Time to readiness for discharge is a valid and reliable measure of short-term recovery after colorectal surgery.

BACKGROUND: Short-term recovery after colorectal surgery has been traditionally investigated through length of stay (LOS). However, this measure is influenced by several confounding factors. This study aimed to investigate the construct validity and reliability of assessing the time to achieve standardized discharge criteria (time to readiness for discharge, or TRD) as a measure of short-term recovery. In a secondary analysis, we compared sample size requirements for randomized controlled trials (RCTs) using TRD or LOS as outcome measures. METHODS: Seventy patients participated in the construct validity study and 21 patients participated in the reliability study. TRD was defined as the number of days to achieve discharge criteria previously defined by consensus. Construct validity was investigated by testing six hypothesis based on the assumption that TRD measures short-term recovery. Reliability was calculated by comparing measures of TRD by two independent assessors. Variability estimates (standard deviations) of LOS and TRD were used for sample size calculations. RESULTS: Five of the six hypotheses were supported by the data (p < 0.05). Interobserver reliability was excellent (ICC2.1 = 0.99). Sample size estimations showed that RCTs using TRD as an outcome measure require approximately 23 % less participants compared to RCTs using LOS. CONCLUSIONS: The results of this research support the construct-validity and reliability of TRD as a measure of short-term recovery. Using TRD as an alternative to LOS may reduce sample size requirements in future RCTs.

Criteria to determine readiness for hospital discharge following colorectal surgery: an international consensus using the Delphi technique.

BACKGROUND: Standardized discharge criteria are considered valuable to reduce the risk of premature discharge and avoid unnecessary hospital stays. The most appropriate criteria to indicate readiness for discharge after colorectal surgery are unknown. OBJECTIVE: The aim of this study is to achieve an international consensus on hospital discharge criteria for patients undergoing colorectal surgery. DESIGN: Fifteen experts from different countries participated in a 3-round Delphi process. In round 1, experts determined which criteria best indicate readiness for discharge and described specific end points for each criterion. In rounds 2 and 3, experts rated their agreement with the use of a 5-point Likert scale. MAIN OUTCOME MEASURES: Consensus was defined when criteria and end points were rated as agree or strongly agree by at least 75% of the experts in round 3. RESULTS: Experts reached consensus that patients should be considered ready for hospital discharge when there is tolerance of oral intake, recovery of lower gastrointestinal function, adequate pain control with oral analgesia, ability to mobilize and self-care, and no evidence of complications or untreated medical problems. Specific end points were defined for each of the criteria. Experts also agreed that after these criteria are achieved, discharge may take place as soon as the patient has adequate postdischarge support and is willing to leave the hospital. If a stoma was constructed, the patient or the patient's family should have received training on stoma care or had outpatient training arranged. LIMITATIONS: The panel comprised mostly experts from developed countries. This may restrict the applicability of these discharge criteria in countries where there are dissimilar health care resources. CONCLUSION: This Delphi study has provided substantial consensus on discharge criteria for patients undergoing colorectal surgery. We recommend that these criteria be used in clinical practice to guide decisions regarding patient discharge and applied in future research to increase the comparability of study results.

Preoperative physiotherapy is cost-effective for preventing pulmonary complications after major abdominal surgery: a health economic analysis of a multicentre randomised trial.

QUESTION: Is preoperative physiotherapy cost-effective in reducing postoperative pulmonary complications (PPC) and improving quality-adjusted life years (QALYs) after major abdominal surgery? DESIGN: Cost-effectiveness analysis from the hospitals' perspective within a multicentre randomised controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS: Four hundred and forty-one adults awaiting elective upper abdominal surgery attending pre-anaesthetic clinics at three public hospitals in Australia and New Zealand. INTERVENTIONS: The experimental group received an information booklet and a 30-minute face-to-face session, involving respiratory education and breathing exercise training, with a physiotherapist. The control group received the information booklet only. OUTCOME MEASURES: The probability of cost-effectiveness and incremental net benefits was estimated using bootstrapped incremental PPC and QALY cost-effectiveness ratios plotted on cost-effectiveness planes and associated probability curves through a range of willingness-to-pay amounts. Cost-effectiveness modelling utilised 21-day postoperative hospital cost audit data and QALYs estimated from Short Form-Six Domain health utilities and mortality to 12 months. RESULTS: Preoperative physiotherapy had 95% probability of being cost-effective with an incremental net benefit to participating hospitals of A$4,958 (95% CI 10 to 9,197) for each PPC prevented, given that the hospitals were willing to pay $45,000 to provide the service. Cost-utility for QALY gains was less certain. Sensitivity analyses strengthened cost-effectiveness findings. Improved cost-effectiveness and QALY gains were detected when experienced physiotherapists delivered the intervention. CONCLUSIONS: Preoperative physiotherapy aimed at preventing PPCs was highly likely to be cost-effective from the hospitals' perspective. For each PPC prevented, preoperative physiotherapy is likely to cost the hospitals less than the costs estimated to treat a PPC after surgery. Potential QALY gains require confirmation. TRIAL REGISTRATION: ACTRN12613000664741.

Duration of anaesthesia, type of surgery, respiratory co-morbidity, predicted VO2max and smoking predict postoperative pulmonary complications after upper abdominal surgery: an observational study.

QUESTION: Can the risk of developing postoperative pulmonary complications be predicted after upper abdominal surgery? DESIGN: Prospective observational study. PARTICIPANTS: 268 consecutive patients undergoing elective upper abdominal surgery who received standardised pre- and postoperative prophylactic respiratory physiotherapy. OUTCOME MEASURES: Predictors were 17 preoperative and intraoperative risk factors. A postoperative pulmonary complication was diagnosed when four or more of the following criteria were present: radiological evidence of collapse/consolidation, temperature > 38 degrees C, oxyhaemoglobin saturation < 90%, abnormal sputum production, sputum culture indicating infection, raised white cell count, abnormal auscultation findings, or physician's diagnosis of pulmonary complication. RESULTS: 35 participants (13%) developed postoperative pulmonary complications. Five risk factors predicted postoperative pulmonary complications: duration of anaesthesia (OR 4.3, 95% CI 1.7 to 10.8); surgical category (OR 2.3, 95% CI 1.1 to 4.7); current smoking (OR 2.1, 95% CI 1.0 to 4.5); respiratory co-morbidity (OR 2.1, 95% CI 1.0 to 4.4); and predicted maximal oxygen uptake (OR 2.0, 95% CI 1.0 to 4.3). A clinical rule for predicting the development of postoperative pulmonary complications predicted 82% of participants who developed complications. The odds of high risk participants developing pulmonary complications were 8.4 (95% CI 3.3 to 21.3) times that of low risk participants. CONCLUSION: This clinical rule for predicting the risk of developing postoperative pulmonary complications from five risk factors may prove useful in prioritising postoperative respiratory physiotherapy. Further research is needed to validate the rule.

Physiotherapy education and training prior to upper abdominal surgery is memorable and has high treatment fidelity: a nested mixed-methods randomised-controlled study.

OBJECTIVES: To (1) assess memorability and treatment fidelity of pre-operative physiotherapy education prior to elective upper abdominal surgery and, (2) to explore patient opinions on pre-operative education. DESIGN: Mixed-methods analysis of a convenience sample within a larger parallel-group, double-blinded, randomised controlled trial with concealed allocation and intention-to-treat analysis. SETTING: Tertiary Australian hospital. PARTICIPANTS: Twenty-nine patients having upper abdominal surgery attending pre-admission clinic within six-weeks of surgery. INTERVENTION: The control group received an information booklet about preventing pulmonary complications with early ambulation and breathing exercises. The experimental group received an additional face-to-face 30-minute physiotherapy education and training session on pulmonary complications, early ambulation, and breathing exercises. OUTCOME MEASURES: Primary outcome was proportion of participants who remembered the taught breathing exercises following surgery. Secondary outcomes were recall of information sub-items and attainment of early ambulation goals. These were measured using standardised scoring of a semi-scripted digitally-recorded interview on the 5th postoperative day, and the attainment of early ambulation goals over the first two postoperative days. RESULTS: Experimental group participants were six-times more likely to remember the breathing exercises (95%CI 1.7 to 22) and 11-times more likely (95%CI 1.6 to 70) to report physiotherapy as the most memorable part of pre-admission clinic. Participants reported physiotherapy education content to be detailed, interesting, and of high value. Some participants reported not reading the booklet and professed a preference for face-to-face information delivery. CONCLUSION: Face-to-face pre-operative physiotherapy education and training prior to upper abdominal surgery is memorable and has high treatment fidelity. TRIAL REGISTRATION: ACTRN-12613000664741.

Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial.

OBJECTIVE: To assess the efficacy of a single preoperative physiotherapy session to reduce postoperative pulmonary complications (PPCs) after upper abdominal surgery. DESIGN: Prospective, pragmatic, multicentre, patient and assessor blinded, parallel group, randomised placebo controlled superiority trial. SETTING: Multidisciplinary preadmission clinics at three tertiary public hospitals in Australia and New Zealand. PARTICIPANTS: 441 adults aged 18 years or older who were within six weeks of elective major open upper abdominal surgery were randomly assigned through concealed allocation to receive either an information booklet (n=219; control) or preoperative physiotherapy (n=222; intervention) and followed for 12 months. 432 completed the trial. INTERVENTIONS: Preoperatively, participants received an information booklet (control) or an additional 30 minute physiotherapy education and breathing exercise training session (intervention). Education focused on PPCs and their prevention through early ambulation and self directed breathing exercises to be initiated immediately on regaining consciousness after surgery. Postoperatively, all participants received standardised early ambulation, and no additional respiratory physiotherapy was provided. MAIN OUTCOME MEASURES: The primary outcome was a PPC within 14 postoperative hospital days assessed daily using the Melbourne group score. Secondary outcomes were hospital acquired pneumonia, length of hospital stay, utilisation of intensive care unit services, and hospital costs. Patient reported health related quality of life, physical function, and post-discharge complications were measured at six weeks, and all cause mortality was measured to 12 months. RESULTS: The incidence of PPCs within 14 postoperative hospital days, including hospital acquired pneumonia, was halved (adjusted hazard ratio 0.48, 95% confidence interval 0.30 to 0.75, P=0.001) in the intervention group compared with the control group, with an absolute risk reduction of 15% (95% confidence interval 7% to 22%) and a number needed to treat of 7 (95% confidence interval 5 to 14). No significant differences in other secondary outcomes were detected. CONCLUSION: In a general population of patients listed for elective upper abdominal surgery, a 30 minute preoperative physiotherapy session provided within existing hospital multidisciplinary preadmission clinics halves the incidence of PPCs and specifically hospital acquired pneumonia. Further research is required to investigate benefits to mortality and length of stay. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ANZCTR 12613000664741.

The quantity of early upright mobilisation performed following upper abdominal surgery is low: an observational study.

QUESTIONS: How much upright mobilisation, particularly uptime, is performed in the first four days following upper abdominal surgery? In what part of the day is the greatest uptime achieved? Is length of stay related to uptime? Is there any difference in uptime in terms of postoperative factors? DESIGN: Prospective observational study. PARTICIPANTS: Fifty patients who had undergone upper abdominal surgery after receiving standardised preoperative education and physiotherapy intervention on the first postoperative day. OUTCOME MEASURES: An activity logger recorded uptime continuously for the first four postoperative days. Postoperative factors such as postoperative pulmonary complications, surgical attachments, pain relief, duration of anaesthesia, and intensive care admission were collected daily. RESULTS: Total median uptime was 3.0 (IQR 8.2), 7.6 (IQR 11 .5), 13.2 (IQR 26.6) and 34.4 (IQR 65.6) minutes for the first four postoperative days respectively. Morning uptime was greater than both afternoon uptime (p = 0.001) and evening uptime (p < 0.001). Uptime over the first four postoperative days predicted length of stay (r2 = 0.50, p < 0.001). Uptime was not significantly less in those who developed postoperative pulmonary complications (p = 0.08 to 0.17). CONCLUSION: This is the first study to quantify upright mobilisation following upper abdominal surgery. The results show that the quantity of upright mobilisation performed is low. Given that uptime predicted length of stay, increasing early upright mobilisation may have a positive effect on reducing length of stay following upper abdominal surgery.

Can simple mobile phone applications provide reliable counts of respiratory rates in sick infants and children? An initial evaluation of three new applications.

BACKGROUND: Respiratory rate is an important sign that is commonly either not recorded or recorded incorrectly. Mobile phone ownership is increasing even in resource-poor settings. Phone applications may improve the accuracy and ease of counting of respiratory rates. OBJECTIVES: The study assessed the reliability and initial users' impressions of four mobile phone respiratory timer approaches, compared to a 60-second count by the same participants. METHODS: Three mobile applications (applying four different counting approaches plus a standard 60-second count) were created using the Java Mobile Edition and tested on Nokia C1-01 phones. Apart from the 60-second timer application, the others included a counter based on the time for ten breaths, and three based on the time interval between breaths ('Once-per-Breath', in which the user presses for each breath and the application calculates the rate after 10 or 20 breaths, or after 60s). Nursing and physiotherapy students used the applications to count respiratory rates in a set of brief video recordings of children with different respiratory illnesses. Limits of agreement (compared to the same participant's standard 60-second count), intra-class correlation coefficients and standard errors of measurement were calculated to compare the reliability of the four approaches, and a usability questionnaire was completed by the participants. RESULTS: There was considerable variation in the counts, with large components of the variation related to the participants and the videos, as well as the methods. None of the methods was entirely reliable, with no limits of agreement better than -10 to +9 breaths/min. Some of the methods were superior to the others, with ICCs from 0.24 to 0.92. By ICC the Once-per-Breath 60-second count and the Once-per-Breath 20-breath count were the most consistent, better even than the 60-second count by the participants. The 10-breath approaches performed least well. Users' initial impressions were positive, with little difference between the applications found. CONCLUSIONS: This study provides evidence that applications running on simple phones can be used to count respiratory rates in children. The Once-per-Breath methods are the most reliable, outperforming the 60-second count. For children with raised respiratory rates the 20-breath version of the Once-per-Breath method is faster, so it is a more suitable option where health workers are under time pressure.

The LIPPSMAck POP (Lung Infection Prevention Post Surgery - Major Abdominal - with Pre-Operative Physiotherapy) trial: study protocol for a multi-centre randomised controlled trial.

BACKGROUND: Post-operative pulmonary complications are a significant problem following open upper abdominal surgery. Preliminary evidence suggests that a single pre-operative physiotherapy education and preparatory lung expansion training session alone may prevent respiratory complications more effectively than supervised post-operative breathing and coughing exercises. However, the evidence is inconclusive due to methodological limitations. No well-designed, adequately powered, randomised controlled trial has investigated the effect of pre-operative education and training on post-operative respiratory complications, hospital length of stay, and health-related quality of life following upper abdominal surgery. METHODS/DESIGN: The Lung Infection Prevention Post Surgery - Major Abdominal- with Pre-Operative Physiotherapy (LIPPSMAck POP) trial is a pragmatic, investigator-initiated, bi-national, multi-centre, patient- and assessor-blinded, parallel group, randomised controlled trial, powered for superiority. Four hundred and forty-one patients scheduled for elective open upper abdominal surgery at two Australian and one New Zealand hospital will be randomised using concealed allocation to receive either i) an information booklet or ii) an information booklet, plus one additional pre-operative physiotherapy education and training session. The primary outcome is respiratory complication incidence using standardised diagnostic criteria. Secondary outcomes include hospital length of stay and costs, pneumonia diagnosis, intensive care unit readmission and length of stay, days/h to mobilise >1 min and >10 min, and, at 6 weeks post-surgery, patient reported complications, health-related quality of life, and physical capacity. DISCUSSION: The LIPPSMAck POP trial is a multi-centre randomised controlled trial powered and designed to investigate whether a single pre-operative physiotherapy session prevents post-operative respiratory complications. This trial standardises post-operative assisted ambulation and physiotherapy, measures many known confounders, and includes a post-discharge follow-up of complication rates, functional capacity, and health-related quality of life. This trial is currently recruiting. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry number: ACTRN12613000664741 , 19 June 2013.

Nursing specialty and burnout.

We examined the relationship between perceived control and burnout among three nursing specialties: nurse practitioners, nurse managers, and emergency nurses. Survey data were collected from 228 nurses from 30 states. Findings indicated that emergency nurses had the least control and the highest burnout, whereas nurse practitioners had the most control and the least burnout. Mediational analyses showed that expected control, hostility, and stressor frequency explained differences between specialties in burnout. The implications of these findings for interventions that reduce burnout and promote nursing retention are discussed.

Effects of cognitive adaptation on the expectation-burnout relationship among nurses.

Burnout has traditionally been thought to result from unrealistically high expectations although research has provided only equivocal support. We explored the impact of cognitive adaptation disposition, including mastery, optimism, and self-esteem, on the expectations-burnout relationship. Nurses (N = 341) who were recruited at professional conferences completed questionnaires that assessed cognitive adaptation, burnout, and initial and current expectations of control. As expected, cognitive adaptation predicted fewer unmet expectations of control, which in turn predicted lower burnout. In addition, optimism and self-esteem predicted lower burnout regardless of perceived initial expectations, whereas mastery lessened the negative consequences of initially high expectations on burnout.

Complementary and alternative medicine use among urban ED patients: prevalence and patterns.

INTRODUCTION: High rates of complementary and alternative medicine (CAM) use are well documented in the general population without clear clinical benefits. Published studies examining prevalence and patterns of CAM use in emergency patients, however, are limited. The objectives of this study were to describe the prevalence and patterns of CAM use in urban ED patients. METHODS: This was a descriptive study of a convenience sample of 174 patients presenting to the emergency department of a level I, urban, Catholic, tertiary teaching center, with an annual ED census of 43,000. RESULTS: CAM use in our study group was high (47%). Although no sociodemographic predictors of CAM users were found, CAM users were more likely to have chronic conditions (P =.044). One third did not disclose CAM use. Prayer (28%), music therapy (11%), and meditation (10%) were the most frequently used types of CAM reported. DISCUSSION: Patients should be questioned routinely about CAM use, given the high rates of use and low disclosure rates. Knowledge of potential positive and negative effects of CAM, interactions with conventional treatments, and sensitivity toward patients' decisions to opt for CAM are imperative. Spiritual support, where available, should be considered for at least some ED patients. The 3 most common types of CAM reported by ED patients at our level I trauma center were prayer/spirituality, music therapy, and meditation.