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Reducing complications following abdominal surgery

Reducing complications following abdominal surgery

What are post-operative complications?

Post-operative complications (eg wound infections) are conditions that may affect a patient’s predicted recovery following surgery and requires additional medical management. Post-operative complications can result in:

  • increase in patient’s length of stay, and associated hospital costs
  • increase in patient morbidity and mortality rates
  • decrease in patient quality of life

For upper abdominal surgery (UAS), the most common complication is a pulmonary complication, with a recent multi-centre study showing where patients developed a complication, 40% were diagnosed with a pulmonary complication (eg pneumonia).


What are we trying to achieve?

Existing clinical guidelines recommend post-operative physiotherapy for all patients undergoing upper abdominal surgery to aid recovery. This includes patients receiving breathing and coughing exercises, and early ambulation.

Evidence from clinical trial suggest that providing a single pre-operative (before surgery) physiotherapy education session may help to reduce the rate of post-operative (after surgery) pulmonary complications (PPC) following upper abdominal surgery by up to 78%. [Insert reference]

However, these findings are not definitive due to the small sample sizes and the variance in methodology. We wanted to determine the effect of a single pre-operative physiotherapy education session on the rate of pulmonary complications for adult patients following upper abdominal surgery.


What have we done?

A trial study was developed across three New Zealand and Australia centres to confirm whether a single pre-operative physiotherapy education session can reduce the rate of PPCs following upper abdominal surgery[1]. The three participating centres were:

  • North Shore Hospital, Auckland (600-bed metropolitan hospital)
  • Launceston General Hospital, Tasmania (330-bed inner regional hospital)
  • North West Regional Hospital, Tasmania (240-bed rural secondary hospital)

Trial preparation

Stocktake and consultation

  • Initial discussions were held between all centres to identify existing care pathways for patients
  • We consulted with many departments and disciplines across our organisation about the study

Standardised guidelines

  • Standardised guidelines were developed for post-operative physiotherapy and early ambulation (walking)
  • At the first available opportunity following surgery, all participants are seen by a physiotherapist for a standardised assisted session, and are seen once daily until discharged from physiotherapy services using defined scoring criteria

Conducting the trial

  1. Booklet about physiotherapy following abdominal surgery432 participants were recruited through the pre-operative assessment clinic
  2. The participants were split into a control group (n=214) and an intervention group (n=218)
  3. Both groups received a standardised single pre-op assessment and were provided with a booklet containing information about physiotherapy following abdominal surgery
  4. The intervention group also received a 30-minute education session with a physiotherapist, and were told that a physiotherapist would assist them with early ambulation, aiming for at least 10 minutes on their first day post-operatively
  5. No deep breathing exercises were done at any point by the physiotherapist post-operatively, and all physiotherapy was standardised across both groups
  6. Patients were assessed daily for a post-operative pulmonary complication, and a number of secondary outcomes were also collected
  1. ‘LIPPSMAck POP’ (Lung Infection Prevention Post Surgery - Major Abdominal - with Pre-Operative Physiotherapy) published trial http://trialsjournal.biomedcentral.com/articles/10.1186/s13063-015-1090-6

Did we make a difference?

Overall we concluded that a single pre-operative physiotherapy education session:

  • significantly improves clinical outcomes
  • improves quality of patient experience

The results from the study showed a significant reduction in PPCs between the control group and the intervention group:

Control Group

Intervention Group

Rate of PPC ( %)

27% (n=214)

12% (n=218)

Rate of PPC for patients with a predicted higher risk pre-operatively for PPC

40% (n=112)

19% (n=103)


Secondary outcomes

There were also significant effects on some important secondary outcomes, for example average length of stay was reduced by almost 2 days for the intervention group, readmission rates to ICU and pneumonia rates were significantly lower.

Outcome

Control Group

Intervention Group

Average Length of Stay (LOS), days

12.1

10.4

Readmitted to ICU, %

9.7%

5.6%

Pneumonia, %

20.3%

8.4%


These outcomes mean that this low-cost intervention can help to reduce hospital costs associated with complications.

Patient feedback

  • Recall from the control group was generally poor and non-specific, and 75% of participants had no recall of information from the pre-operative physiotherapy booklet
  • Recall of pre-operative information was significantly better for the intervention group and patients felt that receiving information face-to-face was highly beneficial to their recovery

Physiotherapy staff feedback

  • Physiotherapy staff reported that patients were more engaged in their own treatment and motivation was improved, which in turn improved staff satisfaction and patient-therapist rapport
  • The overall face-to-face physiotherapy time post-operatively was reduced

Where to from here?

We have now implemented a pre-operative physiotherapy service for patients undergoing upper gastro-intestinal surgery due to their higher risk profile. We aim to roll this service out to other upper-abdominal surgery patients by the end of 2016.