The Surgical Recovery Index

Quality indicators and outcomes in ambulatory surgery

PURPOSE OF REVIEW

Quality indicators are used to monitor the quality and safety of care in ambulatory surgery, a specialty in which major morbidity and mortality remain low. As the demand for safe and cost-effective ambulatory surgical care continues to increase, quality indicators and metrics are becoming critical tools used to provide optimal care for these patients.

RECENT FINDINGS

Quality indicators are tools used by both regulatory agencies and surgical centers to improve safety and quality of ambulatory surgical and anesthetic care. These metrics are also being used to develop value-based payment models that focus on efficient, safe, and effective patient care. Patient reported outcome measures are a growing method of collecting data on the satisfaction and postoperative recovery period for ambulatory surgical patients. Monitoring of perioperative efficiency and utilization using quality metrics are important to the financial health of ambulatory surgical centers.

SUMMARY

Quality indicators will continue to play a growing role in the monitoring of quality and safety in ambulatory surgery, especially with the trend towards value-based reimbursement models and efficient, cost-effective surgical care. Additionally, quality indicators are useful tools to monitor postoperative patient outcomes and recovery pathways and the efficiency of operating room utilization and scheduling.

Evaluation of postoperative recovery: past, present and future

Postoperative recovery, as a window to observe perioperative treatment effect and patient prognosis, is a common outcome indicator in clinical research and has attracted more and more attention of surgeons and anaesthesiologists. Postoperative recovery is a subjective, multidimensional, long-term, complex process, so it is unreasonable to only use objective indicators to explain it. Currently, with the widespread use of patient-reported outcomes, various scales become the primary tools for assessing postoperative recovery. Through systematic search, we found 14 universal recovery scales, which have different structures, contents and measurement properties, as well as their own strengths and weaknesses. We also found that it is urgently necessary to perform further researches and develop a scale that can serve as the gold universal standard to evaluate postoperative recovery. In addition, with the rapid development of intelligent equipment, the establishment and validation of electronic scales is also an interesting direction.

Development and validation of the Efficacy Safety Score (ESS), a novel tool for postoperative patient management

Background

Several reports have shown that postoperative monitoring of general safety and quality issues, including pain treatment, after discharge from recovery is often non-systematic and inadequate. We suggest a new score with assessment of key recovery parameters, as a supportive tool for postoperative care and a call-out algorithm for need of extra help. The aim of this investigation was to validate the score.

Methods

After suggesting a prototype score from a pilot study in 182 postoperative patients, we performed a Delphi process by using international experts to create consensus on the final score contents and called the revised tool the Efficacy Safety Score (ESS). Then, we performed a prospective observational study with the ESS throughout the first 24 h postoperatively in 207 surgical in-patients. We compared ESS with Modified Early Warning Systems (MEWS), and postoperative journal information. We subsequently validated ESS by addressing recognized quality criteria for measurement of health status questionnaires.

Results

A call-out value of ESS ≥10 correlated with MEWS > 0 values and journal information about postoperative concerns with a sensitivity of 94% and 92%, respectively. All serious safety issues were identified with the ESS ≥ 10, and a higher number of quality issues were identified than with routine care or MEWS. We obtained positive ratings for six out of seven tested criteria of questionnaire quality; one criterion had an indeterminate rating.

Conclusion

ESS fulfils suggested criteria for score quality validation and reflects the patient’s postoperative status adequately and with high sensitivity. Further clinical trials are warranted to evaluate the usefulness of ESS as a simple tool for assessment of the postoperative safety and quality of patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-017-0344-0) contains supplementary material, which is available to authorized users.

Tools for the assessment of the recovery process following discharge from day surgery: a literature review

This literature review provides an overview of ten studies which assessed the patient's general recovery after discharge from hospital following elective surgery and anaesthesia. Ten multi-dimensional tools were identified and these included six common domain assessments: pain, physiological function, activities of daily living (ADL), emotions, nausea/vomiting and nutrition/elimination. Most of the tools assessed the recovery process by using patient-subjective reported outcomes on visual analogue (VAS) or pre-graded scales.

Feasibility, reliability, and validity of the Japanese version of the Postoperative Quality of Recovery Scale: a first pilot study

The Postoperative Quality of Recovery Scale (PQRS) is a multi-domain tracking scale to assess recovery after surgery. The PQRS is used in seven countries and five languages; however, the Japanese version of the PQRS (PQRSj) has not been established. We therefore translated the PQRS into Japanese, and examined the feasibility, reliability and validity of the PQRSj. The time taken to complete the test was measured to assess feasibility. Cronbach's alpha was calculated to assess reliability. The Mini Mental State Examination (MMSE) and the Japanese version of the Quality of Recovery Scale 40 (QoR-40 J) were performed for comparison with the PQRSj (validity). Fifty-one patients were enrolled in the study. The mean completion time was 3.9 min for baseline (feasibility). Cronbach's alpha was between 0.40 and 0.94 in each domain (reliability). A relationship was shown between cognitive domain and MMSE at baseline (r = 0.65, P < 0.01); however, no relationship was found between the other domains and the MMSE and QoR-40 J. Ceiling effects were observed in 78% of the questions. These results indicate that the PQRSj can be used to assess recovery after surgery, although it may be better to revise some of the questions to improve the validity of the PQRSj.

The Postoperative Recovery Profile (PRP) - a multidimensional questionnaire for evaluation of recovery profiles

AIMS AND OBJECTIVES

The previously developed Postoperative Recovery Profile (PRP) questionnaire is intended for self-assessment of general recovery after surgery. The aim of this study was to further evaluate the questionnaire regarding the construct validity and ability to discriminate recovery profiles between groups. Furthermore, the item variables of greatest importance during the progress of recovery were investigated.

METHODS

Post-operative recovery was assessed during the period from discharge to 12 months after lower abdominal and orthopaedic surgery. Construct validity was evaluated by comparing the assessments from the PRP questionnaire and a global recovery scale. Recovery profiles of the diagnose groups were displayed by the cumulative proportion recovered participants over time. The importance of item variables was investigated by ranking ordering.

RESULTS

A total of 158 patients were included. Support was given for good construct validity. The result showed that 7.6% of all possible pairs were disordered when comparing the assessments from the PRP questionnaire and the global recovery scale. Twelve months after discharge the PRP assessments discriminated significantly the recovery profiles of the abdominal and orthopaedic groups. The variable pain was one of the top five most important issues at each follow-up occasion in both study groups. The importance of the item variables was thereby emphasized.

CONCLUSIONS

The PRP questionnaire allows for evaluation of the progress of post-operative recovery, and can be useful to assess patient-reported recovery after surgical treatment both on individual and group levels. Knowledge about recovery profiles can assist clinicians in determining the critical time points for measuring change.

Validation of a physical activity questionnaire (CHAMPS) as an indicator of postoperative recovery after laparoscopic cholecystectomy

BACKGROUND

Although many surgical innovations are said to "shorten recovery," recovery has not been consistently defined or measured. The goal of this study was to assess the validity of a physical activity questionnaire (The Community Health Activities Model Program for Seniors [CHAMPS]) as an indicator of postoperative recovery.

METHODS

CHAMPS includes 41 questions asking the subject to estimate the time spent on a range of activities in the previous week; responses are converted into kcal/kg/wk. Patients scheduled for laparoscopic cholecystectomy were assessed preoperatively, 1 week and 1 month postoperatively (sensitivity to change). To assess construct validity, results were compared with other measures used to estimate recovery, including pain (VAS), health-related quality of life (SF-36), and complications. CHAMPS was also compared with a measure of exercise capacity, the 6-minute walk test (6MWT). Data expressed as median (IQR).

RESULTS

A total of 50 patients, 72% female, mean (SD) age 51 (17) years, participated. CHAMPS-estimated energy expenditure decreased from 42 [25-64] preop to 18 [9-30] kcal/kg/wk (P < .001) 1 week postoperatively. It remained below baseline at 30 [16-61] kcal/kg/wk 1 month postoperatively (P = .042). At all time points, SF-36 Physical Function, pain with movement, and 6MWT distance significantly correlated with CHAMPS. At 1 month, physical activity was lower in patients reporting complications (16 [10-32] vs 42 [18-77], P < .01).

CONCLUSION

Evidence is provided for construct validity for a physical activity questionnaire as a measure of surgical recovery.

General surgical patients? perspectives of the adequacy and appropriateness of discharge planning to facilitate health decision-making at home

AIM

To investigate general surgical patients' perspectives of the adequacy and appropriateness of their discharge planning.

OBJECTIVES

To identify any aspects of discharge planning that could be strengthened to assist people in managing their posthospital care and maintaining continuity of care.

BACKGROUND

Appropriate discharge planning is a priority in today's healthcare environment in which patients are discharged 'quicker and sicker', sometimes without home support. Adequate and appropriate discharge planning helps promote health literacy, which has benefits for both patients and their caregivers in helping them manage postsurgical recovery at home.

DESIGN

A qualitative, interpretive study was designed in which patients were interviewed at least one week after they returned home from hospital.

METHODS

Purposeful sampling was used to interview 13 general surgical patients from one of three hospitals (two public and one private) in New South Wales and Queensland, Australia. Data were collected in unstructured interviews and analysed using thematic analysis. Reflective analysis by individual research team members generated preliminary themes, which were then analysed collectively by all members of the research team to achieve consensus on patients' perspectives.

RESULTS

Themes included a 'one-size-fits-all' approach to providing discharge information; inconsistent or variable advice from different health professionals; a lack of predischarge assessment of their home and/or work conditions and the need for follow-up assessment of patient and carer needs.

CONCLUSIONS

The findings of this study illuminate the need for a more individualized approach to discharge planning, taking into account the patient's age, gender, surgical procedure and family and community support for immediate and longer-term nursing follow-up.

RELEVANCE TO CLINICAL PRACTICE

Patients would be more adequately prepared for their recovery period at home, by encouraging client-centred, interdisciplinary communication between health practitioners; adopting a flexible, approach to discharge planning which is tailored to individual needs of postsurgical patients, particularly in relation to advice and information related to recovery; and encouraging and supporting adequate health literacy for self-management.

A Systematic Review of Postoperative Recovery Outcomes Measurements After Ambulatory Surgery

BACKGROUND

Mortality and morbidity in ambulatory surgery are rare, and thus the patient's quality of life (i.e., the ability to resume normal activities after discharge home) should be considered one of the principle end-points after ambulatory surgery and anesthesia. We conducted a systematic review of the instruments to measure the quality of recovery of ambulatory surgical patients in order to advise on the selection of appropriate measures for research and quality assurance.

METHODS

A systematic literature search of MEDLINE, EMBASE, CINAHL, HAPI, PsycINFO, Web of Science Search History, Biosys Previews Search, HealthStar, and ASSIA was performed to identify patient-based outcome measures to assess postoperative recovery from ambulatory anesthesia. The instruments were assessed for eight criteria: appropriateness, reliability, validity, responsiveness, precision, interpretability, acceptability, and feasibility.

RESULTS

Seven articles met the inclusion criteria set for the review. The quality of the identified instruments was variable.

CONCLUSION

Only one instrument, 40-item Quality of recovery score, fulfilled all eight criteria, however this instrument was not specifically designed for ambulatory surgery and anesthesia.

Robotic surgery and training: electromyographic correlates of robotic laparoscopic training

BACKGROUND

Robotic laparoscopic surgery has been shown to decrease task completion time, reduce errors, and decrease training time, as compared with manual laparoscopic surgery. However, current literature has not addressed the physiologic effects, in particular muscle responses, to training with a robotic surgical system. The authors seek to determine the frequency response of electromyographic (EMG) signals of specific arm and hand muscles with training using the da Vinci Surgical System.

METHODS

Seven right-handed medical students were trained in three tasks with the da Vinci Surgical System over 4 weeks. These subjects, along with eight control subjects, were tested before and after training. Electromyographic (EMG) signals were collected from four arm and hand muscles during the testing sessions, and the median EMG frequency and bandwidth were computed.

RESULTS

The median frequency and frequency bandwidth both were increased after training for two of the three tasks.

CONCLUSION

The results suggest that training reduces muscle fatigue as a result of faster and more deliberate movements. These changes occurred predominantly in muscles that were the dominant muscles for each task, whereas the more demanding task recruited more diverse motor units. An evaluation of the physiologic demands of robotic laparoscopic surgery using electromyography can provide us with a meaningful quantitative way to examine performance and skill acquisition.

Robotic surgery training and performance: identifying objective variables for quantifying the extent of proficiency

BACKGROUND

To understand the process of skill acquisition in robotic surgery and to allow useful real-time feedback to surgeons and trainees in future generations of robotic surgical systems, robotic surgical skills should be determined with objective variables. The aim of this study was to assess skill acquisition through a training protocol, and to identify variables for the quantification of proficiency.

METHODS

Seven novice users of the da Vinci Surgical System engaged in 4 weeks of training that involved practicing three bimanual tasks with the system. Seven variables were determined for assessing speed of performance, bimanual coordination, and muscular activation. These values were compared before and after training.

RESULTS

Significant improvements were observed through training in five variables. Bimanual coordination showed differences between the surgical tasks used, whereas muscular activation patterns showed better muscle use through training. The subjects also performed the surgical tasks considerably faster within the first two to three training sessions.

CONCLUSIONS

The study objectively demonstrated that the novice users could learn to perform surgical tasks faster and with more consistency, better bimanual dexterity, and better muscular activity utilization. The variables examined showed great promise as objective indicators of proficiency and skill acquisition in robotic surgery.