Pre-hospital discharge planning: empowering elderly patients through choice

Reductions in the length of stay for acute hospitalization have occurred as a result of Medicare cost containment strategies during the past 20 years. Thus, innovative approaches to the treatment of patients in the acute care hospital setting are necessary, particularly in the practice of discharge planning. The medical literature typically identifies the first day of admission as the time to begin discharge planning in order to minimize the patient's length of stay in the acute care hospital. This strategy has its limitations as elderly patients are often confused by unfamiliar surroundings, surgical anesthesia, postoperative pain, and the rapid pace of hospital recovery typically expected today. Consequently, options for discharge may be limited to the most expedient plan that will ensure safety and continued recovery. This article presents an alternative plan that begins with outpatient education preceding admission and follows the patient throughout the continuum of care including postdischarge.     

Pain management in ambulatory surgery.

Successful ambulatory surgery is dependent on analgesia that is effective, has minimal adverse effects, and can be safely managed by the patient at home after discharge. A number of studies have identified that the provision of effective postoperative analgesia is inadequate for a significant proportion of patients. The following discussion details the current available analgesic options for ambulatory surgery patients and the rationale for their use. Preemptive analgesia should be given to all patients unless there are specific contraindications. Consideration should be given to the use of long-acting oral COX-2 selective nonsteroidal anti-inflammatory drugs (NSAIDs) and long-acting oral opioids to treat postoperative pain. A standardized multimodal postdischarge analgesic regimen tailored to the patient's expected postoperative pain levels should be prescribed. Patient follow-up by telephone questionnaire will confirm those surgical procedures that result in mild or moderate-to-severe postoperative pain and the effectiveness of treatment plans.     

Postoperative pain after hospital discharge

Thirty postoperative adults were surveyed using face-to-face interviews in their homes after hospital discharge. Participants were asked to describe their pain communication during their inpatient hospitalization and pain-related problems after discharge. This study reports the content analysis of participant responses to their pain after discharge. Eighteen (60.0%) described pain-related problems after discharge. Seven (23.3%) identified pain-related fears or complications. Six (20.0%) identified analgesic management problems. Six (20.0%) described difficulty with positioning or moving. Four (13.3%) described sleep disruption from pain. The results identify several pain-related problems encountered by postoperative patients after hospital discharge. Shortened hospital stays make effective postdischarge pain management an essential aspect of care for surgical patients. Teaching patients additional pain management skills, including when and how to communicate with health care providers when pain-related issues occur at home, may lead to more effective pain relief for patients.     

Surgery: not just for hospitals anymore. Part 2: EMS response to postoperative complications

Patients who have undergone a surgical procedure at an ambulatory surgery center, hospital or physician's office may experience postoperative complications. This article examines the types of postoperative complications that can occur following outpatient procedures, with recommendations for EMS patient care and issues related to patient transport.     

Intranasal Ketorolac as Part of a Multimodal Approach to Postoperative Pain

Despite recent advances in the knowledge of pain mechanisms and pain management, postoperative pain continues to be a problem. Inadequately managed postsurgical pain has both clinical and economic consequences such as longer recovery times, delayed ambulation, higher incidence of complications, increased length of hospital stay, and potential to develop into chronic pain. Generally, opioids are the mainstay option for pain management in patients with moderate‐to‐severe postsurgical pain; however, opioids have significant side effects and have abuse potential. To improve patient and economic outcomes after surgery, postoperative pain guidelines have suggested incorporating a multi‐modal/multi‐mechanistic approach to pain treatment. A multi‐modal approach is the simultaneous use of a combination of two or more (usually opioid and non‐opioid) analgesics that provide two different mechanisms of actions. Utilizing a multi‐modal approach may result in a greater reduction in pain vs. single therapies in addition to minimizing opioid use, thus reducing opioid related side effects. However, not all approaches may be effective for all types of patients and not all analgesics may be a viable option for outpatient settings, ambulatory surgery, or the fast‐track surgical procedures. In this report, we present a review of the literature with a focus on intranasal ketorolac in order to provide a timely update regarding past, present, and future multi‐modal treatment options for postoperative pain.     

Complications of weight loss surgery: implications for critical care nursing

Weight-loss surgery (WLS) patients present a relatively new population for the health care system. Lack of clinical information about the WLS patient and the postoperative WLS patient can negatively affect quality of care and put the patient at unnecessary risk. Postoperatively, the bariatric patient is often admitted with complex care management requirements that differ from those of other surgical patients. Acute and critical care nurses must have a thorough understanding of the health implications of obesity, be familiar with common WLS procedures, and remain vigilant regarding the potential postoperative complications that can occur in this particular patient population.     

The Acute Complications After Surgery for Penile Carcinoma and Strategies for Their Management: A Systematic Review of the Literature

ObjectivesTo investigate the contemporary rates of 30-day complications after surgery for penile cancer and to discuss the currently used preventative and therapeutic practices aimed at mitigation of these postoperative adverse events.Data SourcesA systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed, and studies reporting on the contemporary rates, nature, or management of acute complications following primary penile surgery or inguinal lymph node dissection for penile cancer were abstracted. Medline (PubMed) and EMBASE libraries were used to retrieve the articles published between January 1984 and December 2021 (n = 170 articles). Ultimately, 38 articles were included. The primary outcome of interest was 30-day (acute) postoperative complications, stratified by those associated with treatment of the primary penile lesion and those with inguinal lymph node dissection. Risk of bias assessment was undertaken. Special attention was paid to studies reporting management strategies for these complications.ConclusionThis comprehensive review revealed that the quality of existing studies reporting on complications is poor and the risk of bias is high. Within these studies, the rates of acute complications following primary penile surgery and inguinal lymph node dissection ranged between 0% and 29.4% and 6% and 90%, respectively. More than 50% of these complications were wound related. Over the past two decades, several studies have reported on improved surgical techniques and protocolized postsurgical care pathways. Although the newer techniques have been associated with improved outcomes, the absolute rates of complications have remained high even in the most contemporary series. Therefore, there is an urgent need for health care providers and stakeholders to reach consensus regarding preoperative workup and medical optimization goals, stage appropriate therapies, and postoperative care pathways, as has been done for other malignancies associated with high morbidity.Implications for Nursing PracticePenile cancer is a disease of the elderly, and surgical management of the primary lesion or the groins is associated with a high rate of complications. Most complications are wound related. Meticulous surgical technique and careful postoperative monitoring with early intervention are keys to mitigating surgery-related morbidity. However, equally important is dissemination and adoption of these principles by all health care workers universally.     

Postoperative Pain: Nurses’ Knowledge and Patients’ Experiences

The aim of this study was to determine nurses’ knowledge and attitudes regarding postoperative pain and identify postoperative patients’ pain intensity experiences. The assessment and management of acute postoperative pain is important in the care of postoperative surgical patients. Inadequate relief of postoperative pain can contribute to postoperative complications such as atelectasis, deep vein thrombosis, and delayed wound healing. A pilot study with an exploratory design was conducted at a large teaching hospital in the eastern United States. The convenience samples included 31 nurses from the gastrointestinal and urologic surgical units and 14 first- and second-day adult postoperative open and laparoscopic gastrointestinal and urologic patients who received patient-controlled analgesia (PCA). The Knowledge and Attitudes Survey Regarding Pain was used to measure nurses’ knowledge about pain management. The Short-Form McGill Pain Questionnaire (SF-MPQ) was used to measure patients’ pain intensity. The nurses’ mean score on the Knowledge and Attitudes Survey Regarding Pain was 69.3%. Patients experienced moderate pain, as indicated by the score on the SF-MPQ. There is a need to increase nurses’ knowledge of pain management.     

Surgery: not just for hospital anymore. Part I: Responding to the surgical patient in distress

The number of surgical and diagnostic procedures performed on an outpatient basis continues to grow in the U.S. These procedures are often performed in an ambulatory surgery center (ASC) or physician's office. While outpatient surgery is typically safe, a wide variety of complications can occur. When an emergency occurs in these facilities, the patient requires emergency treatment and may need to be transferred to a hospital for additional care. This article examines the types of emergencies that occur and the associated patient care requirements, including the special needs of intraoperative and postoperative patients and their interactions with healthcare providers.     

Use of a modified Postanesthesia Recovery Score in phase II perianesthesia period of ambulatory surgery patients.

Use of discharge criteria in the ambulatory surgery setting has been the topic of many research studies and reviews. This article provides a discussion of a research utilization project regarding the use of a modified Postanesthesia Recovery Score for Ambulatory Patients (PARSAP) in Phase II recovery of a perianesthesia unit. The impetus for this project was the closure of a hospital's only inpatient ward, resulting in all surgery performed on an outpatient basis. Based on community standards and a review of literature, this project evaluated the use of the modified PARSAP on ambulatory surgery patients. The intent of the project was to improve the flow of patients through the recovery process in an effort to contain or reduce costs while still maintaining high-quality patient care standards. Results of the project showed a decreased inpatient length of stay without any increase in reports of postoperative complications. The favorable outcomes of the use of this scoring system have led to its implementation on a permanent basis. This is a U.S. government work. There are no restrictions on its use.     

Ventricular assist devices: what intensive care unit nurses need to know about postoperative management

Patients with advanced heart failure have limited treatment options despite advances in medical management. Ventricular assist devices represent a surgical option that offers improved end-organ function, survival, and quality of life. Postoperative nursing management involves the most complicated aspects of care following cardiac surgery as well as issues unique to advanced heart failure and mechanical circulatory support. Despite growing numbers of ventricular assist device implants, literature about the challenging care of patients following ventricular assist device implantation is limited. This article focuses on the physiological basis for postoperative nursing management strategies and the most important complications of which critical care nurses need to be aware.     

Nursing care of the pediatric patient following strabismus repair surgery

This paper presents the holistic approach to the care of the pediatric patient with strabismus. It discusses preoperative management, contemporary surgical procedures including postoperative suture adjustments, complications and the care and management of the patient and family on the pediatric unit. It reviews discharge instructions including pain management, postoperative safety and the follow-up appointment with the surgeon. Methods of determining the level of knowledge of the child's primary caregiver are also a major focus.     

Retinoblastoma: care and support of the pediatric patient and family

This paper presents the holistic approach to the care of the pediatric patient with strabismus. It discusses preoperative management, contemporary surgical procedures including postoperative suture adjustments, complications and the care and management of the patient and family on the pediatric unit. It reviews discharge instructions including pain management, postoperative safety and the follow-up appointment with the surgeon. Methods of determining the level of knowledge of the child's primary caregiver are also a major focus.     

Techniques to Optimize Multimodal Analgesia in Ambulatory Surgery

Purpose of Review

Ambulatory surgery has grown in popularity in recent decades due to the advancement in both surgical and anesthetic techniques resulting in quicker recovery times, fewer complications, higher patient satisfaction, and reduced costs of care. We review common approaches to multimodal analgesia.

Recent Findings

A multimodal approach can help reduce perioperative opioid requirements and improve patient recovery. Analgesic options may include NSAIDs, acetaminophen, gabapentinoids, corticosteroids, alpha-2 agonists, local anesthetics, and the use of regional anesthesia.

Summary

We highlight important aspects related to pain management in the ambulatory surgery setting. A coordinated approach is required by the entire healthcare team to help expedite patient recovery and facilitate a resumption of normal activity following surgery. Implementation and development of standardized analgesic protocols will further improve patient care and outcomes.

     

Endoscopy unit considerations in the care of obese patients

The dramatic increase in obesity in the general population is accompanied by a concomitant increase in bariatric surgical programs. Gastrointestinal endoscopy has an important role in patient evaluation, postoperative management, and emerging endoscopic bariatric therapies. Endoscopy units must address special design and equipment needs of obese patients in short- and long-range planning. Obese people require more health care resources than nonobese people, with increased physical challenges for staff in administering that care. This article details endoscopy unit considerations pertaining to the bariatric patient, which may apply to pretreatment endoscopic evaluation, managing postoperative bariatric surgical complications, and emerging endoluminal bariatric therapies.     

Postoperative hyperglycaemia of diabetic patients undergoing cardiac surgery – a clinical audit

Background: Previous studies have shown that hyperglycaemia is associated with postoperative complications in cardiac surgical patients. Conversely, well‐controlled glucose levels are said to reduce major infectious complications in diabetic patients. Aim/Objectives: The purpose of this clinical audit was to evaluate the blood glucose levels of diabetic patients undergoing cardiac surgery and to determine the effectiveness of postoperative glycaemic control. Methods: A group of 150 patients from a large Irish cardiac surgery centre was selected by convenience sampling. An audit tool was designed to capture the patients' blood glucose levels, treatment regimes and postoperative complications. Findings: The findings showed major variations between ‘high’, ‘good’ and ‘borderline’ blood glucose levels in the pre‐ and postoperative phase. Although blood glucose testing practices seemed inconsistent, mean levels measured ‘borderline’. Furthermore, the treatment regimes varied greatly and suggest a lack of consensus regarding the management of postoperative hyperglycaemia. A total of 52% (n = 78) patients developed 114 complications with a level of 21·4% (n = 32) postoperative wound infections. Conclusion: The findings from this audit highlight the importance of regular blood glucose testing to enable early detection of hyperglycaemia and timely initiation of appropriate treatments regimes for diabetic patients undergoing cardiac surgery. Findings also show that hyperglycaemia derangement may make a difference in the recovery phase. While patients will benefit from lesser wound infections, hospitals might save costs involved with treating postoperative complications. Relevance to practice: More consistent blood glucose testing might be achieved through the use of evidence‐based protocols. However, the education of staff is as important as it develops knowledge on the complex metabolic interactions of diabetic patients undergoing cardiac surgery. While this means investing in staff education and policy development, costs for daily care and expensive treatments for complications will be saved as patient recovery will be speedier and less eventful.     

Cardiac surgery in the elderly: the critical care phase.

A growing number of elderly patients (aged 70 years and older) are seen in critical care units after valve surgery or coronary artery bypass grafting. While studies show that the elderly demonstrate overall successful results after cardiac surgery, the mortality and morbidity risks are higher than in younger adults. The elderly patient is more likely to experience postoperative complications, prolonging the recovery phase. Commonly reported postoperative complications include dysrhythmias, pneumonia, cerebral vascular accidents, and infection. Elderly surgical candidates must be evaluated preoperatively to determine risk factors that may affect the critical care recovery phase. The length of stay tends to be longer in the intensive care unit, requiring nursing care that takes the aging process into consideration. The following article focuses on trends in cardiac surgery in the elderly, physiologic factors that affect outcome and recovery, and nursing interventions aimed at preventing or limiting postoperative complications.     

Nursing management of postoperative dysrhythmias.

Clinical decision making about postoperative dysrhythmias requires the specialized skills and knowledge of the critical care nurse. During the immediate postoperative period, the critical care nurse must be aware of physiologic alterations and factors that may predispose the cardiac surgery patient to dysrhythmias. Correction of these physiologic alterations is usually the first step in postoperative dysrhythmia management. Should dysrhythmias develop following cardiac surgery, the critical care nurse may use management options that are not available in other surgical or medical patients. AEGs and pacing to suppress ectopy, to augment cardiac output, or to overdrive tachydysrhythmias are some of the available options. The advent of external, temporary DDD pacing will augment these management options. The challenges presented by these options emphasize the vital role of the critical care nurse in postoperative dysrhythmia management.     

I Can’t Read That! Improving Perioperative Literacy for Ambulatory Surgical Patients

Low literacy and low health literacy are surprisingly rampant problems facing health care providers. Patient educators in all settings should consider the need for improved patient education materials that are easy to read and understand for the majority of patients. In the ambulatory surgery setting, patients often have time to prepare for scheduled outpatient surgery, yet education is provided primarily in the postoperative period. This article highlights the need for incorporating education into all phases of the perioperative process, beginning in the preoperative period. Perioperative educators should address all learning styles that provide education in a simple and cost-effective way to appeal to all patients and help to reduce postoperative complications and increase patient satisfaction in the ambulatory surgery setting.