Perioperative Patient Experience Research Articles

Surgical Safety Does Not Happen By Accident: Learning From Perioperative Near Miss Case Studies

Adverse surgical events cause negative patient health outcomes and harm that can often overshadow the safe and effective patient care provided daily by nurses as members of interprofessional healthcare teams. Near misses occur far more frequently than adverse events and are less visible to nurse leaders because patient harm is avoided due to chance, prevention, or mitigation. However, near misses have comparable root causes to adverse events and exhibit the same underlying patterns of failure. Reviewing near misses provides nurses with learning opportunities to identify patient care weaknesses and build appropriate solutions to enhance care. As the operating room is one of the most complex work settings in healthcare, identifying potential weaknesses or sources for errors is vital to reduce healthcare-associated risks for patients and staff. The purpose of this manuscript is to educate, inform, and stimulate critical thinking by discussing perioperative near miss case studies and the underlying factors that lead to errors. Our authors discuss 15 near miss case studies occurring across the perioperative patient experience of care and discuss barriers to near miss reporting. Nurse leaders can use our case studies to stimulate discussion among perioperative and perianesthesia nurses in their hospitals to inform comprehensive risk reduction programs.

Presurgical rehabilitation program for patients with symptomatic lumbar spinal stenosis: A pilot randomized controlled trial protocol

ABSTRACT Background Symptomatic lumbar spinal stenosis (SLSS) is the most common diagnosis associated with spine surgery for those over the age of 55 years. There is a lack of quality research on the effectiveness of prehabilitation on pain, function, and quality of life in patients undergoing surgery for SLSS. This pilot randomized controlled trial (RCT) will evaluate the feasibility of an eHealth prehabilitation program for individuals undergoing SLSS surgery, and an embedded longitudinal qualitative study explores the perioperative patient experience and recovery trajectory. Methods Participants (n = 60) undergoing spine surgery for LSS will be randomized into the 8-week electronic health (eHealth) prehabilitation program or minimal intervention. The prehabilitation program will be delivered virtually using synchronous (one-on-one) and asynchronous (independent) sessions by an experienced clinician, consisting of motivational interviewing, exercise (graded activity), education, peer support groups, and a 6-week booster session. Participants in the minimal care group will receive usual care and will have access to educational videos. Primary outcomes will include (1) recruitment, (2) patient adherence, (3) acceptability of program content, (4) acceptability and compliance with study questionnaires, and (5) attrition. Outcomes will be assessed at baseline, after the intervention, and 3 and 12 months postoperatively. We will conduct semistructured interviews alongside the RCT with 12 to 15 participants. Discussion The proposed project will include the feasibility testing of an eHealth LSS prehabilitation program with potential to improve surgical outcomes. Results of this study will provide the foundation for future fully powered multicenter RCTs. Trial Registration clinicaltrials.gov NCT05073081

Complex Nasal Reconstruction in a Wide-awake Ambulatory Setting: A Study of Efficacy and Perioperative Patient Experience

Background:The use of local anesthesia in nasal surgery has gained popularity as a cost-effective and safe alternative. With the potential benefit of reconstruction without using general anesthesia, the goal of the study was to evaluate the patient-reported experience in addition to surgical outcomes and perioperative complications.Methods:A mixed-methods study was completed with retrospective chart review and patient-reported outcome questionnaire. The primary outcome measures were demographics, oncologic and surgical details, and postoperative complications. Secondary outcome measures were aesthetic outcomes and procedure tolerance, which were gathered from the FACE-Q questionnaire.Results:Of the 22 patients who met inclusion criteria, nine patients (41%) had forehead flaps performed and 13 patients (59%) had multilayer reconstruction with local flaps and cartilage grafts. The average number of surgeries performed, including revisions, was 2.3 ± 0.2. The overall complication rate for reconstructions and revisions was 20%, most of these were minor complications. The overall subjective rating of patient’s appearance was excellent with an average score of 83.9 (± 17.3) out of 100. There was minimal appearance distress as a product of the surgery with an average score of 84.9 (±18.8). On a scale of one to five, patients reported an average of 4.3 for convenience, 3.8 for efficiency of setup and procedure, and 3.4 out of 5 for comfortability with having an operation performed on their face wide awake.Conclusion:Our study demonstrated that complex nasal reconstruction performed under local anesthetic in a minor procedure setting is a feasible and safe option with good patient-reported outcomes.

Quality improvement in New Zealand pediatric anesthesia: National quality direction, patient experience, equity, and collaboration.

The current priorities of the quality and safety of patient care in New Zealand at a central government level are described, with a focus on equity and patient experience. Priorities between stakeholders differ. We report the current quality activities of New Zealand pediatric anesthetists in relation to these governance aims, seeking gaps and suggesting future directions to align governance priorities and local activities. International relevance is also outlined. New Zealand Māori experience health inequity. Complex systemic factors including those of systemic racism and prejudice contribute to the inequity. The specific contributions to health inequity from pediatric anesthetists are unknown but could include aspects of cultural safety, delays in treatment and treatment deficits. Patient experience is correlated positively with other quality domains. Peri-operative patient experience tools require outcomes of interest that matter to patients, including relevant cultural safety domains. Risk identification and critical event review contribute to local learnings in departments and institutions, and more widely to national and binational (with Australia) learnings. Several collaborative projects in Australia and New Zealand, whilst not primarily quality improvement projects, may improve pediatric anesthesia. These collaborations include a pediatric anesthesia professional network, a curriculum for a pediatric anesthetic fellowship, contributions to a document on standards for pediatric anesthesia, and a national quality group researching key performance indicators across New Zealand.

The Perioperative Patient Experience During COVID-19.

BackgroundAccess to elective surgical procedures has been impacted by the COVID-19 pandemic.MethodsWe sought to understand the patient experience by developing and distributing an anonymous online survey to those who underwent non-emergency surgery at a large academic tertiary medical center between March and October 2020.ResultsThe survey was completed by 184 patients; the majority were white (84%), female (74.6%), and ranged from 18 to 88 years old. Patients were likely unaware of case delay as only 23.6% reported a delay, 82% of which agreed with that decision. Conversely, 44% felt that the delay negatively impacted their quality of life. Overall, 82.7% of patients indicated high satisfaction with their care. African American patients more often indicated a “neutral” vs “satisfactory” hospital experience (P < .05) and considered postponing their surgery (P < .01). Interestingly, younger patients (<60) were more likely than older (≥60) patients to note anxiety associated with having surgery during the pandemic (P < .01), feeling unprepared for discharge (P < .02), not being allowed visitors (P < .02), and learning about the spread of COVID-19 from health care providers (P < .02).DiscussionThese results suggest that patients are resilient and accepting of changes to health care delivery during the current pandemic; however, certain patient populations may have higher levels of anxiety which could be addressed by their care provider. These findings can help inform and guide ongoing and future health care delivery adaptations in response to care disruptions.

PATIENT PERIOPERATIVE EXPERIENCE AT ST. BARTHOLOMEW'S DURING THE COVID-19 PANDEMIC

IntroductionThe pressure of the global COVID-19 pandemic led to unprecedented changes in the delivery of healthcare services in a short period of time. Due to the nature of cardiothoracic surgery, there was an urgent need to adapt and continue delivery of services whilst maintaining patient and staff safety (1) St. Bartholomew's Hospital is a Cardiothoracic tertiary centre. The trust underwent mass redistribution of intensive care services and creation of a new hospital (The Nightingale) to manage the influx of COVID-19 patients. Therefore, the delivery of cardiothoracic perioperative services changed significantly, requiring online or telephone appointments for pre-op assessment clinic; strict no visitors policy and the need for patient self-isolation prior to hospital admission. Delivering perioperative care in this new environment was challenging and we wanted to investigate how these changes impacted the perioperative experiences of cardiothoracic patients during this time with the aim of improving any shortcomings identified.MethodsBetween 7-8th September 2020, all patients who were at least 48h post-procedure were given a self-administered paper questionnaire after verbal consent was obtained. This consisted of a total of eight structured and unstructured questions. These were analysed using simple frequency analysis and manual analysis respectively. Common themes were identified.Results51 patients completed the questionnaire - 39 cardiac and 12 thoracic patients. The main themes were pain and surviving the operation with concerns regarding family. 88% of patients positively recalled speaking to an anaesthetist face to face, with over half of these interaction being a day before their surgery. 92% felt meeting the anaesthetist was useful in addressing their worries and helped with anxiety. Information delivery regarding post-operative pain was an overwhelming theme and potential area for improvement. 88% of patients would recommend St. Bartholomew's hospital to friends and family. 64.8% who completed the question “Is there anything else you want to tell your anaesthetists or critical care doctors?” wanted to express their gratitude to all healthcare professionals involved in their care. Interestingly, a number of patients reported that they would like information about lifestyle changes and identified a potential window for signposting for more support.DiscussionUnfortunately, there is little national or international data for direct comparison of our findings. Post-operative pain expectations can be further explored to establish whether more preoperative information surrounding analgesia is required. Anaesthetists should be aware that the perioperative period for major surgery is a teachable moment for potential lifestyle changes and could play an important part in utilising this opportunity. We hope that this simple questionnaire can provide healthcare staff a better insight into perioperative patient experience and the importance of preoperative provision of information. Despite significant changes during the pandemic, it is reassuring to know that the overall patient experience was positive.

Comparing Minor Hand Procedures Performed with or without the Use of a Tourniquet: A Randomized Controlled Trial.

Background:Carpal tunnel syndrome and trigger finger are two of the most common conditions treated by the hand surgeon. During these procedures, a tourniquet is often used to minimize bleeding and improve visualization of the operative field. However, it may be associated with pain and discomfort. To date, there are few prospective studies investigating the safety and patient-centered outcomes of tourniquet-free minor hand procedures.Methods:This is a randomized controlled trial comparing patients undergoing open carpal tunnel or trigger finger release with or without the use of a tourniquet. Perioperative subjective patient experience was investigated for both techniques. This was measured based on a numerical rating scale for pain, anxiety, and overall satisfaction. In addition, this was an equivalence trial in terms of operative time, bleeding scores, and perioperative complication rates.Results:A total of 67 patients were recruited. Both groups were similar with respect to distribution of age, sex, handedness, anti-platelet use, and tobacco use. Median scores for operative time, anxiety, and overall satisfaction were comparable between the 2 groups. With regard to patient discomfort, median scores were significantly higher in the tourniquet group when compared with the no tourniquet group (3.58 versus 1.68, respectively, P = 0.02). Bleeding scores for the tourniquet group were significantly lower than for the no tourniquet group (1.14 versus 1.90, respectively, P = 0.001).Conclusions:The application of wide awake local anesthesia no tourniquet (WALANT) in minor hand surgery procedures has been shown to decrease tourniquet-associated discomfort, improving perioperative patient experience. Additionally, it demonstrated the noninferiority of the tourniquet-free technique with respect to operative time and the rate of perioperative complications.

Comparing Open Carpal Tunnel or Trigger Finger Release Procedures Performed Under Local Anesthesia With or Without the Use of a Tourniquet

BACKGROUND: Carpal tunnel syndrome and trigger finger are 2 of the most common conditions treated by the hand surgeon. During these procedures, a tourniquet is often used to minimize bleeding and improve visualization of the operative field. However, it may be associated with pain and discomfort. To date, there are few prospective studies investigating the safety and patient-centered outcomes of tourniquet-free minor hand procedures. METHODS: This is a randomized controlled trial comparing patients undergoing open carpal tunnel or trigger finger release with or without the use of a tourniquet. Perioperative subjective patient experience was investigated for both techniques. This was measured based on a Numerical Rating Scale for pain, anxiety, and overall satisfaction. In addition, this was an equivalence trial in terms of operative time, bleeding scores, and perioperative complication rates. RESULTS: A total of 67 patients were recruited. Both groups were similar with respect to distribution of age, sex, handedness, antiplatelet use, and tobacco use. Median scores for operative time, anxiety, and overall satisfaction were comparable between the 2 groups. With regard to patient discomfort, median scores were significantly higher in the tourniquet group when compared to the no tourniquet group (3.0 versus 1.0; P = 0.02). Bleeding scores for the tourniquet group were significantly lower than for the no tourniquet group (P = 0.001). CONCLUSION: The application of WALANT in minor hand surgery procedures has been shown to decrease tourniquet-associated discomfort, improving perioperative patient experience. Additionally, it demonstrated the noninferiority of the tourniquet-free technique with respect to operative time and the rate of perioperative complications.

The perioperative patient experience of hand and wrist surgical patients: An exploratory study using patient journey mapping

Patient-centred care is becoming more important in healthcare. The success of patient-centred care can be assessed by exploring the patient experience through a patient journey map. As the number of outpatient surgeries is increasing, it is important to reveal the specific characteristics of this type of surgery. The perioperative patient experience is considered very important for outpatient surgery, because all perioperative activities are condensed in one day. To investigate this experience, we performed a case study of hand and wrist surgery. Six teams of two industrial design engineering students interviewed 40 patients in total in two private and two public hospitals in the Netherlands. All teams created a patient journey map, describing the patient experience. These maps were analysed by the authors to identify common themes among the six journeys. Four time-independent themes and four time-dependent themes were identified. Insecurity, reassurance by staff, loneliness, and lack of information were associated with the whole patient experience. Before surgery, lack of control was the most prominent experience. During surgery, acceptance and curiosity were present. After surgery, relief was the dominant experience. No significant differences between the public and private hospitals were discovered. Several suggestions are given on how to facilitate positive experiences and how to resolve negative experiences in outpatient surgery. These include suggestions for hospital policy and design interventions.

Advance preoperative assessment of cancer patients leads to a lower percentage of same day cancellations, increasing positive perioperative patient experience

Advance preoperative assessment of cancer patients leads to a lower percentage of same day cancellations, increasing positive perioperative patient experience

Enhanced recovery after surgery in thoracic surgery: the past, the present and the future

Enhanced recovery after surgery (ERAS) is a multimodal plan of care based on the application of multiple standardized evidence-based elements and aimed at improving the perioperative patient experience, by accelerating recovery, reducing complications and shortening hospital stay. The multiple elements, which constitute the ERAS pathway cover all temporal domains of the perioperative care: preoperative, intraoperative and postoperative. They are based on the concept of marginal gains. The individual elements may have limited effect on the outcome when used in isolation but they act synergistically when applied in combination to reduce the surgical stress and hasten recovery (1).

Editorial introductions

Editorial introductions

Implications of sarcopenia in major surgery.

Sarcopenia, defined as a decrease in skeletal muscle mass and strength, is an important risk factor in clinical medicine associated with frailty, mortality, and worse surgical and nonsurgical outcomes. Conventional measures of sarcopenia rely on the subjective "eyeball test" and do not adequately describe risk. Computed tomography (CT) imaging studies may be used to objectively measure sarcopenia and may be used for surgical risk stratification and identification of patients for inclusion in a novel clinical remediation program. We describe results observed in the general, vascular, and liver transplant surgery populations determined by analytic morphomics--an analysis of CT scans in a semiautomated process using MATLAB v13.0. A perioperative optimization program has been implemented with the objective of remediating sarcopenia through improvement of patient mental and physical status prior to surgery. Using analytic morphomics, we have noted significantly higher cost and increased rates of mortality and surgical complications among sarcopenic patients. The training program shows initial success, and among participating patients, we have observed reductions in payer and hospital costs and a decrease in length of hospital stay for patients following surgery. Through analytic morphomics, we are able to quantify markers of sarcopenia and identify patients at risk for increased mortality and poor surgical outcomes. Early identification of patients offers us the opportunity to remediate sarcopenia through perioperative training and support. Participating patients spend less time in the hospital and have lower healthcare costs. This program has the potential to improve the perioperative patient experience and ease financial burdens.

Being altered by the unexpected: Understanding the perioperative patient's experience: A case study

The present paper focuses on the process of understanding the patient in the context of perioperative caring and reports a story narrated by a perioperative nurse as well as her emerging understanding of the patient prior to surgery at an operating department. This qualitative case study had a dual purpose; firstly, to describe how the perioperative nurse's understanding of the patient emerged and, secondly, to establish how the researcher interpreted the situation. As a perioperative nurse and researcher, the author is both the narrator and interpreter. To date we have rarely discussed the fact that, in a perioperative context, the patient might feel ashamed of his/her body, even before arriving at the operating department. This new understanding emerged from the hermeneutical dialogue in the present study.

Bedside Leadership Transforms Patient Postoperative Nausea/Vomiting Experience

Staff nurse Quality Council members of the Admission/Testing and Outpatient Surgery Centers of a 316-bed community hospital identified an opportunity to improve the perioperative patient's experience. Follow up calls revealed postoperative and post discharge nausea and vomiting (PONV/PDNV) negatively impacted some patient's recovery. Literature review revealed nausea and vomiting are the number one fear of patients undergoing surgery and 30-35% of all patients suffer this complication. Additionally, PONV/PDNV may increase length of stay and require hospital admission which increases health care costs.