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Postoperative recovery after different orthopedic day surgical procedures
International Journal of Orthopaedic and Trauma Nursing (2011) 15, 165–175
www.elsevier.com/locate/ijotn
Postoperative recovery after different orthopedic day surgical procedures Katarina Berg CRNA,MScN a,*, Ewa Idvall RNT,PhD (Professor) b,c, Ulrica Nilsson RNA,PhD (Associate Professor) d,e, Mitra Unosson RNT,PhD (Professor) f a
¨ping University, Department of Medical and Health Sciences/Division of Nursing Science, SE-581 85 Linko Sweden b ¨ University, Sweden Faculty of Health and Society, Malmo c ˚ne University Hospital, Sweden Ska d ¨ rebro University Hospital, Sweden Centre for Healthcare Sciences, O e ˚ University, Sweden Department of Nursing, Umea f ¨ping University, Sweden Department of Social and Welfare Studies, Faculty of Health Sciences, Linko
KEYWORDS
Abstract Orthopedic day surgery is common. Postoperative recovery may differ according to surgical procedures and personal factors. We studied postoperative recovery up to 2 weeks after different orthopedic day surgical procedures and tried to identify possible predictors associated with recovery. Three-hundred and fifty eight patients who had undergone knee arthroscopy or surgery to the hand/arm, foot/leg or shoulder were included. Data were collected on postoperative days 1, 7 and 14 using the Swedish Post-discharge Surgery Recovery scale, the emotional state, physical comfort and physical independence dimensions in the Quality of Recovery-23 and a general health question. Multiple linear regression was used to explore predictors of recovery. The shoulder patients experienced significantly lower postoperative recovery and general health 1 and 2 weeks after surgery compared to the other patient groups (p < 0.001). Significant predictors of recovery were age, perceived health and emotional status on the first postoperative day and type of surgery. Postoperative recovery after common orthopedic day surgical procedures varies and factors influencing it need to be further explored. The impact of a patient’s emotional state on recovery after day surgery can be of particular interest in this work. Post-discharge planning needs to be tailored to the surgical procedure. c 2011 Elsevier Ltd. All rights reserved.
Day surgery; Postoperative recovery; Orthopedic nursing
* Corresponding author. Tel.: +46 101037774; fax: +46 13123285. E-mail address: [email protected] (K. Berg).
1878-1241/$ - see front matter c 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijotn.2011.02.003
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K. Berg et al.
Editor’s comments There is great demand for day surgery/ambulatory surgery because it is perceived to be an efficient and popular approach to relatively minor orthopedic surgery. It is important, however, that practitioners do not underestimate the impact that this approach can have on the patient’s well being and their experience of their recovery from surgery. This paper, for example, clearly highlights that one particular type of surgery – that to the shoulder – can result in a much poorer experience and outcome in the first few weeks than may be the case for other types of surgery. Practitioners, therefore, must take this issue into account when planning surgery, recovery and discharge and focus on patient support. It may even be necessary to question if this type of surgery is suitable for the day/ambulatory surgery approach. JS
Introduction Day surgery procedures are common and orthopedic surgery constitutes a large part worldwide (Toftgaard and Parmentier, 2006). Following day surgery, patients are discharged after a short period of postoperative surveillance. The care burden of recovery is consequently transferred from the hospital to the patient and significant others at home, which may create anxiety and discomfort for the patient and the carer about the management of clinical care (Boughton and Halliday, 2009). Recovery while still in hospital and the first postoperative days, are frequently studied among day surgery patients (Awad and Chung, 2006; Watt-Watson et al., 2004) but some patients improve slowly and the recovery period is protracted (Rose ´n et al., 2009). Protracted recovery after the first postoperative week is not so well explored (Brattwall et al., 2010b). Recovery might be delayed by comorbidity, a more complex day surgical procedure (Lermitte and Chung, 2005) or by the type of surgery, even if it is commonly performed in the day surgery context (Rose ´n et al., 2009). Moreover, patients with multiple diagnoses, elderly and frail patients are today eligible for day surgery which may influence the recovery period (Bryson et al., 2004). There is still limited empirical understanding of postoperative recovery experienced by patients from discharge to resumption of normal activities (Gudex et al., 2006) as well as what constitutes postoperative recovery in specific surgical populations and factors of importance for late recovery (Rose ´n et al., 2009). To achieve high qualitative postoperative recovery at home these gaps need to be filled in. There is a high rate of satisfaction in day surgery (Krywulak et al., 2005; Mattila and Hynynen, 2009) but there are also symptoms reported post-discharge such as pain, nausea, dizziness and tiredness (Rose ´n et al., 2009; Wu et al., 2002).
Postoperative recovery is seen as a subjective experience (Allvin et al., 2008; Kleinbeck, 2000; Kluivers et al., 2008; Lee and Stephens, 2000) based on, for example, pain and other symptoms (Gilmartin, 2007; Susilahti et al., 2004), functional status (Horvath, 2003) and ability to perform activities in daily life (Young et al., 2000). According to the self-regulatory model by Leventhal et al. (1980), five coherent factors – identity, time-line, cause, consequence and cure/control may also influence an individual’s postoperative recovery. These factors can be illustrated in a patient’s concerns about the magnitude of postoperative symptoms (identity), the recovery time-span (timeline), the need for surgery (cause), the impact of the surgical procedure (consequence) and how to deal with the postoperative situation (control) (McCarthy et al., 2003). Postoperative recovery thereby depends on a variety of factors (Lee and Stephens, 2000). Postoperative recovery following day surgery is described as regained normality and wholeness (Allvin et al., 2007) and a perception of a return to the usual self (Kleinbeck, 2000). Knowledge about factors of importance for returning to the usual self can improve care planning, monitoring and support in day surgery. Systematic follow-ups of postoperative recovery are important for nurses and other health professionals in order to achieve a clear picture of the patient’s condition, to prevent complications, identify symptoms and to provide support for the patient and the carer. In such work, valid assessment methods are required (Susilahti et al., 2004). Valid assessments also contribute to nurses and health organisations gaining an understanding of the quality of care provided. It has become more important to identify patients’ self-reporting of postoperative recovery in order to emphasize evidence-based health care in day surgery (Brattwall et al., 2010a). In day surgery this can be performed using questionnaires. The Post-discharge Surgical
Postoperative recovery after different orthopedic day surgical procedures Recovery (PSR) scale (Kleinbeck, 2000) and the Quality of Recovery-40 (QoR-40) (Myles et al., 2000) are the methods currently reported to have the most satisfactory psychometric properties (Herrera et al., 2007; Kluivers et al., 2008). These instruments assess important variables in orthopedic day surgery such as mobility, physical ability in different aspects and symptoms. To increase the empirical knowledge about patients’ experiences of postoperative recovery at home and why some patients recover more slowly than others, a prospective longitudinal study was undertaken. The aims of this study were to describe postoperative recovery on postoperative days 1, 7 and 14 after different orthopedic day surgical procedures and to identify possible predictors associated with postoperative recovery 2 weeks after surgery.
Methods Day surgery is defined in this study as surgery performed on a patient who is admitted and operated on during the same day and discharged without an overnight stay in the surgery unit. The orthopedic day surgery patients in this study constitute a part of a larger longitudinal study including other groups of day surgery patients. The study followed standard ethical principles for clinical research and was approved by the Regional Ethical Review Board (Dnr 03-333).
Patients Day surgery patients older than 18 years and able to read and speak Swedish were consecutively asked to participate. A total of 459 orthopedic patients (240 male, 219 female) were eligible. Patients were recruited from a county hospital (n = 80), a private surgery unit (n = 172) and a university hospital (n = 207). Of the 459 patients asked to participate, 61 declined and 35 were missed, resulting in 363 patients (79%) giving informed consent to participate. Five patients needed in-hospital postoperative care and were therefore excluded. Consequently, 358 patients (189 male and 169 female) scheduled for common orthopedic day surgical procedures were included and divided into four study groups according to type of surgery. These groups were: arthroscopy (ACI) of the knee (140 subjects), surgery to the hand/arm (128 subjects), surgery to the foot/leg (71 subjects) and surgery to the shoulder (19 subjects). No significant differences regarding age, gender or surgical procedure were noted between
167
patients compared to those who declined participation or who were not asked.
Data collection The Swedish Post-discharge Surgery Recovery (SPSR) scale (Berg et al., 2010) and the Quality of Recovery-23 (QoR-23) (Idvall et al., 2009) were used to assess postoperative recovery. These scales have been modified from their originals (Kleinbeck, 2000; Myles et al., 2000) and psychometrically tested for Swedish patients (Berg et al., 2010; Idvall et al., 2009). The S-PSR scale is a self-rating 12item instrument which assesses the patient’s alertness, pain, tiredness, activity, need for a daytime nap, mobility, living situation, physical exercise, expectations, recovery, normal life and frame of mind. Each item is rated on a ten-point (1–10) semantic differential scale. A recovery score is computed by dividing the patient’s individual sum score by the total possible score and multiplying the result by 100. The final score range is thus 10–100, with higher scores indicating a more favourable postoperative recovery. The scale has satisfactory validity, reliability, data quality and responsiveness (Berg et al., 2010; Kleinbeck, 2000). Patients’ emotional state (8 items), physical comfort (10 items) and physical independence (5 items) were assessed using the QoR-23 (Idvall et al., 2009). The items are rated on a five-point scale (1–5), and responses to the items in their respective dimensions are summed with a maximum score of 40, 50 and 25, respectively. Higher scores indicate a higher quality of recovery. The instrument has been tested for validity and reliability as well as sensitivity to change (Idvall et al., 2009; Myles et al., 2000) and has shown initial usefulness as an outcome measure in the day surgery context (Idvall et al., 2009). Both the S-PSR scale and the QoR-23 are easy to complete and do not take long to respond to. Perception of health was assessed using a general question rated on a ten-point numerical rating scale, where 1 represents very poor health and 10 excellent health. Background data including demographic data (age, gender, residence, employment, and education) and the American Society of Anesthesiologists’ (ASA) physical status classification were collected using a structured questionnaire and patient records.
Procedures On arrival at the surgery unit, each patient received verbal and written information about the
168 research project and informed consent to participate was obtained. As baseline data of perceived health, the patients were asked to assess their experienced health during the preceding 12 months. To construct a baseline score, the patients rated eight items from the S-PSR scale that were possible to assess preoperatively. These items were: patient’s alertness, pain, tiredness, activity, need for a daytime nap, mobility, living situation and physical exercise, also computed by dividing the patient’s individual score by the total possible score and multiplying with 100. The preoperative score range is thus 10–100 as well. Health and postoperative recovery were henceforth assessed on postoperative day (POD) 1 and again on PODs 7 and 14 and were based on the patients’ experience on that particular day. When discharged from the day surgery unit, the patients received a questionnaire including the S-PSR scale, the QoR-23 and the question about perceived health, along with a postage-paid envelope, to be completed at home on POD 1. Identical questionnaires, answered on PODs 7 and 14, were sent to the patients’ homes. No reminders were sent.
K. Berg et al. sion analysis (n = 268). To avoid a strong correlation among the independent variables, biasing the regression model, an inspection of the correlation matrix and assessment of the tolerance and the variance inflation factor (VIF) were performed (Miles and Shevlin, 2001). The tolerance of an independent variable is the extent to which it cannot be predicted by another independent variable. The value varies between zero and one, with zero meaning strong correlation and one meaning that the variables are totally uncorrelated. The VIF indicates whether an independent variable has a strong linear relationship to another independent variable, and should preferably have a value of less than two (Miles and Shevlin, 2001). The final models in the regression analysis were built on significant independent variables. Statistical significance was set at a p-value of <0.05. Statistical analyses were performed using SPSS 17.0 for Windows (Chicago, IL, USA).
Results Demographics and baseline data
Statistical analyses Data are presented as mean and standard deviation to describe postoperative recovery on PODs 1, 7 and 14. Friedman’s ANOVA was used to analyze the development of recovery from POD 1 to POD 7 and 14 in respective surgical group. This was followed by Wilcoxon’s signed rank test to verify between which PODs there were significant differences. The Kruskal–Wallis test was used for comparisons of recovery between the different orthopedic surgical groups (on the respective postoperative day). Concluding that there is a relationship when in fact a relationship does not exist is a risk when performing multiple comparisons (type I error). The Bonferroni correction was used to establish a more conservative significant level when multiple comparisons were run. To identify possible predictors associated with the postoperative recovery score on POD 14, we performed a multiple linear regression analysis. The independent variables used were: age, gender, residence, smoking, employment, education, ASA classification, perceived health on POD 1, emotional state, physical independence, physical comfort on POD 1 and type of surgery. All independent variables were put into the equation in a block, all at the same time, with the S-PSR score on POD 14 as the dependent variable. Only patients with a complete S-PSR score on POD 14 were included in the regres-
The included patients had a mean age of 49.0 (±15.6) years and the women were slightly older (50.8 ± 14.6 years) than the men (47.5 ± 16.4 years), p < 0.05. The majority of the patients were classified in ASA class I, were cohabitating and employed and had an education up to secondary-school level (Table 1). Before surgery there was no difference between the surgical groups regarding the score achieved from the preoperative items (Fig. 1) or perceived health during the preceding 12 months. However, the shoulder patients had significantly more pain preoperatively (4.1 ± 1.8) compared to the ACI patients (5.6 ± 2.2), hand/arm patients (6.5 ± 2.7) and foot/leg patients (6.1 ± 2.8) (p < 0.001). There were also preoperative differences in patient mobility, with ACI patients being more immobile (6.1 ± 2.6) compared to hand/arm patients (7.2 ± 2.7) (p < 0.001) (higher scores represent lower pain and better mobility).
Non-respondents Forty-eight patients (13%) at POD 1 and 36 patients (10%) at POD 14 did not return the questionnaire. The non-respondents were distributed as: 37 in the knee ACI group, 25 in the hand/arm group, 18 foot/leg patients and four in the shoulder group. These patients were significantly younger (p < 0.05) than those who responded. More men
Postoperative recovery after different orthopedic day surgical procedures Table 1 Description of included patients presented in numbers, percentages and gender distribution (n = 358). n (%)
Male/female
Gender ASA classification 1 2 3 Missing
189/169 268 (75) 78 (22) 11 (3) 1
147/121 38/40 4/7
Type of surgery Arthroscopy (knee) Hand/arm Foot/leg Shoulder
140 (39) 128 (36) 71 (20) 19 (5)
93/47 58/70 25/46 13/6
Residence Cohabitating Single Missing
268 (75) 84 (23) 6 (2)
144/124 43/41
Employment Working Retired Unemployed Other Missing
242 (68) 72 (20) 16 (4) 21 (6) 7 (2)
146/96 30/42 6/10 4/17
Education Compulsory school Secondary school Degree from university Missing
104 (29) 149 (42) 97 (27) 8 (2)
54/50 87/62 46/51
169
(p < 0.001) left the study at POD 1, but the proportion of males to females did not differ at POD 14.
Postoperative recovery on PODs 1, 7 and 14 As expected, the S-PSR scores decreased from preoperative to POD 1 in all groups (p < 0.05). Thereafter, the S-PSR scores increased from POD 1 to 14 in all groups (p = 60.001) except the patients who had had shoulder surgery. There was no difference in postoperative recovery score between the surgical groups on POD 1. At PODs 7 and 14, patients who had undergone shoulder surgery showed lower recovery scores than did those in the other surgical groups (p < 0.001) (Fig. 1). In an examination of the different items included in the S-PSR scale the patients significantly improved in all variables, except the shoulder patients, who improved only in usual activity and mobility and worsened in their expectations regarding recovery (Table 2). As evaluated using the QoR-23, all patients improved in physical comfort, emotional state and physical independence from POD 1 to 14 (p < 0.001), except for those who had undergone surgery on their shoulder who had not improved in any of the three dimensions. However, there were some differences between the surgical groups regarding the dimensions. The shoulder patients had significantly lower physical comfort (p < 0.001) and emotional state (p < 0.05) on PODs 7 and 14. At PODs 1, 7 and 14 the hand/arm and shoulder surgery patients were more physically dependent than were those who had undergone
ASA, American Society of Anesthesiologists.
ACI knee Foot/leg
100
Hand/arm Shoulder
90 80
S-PSR score
70 60 50 40 30
***
***
20 10
Preop
POD 1
POD 7
POD 14
Fig. 1 The Swedish Post-discharge surgery recovery (S-PSR) scores for the different groups of orthopaedic day surgery patients (mean ±SD). Preop is a preoperative score composed of the 8 items available before surgery. POD 1, 7 and 14 is the S-PSR score (composed from all 12 items) on postoperative days 1, 7 and 14. *** denotes p < 0.001 for shoulder patients compared to the other surgical groups.
7.5 (2.6)
8.4 (2.3)
<0.001
6.3 (2.7)
7.5 (2.6)
8.3 (2.2)
<0.001
5.2 (2.9)
7.2 (2.9)
7.6 (2.7)
<0.001
5.1 (3.0)
6.0 (2.6)
6.0 (2.6)
ns 3.2 (1.8) 5.8 (2.7)
5.5 (2.3) 8.0 (2.4)
6.6 (2.3) 8.8 (1.9)
<0.001 <0.001
3.9 (2.6) 6.7 (2.7)
6.0 (2.5) 8.2 (2.1)
6.7 (2.5) 8.8 (1.8)
<0.001 <0.001
3.4 (2.5) 5.1 (3.0)
4.8 (2.7) 7.6 (2.4)
5.8 (2.6) 8.3 (2.2)
<0.001 <0.001
2.7 (1.9) 5.3 (3.2)
3.8 (1.9) 5.8 (2.9)
4.5 (2.0) 6.6 (2.4)
0.004 ns 5.8 (2.5)
6.7 (2.5)
7.6 (2.4)
<0.001
6.3 (2.7)
7.2 (2.4)
7.5 (2.5)
<0.001
5.5 (2.4)
6.3 (2.7)
7.3 (2.2)
<0.001
5.5 (2.2)
4.6 (2.0)
5.4 (2.3)
ns 7.4 5.9 4.7 7.7
7.1 6.9 6.1 8.2
7.4 7.5 7.4 8.6
ns <0.001 <0.001 <0.001
7.5 6.2 4.2 7.3
7.7 7.1 5.7 8.0
7.9 8.0 6.6 8.4
0.013 <0.001 <0.001 <0.001
6.8 5.6 4.7 7.2
7.2 7.1 5.5 8.3
8.0 7.6 6.9 9.0
0.032 <0.001 <0.001 <0.001
7.1 5.9 3.7 5.9
6.3 5.4 3.6 5.9
5.6 5.5 3.1 5.3
0.011 ns ns ns
5.
6. 7.
8.
(2.3) (1.9) (2.2) (2.8) (2.6) (2.8) (2.9) (2.7) (1.5) (2.6) (3.0) (3.1) 9. 10. 11. 12.
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p-value in group between different days for assessment measured using Friedman’s ANOVA. a
6.0 (2.5)
(2.2) (2.1) (2.9) (2.0)
ns ns ns 0.002 (2.2) (1.9) (2.0) (1.5) (2.19 (2.0) (2.2) (2.5)
(2.8) (2.4) (3.0) (2.6)
5.8 4.9 6.1 4.5 (2.4) (1.8) (2.1) (2.3) (2.5) (2.6) (1.8) (2.3) (2.3) (2.4) (2.0) (2.7) 8.1 7.8 7.2 6.5 (2.2) (2.3) (2.1) (2.6) (2.4) (2.3) (2.2) (2.3)
(2.6) (2.8) (2.9) (2.8)
5.4 4.6 5.8 4.0 7.4 7.1 7.6 6.8
(2.7) (2.2) (2.6) (2.0) 7.2 7.0 7.1 5.5 7.7 7.2 7.2 5.4
(2.4) (2.1) (2.2) (2.6) 6.7 6.2 6.0 3.8 (2.3) (2.4) (2.0) (2.2)
(2.1) (1.8) (2.9) (2.6)
5.9 5.3 5.3 2.8 5.8 5.2 5.5 4.0 <0.001 <0.001 <0.001 <0.001 7.6 7.0 7.4 7.4 (2.3) (2.2) (2.2) (2.4)
(2.3) (2.4) (2.9) (2.7)
0.004 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
p-value 7.2 6.5 7.1 6.5
(2.1) (2.7) (2.7) (2.8)
p-valuea p-value POD 14 (2.2) (2.0) (1.9) (2.2)
(2.3) (2.0) (2.6) (2.4)
POD 14 POD 14 POD 7 6.3 5.4 6.2 4.2
(2.5) (2.3) (2.8) (2.4)
POD 7 POD 7 POD 1 p-value POD 1
POD 14
Alertness Pain Tiredness Usual activity Daytime nap Mobility Stay at home Physical exercise Expectations Recovery Normal life Frame of mind
(2.3) (2.4) (2.7) (2.5)
POD 1 POD 1
a a a
Shoulder surgery patients (n = 14) Foot/leg surgery patients (n = 47) Hand/arm surgery patients (n = 97) ACI (knee) patients (n = 95) Item (score 1–10)
POD 7 1. 2. 3. 4.
Items mean score (±SD) in the Swedish Post-discharge Surgery Recovery (S-PSR) scale in different orthopedic day surgery patients on postoperative days (POD) 1, 7 and 14.
Table 2
K. Berg et al. ACI in the knee or surgery on the foot/leg (p < 0.05) (Table 3).
Perceived health on PODs 1, 7 and 14 All patients improved in perceived health from POD 1 to 14 (p < 0.001), except the shoulder patients, who did not improve. Perceived health was lower in the shoulder group than in the other groups at PODs 7 and 14 (p < 0.001) (Table 3).
Predictors of postoperative recovery on POD 14 The independent variables correlated from 0.09 to 0.78 with emotional state and physical comfort having the highest correlation to each other (r = 0.78). When these two variables were assessed regarding tolerance and VIF, the emotional state variable had a higher value in tolerance (0.40) compared to the physical comfort dimension (0.38) and a lower VIF value (2.48) than the physical comfort variable (2.60). Because of this, it was decided that the emotional state variable would be included in the subsequent regression analysis. In the multiple linear regression analysis, age (p < 0.05), perceived health on POD 1 (p < 0.001), emotional state on POD 1 (p < 0.01) and shoulder operation (p < 0.001) emerged as predictors of postoperative recovery on POD 14. When these predictors were used in a final model, 34% of the patients’ postoperative recovery on POD 14 was explained (Table 4). Surgery on the shoulder was found to be a significant predictor of postoperative recovery on POD 14. These patients constituted only a minority of this sample (n = 19) and, in an effort to achieve a model that would be useful in a majority of patients, an additional regression analysis was performed in which the shoulder patients were excluded. In this analysis, age (p < 0.05), perceived health on POD 1 (p < 0.001) and emotional state on POD 1 (p < 0.01) were still predictors of postoperative recovery on POD 14. ACI in the knee and surgery on the hand, arm, foot or leg were also significant predictors (p < 0.001). Postoperative recovery on POD 14 was explained to 33% in this model (Table 4).
Discussion In this study we found shoulder patients to have considerably lower postoperative recovery and perceived health compared to other orthopedic day surgery patients 1 and 2 weeks after surgery.
Postoperative recovery after different orthopedic day surgical procedures
171
Table 3 Mean score (±SD) in the different dimensions included in Quality of Recovery (QoR)-23 and perceived health for orthopedic day surgery patients on postoperative days (POD) 1, 7 and 14. Dimensions of QoR-23 and perceived health
Maximum ACI (knee) Hand/arm surgery Foot/leg surgery Shoulder surgery p-valuea patients (n = 93) patients (n = 46) patients (n = 13) score patients (n = 91)
Physical comfort (10 items) POD 1 POD 7 POD 14 p-valueb
50
Emotional state (8 items) POD 1 POD 7 POD 14 p-valueb
40
Physical independence (5 items) POD 1 POD 7 POD 14 p-valueb
25
Perceived health (1 general item) POD 1 POD 7 POD 14 p-valueb
10
43.1 (5.7) 45.7 (5.9) 47.4 (3.7) <0.001
42.2 (5.9) 45.7 (4.4) 46.4 (4.2) <0.001
41.5 (7.2) 45.8 (4.6) 47.6 (2.6) <0.001
39.3 (6.9) 39.7 (5.9) 41.1 (5.3) ns
ns 0.001 <0.001
33.5 (6.0) 34.6 (6.6) 36.4 (4.6) <0.001
33.6 (5.5) 35.3 (4.8) 35.4 (5.5) <0.001
33.1 (5.8) 35.0 (5.5) 37.5 (3.1) 0.001
32.1 (5.0) 30.1 (5.9) 30.5 (6.2) ns
ns 0.012 <0.001
21.8 (2.4) 23.4 (2.2) 24.0 (1.7) <0.001
18.6 (3.8) 20.3 (3.4) 21.2 (3.2) <0.001
21.7 (2.5) 22.8 (2.7) 23.8 (1.4) 0.001
20.0 (3.0) 19.9 (3.1) 20.8 (2.9) ns
<0.001 <0.001 <0.001
6.6 (1.9) 7.4 (1.8) 7.9 (1.8) <0.001
6.8 (2.0) 7.5 (1.8) 8.1 (1.7) <0.001
6.3 (2.3) 7.5 (2.0) 7.9 (1.8) <0.001
5.7 (1.9) 5.9 (1.9) 6.1 (1.7) ns
ns 0.009 0.001
ACI, Arthroscopy. a p-value between surgical groups measured using Kruskal–Wallis test. b p-value in group between different days for assessment measured using Friedman’s ANOVA.
The recovery period for patients undergoing orthopedic day surgery thus differs which needs to be considered when planning postoperative monitoring and support as well as when developing postoperative patient education programs. Shoulder patients in particular seem to need a tailored preoperative education and a close follow-up. The SPSR scale and the QoR-23 are short and easy instruments to fill out and could easily be incorporated into nurses’ telephone follow-ups to derive validated empirical knowledge about postoperative recovery. Orthopedic surgery is painful, and particularly patients undergoing shoulder surgery have a high incidence of pain as shown in this and other studies (McGrath and Chung, 2003). Pain is included in the S-PSR scale and contributes to patients’ experience of recovery and may explain this result to some degree. However, the S-PSR scale and patients’ assessment of physical comfort, emotional state and physical independence through the
QoR-23 show consistently lower values in the shoulder group. This might point to a need for further assessment and more and longer support from nurses in this patient group. Patients who received surgery to their upper extremities were more physically dependent than other patients. The items elucidating physical independence were chiefly related to work or comparable activity and activities of daily living (ADL). Scoring low for physical independence thus seems logical, as many patients who have undergone shoulder surgery or an operation on their hand/ arm need an extensive period of time for rehabilitation, sick leave (Faber et al., 2006; Harth et al., 2008) and support in ADLs. Higher age, emotional state and lower perceived health on POD 1 as well as the type of surgery were predictors of recovery 2 weeks postoperatively. Increased age is a risk factor for unsatisfactory postoperative pain control (Jain et al., 2008), surgical
172 Table 4
K. Berg et al. Predictors associated with recovery on postoperative day (POD) 14. Adjusted R2
Regression coefficient
95% confidence interval
Predictors, all patients 0.336 Perceived health on POD 1 Emotional state on POD 1 Age Shoulder operation
2.67 0.71 0.15 19.32
1.70–3.63 0.36–1.06 0.27 to 0.04 26.69 to 11.95
2.69 0.71 0.15 20.27 18.97 18.37
1.71–3.66 0.36–1.06 0.26– 0.03 12.56–27.98 11.27–26.67 10.31–26.43
Predictors, shoulder patients excluded 0.332 Perceived health on POD 1 Emotional state on POD 1 Age Arthroscopy in knee Surgery on hand/arm Surgery on foot/leg
and postoperative complications and unplanned admission after discharge (Fleisher et al., 2004), which might be due to comorbidity (Ansell and Montgomery, 2004). Data about comorbidity were however not collected in our study, which is a limitation. All patients were assessed according to ASA but the ASA classification is an assessment of the patient’s preoperative status and correlates only roughly to postoperative outcomes. Self-care is necessary for postoperative recovery at home (Lupien et al., 2002) and there is a risk that patients and their carers are unprepared for it. Post-discharge planning and detailed postoperative information are important for the elderly day surgery patient and his/her carer (Burden, 2004). There might be a need for specific quality indicators for elderly day surgery patients (McGory et al., 2009). However, patient age in day surgery considered in the literature (Aldwinckle and Montgomery, 2004; Bettelli, 2009; Bryson et al., 2004; Jain et al., 2008) and further studies focusing on day surgery for elderly patients are needed. In this study, emotional state on POD 1 was a predictor of postoperative recovery on POD 14. Previous studies have also reported that psychological factors influence recovery and surgical outcomes, and have been investigated in intermediate and major orthopedic surgery (Brewer et al., 2007; Johansson et al., 2010). Psychological factors may affect recovery after day surgery, but few studies have investigated this (Nilsson et al., 2009; Tsapakis et al., 2009). In addition, we used a general question about perceived health in this study, and the result is coherent with those of the S-PSR scale and physical comfort, emotional state and physical independence. This seems reasonable, as an individual’s
experience of health is multifaceted and affected by the surgical experience during the recovery process. Recovery is often reported in the literature in a collective way regarding surgical specialties, but different operation types are hypothesized to have unique patterns of recovery which need to be identified and described (Coll and Ameen, 2006). This study contributes to an increased knowledge regarding patterns of recovery following different orthopedic day surgical procedures. We also found that type of surgery predicted postoperative recovery on POD 14: Among the significant predictors, shoulder surgery had a negative influence on postoperative recovery on POD 14. Recovery was also significantly lower on POD 7 in this group of patients. These results may be considered when nursing interventions are planned. However, our model explained postoperative recovery to 33% and other factors not examined in this study contribute to the day surgery patients’ experience of postoperative recovery as well. More research is needed to explore what elements influence late recovery both in general and following a specific surgical procedure. Constitutional psychological factors and psychological consequences of surgery, as mentioned above, could be important. Such factors are poorly understood and require further studies. Coping styles, motivation, economic burden and depression could also influence a patient’s ability to regain his/her health (Kleinbeck, 2000). In this study we used general recovery instruments as outcome measures. These kinds of measures are growing in popularity as primary outcomes in scientific studies (Kluivers et al., 2008). Two types of recovery instruments are distinguished: a general instrument and a disease- or
Postoperative recovery after different orthopedic day surgical procedures site-specific one (Kluivers et al., 2008). Both the SPSR scale and the QoR-23 can be classified as general recovery instruments developed from representative samples of people involved in postoperative recovery (patients, relatives/friends and nursing/medical staff) (Kleinbeck, 2000; Myles et al., 1999). The PSR scale has been found to be a single-dimension instrument measuring perceived at-home postoperative recovery (Berg et al., 2010; Kleinbeck, 2000). The S-PSR scale results in an index of recovery and is sensitive to change in recovery when used at different time points (Berg et al., 2010). Details in patients’ recovery are not elucidated when the S-PSR index is used, but specific items can be studied in those patients with a score below 100. The S-PSR scale is a short instrument and is not time-consuming for the patient, which makes it attractive for use in a clinical setting. The QoR-23 is constructed of different dimensions, and the investigator can choose whether to use the total score or study the dimensions. The physical comfort dimension is today revised with one additional item regarding pain (Nilsson and Idvall, 2010). Both the S-PSR scale and the QoR-23 assess postoperative recovery from a holistic perspective, but from different aspects. In our study the general pattern of recovery was similar between the two instruments used. No gold standard or normal markers of postoperative recovery are currently available and thus need to be established.
Study limitations There are some methodological weaknesses in this study. The sample size was large and consecutively collected; nevertheless the shoulder patients were few in numbers. However, the significant results regarding the shoulder patients were unambiguous indicating that this group of patients are important in the day surgery context. A total of 84 patients did not respond to the questionnaire at POD 14. The non-respondents were younger than the remaining patients, and from preoperative study inclusion to POD 1 more men than women did not answer. Perhaps these patients felt more recovered and did not deem study participation important, but no difference in S-PSR score between the non-respondents and the remaining patients was found. However, it is possible that some patients might have agreed to participate in the study before reflecting sufficiently on the commitment it demanded, and therefore decided to withdraw.
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Conclusion The recovery process following common orthopedic day surgical procedures can differ. Patients undergoing shoulder surgery seem to suffer more than others for at least two postsurgical weeks. Day surgery nurses need to consider a patient’s age, perceived health, emotional state and type of surgery when planning postoperative care and different postoperative programs need to be developed depending on the surgical procedure. The individual’s emotional state might have a greater impact on day surgery patients’ recovery than expected and could be of interest in further investigations.
Role of funding source The funding sources, the Medical Research Council of Southeast Sweden, Linko ¨ping University and ALF ¨ stergo grants from the County Council of O ¨tland have had no involvement in the study.
Ethical statement This study followed common ethical principles for clinical research regulated by the World Medical Association Declaration of Helsinki, and were approved by the Regional Ethical Review Board, Linko ¨ping, Sweden (Dnr 03-333). Each participant received both verbal and written information about the study, and was also informed that participation was voluntary. The participants were clearly informed about the possibility to withdraw from the study whenever they wanted without giving any explanation. The participants were guaranteed confidentiality.
Conflict of interest statement No conflicts of interest exist in this study.
Acknowledgement The financial support from the Medical Research Council of Southeast Sweden, Linko ¨ping University and ALF grants from the County Council of ¨ stergo O ¨tland are thankfully acknowledged. Mats Fredrikson (Ph.D., Department of Clinical and
174 Experimental Medicine, Linko ¨ping University) is acknowledged for his statistical advice.
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Postoperative recovery after different orthopedic day surgical procedures Myles, P., Hunt, J., Nightingale, C., Fletcher, H., Beh, T., Tanil, D., Nagy, A., Rubinstein, A., Ponsford, J., 1999. Development and psychometric testing of a quality of recovery score after general anesthesia and surgery in adults. Anesthesia and Analgesia 88, 83–90. Myles, P., Weitkamp, K., Jones, K., Melick, J., Hensen, S., 2000. Validity and reliability of a postoperative quality of recovery score: the QoR-40. British Journal of Anaesthesia 84 (1), 11– 15. Nilsson, U., Berg, K., Unosson, M., Brudin, L., Idvall, E., 2009. Relation between personality and quality of postoperative recovery in day surgery patients. European Journal of Anaesthesiology 26, 671–675. Nilsson, U., Idvall, E., 2010. Pain assessment in day surgery patients. Journal of Clinical Nursing 19, 2942–2943. Rose ´n, H., Clabo Lauzon, L., Ma ˚rtensson, L., 2009. Symptoms following day surgery: a review of the literature. Journal of Advanced Perioperative Care 4 (1), 7–18. Susilahti, H., Suominen, T., Leino-Kilpi, H., 2004. Recovery of Finnish short-stay surgery patients. MedSurg Nursing 13 (5), 326–335.
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Postoperative recovery after different orthopedic day surgical procedures Katarina Berg CRNA,MScN a,*, Ewa Idvall RNT,PhD (Professor) b,c, Ulrica Nilsson RNA,PhD (Associate Professor) d,e, Mitra Unosson RNT,PhD (Professor) f a
¨ping University, Department of Medical and Health Sciences/Division of Nursing Science, SE-581 85 Linko Sweden b ¨ University, Sweden Faculty of Health and Society, Malmo c ˚ne University Hospital, Sweden Ska d ¨ rebro University Hospital, Sweden Centre for Healthcare Sciences, O e ˚ University, Sweden Department of Nursing, Umea f ¨ping University, Sweden Department of Social and Welfare Studies, Faculty of Health Sciences, Linko
KEYWORDS
Abstract Orthopedic day surgery is common. Postoperative recovery may differ according to surgical procedures and personal factors. We studied postoperative recovery up to 2 weeks after different orthopedic day surgical procedures and tried to identify possible predictors associated with recovery. Three-hundred and fifty eight patients who had undergone knee arthroscopy or surgery to the hand/arm, foot/leg or shoulder were included. Data were collected on postoperative days 1, 7 and 14 using the Swedish Post-discharge Surgery Recovery scale, the emotional state, physical comfort and physical independence dimensions in the Quality of Recovery-23 and a general health question. Multiple linear regression was used to explore predictors of recovery. The shoulder patients experienced significantly lower postoperative recovery and general health 1 and 2 weeks after surgery compared to the other patient groups (p < 0.001). Significant predictors of recovery were age, perceived health and emotional status on the first postoperative day and type of surgery. Postoperative recovery after common orthopedic day surgical procedures varies and factors influencing it need to be further explored. The impact of a patient’s emotional state on recovery after day surgery can be of particular interest in this work. Post-discharge planning needs to be tailored to the surgical procedure. c 2011 Elsevier Ltd. All rights reserved.
Day surgery; Postoperative recovery; Orthopedic nursing
* Corresponding author. Tel.: +46 101037774; fax: +46 13123285. E-mail address: [email protected] (K. Berg).
1878-1241/$ - see front matter c 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijotn.2011.02.003
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Editor’s comments There is great demand for day surgery/ambulatory surgery because it is perceived to be an efficient and popular approach to relatively minor orthopedic surgery. It is important, however, that practitioners do not underestimate the impact that this approach can have on the patient’s well being and their experience of their recovery from surgery. This paper, for example, clearly highlights that one particular type of surgery – that to the shoulder – can result in a much poorer experience and outcome in the first few weeks than may be the case for other types of surgery. Practitioners, therefore, must take this issue into account when planning surgery, recovery and discharge and focus on patient support. It may even be necessary to question if this type of surgery is suitable for the day/ambulatory surgery approach. JS
Introduction Day surgery procedures are common and orthopedic surgery constitutes a large part worldwide (Toftgaard and Parmentier, 2006). Following day surgery, patients are discharged after a short period of postoperative surveillance. The care burden of recovery is consequently transferred from the hospital to the patient and significant others at home, which may create anxiety and discomfort for the patient and the carer about the management of clinical care (Boughton and Halliday, 2009). Recovery while still in hospital and the first postoperative days, are frequently studied among day surgery patients (Awad and Chung, 2006; Watt-Watson et al., 2004) but some patients improve slowly and the recovery period is protracted (Rose ´n et al., 2009). Protracted recovery after the first postoperative week is not so well explored (Brattwall et al., 2010b). Recovery might be delayed by comorbidity, a more complex day surgical procedure (Lermitte and Chung, 2005) or by the type of surgery, even if it is commonly performed in the day surgery context (Rose ´n et al., 2009). Moreover, patients with multiple diagnoses, elderly and frail patients are today eligible for day surgery which may influence the recovery period (Bryson et al., 2004). There is still limited empirical understanding of postoperative recovery experienced by patients from discharge to resumption of normal activities (Gudex et al., 2006) as well as what constitutes postoperative recovery in specific surgical populations and factors of importance for late recovery (Rose ´n et al., 2009). To achieve high qualitative postoperative recovery at home these gaps need to be filled in. There is a high rate of satisfaction in day surgery (Krywulak et al., 2005; Mattila and Hynynen, 2009) but there are also symptoms reported post-discharge such as pain, nausea, dizziness and tiredness (Rose ´n et al., 2009; Wu et al., 2002).
Postoperative recovery is seen as a subjective experience (Allvin et al., 2008; Kleinbeck, 2000; Kluivers et al., 2008; Lee and Stephens, 2000) based on, for example, pain and other symptoms (Gilmartin, 2007; Susilahti et al., 2004), functional status (Horvath, 2003) and ability to perform activities in daily life (Young et al., 2000). According to the self-regulatory model by Leventhal et al. (1980), five coherent factors – identity, time-line, cause, consequence and cure/control may also influence an individual’s postoperative recovery. These factors can be illustrated in a patient’s concerns about the magnitude of postoperative symptoms (identity), the recovery time-span (timeline), the need for surgery (cause), the impact of the surgical procedure (consequence) and how to deal with the postoperative situation (control) (McCarthy et al., 2003). Postoperative recovery thereby depends on a variety of factors (Lee and Stephens, 2000). Postoperative recovery following day surgery is described as regained normality and wholeness (Allvin et al., 2007) and a perception of a return to the usual self (Kleinbeck, 2000). Knowledge about factors of importance for returning to the usual self can improve care planning, monitoring and support in day surgery. Systematic follow-ups of postoperative recovery are important for nurses and other health professionals in order to achieve a clear picture of the patient’s condition, to prevent complications, identify symptoms and to provide support for the patient and the carer. In such work, valid assessment methods are required (Susilahti et al., 2004). Valid assessments also contribute to nurses and health organisations gaining an understanding of the quality of care provided. It has become more important to identify patients’ self-reporting of postoperative recovery in order to emphasize evidence-based health care in day surgery (Brattwall et al., 2010a). In day surgery this can be performed using questionnaires. The Post-discharge Surgical
Postoperative recovery after different orthopedic day surgical procedures Recovery (PSR) scale (Kleinbeck, 2000) and the Quality of Recovery-40 (QoR-40) (Myles et al., 2000) are the methods currently reported to have the most satisfactory psychometric properties (Herrera et al., 2007; Kluivers et al., 2008). These instruments assess important variables in orthopedic day surgery such as mobility, physical ability in different aspects and symptoms. To increase the empirical knowledge about patients’ experiences of postoperative recovery at home and why some patients recover more slowly than others, a prospective longitudinal study was undertaken. The aims of this study were to describe postoperative recovery on postoperative days 1, 7 and 14 after different orthopedic day surgical procedures and to identify possible predictors associated with postoperative recovery 2 weeks after surgery.
Methods Day surgery is defined in this study as surgery performed on a patient who is admitted and operated on during the same day and discharged without an overnight stay in the surgery unit. The orthopedic day surgery patients in this study constitute a part of a larger longitudinal study including other groups of day surgery patients. The study followed standard ethical principles for clinical research and was approved by the Regional Ethical Review Board (Dnr 03-333).
Patients Day surgery patients older than 18 years and able to read and speak Swedish were consecutively asked to participate. A total of 459 orthopedic patients (240 male, 219 female) were eligible. Patients were recruited from a county hospital (n = 80), a private surgery unit (n = 172) and a university hospital (n = 207). Of the 459 patients asked to participate, 61 declined and 35 were missed, resulting in 363 patients (79%) giving informed consent to participate. Five patients needed in-hospital postoperative care and were therefore excluded. Consequently, 358 patients (189 male and 169 female) scheduled for common orthopedic day surgical procedures were included and divided into four study groups according to type of surgery. These groups were: arthroscopy (ACI) of the knee (140 subjects), surgery to the hand/arm (128 subjects), surgery to the foot/leg (71 subjects) and surgery to the shoulder (19 subjects). No significant differences regarding age, gender or surgical procedure were noted between
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patients compared to those who declined participation or who were not asked.
Data collection The Swedish Post-discharge Surgery Recovery (SPSR) scale (Berg et al., 2010) and the Quality of Recovery-23 (QoR-23) (Idvall et al., 2009) were used to assess postoperative recovery. These scales have been modified from their originals (Kleinbeck, 2000; Myles et al., 2000) and psychometrically tested for Swedish patients (Berg et al., 2010; Idvall et al., 2009). The S-PSR scale is a self-rating 12item instrument which assesses the patient’s alertness, pain, tiredness, activity, need for a daytime nap, mobility, living situation, physical exercise, expectations, recovery, normal life and frame of mind. Each item is rated on a ten-point (1–10) semantic differential scale. A recovery score is computed by dividing the patient’s individual sum score by the total possible score and multiplying the result by 100. The final score range is thus 10–100, with higher scores indicating a more favourable postoperative recovery. The scale has satisfactory validity, reliability, data quality and responsiveness (Berg et al., 2010; Kleinbeck, 2000). Patients’ emotional state (8 items), physical comfort (10 items) and physical independence (5 items) were assessed using the QoR-23 (Idvall et al., 2009). The items are rated on a five-point scale (1–5), and responses to the items in their respective dimensions are summed with a maximum score of 40, 50 and 25, respectively. Higher scores indicate a higher quality of recovery. The instrument has been tested for validity and reliability as well as sensitivity to change (Idvall et al., 2009; Myles et al., 2000) and has shown initial usefulness as an outcome measure in the day surgery context (Idvall et al., 2009). Both the S-PSR scale and the QoR-23 are easy to complete and do not take long to respond to. Perception of health was assessed using a general question rated on a ten-point numerical rating scale, where 1 represents very poor health and 10 excellent health. Background data including demographic data (age, gender, residence, employment, and education) and the American Society of Anesthesiologists’ (ASA) physical status classification were collected using a structured questionnaire and patient records.
Procedures On arrival at the surgery unit, each patient received verbal and written information about the
168 research project and informed consent to participate was obtained. As baseline data of perceived health, the patients were asked to assess their experienced health during the preceding 12 months. To construct a baseline score, the patients rated eight items from the S-PSR scale that were possible to assess preoperatively. These items were: patient’s alertness, pain, tiredness, activity, need for a daytime nap, mobility, living situation and physical exercise, also computed by dividing the patient’s individual score by the total possible score and multiplying with 100. The preoperative score range is thus 10–100 as well. Health and postoperative recovery were henceforth assessed on postoperative day (POD) 1 and again on PODs 7 and 14 and were based on the patients’ experience on that particular day. When discharged from the day surgery unit, the patients received a questionnaire including the S-PSR scale, the QoR-23 and the question about perceived health, along with a postage-paid envelope, to be completed at home on POD 1. Identical questionnaires, answered on PODs 7 and 14, were sent to the patients’ homes. No reminders were sent.
K. Berg et al. sion analysis (n = 268). To avoid a strong correlation among the independent variables, biasing the regression model, an inspection of the correlation matrix and assessment of the tolerance and the variance inflation factor (VIF) were performed (Miles and Shevlin, 2001). The tolerance of an independent variable is the extent to which it cannot be predicted by another independent variable. The value varies between zero and one, with zero meaning strong correlation and one meaning that the variables are totally uncorrelated. The VIF indicates whether an independent variable has a strong linear relationship to another independent variable, and should preferably have a value of less than two (Miles and Shevlin, 2001). The final models in the regression analysis were built on significant independent variables. Statistical significance was set at a p-value of <0.05. Statistical analyses were performed using SPSS 17.0 for Windows (Chicago, IL, USA).
Results Demographics and baseline data
Statistical analyses Data are presented as mean and standard deviation to describe postoperative recovery on PODs 1, 7 and 14. Friedman’s ANOVA was used to analyze the development of recovery from POD 1 to POD 7 and 14 in respective surgical group. This was followed by Wilcoxon’s signed rank test to verify between which PODs there were significant differences. The Kruskal–Wallis test was used for comparisons of recovery between the different orthopedic surgical groups (on the respective postoperative day). Concluding that there is a relationship when in fact a relationship does not exist is a risk when performing multiple comparisons (type I error). The Bonferroni correction was used to establish a more conservative significant level when multiple comparisons were run. To identify possible predictors associated with the postoperative recovery score on POD 14, we performed a multiple linear regression analysis. The independent variables used were: age, gender, residence, smoking, employment, education, ASA classification, perceived health on POD 1, emotional state, physical independence, physical comfort on POD 1 and type of surgery. All independent variables were put into the equation in a block, all at the same time, with the S-PSR score on POD 14 as the dependent variable. Only patients with a complete S-PSR score on POD 14 were included in the regres-
The included patients had a mean age of 49.0 (±15.6) years and the women were slightly older (50.8 ± 14.6 years) than the men (47.5 ± 16.4 years), p < 0.05. The majority of the patients were classified in ASA class I, were cohabitating and employed and had an education up to secondary-school level (Table 1). Before surgery there was no difference between the surgical groups regarding the score achieved from the preoperative items (Fig. 1) or perceived health during the preceding 12 months. However, the shoulder patients had significantly more pain preoperatively (4.1 ± 1.8) compared to the ACI patients (5.6 ± 2.2), hand/arm patients (6.5 ± 2.7) and foot/leg patients (6.1 ± 2.8) (p < 0.001). There were also preoperative differences in patient mobility, with ACI patients being more immobile (6.1 ± 2.6) compared to hand/arm patients (7.2 ± 2.7) (p < 0.001) (higher scores represent lower pain and better mobility).
Non-respondents Forty-eight patients (13%) at POD 1 and 36 patients (10%) at POD 14 did not return the questionnaire. The non-respondents were distributed as: 37 in the knee ACI group, 25 in the hand/arm group, 18 foot/leg patients and four in the shoulder group. These patients were significantly younger (p < 0.05) than those who responded. More men
Postoperative recovery after different orthopedic day surgical procedures Table 1 Description of included patients presented in numbers, percentages and gender distribution (n = 358). n (%)
Male/female
Gender ASA classification 1 2 3 Missing
189/169 268 (75) 78 (22) 11 (3) 1
147/121 38/40 4/7
Type of surgery Arthroscopy (knee) Hand/arm Foot/leg Shoulder
140 (39) 128 (36) 71 (20) 19 (5)
93/47 58/70 25/46 13/6
Residence Cohabitating Single Missing
268 (75) 84 (23) 6 (2)
144/124 43/41
Employment Working Retired Unemployed Other Missing
242 (68) 72 (20) 16 (4) 21 (6) 7 (2)
146/96 30/42 6/10 4/17
Education Compulsory school Secondary school Degree from university Missing
104 (29) 149 (42) 97 (27) 8 (2)
54/50 87/62 46/51
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(p < 0.001) left the study at POD 1, but the proportion of males to females did not differ at POD 14.
Postoperative recovery on PODs 1, 7 and 14 As expected, the S-PSR scores decreased from preoperative to POD 1 in all groups (p < 0.05). Thereafter, the S-PSR scores increased from POD 1 to 14 in all groups (p = 60.001) except the patients who had had shoulder surgery. There was no difference in postoperative recovery score between the surgical groups on POD 1. At PODs 7 and 14, patients who had undergone shoulder surgery showed lower recovery scores than did those in the other surgical groups (p < 0.001) (Fig. 1). In an examination of the different items included in the S-PSR scale the patients significantly improved in all variables, except the shoulder patients, who improved only in usual activity and mobility and worsened in their expectations regarding recovery (Table 2). As evaluated using the QoR-23, all patients improved in physical comfort, emotional state and physical independence from POD 1 to 14 (p < 0.001), except for those who had undergone surgery on their shoulder who had not improved in any of the three dimensions. However, there were some differences between the surgical groups regarding the dimensions. The shoulder patients had significantly lower physical comfort (p < 0.001) and emotional state (p < 0.05) on PODs 7 and 14. At PODs 1, 7 and 14 the hand/arm and shoulder surgery patients were more physically dependent than were those who had undergone
ASA, American Society of Anesthesiologists.
ACI knee Foot/leg
100
Hand/arm Shoulder
90 80
S-PSR score
70 60 50 40 30
***
***
20 10
Preop
POD 1
POD 7
POD 14
Fig. 1 The Swedish Post-discharge surgery recovery (S-PSR) scores for the different groups of orthopaedic day surgery patients (mean ±SD). Preop is a preoperative score composed of the 8 items available before surgery. POD 1, 7 and 14 is the S-PSR score (composed from all 12 items) on postoperative days 1, 7 and 14. *** denotes p < 0.001 for shoulder patients compared to the other surgical groups.
7.5 (2.6)
8.4 (2.3)
<0.001
6.3 (2.7)
7.5 (2.6)
8.3 (2.2)
<0.001
5.2 (2.9)
7.2 (2.9)
7.6 (2.7)
<0.001
5.1 (3.0)
6.0 (2.6)
6.0 (2.6)
ns 3.2 (1.8) 5.8 (2.7)
5.5 (2.3) 8.0 (2.4)
6.6 (2.3) 8.8 (1.9)
<0.001 <0.001
3.9 (2.6) 6.7 (2.7)
6.0 (2.5) 8.2 (2.1)
6.7 (2.5) 8.8 (1.8)
<0.001 <0.001
3.4 (2.5) 5.1 (3.0)
4.8 (2.7) 7.6 (2.4)
5.8 (2.6) 8.3 (2.2)
<0.001 <0.001
2.7 (1.9) 5.3 (3.2)
3.8 (1.9) 5.8 (2.9)
4.5 (2.0) 6.6 (2.4)
0.004 ns 5.8 (2.5)
6.7 (2.5)
7.6 (2.4)
<0.001
6.3 (2.7)
7.2 (2.4)
7.5 (2.5)
<0.001
5.5 (2.4)
6.3 (2.7)
7.3 (2.2)
<0.001
5.5 (2.2)
4.6 (2.0)
5.4 (2.3)
ns 7.4 5.9 4.7 7.7
7.1 6.9 6.1 8.2
7.4 7.5 7.4 8.6
ns <0.001 <0.001 <0.001
7.5 6.2 4.2 7.3
7.7 7.1 5.7 8.0
7.9 8.0 6.6 8.4
0.013 <0.001 <0.001 <0.001
6.8 5.6 4.7 7.2
7.2 7.1 5.5 8.3
8.0 7.6 6.9 9.0
0.032 <0.001 <0.001 <0.001
7.1 5.9 3.7 5.9
6.3 5.4 3.6 5.9
5.6 5.5 3.1 5.3
0.011 ns ns ns
5.
6. 7.
8.
(2.3) (1.9) (2.2) (2.8) (2.6) (2.8) (2.9) (2.7) (1.5) (2.6) (3.0) (3.1) 9. 10. 11. 12.
170
p-value in group between different days for assessment measured using Friedman’s ANOVA. a
6.0 (2.5)
(2.2) (2.1) (2.9) (2.0)
ns ns ns 0.002 (2.2) (1.9) (2.0) (1.5) (2.19 (2.0) (2.2) (2.5)
(2.8) (2.4) (3.0) (2.6)
5.8 4.9 6.1 4.5 (2.4) (1.8) (2.1) (2.3) (2.5) (2.6) (1.8) (2.3) (2.3) (2.4) (2.0) (2.7) 8.1 7.8 7.2 6.5 (2.2) (2.3) (2.1) (2.6) (2.4) (2.3) (2.2) (2.3)
(2.6) (2.8) (2.9) (2.8)
5.4 4.6 5.8 4.0 7.4 7.1 7.6 6.8
(2.7) (2.2) (2.6) (2.0) 7.2 7.0 7.1 5.5 7.7 7.2 7.2 5.4
(2.4) (2.1) (2.2) (2.6) 6.7 6.2 6.0 3.8 (2.3) (2.4) (2.0) (2.2)
(2.1) (1.8) (2.9) (2.6)
5.9 5.3 5.3 2.8 5.8 5.2 5.5 4.0 <0.001 <0.001 <0.001 <0.001 7.6 7.0 7.4 7.4 (2.3) (2.2) (2.2) (2.4)
(2.3) (2.4) (2.9) (2.7)
0.004 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
p-value 7.2 6.5 7.1 6.5
(2.1) (2.7) (2.7) (2.8)
p-valuea p-value POD 14 (2.2) (2.0) (1.9) (2.2)
(2.3) (2.0) (2.6) (2.4)
POD 14 POD 14 POD 7 6.3 5.4 6.2 4.2
(2.5) (2.3) (2.8) (2.4)
POD 7 POD 7 POD 1 p-value POD 1
POD 14
Alertness Pain Tiredness Usual activity Daytime nap Mobility Stay at home Physical exercise Expectations Recovery Normal life Frame of mind
(2.3) (2.4) (2.7) (2.5)
POD 1 POD 1
a a a
Shoulder surgery patients (n = 14) Foot/leg surgery patients (n = 47) Hand/arm surgery patients (n = 97) ACI (knee) patients (n = 95) Item (score 1–10)
POD 7 1. 2. 3. 4.
Items mean score (±SD) in the Swedish Post-discharge Surgery Recovery (S-PSR) scale in different orthopedic day surgery patients on postoperative days (POD) 1, 7 and 14.
Table 2
K. Berg et al. ACI in the knee or surgery on the foot/leg (p < 0.05) (Table 3).
Perceived health on PODs 1, 7 and 14 All patients improved in perceived health from POD 1 to 14 (p < 0.001), except the shoulder patients, who did not improve. Perceived health was lower in the shoulder group than in the other groups at PODs 7 and 14 (p < 0.001) (Table 3).
Predictors of postoperative recovery on POD 14 The independent variables correlated from 0.09 to 0.78 with emotional state and physical comfort having the highest correlation to each other (r = 0.78). When these two variables were assessed regarding tolerance and VIF, the emotional state variable had a higher value in tolerance (0.40) compared to the physical comfort dimension (0.38) and a lower VIF value (2.48) than the physical comfort variable (2.60). Because of this, it was decided that the emotional state variable would be included in the subsequent regression analysis. In the multiple linear regression analysis, age (p < 0.05), perceived health on POD 1 (p < 0.001), emotional state on POD 1 (p < 0.01) and shoulder operation (p < 0.001) emerged as predictors of postoperative recovery on POD 14. When these predictors were used in a final model, 34% of the patients’ postoperative recovery on POD 14 was explained (Table 4). Surgery on the shoulder was found to be a significant predictor of postoperative recovery on POD 14. These patients constituted only a minority of this sample (n = 19) and, in an effort to achieve a model that would be useful in a majority of patients, an additional regression analysis was performed in which the shoulder patients were excluded. In this analysis, age (p < 0.05), perceived health on POD 1 (p < 0.001) and emotional state on POD 1 (p < 0.01) were still predictors of postoperative recovery on POD 14. ACI in the knee and surgery on the hand, arm, foot or leg were also significant predictors (p < 0.001). Postoperative recovery on POD 14 was explained to 33% in this model (Table 4).
Discussion In this study we found shoulder patients to have considerably lower postoperative recovery and perceived health compared to other orthopedic day surgery patients 1 and 2 weeks after surgery.
Postoperative recovery after different orthopedic day surgical procedures
171
Table 3 Mean score (±SD) in the different dimensions included in Quality of Recovery (QoR)-23 and perceived health for orthopedic day surgery patients on postoperative days (POD) 1, 7 and 14. Dimensions of QoR-23 and perceived health
Maximum ACI (knee) Hand/arm surgery Foot/leg surgery Shoulder surgery p-valuea patients (n = 93) patients (n = 46) patients (n = 13) score patients (n = 91)
Physical comfort (10 items) POD 1 POD 7 POD 14 p-valueb
50
Emotional state (8 items) POD 1 POD 7 POD 14 p-valueb
40
Physical independence (5 items) POD 1 POD 7 POD 14 p-valueb
25
Perceived health (1 general item) POD 1 POD 7 POD 14 p-valueb
10
43.1 (5.7) 45.7 (5.9) 47.4 (3.7) <0.001
42.2 (5.9) 45.7 (4.4) 46.4 (4.2) <0.001
41.5 (7.2) 45.8 (4.6) 47.6 (2.6) <0.001
39.3 (6.9) 39.7 (5.9) 41.1 (5.3) ns
ns 0.001 <0.001
33.5 (6.0) 34.6 (6.6) 36.4 (4.6) <0.001
33.6 (5.5) 35.3 (4.8) 35.4 (5.5) <0.001
33.1 (5.8) 35.0 (5.5) 37.5 (3.1) 0.001
32.1 (5.0) 30.1 (5.9) 30.5 (6.2) ns
ns 0.012 <0.001
21.8 (2.4) 23.4 (2.2) 24.0 (1.7) <0.001
18.6 (3.8) 20.3 (3.4) 21.2 (3.2) <0.001
21.7 (2.5) 22.8 (2.7) 23.8 (1.4) 0.001
20.0 (3.0) 19.9 (3.1) 20.8 (2.9) ns
<0.001 <0.001 <0.001
6.6 (1.9) 7.4 (1.8) 7.9 (1.8) <0.001
6.8 (2.0) 7.5 (1.8) 8.1 (1.7) <0.001
6.3 (2.3) 7.5 (2.0) 7.9 (1.8) <0.001
5.7 (1.9) 5.9 (1.9) 6.1 (1.7) ns
ns 0.009 0.001
ACI, Arthroscopy. a p-value between surgical groups measured using Kruskal–Wallis test. b p-value in group between different days for assessment measured using Friedman’s ANOVA.
The recovery period for patients undergoing orthopedic day surgery thus differs which needs to be considered when planning postoperative monitoring and support as well as when developing postoperative patient education programs. Shoulder patients in particular seem to need a tailored preoperative education and a close follow-up. The SPSR scale and the QoR-23 are short and easy instruments to fill out and could easily be incorporated into nurses’ telephone follow-ups to derive validated empirical knowledge about postoperative recovery. Orthopedic surgery is painful, and particularly patients undergoing shoulder surgery have a high incidence of pain as shown in this and other studies (McGrath and Chung, 2003). Pain is included in the S-PSR scale and contributes to patients’ experience of recovery and may explain this result to some degree. However, the S-PSR scale and patients’ assessment of physical comfort, emotional state and physical independence through the
QoR-23 show consistently lower values in the shoulder group. This might point to a need for further assessment and more and longer support from nurses in this patient group. Patients who received surgery to their upper extremities were more physically dependent than other patients. The items elucidating physical independence were chiefly related to work or comparable activity and activities of daily living (ADL). Scoring low for physical independence thus seems logical, as many patients who have undergone shoulder surgery or an operation on their hand/ arm need an extensive period of time for rehabilitation, sick leave (Faber et al., 2006; Harth et al., 2008) and support in ADLs. Higher age, emotional state and lower perceived health on POD 1 as well as the type of surgery were predictors of recovery 2 weeks postoperatively. Increased age is a risk factor for unsatisfactory postoperative pain control (Jain et al., 2008), surgical
172 Table 4
K. Berg et al. Predictors associated with recovery on postoperative day (POD) 14. Adjusted R2
Regression coefficient
95% confidence interval
Predictors, all patients 0.336 Perceived health on POD 1 Emotional state on POD 1 Age Shoulder operation
2.67 0.71 0.15 19.32
1.70–3.63 0.36–1.06 0.27 to 0.04 26.69 to 11.95
2.69 0.71 0.15 20.27 18.97 18.37
1.71–3.66 0.36–1.06 0.26– 0.03 12.56–27.98 11.27–26.67 10.31–26.43
Predictors, shoulder patients excluded 0.332 Perceived health on POD 1 Emotional state on POD 1 Age Arthroscopy in knee Surgery on hand/arm Surgery on foot/leg
and postoperative complications and unplanned admission after discharge (Fleisher et al., 2004), which might be due to comorbidity (Ansell and Montgomery, 2004). Data about comorbidity were however not collected in our study, which is a limitation. All patients were assessed according to ASA but the ASA classification is an assessment of the patient’s preoperative status and correlates only roughly to postoperative outcomes. Self-care is necessary for postoperative recovery at home (Lupien et al., 2002) and there is a risk that patients and their carers are unprepared for it. Post-discharge planning and detailed postoperative information are important for the elderly day surgery patient and his/her carer (Burden, 2004). There might be a need for specific quality indicators for elderly day surgery patients (McGory et al., 2009). However, patient age in day surgery considered in the literature (Aldwinckle and Montgomery, 2004; Bettelli, 2009; Bryson et al., 2004; Jain et al., 2008) and further studies focusing on day surgery for elderly patients are needed. In this study, emotional state on POD 1 was a predictor of postoperative recovery on POD 14. Previous studies have also reported that psychological factors influence recovery and surgical outcomes, and have been investigated in intermediate and major orthopedic surgery (Brewer et al., 2007; Johansson et al., 2010). Psychological factors may affect recovery after day surgery, but few studies have investigated this (Nilsson et al., 2009; Tsapakis et al., 2009). In addition, we used a general question about perceived health in this study, and the result is coherent with those of the S-PSR scale and physical comfort, emotional state and physical independence. This seems reasonable, as an individual’s
experience of health is multifaceted and affected by the surgical experience during the recovery process. Recovery is often reported in the literature in a collective way regarding surgical specialties, but different operation types are hypothesized to have unique patterns of recovery which need to be identified and described (Coll and Ameen, 2006). This study contributes to an increased knowledge regarding patterns of recovery following different orthopedic day surgical procedures. We also found that type of surgery predicted postoperative recovery on POD 14: Among the significant predictors, shoulder surgery had a negative influence on postoperative recovery on POD 14. Recovery was also significantly lower on POD 7 in this group of patients. These results may be considered when nursing interventions are planned. However, our model explained postoperative recovery to 33% and other factors not examined in this study contribute to the day surgery patients’ experience of postoperative recovery as well. More research is needed to explore what elements influence late recovery both in general and following a specific surgical procedure. Constitutional psychological factors and psychological consequences of surgery, as mentioned above, could be important. Such factors are poorly understood and require further studies. Coping styles, motivation, economic burden and depression could also influence a patient’s ability to regain his/her health (Kleinbeck, 2000). In this study we used general recovery instruments as outcome measures. These kinds of measures are growing in popularity as primary outcomes in scientific studies (Kluivers et al., 2008). Two types of recovery instruments are distinguished: a general instrument and a disease- or
Postoperative recovery after different orthopedic day surgical procedures site-specific one (Kluivers et al., 2008). Both the SPSR scale and the QoR-23 can be classified as general recovery instruments developed from representative samples of people involved in postoperative recovery (patients, relatives/friends and nursing/medical staff) (Kleinbeck, 2000; Myles et al., 1999). The PSR scale has been found to be a single-dimension instrument measuring perceived at-home postoperative recovery (Berg et al., 2010; Kleinbeck, 2000). The S-PSR scale results in an index of recovery and is sensitive to change in recovery when used at different time points (Berg et al., 2010). Details in patients’ recovery are not elucidated when the S-PSR index is used, but specific items can be studied in those patients with a score below 100. The S-PSR scale is a short instrument and is not time-consuming for the patient, which makes it attractive for use in a clinical setting. The QoR-23 is constructed of different dimensions, and the investigator can choose whether to use the total score or study the dimensions. The physical comfort dimension is today revised with one additional item regarding pain (Nilsson and Idvall, 2010). Both the S-PSR scale and the QoR-23 assess postoperative recovery from a holistic perspective, but from different aspects. In our study the general pattern of recovery was similar between the two instruments used. No gold standard or normal markers of postoperative recovery are currently available and thus need to be established.
Study limitations There are some methodological weaknesses in this study. The sample size was large and consecutively collected; nevertheless the shoulder patients were few in numbers. However, the significant results regarding the shoulder patients were unambiguous indicating that this group of patients are important in the day surgery context. A total of 84 patients did not respond to the questionnaire at POD 14. The non-respondents were younger than the remaining patients, and from preoperative study inclusion to POD 1 more men than women did not answer. Perhaps these patients felt more recovered and did not deem study participation important, but no difference in S-PSR score between the non-respondents and the remaining patients was found. However, it is possible that some patients might have agreed to participate in the study before reflecting sufficiently on the commitment it demanded, and therefore decided to withdraw.
173
Conclusion The recovery process following common orthopedic day surgical procedures can differ. Patients undergoing shoulder surgery seem to suffer more than others for at least two postsurgical weeks. Day surgery nurses need to consider a patient’s age, perceived health, emotional state and type of surgery when planning postoperative care and different postoperative programs need to be developed depending on the surgical procedure. The individual’s emotional state might have a greater impact on day surgery patients’ recovery than expected and could be of interest in further investigations.
Role of funding source The funding sources, the Medical Research Council of Southeast Sweden, Linko ¨ping University and ALF ¨ stergo grants from the County Council of O ¨tland have had no involvement in the study.
Ethical statement This study followed common ethical principles for clinical research regulated by the World Medical Association Declaration of Helsinki, and were approved by the Regional Ethical Review Board, Linko ¨ping, Sweden (Dnr 03-333). Each participant received both verbal and written information about the study, and was also informed that participation was voluntary. The participants were clearly informed about the possibility to withdraw from the study whenever they wanted without giving any explanation. The participants were guaranteed confidentiality.
Conflict of interest statement No conflicts of interest exist in this study.
Acknowledgement The financial support from the Medical Research Council of Southeast Sweden, Linko ¨ping University and ALF grants from the County Council of ¨ stergo O ¨tland are thankfully acknowledged. Mats Fredrikson (Ph.D., Department of Clinical and
174 Experimental Medicine, Linko ¨ping University) is acknowledged for his statistical advice.
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