Home Recovery Research Articles

Water-Assisted Colonoscopy.

The current review will attempt to describe the important lessons learned from published randomized controlled trials (RCT) comparing water immersion (WI) or water exchange (WE) techniques with gas insufflation colonoscopy. Air insufflation (AI) to distend the colon to permit visualization and passage through the lumen was developed for diagnostic colonoscopy. When screening colonoscopy was adopted, the same AI method was used. Interval cancers, diagnosed within 3 to 5years after an index screening colonoscopy, appeared to be linked to low adenoma detection rate (ADR). Conscious sedation was introduced to manage insertion pain a few decades ago, incurring moderate costs of nursing staff, space for recovery, patient burdens of escort requirement, and at home recovery time. Recent advancement to deep sedation entailed additional costs of anesthesia staff support. In the past decade, investigators worldwide evaluated the use of water-assisted methods as an adjunct or in lieu of gas insufflation during insertion to minimize discomfort and improve ease of insertion. For convenience, one approach embraced the removal of infused water during withdrawal (WI). A subsequent evolution entailed removal of infused water predominantly during insertion (WE), specifically designed to further minimize insertion pain. Results of RCT shed light on the impact of WI and WE on insertion pain (primary outcome) and adenoma detection (secondary outcome). Water immersion is easier to learn and apply than WE, but mastery of the WE technique appears to have two major advantages. Current RCT data suggest that both WI and WE decrease insertion pain and facilitate completion of difficult colonoscopy, with WE having a superior impact than WI. Water exchange was serendipitously associated with an increase in ADR; this has been repeatedly confirmed in follow-up studies. When it is unknown which patient's colonoscopy will be difficult, it would seem prudent for the average colonoscopist to optimize the chance of success and increase in ADR by using WE from the very start.

Abstract WP325: Designing Patient-centered Solutions for Enhanced Home-based Recovery After Mild-moderate Stroke

Introduction: After discharge from a structured rehabilitation setting, mild-moderate stroke patients report feeling unprepared to manage their home recovery plan. Through Design for America, we worked with undergraduate students to develop prototypes to empower patients in their post-stroke home-based recovery. Methods: “User centered design”, a six step process, was applied over a 6-week summer program, with design and process experts’ mentorship. We obtained qualitative data from patients, caregivers and healthcare professionals through focus groups, interviews and web-based surveys (N=60). The insights gained from users were utilized to design solutions. Results: Insights gained include: 1) 96% of patients reported they were unable to follow home rehabilitation schedules; 2) 66.7% reported being “comfortable” with technology and 10% having previously used Apps for exercise; 3) often insurance does not cover rehabilitation in mild strokes cases; and 4) patients like to hear from others and often develop their own exercises. Solutions designed included:1) a wearable device (Figure 1A) for stroke survivors to alert them of exercise schedule, track activity, appointments, and medication reminders, 2) a website (Figure 1B) that provides patients an online community to find user-submitted therapeutic exercises, share stories, and motivate others. Conclusion: In partnership with Design for America, we created unique solutions that fill a gap in the continuity of stroke recovery: community-based, patient-centered, and self-empowering tools. In the coming months, we plan to build and pilot test these products in a clinical setting.

Early and Intermediate Hospital-to-Home Transition Outcomes of Older Adults Diagnosed With Diabetes.

The purpose of this study was to identify factors affecting early and intermediate hospital-to home transition outcomes of older adults with preexisting diabetes mellitus. A mixed-methods design was used. A sample of 96 hospitalized older adults with a prior diagnosis of diabetes were recruited within 4 hours of discharge. Data reflective of general health status, diabetes status, perceived discharge readiness (Readiness for Hospital Discharge Scale), hospitalization, and anticipated postdischarge support were gathered upon enrollment. Transition outcome data including unplanned care encounter occurrences, perceived transition quality (Care Transition Measure-15), and postdischarge difficulty (scale and free responses to the Post-Discharge Coping Difficulty Scale [PDCDS]) were obtained by telephone interview 7 and 30 days after discharge. Three unique, dichotomous variables were created from recurrent subthemes that emerged during content analysis of free-response data and were used in statistical testing. Binary logistic regression was performed to identify predictive factors for an unplanned care encounter within 30 days of discharge. Multimorbidity was prevalent in participants. Difficulties managing medications, blood glucose, and chronic illnesses other than diabetes were common problems. Higher PDCDS scores 7 and 30 days following discharge and difficulty managing a nondiabetes chronic health problem were predictive of an unplanned care encounter within 30 days of discharge. Multimorbidity complicates home recovery of older adults with diabetes. Diabetes adds complexity to hospital-to-home care transitions. Transition difficulties predict higher risk for an unplanned care encounter. More intensive follow-up of older adults with diabetes during the first month following discharge is recommended.

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Learning Objectives: The creation of person centred care is central to national and international policy. One way of achieving person centred care within the critical care environment is to ensure that patients and family members co-produce healthcare services and are involved in the quality improvement agenda. This can be achieved through the use of a Patient and Family Advisory Council (PFAC). Methods: We invited 12 patient and family members to our first PFAC. We recruited a variety of participants including those who had made a complaint about aspects of our service and those from different backgrounds and specialities. The PFAC met bimonthly in a room off of the ICU. The PFAC was co-chaired by a patient or carer. The agenda for each meeting was also co-produced by the Council. Results: The PFAC identified five main stages of the critical care journey for patient and carers: arrival in ICU, the ICU stay, discharge to the ward, discharge home and ongoing recovery. This led to significant changes within our ICU including: improvements in the provision of information for relatives and patients, improved signage to the ICU and the creation of an information leaflet for ward staff. The PFAC has also helped design our current ICU rehabilitation program. Changes to the downstream ward areas are an ongoing area of work but will include patient volunteers. The PFAC will approve a final report which will be sent to the Chief Executive of our organization. This ICU PFAC Framework will be used for future Councils in our hospital to shape improvements in care. Conclusions: The creation of a PFAC is feasible and appropriate in the ICU environment. Our PFAC has helped established meaningful change in both our ICU and hospital.

Development of exhaustion for high-performance coaches in association with workload and motivation: A person-centered approach

ObjectivesThe aim of the current study was twofold. First, to explore whether there were different trajectories of exhaustion among high-performance coaches over the course of a competitive season. Then, to investigate whether workload-related variables and motivational regulations were associated with exhaustion class membership. Methods and design299 high-performance coaches responded to an online survey at the start, middle, and end of a competitive season, assessing exhaustion, workload, work home interference (WHI), recovery, and motivational regulations. Latent class growth analyses were used to identify different trajectories of perceived exhaustion. Further, multinomial logistic regression examined class associations for workload-related variables and motivational regulations at the start and at the end of competitive season. ResultsFour different trajectories of perceived exhaustion among coaches were identified, termed respectively “High” (10%), “Increase” (15%), “Decrease” (4%) and “Low” (71%). Higher levels of workload and WHI were associated to classes with higher levels of exhaustion. Higher levels of recovery, and intrinsic and identified regulations were associated to classes with lower levels of exhaustion. Adaptive and maladaptive profiles were identified. ConclusionsDifferent trajectories of exhaustion among high-performance coaches over the course of a competitive season were found. A maladaptive profile was associated with higher perceived workload and WHI, as well as lower levels of recovery, intrinsic and identified regulations, when compared to the adaptive profile.

Sa1439 Water Exchange Colonoscopy Reduced Sedation Requirement Without Compromising Success of Cecal Intubation in Patients Accepting the Option of on Demand Sedation in Chinese Patients in Hong Kong

Water exchange (WE) reduced sedation and pain scores (vs. air insufflation, AI) in patients with on demand sedation for colonoscopy. Completion without sedation offers savings in institutional costs and minimizes patient onsite and at home recovery burdens. With the government poised to introduce colorectal cancer screening (CRCS), assessment of the impact of WE and on demand sedation in Hong Kong is instructive.

Impact of specialist neurovascular care in subarachnoid haemorrhage

BackgroundThe management of neurosurgical disorders has become increasingly specialised. The care of patients with subarachnoid haemorrhage (SAH) has generally been part of core neurosurgical practice, provided by general neurosurgeons whatever their specialist interest. The aim of this present study therefore is to ascertain if, and to what extent care provided by a dedicated neurovascular team (compared to care provided by a general neurosurgical team) change patient disposition in SAH. MethodsThis is a retrospective analysis of SAH patients, identified from a departmental database of a single neurosurgical centre. In 2008, the service was reorganised such that a neurovascular team cared for all SAH patients. We compared clinical outcome in people admitted prior to this service reorganisation (Period A, 2004-2007) with patients admitted afterwards (Period B, 2009-2011). Survival and recovery were assessed according to the Glasgow Outcome Scale (GOS). Multi-factorial logistic regression analysis was performed to determine the injury and age adjusted incidence of complications, odds of survival at discharge, discharge home, mortality, good recovery (GOS 5) and favourable outcome, by dichotomising GOS (GOS 4-5 vs. GOS 1-3) at 3 months. Results1114 patients were included in the study. The mean age of patients presenting in Period A (n=543) was younger [50 years (SD 13.5)] than those in Period B (n=571) [53 years (SD 13)]. Patients admitted in Period B were more likely to present as poor grade (World Federation of Neurological surgeons (WFNS) grades 4 and 5) compared to Period A (26.5% vs. 21.3%). No statistical differences between the groups in the incidence of pre-operative re-bleeding (3% vs. 5%) or rates of delayed cerebral ischaemia (16.1% vs. 16.1%) were observed.After adjustment for age, sex and injury severity, the odds of patient time to discharge, discharge home and good recovery (GOS 5) were 27% (p<0.001), 45% (p=0.001) and 93% (p<0.001) higher respectively in Period B than Period A. ConclusionsThe data presented here demonstrates that management of SAH by a dedicated neurovascular team improves the potential for patient recovery.

Predictors of physical functioning in postoperative brain tumor patients.

A cross-sectional predictive design was used to study the relationships among recovery symptoms, mood state, and physical functioning and to identify predictors of physical functioning in patients who underwent surgery for brain tumor at the first follow-up visit (2 weeks) after hospital discharge. The sample included 88 patients who were 18 years or older, had full level of consciousness, and underwent first-time surgery for brain tumor without other adjuvant treatments from a tertiary hospital in Bangkok, Thailand. Descriptive statistics, Pearson product-moment correlation coefficient, and multiple regression were used for data analysis. The results revealed that most participants were women (75%) with an average age of 45.18 ± 11.49 years, having benign brain tumors (91%) and pathological results as meningioma (48.9%). The most common recovery symptoms were pain (mean = 3.2, SD = 2.6) and sleep disturbance (mean = 3.1, SD = 3.0). As for mood state, the problem of confusion was found the most (mean = 4.6, SD = 2.7). The physical functioning problem found the most was work aspect (mean = 66.3, SD = 13.3). Recovery symptoms had positive relationships with physical functioning and mood state (r = .406, .716; p < .01), respectively. At the same time, mood state had positive relationships with physical functioning (r = .288, p < .01). Recovery symptoms, total mood disturbance, fatigue, and vigor were statistically significant predictors of physical functioning and could explain variance of postoperative physical functioning in these patients at 2 weeks after discharge by 35%. Total mood disturbance was the strongest predictor of physical functioning followed by vigor, fatigue, and recovery symptom, respectively. Interventions to improve physical functioning in postoperative brain tumor patients during home recovery should account for not only recovery symptom management but also mood state.

Home recovery following day surgery: a patient perspective.

To investigate aspects of care potentially most influencing home recovery following day surgery. Elective surgery undertaken on a day-case basis is expanding. Many medical aspects of recovery have been investigated although less is known about the psychosocial view of postdischarge recovery. Greater insight into such issues is required for the development of a more coordinated nurse-led approach. Cross-sectional questionnaire. As part of a larger study, questionnaires were distributed to 2401 adult patients on the day of operation (September 2010-October 2011) to examine patients' experiences of psychosocial recovery. Participants were requested to complete and return the questionnaire by mail one week after surgery with 684 returned. Eighty-five per cent were fully prepared for all events during home recovery. Satisfaction with pre- and postoperative surgical information was high although less so anaesthetic information. Using factor analysis, preoperative information, pain management, postdischarge information, anxiety management, postoperative nausea and vomiting, help and rest once home were central features. Multiple regression analysis demonstrated pre- and postoperative information provision to have a statistically significant positive association with patients' being 'fully prepared for all events during home recover'. Unsatisfactory pain management, increased anxiety and reduced help once home had a statistically significant negative association with patients' being 'fully prepared for all events during home recovery'. Focusing on the delivery of surgical and anaesthetic information, managing pain and anxiety and ensuring support once home may help to enhance recovery. A more comprehensive plan embracing such aspects could help enhance the day surgery patients' experience. Increased satisfaction and surgical/anaesthetic information are central to the continued success of minimal-stay surgery. A broader hospital/home strategy is required as too frequently nursing care can become fragmented between the preoperative outpatient visit, preassessment, day of surgery and postoperative outpatient visit.

Life changed existentially: a qualitative study of experiences at 6–8 months after mild stroke

Purpose: To explore experiences of mild-stroke survivors in the context of early supported discharge. The meanings patients attributed to activities and participation in the home recovery process were our main interest. Methods: Eight participants (45–80 years) from a randomised controlled study were selected for this sub-study. This purposive sample had received rehabilitation in their homes in the post-stroke acute phase of recovery as part of the larger study. Extensive interview data were analysed using an interpretive strategy and systematic text condensation. Coping theory was included in later stages of analysis. Findings: The mild-stroke survivors’ stories revealed that life had changed profoundly. Differences and similarities in experienced changes were related to: self-perceived health, the body, practical activities, taking part in society, and self-perception. The findings showed the ways in which life changed for mild-stroke survivors, experienced challenges, and survivors’ thoughts about the future. Conclusions: Mild-stroke rehabilitation should focus more strongly on basic concerns related to self-perceived health, self-perception, and body, since these dimensions seem to complicate daily activities and close relationships. Professionals should also be aware of patients who experience an uncertain situation and unresolved rehabilitation needs, which still can be present 6–8 months after the stroke.Implications for RehabilitationWhen living with mild stroke, entrance to practical and social activities seemed founded on the patients’ perception of the body and self as comprehensible or not.Comprehending their own changed body and sense of self seem to be a long-term process when living with mild stroke.It is suggested that long-term follow-up be incorporated in home rehabilitation service, also in the context of early supported discharge.This may contribute to help patient cope more optimally with activities and participation of importance to them.

A Systematic Review of Web-Based Educational Interventions

A complement to in-hospital educational interventions is web-based patient education accessed during the home recovery period. While findings demonstrate the effectiveness of web-based patient education interventions on patient outcomes, they fall short of identifying the characteristics that are associated with desired outcomes. The purpose of this systematic review was to determine the characteristics of web-based patient education interventions that are associated with producing changes in self-care behaviors. A systematic review involving 19 studies was conducted to determine the most effective components of a web-based intervention. Findings suggest that the most effective form of web-based patient education is one that is interactive and allows patients to navigate the online system on their own. The findings from this systematic review allow for the design of a web-based educational intervention that will promote increased performance of self-care behaviors during the home recovery period.

Patient experiences of enhanced recovery after surgery (ERAS)

Enhanced recovery after surgery (ERAS) is a multimodal pathway whose strong evidence base is changing the methods used to care for patients before, during and after surgery. As a result, patients are being safely discharged at a much earlier stage than has previously been thought possible. Literature concentrates on the surgical and economical benefits of ERAS. There is a lack of research into the patients' perspective of the programme. This study used semi-structured interviews to investigate issues of significance to ERAS patients. The issues were grouped into themes: information provision, inpatient experiences, home recovery experiences (i.e. home convalescence) and psychological and emotional experiences. Although participants reported many good aspects of their ERAS experience, the findings highlighted the need for improvement particularly with regard to post-discharge support from both community services and hospital follow-up.

Challenges associated with delivering education to patients after heart surgery.

The aim of this report is to provide a detailed description of the challenges that arose throughout the implementation of an individualized patient education intervention delivered to patients during their home recovery following heart surgery. The intervention was delivered at two points in time by telephone to patients following heart bypass and/or valvular replacement. The individualized patient education intervention was found to be effective in reducing the rate and number of complications developed during the first three months following hospital discharge. However, throughout the implementation of this intervention, specific challenges arose that included: onset of symptoms that interfered with intervention delivery, patient's request for information beyond the scope of the teaching interaction, and the need to provide continued support to the therapist. These challenges were addressed throughout the course of the study and the strategies are currently being implemented into the planned knowledge translation activities associated with this intervention.

Point/Counterpoint

Point/Counterpoint

Vegetable gardens and their impact on the attainment of the Millennium Development Goals

The attainment of the Millennium Development Goals is at severe risk, owing to rising malnutrition and high child stunting and mortality rates, greater poverty, a large increase in the incidence of noncommunicable diseases, and lack of progress in women's empowerment. Here, the role of vegetable home, school, community, and disaster recovery gardens as a pro-poor and pro-environment intervention in the developing world is reviewed. This includes the contribution of vegetable gardens in improving food and nutritional security, generating additional income, providing employment, contributing to better health, and helping to empower disadvantaged groups in society. The implications of global research in the tropics and subtropics over the last 20–30 years are assessed over a wide geographic and linguistic range. The effectiveness and sustainability of such interventions are considered in the light of their contribution to the attainment of the Millennium Development Goals. Suggestions for potential new directions for research are made, and a call for better integration of effort in research and development between the agriculture, nutrition, and health sectors is presented as a key issue if rapid development progress is to be made and sustained.

An Ear-Worn Sensor for the Detection of Gait Impairment After Abdominal Surgery

Surgery to the trunk often results in a change of gait, most pronounced during walking. This change is usually transient, often as a result of wound pain, and returns to normal as the patient recovers. Quantifying and monitoring gait impairment therefore represents a novel means of functional postoperative home recovery follow-up. Until now, this type of assessment could only be made in a gait lab, which is both expensive and labor intensive to administer on a large scale. The objective of this work is to validate the use of an ear-worn activity recognition (e-AR) sensor for quantification of gait impairment after abdominal wall and perianal surgery. The e-AR sensor was used on 2 comparative simulated data sets (N = 32) of truncal impairment to observe walking patterns. The sensor was also used to observe the walking patterns of preoperative and postoperative surgical patients who had undergone abdominal wall (n = 5) and perianal surgery (n = 5). Methods for multiresolution feature extraction, selection, and classification are investigated using the raw ear-sensor data. Results show that the method demonstrates a good separation between impaired and nonimpaired classes for both simulated and real patient data sets. This indicates that the e-AR sensor may be used as a tool for the pervasive assessment of postoperative gait impairment, as part of functional recovery monitoring, in patients at their own homes.

Anxiety, Depression, and Self-Management

The purpose of this article was to address the clinically relevant question: In the presence of anxiety and/or depression, do patients who have had heart surgery engage in self-management behaviors following hospital discharge? A systematic review of 16 studies that examined the psychological condition of patients who had coronary artery bypass graft (CABG) and/or valvular replacement surgery was conducted. Moderate to severe levels of anxiety and depression exist during the first month of home recovery and appear to have an effect on performance of self-management behaviors. As the influence of patients' psychological condition is continued to be examined, it is imperative for health care providers to manage increased rates of anxiety and/or depression following heart surgery. Music and relaxation therapy are presented as evidenced based recommendations for managing anxiety and depression in patients following heart surgery.

Recovery at Home After Major Gynecologic Surgery

To describe women's recovery and pain control during the first 6 weeks after hospital discharge after gynecologic surgery and estimate the prevalence of inadequate pain control during the first 2 weeks of home recovery after abdominal compared with vaginal gynecologic surgery. Participants, women without chronic pelvic pain undergoing benign nonlaparoscopic gynecologic surgery, completed daily evaluation of pain and pain medication use during the first 2 weeks after discharge and a validated recovery instrument 1, 2, and 6 weeks after discharge. Inadequate pain control was defined as a score of 4 or more (out of 10) on the four-item Surgical Pain Scale. Of 140 eligible participants, 13 were lost to follow-up. Of remaining 127 women, 80 underwent vaginal and 47 abdominal surgery. Inadequate pain control was reported by 45% and 51% of women after vaginal and abdominal surgery, respectively, on recovery day 3 (P=.5); 23% and 30%, respectively, on day 7 (P=.4); and 5% and 23%, respectively, on day 14 (P<.005). Two weeks after discharge, 10% and 32% of women after vaginal and abdominal surgery, respectively, required narcotic pain medications (P<.01). By 6 weeks, approximately half of the women in either group reported they felt recovered and two-thirds felt "back to normal." Pain control after hospital discharge is suboptimal for many women after both vaginal and abdominal surgery. The time to full recovery is longer than 6 weeks for half of women. Given increasingly rapid hospital discharge, optimizing the patient's experience at home is a priority. II.

Ear-worn body sensor network device: an objective tool for functional postoperative home recovery monitoring

Patients' functional recovery at home following surgery may be evaluated by monitoring their activities of daily living. Existing tools for assessing these activities are labor-intensive to administer and rely heavily on recall. This study describes the use of a wireless ear-worn activity recognition sensor to monitor postoperative activity levels continuously using a Bayesian activity classification framework. The device was used to monitor the postoperative recovery of five patients following abdominal surgery. Activity was classified into four groups ranging from very low (level 0) to high (level 3). Overall, patients were found to be undertaking a higher proportion of level 0 activities on postoperative day 1 which was gradually replaced by higher-level activities over the next 3 days. This study demonstrates how a pervasive healthcare technology can objectively monitor functional recovery in the unsupervised home setting. This may be a useful adjunct to existing postoperative monitoring systems.

A Proof-of-Concept RCT to Confirm the Beneficial Effects of the Water Method on U.S. Veterans Undergoing Colonoscopy with the Option of On-demand Sedation

Purpose: Whether the water method can facilitate completion of unsedated colonoscopy in patients who received sedation for prior colonoscopy is unknown. Sedation for colonoscopy imposes recovery time burden on patients (median 47 minutes onsite and 17.7 hours at home) (AJG 2007;102:2401). The objective of this abstract is to report the impact of the water method and on demand sedation on completion of unsedated colonoscopy and patient recovery time burden. Methods: Veterans accepting on demand sedation for screening or surveillance colonoscopy were randomized to air or water method for colonoscope insertion. Main outcome measurements: Completion of colonoscopy without sedation, onsite and at home recovery times. Results: 100 patients were randomized, 50/group. 27 in the air and 39 in the water group completed colonoscopy without requiring sedation (p<0.05, Fisher's exact test). Thirteen of the 100 patients had prior sedated colonoscopy requiring Midazolam 1-5 mg, Fentanyl 25-100 μg and Benadryl 50 mg. Ten of the 13 patients completed colonoscopy without sedation (3 in the air and 7 in the water group). The water method reduced onsite and at home recovery times (Tables 1). Table 2 lists the actual and hypothetical times saved. Limitations: Single VA site, predominantly male veterans, unblinded examiners.[1478] Table 1. Patient recovery time on site and at home[1478] Table 2. Actual and hypothetical patient recovery times savedConclusion: When veterans accepted the option of on demand sedation, the water method facilitated completion of unsedated colonoscopy, including those with a prior history of sedated colonoscopy, and reduced total patient onsite and at home recovery time burden.