Capturing the experience of the hospital-stay journey from admission to discharge using diaries completed by patients in their own words: a qualitative study

OBJECTIVE

To capture and better understand patients' experience during their healthcare journey from hospital admission to discharge, and to identify patient suggestions for improvement.

DESIGN

Prospective, exploratory, qualitative study. Patients were asked to complete an unstructured written diary expressed in their own words, recording negative and positive experiences or anything else they considered noteworthy.

PARTICIPANTS AND SETTING

Patients undergoing vascular surgery in a metropolitan hospital.

PRIMARY OUTCOME MEASURES

Complete diary transcripts underwent a general inductive thematic analysis, and opportunities to improve the experience of care were identified and collated.

RESULTS

We recruited 113 patients in order to collect 80 completed diaries from 78 participants (a participant response rate of 69%), recording patients' experiences of their hospital-stay journey. Participating patients were a median (range) age of 69 (21-99) years and diaries contained a median (range) of 197 (26-1672) words each. Study participants with a tertiary education wrote more in their diaries than those without-a median (range) of 353.5 (48-1672) vs 163 (26-1599) words, respectively (Mann-Whitney U test, p=0.001). Three primary and eight secondary themes emerged from analysis of diary transcripts-primary themes being: (1) communication as central to care; (2) importance of feeling cared for and (3) environmental factors shaping experiences. In the great majority, participants reported positive experiences on the hospital ward. However, a set of 12 patient suggestions for improvement were identified, the majority of which could be addressed with little cost but result in substantial improvements in patient experience. Half of the 12 suggestions for improvement fell into primary theme 1, concerning opportunities to improve communication between healthcare providers and patients.

CONCLUSIONS

Unstructured diaries completed in a patient's own words appear to be an effective and simple approach to capture the hospital-stay experience from the patient's own perspective, and to identify opportunities for improvement.

Impact of Anxiety in Ambulatory Superficial Venous Surgery : A Prospective Study Using the HADS-A Scale

BACKGROUND

The aim of the present prospective clinical study is to evaluate the impact of the level of anxiety in patients undergoing ambulatory superficial venous surgery (SVS) and to select a specific group of patients who need more of our attention to reduce the postoperative adverse events.

METHODS

Preoperative anxiety was assessed using the Hospital Anxiety and Depression Scale (HADS), especially the HADS-A (Anxiety subscale) in 340 consecutive patients undergoing elective SVS. Venous disease was assessed in all patients according to the established CEAP classification, the Venous Clinical Severity and the Venous Disability scores.

RESULTS

According to the HADS-A scores, we could distinguish two groups of patients, with (group A with score ≥ 8; 61 patients) and without potential anxious state (group B with score ≤ 7; 279 patients). Demographic data, varicose veins risk factors and preoperative symptoms were comparable in both groups. The median HADS-A score was 9 (8-17; IQR: 2) in group A and 3 (0-7; IQR: 3) in group B. The rate of complications or adverse events in the recovery room, the mean postoperative pain scores, the apprehension before discharge hospital and the incidence of unexpected hospitalisation rate were significantly higher in group A when compared with group B.

CONCLUSIONS

We observed that the presence of preoperative anxiety, even although infrequent, was associated with high incidence of complications or adverse events in the recovery room and a greater postoperative pain level. In this context, this group of patients needs more of our attention, particularly to limit potential anxiety and improve their satisfaction score.

Attitude towards one's illness vs. attitude towards a surgical operation, displayed by patients diagnosed with asymptomatic abdominal aortic aneurysm and asymptomatic internal carotid artery stenosis

AIM

Two most frequent asymptomatic diseases qualifying for vascular surgery are abdominal aortic aneurysm (AAA) and internal carotid artery stenosis (ICAS). Emotions experienced by the patient activate processes of dealing with the cognitive dissonance of asymptomatic disease. The aim of this paper was to compare the reasons involved in decision making on surgery in two asymptomatic vascular pathologies.

METHODS

Fifty patients were divided into two groups: the ICAS group-27 (CAS or CEA) and the AAA group-23 (EVAR or open surgical operation (OSR). Specific questionnaire regarding: 1) self-image; 2) attitude to one's illness; 3) reasons for decision on surgery was applied for the study. The χ² test was used to for the analysis.

RESULTS

The AAA patients reacted emotionally (88.2%) comparing to ICAS patients reacting "rationally" (59.3%) (α=0.05). In AAA patients attitude towards themselves had worsened (α=0.001) AAA patients were less likely to seek support in decision on surgery (α=0.01). ICAS patients are internally motivated (78.7%), whereas AAA patients are externally motivated (63.9%) (α=0.001). Reasons underlying the decision on surgery, were predominantly rational (55.8%).

CONCLUSION

In the process of decision-making on surgery by asymptomatic patients, evolutionary transformation takes place - the emotional attitude to one's illness leads to rationally evaluated decision. Regardless of the causes the process of making a decision on surgical operation tended to run more smoothly in ICAS patients. The ICAS patients tended to display a rational attitude to their illness. AAA patients displayed a distinctly emotional attitude towards their illness.

The drama of being diagnosed with an aortic aneurysm and undergoing surgery for two different procedures: open repair and endovascular techniques

The purpose of this study is to describe and interpret what it means for patients to be diagnosed with an abdominal aortic aneurysm (AAA) and how they experience treatment. AAA is usually asymptomatic and often discovered coincidentally in conjunction with a diagnostic workup for other medical problems. Twenty patients who had undergone 2 different surgical procedures were sequentially invited for interviews 1 month following surgery. A hermeneutic approach was used. For all patients three themes emerged: an inability to come to terms with a life-threatening condition, a sense of living on borrowed time, and a sense of being granted a new lease on life. The theme that emerged for patients with open repair was that diagnosis with AAA was an ordeal to endure, while the theme for patients who underwent endovascular treatment was a sense of gratitude, security, and insecurity. Once the aneurysm was discovered patients were convinced that they were both blessed and saved, along with a sense of gratitude. Pre- and postoperative nursing care strategies can be developed based on the findings from this study.

[Assessment of mental condition and anxiety in patients receiving neuroendovascular treatment]

OBJECTIVE

Neuroendovascular treatment (NET) is an effective and minimally invasive procedure used for patients with vascular disease of the central nervous system. The purpose of this study was to examine anxiety levels using standardized psychometric tools and an original questionnaire among patients before and after NET.

METHOD

A total of 40 patients who underwent NET were included. There were 18 patients with unruptured cerebral aneurysm, 18 with carotid stenosis, and 4 other cases. Patients were asked to complete a State-Trait Anxiety Inventory (STAI) and also to fill out a questionnaire about perioperative anxiety. It elicited the following information: (a) state-anxiety score and level before and after NET; (b) trait-anxiety score and level before and after NET; and (c) perioperative anxiety about NET. In all cases, the procedure was performed under local anesthesia.

RESULTS

The preprocedural state-anxiety score was high in many patients (82%). The principal cause of the preprocedural anxiety was the procedure-related complications (92%). Patients with cerebral aneurysm experienced anxiety during the procedure because they could not know which stage of the procedure was involved. Their state-anxiety score was improved in the postprocedural examination (88%). However, patients were still anxious about postoperative complications and recurrence, particularly those with cerebral aneurysm. Patients with cerebral aneurysm generally tended to experience a higher level of anxiety than those with carotid stenosis.

CONCLUSION

Though NET is apt to be thought as a relatively easy procedure, patients actually felt much anxiety, especially those with cerebral aneurysm. Due care for perioperative anxiety in patients who undergo NET is important.

Brief report: do patients with poor outcomes regret having had infrainguinal bypass surgery?

BACKGROUND

Retrospection and hindsight bias may lead patients with bad outcomes to regret the choice of infrainguinal bypass surgery.

OBJECTIVE

To assess patients' retrospective evaluations of surgery stratified by common criteria to judge surgical success. SURVEY DESIGN: Cross-sectional phone surveys of 33 patients, an average of 162 d following infrainguinal bypass surgery.

RESULTS

Of the 33 patients evaluated, 26 (79%) experienced undesirable outcomes, including amputation (4, 12%), prolonged hospitalization (8, 24%), wound infection (8, 24%), readmission to the hospital (12, 36%), additional surgery (11, 33%), and other complications (16, 48%). Of the patients surveyed, nearly all (30, 91%) reported that they would still want to have had the surgery if they had a 5-y 50% mortality, and the same proportion reported they would recommend the surgery to someone else with similar medical problems (30, 91%).

CONCLUSIONS

If confirmed in larger populations, these findings suggest that when viewed retrospectively, results traditionally considered poor outcomes may not deter many patients' preferences for surgical management of their infrainguinal vascular disease.

[Surgical site infections following vascular surgery]

OBJECTIVE

The aim of this paper was to perform epidemiological and microbiological analyses of surgical site infections diagnosed in patients after vascular surgery in two highly specialist centers in the year 2005.

METHODS

The study was conducted in two highly specialist wards in 2005 and covered totally 413 procedures. SSI's detection was based on definitions developed according to CDC guidelines. Post-discharge detection was included in the study. Collected data enabled evaluation of incidence rates and, additionally, in one hospital, assessing detailed rates included standardized SSI risk index.

MAIN OBSERVATIONS

Patients underwent analyzed procedures was mainly male (80%), aged 60 and more. In hospital I SSI incidence rate reached 2,6% and in the other (hospital II)--5,6%. Among the etiological factors isolated from patients with SSI staphylococci were the most common (45,5%) and it was mainly Staphylococcus aureus.

CONCLUSIONS

The study which was performed showed the incidence of SSIs in patients undergoing vascular surgery at the level of 2.6 and 5.6%. It was shown that it is possible to introduce an effective post-discharge surveillance, which encompassed 50-66% diagnosed cases of SSI.

[Long-term results of peripheral vascular injuries in patients' limbs following reconstructive surgical procedures and influence on the quality of life]

Major vascular injuries in extremities are rare and constitute problems for surgeons and their sequelae strongly influence remote future of the patients. The aim of study is to evaluate surgical treatment of vascular injuries in extremities and some aspects of quality of life. Since 1983 until 2002 sixty four patients with vascular limbs injuries were treated in the department. Remote evaluation has been performed in 33 persons. Severity of limb injuries was measured by Mangled Extremity Severity Score (MESS). In 20 patients (60.6%) very good and good recent results were obtained, satisfactory in 24.2% and bad results in 15.2% persons. Evaluation of functional status has been made by means of locomotion test and Jebsen-Taylor's test, social approval questionnaire, depression Beck's scale, the scale of hypochondria and by an original questionnaire to evaluate the quality of life. As considerable interdependence has been found between the functional status and the following factors: injury severity expressed in MESS (p < 0.01), clinic reception procedure (p < 0.001), ischemia time (p < 0.01), coincidence of other injuries (fractures and dislocations, muscle, tendon and nerve lesions) (p < 0.01), limb amputation (p < 0.01). Hand function significantly influences the quality of life. Patients who were in shock after trauma in the remote assessment showed susceptibility to the lowered mood and depression (p < 0.05). Quality of life is strongly connected with the features of personality, correlating mainly with the mood and tendencies of concentration upon somatic symptoms. Function of the hand influences strongly the quality of life. Amputated patients may in spite of their crippling limitations are able to adapt to everyday life.

Patient satisfaction after surgery for trigeminal neuralgia--development of a questionnaire

OBJECTIVE

This project aimed to prepare a self complete patient satisfaction survey for patients who have undergone surgery for trigeminal neuralgia and then assess its reproducibility, validity and acceptability in one centre.

METHODS

The questionnaire, for initial use in patients who had undergone posterior fossa surgery for trigeminal neuralgia, was designed after a systematic review of the surgical literature had been performed and discussions held at the US and UK Trigeminal Neuralgia Support group meetings. It underwent several changes after input from neurosurgeons, patients, copywriter and statistician and finally contained 44 questions, the SF12, Hospital Anxiety and Depression Scale (HAD), Brief Pain Inventory (BPI) and McGill Pain questionnaire (MPQ). From the total number of 413 patients in the database of one centre the questionnaire was sent with a covering letter to 305 patients, the rest had died (25), were lost to follow up (26) or did not meet the inclusion criteria (56). One patient had bilateral PSR. The completed questionnaires were evaluated by an independent physician, neurosurgeon and patient. A repeat questionnaire was sent to 10% of the patients to check reproducibility.

RESULTS

The questionnaires were well completed with a final response rate of 92%. It appeared to be highly acceptable and reproducible but needed adjustment to improve its validity before being used in other centres and for all surgical procedures. A new questionnaire is proposed which could be used on an annual basis.

CONCLUSIONS

A questionnaire has been developed for use in patients who have undergone surgical management for trigeminal neuralgia and which is acceptable to patients.

[Quality of life of patients after surgical treatment of ascending aorta aneurysms]

Quality of life (QL) of 65 patients with ascending aorta aneurysms before and after surgical treatment was studied with SF-36 questionnaire. This group of patients demonstrates initial lower indices of QL on all the scales of questionnaire. In long-term period after surgery these indices significantly improve and correlate with clinical and hemodynamical result of surgery.

Risk factors for postoperative delirium in vascular surgery

The aim of this study was to identify psychiatric and somatic risk factors associated with the development, severity and duration of postoperative delirium after vascular surgery. Forty-seven patients underwent aortic, carotid artery and peripheral artery surgery. Both, surgeon and psychiatrist, monitored patients preoperatively with daily follow up. Preoperative psychiatric assessment included standardized psychopathological scales for the detection of psychiatric symptoms and cognitive deficits. We diagnosed delirium using DSM IV criteria. Delirium Rating Scale was used to estimate delirium severity. Surgical parameters included patient history, diagnoses, medication and laboratory parameters. A statistical analysis was performed using multivariate regression analyses to find factors significantly associated with delirium development, severity, and duration. Thirty-six percent of the patients developed postoperative delirium after surgery. Comparison of different parameters revealed that especially preoperative depression symptoms and perioperative transfusions/infusions had significant predictive value for the development as well as for the severity of postoperative delirium.

The Vascular Project: using data to improve processes and outcomes

Fiscal accountability by health care providers has become a theme in health care delivery systems; however, evaluation of outcomes on the basis of cost alone may minimize the importance of patient needs and the quality of the care delivered. Mechanisms related to resource identification and allocation has to be driven by internal data and information systems that consider clinical, financial, administrative, and patient satisfaction data. This article will define processes, outcomes and outcomes measurement, and management. Various nursing-sensitive outcomes will be presented and their establishment, tracking, interpretation, and effect on the delivery of patient care in a newly opened vascular unit will be highlighted.

Quality vascular surgical care: the importance of innovation and change in an era of dwindling reimbursement

BACKGROUND

Reductions in vascular surgery reimbursement emphasize the need to decrease cost while maintaining quality. Hospital solvency is essential if we are to preserve acceptable levels of nursing/support personnel and acquire new diagnostic and treatment programs.

METHODS

Care processes for patients undergoing carotid, aortic, or dialysis access surgery were retrospectively analyzed and new quality- and cost-oriented treatment algorithms and clinical pathways were developed and implemented using case management principles. Preoperative risk stratification, length of stay, costs, complications, outcomes, and patient satisfaction were compared before and after these revisions in the care process. Statistical analyses were done using the Wilcoxon Rank sum test and Fisher exact test.

RESULTS

Significant reductions in length of stay, intensive care use, and cost of treatment and diagnosis were achieved without adversely affecting morbidity, mortality, or patient satisfaction.

CONCLUSION

Use of algorithm, clinical pathway, and case management principles resulted in a marked improvement in the "bottom line" for vascular surgical procedures in our academic medical center.

Effects of vascular surgery on the elderly vascular patient

The majority of vascular patients are elderly and present a unique set of problems after an operation. Age plays a major role in their recovery, but the greatest challenge is their preexisting medical problems. The changes that occur with aging in the following body systems will be discussed: cardiac, pulmonary, renal, gastrointestinal, genitourinary, and central nervous system. Special concerns related to pain management, risk of delirium, and wound healing present continuing nursing challenges that require close observation after surgery.

Informed consent: how much information is enough?

BACKGROUND

Recent judicial decisions involving informed consent have led to some medical practitioners altering the way they obtain consent. The aim of this study was to determine the degree to which patients understood the risks associated with a surgical procedure after giving routine consent and whether providing additional detailed verbal and/or written information improved their understanding. It was further determined whether the provision of more extensive information altered patients' anxiety levels.

METHODS

Patients undergoing femoral popliteal bypass or carotid surgery were randomized to obtain either routine consent only or routine consent with verbal or written or verbal and written consent. Patients undertook a pre-operative risk and complication questionnaire, a pre- and postoperative anxiety and depression evaluation and a follow-up questionnaire 6 weeks after discharge.

RESULTS

Thirty-two patients were included in the trial. The comprehension questionnaire resulted in a correct percentage response of 48% for the routine information only, 59% with added verbal information, 59% with added written information and 55% with added written and verbal information. Twenty-five per cent of patients stated that they had a poor understanding of the risks and complications of the procedure.

CONCLUSIONS

Additional written or verbal information did not improve a patient's understanding of risks and complications of the procedure. It also did not improve patients' perceived understanding of the operation or its complications. Patients' anxiety levels were unaltered by the increase in the information they were given. The information provided to patients should be simple, easy to understand and list any possible major complications to enable the patient to determine whether to undergo or decline a procedure.

Abdominal aortic aneurysmectomy in the octogenarian

The risks, results, and postoperative quality of life were evaluated in 11 patients aged 80 years or older who underwent resection of an abdominal aortic aneurysm (AAA). The operative mortality was 9% (1/11). Three patients underwent urgent operation, 1 for impending rupture, 1 for contained rupture, and 1 for rupture into the sigmoid colon. Preoperative risk factors such as hypertension, electrocardiographic abnormalities, and respiratory dysfunction were found in about half of the patients. Neither operative mortality nor long-term survival were influenced by the preoperative risk factors. The quality of life enjoyed by these patients was not adversely affected by AAA resection. Surgical treatment of AAA should be undertaken in selected octogenarians to prevent rupture. Physiologic status rather than chronologic age should determine which patients undergo aneurysm resection.

[Comparison of anxiety in patients before surgery for varicose veins and laparoscopic cholecystectomy]

The trial of estimation of the fear degree before operation and its dependence on the patient's sex, type of operation and anaesthesia was performed. 76 patients before the operation were examined: group I--38 patients, including 27 women and 11 men waiting for the repair of lower extremities varicose veins under local anaesthesia, and group II--also 38 patients, including 27 women and 11 men before the laparoscopic cholecystectomy due to cholecystolithiasis. The Polish version of the Spilberg's State--Trait Anxiety Inventory was used in the estimation of the fear. The statistically significant difference of the preoperative fear degree between examined groups was not found. There were also no significant differences between men and women in the same group. Women in both groups displayed a significantly higher values of the fear as a trait. Probably laparoscopic operations are considered by the patients as more safe than traditional ones, and maybe the trust in doctors causes the fact that the operation under general anaesthesia is connected with low fear as well as the operation under local anaesthesia.

Which treatment would patients prefer for their varicose veins?

This questionnaire-based study investigated the preferences of patients with varicose veins for injection treatment or surgery, based on a series of explicit facts about each method. In all, 72 questionnaires were returned (77% response rate). Factors influencing patients in favour of injections were no time off work (38%) and no general anaesthetic (31%). A bandage on the leg for 3-6 weeks influenced 44% against injections. A lower chance of recurrence at 5-10 years influenced 80% of patients towards surgery. Overall, 25% expressed an overall preference for injections, and 63% preferred surgery (12% no preference). Patients with bilateral varicose veins were asked about their preferences for two unilateral day case operations or one bilateral inpatient procedure. The majority preferred a single bilateral operation, based on one general anaesthetic (88%) and one admission only (77%), less time off work (58%), and discomfort on one occasion only (50%). These preferences, expressed by well-informed patients, should be considered when planning services for the treatment of varicose veins.

The psychological impact of microvascular free toe transfer for children and their parents

This paper is based on a prospective study of microvascular toe transfers which examined psychosocial, functional and aesthetic outcome for children with congenital hand anomalies and their parents. 14 families were assessed both pre-operatively and 2 years post-operatively. There were five boys and nine girls. Their ages ranged from 6 months to 13 years (mean age = 5.08 years). The parents were assessed on the basis of a parental adjustment measure, a detailed semi-structured interview and a measure of anxiety and depression. The children were assessed on the basis of behaviour and social competence, social experience, self-consciousness about the hand and the perceptions of their own functional competence. Both parents and children were asked to rate their satisfaction with the hand. In addition, function and appearance was assessed using an independent professional panel. It was found that parental adjustment to the hand was an important independent variable in determining psychosocial outcome. The children of poorly-adjusted parents had more social and psychological problems prior to surgery, and showed an increase in behavioural problems after surgery. Their parents were less anxious and happier after surgery and it was of particular benefit to them. The children of well-adjusted parents had fewer pre-operative problems and showed a general slight improvement after surgery. For all the children, there was a significant improvement in both function and appearance of the hands after surgery.

Family recovery after vascular surgery

Twenty-one families were observed in a 3-month study to assess family coping with major vascular surgery and recovery. Analysis of family measures data (the Family APGAR, the Family Inventory of Resource for Management, and the Family Crisis Oriented Personal Evaluation Scales) was combined with grounded theory method to assess family responses over time and recovery outcomes. Containment emerged as the major conceptual category of the grounded theory. Containment refers to a constellation of constructed meanings for events and behavioral responses used by families to regulate the impact of the surgical crisis and reduce family disruption. This "contained" coping pattern was manifested in families' avoidant behaviors and narrow definitions of the problem: that is, they defined their situation in terms of the surgical repair as cure rather than palliative intervention for a chronic, progressive disease. Situational factors such as the insidious development of the illness and the primary focus of care providers in the hospital on surgical care (allowing families' narrow definitions of their situation to remain unchallenged) also contributed to containment. Containment resulted in poor risk factor management as a major recovery outcome. Isolation and family conflict were evident throughout the recovery period. Concerns generated by continued evidence of morbidity during recovery contributed to a developing awareness of underlying disease, and diminishing containment when this growing awareness was openly shared within the family. Significant findings of the family measures analysis were compared with the grounded theory of the qualitative data. Each corroborated the other in key dimensions.

Feelings and attitudes during early convalescence following vascular surgery

This descriptive study examined patients' attitudes and feelings towards convalescence following vascular surgery. A convenience sample of 25 subjects consisted of patients who had initial (18) and repeat (7) surgery. A self-administered questionnaire and a semi-structured interview guide were utilized to examine patients' perceptions concerning health, uncertainty about the outcome of surgery and course of disease, and their degree of adherence to discharge instructions. The findings suggested that the early convalescent period was difficult for all patients, but particularly for those in the repeat surgery group. Although data analysis revealed no statistically significant differences in perceptions between groups, repeat surgery patients tended to experience less favourable perceptions of health, a higher level of uncertainty, and a lower rate of adherence to discharge instructions.