Introduction

Cardiothoracic surgery is an evolving and challenging area of practice for healthcare professionals. This specialty serves a vast patient population from infancy to senior adulthood, encompassing a wide-range of complex cardiac, thoracic, congenital and transplantation surgical procedures.

The cardiothoracic advanced nurse practitioner (ANP) service has been developing and progressing since its early emergence in the late 1990s. As the cardiothoracic specialty progresses, it is imperative that advanced practice roles within it continually evolve to meet the new challenges that the cardiothoracic service of the future will present.

In recent years, advanced nurse practitioner and specialist roles have been introduced and developed throughout the cardiothoracic specialty (Kindness 2013). These roles have pioneered new ways of caring for patients throughout their journey. Clinically, there have also been major developments in surgical techniques, such as minimally invasive surgery. When combined with improvements to preoperative and postoperative management, all these developments have enabled many patients (who would have previously been precluded due to age or increased risk) to undergo life-changing surgery (McCrory, LaGrange & Hallbeck 2014).

Today, cardiothoracic surgery encompasses several different types of surgery, including cardiac, thoracic and congenital procedures. To facilitate any form of cardiothoracic surgical procedure, a large multidisciplinary team is required to provide safe, effective and high-quality care at every stage of the patient’s journey. While every team member has their own individual role to play, the cardiothoracic ANP provides a constant presence throughout the patient journey from initial preoperative assessment to point of discharge. The cardiothoracic ANP has expert knowledge, advanced clinical skills and competencies that can be employed throughout the patient journey to ensure effective monitoring, treatment and early intervention in any postoperative complications (Kindness 2013).

Overview of advanced practice

The paramount goal of all healthcare professionals is to deliver safe, effective and cost-effective healthcare to the population they serve. However, the provision and delivery of this service faces many challenges from a variety of internal and external pressures. These include a growing ageing population (with a corresponding increase in comorbidities); an increasing number of patients requiring chronic disease management; and the pressure to provide access to new and innovative treatments with limited financial resources (Baileff 2015).

Despite all these pressures, vast strides have been made in the treatment of many healthcare conditions, and innovative treatment technologies have been created, leading to improved outcomes for patients (Omachonu & Einspruch 2010). However, these developments have not taken place in isolation. In order to meet these challenges, all healthcare professionals have had to review and adapt their practice to be able to deliver a good-quality service to the patients within their care. This can be seen especially clearly in the field of nursing which has seen the scope of nurses’ practice change exponentially, over many decades, with the subsequent evolution of a variety of advanced practice roles to address shortfalls in medical healthcare provision (Schober 2013).

Early development of advanced nursing practice

In the early 1960s, due to a recognised lack of medical staff, physicians in the USA began mentoring expert nurses, which ultimately led to the evolution of the role of the nurse practitioner (Lowe et al. 2011). This was further expanded within the USA and was adopted in the UK and other countries in the 1980s. Drivers for this expansion included the recognition that it was necessary to develop a sustainable workforce that could provide high-quality, cost-effective care in the face of global financial healthcare constraints. In addition, there was a palpable reduction in the availability of medical staff worldwide; and in Europe the introduction of the European Working Time Directives led to a reduction in junior doctors’ working hours. All these factors accelerated the requirement for advanced nurse practitioners within the United Kingdom (Royal College of Nursing Competencies 2012).

Subsequently, these common drivers have forced other countries around the world to assess their ability to meet the needs of the populations they serve, leading to the introduction of ANPs in a variety of settings globally. In recent years, there has been an unprecedented rise in the number and types of advanced practice roles especially within nursing (Department of Health and Social Care 2010). While this has enabled patients to access expert clinical care, it is also recognised that there has been some unrest and confusion among healthcare professionals in relation to these roles (NHS Education for Scotland 2012).

There have been, and continue to be, many challenges to the development of advanced practice nursing roles. Opposition and lack of understanding of the role was initially evident in the reactions of medical colleagues who were ill at ease with what they saw as the ‘blurring’ of professional boundaries (Barton, Bevan & Mooney 2012); and, despite the ongoing development of advanced nursing practice, small pockets of resistance remain.

A number of ward-based healthcare professionals also believed that the introduction of advanced practitioners to clinical areas could lead to the deskilling of nurses and thus reduce the quality of care provided (Marshall & Luffingham 2013). These ongoing issues – including confusion over professional titles, a lack of consensus on educational standards and regulation, and a lack of clarity in relation to scope and standards of practice – continue to be problematic (King, Tod & Saunders 2017; Parker & Hill 2017).

Despite these difficulties, efforts have been (and continue to be) made, to address these issues through ongoing research, discussions and agreements, both nationally and globally to enable the delivery of advanced nursing practice expert clinical competencies and skills. The momentum to drive forward the advanced nursing practice agenda has been demonstrated by the number of new advanced practice roles evolving to provide high-quality care in almost every healthcare setting worldwide (Kleinpell et al. 2014).

An international survey, conducted from 2001 to 2008, estimated that approximately 30– 60 countries around the world were at that time exploring the development of advanced practice nursing roles (Pulcini et al. 2010). In 2014, this was validated, and increased numbers confirmed, by the International Council for Nurses (ICN), who had noted that a vast number of countries had indicated interest in the ICN nurse practitioner/advanced nurse practitioner network (Schober 2013). More recently, within the UK, the Royal College of Nursing (RCN) has moved to establish an accreditation process for ANPs, in the absence of structured recognition and registration by the Nursing and Midwifery Council (RCN 2017). It is therefore clear that the requirement for expert ANPs continues to grow, internationally, within every specialty, in both primary and secondary care.

Definitions

The international healthcare community has made several attempts to provide clarity and consistency on the advanced practice role by developing a number of definitions. As early as 2001, the International Council of Nurses (ICN 2001, p. 1) defined advanced nursing practice as:

Following this, in 2006 the Nursing and Midwifery Council in the UK created their own, shorter definition (NMC 2006, p. 1) stating that: ‘Advanced nurse practitioners are highly experienced and educated members of the care team who are able to diagnose and treat your healthcare needs or refer you to an appropriate specialist if needed.’

The drive to define advance practice concisely continues. The Nursing and Midwifery Board of Australia is in the process of reviewing their definition of advanced practice nursing (Nursing and Midwifery Board of Australia 2013, p. 1). However, it currently states that: ‘Advanced practice nursing is the term used to define a level of nursing practice that uses comprehensive skills, experience and knowledge in nursing care.’

Meanwhile, in the USA, the American Nurses Association (American Nurses Association 2016, p. 1) currently states that:

As can be seen from the variety of statements and definitions from around the world, there are many similarities in thinking but as yet no single, clear definition that links the international advanced practice network.

Regulation and education

Traditionally, the main component of an advanced practice role was merely the possession of high levels of clinical skill and specialist competencies (RCN Competencies 2012). However, this is considered to be a serious misconception, as it does not fully address the variety of skills encompassed by an ANP role and it certainly does not address the skills and competencies held by advanced practitioners who practise within the non-clinical areas (NHS Education for Scotland 2012).

As part of this effort, the International Council of Nurses has attempted to establish and outline the standards and competencies for advanced practice nursing roles (Sastre-Fullana et al. 2014). With this encouragement, many countries have established their own educational frameworks for advanced practice.

There is continued international debate over the regulation of ANPs and many countries are striving to provide clarity on the advanced nurse practitioner role, scope of practice and educational requirements. Nevertheless, regulation of ANPs remains sparse, as demonstrated by the international snapshot given in Table 14.1 (below).

Within the United Kingdom, an excellent reference resource, known as the Advanced Nursing Practice Toolkit, was developed initially in 2008 and launched by NHS Education for Scotland. This resource was designed to act as a continually evolving information repository. Athough initially developed in Scotland, it was contributed to by all areas of the UK. This document provides up-to-date information on ANP developments and recommendations and continues to be used as a main reference for advanced practice today (NHS Education for Scotland 2012). The underlying principles contained within the Advanced Nursing Practice Toolkit were accepted by NHS Wales in 2009 and these principles formed the basis of their own equivalent document, Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales (NHS Wales 2010).

The four pillars of advanced practice

The four pillars of advanced practice are now recognised by many international forums. They are underpinned by the implementation of autonomous practice, expert clinical judgement, critical decision-making, and the provision of quality patient care and the ongoing development of clinical practice (NHS Education for Scotland 2012).

However, the implementation of such expert skills and competencies demands a high level of responsibility and accountability. It is therefore crucial that ANPs are aware of the expectations of their individual regulatory or governing nursing bodies and recognise their own responsibility and accountability for their actions, to ensure that they always act within the limitations of their own competence and practice.

The cardiothoracic advanced nurse practitioner

Demonstrable expert clinical practice within the multidisciplinary team is vital in order to achieve a successful outcome for any patient undergoing a cardiothoracic procedure. There are now many models of advanced nursing practice, with ANPs working in a variety of settings within primary and secondary care all over the world. Within the cardiothoracic team, each member of the vast multidisciplinary team plays a vital part in the delivery of cardiothoracic care. This chapter explores the role of cardiothoracic ANPs working in a variety of clinical settings to provide excellent ongoing clinical care for patients requiring cardiac or thoracic surgical interventions.

Professional development

Local and national formal clinical and advanced practice education has now been established both locally and nationally. There are also well-established, advanced practice Master’s level degree courses available nationwide in the UK, with a ratified curriculum to provide consistency of education for the ANP role (Morgan, Barry & Barnes 2012). Within the cardiothoracic specialty, there has also been the development of international advanced practice courses specific to this surgical area, such as the Cardiac Surgery Advanced Life Support course (Mujahid 2011). In addition, the Society for Cardiothoracic Surgery has a well-established portfolio of education for nurses and allied health professionals (AHPs) which extends to our European colleagues and encompasses the advanced practice role.

Communication

The ANP acts as a ‘bridge’ between multidisciplinary team members, to establish ongoing communication between the disciplines to ensure the delivery of holistic quality care (Williamson et al. 2012). In addition, the presence of an ANP within a specific clinical area, such as cardiothoracic surgery, provides the benefit of continuity of clinical care, due to their greater knowledge of the clinical status of all individual patients under their care.

In many centres around the world, formal interdisciplinary education is frequently undertaken by ANPs. This may include formal presentations at national conferences, undertaking audits to promote and underpin practice and attending local and national meetings. However, it is often the daily informal teaching that provides the most impact at the service provision level.

The cardiothoracic ANP also acts as a key information resource not only for medical and nursing staff but also for all disciplines that contribute to the patient’s journey (Baileff 2015). The cardiothoracic ANP’s ongoing presence within all the clinical areas provides consistency and the opportunity to carry out a daily review of the individual patients within their care; thus, the ANP is well positioned to ensure excellent communication of the patient’s daily management plan to other healthcare professionals. This interdisciplinary communication is vital to the patient’s ongoing recovery because it ensures that specific interventions (such as additional investigations, referrals and discharge planning) can be anticipated. Even more importantly, it ensures that any deterioration in the patient’s condition is identified and assessed and interventions are commenced expeditiously (Williamson et al. 2012).

Leadership

Effective leadership is considered essential within any area of clinical practice but the leadership responsibilities within advanced nursing practice roles encompass a number of key areas. One of these key areas is the demonstration of excellent clinical leadership to ensure the provision of high-quality patient care (Department of Health and Social Care 2010). To achieve this, the cardiothoracic ANP must act as an advocate, both for patients within their care and also for other members of the multidisciplinary team. This will, in turn, encourage and develop high standards of excellence in healthcare delivery (Campagna 2013).

The demonstration of professional leadership by the ANP is also essential; the ANP needs to act as a role model and mentor to colleagues within the cardiothoracic area to ensure effective collaboration within the multidisciplinary team (Frankel 2011). In addition, an ANP plays a leading role within the larger healthcare organisation, engaging in new initiatives, projects and policy changes that may influence the wider clinical agenda. As part of this endeavour, the ANP’s participation in research and audit helps in the ongoing development of effective healthcare provision. Within the cardiothoracic specialty, all members of the multidisciplinary team are encouraged to follow the best clinical and evidence-based practice, which can only be derived from ongoing involvement in new and innovative research and audit.

When patients first present with suspected cardiac or thoracic issues, various investigations are often carried out by cardiologists or respiratory physicians, which may ultimately lead to a decision to carry out cardiothoracic surgery. These investigations provide vital information that guide the surgeon’s decision as to which surgical procedure would be most effective in treating individual patients under their care (Bhakhri, Teoh & Yap 2016). Some of these specific investigations are listed below:

• Exercise tolerance test

• CT coronary angiogram

• Invasive coronary angiography

• Cardiac magnetic resonance imaging

• Stress echocardiography

• Trans-oesophageal echo (TOE)

• Transthoracic echo (TTE)

• Chest X-ray

• PFT

• Chest computed tomography scan and biopsy

• Diagnostic bronchoscopy and biopsy

• Positron emission tomography scan

• Sputum analysis.

The specific tests listed above are the most common diagnostic investigations used to diagnose cardiac and thoracic conditions, and the results of these tests may lead to cardiothoracic surgery. Other, more specialised investigations may also be performed, based on assessment of the individual patient’s condition and needs. Cardiac surgery patients may have pre-existing respiratory issues; and conversely thoracic surgery patients may have pre-existing cardiac issues. It is therefore appropriate that both cardiac and thoracic diagnostic assessment be performed in any cardiothoracic surgical patient to ensure that healthcare practitioners have as much information as possible about the patient’s current clinical condition.

The cardiothoracic patient’s journey

Preoperative assessment clinic

When a patient has been accepted by a clinician for any form of cardiothoracic surgery, it is accepted that the proposed surgery is necessary to improve the patient’s quality of life or to cure an underlying condition. It is also understandable that the patient facing the prospect of such surgery will experience a certain degree of anxiety associated with the commencement of this journey. To manage these concerns, the patient should be given access to as much information and support as possible. It is also essential to ensure that the patient is in the best possible state of health before their surgery by identifying and managing any potential risks from existing or unknown morbidities (Bojar 2011). The best way to achieve this is to ensure that the patient is fully reviewed at a preoperative assessment clinic prior to their surgery date to assess not only their fitness for surgery but also for anaesthesia.

Taking a comprehensive history gives the ANP to an in-depth understanding of the patient’s past and ongoing medical history, which could affect their recovery from surgery. Good history taking relies on well-developed communication skills (Tidy 2015). When implemented, these skills enable the ANP to extract the essential information from the patient. This information includes details of the patient’s presenting complaint and symptoms, their past medical history (including any known comorbidities) and their current medication regimen (including identification of any potential allergies). This dedicated time with the patient also provides an opportunity to discuss any psychological or social concerns that the patient may have in relation to their admission to hospital (Muhrer 2014). The information gained during history taking, combined with the associated physical examination, also guides the ANP in their decision-making process regarding any specific investigations that may be required.

Physical examination

Any clinical assessment should ideally include a complete physical examination (Muhrer 2014). However, given the time restraints in a preoperative assessment clinic, it is often necessary to take a more focused approach to the physical examination, based on the history the patient has provided and the procedure they are to undergo. Regardless of the approach used, physical examination requires a combination of the skills of observation, palpation, percussion and auscultation (Zator-Estes 2013) to provide further anatomical information that will contribute to the patient’s assessment of fitness to proceed to surgery.

A head-to-toe review of the patient is essential in order to obtain additional information regarding their current health status. This process may expose any previously undiscovered physical anomalies, which can then be discussed and further reviewed with the patient in the first instance. Following this review, the surgeon may also choose to discuss the individual patient’s case at a multidisciplinary team (MDT) forum where the new findings can be discussed and the various options (conventional surgery, non-surgical intervention or no intervention) can be discussed and the risks and benefits of each can be assessed. The findings of this MDT forum can then be discussed with the patient so that they can make an informed decision on all treatment options. In addition, the physical examination can highlight any concerns regarding the patient’s airway or fitness for anaesthesia. Any issues can be identified and ideally the patient can be reviewed by an anaesthetist during their preoperative assessment (AAGBI 2010).

Before attending the preoperative assessment clinic, the ANP will ensure that the standard cardiac or thoracic diagnostic/assessment reports (carried out prior to the patient’s referral for surgery) are available, have been reviewed and have not been deemed clinically out of date. For instance, if any investigation has been done some time in the past it may be necessary to repeat it, as the patient’s clinical condition may have changed in the intervening period, from the point of initial referral and the preoperative clinic assessment.

• Repeat CXR – within 6 weeks of surgical procedure

• Repeat ECG – within 6 weeks of surgical procedure

• Repeat ECHO – within 6 months of surgical procedure or if change noted in condition

• Repeat CT/Pet if more than 2 months.

• Repeat angiography – 3 months to 1 year from initial angiogram, depending on surgeon’s preference.

It is accepted that the above information represents the practice of a number of cardiothoracic centres and the timings of preoperative testing may vary. Clearly, it is best to have as short a time lapse as possible between the investigatory process and the surgical intervention, as this reduces the likelihood of further deterioration in the patient’s condition, which could affect the subsequent overall outcome. It is therefore essential that individual cardiothoracic centres follow their local protocols when deciding to repeat any investigations. This decision will also be informed by a review of the patient’s existing investigation results, the patient’s clinical presentation, any deterioration in their condition and the outcome of the preoperative clinical assessment.

Cardiothoracic standardised preoperative investigations

While attending the cardiothoracic pre-assessment clinic, the patient may undergo several standardised investigations. The ANP is not always directly involved in undertaking the following investigations but they are often responsible for ensuring that the reports on the investigations have been collated, reviewed and acted upon if indicated. In addition, the ANP ensures that any additional specific investigations are arranged, based on their clinical assessment of the patient. Specific investigations that may be required include pulmonary function testing for cardiac patients who have underlying pulmonary conditions, and trans-thoracic echocardiograms for thoracic patients with underlying cardiac issues. These basic investigations will be summarised and discussed below.

Basic blood tests

Full blood count

Biochemistry

Prior to any major surgery, it is important that the patient undergoes preoperative biochemistry evaluation. This includes review of the urea, creatinine and electrolytes which will highlight any concerns in relation to the patient’s preoperative renal status and again give a baseline against which postoperative levels can be gauged (NICE 2016). In many centres hepatic enzymes are also reviewed routinely preoperatively in all patients but especially if the patients have a history of hepatic conditions or excess alcohol consumption (Pasternak 2011). This test can also facilitate the measurement of C-reactive protein level, which rises in the presence of inflammation or infection. However, despite this test being regularly carried out prior to cardiothoracic surgery, it is not recommended as essential by NICE (2016). Elevated levels of CRP can often be seen in patients with a chronic inflammatory disorder such as rheumatoid arthritis. It is therefore essential to look at the average level of the CRP of such patients prior to surgery so that their baseline level is known.

Coagulation testing

Coagulation testing is routinely carried out at cardiothoracic preoperative assessment clinics, as it enables any potential coagulopathy issues to be highlighted in those patients who are not taking any form of anti-coagulation therapy. It is essential in order to discover any undiagnosed or unreported coagulation issues, as failure to do so could greatly increase the risk of the procedure due to excessive bleeding (Cornelisson & Arrowsmith 2015). Nevertheless, the performance of this basic test on all preoperative patients has been criticised by many as a wasted investigation (Akhtar, MacFarlane & Wasseem 2013) because at the preoperative stage many patients are still taking anti-coagulant therapies (NICE 2016). This patient group will need to undergo a further coagulation screen at the point of admission, after they have discontinued their anti-coagulation medications.

Glucose and HbA1c test

It has been well established, from the literature, that patients with diabetes have increased morbidity and mortality following coronary artery surgery (Reddy, Duggar & Butterworth 2014). Complications such as stroke, renal failure and sternal wound infections have been found to be much more prevalent in diabetic patients (Tsai, Jensen & Thourani 2016). This has also been reflected in patients undergoing major non-cardiac surgical procedures where chronic hyperglycaemia was associated with poor surgical outcomes (Underwood et al. 2014). It is therefore important that all patients have their glucose and HbA1c checked preoperatively to identify any individual with elevated levels. This is essential in order that patients previously undiagnosed with high glucose or HbA1C levels can be further investigated and also any poorly controlled diabetic patient can be further optimised prior to surgery.

The cardiothoracic surgical specialty spans every generation, from newborns to the elderly, and many female patients who need to undergo elective cardiothoracic procedures are of child-bearing age. In pregnancy, it is recognised that there are increased risks and often poor outcomes for a foetus due to the general anaesthetic and surgical procedure undertaken (NICE 2016). To achieve the best overall outcome, it has been recommended by NICE (2016) that all hospitals have a protocol in place to ensure that female patients of child-bearing age are approached preoperatively, and a pregnancy test is undertaken if possible.

Summary of blood investigations

The above tests are undertaken to verify that a patient’s blood tests are within the normal range designated by the laboratory values set within the country in which the tests are being performed. Patients will often have abnormal blood test results due to pre-existing medical conditions. However, in such cases it is important to ensure that any noted deterioration in their blood results is not an ongoing process that may affect the patient proceeding to surgery. It is imperative that the surgeon is made aware of any anomalies with blood investigations so that further investigations or referrals to other disciplines can be made.

Other preoperative investigations

Chest X-ray

Although a standard chest X-ray is usually performed as an initial diagnostic test at the beginning of a patient’s cardiac or thoracic investigatory journey, it is often repeated as a standard preoperative investigation. In major surgical procedures, an up-to-date CXR may be used to rule out new chest infection and also to identify any other issues that may cause anaesthetic concerns (Duncan & Wijeysundera 2016), such as undiagnosed abnormalities that may require further investigation before proceeding to surgery.

Electrocardiogram

A 12-lead electrocardiogram (ECG) is a standard preoperative investigation for any patient undergoing any type of major surgery (Payne et al. 2010). It is recognised that a significant number of patients undergoing cardiac or thoracic surgical procedures may present with an abnormal ECG at the preoperative assessment clinic (Whittle & Kelleher 2016). These ECG abnormalities may reflect previous cardiac events, evidence of hypertrophy, conduction issues or arrhythmias. It is imperative however, that a preoperative ECG is obtained to act as a baseline record against which any postoperative ECG can be compared (Fleicher et al. 2014).

Carotid Doppler imaging

Carotid Doppler imaging is carried out using an ultrasound probe which provides images of the structure and degree of patency of the carotid arteries. This test can demonstrate any obstruction or stenosis that could impact on the blood flow through the carotid vessels and increase the risk of a cerebral incident.

The current recommendations are:

• In patients undergoing coronary artery bypass grafting (CABG), carotid Doppler ultrasound scanning is recommended in individuals with a history of stroke, transient ischaemic attack or evidence of carotid bruit.

• Carotid doppler ultrasound should be considered in patients with multi-vessel coronary artery disease, peripheral artery disease, or in patients who are more than 70 years of age.

• In addition, magnetic resonance imaging (MRI) or computed tomography (CT) angiography may be considered if carotid artery stenosis as demonstrated by carotid artery ultrasound is >70% and myocardial revascularisation is contemplated.

• Finally, screening for carotid stenosis is not indicated in patients with unstable coronary artery disease requiring emergency CABG with no recent stroke or transient ischaemic attack.

While these criteria are commonly seen in cardiothoracic services, it is recognised that there are local variations in the criteria set for undertaking carotid screening. In addition, even if the criteria for screening are met and anomalies discovered, progression to subsequent intervention (such as carotid stenting or surgical intervention) prior to cardiothoracic surgery remains rare. Any anomalies discovered following carotid screening will therefore only enable the surgeon to provide a fully disclosed risk assessment of the proposed surgery and the patient to give informed consent.

Pulmonary function tests

Pulmonary function tests (PFTs) provide an invaluable tool in the ongoing investigation and management of patients with suspected or known respiratory disease. The information these tests provide can assist in formal diagnosis; they can also help clinicians make decisions regarding further treatment and the possibility of surgical intervention. In relation to thoracic surgery, PFTs provide important information to help determine if the patient is fit for general anaesthesia, fit for the proposed thoracic surgery and if any additional treatment strategies are required prior to surgery to reduce surgical risk (Ranu, Wilde & Madden 2011). Again, pulmonary function testing is not only performed in thoracic surgical patients but also in patients undergoing cardiac surgical procedures who are known to have respiratory issues or concerns.

Internationally, all cardiothoracic centres make every effort to reduce the incidence of hospital-acquired infection. Despite this, infection due to methicillin-resistant/sensitive staphylococcus aureus (MRSA/MSSA) is still seen as a complication of cardiac and thoracic surgical procedures and is associated with significant morbidity, prolonged length of stay, readmission and even death (Yavuz et al. 2014). To reduce these risks, preoperative screening for MRSA/MSSA has become the norm for all elective surgical patients, including those undergoing cardiothoracic procedures (Lee et al. 2010). Each cardiothoracic centre will have their own MRSA/MSSA screening protocol, based on the individual health directives of their country of origin. At the cardiothoracic preoperative assessment clinic, screening for MRSA will be carried out, and if the results prove positive for MRSA, decolonisation therapy (as per the locally agreed protocol) will commence.

Dental review

It is recommended that all patients undergoing cardiac surgery should have a dental review, but it is considered vital if they have to undergo valvular surgery. This is because patients with existing valvular disease, existing replacement heart valves or congenital heart conditions are considered particularly at risk for developing bacterial endocarditis (Leishman, Do & Ford 2010; Habib et al. 2015). It has been shown that bacteria can enter the body through a variety of routes. However, the presence of bacteria in areas of poor oral hygiene, with friable gum tissue, provides an ideal route for infection to enter the vascular system (Smith et al. 2014).

Discontinuation of medications

Prior to any surgery, including cardiac and thoracic surgical procedures, certain medications that patients are taking may need to be discontinued. Anti-platelet medications (such as Clopidogrel and Ticagrelor) are usually discontinued 7 days prior to surgery, as these medications have a significant effect in diminishing platelet function and can lead to increased postoperative blood loss (Ford 2015). Aspirin is often continued till 24 hours prior to surgery to provide some cardiac protection, especially in patients with severe left main stem disease or recently diagnosed, unstable symptoms (Aboul-Hassan et al. 2017).

Warfarin and nouvelle anticoagulants are usually discontinued 5–7 days prior to surgery but these patients should have an updated coagulation screen performed at the point of admission to ensure that their coagulation was within normal range. In addition, patients with a pre-existing mechanical valve would need to be admitted a few days preoperatively to facilitate heparin cover for the existing valve while their Warfarin level falls.

Within the preoperative clinic setting, the ANP will play a key role in advising the patient and/or their relatives in order to ensure their compliance with the discontinuation of specific medications as per the local protocol of the cardiothoracic centre.

Collation of information

Once all the investigations have been completed at the preoperative assessment clinic, it is essential that all the individual patient’s results are collated, reviewed and placed or documented within their case record. Fortunately, most patients proceed to their surgical admission date following a successful review at the preoperative clinic. However, on occasion, previously unknown clinical issues will arise. At this point, the ANP will assess any anomalies discovered and then discuss them with the individual consultant surgeon responsible for the patient’s care.

Ongoing referral

Every attempt will be made to resolve any clinical concerns prior to a patient’s admission date. However, this sometimes proves impossible and the patient’s admission for surgery must be delayed. There are many possible reasons for such delays and the patient may need to be referred back to their General Practitioner for immediate treatment of long-standing conditions which are currently poorly controlled such as diabetes or hypertension.

There may also be a need for ongoing referral to other disciplines to facilitate further investigations. Unfortunately, due to the current pressures on healthcare services and limited clinical resources, these investigations may be delayed. Nevertheless, the preoperative clinic ANP will often take overall responsibility for facilitating these referrals while liaising with the consultant surgeon involved, the admission team and the patient. The ANP at the cardiothoracic preoperative clinic must therefore not only demonstrate expert clinical skills and knowledge but also apply their critical judgement to ensure the safety of patients undergoing cardiothoracic procedures. As part of this process, excellent communication with the internal and external multidisciplinary healthcare team throughout the preoperative assessment process is essential.

Critical care/Intensive care area