Postoperative mobilisation as an indicator for the quality of surgical nursing care

Background

To move is a fundamental human need and to assist patients in mobilising is one of the basic principles of nursing care that Virginia Henderson conceptualised for the nurse's role (Current Nursing, 2020). Thus, postoperative mobilisation is a fundamental nursing intervention. Furthermore, it is one of the cornerstones of fast-track and enhanced recovery programmes (Kehlet and Wilmore, 2008; Gustafsson et al, 2013), because immobilisation, according to the pathophysiology of bed rest, leads to postoperative complications such as heart, lung and vascular complications, muscle atrophy and weakness (Convertino et al, 1997; Brower, 2009). Enhanced recovery after surgery (ERAS) comprises multimodal perioperative care to achieve early recovery for patients undergoing major surgery (Nelson et al, 2019). However, failure to mobilise is one of the most common reasons for deviation from the ERAS guidelines and associated with prolonged hospitalisation (Smart et al, 2012). Thus, there is clear evidence that increased mobilisation within the frame of fast-track programmes has a positive effect on postoperative recovery, and that mobilisation on postoperative day 1-3 is significantly associated with a successful surgical outcome for the patient (Basse et al, 2002; Kehlet, 2011; Vlug et al, 2011). Despite this, immobilisation is still a widespread problem that is related to clinical factors such as inadequate pain control and patient motivation, along with pre-existing comorbidities, as well as organisation and tradition in care regimens (Van der Leeden et al, 2016).

In this study, optimising the quality of care provided to patients undergoing ovarian cancer surgery was originally initiated by the fact that Danish women, for unknown reasons, were suffering from one of the world's highest incidences of ovarian cancer, and some of the highest mortality rates from the disease (Coleman et al, 2011). The most probable explanations for the poor survival rates were few operations performed by different types of surgeon in every of the 32 national departments, operating on all stages of ovarian cancer with no guidelines or only local guidelines (Marx et al, 2007). Consequently, there has been a strong medical and political focus on improving treatment outcomes.

In relation to ovarian cancer treatment, surgery plays a pivotal role (Kehoe, 2006). Surgery therefore was reorganised and centralised to only four gynaecological oncology centres, with certified gynaecological oncology surgeons, national guidelines, national political-dictated cancer pathways, and by law required registration in the national Danish Gynecologic Cancer Database (DGCD) for continuous quality assessment (Sørensen et al, 2016). Relatively soon after introduction it was possible to document an 8% improvement in survival (Fagö-Olsen et al, 2011; Edwards et al, 2016).

Besides the organisational and intraoperative efforts, good quality in perioperative care is essential to improve postoperative outcomes, and to make sure that complications or a poor general condition do not delay the recovery and subsequent chemotherapy for the individual patient (Kehlet and Wilmore, 2008). The multimodal evidence-based ERAS methodology (Kehlet, 2011; Ljungqvist et al, 2017), which was originally developed within colonic surgery (Basse et al, 2002), has demonstrated ability to significantly enhance postoperative recovery and reduce morbidity, including in patients undergoing ovarian cancer surgery (Marx et al, 2006; Lu et al, 2015; Lindemann et al, 2017). Against this background, a fast-track programme for patients undergoing ovarian cancer surgery was developed by a Danish multidisciplinary fast-track unit, and subsequently implemented at national level. However, quality assessments showed difficulties in implementing the fast-track programme for patients undergoing ovarian cancer surgery, especially with reference to mobilisation, nutrition, nausea and pain, with large variations across the country. In the same period, more extensive abdominal surgery was introduced, and the existing clinical guidelines proved insufficient in pain management, nutrition and fluid therapy when the surgical trauma was far more comprehensive. Results from a national audit were presented at multidisciplinary workshops, and it was decided to optimise perioperative care with new guidelines for pain and fluid management, and to develop a specific clinical guideline for patients having extensive abdominal surgery. Consensus was reached on these clinical guidelines in 2010 and they were implemented nationwide at the four gynecological oncology centres in Denmark, where patients undergo ovarian cancer surgery.

Methods

DGCD Nursing

During the past decade, a group of specialist nurses representing the four gynecological oncological centres have worked on continuous quality improvement in postoperative care, especially in terms of the standardisation of nursing care for patients undergoing ovarian cancer surgery. Figure 1 illustrates a standard care plan for postoperative mobilisation used by the staff members to ensure goal-directed nursing care. In 2011, a nursing database equivalent to the medical database, DGCD Nursing, was integrated into the pre-existing DGCD (Sorensen et al, 2016), with a special focus on fundamental postoperative care and containing data concerning basic elements of perioperative care.

Mobilisation as quality indicator

Mobilisation is one of the key parameters to avoid postoperative complications, and enhanced recovery programmes work with detailed daily goals for mobilisation. The national group of gynecological specialist nurses defined a national goal for mobilisation on the first postoperative day of 3 hours out of bed for patients undergoing ovarian cancer surgery. Because there were no data available in relation to ovarian cancer surgery, the 3-hour goal was based on transfer of evidence from colorectal surgery (Lassen et al, 2009; Nelson et al, 2019) and consensus in clinical experience. In continuation of this, the quality indicator for mobilisation was defined as at least 3 hours out of bed on postoperative day 1 in at least 60% of all patients. Mobilisation is defined as all activities where the patient is out of bed, such as standing at the bedside, sitting in a chair or going for a walk in the hallway (Kalisch et al, 2014).

To ensure correct data registration and to engage patients in care and goal setting, patient diaries were introduced. The diary was placed at the bedside and was used by both nurses and patients to document mobilisation, fluid intake and nutrition, as well as the level of pain and nausea in real time (Figure 2).

The extent of surgery is classified by cancer ovarian (COVA) groups, where COVA 1 covers bilateral salpingo-oophorectomy, total hysterectomy, omentectomy, appendectomy in case of a mucinous tumour, and possibly pelvic lymphadenectomy. COVA 2 comprises COVA 1 plus at least one of the following: radical hysterectomy, extensive pelvic peritonectomy, bowel resection with or without colon stoma or small intestine ostomy, splenectomy, cholecystectomy, or aortic lymphadenectomy. Finally, patients undergoing COVA 3 surgery have COVA 2 plus at least one of the following: extensive peritonectomy in the upper abdomen or diaphragm resection or resection of the liver (Bjørn et al, 2017).

Results

In the period 2011-2017 more than 5700 gynecological cancer patients were registered; of these, 4400 had a final ovarian cancer diagnosis.

Table 1 shows baseline characteristics of the ovarian cancer patients included in the study, according to the extent of surgery, age and comorbidity, recorded by the four centres over 2011-2017. Of a total of 4400 patients, 73% were COVA 1, 20% were COVA 2+3 and in 7% if cases the extent of surgery was not stated. More than 56% (2505/4400) of this patient population suffered from comorbidity, and this applied to all COVA groups.

Table 2 shows numbers of patients mobilised for 3 hours or more, according to extent of surgery, in each cancer centre. Overall, 47% of patients fulfilled the criteria of mobilisation on the first postoperative day, but variation was observed between the centres and between the COVA 1 group on 52% and COVA 2 + 3 groups on 31%.

Table 3 illustrates the type of activities the ovarian cancer patients achieved on postoperative day 1, based on registrations in the standard care plan from the patient diaries. Of the total 4400 patients, there were data from 2980 patients (67%). For the remaining 33% of patients, detailed data on mobilisation were not documented. However, data showed that discounting the length of their mobilisation, on average 51.8% of patients had been walking in the hallway of the department on the first postoperative day.

Table 4 illustrates the reasons why patients did not meet the goal of 3-hour mobilisation on the first postoperative day. The numbers are small, but the data available show that 5% of the 1940 patients who did not meet the mobilisation goal indicated pain, 11% indicated fatigue/tiredness and 6% indicated dizziness as the main reason for not reaching goals.

Discussion

As shown in Table 1, patients with ovarian cancer have a high degree of comorbidity regardless of the extent of their surgery, which strengthens the importance of early mobilisation in preventing complications (Brower, 2009). Patients who have undergone extensive surgery have even more difficulties in achieving the goal of staying out of bed for 3 hours or more on the first postoperative day (Table 2). One might have expected this finding, since the surgical procedure is more extensive with severe postoperative complications. Therefore, future strategies must be discussed for patients undergoing extensive surgery; this includes whether patients undergoing extensive surgery are actually capable or need to be mobilised in the same number of hours as those who have had less extensive surgery, and if they do so, optimised pain treatment and intensified physiotherapy may be needed. In any case further research is needed in this area.

The definition of mobilisation is that the patient has been out of bed, which covers sitting, standing and walking around (Kalisch et al, 2014). As seen in Table 3, in total 63% of the patients had been walking in the hallway on the first postoperative day, even though they had not met the full goal of 3 hours of mobilisation. These findings are positive, but they also indicate that it may be necessary to distinguish not only the duration of mobilisation but also the degree of mobilisation, because it is presumed better to walk around than to sit in a chair. However, the type of activity was not stated for 35% of the patients during the study period. The database has subsequently been revised so that it is mandatory to specify a type of activity. The highest form of activity is stated, which means that, if the patient is walking in the department, she is also able to sit in a chair.

To achieve increased mobilisation, it is necessary to know the reasons for the lack of mobilisation (Table 4). However, the reason for lack of mobilisation was not indicated by 57%/41% of patients (COVA 1/COVA 2 + 3) due to an error in the database, as the nurse was not asked to fill in the type of activities if he or she could not answer how long the patient had been mobilised on that day. Furthermore, it has become clear that there should be an opportunity to state more than one reason for not achieving goals during registration. Although the numbers of these missing values are high, the authors find the numbers representative and thus useful for further improvements. For the remaining group, the lack of mobilisation can be divided into organisational conditions (late return from surgery, staff too busy) and patient-related issues (pain, dizziness, nausea, fatigue). However, fatigue in particular as a reason for reduced mobilisation needs to be discussed from a professional perspective, because it has been shown that mobilisation overcomes fatigue (Christensen and Kehlet, 1993; Hjort Jakobsen et al, 2006; Zargar-Shoshtari et al, 2009).

In all cases, and to ensure that the pre- and postoperative care is taking place in a patient-centred way, goal setting concerning mobilisation needs to take place in close cooperation with the patient and her family (Seibæk et al, 2018a). In evidence-based care, the patient perspective represents a crucial element (Sackett et al, 1996), and patients should be supported to make informed decisions about their treatment and care (Ahmad et al, 2014). Preoperative and ongoing information concerning both the benefits and the challenges of early postoperative mobilisation, followed by support and bedside care from the nursing staff during mobilisation, is therefore mandatory. Previous research concerning recovery indicates that the patients' physical condition may be less affected if they receive supportive care even before the surgery, so-called pre-habilitation, followed by an ERAS programme. Receiving basic nursing care, including psychosocial support, the patients experienced not only physical comfort, but also a positive impact on their hope and life courage (Seibaek et al, 2013; 2018a). During this process the challenge for the nurse is to understand and respect the patient as person, along with her reasons, values and actions in that specific situation, while focusing on the biological aspects (Bach et al, 2016). With this in mind, the authors assume that the findings will bring about a greater professional focus on alleviating postoperative fatigue, along with more provision of information about the relationship between fatigue and mobilisation to patients and their families.

As illustrated in this study, DGCD Nursing can be used to investigate and measure postoperative mobilisation and helps to ensure a national standardisation of care for patients undergoing ovarian cancer surgery. By having a clinical database, with not only surgical, pathology and oncology data but also perioperative nursing data, researchers have access to data from the total clinical pathway and thus a unique opportunity to reflect on and examine specific subgroups.

High-quality health care requires high-quality reliable and detailed documentation of the nursing care provided. Thus, a patient diary was developed in which the degree of mobilisation was specified in each shift (day, evening, night). The detailed documentation created useful knowledge of when patients were actually mobilised. Others have tested a wristband or an actigraph (activity tracker) for achieving precise monitoring of postoperative mobilisation (Basse et al, 2005; Wolk et al, 2017). This would clearly have given a more precise measure and should be considered prospectively. Finally, when the purpose of a database is quality improvement, the registration must be systematised, which is a time-consuming process, especially because different centres may have different registration cultures.

It has been a challenge to adapt the data entry process, because the database is not yet integrated with the pre-existing electronic patient file. As a consequence, the data entry has caused an extra workload in documentation for the clinical nurses. Consequently, nursing resources have been required to get staff trained and new routines introduced to ensure data are entered, but up to now there has been a major commitment and surprisingly little resistance. The reason for this may be that local representatives were able to motivate the staff, so that the work was felt to be meaningful, and that the data were available in the department and gave a good overview of the outcomes during the perioperative period.

A DGCD report with national data and quality indicators is published once a year, but each surgical centre can have its own data as often as needed. The establishment of DGCD nurse working groups and the implementation of DGCD Nursing, connected to other clinical data in DGCD, has initiated nursing research in this important postoperative area, which is severely lacking in evidence-based guidelines (Seibæk et al, 2018b). Furthermore, it is possible to compare data from the four gynecological oncology centres and learn from the centres with the best compliance.

An important point is that a database will only improve postoperative mobilisation, if the information is discussed and acted upon. Data from DGCD Nursing have resulted in valuable scientific discussions and led to quality improvements in clinical practice, locally as well as nationwide. The national annual DGCD report illustrates such clinical progress, because one of the nursing indicators is the proportion of patients who are mobilised for at least 3 hours on the first postoperative day. Here a national increase from 47% to 57% has been achieved in the period from 2014 to 2019, with a local increase from 45% to 73% at one of the cancer centres.

During this quality improvement process we have realised that mobilisation is not as simple as it may sound. Rather, it represents a complex intervention that comprises dialogue with patients and family, and education of staff members concerning the importance of mobilisation, the best way to get out of and into bed, and so on. In Denmark, the nurses are responsible for daily postoperative mobilisation, and physiotherapists are required only for special needs. However, it is most likely that a multidisciplinary approach, including assistance from physiotherapists, would improve the extent and quality of postoperative mobilisation. In addition, patients should be offered a diet rich in protein to build up muscle capacity and reduce postoperative fatigue (Nelson et al, 2019), and last but not least the interior of the ward needs adaption in terms of comfortable chairs, available walkers and living rooms that makes it attractive to stay out of bed.

In addition, the latest data showed insufficient pain management on the first postoperative days, which has resulted in a new national clinical guideline for pain management for extensively operated and non-extensively operated patients. The guidelines are now under implementation and will be evaluated. Likewise, data on breakthrough pain compared with the given pain management may be used to optimise pain therapy by means of national clinical guidelines for pain management. Also, the relationship between mobilisation, pain management, nausea and comorbidities needs investigation.

A quality improvement of care is a continuous process. There must be focus and action on data as described in the quality improvement cycles—Plan-do-study-act (PDSA), a widely accepted method in healthcare improvement (Taylor et al, 2014). A prerequisite for any quality improvement is, however, that data are available and are being used actively, as in the case of mobilisation. As illustrated, the system does not yet have complete data from all patients, but we are in the process of improving the registration.

Conclusion

DGCD Nursing is a bank of knowledge that gives opportunities to optimise care and strengthen nursing research. The database allows for national discussions on fundamental nursing care by comparing the outcome and quality of nursing care over time and between gynecological centres. By comparing the nursing data with oncological, surgical and pathology data at DGCD, it is possible to elaborate further by analysing mobilisation in relation to cancer stage, comorbidity, treatment or, more relevantly, in relation to the extent of surgery. Furthermore, health data have been given increasing importance in health management, as described by Seibæk et al (2018b).

Only 47% of the patients fulfilled the criteria of mobilisation for at least 3 hours on the first postoperative day, but in total 52% of the patients had been walking in the hallway on the first postoperative day, even though they had not met the goals for 3 hours of mobilisation. Large differences were found between centres and between the COVA 1 and COVA 2 + 3 groups. The findings have initiated discussions on changes in postoperative care. However, type and length of sufficient mobilisation need further investigation.

The database has the potential to be a powerful tool for optimising care, but we are not there yet. Therefore, the first premise is to allocate time to document care and enter the data. This requires a management decision. Quality work costs time, but when it leads to improvements in patient care it is worth it.

As a final point, the ambitions for the future are not only to focus on how patients adhere to care plans but also to include data on patient experience of fundamental care, which is an overlooked aspect as described by Jeffs et al (2018). Relevant indicators must be selected in close collaboration with the patients and their relatives to improve the quality of the database in the future.

KEY POINTS

CPD reflective questions