Benefits of Mobilisation Programs for Post-operative - Term Paper Example

«Benefits of Mobilisation Programs for Post-operative» Introduction Post-operative abdominal surgery is one of the major surgeries which patients undergo for a variety of diseases and diagnostic procedures. In most cases, it is intrusive and highly disruptive to the normal physiological functioning of the patients involved. Since the patient is subjected to major feelings of discomfort after the surgery, medical practitioners often feel the need to implement interventions which help to ease these discomforts. One such intervention is the early mobilisation program. Early mobilisation programs have been suggested as post-surgery options which help reduce hospital stay, reduce complications, and speed up patient recovery. Other practitioners have remained sceptical over this intervention, claiming that it is dangerous to encourage early mobilisation on the post-abdominal surgery patient. Moreover, the early mobilisation programs have not been studied and fully supported by sufficient and adequate research. Based on these considerations, this paper shall seek to answer the issue: whether or not early mobilisation programs improve outcomes for post-abdominal surgery patients. This paper shall critically appraise literature in a systematic manner and then make recommendations for practice change. It shall also identify drivers and barriers to change in their work environment, as well as strategies that might be used to effect practice change in this environment. Discussion PICO question: P (population/problem) – post-abdominal surgery patients/post-abdominal surgery I (intervention) – early mobilisation programs C (comparison) – no early mobilisation programs O (outcomes) – faster recovery, fewer complications, earlier discharge Question Do early mobilisation programs produce better patient outcomes for post-abdominal surgery patients? List of search terms and search history: Relevant search terms: 1. Early mobilisation post-abdominal surgery 2. Early mobilisation programs post-surgery 3. Early mobilisation impact post-abdominal surgery 4. Early mobilisation benefits post-abdominal surgery 5. Early mobilisation risks post-abdominal surgery 6. Early mobilisation compared no mobilisation post-abdominal surgery 7. Early mobilisation effects abdominal surgery improved patient outcomes The search terms were first used in Google Scholar. Studies which matched the search parameters were then downloaded for future scrutiny. A more specific search of reputable databases like Cochrane, Medline, BMJ, ANA, PubMed, and similar databases was also conducted. Studies matching the search parameters were also downloaded for future evaluation. Researches included for further analysis and evaluation for this research included those which were not more than six years old, which were peer-reviewed and published in reputable journals. Articles which underwent the logical and reliable research processes were included in this study. Moreover, identified materials were further evaluated based on their relevance to the question being raised by this paper. Materials which were older than six years and which did not help to answer the questions raised by this report were eliminated and were not included this paper. Studies which were not peer-reviewed and which were not published in reputable journal publications were also not included in this literature review. Summary of critical appraisal of articles Brustia, et.al., (2007) conducted their study based on the premise that the use of fast-tracking multidisciplinary programs would lead to good results in the postoperative outcomes in various surgeries. The authors assessed a multimodal clinical program on mininvasive surgery, epidural anaesthesia and early mobilisation and feeding among abdominal aortic surgeries. Their study was conducted from June 2000 to October 2005, covering 323 patients who underwent abdominal aortic surgery for conditions related to atherosclerotic aorto-iliac occlusive disease and aorto-iliac aneurysm (Brustia, et.al., 2007). Sensory block was achieved through the incorporation of bupivacaine 0.5% via epidural catheter at T6-T7 interspace. Light anaesthesia was also used via sevoflurane through laryngeal mask in spontaneous breathing. Nasogastric tubes were not used during surgery (Brustia, et.al., 2007). The bowel was handled with care and manipulated inside the abdominal cavity; standard surgical instruments were used and no drains were placed. At the end of the surgery, the patients were transferred to the surgical ward where they were mobilized early and asked to drink and eat as early as possible post-surgery (Brustia, et.al, 2007). Pain relief was ensured through the infusion of bupivacaine 0.25%, with oral ibuprofen supplementation when requested. After figures were evaluated and assessed, the study observed a mortality rate of 2.4% and a low postoperative morbidity rate (Brustia, et.al., 2007). Cardiac complications of 1.4% were seen; increase of 3.7% in transient creatinine was seen; however, no pulmonary complications were seen. The patients were able to ambulate at a distance of 536 m on the day of the surgery and 2544m a day after the surgery (Brustia, et.al., 2007). They also ingested an oral diet 36.2% of their daily caloric requirement on the day of the surgery and 1583 kcal the day after their surgery. They stayed a mean number of 3 days in the hospital and were soon after discharged to their homes (Brustia, et.al., 2007). Based on these results, the authors concluded that the length of hospital stay and the rate of morbidity after abdominal surgery can be reduced through the application of mininvasive surgical procedures, thoracic epidural anaesthesia-analgesia, and through the implementation of aggressive postoperative nursing while the patient is wheeled into the ward (Brustia, et.al., 2007). The authors also concluded that applying a multidisciplinary program for abdominal surgery patients can be implemented and can achieve improved patient outcomes. This study was peer-reviewed and carried out by authors very much qualified in their field of practice. The question raised is relevant to the current research topic. The sample size is large enough to validate the research process. The process chosen is appropriate for the question raised. The statistical analysis also produced valid and reliable results. Consequently, the conclusions drawn are reliable, valid and not based on fallacies. In a prospective observational study covering, Browning, Denehy, and Scholes (2007), the authors set out to determine how much upright mobilisation, particularly uptime, is manifested in the first four days after upper abdominal surgery. They also set out to determine what part of the day when greatest uptime is reached; if length of stay is related to uptime; and if there is a difference in postoperative factors (Browning, Denehy, & Scholes, 2007). The study covered 50 patients who underwent upper abdominal surgery. These patients received standard preoperative teaching and physiotherapy interventions on their first postoperative day (Browning, Denehy, & Scholes, 2007). Outcome measures assessed from the patients included: postoperative pulmonary complications, surgical attachments, pain relief, duration of anaesthesia, and admission to intensive care. The study revealed that morning uptime was greater than afternoon and evening uptime. Moreover, the amount of uptime in the first four days following the surgery also dictated the length of hospital stay (Browning, Denehy, & Scholes, 2007). The uptime for those with postoperative pulmonary complications did not register lower numbers, indicating equal benefits earned for those with or without pulmonary complications. The authors concluded that based on the results, the amount of upright mobilisation is low. Considering that uptime often dictated the length of the patient’s hospital stay, increasing early upright mobilisation can have a positive impact on decreasing the length of hospital stay of patients undergoing upper abdominal surgery (Browning, Denehy, & Scholes, 2007). This study is another peer-reviewed journal carried out by highly qualified practitioners in the medical field. The population of the study is sufficient, but this study can benefit from a greater sample population for a better applicability to the general population. The methods used are appropriate; they help answer the questions being raised by the study. The results are based on logical and valid totals after statistical analysis. The conclusions drawn are based on the results; and no logical fallacies are apparent in the study. Mohn, et.al., (2009) focused their study on the premise that enhanced recovery after surgery (ERAS) can reduce median hospital stay from 8-10 days after traditional peri-operative routines four days. Their study sought to introduce ERAS in the hospital and evaluate its impact on hospital stay, complications, and quality of life after discharge. The study covered 94 patients, at 66 median years in a prospective randomised observational study at the Haukeland University Hospital and Haugesund Hospital from October 2000 to February 2003 (Mohn, et.al., 2009). Following three months of preparation, the ERAS was implemented in these hospitals and their impact was assessed through questionnaires and follow-ups at 8-10 and 30 days following surgery. These results were placed against the impact of colorectal surgery before the implementation of accelerated recovery (Mohn, et.al., 2009). The study revealed that 48% and 78% of patients discharged were discharged within three and five days after surgery after the implementation of ERAS; in contrast to 0% and 7% patients discharged under traditional recovery. Complications rated at 31% under ERAS with a readmission rate of 15% after a week; and about 57% were able to resume their daily activities at home (Mohn, et.al., 2009). After about a month, 65% of the patients were able to go back to their normal and leisure activities. The authors concluded that with proper preparation, the ERAS principles can be effectively applied in the surgical unit, supported by decreased median hospital stay and faster return to normal activities for abdominal surgeries (Mohn, et.al., 2009). This study is a peer-reviewed study conducted by researchers and practitioners who are highly qualified in their field. The question posed in the study is very much relevant to the current topic. Its methodology is appropriately matched to the aims and objectives of the study. The results and conclusions drawn are based on valid and reliable data and observations. Wennstrom, et.al., (2009) were also eager to weigh in on establishing ways to improve patient postoperative care. Their study sought to evaluate patient symptoms during the first four weeks following elective colon surgery; and to establish ways on how to improve inpatient data and postoperative care (Wennstrom, et.al., 2009). Their study was based on the premise that fast-track recovery after colon surgery is beneficial to patients during their early postoperative phase. They covered 32 consecutive patients planned for elective colon surgery who also underwent fast-track protocol in the hospital. Their outcomes were measured based on the quality of their life (Wennstrom, et.al., 2009). After data was gathered and analysed, the research revealed that the hospital stay was six days and 10% of the patients were eventually readmitted. The fast-track intervention was effective and the major problems seen after discharge involved fatigue, nausea, and bowel disturbance; and all of these symptoms were not seen after four weeks following the fast-track recovery (Wennstrom, et.al., 2009). The study concluded that although improved results can be reached through the implementation of fast-track recovery, there is a need for more research to be conducted on how to reduce fatigue and anxiety for patients. Therefore, improvements in this regard can help reduce peri-and postoperative side-effects seen after surgery (Wennstrom, et.al., 2009). This study is very much reliable and valid. Its authors are reliable experts in their medical practice. They have presented reliable and replicable results which are based on comprehensive figures and documentation in the course of the study. Finally, the conclusions drawn are very much based on valid and reliable results; and no logical fallacies are apparent in the study. In a recent study by Baird, et.al., (2010), the authors compared the outcomes of a fast-track program implemented among patients undergoing laparoscopic colorectal surgery with patients receiving traditional postoperative care following similar surgery. The study also sought to evaluate whether patients on the fast-track recovery program were able to tolerate diet, early ambulation, and decreased use of drains (Baird, et.al., 2010). The study covered about 100 patients undergoing laparoscopic surgery on the fast-track program at a major Midwestern hospital. The study revealed a statistical significant difference of 1 day between patients exposed to traditional care and those under the fast-track program (Baird, et.al., 2010). In conclusion, the study established that patients under the fast-track program were discharged one day sooner than their traditional program counterparts. The authors recommend the fast-track method as an effective means of reducing hospital stay and speeding up patient recovery (Baird, et.al., 2010). This is another peer-reviewed study covering a sample population sufficient enough to represent a greater population. The methods of the study are appropriate for the questions raised and the results drawn from such methods are detailed enough for adequate reliability and validity. The conclusions established are promptly based on valid and reliable results. In a prospective, randomised controlled study by Khoo, et.al., (2007), the authors evaluated the application of a multimodal perioperative management protocol among patients undergoing elective colorectal resection for cancer. The respondents were divided into the multimodal group and the traditional care group. The multimodal group received intravenous fluid restriction, unrestricted oral intake with prokinetic agents, early ambulation and fixed regimen epidural anaesthesia (Khoo, et.al., 2007). Control respondents received IV fluids, restricted oral intake and weaning regiment epidural analgesia. Both groups were assessed for postoperative stay and achievement of independence milestones; other outcome measures included postoperative complications, readmission rates, and mortality (Khoo, et.al., 2007). After results were tallied and evaluated, the study revealed that in comparing the median hospital stay of these two groups, the multimodal group was able to display shorter hospital stay as compared to the control group. In fact, patients in the control group were 2.5 times more likely to stay more than 5 days in the hospital (Khoo, et.al., 2007). Patients who were in the multimodal group had fewer cardiorespiratory complications; however they had more readmissions. The authors were able to successfully establish that the multimodal group has a greater chance of reducing postoperative stay as compared to the control group (Khoo, et.al., 2007). This paper presents a comprehensive and reliable picture of the question being evaluated in this study. The methods applied were appropriately chosen for the study. Results which were reached were based on accurate and reliable statistical computations and processes. The conclusions drawn were also based on accurate results and were not based on logical fallacies. Muller, et.al. (2009) set forth their study based on the premise that a fast-track program is a multimodal intervention for patients who are about to undergo colonic surgery. It is a remedy which combines the basic features of perioperative care like fluid restriction, optimized analgesia, forced mobilization, and early oral feeding. In their study, they sought to evaluate the impact of a fast-track method on postoperative morbidity among patients post-colonic surgery (Muller, et.al., 2009). Their study covered patients in 4 teaching hospitals in Switzerland assigned to either the fast-track program or the standard care. Their outcome measure focused on the 30-day complication rate, severity of complications, hospital stay, and compliance with the fast-track protocol (Muller, et.al,, 2009). In the course of their research, they were able to establish that the fast-track program was able to effectively decrease the number of complications among the patients. Consequently, with fewer complications, patients also had shorter hospital stay. All in all, this study was able to reveal that the fast-track program reduced postoperative complications and the length of hospital stay (Muller, et.al., 2009). They recommended that the fast-track program should be favoured over the standard program in the postoperative setting. This is another peer-reviewed journal. An initial scrutiny of the author’s qualifications does not clearly indicate their experience and background. An independent search of their names online however reveals that they are experts in their field. This study reveals valid results based on appropriately chosen methodology. Conclusions drawn are valid and reliable. Teeuwen, et.al., (2009) conducted their study based on the premise that the application of Enhanced Recovery after Surgery (ERAS) programs are linked with fewer hospital morbidity and mortality. Based on this premise, the authors set out to assess whether the application of ERAS program improved the adverse events seen in colorectal surgery (Teeuwen, et.al., 2009). Their study compared the mortality, morbidity, length of hospital stay, fluid intake, number of relaparotomies, and number of readmissions within 30 days between patients under ERAS and matched historical controls. About 60 patients were placed under the ERAS program and were compared to those who underwent conventional postoperative care (Teeuwen, et.al., 2009). Comparable data was seen in morbidity rates which were lower in the ERAS group as compared to the control group. Moreover, patients under the ERAS group received significantly less fluid and were admitted for a shorter hospital stay (Teeuwen, et.al., 2009). No difference in mortality rate and readmission rates were seen between these two groups. Nevertheless, the authors conclude that the application of the ERAS program is more beneficial for improved postoperative patient outcomes. This is another peer-reviewed journal, conducted by qualified experts in the medical practice. The methods of research applied are appropriate for the study. The results drawn are based on comprehensive and accurate statistical data and treatment. The conclusions drawn are logical, valid, and reliable. Recommendations for Practice Change Based on the results of the research as summarised above, recommendations for practice change include the following practices: 1. Implementation of fast-track programs in the postoperative set-up for abdominal surgeries (Kahokehr, 2009) 2. Gradual implementation of ERAS in the hospitals following major surgeries (Lighter & Fair, 2004) 3. Improved, aggressive, and vigilant application of nursing interventions in the recovery room following major surgeries (Needleman, et.al., 2002) 4. Assisting patients in making the safe transition from surgery to recovery. This would include assisting them in moving about safely soon after surgery; taking in semi-solid to solid foods; and engaging in their routine daily activities the soonest possible time after surgery (Engblom, et.al., 1997). 5. Training medical surgical health practitioners proper and safe ways to carry out early mobilization, ERAS, and fast-track programs for patients post-abdominal surgery (Birth, et.al., 2009). 6. To ensure that patients have shorter hospital stay after their surgery and that they can return to their normal activities as soon as possible (Morgan, 2008). Drivers, barriers, and strategies for practice change Drivers Barriers Strategies for Practice Change To achieve faster and earlier mobilization for post-abdominal surgical patients (Siribaddana, 2010) Limited acceptability among health practitioners (Siribaddana, 2010) Conduct trainings for health practitioners highlighting the benefits of early mobilization (Birth, et.al., 2009) To ensure shorter length of hospital stay for patients after abdominal surgery (Morgan, 2008) Presence of post-operative complications (Gordon & Cameron, 2000) Application of vigilant monitoring for bleeding, vital signs, pain, and fluid balance in the hours immediately following surgery (Needleman, et.al., 2002) Immediate referral to the medical practitioner for danger signs involving the above symptoms (Needleman, et.al., 2002) To ensure early return to activities of daily living (Engblom, et.al., 1997) Physical and mental difficulties in patient mobilization (DeLisa, Gans, & Walsh, 2005) Rehabilitation measures with trained therapists to ensure safe conduct of daily activities (Engblom, et.al., 1997) Teaching patients to conduct their activities independently (how to bathe, prepare their meals, go to and from the bathroom, and how to groom and dress themselves independently) (Hills, 2009) Assure the patient that it is safe for him to move about and gain independence in his activities; that a therapist would assist him in safely gaining mobility (Hills, 2009). To implement fast-track programs and ERAS programs in as many hospitals as possible (Kahokehr, 2009) Difficulties in implementation and acceptance among practitioners (Kahokehr, 2009) Publishing as much research as possible on evidence which help lend support to the effectiveness of these programs (Melnyck & Overholt, 2010) Conducting trainings and seminars to highlight the importance and the benefits of the fast-track programs (Birth, et.al., 2009) Slowly and gradually implementing the program into the hospital setting, until it gains acceptability among practitioners (Lighter & Fair, 2004) Works Cited Baird, G., Maxson, P., Wrobleski, D., & Luna, B. (2010) Fast-track Colorectal Surgery Program Reduces Hospital Length of Stay, Clinical Nurse Specialist, volume 24, number 4, pp. 202-208 Browning, L., Denehy, L., & Scholes, R. (2007) The quantity of early upright mobilisation performed following upper abdominal surgery is low: an observational study. Australian Journal of Physiotherapy, volume 53, pp. 47-52 Birth, M., Figueras, J., Bernardini, S., Troen, T., Gunther, K., Mirza, D., & Mortensen, F. (2009) Collagen fleece-bound fibrin sealant is not associated with an increased risk of thromboembolic events or major bleeding after its use for haemostasis in surgery: a prospective multicentre surveillance study. Patient Safety in Surgery, volume 2, pp. 1-13 Brustia, P., Renghi, A., Fassioloa, A., Gramaglia, L., Corte, F., Cassatella, R. & Cumino, A. (2006) Aortic and aneurismal : Fast-track approach in abdominal aortic surgery: left subcostal incision with blended anesthesia. Interactive CardioVascular and Thoracic Surgery, volume 6, pp. 60–65 DeLisa, J., Gans, B. & Walsh, N. (2005) Physical medicine and rehabilitation: principles and practice, Volume 1. Pennsylvania: Lippincott Williams & Wilkins Engblom, E., Korpilahti, K., Hamalainen, H., Ronnemaa, T., Puukka, P. (1997) Quality of Life and Return to Work 5 Years After Coronary Artery Bypass Surgery: Long-term results of cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation, volume 17, number 1, pp. 29-36 Gordon, T. & Cameron, J. (2000) Evidence-based surgery. USA: PMPH Hills, E. (2009) Adult Physiatric History and Examination. eMedicine. Retrieved 23 September 2010 from http://emedicine.medscape.com/article/317515-overview Kahokehr, A., Sammour, T., Zargar-Shoshtari, K., Thompson, L., & Hill, A. (2008) Implementation of ERAS and how to overcome the barriers. Internal Journal of Surgery, volume 7, number 1, pp. 16-9 Khoo, C., Vickery, C., Forsyth, N., Vinall, N., & Eyre-Brook, I. (2007) A Prospective Randomized Controlled Trial of Multimodal Perioperative Management Protocol in Patients Undergoing Elective Colorectal Resection for Cancer, Ann Surg volume 245, pp. 867–872 Lighter, D. & Fair, D. (2004) Quality management in health care: principles and methods. Massachusetts: Jones & Bartlett Melnyck, B. & Fineout-Overholt, E. (2010) Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. Pennsylvania: Lippincott Williams & Wilkins Mohn, C., Bernardshaw, S., Ristesund, S., Hansen, P., & Rokke, O. (2009) Enhanced Recovery after Colorectal Surgery: Results from a prosprective observational two-centre study. Scandinavian Journal of Surgery, volume 98, pp. 155–159 Morgan, P. & Rhodes, A. (2008) Goal-directed Hemodynamic Therapy for Surgical Patients. Yearbook of Intensive Care and Emergency Medicine, 2008, volume 2008, number 15, pp. 631-637, Muller, S., Zalunardo, M., Hubner, M., Clavien, P., & Demartines, N. A Fast-Track Program Reduces Complications and Length of Hospital (2009) Stay After Open Colonic Surgery. Gastroentorology, volume 136, pp. 842–847 Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky (2002) Nurse-Staffing Levels and the Quality of Care in Hospitals. New England Journal of Medicine, volume 346, pp. 1715-1722 Siribaddana, P. (2010) The benefits of early mobilization following surgery. Helium.com. Retrieved 23 September 2010 from http://www.helium.com/items/1685732-benefits-of-early-mobilization-following-surgery Teeuwen, P., Bleichrodt, R., Strik, C., Groenewoud, J., Brinkert, W., van Laarhoven, C., van Goor, H., & Bremers, A. (2010) Enhanced Recovery After Surgery (ERAS) Versus Conventional Postoperative Care in Colorectal Surgery, Journal of Gastrointestinal Surgery, volume 14, pp. 88–95 Wennstrom, B., Stomberg, W., Modin, M., & Skullman, S. (2007) Patient symptoms after colonic surgery in the era of enhanced recovery – a long-term follow-up, Journal of Clinical Nursing, volume 19, pp. 666–672 Read More