Dalhousie University, Canada
Abstract
Increased pressures from multiple sources are leading to earlier patient discharge following surgery. Our objective was to test the feasibility of self-care web applications to inform women if, when, and where to seek help for symptoms after hysterectomy. We asked 31 women recovering at home after hysterectomy
Corresponding author:
Norman J MacDonald, Dalhousie University, 5850/5890 University Avenue, Halifax, NS B3K 6R8, Canada.
Email: [email protected] 647759JHI0010.1177/1460458216647759Health Informatics JournalGilmour et al.
research-article2016
Article
280 Health Informatics Journal 23(4) at two centers to sign into a website on a schedule. For each session, the website informed them about normal postoperative symptoms and prompted them to complete an interactive symptom questionnaire that provided detailed information on flagged responses. We interviewed eight women who experienced an adverse event. Six of these women had used the web application regularly, each indicating they used the information to guide them in seeking care for their complications. These data support that self-care applications may empower patients to manage their own care and present to appropriate health care providers and venues when they experience abnormal symptoms.
Keywords
education of patients, hysterectomy, patient safety, postoperative complications, web-based applications
Introduction
Hysterectomy is one of the most common surgical procedures performed on women in developed countries.1 There are 650,000–700,000 hysterectomies performed in Canada and the United States each year.2,3 Hysterectomy can lead to major peri-operative morbidity, including urinary tract and bowel injury, infection, hemorrhage, thromboembolism, and death.4 A prospective clinical audit of 1330 hysterectomies with a form specifically designed to record complications from hysterectomy demonstrated that 26.4, 23.9, and 17.0 percent of patients with abdominal, laparoscopic, and vagi- nal hysterectomies, respectively, experienced adverse events.5 A larger prospective cohort study with detailed questionnaires on 5279 hysterectomies demonstrated complication rates of 19.2, 15.4, and 11.7 percent in patients with abdominal, laparoscopic, and vaginal hysterectomies, respectively.6 Because adverse events following hysterectomy can be common and some of the adverse events can be serious, we need excellent pre-surgical/in hospital patient education by health professionals and reliable methods of providing accurate information to women and their families once they return home.
Adverse events and their consequences after elective hysterectomy can be significant and costly for patients, surgeons, the health care system, and society. Diagnosing and managing serious adverse events often requires multiple outpatient and inpatient laboratory, imaging, medical, and surgical resources.3 These investigations and procedures are uncomfortable, associated with their own risks and side effects, and costly.3 Major adverse events after hysterectomy can negatively and permanently impact an individual’s length and quality of life. Even non-serious adverse events, such as urinary tract, wound, or pelvic infections, can cause discomfort, stress, and anxiety for patients. These less severe adverse events may also be inefficiently and ineffectively managed if patients present to inappropriate health care venues for evaluation and treatment. A recent retro- spective chart review of laparoscopic hysterectomy and same-day discharge found that the most common reasons for visiting the emergency department within 48 h were pain and nausea.7 The study concluded that detailed postoperative instructions may have prevented many of these early postoperative visits.7
Gap in recovery information provided to patients
At present, informing and educating patients about their surgery and postoperative recovery con- sists of preoperative visits with their surgeons and nurses along with verbal and written instructions provided at discharge. At most Canadian hospitals, preoperative teaching is done by a registered nurse usually during a pre-admission visit a week or more before scheduled surgery. The majority of postoperative teaching in hospital is provided by nurses and is usually done as the patient is
Gilmour et al. 281 being discharged from hospital. Although this is the standard of care for Canadian postoperative patients, it is sometimes ineffective as women are often experiencing pain, and may be under the influence of anesthetic and narcotics, as well as feeling anxious or rushed about their discharge.
Increased emphasis on cost-savings has reduced the amount of time spent in preoperative sessions with nurses.8 About one-third of 102 hysterectomy patients surveyed felt that they had been pro- vided insufficient information.9
Patients are increasingly supplementing verbal and written information with online resources.
The use of Internet-based self-management tools has improved the health status of patients with chronic disease when compared to standard non-Internet self-management programs.10 Online tools have been developed to educate women about family planning11 and to help quit smoking during pregnancy.12 Online patient portals developed by hospitals to manage chronic diseases such as diabetes in children have been studied and found to have potential.13 Electronic support tools available for aiding in recovery from surgery include the website Hystersisters.com, which has information that is not created by health care professionals but is instead centered on peer-support.
In a study of 137 women who used the Hystersisters.com website, women found the information about recovery helpful; however, 39 percent found some aspect (often negative postings from some members) of the website not helpful in their recovery.14 One study demonstrated that patients who used Hystersisters.com valued some information more if it was provided by a member perceived as knowledgeable.15 A meta-analysis of 191 studies found that increased patient education shortens length of stay in hospital by an average of 11.5 percent and has beneficial effects for recovery, pain, and psychological distress.16 A recent randomized controlled trial has shown that orthopedic patients who were given supplemental online information from authoritative sources to research on their own prior to their surgery modified their decision on spinal versus general anesthesia.17 All of these studies suggest there may be a gap in the knowledge that patients have about their surgery and that it may be possible to help fill that gap with authoritative and reliable online or mobile app resources. With adverse events after hysterectomy occurring at home being relatively common and potentially serious, we also need to ensure these resources provide accurate, timely, and reassuring information tailored to their concerning symptoms and type of surgery.
Efficient navigation of a complex health care system
The Canadian health care system—with its many types of care providers and multiple access points for care—may leave patients uncertain as to where they should go when they experience symptoms of adverse events at home after surgery.18 Early presentation, diagnosis, and treatment of evolving adverse events are critical steps in limiting their short-term and long-term sequelae. Early diagno- sis and treatment of an adverse event also has a positive effect on the health care system, as early intervention can often prevent a hospital admission. Currently, no formal screening mechanisms are in place to survey patients quickly, routinely, and comprehensively for specific symptoms of adverse events after hysterectomy and to advise them when and where to go for appropriate care.
Proposal to fill information gaps
In response to all of these information needs and health systems gaps, we created the SAFER (Studying Adverse Events From Elective Surgery Research) web application.19 The application consisted of surgery-specific, interactive applications designed to inform and empower patients to better care for themselves after surgery. We conducted a small study on 31 abdominal hysterec- tomy patients to see if they would access the self-care application from home after surgery and use the information to assist them in caring for themselves. Here, we report on 11 of the 31
282 Health Informatics Journal 23(4) women who suffered adverse events during the study and how using the application impacted their care and outcomes.