anterior cervical discectomy and fusion (ACDF)

The patient chosen for this case study is 45 years old  male patient ASA grade 3 and has a type 2 diabetes. The patient is given the name John and suffers from ACDF (anterior cervical discectomy and fusion).

 

The essay needs to written in order from when the patient is in the anaesthetic room till the end of the surgery. This essay needs to be written like someone that is living it directely. This person is an ODP (operating Departement Practitioner) . The ODP is relating a surgery he/she participated from the beginning till the end by following all the polices and procedures.

 

The assignment is a case study that allows the student to reflect on and evaluate the care strategies required to support and manage the needs of the intraoperative patient. The work must include relevant literature and research and references to appropriate national and local NHS policies, standards and guidelines (preferably the UK)

 

Learning Outcome 1: Identify and discuss guidelines and policies applied during the intra-operative phase.

Learning Outcome 2: Evaluate care strategies and interventions undertaken by the perioperative practitioner across a diverse range of surgical procedures and patient groups.

Learning Outcome 3: Analyse and utilise communication strategies that facilitate multidisciplinary teamwork during the intra-operative phase.

Learning Outcome 4: Demonstrate safe and skilled support during the intra-operative phase by working as an effective member of the surgical team.

 

General points

  • Remember essay structure; introduction, main body and conclusion
  • Maintain patient confidentiality and organisational and individual anonymity. You do not need to refer to this action.
  • Word counts and weighting of material; usually allow 10% for introduction and 10% for conclusion.
  • Use literature to support points raised/justify actions taken

 

  • Use APA6 for referencing using Refworks or the referencing tool in Microsoft Word – consult
  • Centre align your script and use arial 11 font. Place a page number in the footer.

 

Essay planning

Select a case you have been present at and discuss the management of the patient during that operation. The case does not have to be complex surgery – common issues run through all surgical cases. Identify the care strategies and interventions relevant to the case you have chosen. Review Department of Health policies, NICE guidelines, NHS Trust policies and AFPP standards and guidelines and analyse if the care delivered was appropriate to support and manage the needs of the intraoperative patient chosen.

 

Essay Writing

Introduction and rationale

(300 words approx)

Outline what you are going to discuss in the main body. Discuss how you are going to support your findings .

  • Have you found a statistic that had an impact on you and is relevant to surgical care and especially patient safety during surgery? Use it, I like stats!
  • Briefly describe the procedure. Use precise anatomical and surgical terms – your intended audience is familiar with these terms.
  • Briefly describe the patient. What is their ASA status and associated co-morbidities?
  • Describe the issues directly relating to care management for a patient undergoing the procedure. Describe the complications associated with their co-morbidities.
  • Summarise your conclusion.

 

 

You do not need to mention that you have a professional duty to maintain patient confidentiality. It just takes up precious words which you may use for analysis and evaluation (and to increase your grade). Simply refrain from identifying the patient, your colleagues and your organisation. Be flexible with your introduction – you may have to change it as your essay evolves and new issues arise. Consider leaving it until the main body is completed.

This is an example of an introduction from a previous student’s essay;

“This scriptanalyses the fundamental aspects of the perioperative process of a patient, consented for an open right hemi-colectomy. Incorporating guidelines, polices and literature to support relevant care strategies and interventions, reflecting on the role of the operating department practitioner (ODP) throughout.

The perioperative care-pathway of a 65 year-old female, an American society of anaesthesiologist (ASA) grade three is described and analysed. Chronic Crohn’s Colitis, an inflammatory disease affecting the gastrointestinal tract is the procedural indication (Crohn’s and colitis UK, 2013). The inflammation can be severe and involve the lymph nodes and layers of mucosa (Tortora & Derrickson, 2011). The surgical approach was considered due to the ineffective pharmacological/ nutritional therapies.  

Lohsiriwat et al (2008) defines an open right hemi-colectomy as the resection of the right half of the colon by mobilising the hepatic flexure, sacrificing the ileo-colic branches of the superior mesenteric artery. Anastomosis of the ileum and transverse colon is achieved through an abdominal midline incision. Rothrock (2008) highlights the importance of the incision site, factoring in aspects to minimise trauma, optimise access and maximise wound strength. The advantages of a midline incision is abdominal exposure with achievable haemostasis, however if the incision is above the umbilicus, it can increase risk of postoperative hernia. Advantages to the laparoscopic approach are, a reduction in pain and wound complications (Papaconstantinou, Sharp, & Thomas, 2010). Despite the laparoscopic advantages the patient was unsuitable, due to the extensive adhesions caused by the chronic inflammation healing process.  

An ASA status indicates the extent of intervention required, the grade given assess the degree of physical standing (factoring co-morbidities), grading the associate risk (Gwinnutt & Gwinnutt, 2012). However the ASA grading is not a definitive indicator, it is decidedly subjective. This 65 year old female presented with a history of type-two diabetes mellitus (DM), morbid obesity, and various severe systemic diseases. All of which conformed to the suggested criteria of an ASA grade three.

This introduction is slightly longer than 10% of the word count recommended. Although this introduction is good, it is not perfect. What might you do differently?

Main Body

A case study presents an account of what happened. It identifies a situation and issues, the  solutions that were selected to resolve the issues and a summary of the final results or the outcome. It chronicles the events the practitioner had to deal with and records that practitioner’s response. Consequently, when you analyse cases, you will be like a detective who examines and probes what happened, actions which should have happened and what the outcome was. When evaluating a case, it is important to be systematic. Analyse the each topic in a logical sequence. Ensure that you include patient outcomes.

Learning Outcome 1: Identify and discuss guidelines and policies applied during the intra-operative phase.

  • Identify a care strategy, intervention or complication specific to the procedure or the patient
  • Describe the theoretical perspective of the identified issue
  • Review the Department of Health policies, NICE guidance, AFPP guidelines and local Trust policies relevant to the identified issue

 

Learning Outcome 2: Evaluate care strategies and interventions undertaken by the perioperative practitioner across a diverse range of surgical procedures and patient groups.

  • Analyse the actions of the multi-disciplinary team against the policies and guidance highlighted in learning outcome number one
  • Evaluate the actions of the multi-disciplinary team in clinical care delivery for the topics you have chosen
  • Do the actions of the practitioner and team attain those interventions described in the guidance? What actions would you recommend to comply with policies and guidelines?

Approach learning outcomes one and two logically

  • Identify an issue
  • Develop the theoretical perspective of the issue e.g. by discussing the pathophysiology of the complication, virulence of skin micro-organisms, the innate immune response etc.
  • Discuss the guidelines, policy or evidence aimed at managing the issue
  • Analyse and evaluate the clinical care delivered by the multidisciplinary team against the guidelines
  • Make recommendations as necessary

 

This is an example of a student’s discussion of the routine for surgical hand asepsis;

“Once the team-brief is complete the SP prepares for the surgical case by achieving surgical hand asepsis. Adhering to the eight step technique, adapted from the Association for Perioperative practice (AFPP) (Pirie, 2010; Trust, 2012a). Conforming to this technique is proven to reduce the number of resident and transient flora, inhibit re-colonisation, in comparison to the social hand-wash which just removes transient (Pirie, 2010). The purpose of the surgical scrub is to reduce inadvertent transmission of micro-organisms to the surgical patient. Barnard (2002) identifies improper surgical hand asepsis contributes to an increase risk of surgical site infection (SSI). SSI is a significant form of hospital acquired infection (HAI), accounting for 10% of cases annually within the United Kingdom (Tanner, Swarbrook, & Stuart, 2008). 

The SP followed the trusts surgical scrub protocol, using soap and water followed by an alcohol hand rub (60% isopropanol-based). The surgeon opted for the antimicrobial 4% chlorhexidine gluconate (Hibiscrub©), 7.5% povidone iodine (Videne©) was also available. There are no identifiable difference between alcohol rubs and aqueous scrubs in reducing SSI. However chlorhexidine is more effective in reducing the amount of bacteria than povidone iodine, chlorhexidine has a residual effect compared to alcohol rubs (Tanner, Swarbrook, & Stuart, 2008).

The surgical scrub process is conflicted by the use of scrub-brushes and nail picks, questioning their effectiveness in reducing bacteria. Tanner (2009) states chlorhexidine alone is more effective then combined with scrub-brush or pick. Implementing the nail-pick and brush as part of the scrub routine is costly (due to ineffectiveness), therefore recommendations are to remove them from practice (Tanner, 2009). Another disputed factor is scrub duration, a scrub duration lasting between 2-3 minutes is just as effective as a 5 minute scrub. However anything less than 2 minutes increases the risk of microbial colony forming units (CFU) (Tanner, 2008).”

This is a really effective discussion which is supplemented by valid references. However, what might you do differently? You do not need to be brilliant at literature searching for this module. Many articles are available on Blackboard. However, I would recommend that you use a minimum of 30 references from reputable, peer-reviewed sources.

 

Learning Outcome 3: Analyse and utilise communication strategies that facilitate multidisciplinary teamwork during the intra-operative phase.

  • What national and local guidelines are available to optimise communication during perioperative care?
  • Is there a theoretical perspective of facilitating communication?
  • Critically analyse the effective application of communication strategies during the chosen case
  • Evaluate the impact of these strategies on the care of the patient
  • Remember to make recommendations

You should discuss your experience of effective and ineffective communication, particularly during the team brief, and how you perceived that team cohesion may be affected. You should also analyse the Time Out and evaluate its effectiveness at achieving the appropriate interventions at the appropriate time.

 

Learning Outcome 4: Demonstrate safe and skilled support during the intra-operative phase by working as an effective member of the surgical team.

  • This is demonstrated by effectively completing learning outcomes 1-3

You should discuss 6 – 8 issues in detail. Each of these issues should be approximately 300-400 words (the student used almost 300 words to discuss hand asepsis). The issues should be relevant. These may include team briefing, management of inadvertent hypothermia, positioning and prevention of pressure ulcer development, DVT prophylaxis, infection control strategies, fluid balance, effective choice of dressings and drains and de-briefing.

Use of ancillary equipment such as diathermy, positioning aids, sutures and tourniquets should not be neglected. These topics are useful for linking two major topics;

“Once anaesthetised, Mrs Clover was transferred onto the theatre table via a slide board by six members of the multi-disciplinary team, transfer being initiated by the anaesthetist.  Using a slide board and a coordinated movement ensures safe transfer of the patient and limits damage to the patient’s skin from shearing stresses which contribute to the development of pressure lesions (Servant and Purkiss, 2002).”

This student effectively linked the team brief and patient positioning by this short paragraph.

Remember you may choose to look at all aspects of intraoperative care. I enjoy reading topics that are quite abstract; non-technical skills to prevent swab loss and interprofessional working are good examples of abstract topics.

Include your analysis of the perioperative practitioner’s role during surgery. Can you think what may be included in this section?

 

Conclusion

(300 words approx)

Summary of main body and your findings

  • Brief overview of main body
  • Draws together your findings
  • Convey the implications and applicability of what you have learned from your case study in your conclusion – especially your analysis of the role of the theatre practitioner.

There are some things you should avoid in the essay;

Don’t discuss the anaesthetic, monitoringor sign in unless it is directly relevant – VTE prophylaxis and spinal anaesthesia, leadership by anaesthetists or the contribution of anaesthesia to hypothermia may be relevant.

Use 23 words to tell me something when you can use three.

Inappropriate terminology – “Thigh bone, cuts in the skin” have both been used by previous students.

Don’t tell me the process for establishing hand asepsis – concentrate on telling me about the practice, the research and what you think.

 

 

 

 

 

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