Outpatient surgery fails on speedy recovery promise
Outpatient surgery fails on speedy recovery promise
Patients flounder during critical recovery period
For clinical outcomes, ambulatory surgery shines. And above all, it meets patients’ expectations, especially for those who have been through it before.
"Most patients like coming to the hospital in the morning and going home to recover in their own beds," says Dorothy Jones, EdD, RN, FAAN, professor at Boston College School of Nursing and a nurse scientist at Massachusetts General Hospital in Boston. But routine patient satisfaction surveys don’t uncover post-surgical care needs that often complicate the course of recovery.
Generally, people describe the surgical experience as good when first asked, Jones finds. However, further probing through several preliminary studies revealed a need for better care in the 24 to 72 hours following surgery. "People were suffering whether they were 25 or 90 years old," she notes. Foremost among QI opportunities in ambulatory surgery is a stronger nursing component, including teaching, to help people set realistic expectations for recovery. Equally important is prompt, close telephone follow-up during the 72-hour postoperative period.
Most problems follow general anesthesia
Jones conducted one preliminary study on patients who had local anesthesia and another on patients who had general anesthesia.
Among 58 patients with local anesthesia, 93% found printed after-care information easy to understand at first reading. However, 44% found the instructions difficult to understand once they got home. When asked how they managed after surgery, 68% reported no problems, and 68% reported overall satisfaction with the experience.
Among 95 patients with general anesthesia, nurses made follow-up calls 24 and 72 hours postoperatively. At 24 hours, most patients reported greater discomfort and less effective pain control than expected. More than 90% contacted a provider for better pain control during this period. "Since most of the people traveled long distances to the ambulatory surgery center," Jones explains, "they often contacted their primary care providers or visited a local emergency department about the postoperative pain or symptom management. Data at the ambulatory surgery site never show those cases."
These are highlights from Jones’ studies:
• Patients were confused about medication instructions and often took incorrect dosages because of uncertainty or fear of overdosing.
By the time the first follow-up call was made 24 hours after surgery, patients reported difficulty getting around, interrupted sleep, nausea, and anxiety. Inadequate information about managing postoperative symptoms was particularly acute for the elderly and those living alone.
• About 45% of the overall sample called friends or nurses they knew for help with unplanned dressing changes, crutch walking, pain management, food preparation, or interpretation of postoperative instructions.
Generally, patients experienced much greater fatigue than anticipated. That interfered with resumption of everyday activities and adherence with therapeutic exercise regimens.
• By 72 hours post-surgery, 50% of the patients reported general improvement.
However, the remaining 50% required continued pain medication. Others still had interrupted sleep, compromised nutrition, and difficulty with self-care activities such as bathing, toileting, and cooking. "Routine" tasks, such as accessing food and liquids or walking a pet, presented moderate to severe difficulty. Twenty-five percent of the sample still had moderate to severe pain, while another 20% to 25% went back to the hospital, physician’s office, or emergency room to resolve problems of bleeding from the surgical site and uncontrolled pain.
• Impaired mobility from pain or stiffness led to problems including delay of rehabilitative exercises.
A typical comment was, "They say I’m supposed to exercise, but I can’t even get out of bed."
• For elderly patients, recovering at home was especially difficult.
They or their spouse frequently expressed the wish to have stayed in the hospital "just one more night." Those who lived alone, whether young or old, often went without needed assistance because they couldn’t recruit help on short notice. Among middle-aged adults, there was a sense of preparedness because they’d been through a similar experience in the past or because they lived with someone who could help them if necessary.
• Three factors significantly compromise the patient’s speed of recovery and comfort through the first 72 hours following ambulatory surgery:
— uncontrolled pain;
— nausea;
— uncontrolled vomiting.
Although patients can manage at home, it is not without significant and probably unnecessary suffering. Confusion and discomfort contribute to anxiety, which heightens the perception of pain and general misery.
Asked whether the findings negate the value of ambulatory surgery, Jones explains that the medical benefits are indisputable. "In the long run, patients recover according to expectations," she says. "Physicians do an effective job of screening candidates for outpatient procedures. The only exception might be the elderly, even those with a spouse who can care for them."
From a nursing perspective, however, there’s plenty of opportunity for improvement. "Patients need a caring component — someone to talk to about their symptoms and their medication concerns," she says. Better pain management is essential to recovery.
Jones suggests that some of the uncontrolled pain might stem from a provider’s wrong choice of meds, or a patient’s undue fear of getting hooked. The latter, of course, is a patient education issue.
The prolonged fatigue or confusion following general anesthesia often causes anxiety as patients begin to fear they’re sicker than they really are. The opportunity to talk with a nurse could allay the anxiety and speed recovery, she points out.
"The promise that they’ll be back to normal within three days is not fulfilled in each instance," she insists. Better pre-surgical teaching could help people plan for slightly longer recovery periods. Instruction in relaxation techniques could augment the relief of pain medications.
To the degree possible, says Jones, people should be urged to have a family member or friend present to hear the home care instructions because the effect of the anesthesia clouds a patient’s memory and comprehension.
Usually, people need the most help six to eight hours after surgery. That’s when the anesthesia wears off and the problems begin. Even the ride home from the hospital can be excruciating, especially when it takes an hour or more. By 24 hours, when most patients receive a follow-up call, they’re already in trouble.
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