Extended mobility scale (AMEXO) for assessing mobilization and setting goals after gastrointestinal and oncological surgery: a before-after study

Surgical outcomes in surgical oncology patients who participated in a family involvement program

BACKGROUND

There is a lack of evidence regarding the relationship between family involvement and outcomes in gastrointestinal oncology patients after surgery. To evaluate the effect of a family involvement program for patients undergoing oncologic gastrointestinal surgery on unplanned readmissions within 30 days after surgery.

METHODS

A multicenter patient-preference cohort study compared 2 groups: patients who participated in the family involvement program versus usual care. The program comprised involvement of family caregivers in care and training of health care professionals in family-centered care. Multivariable regression analyses were used to evaluate the effect of the FIP on the number of unplanned readmissions up to 30 days after surgery. Secondary outcomes included complications sensitive to fundamental care activities, emergency department visits, intensive care unit admissions, hospital length of stay, and the need for professional home care after discharge.

RESULTS

Of the 301 patients included, 152 chose the family involvement program, and 149 chose usual care. Postoperative readmissions occurred in 25 (16.4%) patients in the family involvement program group, and 15 (10.1%) in the usual care group (P = .11). A significant reduction of 16.2% was observed in the need for professional home care after discharge in the family involvement program group (P < .01). No significant differences were found between the 2 groups in the other secondary outcomes.

CONCLUSION

The family involvement program did not reduce the number of unplanned readmissions, but it led to a substantial reduction in-home care, which suggests an economic benefit from a societal perspective. Implementation of the family involvement program should, therefore, be considered in clinical practice.

Mobility level and factors affecting mobility status in hospitalized patients admitted in single-occupancy patient rooms

BACKGROUND

Although stimulating patients' mobility is considered a component of fundamental nursing care, approximately 35% of hospitalized patients experience functional decline during or after hospital admission. The aim of this study is to assess mobility level and to identify factors affecting mobility status in hospitalized patients admitted in single-occupancy patient rooms (SPRs) on general wards.

METHODS

Mobility level was quantified with the Johns Hopkins Highest Level of Mobility Scale (JH-HLM) and EQ-5D-3L. GENEActiv accelerometer data over 24 h were collected in a subset of patients. Data were analyzed using generalized ordinal logistic regression analysis. The STROBE reporting checklist was applied.

RESULTS

Wearing pajamas during daytime, having pain, admission in an isolation room, and wearing three or more medical equipment were negatively associated with mobilization level. More than half of patients (58.9%) who were able to mobilize according to the EQ-5D-3L did not achieve the highest possible level of mobility according to the JH-HLM. The subset of patients that wore an accelerometer spent most of the day in sedentary behavior (median 88.1%, IQR 85.9-93.6). The median total daily step count was 1326 (range 22-5362).

CONCLUSION

We found that the majority of participating hospitalized patients staying in single-occupancy patient rooms were able to mobilize. It appeared, however, that most of the patients who are physically capable of walking, do not reach the highest possible level of mobility according to the JH-HLM scale. Nurses should take their responsibility to ensure that patients achieve the highest possible level of mobility.

Comparison of postoperative mobilization measurements by activPAL versus Johns Hopkins Highest Level of Mobility scale after major abdominal surgery

BACKGROUND

The Johns Hopkins Highest Level of Mobility scale is a validated tool for assessing patient mobility in the hospital. It has excellent inter-rater and test-retest reliabilities, but it is unknown how accurately Johns Hopkins Highest Level of Mobility documentation reflects the patients' mobility performance in the immediate postoperative period compared to objective measures such as accelerometers.

METHODS

In this single-center observational study, consented adults undergoing open abdominal surgery wore a research-grade accelerometer, activPAL, starting immediately postoperatively until hospital discharge or up to 7 days. We collected the Johns Hopkins Highest Level of Mobility scores documented by hospital staff via retrospective chart review and evaluated their accuracy in describing the type, frequency, and volume of postoperative out-of-bed mobilization using the activPAL as the criterion.

RESULTS

We analyzed data from 56 participants. The activPAL showed that participants spent 97.7% of their time lying in bed or sitting in a chair. Meanwhile, the Johns Hopkins Highest Level of Mobility documentation of preambulatory activities (scores 1-5) was rare. The activPAL detected 4 times more out-of-bed mobilization than routine Johns Hopkins Highest Level of Mobility documentation. Whereas the frequency of activPAL-measured out-of-bed mobilization increased steadily to a median of 9 sessions by postoperative day 6, the number of Johns Hopkins Highest Level of Mobility documentation remained around twice daily. ActivPAL measurements demonstrated that Johns Hopkins Highest Level of Mobility documentation of ambulatory sessions (scores 6-8) was accurate.

CONCLUSIONS

We found that routine Johns Hopkins Highest Level of Mobility documentation did not accurately detect preambulatory activities or the overall frequency of out-of-bed mobility sessions, poorly reflecting the highly sedentary behaviors of the acute postoperative inpatients and highlighting the need to improve clinical documentation or use alternative methods to track postoperative mobilization.

Effects of early postoperative mobilization following gastrointestinal surgery: systematic review and meta-analysis

BACKGROUND

Early postoperative mobilization is considered a key element of enhanced recovery after surgery protocols. The aim of this study was to summarize the effect of early postoperative mobilization following gastrointestinal operations on patient recovery, mobility, the morbidity rate and duration of hospital stay.

METHODS

A systematic literature search was conducted in December, 2022, using PubMed, Web of Science and the Cochrane Central Register of Controlled Trials. Controlled trials reporting the effects of early postoperative mobilization after gastrointestinal surgery were included. The risk of bias was assessed using a modified Downs and Black tool and the Cochrane Collaboration tool for randomized trials. The outcomes of interest were gastrointestinal recovery (defined passage of first flatus or bowel movements), mobility (step count on postoperative day 3), the morbidity rate and duration of hospital stay.

RESULTS

After elimination of duplicates, 3678 records were identified, and 71 full-text articles were screened. Finally, 15 studies (eight RCTs) reporting on 3538 patients were included. Most trials evaluated early postoperative mobilization after different gastrointestinal operations, including upper gastrointestinal (n = 8 studies), hepatopancreatobiliary (n = 10 studies) and colorectal resections (n = 10 studies). The investigated early postoperative mobilization protocols, operative techniques (minimally invasive or open) and outcome parameters were heterogeneous between the studies. Early postoperative mobilization seemed to significantly accelerate clinical gastrointestinal recovery (mean difference, hours: -11.53 (-22.08, -0.97), P = 0.03). However, early postoperative mobilization did not significantly improve the morbidity rate (risk ratio: 0.93 (0.70, 1.23), P = 0.59), postoperative mobility of patients (step count mean difference: 1009 (-803, 2821), P = 0.28) or shorten the duration of hospital stay (mean difference, days: -0.25 (-0.99,0.43), P = 0.47) in randomized trials.

CONCLUSION

There is a large heterogeneity among the study cohorts, operations and interventions. The available evidence currently does not support specific early postoperative mobilization protocols as an isolated element to further reduce the morbidity rate and duration of hospital stay. Further well-designed trials are required to identify effective early postoperative mobilization protocols.

Early mobilization after esophageal cancer surgery: a retrospective cohort study

A key component of the Enhanced Recovery After Surgery pathway for esophagectomy is early mobilization. Evidence on a specific protocol of early and structured mobilization is scarce, which explains variation in clinical practice. This study aims to describe and evaluate the early mobilization practice after esophagectomy for cancer in a tertiary referral center in the Netherlands. This retrospective cohort study included data from a prospectively maintained database of patients who underwent an esophagectomy between 1 January 2015 and 1 January 2020. Early mobilization entailed increase in activity with the first target of ambulating 100 meters. Primary outcomes were the number of postoperative days (PODs) until achieving this target and reasons for not achieving this target. Secondary outcomes were the relationship between preoperative factors (e.g. sex, BMI) and achieving the target on POD1, and the relationship between achieving the target on POD1 and postoperative outcomes (i.e. length of stay, readmissions). In total, 384 patients were included. The median POD of achieving the target was 2 (IQR 1-3), with 173 (45.1%) patients achieving this on POD1. Main reason for not achieving this target was due to hemodynamic instability (22.7%). Male sex was associated with achieving the target on POD1 (OR = 1.997, 95%CI 1.172-3.403, P = 0.011); achieving this target was not associated with postoperative outcomes. Ambulation up to 100 m on POD1 is achievable in patients after esophagectomy, with higher odds for men to achieve this target. ERAS pathways for post esophagectomy care are encouraged to incorporate 100 m ambulation on POD1 in their guideline as the first postoperative target.

Activating Relatives to Get Involved in Care After Surgery: Protocol for a Prospective Cohort Study

BACKGROUND

Postoperative complications and readmissions to hospital are factors known to negatively influence the short- and long-term quality of life of patients with gastrointestinal cancer. Active family involvement in activities, such as fundamental care activities, has the potential to improve the quality of health care. However, there is a lack of evidence regarding the relationship between active family involvement and outcomes in patients with gastrointestinal cancer after surgery.

OBJECTIVE

This protocol aims to evaluate the effect of a family involvement program (FIP) on unplanned readmissions of adult patients undergoing surgery for malignant gastrointestinal tumors. Furthermore, the study aims to evaluate the effect of the FIP on family caregiver (FC) burden and their well-being and the fidelity of the FIP.

METHODS

This cohort study will be conducted in 2 academic hospitals in the Netherlands. The FIP will be offered to adult patients and their FCs. Patients are scheduled for oncological gastrointestinal surgery and have an expected hospital stay of at least 5 days after surgery. FCs must be willing to participate in fundamental care activities during hospitalization and after discharge. Consenting patients and their families will choose to either participate in the FIP or be included in the usual care group. According to the power calculation, we will recruit 150 patients and families in the FIP group and 150 in the usual care group. The intervention group will receive the FIP that consists of information, shared goal setting, task-oriented training, participation in fundamental care, presence of FCs during ward rounds, and rooming-in for at least 8 hours a day. Patients in the comparison group will receive usual postoperative care. The primary outcome measure is the number of unplanned readmissions up to 30 days after surgery. Several secondary outcomes will be collected, that is, total number of complications (sensitive to fundamental care activities) at 30 and 90 days after surgery, emergency department visits, intensive care unit admissions up to 30 and 90 days after surgery, hospital length of stay, patients' quality of life, and the amount of home care needed after discharge. FC outcomes are caregiver burden and well-being up to 90 days after participating in the FIP. To evaluate fidelity, we will check whether the FIP is executed as intended. Univariable regression and multivariable regression analyses will be conducted.

RESULTS

The first participant was enrolled in April 2019. The follow-up period of the last participant ended in May 2022. The study was funded by an unrestricted grant of the University hospital in 2018. We aim to publish the results in 2023.

CONCLUSIONS

This study will provide evidence on outcomes from a FIP and will provide health care professionals practical tools for family involvement in the oncological surgical care setting.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38028.

Impact of family visit restrictions due to COVID-19 policy on patient outcomes: A cohort study

AIM

To investigate the impact of family visit restrictions during the COVID-19 pandemic on deliriums, falls, pneumonia, pressure ulcers and readmissions among surgical inpatients with gastrointestinal (oncologic) diseases.

DESIGN

Cohort study.

METHODS

This study was conducted among adult inpatients undergoing gastrointestinal surgery in two academic hospitals. During the COVID-19 outbreak in 2020, over a 10-week period, one cohort was subjected to family visit restrictions. Per patient, one person per day was allowed to visit for a maximum of 30 min. This cohort was compared with another cohort in which patients were not subjected to such restrictions during a 10-week period in 2019. Logistic regression analyses were used to investigate the impact of the restrictions on deliriums, falls, pneumonia, pressure ulcers and readmissions.

RESULTS

In total, 287 patients were included in the 2020 cohort and 243 in the 2019 cohort. No differences were observed in the cohorts with respect to baseline characteristics. Logistic regression analyses showed no significant differences in deliriums, falls, pneumonia, pressure ulcers and readmissions between the cohorts.

CONCLUSION

We cautiously conclude that the family visit restrictions during the COVID-19 pandemic did not contribute to deliriums, falls, pneumonia, pressure ulcers or readmissions in surgical patients with gastrointestinal (oncologic) diseases.

IMPACT

COVID-19 influenced family-centred care due to family visit restrictions. Nurses need to continue monitoring outcomes known to be sensitive to family-centred care to gain insight into the effects of visit restrictions and share the results in order to include nurses' perspectives in COVID-19-decision-making. Re-implementing of family visit restrictions should be carefully considered in policy-making.