A multidisciplinary approach to total joint replacement.

A multidisciplinary team was formed to look at consolidating and improving patient education for patients preparing to undergo total knee replacement or total hip replacement. The objective was to encompass disciplines from across the continuum of care, beginning with the surgeon's office through postdischarge rehabilitation. Project goals for the team were to develop the "ideal" pre and postoperative orders for total joint patients, review and revise current clinical and patient pathways for the total knee replacement patient and the total hip replacement patient, add rehabilitation services to clinical pathways, and develop a patient education class and patient education booklet. This article describes how working together with all disciplines involved resulted in a consolidated order set, clinical and patient pathways that reflected actual care and processes, a user-friendly patient education book, and a multidisciplinary patient education class. The end products led to consistency in the quality of care across the continuum from preadmission through postdischarge rehabilitation for total joint replacement patients.

Nurses are everywhere: a practical perspective on the surgical team in managing postoperative ileus.

Because the availability of new, peripherally acting mu-opioid-receptor antagonists is expected soon, it is important for all members of the surgical team to familiarize themselves with new approaches and also re-evaluate older approaches to help improve patient outcomes. "Preop nurses" have numerous responsibilities, among which are mitigating some of the adverse outcomes of surgery such as postoperative ileus (POI), making these nursing personnel indispensable to the proper implementation of multimodal management protocols for POI. Establishing basic preoperative procedures is an important primary consideration. Preoperative evaluation of general health, medical history (including surgical history), and an assessment of gastrointestinal (GI) function and habits should all be part of careful up-front assessment for each patient, especially because POI and other GI adverse effects are so often encountered in the PACU. Hand-in-hand with how we as nurses interact with our surgical colleagues is patient education regarding hospitalization and postrecovery expectations. PACU nurses will be key players in maintaining proper implementation of multimodal regimens, essentially doing this in two "phases": Phase I interventions comprise the ongoing assessment and monitoring of patients, administering medications, and evaluating patient satisfaction and overall status; Phase II considerations encompass a further set of practice guidelines that center on optimizing discharge status, including pain management and education as well as other discharge needs. Where new agents may fit into multimodal regimens that optimally incorporate preoperative and postanesthesia protocols remains to be determined. What is clear is that as nurses and the entire surgical team strive to enhance patient satisfaction, nursing personnel must assume leadership roles in how new multimodal strategies are implemented and executed. Advanced clinical data for the new peripherally acting mu-opioid-receptor antagonist alvimopan, and for the drug class as a whole, have contributed to a greater impetus on reassessing perioperative protocols and policy, helping to broach innovative clinical frontiers of how we treat pain and POI, and thus improve patient outcomes.

Preparing the older adult for surgery and anesthesia.

Life expectancy in the United States has increased significantly over the past 100 years. It has been suggested that by the year 2050, approximately 20% of the population may be over the age of 65. Many of these older adults will undergo surgery and anesthesia. Preadmission testing nurses need to be able to deal with the various challenges that accompany this group of patients. While many of the elderly are quite active, there are others with multiple disease processes that put them at an increased risk over the general population. It will be to the advantage of all involved if health care providers can develop a better understanding and an increased expertise in caring for the geriatric surgical patient. This article describes the importance of the preanesthetic nursing assessment and evaluation in helping to identify potential problems so that a plan of care to prevent those problems can be formulated and communicated to other members of the health care team.

Restraints use and falls prevention.

The Health Care Financing Administration defines physical restraints as "any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Restraints have the potential to produce serious outcomes, including physical or psychological harm, loss of dignity, violation of a patient's rights, and possibly death. Health care providers need to identify opportunities to decrease the risks associated with the use of restraints through preventive strategies, innovative alternatives, and process improvements to help focus on the patient's overall well-being, health, and safety.

Accreditation: a "voluntary" regulatory requirement.

Hospitals and ambulatory surgery centers may choose to voluntarily apply for accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Accreditation Association for Ambulatory Health Care (AAAHC), or the American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF) as appropriate. The facilities must comply with written standards regarding the environment of care, the provision of care, and the quality of care. Regular surveys of the organization's performance by the accrediting agency are intended to ensure the quality of care provided to the patients entrusted to our care. The accreditation process certifies to the health care community and the community-at-large that the facilities meet nationally accepted standards through a recognized accreditation program. Perianesthesia nurses should have an understanding of the regulatory agencies that influence daily patient care. This article provides an overview of the 3 accrediting bodies: JCAHO, AAAHC, and AAAASF. These agencies are committed to improving safety by providing standards of care, survey evaluations, and professional consultative and educational services, and they have an important role in our health care environments.