Improving telephone follow-up after ambulatory surgery

Improving Telephone FollowUp After Ambulatory Surgery RUTH

M.

KLEINPELL

PhD,

RN,

ACNP,

CCRN

The number of ambulatory surgery procedures performed annually is steadily increasing. Telephone follow-up of patients after ambulatory surgery remains an important component of care for ambulatory surgery patients. The purpose of this prospective quality improvement project was to obtain a more comprehensive telephone follow-up of ambulatory surgery patients in a large metropolitan medical center. During a 3 month evaluation period, 485 patients (61% of a convenience sample of 798 who had undergone an ambulatory surgical procedure) were interviewed to determine the incidence of side effects and elicit patient satisfaction. Postoperative side effects reported most frequently included pain, bleeding, nausea, dizziness, and fever. A majority of patients reported receiving adequate discharge instructions and excellent nursing care. This quality improvement project initiated by staff n urses resulted in changes in the procedure for documenting postoperative phone assessments from narrative notes to the use of a semistructured form for telephone follow-up after ambulatory surgery. 9 1997 by American Society of PeriAnesthesia Nurses.

DVANCES IN surgery and anesthesia, relative cost savings associated with ambulatory care, managed care, Medicare mandates, and changes in hospitalization practices continue to increase the number of ambulatory surgical procedures being performed each year. The growth of outpatient surgical procedures is staggering, increasing from 16% of all surgeries in 1980 to over 56% by 1994.1 In a recent survey, hospital administrators predicted that by the year 2000, outpatient services will account for nearly half of hospital net patient revenues. 2 Examination of patient outcomes is an important component when analyzing outpatient surgery. Patient outcomes are the end result of

A

Ruth M. Kleinpell, PhD, RN, ACNP, CCRN, is a TeacherPractitioner, Surgical Nursing, Rush Presbyterian St. Luke's Medical Center, and an Associate Professor, Rush University College of Nursing, Chicago, IL. Address correspondence to Ruth M. Kleinpell, PhD, RN, ACNP, CCRN, 600 South Paulina, 1062B AAC, Chicago, 1L 60612. 9 1997 by American Society of PeriAnesthesia Nurses. 1089-9472/97/1205-0004503.00/0

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medical care and the consequences of care delivery structure and process. 3 Important reasons for monitoring outcomes are to describe the impact of care, to establish a more accurate and reliable basis for clinical decision making, to evaluate the effectiveness of care, and to identify opportunities for improvement. 4 Outcomes after ambulatory surgery have been traditionally assessed in terms of surgical and anesthesia-related complications including unanticipated hospital admission, recovery time after anesthesia, postoperative physician or emergency room visit, mortality, and major morbidity incidences (myocardial infarction, central nervous system deficit, pulmonary embolism, and respiratory failure). 5-8 Patient outcomes after ambulatory surgery have also been assessed in terms of patient experiences including incidence of postoperative nausea and vomiting, pain/surgical discomfort, drowsiness, dizziness, sore throat, return to usual activity level, and patient satisfaction. 9'1~However, previous follow-ups of patients after outpatient surgery have varied in the amount and type of parameters assessed, including evaluations of nursing care received.

Journal of PeriAnesthesia Nursing, Vol 12, No 5 (October), 1997: pp 336-340

IMPROVING TELEPHONE FOLLOW-UP Current nursing practices of collecting data from patients after outpatient surgery are diverse. 11-13Usual information gathered in the postoperative phone evaluation that occurs 24 to 48 hours after surgery includes assessment of nausea/vomiting, pain, bleeding or wound drainage, elevated temperature, general condition, and any specific problems. The use of mail-back questionnaires to assess the overall outpatient surgical experience have also been used; however, difficulty with low response rates (usually 20% to 40%) remains problematic. 12

337 operative discharge instructions, nursing care received, and satisfaction with the overall outpatient experience were also assessed to identify areas for nursing intervention improvements. The assessment form was tested with 30 ambulatory surgery patients. The form was subsequently revised for clarity to facilitate data collection. During a 3-month period, attempts were made to contact all patients aged 18 years and older who had undergone an outpatient surgical procedure. Calls were attempted by a PAR/ASU nurse 24 to 48 hours after surgery. Two phone call attempts were made to each patient.

PURPOSE

The purpose of this project was to conduct a prospective quality improvement initiative to obtain more comprehensive information of ambulatory surgery patients, and identify improvements for nursing interventions. The site for this project was a large metropolitan 903-bed medical center which performs over 7,000 outpatient surgical procedures annually. Follow-up of outpatient surgical patients consisted of a phone call made by a Postanesthesia Recovery/Ambulatory Surgery Unit (PAR/ASU) nurse to patients 1 to 2 days postoperatively. Two attempts were made to contact the patients by phone. The patients were asked about their general condition and if they had been experiencing any difficulties. The phone contact and information obtained was documented in the patient charts. However, because there were no standard protocol questions, assessments of patient outcomes were inconsistent. It was felt that a structured assessment form would provide information that could be used to better assess patient status and improve nursing practices. METHOD

The data collection assessment form developed for use in this project was based on a review of the literature and suggestions gathered from postanesthesia assessment forms used by area hospitals (Appendix). Data collected included incidences of postoperative complications as defined by patients and included pain, nausea and vomiting, fever, bleeding, incisional drainage, sore throat, hoarseness, cough, dizziness, and activity level changes. No definitions were given, but patients reported their experiences after surgery. Evaluations of the helpfulness of post-

RESULTS

Of the 485 contacted patients, 38% were male and 62% were female. Patients ranged in age from 18 to 92 years. Patients underwent a variety of surgical procedures, with obstetrical/gynecological; eyes, ears, nose, and throat; renal/genitourinary, and orthopaedic-related procedures being performed most frequently (Table 1). A majority of patients received either general anesthesia (44%), local anesthesia (40%), or monitored anesthesia care (7.4%). Overall incidences of postoperative side effects were experienced infrequently (cough, fever, wound drainage) to occasionally (bleeding) to frequently (pain). Table 2 lists the side effects by frequency. Patients were asked to rate the pain they experienced within the past 24 hours on a scale of 0 (no pain) to 10 (very severe pain). Table 3 outlines severity of pain and the type of analgesics patients reported. A majority of patients reported receiving "adequate" discharge instructions--defined as receiving information

Table 1. Sample Characteristics Operative Procedure

Number

Percent

Ear/nose/th roat/eye Obstetrical/gynecological Renal/genitourinary Orthopaedic Operative procedure unavailable Hernia repair Liver biopsy Line placement Dermatologic Vascular reconstruction Bronchoscopy Other

117 112 90 46 30 17 16 15 11 11 10 10

24.2 23.0 18.6 9.5 6.0 3.5 3.3 3.1 2.3 2.3 2.1 2.1

RUTH M. KLEINPELL

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Table 2. Postoperative Side Effects

Table 4. Care Evaluations

Postoperative Side Effects

Number

Percent

Pain No reported side effect Bleeding Nausea/vomiting Sore throat Hoarseness Dizziness Cough Fever Wound drainage

218 131 41 24 24 14 13 10 4 6

45.0 27.0 9.0 5.3 5.3 3 2.9 2.2 2 1.3

which proved to be helpful. A majority of patients also reported receiving "excellent" nursing care--defined as receiving consistent, competent nursing care. Table 4 presents patient responses.

Postoperative Instructions Helpful? Yes--Instructions useful/clear No--Instructions not useful/clear Nursing Care: Satisfactory--Nursing care was adequate Excellent--Nursing care was consistently competent and attentive Overall Experience: Unsatisfactory--Dissatisfied with experience Satisfactory--Satisfied, no complaints Excellent--Very pleased with experience

Number

Percent

471 11

97.7 23.3

Number

Percent

44

9.1

439

90.9

Number

Percent

3 76 399

0.6 15.9 83.5

Note. Three patients did not answer the first question, two patients did not answer the second question, and seven patients did not answer the third question.

Table 3. Pain

DISCUSSION Severity of Pain: Scale of 0 (None) to 10 (Very Severe) Value 0 1 2 3 4 5 6 7 8 9 10 Effectiveness of Pain Relief: Poor--little to no pain relief Fair--some pain relieved Adequate--most pain relieved G o o d - - m o s t pain relieved Excellent--all pain relieved Type of Analgesia: None Hyd rocodone/aceta minophen Acetaminophen Acetaminophen with codeine Nonsteroidal antiinflammatory Other

Number

Percent

250 21 40 25 27 35 15 16 11 6 8

55.0 4.6 8.8 5.5 5.9 7.7 3.5 3.5 2.4 1.3 1.8

Number

Percent

4 31 54 101 37

1.8 13.7 23.8 44.4 16.3

Number

Percent

281 76 36 34 11 10

62.7 17.0 8.0 7.6 2.5 2.2

Note. 30 patients did not answer the first question, 258 did not answer the second question, and 37 did not answer the third question.

This quality improvement project sought to improve the telephone follow-up process for ambulatory surgery patients. A semi-structured telephone follow-up form was used in an attempt to better elicit information on postoperative status and patient satisfaction. The form helped to better structure the postoperative call, but proved to be somewhat lengthy and did not provide as much meaningful information as initially conceived. The use of a questionnaire with " y e s " and ' 'no" responses limited the information obtained. Responses with answers such as " n o n e , " " s o m e , " " m u c h , " or scale responses such as "from 1 to 10" would have provided more meaningful information. An additional project limitation included that a significant number of potential study subjects (39%) could not be reached by phone. Of those not interviewed, 20% could not be reached despite two phone call attempts, 10% had no phone, 4.6% had message recorders, 2% were the wrong phone number, 1% refused to answer questions, and 1% had a consistently busy phone despite two to four repeated attempts to contact. Insufficient nursing time to attempt to call all patients until they were reached was identified in the units current protocol. The need for budgeting a portion of an ASU position to be devoted to postoperative phone calls is currently being considered based on the project findings.

I M P R O V I N G TELEPHONE F O L L O W - U P Although an original data collection form was designed to assess in depth patient postoperative experiences, pilot testing showed that it was too lengthy. The revised data collection form assessed many areas; however, time limited a comprehensive assessment of all potential patient outcomes after ambulatory surgery. The potential for bias in response may also exist because staff nurses who had cared for the patients were conducting the phone interviews. Additionally, the incidence of complications that may have occurred after the postoperative phone calls is not known. This quality improvement project initiated by staff nurses provided an initial information base and resulted in changes in the procedure for documenting postoperative phone assessments. Before the project, no standard protocol questions or assessment form existed. Call assessments varied in content, and were documented in various locations in the progress notes. As a result of the project, a new documentation form was developed to incorporate the phone assessment information on a specific discharge instruction form within the patient chart. Additionally, nurses now verify the postoperative phone number where the patient can be reached before discharge. This project highlights the importance of analyzing current practices for phone follow up in same-day surgical settings. Plans for conducting new telephone follow-up methods need to be evaluated before use to elicit information that is clearly helpful. Consultation with persons who have experience in form development may be indicated to facilitate the process.

339 The postoperative follow-up phone call is an important component of care for ambulatory surgery patients. It has become one tool that nurses can use to help in evaluating a patient' s postoperative condition, reinforce postoperative teaching, and obtain performance feedback. 13 Monitoring patient outcomes after ambulatory surgery is essential in assessing the presence of postoperative complications and in ensuring patient comfort, pain relief, and satisfaction. As the number of outpatient surgical procedures steadily increases, the importance of monitoring patient status postoperatively in the home setting becomes even more evident. Several phone assessment contacts may be even more beneficial in assessing outcome status and occurrence rates of complications. For example, a telephone call at the traditional time of 24 to 48 hours after surgery and a call 1 week after surgery may prove to be a better method of comprehensively assessing outcomes after ambulatory surgery. To make optimal use of the postoperative phone call assessment, alternative methods of phone call follow-up need to be explored. ACKNOWLEDGEMENT The author would like to acknowledge the assistance of all of the Ambulatory Surgery-Post Anesthesia Nursing staff, Rush Presbyterian St. Luke's Medical Center, Chicago, IL who participated in the research project. Nurses overseeing the project included: Janet Dougherty, MS, RN; Lisa Mendelson MS, RN; Sue Quilaton, RN; Cora Seguban, RN; Dawn McCarthy, RN; Lynn Angotti, RN; Sonja Tudor, RN; Winci Rivera, RN; Caroline Duquette, RN; Arleen Todd, RN; Kathy Knorr, RN; Grace Borkowicz, RN; Jeff Hibbert, RN; Leslie Johns, RN; and Belle Pecson, RN.

REFERENCES 1. American Hospital Association: Hospital Statistics. Chicago, IL, American Hospital Association, 1994 2. American Hospital Association: Ambulatory care trendlines: Outpatient surgery trends 1980-1992, vol 1. Chicago, IL, American Hospital Association, 1994 3. Jennings B: Outcomes: Two directions--Research and management. AACN Clin Iss Crit Care 6:79-88, 1995 4. Davies A, Doyle M, Lansky D, et al: Outcomes assessment in clinical settings: A consensus statement on principles and best practices in project management. J Qual lmprov 20:6-16, 1994 5. Chye E, Young I, Osborne G, et al: Outcome after same-day oral surgery: A review of 1180 cases at a major teaching hospital. J Oral Maxillofac Surg 51:846-849, 1993 6. Heino A, Vainio J, Turunen M, et al: Results of 500 general surgery patients operated on in the ambulatory surgery unit. Ann Chir Gynaecol 81:295-299, 1992 7. Osborne G, Rudkin G: Outcome after day-care surgery

in a major teaching hospital. Anaesth Intensive Care 21:822827, 1993 8. Warner M, Shields S, Chute C: Major morbidity and mortality within 1 month of ambulatory surgery and anesthesia. JAMA 270:1437-1441, 1993 9. Parnass S: Ambulatory surgical patient priorities. Nurs Clin North Am 28:531-545, 1993 10. Philip B: Patients' assessment of ambulatory anesthesia and surgery. J Clin Anesth 4:355-358, 1992 11. Burden N: Telephone follow-up of ambulatory surgery patients following discharge is a nursing responsibility. J Post Anesth Nurs 7:256-261, 1992 12. Young C: The postoperative follow-up phone call: An essential part of the ambulatory surgery nurse's job. J Post Anesth Nurs 5:273-275, 1990 13. Linden 1, Engberg I: Nursing discharge assessment of the patient post-inguinal herniorrhapy in the ambulatory surgery setting. J Post Anesth Nurs 9:14-19, 1994

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RUTH M. KLEINPELL

APPENDIX PT ADDRESSOGRAPH INFO STAMPED HERE IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII

I I I I

AGE DIAGNOSIS PROCEDURE TYPE OF ANESTHESIA DATE OF PROCEDURE

SEX

1. After your out-patient procedure did you experience any: (if patient did experience an event, assess average severity the past 24 hours on a scale of 0 to 10 where 0 is never and 10 is very severe): Pain Nausea/vomiting Fever Bleeding (site ) Incision drainage (type ) 2. Is your activity limited due to surgery?: If YES, how?

Sore throat Hoarseness Cough Dizziness Other (describe NO

YES

3. Were the postoperative instructions you received helpful? YES NO If NO, how could they have been better? 4. Would you have liked to have more information? NO YES If YES, what additional information would have been helpful? 5. How would you rate: Excellent The nursing care you received The overall outpatient experience If unsatisfied, what were you dissatisfied with?

Satisfactory

Unsatisfactory

6. Is there anything else you want to relate about your experience? 7. Unit Response (Indicate if patient reached on 1st or 2nd attempt, patient unreached, patient was referred to MD for problems, etc.)

Date and time patient called:

Signature