Nicholson Amanda, Coldwell Chris H, Lewis Sharon R, Smith Andrew F
Faculty of Health and Medicine, Furness Building, Lancaster University, Lancaster, UK, LA1 4YG.
Cochrane Database Syst Rev. 2013 Nov 12;2013(11):CD010160. doi: 10.1002/14651858.CD010160.pub2.
The organization of elective surgical services has changed in recent years, with increasing use of day surgery, reduced hospital stay and preoperative assessment (POA) performed in an outpatient clinic rather than by a doctor in a hospital ward after admission. Nurse specialists often lead these clinic-based POA services and have responsibility for assessing a patient's fitness for anaesthesia and surgery and organizing any necessary investigations or referrals. These changes offer many potential benefits for patients, but it is important to demonstrate that standards of patient care are maintained as nurses take on these responsibilities.
We wished to examine whether a nurse-led service rather than a doctor-led service affects the quality and outcome of preoperative assessment (POA) for elective surgical participants of all ages requiring regional or general anaesthesia. We considered the evidence that POA led by nurses is equivalent to that led by doctors for the following outcomes: cancellation of the operation for clinical reasons; cancellation of the operation by the participant; participant satisfaction with the POA; gain in participant knowledge or information; perioperative complications within 28 days of surgery, including mortality; and costs of POA. We planned to investigate whether there are differences in quality and outcome depending on the age of the participant, the training of staff or the type of surgery or anaesthesia provided.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and two trial registers on 13 February 2013, and performed reference checking and citation searching to identify additional studies.
We included randomized controlled trials (RCTs) of participants (adults or children) scheduled for elective surgery requiring general, spinal or epidural anaesthesia that compared POA, including assessment of physical status and anaesthetic risk, undertaken or led by nursing staff with that undertaken or led by doctors. This assessment could have taken place in any setting, such as on a ward or in a clinic. We included studies in which the comparison assessment had taken place in a different setting. Because of the variation in service provision, we included two separate comparison groups: specialist doctors, such as anaesthetists; and non-specialist doctors, such as interns.
We used standard methodological approaches as expected by The Cochrane Collaboration, including independent review of titles, data extraction and risk of bias assessment by two review authors.
We identified two eligible studies, both comparing nurse-led POA with POA led by non-specialist doctors, with a total of 2469 participants. One study was randomized and the other quasi-randomized. Blinding of staff and participants to allocation was not possible. In both studies, all participants were additionally assessed by a specialist doctor (anaesthetist in training), who acted as the reference standard. In neither study did participants proceed from assessment by nurse or junior doctor to surgery. Neither study reported on cancellations of surgery, gain in participant information or knowledge or perioperative complications. Reported outcomes focused on the accuracy of the assessment. One study undertook qualitative assessment of participant satisfaction with the two forms of POA in a small number of non-randomly selected participants (42 participant interviews), and both groups of participants expressed high levels of satisfaction with the care received. This study also examined economic modelling of costs of the POA as performed by the nurse and by the non-specialist doctor based on the completeness of the assessment as noted in the study and found no difference in cost.
AUTHORS' CONCLUSIONS: Currently, no evidence is available from RCTs to allow assessment of whether nurse-led POA leads to an increase or a decrease in cancellations or perioperative complications or in knowledge or satisfaction among surgical participants. One study, which was set in the UK, reported equivalent costs from economic models. Nurse-led POA is now widespread, and it is not clear whether future RCTs of this POA strategy are feasible. A diagnostic test accuracy review may provide useful information.
近年来，择期手术服务的组织方式发生了变化，日间手术的使用增加，住院时间缩短，术前评估（POA）在门诊进行，而非入院后由医院病房的医生进行。护士专家通常主导这些基于门诊的POA服务，并负责评估患者的麻醉和手术适宜性，以及安排任何必要的检查或转诊。这些变化为患者带来了许多潜在益处，但随着护士承担这些责任，证明患者护理标准得以维持很重要。
我们希望研究由护士主导的服务而非医生主导的服务是否会影响所有年龄段需要区域或全身麻醉的择期手术参与者的术前评估（POA）质量和结果。我们考虑了以下结果方面的证据，即护士主导的POA与医生主导的POA相当：因临床原因取消手术；参与者取消手术；参与者对POA的满意度；参与者知识或信息的增加；术后28天内的围手术期并发症，包括死亡率；以及POA的成本。我们计划调查根据参与者年龄、工作人员培训、手术类型或提供的麻醉类型，质量和结果是否存在差异。
我们于2013年2月13日检索了Cochrane对照试验中心注册库（CENTRAL）、MEDLINE、EMBASE和两个试验注册库，并进行了参考文献核对和引文检索以识别其他研究。
我们纳入了计划进行需要全身、脊髓或硬膜外麻醉的择期手术的参与者（成人或儿童）的随机对照试验（RCT），这些试验比较了由护理人员进行或主导的POA（包括身体状况和麻醉风险评估）与由医生进行或主导的POA。这种评估可以在任何环境中进行，如病房或门诊。我们纳入了比较评估在不同环境中进行的研究。由于服务提供的差异，我们纳入了两个单独的比较组：专科医生，如麻醉师；和非专科医生，如实习生。
我们采用了Cochrane协作网期望的标准方法学方法，包括由两位综述作者独立评审标题、提取数据和评估偏倚风险。
我们确定了两项符合条件的研究，均比较了护士主导的POA与非专科医生主导的POA，共有2469名参与者。一项研究是随机的，另一项是半随机的。工作人员和参与者对分配情况无法进行盲法。在两项研究中，所有参与者均由一位专科医生（实习麻醉师）进行额外评估，该专科医生作为参考标准。两项研究中，参与者均未从护士或初级医生的评估进入手术阶段。两项研究均未报告手术取消情况、参与者信息或知识的增加或围手术期并发症。报告的结果侧重于评估的准确性。一项研究对少数非随机选择的参与者（42次参与者访谈）对两种形式的POA的满意度进行了定性评估，两组参与者对所接受的护理均表示高度满意。该研究还根据研究中记录的评估完整性，对护士和非专科医生进行的POA成本进行了经济建模，发现成本无差异。
目前，随机对照试验中没有证据可用于评估护士主导的POA是否会导致手术取消或围手术期并发症增加或减少，以及手术参与者的知识或满意度增加或减少。一项在英国进行的研究报告了经济模型中的等效成本。护士主导的POA目前很普遍，尚不清楚未来对这种POA策略进行随机对照试验是否可行。诊断试验准确性综述可能会提供有用信息。
