repair. ■ Inguinal herniotomy. (British Association of Paediatric Surgeons 2011)
18 October 2014 | Volume 26 | Number 8
Safety and efficacy Senior clinicians in the UK had previously raised concerns about the value and safety of nurses and AHPs extending their skills to include those previously associated with doctors (Scott 2004, Aning 2006, Freudmann 2006). Studies have, however, found that SCPs can be suitably qualified and trained to safely assist with and perform surgery in adults and children (Hickey and Cooper 2009, Hall 2011, Quick 2013). The national curriculum framework for SCPs, recently revised, incorporates general and specialist knowledge and skills acquisition in various surgical specialties including paediatric surgery (RCSE 2014). Completion of the curriculum promotes safety and high standards among practitioners in the role. This demonstrates that the SCP job description adheres to professional regulatory standards (Nursing and Midwifery Council (NMC) 2008) to ensure the best patient care and reduce the risk of harm. Findings have suggested that SCPs are also able to recognise situations outside their scope of practice when assessing children and adults (Newey et al 2006, Quick 2013).
Audit At the NHS trust, the GPS team assesses and treats neonates and children up to the age of 15 years for a variety of congenital and acquired general conditions; this includes ankyloglossia (tongue tie), phimosis (unusually tight foreskin), inguinal hernia and undescended testes. There are four children’s outpatient clinic sessions and two dedicated GPS operating sessions each month. The SCP works alongside the consultant surgeon at two clinic sessions, and undertakes consultations with new and follow-up referrals, and specified operative procedures – including freehand circumcision, tongue-tie release and foreskin stretch – as well as providing general surgical assistance during each theatre session. Measuring practice Audit allows healthcare professionals the opportunity to evaluate the care they provide (Sinclair and Bridgewater 2007). Analysis of readmission and complication rates can provide a measure of service quality offered by SCPs (Abraham 2011). The service provided by the interprofessional GPS team was therefore measured against criteria issued by the British Association of Paediatric Surgeons (BAPS) (2011) (Box 2). Data were collected retrospectively by the SCP from the NHS trust’s patient management systems for 24 months, starting June 2011, relating to children aged 0-15 years who underwent any of the specified procedures under the care of the GPS team. NURSING CHILDREN AND YOUNG PEOPLE
Nursing Children and Young People 2014.26:16-20. Downloaded from journals.rcni.com by FLINDERS UNIVERSITY on 12/05/15. For personal use only.
Information was then collated to identify children discharged by the GPS team who: ■ Underwent subsequent readmission or a repeated operation under the care of the same GPS team. ■ Were readmitted as an emergency under any on-call consultant general surgeon. ■ Attended the ward under the GPS consultant or other consultant surgeon or paediatrician. The medical records of these children were then examined by the author to determine diagnosis and reintervention. Pre-established exclusion criteria eliminated three children who had been readmitted for an unrelated diagnosis and one who was readmitted and treated for complications of general anaesthesia. Results Of 250 children who underwent elective day-case procedures performed by the GPS team over the two years, 147 were treated with a surgical procedure specified in the BAPS criteria. One child had bilateral orchidopexy and this was classed as two separate procedures in the data. The age range was 1-15 years, and 139 of the children were boys (93.8%). The operation was performed by the consultant surgeon for 121 (81.8%) of these children and the SCP operated for 27 (18.2%). As shown in Figure 1, the 148 procedures consisted of: ■ Circumcision (either Plastibell, a less invasive technique, or freehand). ■ One-stage orchidopexy. ■ Inguinal herniotomy. ■ Umbilical hernia repair. ■ Hydrocele repair. No child underwent a repeated operation within 28 days of the initial procedure. There were three ward attenders, all of whom had undergone circumcision; no reintervention or readmission was required, and they were reassessed and discharged by the consultant general paediatric surgeon. Two children had unplanned readmissions within 28 days; both had their initial operation performed by the consultant paediatric surgeon. Of these, one two-year-old child was readmitted under the care of the GPS team four days after a right orchidopexy with a wound infection. The other child, aged ten years, was readmitted with a urinary tract infection eight days after undergoing a circumcision. Both were discharged after receiving oral antibiotics. For the consultant general paediatric surgeon, these figures are comparable to outcomes published in the literature (Hutton and Sau 2007, Weiss et al 2010). The zero rate of complications experienced by children undergoing medical circumcision by the SCP is considerably less than that documented in the literature (14%). Unlike the provision of circumcisions NURSING CHILDREN AND YOUNG PEOPLE
Figure 1 Procedures undertaken (n=148) 3% (5) 7% (11) 10% (14)
14% (21) 66% (97)
Key: Circumcision Orchidopexy Inguinal herniotomy
Hydrocele repair Umbilical hernia repair
performed by unsupervised non-medical providers in community settings reported by Weiss et al (2010), this result is likely to be due to a number of factors, including the experience and competency of the nurse, the supervision by the consultant paediatric surgeon and the performance of the procedures in a sterile hospital environment.
Discussion The SCP post is well established at the NHS trust. Despite a number of studies identifying the benefits that the work of the SCP has on surgical outcomes, few studies have explored the role of the SCP in children’s services. The 2011 census revealed that Walsall, with a medium-sized district general hospital, has a greater proportion of 0-15 year olds in the population than nationally (Census Report 2011). RCSE (2013) stipulates that children who require surgery should be treated in a suitably equipped and safe environment close to their homes by suitably trained healthcare professionals. In this context, smaller district general hospitals can experience difficulties in providing timely, safe and high quality local services for children and their families (RCSE 2007), although outcomes comparable with those of regional paediatric centres have been reported (Hart Prieto and Jones 2011). The results of this audit suggest that surgical outcomes among children who undergo specified elective day-case procedures provided by the interprofessional surgical team are within or below national figures for readmission, repeated October 2014 | Volume 26 | Number 8 19
Nursing Children and Young People 2014.26:16-20. Downloaded from journals.rcni.com by FLINDERS UNIVERSITY on 12/05/15. For personal use only.
Art & science | audit operations or reintervention at 20 days post procedure for any of the procedures listed in Box 2. This supports the premise that a high quality GPS service can be provided by a medium-sized district general hospital, since acceptable outcomes for children undergoing elective day-case procedures have been demonstrated (RCSE 2010). The results also show that post-operative complications were within or below national limits for surgical outcomes performed by non-medical providers when the SCP performed operative procedures or assisted during day-case elective GPS. This is comparable with the findings of other surgical teams that include an SCP (Alex et al 2003, Newey et al 2006, Hickey and Cooper 2009) and establishes that the SCP role is safe and effective in GPS. In addition, since acceptable outcomes are demonstrated, these findings support the nurse and consultant surgeon in the demonstration of professional revalidation (BAPS 2011, NMC 2011). The addition of a specialist nurse to the surgical team has been found to be beneficial for ensuring continuity of care for adults, children and their families, while maintaining and improving services (Abraham 2011, Kumar et al 2013, Quick 2013). This is confirmed by the present evaluation and supports the premise that high quality GPS can be provided by a medium-sized district general hospital, so clients can be seen locally and in a timely fashion. More children live in Walsall than any other borough in the UK, and improvement enables a greater number of them
to receive treatment close to home, as specified by national paediatric surgical standards (RCSE 2013). Limitations This audit did not include children who may have been readmitted, had a repeated operation or underwent a reintervention under the care of an alternative healthcare provider. Nor does it evaluate post-operative complications assessed and treated in primary care. It was outside the scope of this audit to examine the long-term complications of any procedure. All these are areas for future evaluations.
Conclusion Children need to be cared for holistically, with the child’s needs considered alongside those of the parents and family. Unplanned readmission or ward attendance may have a significant effect on the family unit. The presence of an SCP as part of the GPS team has positive effects on children’s and families’ experiences, surgical outcomes and continuity of holistic care. The SCP enhances interprofessional interactions with clients and their carers, while contributing to the safe performance of surgical interventions and to the experience of junior doctors, by exposing them to a GPS in a non-regional centre. The unit’s readmission and post-operative complication rates are within or below national averages, with the SCP’s personal figures for these parameters lower. This benefits children, their families and the employing hospital.
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
References Abraham J (2011) Innovative perioperative role improves patient and organisational outcomes in minimal invasive surgery. Journal of Perioperative Practice. 21, 5, 158-164. Alex J et al (2003) Surgical nurse assistants in cardiac surgery: a UK trainee’s perspective. European Journal of Cardiothoracic Surgery. 25, 1, 111-115. Aning J (2006) Surgical care practitioners: The case against. British Medical Journal Careers. careers.bmj.com/careers (Last accessed: September 5 2014.) British Association of Paediatric Surgeons (2011) Using Outcomes Information for Revalidation in Paediatric Surgery. tinyurl. com/baps-revalidation-guide (Last accessed: September 10 2014.). Census Report (2011) Key Statistics for Walsall: Borough Summary. tinyurl. com/walsall-census-2011 (Last accessed: September 10 2014.) Department of Health (1999) Making a Difference: Strengthening the Contribution of Nurses, Midwives and Health Visitors to Health and Healthcare. The Stationery Office, London.
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