Patient participation in postoperative care activities in patients undergoing total knee replacement surgery: Multimedia Intervention for Managing patient Experience (MIME). Study protocol for a cluster randomised crossover trial

Association between patient activation and adherence to a colorectal enhanced recovery pathway: a prospective cohort study

BACKGROUND

Low adherence to enhanced recovery pathways (ERPs) may negatively affect postoperative outcomes. The objective of this study was to assess the extent to which patient activation (PA, i.e., knowledge, skills, and confidence to participate in care) is associated with adherence to an ERP for colorectal surgery.

METHODS AND PROCEDURES

This cohort study included adult patients (≥ 18 yo) undergoing in-patient elective colorectal surgery at two university-affiliated hospitals in Montreal, Canada. Preoperatively, patients completed the Patient Activation Measure (PAM) questionnaire (score 0-100, categorized into low PA [≤ 55.1] vs. high PA [≥ 55.2]). All patients were managed with an ERP including 15 interventions classified into 2 groups: those requiring active patient participation (5 active ERP interventions, including early oral intake and mobilization) and those directed by the clinical team (10 passive ERP interventions, including early termination of IV fluids and urinary drainage). The adjusted association between PA and ERP adherence was evaluated using linear regression.

RESULTS

A total of 286 patients were included (mean age 59 ± 15 years, 45% female, 62% laparoscopic, 33% rectal, median length of stay 4 days [IQR 2-6]). Most patients had high levels of PA (74%). Mean adherence was 90% (95% CI 88-91%) for passive ERP interventions and 72% (95% CI 70-75%) for active interventions. On regression analysis, high PA was associated with increased adherence to active ERP interventions (+ 6.8% [95% CI + 1.1 to + 12.5%]), but not to passive interventions (+ 2.5% [95% CI - 0.3 to + 5.3%]). Increased active ERP adherence was associated with reduced length of stay, 30-day complications, and hospital readmissions.

CONCLUSION

This study supports that high PA is associated with increased adherence to ERP interventions, particularly those requiring active patient participation. Preoperative identification of patients with low activation may inform interventions to optimize patient involvement with ERPs and improve postoperative outcomes.

A home-based tele-rehabilitation exercise system for patients after knee replacement surgery

BACKGROUND

Knee arthritis is a destructive disorder that affects the knee joints and causes pain and reduced mobility. Drug treatments, weight loss, and exercise control the symptoms of the disease, but these methods only delay the disease process and eventually, knee joint replacement surgery will be needed. After surgery, with the help of a proper physiotherapy program, full recovery takes an average of 6-12 months. However, currently, there is no similar tool to facilitate this process in Iran.

OBJECTIVE

The purpose of this research is to design and develop the prototype of a rehabilitation system for patients after knee replacement surgery, which provides patients with information and appropriate physiotherapy programs.

METHODS

This study was development-applied and was done in three stages. In the first stage, the needs and content of education and therapeutic exercises were prepared in the form of a checklist, and then the necessity of each item was checked in the evaluation sessions. In the second stage, the prototype of the system was developed using Adobe XD software and based on the requirements approved from the previous stage. In the third stage, the usability of the program was analyzed from the point of view of experts using the exploratory evaluation method with Nielsen's 13 principles of usability.

RESULTS

At first, the system requirements were extracted and prepared in two checklists of content (51 exercises) and capabilities (60 items). Then after a survey of experts based on the Delphi technique, content information (43 exercises) and functional and non-functional requirements (53 items) were obtained. A survey of experts helped to finalize the information elements, categorize them, and prepare the final version of the checklists. Based on this, the system requirements were classified into 11 categories, and the training content was classified into 3 training periods. Finally, the design and development of the system was done. This system has admin, physician, and patient user interfaces. The result of usability showed that this system is efficient and there are only a few problems in the feature of helping users to detect and recover from errors.

CONCLUSION

It seems necessary to develop a system based on the principles of usability by therapists and rehabilitation specialists to train and monitor the remote rehabilitation process of patients after knee joint replacement at home. And the importance of involving stakeholders in the design and development of remote rehabilitation systems is not hidden from anyone. Kara system has all of the above.

Mobile and Computer-Based Applications for Rehabilitation Monitoring and Self-Management After Knee Arthroplasty: Scoping Review

BACKGROUND

Successful post-knee replacement rehabilitation requires adequate access to health information, social support, and periodic monitoring by a health professional. Mobile health (mHealth) and computer-based technologies are used for rehabilitation and remote monitoring. The extent of technology use and its function in post-knee replacement rehabilitation care in low and middle-income settings are unknown.

OBJECTIVE

To inform future mHealth intervention development, we conducted a scoping review to map the features and functionality of existing technologies and determine users' perspectives on telerehabilitation and technology for self-management.

METHODS

We followed the Joanna Briggs Institute methodology for scoping reviews. We searched the Embase, Medline, PsycINFO via OVID, and Cochrane Central Register of Controlled Trials databases for manuscripts published from 2001 onward. We included original research articles reporting the use of mobile or computer-based technologies by patients, health care providers, researchers, or family members. Studies were divided into the following 3 categories based on the purpose: validation studies, clinical evaluation, and end user feedback. We extracted general information on study design, technology features, proposed function, and perspectives of health care providers and patients. The protocol for this review is accessible in the Open Science Framework.

RESULTS

Of the 5960 articles, 158 that reported from high-income settings contributed to the qualitative summary (64 studies on mHealth or telerehabilitation programs, 28 validation studies, 38 studies describing users' perceptions). The highest numbers of studies were from Europe or the United Kingdom and North America regarding the use of a mobile app with or without wearables and reported mainly in the last decade. No studies were from low and middle-income settings. The primary functions of technology for remote rehabilitation were education to aid recovery and enable regular, appropriate exercises; monitoring progress of pain (n=19), activity (n=20), and exercise adherence (n=30); 1 or 2-way communication with health care professionals to facilitate the continuum of care (n=51); and goal setting (n=23). Assessment of range of motion (n=16) and gait analysis (n=10) were the commonly validated technologies developed to incorporate into a future rehabilitation program. Few studies (n=14) reported end user involvement during the development stage. We summarized the reasons for satisfaction and dissatisfaction among users across various technologies.

CONCLUSIONS

Several existing mobile and computer-based technologies facilitate post-knee replacement rehabilitation care for patients and health care providers. However, they are limited to high-income settings and may not be extrapolated to low-income settings. A systematic needs assessment of patients undergoing knee replacement and health care providers involved in rehabilitation, involving end users at all stages of development and evaluation, with clear reporting of the development and clinical evaluation can make post-knee replacement rehabilitation care in resource-poor settings accessible and cost-effective.

Time Effect on Acute Postoperative Pain After Total Knee Replacement Surgery: An Exploratory Study Using the Experience Sampling Method

OBJECTIVES

Acute postoperative pain (APP) is the main cause of postoperative dissatisfaction; however, traditional methods of pain assessment provide limited insights into the dynamics and development of APP. This study used the experience sampling method to understand the dynamics of APP over time in relation to various patient factors.

MATERIALS AND METHODS

Forty patients scheduled to undergo total knee replacement surgery were recruited in this study. Following an initial assessment, a short report questionnaire was sent to the patients through 10 digital alerts per day to assess the pain levels during 2 preoperative and the first 6 postoperative days. The data were analyzed using multilevel regression, including random intercept and slope.

RESULTS

Thirty-two patients submitted the prespecified minimum of 30% of their short reports, yielding 1217 records. The analysis revealed significant ( P <0.001) linear and quadratic decreases in APP and a quadratic time effect. The lowest between-day and within-day pain levels were observed on postoperative day 4.8 and during the time slot 3.8 or ~19:15, respectively. Significant random intercepts and slopes were noted, indicating variations in the mean pain level between patients and a decrease in pain. None of the 10 patient factors had any confounding effect.

DISCUSSION

Using the experience sampling method data combined with multilevel analysis, we were able to evaluate the postoperative pain course while considering inter-individual differences in the baseline pain level and nonlinear pain course over time. The findings of this study could aid clinicians in personalizing the treatment for APP.

The Effect of Education Planned According to Health Literacy Level on Functionality, Problems Experienced, and Quality of Life in Patients Undergoing Total Knee Replacement: A Nonrandomized Comparison Group Intervention Study

Total knee arthroplasty procedures significantly improve quality of life for persons with debilitating pain. It is essential to plan patient education according to the level of health literacy. This nonrandomized comparison group intervention study examines the effect of education planned according to health literacy level on functionality, postoperative problems (pain and anxiety), and quality of life in patients who undergo total knee replacement. During the study, patients in the intervention group (n = 51) were provided with the planned patient education according to their health literacy level, whereas patients in the comparison group were given routine care (n = 51). Patients in the postoperative intervention group experienced fewer problems (p < .05). Education tailored to patients' health literacy levels had a positive effect on their functionality and quality of life (p < .05). Our findings suggest planning education according to patient health literacy levels may have a positive influence on functionality, postoperative problems, and quality of life among patients undergoing total knee replacement.

Impact of Pain on Postoperative Recovery and Participation in Care Following Knee Arthroplasty Surgery: A Qualitative Descriptive Study

BACKGROUND

Patient participation in care is key to optimising postsurgical outcomes and the quality of acute care delivery.

AIMS

This study explored patient perceptions of the impact of pain on acute recovery following Total Knee Arthroplasty (TKA), and barriers and facilitators to participating in pain management.

DESIGN

An exploratory-descriptive qualitative study involving semi-structured interviews.

SETTINGS

A private-sector health service.

PARTICIPANTS/SUBJECTS

Participants were adults undergoing TKA allocated to the control ward of a cluster randomised controlled trial who received standard care.

METHODS

To allow adequate opportunity for participation in their care, interview and pain data were collected on postoperative Day 3. Acute pain was assessed using an 11-point Numerical Rating Scale (NRS). Interviews were analysed using combined qualitative thematic analysis and quantitative content analysis.

RESULTS

Overall, 120 patients, 69 females (50.4%) and 68 males, were interviewed (mean age = 66.8 years, stadard deviation [SD] = 8.5). Most reported severe (NRS 7-10), day 3 pain (n = 76, 63.3%). Two themes emerged from interviews: (1) participants' postoperative pain experience; and (2) participation in postoperative pain management was limited. Pain experience was characterised by variation in pain and its qualities, having uncontrolled pain and distress, and influence from preoperative expectations. Patient participation was characterized by reliance upon prior staff instruction, barriers from limited knowledge, inconsistent promotion of non-pharmacologic strategies, and suboptimal clinician-patient communication. Regular analgesia was identified to facilitate participation.

CONCLUSIONS

Despite the known benefits of patient participation in pain management, gaps remain in providing patients with the knowledge and opportunity to take an active role in their recovery. Interventions to overcome identified barriers need to be developed and evaluated.

Predicting factors that determine patients' satisfaction with post-operative pain management following abdominal surgeries at Komfo Anokye Teaching Hospital, Kumasi, Ghana

Introduction

Poorly controlled postoperative pain has been known to be characterized by longer post-operative care, longer hospital stays with increased readmission rates, and decreased patient satisfaction. Post-operative pain has been continuously addressed in the past three (3) to four (4) decades and has been shown that 20 to 80% of post-operative patients suffer ineffective pain management.

Objective

The study was aimed at assessing the factors that may predict the satisfaction of patients with early postoperative pain management following abdominal surgeries at the Komfo Anokye Teaching Hospital, Kumasi.

Methodology

A descriptive cross-sectional study was conducted among patients who had undergone abdominal surgeries between October 2019 and December 2019 at the Komfo Anokye Teaching Hospital. Structured questionnaires based on the IPO-Q were used to obtain responses from the patients. Descriptive and Inferential statistical analysis were employed in analyzing the data obtained from the respondents of the study.

Results

138 patients were involved in this study. The mean age of patients in the study was 45.81 (±16.81) years. A higher percentage, 58.7% of the patients were males. 39.1% had completed their tertiary level of education. The majority (50.7%) of the patients had had persistent pain for more than three (3) months. The satisfaction of the patients with the post-operative pain management received was generally high among a significant majority of the patients. Meanwhile, among the factors that influence the satisfaction of the patients with the post-operative pain management received, type of analgesia and pain relief methods (Pearson Coefficient = 0.523, p-value <0.05), patient’s ability to request more pain relief, (Pearson Coefficient = 0.29, p-value <0.05), patient’s access to information about their pain treatment options from the Nurses (Pearson coefficient = -0.22, p<0.05), were the only predictors of satisfaction in patients.

Conclusion

This study found out that patients were generally satisfied with the post-operative pain management offered by their healthcare providers although the degree of satisfaction depended largely on the type of analgesia and pain relief methods, the ability to request for more pain relief, and access to information on pain treatment.

Impact of demonstration in a realistic simulation environment as a postoperative education in patients' experience

OBJECTIVE

To evaluate the impact of training in the Practical Life Room on patients experience during hospitalization.

METHODS

Subjects submitted to orthopedic surgeries were randomized to two groups (Control and Intervention) in the postoperative period. The Control Group received only the printed guidelines regarding the postoperative period, and the Intervention Group received the printed guidelines and a demonstration and training session with a physical therapist, in an environment created to simulate a house and its rooms (living room, bedroom, kitchen, laundry and bathroom). The participants of both groups answered the questionnaire Hospital Consumer Assessment of Healthcare Providers and Systems on the day of discharge.

RESULTS

Sixty-eight subjects were included in the study, 30 (44.1%) in the Control Group and 38 (55.9%) in the Intervention Group. The Hospital Consumer Assessment of Healthcare Providers and Systems questionnaire score showed no significant difference between the groups (p=0.496).

CONCLUSION

There was no influence of the proposed intervention on the results of the Hospital Consumer Assessment of Healthcare Providers and Systems questionnaire, perhaps because of the limitation of the instrument or due to the fact it was employed when patients were still hospitalized. However, by reports from patients in the Intervention Group about felling better prepared and safer for performing daily activities, it is believed that patient education approaches through demonstration should be included as part of the process to prepare for discharge, whenever possible.

The Effect of an App for Day-to-Day Postoperative Care Education on Patients With Total Knee Replacement: Randomized Controlled Trial

Background

Patients who undergo primary Total Knee Replacement surgery (TKR) are often discharged within 1-3 days after surgery. With this relatively short length of hospital stay, a patient’s self-management is a crucial factor in optimizing the outcome of their treatment. In the case of TKR, self-management primarily involves adequate pain management, followed by physiotherapy exercises and daily self-care activities. Patients are educated on all these topics by hospital staff upon discharge from the hospital but often struggle to comprehend this information due to its quantity, complexity, and the passive mode of communication used to convey it.

Objective

This study primarily aims to determine whether actively educating TKR patients with timely, day-to-day postoperative care information through an app could lead to a decrease in their level of pain compared to those who only receive standard information about their recovery through the app. In addition, physical functioning, quality of life, ability to perform physiotherapy exercises and daily self-care activities, satisfaction with information, perceived involvement by the hospital, and health care consumption were also assessed.

Methods

A multicenter randomized controlled trial was performed in five Dutch hospitals. In total, 213 patients who had undergone elective, primary, unilateral TKR participated. All patients had access to an app for their smartphone and tablet to guide them after discharge. The intervention group could unlock day-to-day information by entering a personal code. The control group only received weekly, basic information. Primary (level of pain) and secondary outcomes (physical functioning, quality of life, ability to perform physiotherapy exercises and activities of daily self-care, satisfaction with information, perceived involvement by the hospital, and health care consumption) were measured using self-reported online questionnaires. All outcomes were measured weekly in the four weeks after discharge, except for physical functioning and quality of life, which were measured at baseline and at four weeks after discharge. Data was analyzed using Student t tests, chi-square tests, and linear mixed models for repeated measures.

Results

In total, 114 patients were enrolled in the intervention group (IG) and 99 in the control group (CG). Four weeks after discharge, patients in the IG performed significantly better than patients in the CG on all dimensions of pain: pain at rest (mean 3.45 vs mean 4.59; P=.001), pain during activity (mean 3.99 vs mean 5.08; P&lt;.001) and pain at night (mean 4.18 vs mean 5.21; P=.003). Additionally, significant differences were demonstrated in favor of the intervention group for all secondary outcomes.

Conclusions

In the four weeks following TKR, the active and day-to-day education of patients via the app significantly decreased their level of pain and improved their physical functioning, quality of life, ability to perform physiotherapy exercises and activities of daily self-care, satisfaction with information, perceived involvement by the hospital, and health care consumption compared to standard patient education. Given the rising number of TKR patients and the increased emphasis on self-management, we suggest using an app with timely postoperative care education as a standard part of care.

Trial Registration

Netherlands Trial Register NTR7182; https://www.trialregister.nl/trial/6992

Patient activation intervention to facilitate participation in recovery after total knee replacement (MIME): a cluster randomised cross-over trial

Background

Patient participation in care is a fundamental element of safe and high-quality healthcare with the potential to enhance health outcomes and improve patient satisfaction.

Objectives

To test the efficacy of a clinician-facilitated, bedside multimedia (MyStay) intervention designed to support patient participation in their recovery after total knee replacement surgery. The primary outcome was patients’ reported worst pain intensity on postoperative day 3. Secondary outcomes were patient activation, length of hospital stay, knee function and satisfaction with care.

Methods

Unmasked, cluster randomised, four-period cross-over trial with a simultaneous process evaluation within in a large private, not-for-profit, metropolitan teaching hospital. Statistical analyses used linear mixed models with random effects for wards, cohorts within wards and patients within cohorts and fixed effects for treatment and period.

Results

241 patients were recruited between March 2014 and June 2015. Patients were admitted to intervention (104) or control (137) clusters. Intervention group patients reported significantly lower mean pain intensity scores on postoperative day 3 (6.1 vs 7.1, 95% CI −1.94 to −0.08, p=0.04). The percentages of patients who reported severe pain (score ≥7) were 43.7% and 64.2% in the intervention and control groups, respectively (χ² 9.89, p=0.002; generalised linear mixed model Wald test, p=0.05). Intervention group patients on average stayed in hospital one less day (5.3 vs 6.3, 95% CI 0.05 to 1.94, p=0.04), reported higher activation (45.1% vs 27.1% at level 4 activation) (p=0.04) and higher overall satisfaction with care (9.3 vs 8.6, 95% CI 1.09 to 0.219, p=0.01), and were more likely to refer family or friends to the health service (9.3 vs 8.7, 95% CI 1.07 to 0.13, p=0.02).

Conclusion

The clinician-facilitated, MyStay bedside multimedia intervention enhanced patients’ activation and participation in their care after surgery; pain intensity and length of stay in hospital were reduced and patients were more satisfied with their care.

Trial registration

ACTRN12614000340639 (http://www.anzctr.org.au/default.aspx).

Effects of Elastic Band Exercise on Lower Limb Rehabilitation of Elderly Patients Undergoing Total Knee Arthroplasty

PURPOSE

The aim of the study was to investigate the effect of elastic band exercise activities on lower extremity rehabilitation in elderly patients subjected to an elastic band exercise intervention 2 and 4 weeks after total knee arthroplasty.

DESIGN

A quasiexperimental study was conducted. Participants were recruited from southern Taiwan who were over 65 years old and had a first unilateral total knee arthroplasty for osteoarthritis.

METHODS

The control and experimental groups comprised 25 patients each. The control group received conventional treatment after total knee arthroplasty; by contrast, the experimental group engaged in elastic band exercise activities demonstrated by instructors, in addition to receiving conventional treatment. Effects of the lower extremity rehabilitation of the two groups were evaluated 2 and 4 weeks after total knee arthroplasty.

FINDINGS

Most of the participants were above 70 years of age, 17 of whom were in the control group (68%) and 16 in the experimental group (64%). The active and passive knee flexion angles of the experimental group were greater than those of the control group (p < .001) 2 and 4 weeks after surgery. The muscle strength of the quadriceps of the experimental group was higher than that of the control group (p < .001) 2 and 4 weeks after surgery. The experimental group exhibited significantly higher physical function than that of the control group 2 and 4 weeks after surgery (p < .001).

CONCLUSIONS

The elastic band exercise program shows promising effects on improving the lower limb rehabilitation of elderly patients with total knee arthroplasty.

CLINICAL RELEVANCE

Healthcare professionals who work with elderly patients with total knee arthroplasty may consider recommending and implementing the elastic band exercise program as a home rehabilitation method for this population. However, we recommend further testing of the long-term effects of this program on a larger population.

Patient participation in inpatient ward rounds on acute inpatient medical wards: a descriptive study

BACKGROUND

Meaningful partnering with patients is advocated to enhance care delivery. Little is known about how this is operationalised at the point of care during hospital ward rounds, where decision-making concerning patient care frequently occurs.

OBJECTIVE

Describe participation of patients, with differing preferences for participation, during ward rounds in acute medical inpatient services.

METHODS

Naturalistic, multimethod design. Data were collected using surveys and observations of ward rounds at two hospitals in Melbourne, Australia. Using convenience sampling, a stratified sample of acute general medical patients were recruited. Prior to observation and interview, patient responses to the Control Preference Scale were used to stratify them into three groups representing diverse participation preferences: active control where the patient makes decisions; shared control where the patient prefers to make decisions jointly with clinicians; and passive control where the patient prefers clinicians make decisions.

RESULTS

Of the 52 patients observed over 133 ward rounds, 30.8% (n=16) reported an active control preference for participation in decision-making during ward rounds, 25% (n=13) expressed shared control preference and 44.2% (n=23) expressed low control preference. Patients' participation was observed in 75% (n=85) of ward rounds, but few rounds (18%, n=20) involved patient contribution to decisions about their care. Clinicians prompted patient participation in 54% of rounds; and in 15% patients initiated their own participation. Thematic analysis of qualitative observation and patient interview data revealed two themes, supporting patient capability and clinician-led opportunity, that contributed to patient participation or non-participation in ward rounds.

CONCLUSIONS

Participation in ward rounds was similar for patients irrespective of control preference. This study demonstrates the need to better understand clinician roles in supporting strategies that promote patient participation in day-to-day hospital care.