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Eur J Cardiothorac Surg 2004;25:111-115
© 2004 Elsevier Science NL

Surgical nurse assistants in cardiac surgery: a UK trainee's perspective

Castle Hill Hospital, Cottingham, Hull, UK

Received 11 July 2003; received in revised form 22 August 2003; accepted 29 August 2003.

^* Corresponding author. The Cottage, Main Road, Covenham St. Bartholomew, Louth LN11 0PF, UK. Tel./fax: +44-1507-363541
e-mail: mrjosephalex{at}yahoo.co.uk

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Objective: To assess the impact of surgical nurse assistants on surgical training based on a comparative audit of case-mix and outcome of coronary revascularizations assisted by surgical nurse assistants vs. surgical trainees. Methods: Relevant recent articles on Calman reform of specialist training and European working time directive (EWTD) on junior doctor working hours were reviewed for the discussion. For the audit prospectively entered data of elective and expedite first time coronary artery bypass grafting cases from 2000 to 2003 were analysed. Group A (n=233, Consultant+Surgical nurse assistant), group B (n=1067, Consultant+Junior surgical trainee). Chi-square test, t-test and Fisher's test were used as appropriate for statistical analysis. Results: Comparative preoperative variables were gender (P=0.8), body mass index (P=0.9), smoking (P=0.3), diabetes mellitus (P=0.2), hypertension (P=1), peripheral vascular disease (P=0.5), previous cerebrovascular accident (CVA)/transient ischemic attack (TIA) (P=0.3), renal dysfunction (P=0.4), preoperative rhythm disturbances (P=0.3), previous Q-wave myocardial infarction (MI) (P=0.4), Canadian Cardiovascular Society angina class (P=0.4), New York Heart Association heart failure class (P=0.4) and left ventricular function (P=0.4). Patients in group B were of higher risk due to age (P=0.01), coronary disease severity (P=0.05), left main stem disease (P=0.001), Parsonnet score (P=0.0001) and Euroscore (P=0.005. Regarding the myocardial protection technique, intermittent cross-clamp fibrillation was used more frequently in group A while antegrade–retrograde cold blood cardioplegia and off-pump coronary artery bypass were used more in group B (P=0.0001). The cross-clamp (P=0.0001) and operation time (P=0.0001) were significantly lower in group A despite a comparable mean number of grafts (P=0.2). There was no significant difference in the immediate postoperative outcome ventilation time (P=0.2), intensive care unit stay, postoperative stay (P=0.2), re-exploration for bleeding (P=0.5), inotrope+intra-aortic balloon pump (P=0.2), postoperative MI (P=0.9), postoperative rhythm disturbances (P=0.9), CVA/TIA (P=0.8), renal dysfunction (P=0.6), wound infection (P=0.7), sternal re-wiring (P=0.2), multi-organ failure (P=0.4) or mortality (P=0.1). Conclusions: Surgical nurse assistants can be used effectively in low-risk cases without compromising postoperative results. However, initiatives to tackle the EWTD should be focused on areas that do not compromise the training needs of junior surgical trainees. An intermediate grade between the present senior house officer and registrar grades could be a way forward.

Key Words: Coronary revascularization • Surgical nurse assistant • Outcome • European working time directive • Training

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Over the past decade surgical nurse assistants have played an increasing role in many cardiothoracic centres across the United Kingdom. We undertook this audit to analyse the risk profile, case-mix and immediate postoperative outcome in coronary revascularizations assisted by surgical assistants and those assisted by cardiothoracic trainees. We also discuss the potential impact the use of surgical nurse assistants could have on the training needs of junior cardiothoracic trainees in the light of Calman reforms and the European working time directive (EWTD) on junior doctors’ working hours.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
All data were prospectively entered into the patient analysis and tracking system (PATS) database. Subsequent to data entry, it was independently checked, compared to patient notes and validated for completeness and accuracy. Thirteen hundred consecutive elective and expedite first-time coronary artery bypass grafting (CABG) cases from November 2000 to April 2003 were identified, and data were retrieved from the PATS database and analysed. Emergency, urgent, expedite and redo cases were not included. Group A (n=233, Consultant+Surgical nurse assistant) and Group B (n=1067, Consultant+Surgical trainee). Chi-square test and Fisher's test were used for categorical data while the Student's t-test was used for numerical data. Statistical significance was set at P<0.05. SPSS version 11.0 for Windows programme (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Relevant recent articles on myocardial protection techniques [1–14], Calman reform of specialist training and the EWTD on junior doctor working hours were collected from the Medline, Embase, Cinhal and Sigle databases, and reviewed for the discussion.

The anaesthetic technique including premedication, induction, maintenance and reversal of anaesthesia were essentially similar in both groups. Cardiopulmonary bypass was established between the right atrium and ascending aorta using a 34/48-F two-stage venous cannula (Medtronic VC2, 93448C, Minneapolis, MN, USA) and a 24-F straight-tip flexible-arch arterial cannula (Medtronic DLP, 71424), respectively connected to the perfusion tubing system (COBE Cardiovascular, 025006021, Sorin Biomedica UK Ltd., Gloucester, UK). The Stockert SIII roller pump bypass machine (Stockert Instrumente GmbH, Munich, Germany) using adult hollow fibre oxygenator with integral hardshell venous cardiotomy reservoir (D903 Avant PHISIO/M, 05334, Dideco, Mirandola, Italy) and a 38-µm arterial line filter (Medtronic Affinity352, 61399401153) was used in all cases. Moderate systemic hypothermia 32–33 °C was maintained during bypass in all cases.

The cardioplegia solution used consisted of 50 ml of St. Thomas formula (Manor Park Pharmaceutical, Bristol, UK) mixed with 450 ml of Ringer's solution and 500 ml of oxygenated blood from the pump maintained at 4 °C. Following cross-clamp application antegrade instillation was done through a 11-F aortic root cannula (Medtronic DLP, 24009) at a pressure of 100 mmHg, followed by retrograde instillation through a 15-F retrograde coronary sinus perfusion cannula with a manual-inflate cuff (Medtronic DLP, 94665) at a pressure of 20–40 mmHg. The first dose of 400 ml antegrade and 600 ml retrograde was followed by 200 ml retrograde every 15 min. All bottom ends were anastomosed with the aorta cross-clamped and the cardioplegic arrest of the myocardium followed by declamping and top-end anastomosis during partial aortic occlusion while the heart started beating again.

Ventricular fibrillation was induced using 10 mA alternate current through a fibrillator prior to cross-clamping of the aorta for bottom-end anastomosis. On completion of each bottom end the aorta was declamped, the heart perfused and defibrillated with 10–15 J direct current shock before the corresponding top end was anastomosed. This sequence was repeated with each graft. Systemic rewarming was commenced during the final distal anastomosis in both groups. In both groups weaning from the bypass machine was attempted when the nasopharyngeal temperature reached 36 °C.

Off-pump coronary artery bypass (OPCAB) was performed using either the Medtronic Octopus 3 tissue stabilizer (28400) or the CTS vortex vacuum assist stabilization system (OM-3000S, Cardio Thoracic Systems Inc., USA) with the aid of the Flo-Thru intraluminal shunt (FT-12150-1, Bio-Vascular Inc., USA) when indicated.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Both groups were comparable in terms of gender (P=0.8), body mass index (P=0.9), smoking (P=0.3), diabetes mellitus (P=0.2), hypertension (P=1), peripheral vascular disease (P=0.5), previous cerebrovascular accident (CVA)/transient ischemic attack (TIA) (P=0.3), renal dysfunction (P=0.4), preoperative rhythm disturbances (P=0.3), previous Q-wave myocardial infarction (MI) (P=0.4), Canadian Cardiovascular society (CCS) angina class (P=0.4), New York Heart Association (NYHA) heart failure class (P=0.4) or left ventricular function (P=0.4) (Table 1).

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Within the present system, the duration of cardiothoracic training in the United Kingdom takes between 13 and 16 years following graduation from medical school. During junior surgical training the first year is spent as a house officer (HO) followed by 3 years as a senior house officer (SHO) undertaking the basic surgical training (BST) rotation in a variety of surgical specialities. The BST period is followed by 1–3 years as a speciality SHO gaining specific skills and a further 2–3 years in research before starting higher specialist training.

Following the recommendations of the working group set up by Sir Kenneth Calman to reform higher specialist medical and surgical training in the UK was implemented in 1997 [15,16], the old registrar and senior registrar grades were combined into a single specialist registrar grade. This system emphasized the need for educational target setting, training agreement between trainees and trainers, structured and supervised teaching, rotation to offer specified experience, and regular feedback from supervising consultants. However the major drawback, significant to a surgical trainee, is that the reforms shortened the duration of higher specialist training from about 10 years in the old system to 6 years with the new system. With the deadline for the implementation of the European working time directive (EWTD) on junior doctor working hours set for August 2004, the maximum working hours of a surgical trainee will be reduced to 58 h per week and from 2009 this will be further reduced to 48 h. All hours spent in hospital whilst on call will be classed as work and continuous work will be limited to 13 h per day [17–20]. As the directive is a non-negotiable part of the Health and Safety legislation, many National Health Service (NHS) trusts have had to develop and create new roles and posts for nurse practitioners and surgical nurse assistants. This interaction and collaboration between physicians and other healthcare professionals has undoubtedly grown across the spectrum in all medical and surgical specialities. Given the patient profile and the intensity of multidisciplinary perioperative care in cardiac surgery, there is a definite need and scope for nurse practitioner-led initiatives into certain aspects of patient care and management.

The role of surgical nurse assistants in the operating room is but one example of this trend, the more emphatic ones being nurse-led clinics in various disciplines and nurse practitioner-led minor injuries units across the country. While this collaboration and co-operation between disciplines is aimed at reducing the workload of junior trainees without disrupting the working of the NHS, certain aspects of this trend do evoke the inevitable concerns. Across the Atlantic, rapid changes in divisions of labour and a reorientation of attitudes and roles caused controversies in the late 1990s [21,22]. Admirably and not surprisingly, some from the nursing cadres seem willing to step up and acquire operative and surgical assistant skills. In recognition of this Registered Nurse first assistant programs that acknowledge an increasing emphasis on acquiring operative skills rather than didactic skills have been floated [23]. Here in the UK, the Norfolk and Norwich healthcare NHS Trust was one of the first to recognize the need to fill the lacuna between the traditionally distinct roles of doctors and nurses by offering specialized competence-based courses in this area [24]. In our own study the involvement of surgical assistants in the absence of surgical trainees did not increase the complication rates. However, the fact that results were no worse in group A was an expectation. Fine motor skills, hand–eye coordination, a sound knowledge of the roles of various operating department personnel, as well as a familiarity with stages of standard operative procedures – basic tenets of a good first assistant – are by no means exclusive to trainees who have passed through medical school. A similar study at the Duke University Medical Center saw that complication rates of cardiac catheterization performed by physician-assistants were similar to those by cardiology fellows-in-training [25]. Most cardiac surgical nurse assistants are involved in the harvesting of conduits, median sternotomy and closure, thoracotomy and closure, and also function as first assistants – all procedures and experiences that a junior surgical trainee would immensely benefit from.

Analysing local audit results, the significantly higher cross-clamp time (P=0.0001) and operation time (P=0.0001) in group B can be explained by the fact that median sternotomy, exposure, cannulation, going onto bypass, a proportion of the bottom- and top-end anastomosis, weaning off bypass, and final closure were performed by trainees. In addition, a greater percentage of patients in the group had antegrade–retrograde cardioplegia which further increased the operation time. Although the overall outcome, morbidity and mortality were comparable between the groups, perhaps more importantly, it is clear from the audit that the risk profile of patients in group A was significantly lower than that of group B. Patients in group A were of a lower age group (P=0.01), had less severe disease severity (P=0.05) and left main stem disease (P=0.001), and lower Parsonnet (P=0.0001) and Euroscores (P=0.005). Junior trainees, unable to leave the wards due to the sheer volume of work thrust upon them, would undoubtedly have benefited from acquiring basic operative skills and perhaps have even played a more active role in these ideal ‘teaching’ cases than was perhaps expected or experienced by the surgical nurse assistants.

With the present system of a single consultant grade in the UK, despite a reduction in the duration of training, there is still no ‘transition’ grade of a ‘junior’ consultant during which one could continue to advance complex surgical skills and experience after attaining the certificate of completion of surgical training (CCST). With this continuing reduction in training time, there is no doubt that surgical training has to be focused on early achievement of basic surgical skills followed by an aggressive but stepwise and streamlined acquisition of advanced skills. Junior surgical trainees need the assistance from nurses and paramedical staff in reducing their workload, but a greater involvement of specialist nursing staff in pre-assessment and follow-up clinics, phlebotomy, liaising with radiology and laboratory services, and discharge planning, may be more judicious measures which would not compromise the surgical training requirement of the juniors. Another alternative would be for the 1–3 years spent as a speciality SHO to be scheduled in such a way that the first year is spent gaining experience on the wards, intensive therapy unit and clinics followed by a period spent solely in theatre performing the role of a surgical assistant and gaining basic surgical experience.

We wish to emphasize and recognize the fact that in our own unit surgical assistants have been extremely helpful and have taught many junior trainees the technique of conduit harvest. Our concerns are not about individuals, but the methods used to comply with the EWTD. Although this audit and discussion do not offer watertight solutions to the questions raised, it must be recognized that a further revamping and reshuffling of roles is inevitable. There needs to be a realization on the part of the government, NHS trusts, general medical council (GMC) and the British medical association (BMA) that the intensity and level of training requirement in surgical specialities such as cardiothoracic surgery, where training is based on a form of apprenticeship, is much greater than many other specialities. The saying, ‘You can train a monkey to operate’ may be true, but let us make an effort to train the ‘monkey’ first. Achievement of EWTD should not be at the cost of the very training needed to improve patient care, the goal of every individual in this health care system.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alex R.J. Cale Steven C. Griffin Michael E. Cowen Levent Guvendik Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Alex, J. Articles by Guvendik, L. Search for Related Content PubMed PubMed Citation Articles by Alex, J. Articles by Guvendik, L. Related Collections Cardiac - other Education Professional affairs