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Development and implementation of a photographic atlas for parental instruction and guidance after outpatient penile surgery
Journal of Pediatric Urology (2012) 8, 521e526
Development and implementation of a photographic atlas for parental instruction and guidance after outpatient penile surgery Caleb P. Nelson*, Ilina Rosoklija, Rosemary Grant, Alan B. Retik Department of Urology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, HU-359, Boston, MA 02115, USA Received 15 August 2011; accepted 27 September 2011 Available online 20 October 2011
KEYWORDS Circumcision; Postoperative care; Pediatrics
Abstract Objective: To develop and evaluate a visual tool to assist parents in assessing healing after surgical circumcision or revision circumcision (SCRC). Methods: Among children undergoing SCRC, photographs were taken on postoperative days 0-1-2-3-5-7-10-14-21, and compiled into an atlas. Atlas utility was assessed during two 1-month periods. During the first period (M1) families received routine postoperative instructions only; during the second period (M2), families received the atlas in addition to routine instructions. Families were surveyed by phone and calls/contacts were tracked. Results: 33 families (among 83 SCRCs) were surveyed during M1, vs 39 families (among 77 SCRCs) during M2 (p Z 0.17). Nearly all reported the atlas helpful (59% very helpful, 27% moderately helpful, 9% somewhat helpful). All but one family used the atlas. There was a trend toward families receiving the atlas being more comfortable (64% vs 82% very comfortable, p Z 0.12). Survey scores were similar between M1 and M2 for total score, satisfaction, and the number whose expectations were met (58% vs 55%, p Z 0.21). Phone contacts decreased between M1 and M2, both in absolute number (M1 Z 24 calls vs M2 Z 12 calls), and as a proportion of total cases performed (29% vs 16%, p Z 0.04). Conclusions: The circumcision atlas was well received by families and was associated with a significant decrease in post-surgical telephone calls. The atlas has been put into routine clinical use with excellent response. ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ1 617 355 3776; fax: þ1 617 730 0474. E-mail address: [email protected] (C.P. Nelson). 1477-5131/$36 ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2011.09.012
522
Introduction Ambulatory surgery has advantages including low cost and high patient satisfaction [1,2e4]. However, ambulatory surgery poses challenges for patients and families, as well as clinicians, in terms of management and assessment of postoperative complications [5e7]. Sending the patient home on the day of surgery means that the patient and family are responsible for monitoring the postoperative recovery, identifying abnormal events or conditions, and determining whether healing is progressing normally. These responsibilities may be particularly challenging for parents of young children undergoing surgery, and this responsibility, along with a lack of knowledge and experience, can be a source of stress and anxiety [8]. Among the more common ambulatory procedures performed in pediatric urology are surgical circumcision and circumcision revision (SCRC). Unlike many surgical procedures in which the operative site is primarily internal, SCRC is performed on an external structure that parents examine multiple times each day. The large volume of SCRCs performed on an ambulatory basis at our institution means that our surgical support staff spend considerable time and effort communicating with families in the postoperative period. Many of these contacts are generated by the fact that parents are unfamiliar with the expected appearance of the penis during the postoperative period. Our hypothesis was that a visual atlas of normal penile healing after SCRC would provide parents with a resource for better understanding ‘normal’ surgical recovery, avoid unnecessary stress and anxiety, reduce the number of postoperative contacts, and simplify postoperative contacts that do occur by giving both parents and providers a common reference for comparison. We sought to develop and validate such an atlas.
Methods This project was a quality improvement project via the Program for Patient Safety and Quality at our institution. Institutional review board approval and waiver of informed consent was obtained.
Generation of image catalog The parents of children aged 6e18 months undergoing SCRC by one of 11 surgeons were approached regarding possible participation. Interested families signed a photo release. Photographs were taken by trained research assistants on postoperative days 0, 1, 2, 3, 5, 7, 10, 14 and 21 using a 10þ megapixel digital camera. All identifiers were destroyed after the photo sequence was complete for each subject. No identifying marks were present in any images.
Creation of the photographic atlas The most representative images were compiled into a visual education aide, in the form of a small atlas. Sixteen subjects were included. Each individual subject is represented once on each page, with one page for each postoperative day
C.P. Nelson et al. (Fig. 1). Once final editing and graphic design was complete, atlases were printed using high-resolution digital printing systems. Print and material cost of the atlas when ordered in bulk is less than one dollar per copy.
Evaluation of the utility of the photographic atlas The atlas was assessed via a prospective evaluation, again approved by the IRB and with waivers of informed consent. Two non-consecutive month-long assessments were performed. The first assessment month (M1) was conducted prior to creation of the atlas. Once the atlas was completed and available, a second month-long assessment period (M2) was conducted; M1 and M2 took place 22 months apart. The effect was to achieve a convenience randomization wherein patients undergoing SCRC during M1 served as controls, and patients undergoing SCRC during M2 served as atlas recipients (cases). During M1, standard post-SCRC instructions and care were provided. During M2, the atlas was provided to families in the post-anesthesia care unit after ambulatory SCRC, with brief instructions for use, to take home at discharge; standard post-SCRC instructions and care were also provided. Postoperative outcome measures during M1 (- atlas) and M2 (þatlas) were compared. The primary outcome was a calculated score on an 8-item postoperative parental survey (10 items for the M2 period) evaluating parental stress, satisfaction with postoperative information, and parental comfort with management at home (Appendix A). Because no validated survey instrument exists for assessment of parental anxiety, experience, and satisfaction after SCRC, we developed a survey using selected validated items from two validated instruments: 1) the StateTrait Anxiety Inventory, a widely used validated instrument for measurement of anxiety in adults [9], and 2) the Amsterdam Preoperative Anxiety and Information Scale [10,11], another assessment of parental peri-operative knowledge and stress. From these we modified items addressing parental satisfaction and comfort with postoperative knowledge and management. Face validity was assessed by the involved surgeons. The survey was administered by telephone on postoperative day 3. Possible scores for the survey range from 8 to 32 (higher scores indicate more anxiety and less satisfaction). During M2, the survey had two additional items asking if the family received the atlas, and asking them how useful they found the atlas during the postoperative period. The secondary outcome was the number of SCRC-related postoperative phone contacts received by the Department of Urology during each assessment month. Calls were logged by Department nursing staff, noting the reason for the call, whether or not the family had received the atlas, whether they or the family referred to the atlas during the call, and whether the atlas helped or hindered the evaluation. Outcomes were compared during M1 and M2. Continuous variables were compared using t-tests and categorical variables with chi-square tests. All tests were two-sided and p-values of 0.05 or less were considered significant.
Results Eighty-three SCRC procedures were performed during M1 versus 77 procedures during M2. During M1, 33 families
Photo atlas for parental guidance after penile surgery
Figure 1
523
Selected page from Atlas of Healing after Surgical Circumcision (postoperative day 7).
(40%) were surveyed; 39 families (51%) were surveyed in M2 (p Z 0.17). Of the M2 families who were surveyed, 22 (56%) had received the atlas with their postoperative instructions.
Among those who were surveyed and received the atlas (n Z 22), the response was overwhelmingly positive. Nearly all respondents reported that the atlas was helpful (59% very helpful, 27% moderately helpful, and 9% somewhat
524 helpful). Only one family who received the atlas reported not using it. Among the 18 families surveyed during M2 who did not receive the atlas, 61% reported that they would like to have received a copy and most of these requested that a copy be sent. On the postoperative surveys of parental anxiety and comfort, there was no significant difference in overall summary scores between responses in M1 and in M2 (11.8 vs 12.4, p Z 0.62). On individual items, there was no significant difference in the proportion who were very satisfied with the care they were able to provide their child after surgery (76% vs 82%, p Z 0.31) or who knew what to expect after surgery (58% vs 55%, p Z 0.21). There was a trend toward families who received the atlas being more comfortable with the overall postoperative instructions, although the difference was not significant (64% vs 82% very comfortable, p Z 0.12). The number of calls to the Department of Urology decreased during M2 compared to M1. There were 24 calls during M1 regarding procedures performed that month, versus 12 calls during M2. The number of calls as a proportion of total cases during the month was lower in M2 (16% vs 29%, p Z 0.04). Of those who called during M2, 5 (42%) reported that the atlas was useful during the postoperative period. The atlas was directly utilized for reference by the nursing staff during 3 of the 12 calls (25%). Of the calls during M1, 42% (10/24) pertained to concerns about penile appearance, compared to 17% of calls during M2 (2/12), although the difference was not significant (p Z 0.13). The other calls during both periods included a mix of concerns regarding dressing removal, pain control, and bleeding.
Discussion In recent years, most surgical procedures in pediatric urology have transitioned from inpatient or same-day admission to ambulatory care. While this trend has benefits regarding efficiency and cost, a significant number of postoperative care responsibilities have been transferred from the trained staff of the hospital to the child’s parents or other caregivers. Most of these parents have little or no medical training, and their experience with postoperative management of incisions, dressings, and other surgical facts of life is likely to be minimal. The result of this transition is that, after ambulatory surgery, parents are primarily responsible for evaluating the patient’s postoperative status, and making potentially critical decisions regarding the need for further evaluation of possible problems. For many parents, this responsibility is a source of stress and anxiety [8]. The lack of knowledge and experience can result in unnecessary discomfort and adverse outcomes [12,13]. Rare but widely reported catastrophic outcomes after simple procedures such as circumcision are often attributed to a failure to recognize abnormal postoperative events [14]. To address these issues, ambulatory surgery programs have developed systems to provide follow-up care, mostly centered around telephone contacts with families [15e17]. These contacts serve to confirm that recovery is going well, to answer parental questions about the recovery process, and to identify impending or actual problems. However,
C.P. Nelson et al. telephone contacts consistently reveal that many parents have misperceptions about ‘normal’ recovery patterns during the postoperative period [18]. Efforts to improve parent education and understanding, and to reduce parental stress have consistently demonstrated that these approaches can result in better transmission of information to parental caregivers with resulting improvements in care of the pediatric patient after discharge [19e21]. In many cases, the physician or nurse must base their postoperative evaluation on a description of the penile appearance by the parent, and these tend to be vague. We developed the circumcision atlas as a tool to facilitate evaluation by the parents, as well as communication between families and hospital-based staff. The response to the atlas by both our patients’ families and our nursing and surgical staff has been highly positive. It is now routinely included in postoperative education materials for all SCRC patients under age 12. Although we did not observe a difference in overall survey scores with atlas usage, we have found that in daily practice families greatly appreciate the visual reference cues that the atlas provides, and it is our subjective impression that it does enhance both patient safety and quality of care in the ambulatory surgery program at our institution. By providing parents with a reference tool to which they can compare their child’s postoperative recovery, we enable parents to better appreciate deviations from normal recovery and contact us when needed. In theory, improved recognition of such deviations may help to prevent delays in diagnosis and treatment of serious postoperative complications such as infection (although we have not documented any specific examples of this). Furthermore, it is our belief that quality surgical care requires improved communication with parental caregivers. In ambulatory surgery, we rely on parental caregivers to serve as proxies for trained medical professionals. Parents need information about postoperative recovery that is usable and that is appropriate to their level of knowledge and experience. The postoperative atlas significantly improves the quality of care by providing an additional tool for assessment by parents, while also addressing parental anxiety and concern during an otherwise normal recovery. With the widespread availability of digital cameras and email over the past 10 years, families often send photos to our staff as attachments in email communications, expressing concern about their child’s progress. Although these photographs are often of limited utility due to blurry imaging or inadequate angle or lighting, the basic soundness of this concept led us to the idea of a comprehensive ‘standardized’ atlas of images of normal healing. To our knowledge, this type of post-surgical atlas has not been developed previously for SCRC. The result of this study should be interpreted in light of its limitations. This was a single-site study and, as such, the results may not be generalizable to all practices or institutions. There may be unique features of our surgeons, surgical processes, postoperative instructions, and patients that make the atlas more useful in this setting than in others. Overall, however, we believe that this tool will be broadly applicable. Eleven different surgeons perform these procedures at our institution, reducing the impact of
Photo atlas for parental guidance after penile surgery
525
individual surgeon practices. Similarly, our panel of 16 photo patients represented a range of races, ethnicities, and socioeconomic groups. Nonetheless, any outside institution wishing to implement this tool would have to consider whether it would fit into their own practice pattern and patient population. In theory, it would be ideal if each institution were to develop its own atlas using patients operated on by surgeons at that site. However, given the tremendous time and effort required to produce the current tool, this is probably impractical. Another limitation was that we conducted this study using a convenience randomization, meaning that the preand post-implementation periods were conducted at different time points to allow for comparison of groups. This methodology should not be confused with a true randomized controlled trial; it is possible that confounding factors (other than the atlas itself) were present that could have resulted in any differences in outcomes between periods. However, we are unaware of any such differences, in that our surgical and postoperative care practices and instructions remained stable and constant during both measurement periods. While there was some variation in the numbers of procedures performed by each of the 11 surgeons, the procedures were widely distributed among the surgeons, with no individual surgeon performing more than 20% of the cases in either time period. All surgeons but one performed cases during both time periods, with the lone exception performing 3 cases in M1 and 0 cases in M2. One benefit of this study design is that this was a default enrollment; no families during M1 received the atlas (as it did not yet exist), while all families during M2 were enrolled by default (as the atlas was integrated into routine postoperative care). Granted, not all patients in the postimplementation group (M2) received the atlas. This was a consequence of challenges encountered in modifying postoperative care practices and involving the many providers in the project, including nursing. We do not believe that there were any systematic differences between those families who did or did not receive the atlas during M2; failure to receive the atlas appears to have been random. The lower number of families who received the atlas did reduce our power to detect differences in parental responses, particularly on the anxiety and comfort survey. It is possible that with larger numbers the small differences seen would have been statistically significant. However, the study as executed was powered to detect an absolute difference in total scores of 2.8, which would be an approximately 10% difference in scores. Smaller differences
1. 2. 3. 4. 5. 6.
I am tense........... I feel strained ......... I feel frightened....... I feel nervous........ I am worried.......... I feel comfortable with the instructions and information provided after my child’s surgery.........
Not Not Not Not Not Not
at at at at at at
all all all all all all
than this are not likely to be clinically meaningful. Nonetheless, we believe that the data do suggest that, at the very least, implementation of the atlas resulted in no adverse impact on family satisfaction or postoperative care.
Conclusions We developed an atlas of post-circumcision healing that was well-received by families, and that was associated with a significant decrease in post-surgical telephone calls. Parental postoperative anxiety did not change measurably. The atlas has been put into routine clinical use with excellent response.
Ethical approval This work was evaluated by the IRB at our institution and it was determined that, as a quality improvement project, a waiver from full IRB review was appropriate. All project activities were carried out in full accordance with the principles laid down in the Declaration of Helsinki. All families who consented to photography signed a release.
Funding This quality improvement project was supported by a grant from the Program for Patient Safety and Quality (gs1) at our institution. The sponsors had no involvement in the study design, execution, or manuscript preparation.
Conflict of interest statement None.
Appendix A Parental anxiety and satisfaction after child circumcision Post-operative survey Read the following to the parent “This short survey measures how anxious or confident you have felt about taking care of your son after his circumcision. Please answer as accurately as you can, telling us how you have felt over the past 3 days, up until right now. ”
[1] [1] [1] [1] [1] [4]
Somewhat Somewhat Somewhat Somewhat Somewhat Somewhat
[2] [2] [2] [2] [2] [3]
Moderately Moderately Moderately Moderately Moderately Moderately
[3] [3] [3] [3] [3] [2]
Very Very Very Very Very Very
Much Much Much Much Much Much
[4] [4] [4] [4] [4] [1]
(continued on next page)
526
C.P. Nelson et al.
(continued) 7.
I knew what to expect after my child’s surgery......... 8. I am satisfied with the care I was able to provide my child after his surgery......... *Did you receive the booklet of pictures of normal healing after circumcision? *How useful or helpful did you find the booklet during your child’s post-surgery period?
Not at all [4]
Somewhat [3]
Moderately [2]
Very Much [1]
Not at all [4]
Somewhat [3]
Moderately [2]
Very Much [1]
Yes [1]
No [0]
Moderately [2]
Very Much [1]
Not at all [4]
Somewhat [3]
*items only asked during second assessment month (post-intervention).
References [1] Ahmad NZ, Byrnes G, Naqvi SA. A meta-analysis of ambulatory versus inpatient laparoscopic cholecystectomy. Surg Endosc 1928;22:2008. [2] Bain J, Kelly H, Snadden D, Staines H. Day surgery in Scotland: patient satisfaction and outcomes. Qual Health Care 1999;8:86. [3] Lemos P, Pinto A, Morais G, Pereira J, Loureiro R, Teixeira S, et al. Patient satisfaction following day surgery. J Clin Anesth 2009;21:200. [4] Marla S, Stallard S. Systematic review of day surgery for breast cancer. Int J Surg 2009;7:318. [5] Michaels JA, Reece-Smith H, Faber RG. Case-control study of patient satisfaction with day-case and inpatient inguinal hernia repair. J R Coll Surg Edinb 1992;37:99. [6] Gilmartin J. Contemporary day surgery: patients’ experience of discharge and recovery. J Clin Nurs 2007;16:1109. [7] Mezei G, Chung F. Return hospital visits and hospital readmissions after ambulatory surgery. Ann Surg 1999;230:721. [8] Hughes JM, Callery P. Parents’ experiences of caring for their child following day case surgery: a diary study. J Child Health Care 2004;8:47. [9] Spielberger CD, Gorsuch RL, Lushene RE, Vagg PR, Jacobs AG. Manual for the state-trait anxiety inventory (Form Y). Palo Alto, CA: Consulting Psychologists Press; 1983. [10] Moerman N, van Dam FS, Muller MJ, Oosting H. The Amsterdam Preoperative Anxiety and Information Scale (APAIS). Anesth Analg 1996;82:445. [11] Miller KM, Wysocki T, Cassady Jr JF, Cancel D, Izenberg N. Validation of measures of parents’ preoperative anxiety and anesthesia knowledge. Anesth Analg 1999;88:251.
[12] Finley GA, McGrath PJ, Forward SP, McNeill G, Fitzgerald P. Parents’ management of children’s pain following ’minor’ surgery. Pain 1996;64:83. [13] Chambers CT, Reid GJ, Craig KD, McGrath PJ, Finley GA. Agreement between child and parent reports of pain. Clin J Pain 1998;14:336. [14] Baby bleeds to death after circumcision. Deseret News. Salt Lake City [Newspaper] 6-27-1993; Available from: http://www. deseretnews.com/article/297286/BABY-BLEEDS-TO-DEATHAFTER-CIRCUMCISION.html [15] Petersen CA. Postoperative follow-up: tracking compliance and complications. Semin Periop Nurs 1992;1:255. [16] Barnes S. Not a social event: the follow-up phone call. J Perianesth Nurs 2000;15:253. [17] Marley RA, Swanson J. Patient care after discharge from the ambulatory surgical center. J Perianesth Nurs 2001;16: 399. [18] Dewar A, Scott J, Muir J. Telephone follow-up for day surgery patients: patient perceptions and nurses’ experiences. J Perianesth Nurs 2004;19:234. [19] Huth MM, Broome ME, Mussatto KA, Morgan SW. A study of the effectiveness of a pain management education booklet for parents of children having cardiac surgery. Pain Manag Nurs 2003;4:31. [20] Greenberg RS, Billett C, Zahurak M, Yaster M. Videotape increases parental knowledge about pediatric pain management. Anesth Analg 1999;89:899. [21] Chan CS, Molassiotis A. The effects of an educational programme on the anxiety and satisfaction level of parents having parent present induction and visitation in a postanaesthesia care unit. Paediatr Anaesth 2002;12:131.
Development and implementation of a photographic atlas for parental instruction and guidance after outpatient penile surgery Caleb P. Nelson*, Ilina Rosoklija, Rosemary Grant, Alan B. Retik Department of Urology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Avenue, HU-359, Boston, MA 02115, USA Received 15 August 2011; accepted 27 September 2011 Available online 20 October 2011
KEYWORDS Circumcision; Postoperative care; Pediatrics
Abstract Objective: To develop and evaluate a visual tool to assist parents in assessing healing after surgical circumcision or revision circumcision (SCRC). Methods: Among children undergoing SCRC, photographs were taken on postoperative days 0-1-2-3-5-7-10-14-21, and compiled into an atlas. Atlas utility was assessed during two 1-month periods. During the first period (M1) families received routine postoperative instructions only; during the second period (M2), families received the atlas in addition to routine instructions. Families were surveyed by phone and calls/contacts were tracked. Results: 33 families (among 83 SCRCs) were surveyed during M1, vs 39 families (among 77 SCRCs) during M2 (p Z 0.17). Nearly all reported the atlas helpful (59% very helpful, 27% moderately helpful, 9% somewhat helpful). All but one family used the atlas. There was a trend toward families receiving the atlas being more comfortable (64% vs 82% very comfortable, p Z 0.12). Survey scores were similar between M1 and M2 for total score, satisfaction, and the number whose expectations were met (58% vs 55%, p Z 0.21). Phone contacts decreased between M1 and M2, both in absolute number (M1 Z 24 calls vs M2 Z 12 calls), and as a proportion of total cases performed (29% vs 16%, p Z 0.04). Conclusions: The circumcision atlas was well received by families and was associated with a significant decrease in post-surgical telephone calls. The atlas has been put into routine clinical use with excellent response. ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ1 617 355 3776; fax: þ1 617 730 0474. E-mail address: [email protected] (C.P. Nelson). 1477-5131/$36 ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2011.09.012
522
Introduction Ambulatory surgery has advantages including low cost and high patient satisfaction [1,2e4]. However, ambulatory surgery poses challenges for patients and families, as well as clinicians, in terms of management and assessment of postoperative complications [5e7]. Sending the patient home on the day of surgery means that the patient and family are responsible for monitoring the postoperative recovery, identifying abnormal events or conditions, and determining whether healing is progressing normally. These responsibilities may be particularly challenging for parents of young children undergoing surgery, and this responsibility, along with a lack of knowledge and experience, can be a source of stress and anxiety [8]. Among the more common ambulatory procedures performed in pediatric urology are surgical circumcision and circumcision revision (SCRC). Unlike many surgical procedures in which the operative site is primarily internal, SCRC is performed on an external structure that parents examine multiple times each day. The large volume of SCRCs performed on an ambulatory basis at our institution means that our surgical support staff spend considerable time and effort communicating with families in the postoperative period. Many of these contacts are generated by the fact that parents are unfamiliar with the expected appearance of the penis during the postoperative period. Our hypothesis was that a visual atlas of normal penile healing after SCRC would provide parents with a resource for better understanding ‘normal’ surgical recovery, avoid unnecessary stress and anxiety, reduce the number of postoperative contacts, and simplify postoperative contacts that do occur by giving both parents and providers a common reference for comparison. We sought to develop and validate such an atlas.
Methods This project was a quality improvement project via the Program for Patient Safety and Quality at our institution. Institutional review board approval and waiver of informed consent was obtained.
Generation of image catalog The parents of children aged 6e18 months undergoing SCRC by one of 11 surgeons were approached regarding possible participation. Interested families signed a photo release. Photographs were taken by trained research assistants on postoperative days 0, 1, 2, 3, 5, 7, 10, 14 and 21 using a 10þ megapixel digital camera. All identifiers were destroyed after the photo sequence was complete for each subject. No identifying marks were present in any images.
Creation of the photographic atlas The most representative images were compiled into a visual education aide, in the form of a small atlas. Sixteen subjects were included. Each individual subject is represented once on each page, with one page for each postoperative day
C.P. Nelson et al. (Fig. 1). Once final editing and graphic design was complete, atlases were printed using high-resolution digital printing systems. Print and material cost of the atlas when ordered in bulk is less than one dollar per copy.
Evaluation of the utility of the photographic atlas The atlas was assessed via a prospective evaluation, again approved by the IRB and with waivers of informed consent. Two non-consecutive month-long assessments were performed. The first assessment month (M1) was conducted prior to creation of the atlas. Once the atlas was completed and available, a second month-long assessment period (M2) was conducted; M1 and M2 took place 22 months apart. The effect was to achieve a convenience randomization wherein patients undergoing SCRC during M1 served as controls, and patients undergoing SCRC during M2 served as atlas recipients (cases). During M1, standard post-SCRC instructions and care were provided. During M2, the atlas was provided to families in the post-anesthesia care unit after ambulatory SCRC, with brief instructions for use, to take home at discharge; standard post-SCRC instructions and care were also provided. Postoperative outcome measures during M1 (- atlas) and M2 (þatlas) were compared. The primary outcome was a calculated score on an 8-item postoperative parental survey (10 items for the M2 period) evaluating parental stress, satisfaction with postoperative information, and parental comfort with management at home (Appendix A). Because no validated survey instrument exists for assessment of parental anxiety, experience, and satisfaction after SCRC, we developed a survey using selected validated items from two validated instruments: 1) the StateTrait Anxiety Inventory, a widely used validated instrument for measurement of anxiety in adults [9], and 2) the Amsterdam Preoperative Anxiety and Information Scale [10,11], another assessment of parental peri-operative knowledge and stress. From these we modified items addressing parental satisfaction and comfort with postoperative knowledge and management. Face validity was assessed by the involved surgeons. The survey was administered by telephone on postoperative day 3. Possible scores for the survey range from 8 to 32 (higher scores indicate more anxiety and less satisfaction). During M2, the survey had two additional items asking if the family received the atlas, and asking them how useful they found the atlas during the postoperative period. The secondary outcome was the number of SCRC-related postoperative phone contacts received by the Department of Urology during each assessment month. Calls were logged by Department nursing staff, noting the reason for the call, whether or not the family had received the atlas, whether they or the family referred to the atlas during the call, and whether the atlas helped or hindered the evaluation. Outcomes were compared during M1 and M2. Continuous variables were compared using t-tests and categorical variables with chi-square tests. All tests were two-sided and p-values of 0.05 or less were considered significant.
Results Eighty-three SCRC procedures were performed during M1 versus 77 procedures during M2. During M1, 33 families
Photo atlas for parental guidance after penile surgery
Figure 1
523
Selected page from Atlas of Healing after Surgical Circumcision (postoperative day 7).
(40%) were surveyed; 39 families (51%) were surveyed in M2 (p Z 0.17). Of the M2 families who were surveyed, 22 (56%) had received the atlas with their postoperative instructions.
Among those who were surveyed and received the atlas (n Z 22), the response was overwhelmingly positive. Nearly all respondents reported that the atlas was helpful (59% very helpful, 27% moderately helpful, and 9% somewhat
524 helpful). Only one family who received the atlas reported not using it. Among the 18 families surveyed during M2 who did not receive the atlas, 61% reported that they would like to have received a copy and most of these requested that a copy be sent. On the postoperative surveys of parental anxiety and comfort, there was no significant difference in overall summary scores between responses in M1 and in M2 (11.8 vs 12.4, p Z 0.62). On individual items, there was no significant difference in the proportion who were very satisfied with the care they were able to provide their child after surgery (76% vs 82%, p Z 0.31) or who knew what to expect after surgery (58% vs 55%, p Z 0.21). There was a trend toward families who received the atlas being more comfortable with the overall postoperative instructions, although the difference was not significant (64% vs 82% very comfortable, p Z 0.12). The number of calls to the Department of Urology decreased during M2 compared to M1. There were 24 calls during M1 regarding procedures performed that month, versus 12 calls during M2. The number of calls as a proportion of total cases during the month was lower in M2 (16% vs 29%, p Z 0.04). Of those who called during M2, 5 (42%) reported that the atlas was useful during the postoperative period. The atlas was directly utilized for reference by the nursing staff during 3 of the 12 calls (25%). Of the calls during M1, 42% (10/24) pertained to concerns about penile appearance, compared to 17% of calls during M2 (2/12), although the difference was not significant (p Z 0.13). The other calls during both periods included a mix of concerns regarding dressing removal, pain control, and bleeding.
Discussion In recent years, most surgical procedures in pediatric urology have transitioned from inpatient or same-day admission to ambulatory care. While this trend has benefits regarding efficiency and cost, a significant number of postoperative care responsibilities have been transferred from the trained staff of the hospital to the child’s parents or other caregivers. Most of these parents have little or no medical training, and their experience with postoperative management of incisions, dressings, and other surgical facts of life is likely to be minimal. The result of this transition is that, after ambulatory surgery, parents are primarily responsible for evaluating the patient’s postoperative status, and making potentially critical decisions regarding the need for further evaluation of possible problems. For many parents, this responsibility is a source of stress and anxiety [8]. The lack of knowledge and experience can result in unnecessary discomfort and adverse outcomes [12,13]. Rare but widely reported catastrophic outcomes after simple procedures such as circumcision are often attributed to a failure to recognize abnormal postoperative events [14]. To address these issues, ambulatory surgery programs have developed systems to provide follow-up care, mostly centered around telephone contacts with families [15e17]. These contacts serve to confirm that recovery is going well, to answer parental questions about the recovery process, and to identify impending or actual problems. However,
C.P. Nelson et al. telephone contacts consistently reveal that many parents have misperceptions about ‘normal’ recovery patterns during the postoperative period [18]. Efforts to improve parent education and understanding, and to reduce parental stress have consistently demonstrated that these approaches can result in better transmission of information to parental caregivers with resulting improvements in care of the pediatric patient after discharge [19e21]. In many cases, the physician or nurse must base their postoperative evaluation on a description of the penile appearance by the parent, and these tend to be vague. We developed the circumcision atlas as a tool to facilitate evaluation by the parents, as well as communication between families and hospital-based staff. The response to the atlas by both our patients’ families and our nursing and surgical staff has been highly positive. It is now routinely included in postoperative education materials for all SCRC patients under age 12. Although we did not observe a difference in overall survey scores with atlas usage, we have found that in daily practice families greatly appreciate the visual reference cues that the atlas provides, and it is our subjective impression that it does enhance both patient safety and quality of care in the ambulatory surgery program at our institution. By providing parents with a reference tool to which they can compare their child’s postoperative recovery, we enable parents to better appreciate deviations from normal recovery and contact us when needed. In theory, improved recognition of such deviations may help to prevent delays in diagnosis and treatment of serious postoperative complications such as infection (although we have not documented any specific examples of this). Furthermore, it is our belief that quality surgical care requires improved communication with parental caregivers. In ambulatory surgery, we rely on parental caregivers to serve as proxies for trained medical professionals. Parents need information about postoperative recovery that is usable and that is appropriate to their level of knowledge and experience. The postoperative atlas significantly improves the quality of care by providing an additional tool for assessment by parents, while also addressing parental anxiety and concern during an otherwise normal recovery. With the widespread availability of digital cameras and email over the past 10 years, families often send photos to our staff as attachments in email communications, expressing concern about their child’s progress. Although these photographs are often of limited utility due to blurry imaging or inadequate angle or lighting, the basic soundness of this concept led us to the idea of a comprehensive ‘standardized’ atlas of images of normal healing. To our knowledge, this type of post-surgical atlas has not been developed previously for SCRC. The result of this study should be interpreted in light of its limitations. This was a single-site study and, as such, the results may not be generalizable to all practices or institutions. There may be unique features of our surgeons, surgical processes, postoperative instructions, and patients that make the atlas more useful in this setting than in others. Overall, however, we believe that this tool will be broadly applicable. Eleven different surgeons perform these procedures at our institution, reducing the impact of
Photo atlas for parental guidance after penile surgery
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individual surgeon practices. Similarly, our panel of 16 photo patients represented a range of races, ethnicities, and socioeconomic groups. Nonetheless, any outside institution wishing to implement this tool would have to consider whether it would fit into their own practice pattern and patient population. In theory, it would be ideal if each institution were to develop its own atlas using patients operated on by surgeons at that site. However, given the tremendous time and effort required to produce the current tool, this is probably impractical. Another limitation was that we conducted this study using a convenience randomization, meaning that the preand post-implementation periods were conducted at different time points to allow for comparison of groups. This methodology should not be confused with a true randomized controlled trial; it is possible that confounding factors (other than the atlas itself) were present that could have resulted in any differences in outcomes between periods. However, we are unaware of any such differences, in that our surgical and postoperative care practices and instructions remained stable and constant during both measurement periods. While there was some variation in the numbers of procedures performed by each of the 11 surgeons, the procedures were widely distributed among the surgeons, with no individual surgeon performing more than 20% of the cases in either time period. All surgeons but one performed cases during both time periods, with the lone exception performing 3 cases in M1 and 0 cases in M2. One benefit of this study design is that this was a default enrollment; no families during M1 received the atlas (as it did not yet exist), while all families during M2 were enrolled by default (as the atlas was integrated into routine postoperative care). Granted, not all patients in the postimplementation group (M2) received the atlas. This was a consequence of challenges encountered in modifying postoperative care practices and involving the many providers in the project, including nursing. We do not believe that there were any systematic differences between those families who did or did not receive the atlas during M2; failure to receive the atlas appears to have been random. The lower number of families who received the atlas did reduce our power to detect differences in parental responses, particularly on the anxiety and comfort survey. It is possible that with larger numbers the small differences seen would have been statistically significant. However, the study as executed was powered to detect an absolute difference in total scores of 2.8, which would be an approximately 10% difference in scores. Smaller differences
1. 2. 3. 4. 5. 6.
I am tense........... I feel strained ......... I feel frightened....... I feel nervous........ I am worried.......... I feel comfortable with the instructions and information provided after my child’s surgery.........
Not Not Not Not Not Not
at at at at at at
all all all all all all
than this are not likely to be clinically meaningful. Nonetheless, we believe that the data do suggest that, at the very least, implementation of the atlas resulted in no adverse impact on family satisfaction or postoperative care.
Conclusions We developed an atlas of post-circumcision healing that was well-received by families, and that was associated with a significant decrease in post-surgical telephone calls. Parental postoperative anxiety did not change measurably. The atlas has been put into routine clinical use with excellent response.
Ethical approval This work was evaluated by the IRB at our institution and it was determined that, as a quality improvement project, a waiver from full IRB review was appropriate. All project activities were carried out in full accordance with the principles laid down in the Declaration of Helsinki. All families who consented to photography signed a release.
Funding This quality improvement project was supported by a grant from the Program for Patient Safety and Quality (gs1) at our institution. The sponsors had no involvement in the study design, execution, or manuscript preparation.
Conflict of interest statement None.
Appendix A Parental anxiety and satisfaction after child circumcision Post-operative survey Read the following to the parent “This short survey measures how anxious or confident you have felt about taking care of your son after his circumcision. Please answer as accurately as you can, telling us how you have felt over the past 3 days, up until right now. ”
[1] [1] [1] [1] [1] [4]
Somewhat Somewhat Somewhat Somewhat Somewhat Somewhat
[2] [2] [2] [2] [2] [3]
Moderately Moderately Moderately Moderately Moderately Moderately
[3] [3] [3] [3] [3] [2]
Very Very Very Very Very Very
Much Much Much Much Much Much
[4] [4] [4] [4] [4] [1]
(continued on next page)
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C.P. Nelson et al.
(continued) 7.
I knew what to expect after my child’s surgery......... 8. I am satisfied with the care I was able to provide my child after his surgery......... *Did you receive the booklet of pictures of normal healing after circumcision? *How useful or helpful did you find the booklet during your child’s post-surgery period?
Not at all [4]
Somewhat [3]
Moderately [2]
Very Much [1]
Not at all [4]
Somewhat [3]
Moderately [2]
Very Much [1]
Yes [1]
No [0]
Moderately [2]
Very Much [1]
Not at all [4]
Somewhat [3]
*items only asked during second assessment month (post-intervention).
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[12] Finley GA, McGrath PJ, Forward SP, McNeill G, Fitzgerald P. Parents’ management of children’s pain following ’minor’ surgery. Pain 1996;64:83. [13] Chambers CT, Reid GJ, Craig KD, McGrath PJ, Finley GA. Agreement between child and parent reports of pain. Clin J Pain 1998;14:336. [14] Baby bleeds to death after circumcision. Deseret News. Salt Lake City [Newspaper] 6-27-1993; Available from: http://www. deseretnews.com/article/297286/BABY-BLEEDS-TO-DEATHAFTER-CIRCUMCISION.html [15] Petersen CA. Postoperative follow-up: tracking compliance and complications. Semin Periop Nurs 1992;1:255. [16] Barnes S. Not a social event: the follow-up phone call. J Perianesth Nurs 2000;15:253. [17] Marley RA, Swanson J. Patient care after discharge from the ambulatory surgical center. J Perianesth Nurs 2001;16: 399. [18] Dewar A, Scott J, Muir J. Telephone follow-up for day surgery patients: patient perceptions and nurses’ experiences. J Perianesth Nurs 2004;19:234. [19] Huth MM, Broome ME, Mussatto KA, Morgan SW. A study of the effectiveness of a pain management education booklet for parents of children having cardiac surgery. Pain Manag Nurs 2003;4:31. [20] Greenberg RS, Billett C, Zahurak M, Yaster M. Videotape increases parental knowledge about pediatric pain management. Anesth Analg 1999;89:899. [21] Chan CS, Molassiotis A. The effects of an educational programme on the anxiety and satisfaction level of parents having parent present induction and visitation in a postanaesthesia care unit. Paediatr Anaesth 2002;12:131.