The Effectiveness of Nurse-Led Pre-Operative Assessment Clinics for Patients Receiving Elective Orthopaedic Surgery: A Systematic Review

Saturday, 26 July 2014: 3:30 PM

Sau Man Conny Chan, RN, BN, MN
The Nethersole School of Nursing, The Nethersole School of Nursing, The Chinese Univeristy of Hong Kong, Hong Kong, Hong Kong
Wan Yim Ip, RN, RM, BN, MPhil, PhD
The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong SAR, China
Janita Pak-Chun Chau, RN, BN, MPhil, PhD
Nethersole School of Nursing, Faculty of Medicine, Chinese Univerisity of Hong Kong, Hong Kong, Hong Kong

The effectiveness of nurse-led pre-operative assessment clinics for patients receiving elective orthopaedic surgery : a systematic review


Key words : nurse-led clinic, pre-operative assessment, orthopaedic nursing





Patients are usually admitted to hospital on the day before a scheduled surgery. However, patients are often found not fit for surgery due to changes in their medical or social conditions since the last medical consultation. This results in high cancellation rates on the day of surgery. Evidence suggesting that day of surgery cancellations waste hospital resources and cause anxiety in patients.

Nurse-led preoperative assessment clinic (POAC) has been introduced in many specialty areas to assess and prepare patients prior to surgery. As the population ages, there is an increase in the number of elective orthopedic surgeries. The POAC clinics can provide timely and effective care to older people requiring orthopaedic surgery and those patients who are at high risk of perioperative morbidity and mortality.

However, not all patients are referred to PAOC before surgery and the benefits of nurse-led POAC are not well documented.Thus, a systematic review has been carried out to affirm nurse-led POAC as a significant area of clinical practice.

Aim and objectives of the systematic review

Aim :

The aim of this systematic review was drawn on the effectiveness of nurse-led POAC to summarize and identify the best available research evidence in order to better inform of the current practice, promote better care, guide health-care decision making, and to identify the practice gap in the existing evidence and clinical practice.

Objectives :


  • To examine the effectiveness of nurse-led POAC on orthopaedic patient outcomes such as levels of satisfaction with the process of pre-operative assessment, incidence of post-operative complications, post-operative recovery, as well as levels of fear and anxiety before surgery.


  • To synthesize the evidence on the impact of nurse-led POAC for elective orthopaedic patients on health service outcomes, including cancellation or delay of surgery, length of hospital stay and waiting time for pre-operative assessment and surgery.



This systematic review included all studies of adult patients who were 18 years old or above required elective orthopaedic surgeries e.g. total knee replacement, total hip replacement, reduction of fracture or procedure of arthroscopy etc in hospitals or day surgery centers, and had attended a nurse-led POAC 2 to 4 weeks prior to the scheduled elective orthopaedic surgery. The nurse-led POAC could be solely run by nurses, or nurses worked collaboratively with physicians.

While, the adult elective orthopaedic surgical patients within the American Society of Anesthesiologist (ASA) Physical Status Classification of 1 or 2 are eligible for inclusion in the review. ASA classification 1 : patients are considered to be healthy and normal, and ASA classification 2 : patients are patients with mild systemic disease such as mild asthma, well-controlled hypertension, or well-controlled diabetes.

The review included randomized control trials, pseudo-randomized controlled trial, quasi-experimental studies, cohort studies, and case-control studies among adult elective orthopaedic patients who attended a nurse-led POAC. Electronic databases search encompassed all published and unpublished studies in English and Chinese from inception to 2012. Given that the clinical and methodological diversity among the studies, the review findings are presented in a narrative form.



Systematic review of the pertinent literatures summarized and discussed the benefit of nurse-led POAC for elective orthopedic patient. The existing systematic review on this specific field of knowledge informed that nurse-led POAC can offer a very positive contribution to the optimization of care delivery for patient before surgery experience.

Eleven studies were critically appraised in terms of the benefits of attending a nurse-led POAC. The results showed nurse-led POAC could effectively reduce the rate of cancellations of impending surgery. These studies suggested a reduction in the rate of post-operative mortality, blood transfusion requirement after surgery, and length of hospital stay. In addition, the level of satisfaction towards services provided was significantly high which affirmed the effectiveness of establishing POAC in current practice.


Implications and Conclusions

While POAC is being increasingly implemented worldwide, the development of clinical guidelines, pathways and protocols was advocated. Adherence to these protocols promotes efficiency by streamlining in clinical decision making and minimizing unnecessary consults and costly diagnostic testing.

Moreover, this review suggests that collaborative multidisciplinary team approach in POAC can increase patients’ understanding of the peri-operative processes and enhanced post-operative recovery. Likewise, POAC can inform service improvement and policy development in the scheduling of theatre list and thus enable better utilization of theatre and ward facilities.

In addition, the review further recognizes the educational role of nurses in POAC where they prepare patients psychologically for the forthcoming surgery through education and information giving, to allay fear and anxiety, as well as increase peri-operative knowledge for better compliance of post-operative outcomes.

In conclusion, the best available evidence asserted that nurses in the POAC could serve as effective coordinators, assessors and educators. The nurse-led practice optimized patients’ condition before surgery and hence minimized elective surgery cancellations.