Reshaping the role of nurses in surgical care

Picture a baby’s heart, the size of a strawberry. Now imagine that this little heart is incomplete, it has missing parts, and a newborn child will need open-heart surgery.

The thought of a child undergoing heart surgery is distressing. In Pakistan, 60,000 babies are born each year with congenital heart defects (CHD). Cardiac malformations, including abnormalities occurring in the heart’s valves and walls, or its blood vessels, create all sorts of complications precluding young babies to lead normal lives. Defects impact the blood flow to the heart, creating too much pressure and interfering with the heart’s ability to pump blood properly, and at times even have severe implications on brain development.

On the bright side, the success rate of paediatric CHD corrective surgery has surged and we have made great strides in Pakistan. Today, we have institutions fitted out with the latest technology, and internationally trained surgeons at hospitals, where patients with congenital heart defects receive treatment options never thought possible.

Needless to say, surgical success depends on the quality of intervention. However, an area many institutions continue to struggle with is that of post-operative care. Emerging programmes in low- and middle-income countries, like Pakistan, lack the institutional framework and skilled multi-disciplinary teams necessary to provide appropriate post-operative care. And, therefore, surgical morbidity can be 10 times higher than the developed world.

To put it simply, blood infections can occur after surgery; and nurses’ ability to identify deteriorating patients can make or break the outcome of the surgery. In 2013, we recognised this problem as such infections had risen to 30 per cent at the AKUH. Recognising this as a cause for concern, we gathered the infection control teams, cardiac ICU and PICU nurses, and decided to get to the bottom of this issue.

There were two overarching explanations for this rise in blood infections in our paediatric population. Firstly, we had limited space, and therefore the paediatric patient population was mixed with the adult patients after their surgeries, increasing the risk of cross-contamination. Another impediment was the high staff turnover, resulting in poorly trained and unspecialised nurses. These two reasons led to sub-par post-operative care, even when the surgery was successful.

The first move was to separate the paediatric patients from adult patients. Next, we joined the International Quality Improvement Collaborative (IQIC), a body formed to improve CHD surgery outcomes in low- and middle-income countries. IQIC advocated for a shift in the traditional top-down approach. A team of specialised nurse practitioners, trained specifically for paediatric cardiac patients was created, and nurses began taking the lead on infection control practices. They were responsible for inculcating IQIC guidelines by training interns, residents and other hospital staff on infection control, and adequate post-operative care.

Today, we have successfully dedicated and designed nursing training specifically to care for children after cardiothoracic surgery. The measures taken not only improved our overall patient experience at the hospital, but also reduced blood infections significantly.

Access to high quality nursing services is one of the major problems of Pakistan’s health system. Our inpatient nursing staff serves a vital role in the care of our young patients. Treatment plans can be complex and without a specialised, well-trained and empowered nurse, a patient has a significantly lower chance of recovering after their surgery. Our study within Pakistan bolsters the case for improved and specialised nursing care.

Nurses across hospitals in Pakistan continue to struggle with poor working conditions, and a general lack of respect, recognition and reward for their profession. We urge our counterparts in Pakistan to make this change.

Published in The Express Tribune, January 10^th, 2018.

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