Enhanced recovery and nurse-led telephone follow-up post surgery

Jennie Burch
Aim: Nurse-led telephone follow-up was undertaken for patients after major colorectal surgery on the enhanced recovery programme following their discharge, with the aim of ensuring they were provided with adequate advice and information to enable their recovery at home. Methodology: A total of 200 patients were prospectively called within 4weeks of discharge home from hospital by the enhanced recovery nurse. Results: Diet was generally tolerated and mobility was continued at home. Many of the patients had seen a health professional since their discharge home for issues such as wound care or stoma review. Readmission rates were low and most concerns that patients reported were addressed during the telephone call. Discussion: It is reassuring that the majority of patients were coping well and many of the concerns reported were simply addressed over the telephone with advice. After the first 100 patients were telephoned, improvements were made to the discharge advice provided to the second 100 patients. The responses suggest that there were less community nurse visits in the second half of the patient cohort and this may be associated with changes made to discharge advice. Conclusion: Patients continue to recover well once discharged home following colorectal surgery on the enhanced recovery pathway. Nurse-led telephone follow-up may be a suitable method for short-term follow-up and, potentially, it is also suitable for long-term follow-up of select groups of cancer patients.
n

Abstract

Enhanced recovery
Enhanced recovery results in less surgical stress and a faster postoperative recovery. Enhanced recovery is designed to optimise patients before, during and after surgery (Lassen et al, 2009). Used originally in colorectal surgery, enhanced recovery is now used in many specialties, including urology (Gravante and Elmussareh, 2012). The enhanced recovery elements include early resumption of oral intake, early mobilisation postoperatively, smaller incisions which may result in better pain control, and earlier resumption of daily activities. Before discharge, patients must be able to tolerate oral intake, have passed flatus/bowel motion, have pain controlled on oral analgesia and be able to mobilise unaided as described by Fiore et al (2010). In the authors workplace, when patients are discharged they are provided with both verbal and written advice.This includes who to contact in the event of a problem and a 24-hour helpline in the form of a ward nurse contact out of hours and specialist nurses during working hours.The transition from hospital to home needs to be seamless to ensure continuity of care and a safe discharge.

Telephone follow-up in enhanced recovery

Follow-up of patients who were on the enhanced recovery pathway, however, is poorly documented and understood. In January 2011, nurse-led follow-up telephone calls were carried out by the author for patients undergoing colorectal surgery. The first 100 patients telephone calls were explored (Burch and Taylor, 2012) and some changes were made to the questions asked, as well as to the follow-up care. Telephone follow-up aims to ensure a safe transition from hospital to home and, additionally, to examine how patients recover at home. This was undertaken as a result of a focus group (Taylor and Burch, 2011) to try and further understand patients needs in the immediate period following discharge at home after their surgery and to ensure that their needs were met. Literature is non-specific about the ideal time to undertake telephone follow-up. Telephone calls were planned to be made within 4 weeks of surgery, ideally 2 weeks following discharge home from hospital. It is also important to consider follow-up in general to establish whether or not the outpatient clinic is the most appropriate setting for longterm follow-up of patients with colorectal cancer.

Key words: Enhanced recovery n Nurse-led telephone follow-up Postoperative n Colorectal surgery elephone follow-up undertaken by nurses in a variety of settings is likely to be beneficial to patients. This article focuses on follow-up for patients on the enhanced recovery pathway. Enhanced recovery is the use of a variety of research-based elements that improve recovery after surgery, in this instance, colorectal surgery. Use of these enhanced recovery elements results in a shorter length of stay and fewer complications, such as infections. A total of 200 patients from the authors workplace were contacted by telephone in the postoperative period and asked a set of questions. After the first 100 telephone calls, the responses were reviewed and some changes were made to both the questions asked and the discharge advice provided. The results of the telephone follow-ups are analysed and used to improve care.
Jennie Burch is Enhanced Recovery Nurse, St Marks Hospital, London Accepted for publication: August 2012

The review proforma

A selection of predetermined questions were asked of the patients, commencing with whether they had any concerns or anything they wanted to discuss. The first 100 questions were slightly different to the second 100surveys. The latter

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ENHANCED RECOVERY
surveys encompassed additional questions including whether the telephone call was valued by the patient and also recorded the intervention of the nurse making the call. A simple data collection tool was created focusing on several areas. The subjects chosen were considered to be important based on the results of the focus group, the published literature and the published articles on telephone follow-up. These topics were eating, wounds, pain, bowel function, energy levels, mobilising outside and driving. In addition, demographic data of the hospital number, date of discharge home and date of the telephone call were collected. Other community or hospital intervention was also assessed by asking whether any health professional had been seen and the reason for this contact. Dates for outpatient appointments were regularly requested by patients in the first telephone follow-up. This was addressed and resolved for the second 100 patients by the nurse checking for follow up dates in advance and making any necessary ????????????????? appointments when the telephone call was undertaken. Any telephone follow-up from the nurse was noted and patients were asked whether or not they felt the call to be useful. There was also space for general comments. Finally, the nurse graded the call to see if an adverse event was preventable as a result of the call.

% age of patients 80 70 60 50 40 30 20 10 0 contacted within 2 weeks acceptable dietary intake acceptable energy levels acceptable mobility

Figure 1. Results of the telephone follow-up

Method
The enhanced recovery nurse attempted to contact all patients by telephone. The calls were made before the surgical clinic appointment and following discharge home after major colorectal surgery. A pre-printed proforma was used to guide the questions, which included discussion on diet, mobility, pain, wound healing, bowel or stoma function and any contact with a health professional. Furthermore, questions were asked to establish how well patients were coping at home, to address any problems they reported and to assess and attempt to prevent future problems from occurring by providing advice on the telephone.

Results
Out of 237 consecutive patients, 200 were contacted by telephone between January 2011 and March 2012. There were 97 men and 103 women who were reached by telephone following their discharge home after their colorectal surgery. As slightly different data were collected for the first 100 and the second 100 patients, some results relate to only one of these two groups. The results showed that three quarters of patients were contacted within the first 2weeks (Figure 1), 39% of which were contacted in the first week following their discharge home. Half of the second 100 patients were untroubled by their wound (53%), pain (59%), bowels (48%) and raised no concerns when initially asked (54%). There were 102 concerns expressed by 94 respondents. Six patients had two problems and one person had three areas of concern that they wanted to discuss. The main areas of concern were wounds (8%), bowels (11%), stoma-related topic (5%), lack of energy (3%) and pain (3%). Over a quarter of the patients were not yet driving (27%) and about a fifth of the total were non-drivers (18%);

although 51% did not discuss driving. At the time of the follow-up call, 4% of patients were already driving. However, it should be noted that only 16% of the first 100 patients were questioned on this topic. More than half of the patients (58%) did not discuss the usefulness of the call; however, all patients who were asked (42%) considered the call to be useful or reassuring. A quarter of the patients (24%) had not seen a health professional. Review by a member of the multidisciplinary team was undertaken predominantly by a nurse (50%); a fifth saw the GP (18%) and 10% did not discuss this. A total of 17 patients (9%) saw two or more health professionals and 12 patients (6%) were readmitted to hospital; one for a planned urinary catheter removal. In the first half of the patients questioned, about half had seen a nurse (mainly community nurses) to review the wound or for a general review, but some also saw the stoma specialist nurse. In the second half of the patients questioned, the reason for the health professional contact for a third of patients (36%) was for a problem that needed assessing. Thirteen per cent were seen routinely for reassurance, seven (10%) were seen urgently and, for 10%, this was not discussed. The topics that were reviewed are displayed in Table 1. The intervention undertaken by the nurse as a result of making the call was only monitored for the latter 100patients; 76% of the calls were for advice or suggestions and 27% were to arrange a medical clinic follow-up appointment. Seventeen (9%) patients needed both a clinic appointment and advice. It was difficult to assess whether a problem had been prevented by the majority of the telephone calls and this was only examined in the last 100 patients. In most situations, the nurse assessed that problems were not prevented by the telephone calls (84%) but considered that they probably were for two patients and, possibly, for a further 11 patients. Data were missing for three patients.

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Table 1. Top 5 reasons to see a health professional

First 100 patients Percentage Second 100 patients Percentage

Wound Stoma Infection Bowels Pain

45 13 3 3 5

Wound Stoma Infection Bowels Pain

15 4 1 1 1

Discussion
This discussion will only focus on a few of the results. There are limited published data on follow-up and enhanced recovery; however, Wennstrm et al (2010) did provide some exploring patients experiences in the initial period at home. This group was reviewed through a questionnaire at 5weeks and 1 year after surgery. Patients reported pain levels to be low and paracetamol was the main analgesia used with effect. The same group also reported defecation problems for 29% of their respondents at one week, reducing to 4% after 4weeks (Wennstrm et al, 2010). Half of patients reported no problems with their bowels, and only 10% were concerned about their bowels. Wennstrm et al (2010) also reported on fatigue, which they found to be problematic, partially owing to difficulties in sleeping (59%). Sleep was not specifically discussed in this study and was rarely brought up as a problem; therefore, this cannot be commented on for the patient group followed up by this telephone follow-up. Only 3% of patients in this telephone follow-up group reported fatigue as a concern. However, Basse et al (2005) reported that patients on the enhanced recovery pathway are less troubled by fatigue than patients receiving conventional care. When broken down, data suggested that 57% of the first 100 patients had seen a nurse since discharge home and for the latter 100 patients, this had reduced to 40%. The number of GP reviews remained unchanged at 18%. These results could be explained by a number of possible factors. The calls were made a little earlier for the latter patient group so this may skew comparisons between the groups. For example, planned visits may not have occurred yet. However, it could also be that following the first 100 patients, care was reviewed and subsequent patients were given additional advice before discharge; this action may have reduced the need for an unplanned community nurse review. The most common reason to see a health professional in the telephone followup group was a wound. However, it should be noted that 41 were stoma closures and that it is not routine practice to close the wound at the skin surface, thus, a community nurse follow-up for a short period of wound dressings is expected. Harrison et al (2011) reported on a retrospective review of notes for over 6 months following discharge home. The greatest numbers of unmet needs were within the first week at home but some persisted for the whole review period. A quarter of their patients, had unplanned contact with a health professional in the first week following discharge home from hospital, but did not require readmission. Three quarters of

these contacts were via the telephone and two thirds were with a nurse. Similar problems were identified in the group reviewed in the telephone follow-up as those discussed in this article. However, data cannot be easily compared between these two groups because of the different times the information was gathered. It does, however, suggest that an early telephone follow-up might help reduce the number of unplanned health professional contacts. Topics of concern raised by patients during the telephone follow-up were similar to many of the reasons patients were reviewed by health professionals. Thus, it could be surmised that, if these issues were addressed sooner after discharge home, before these concerns became problems, it might reduce the need for community reviews. At times, the patients did not consider an issue to be something of a concern but the nurse making the telephone call considered it necessary to provide advice in order to potentially help prevent a problem. Eight patients had already been driving when telephoned. King et al (2008) compared colorectal patients having open and laparoscopic surgery. They report that patients having laparoscopic surgery resumed driving more quickly than patients having a laparotomy. None of their patients having an open operation at 12 days had resumed driving. In fact, comparing enhanced recovery for both open and laparoscopic surgical patients, it was found that the latter resumed activities of daily living earlier. The vast majority of patients in the telephone follow-up had laparoscopic surgery, which may help explain the lack of problems with mobility and how driving was resumed early in this patient group. However, King et al (2008) also reported on 12-month follow-up. They suggest there is still a disparity in recovery rates between patients having laparoscopic and open surgery. However, this review does not add any data related to longterm recovery. In their observational study, Mohn et al (2009) found that, at 1 week, more than half of their patients (57%) had resumed general activities. Although this was not specifically discussed during the conversations in this telephone followup study, it seemed that this was also similar for the patients followed up in this review as indicated by their mobility, driving and general activities undertaken. In general, nurse-led follow-up by telephone has been well received without any associated physical or psychological disadvantages in breast cancer follow-up for women without a high chance of recurrence. It also suited women who had long distances to travel to the hospital or patients with mobility problems and it certainly reduced clinic follow-ups (Beaver et al, 2009). Hospital follow-up replaced with nurseled telephone follow-up was also found to be acceptable by Kimman et al (2010). In Northern Ireland, patients undergoing selected minor emergency and elective surgery received a nurse-led telephone follow-up call at 6 weeks postoperatively. Patients found this telephone service to be acceptable and for the hospital, it was very cost effective, saving money on outpatient reviews (Gray et al, 2010). This echoes responses from the latter 100 patients telephoned during this review in relation to their satisfaction with telephone follow-up before clinic review.

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In Sweden, Strand et al (2011) examined nurse-led and surgical outpatient clinic follow-up for rectal cancer patients. They considered it was important to follow up patients to detect local or distant cancer recurrences and provide psychological support. They reported that, in their randomised trial, although the time spent in clinic with the nurse was slightly longer than with the surgeon, and although the nurse requested more blood tests, nurses were still slightly but non-significantly cheaper than the surgeon. Patients were happy with both services and there were no differences in local recurrences, of which none were detected. Jeyarajah et al (2010) also reported monetary savings with no oncological disadvantage to nurse-led follow-up. They even suggested that nurse-led follow-up might be superior to doctor-led follow-up with the former providing holistic care including symptom management. Any method to reduce costs within the NHS without compromising care is beneficial. It might be seen that for selected patients, followup by telephone might be useful to them.This would include patients who will not need to attend the hospital, those who live a long way away and patients with reduced mobility. For the hospital staff, it can ensure patients are safely reviewed while reducing the length of time they spend in clinic. The author was unable to prove definitive benefits of the telephone follow-up, but considered that for 13% of patients contacted in the latter group of 100 patients, it probably or possibly prevented problems. Early follow-up support is associated with a reduced number of hospital readmissions for patients with chronic obstructive pulmonary disease (COPD). In Lawlor et als (2009) study, this follow-up support included education, telephone support and a rapid access clinic. Thus, it can be surmised that a similar support system for postoperative colorectal patients might also lead to a reduced number of readmissions. As Mistiaen and Poot (2006) discussed, early complications can be recognised by telephone follow-up. However, they stated that published data cannot prove it is an effective intervention, although it is safe and appreciated by patients. Harrison et al (2011) reported that readmission is associated with older patients and increased initial length of stay in hospital. However, they found that a discharge call was associated with a reduced rate of readmissions within 30days of discharge home. The unplanned readmission rates for patients in the telephone follow-up group were 6%, with other published data reporting 11% (Wick et al, 2011). DAmore et al (2011) suggested that modest reductions in readmission rates are associated with telephone follow-upas they found readmission rates reduced from 10.8% to 9.5%.

In addition, the dietitians at the authors workplace are in the process of devising an information leaflet for gradual reintroduction of fibre back into the diet. This is a topic that patients often request advice on when in the outpatient clinic. It is possible that long-term follow-up for select patients, such as those with colorectal cancer, could be nurse-led by telephone and could include appropriate investigations. This will ensure continuity of care for patients with a cancer, who have a low risk of recurrence or metastases, and will result in fewer outpatient clinic appointments, which will save money and reduce the stress associated with multiple hospital visits for the patient. Obviously, this short-term follow-up cannot establish whether long-term telephone follow-up would be as efficacious. However, published data in other specialities found telephone calls to be a suitable method of follow-up (Beaver et al, 2009; Kimman et al, 2010).

Limitations
The limitations of the telephone follow-up review include missing data. This may reflect differences between patients that respond to or avoid certain questions. This is partially resolved by adding the two cohorts together giving a greater number of patients. In addition, 37 patients were not contacted on the telephone and these patients may have different needs to those that were. All patients did, however, receive clinic follow-up with the surgical team. It is still unknown whether the first 2weeks are the ideal time to contact patients by telephone. However, it is surmised that problems can, therefore, be identified earlier and advice or interventions can be implemented sooner. This may prevent problems from occurring or worsening and reduce the number of community health professional contacts.

Conclusion
It can be seen that patients generally find telephone followup suitable to meet needs such as advice giving and to provide reassurance on issues of concern. The best time to undertake these calls might be within the first week following discharge home to ensure that patients are generally coping. It is potentially possible that complications might be prevented but this review does not easily allow this to be examined. It is reassuring to see that infection rates are low and half of the patients are unconcerned about their wound, pain and bowels. All the patients that were asked found the follow-up call to be useful, confirming published data related to follow-up calls. Furthermore, nurse-led telephone follow-up in conjunction with the necessary scans might be a suitable solution to reduce clinic visits in BJN the long term for colorectal cancer patients. Conflict of interest: none
Basse L, Jakobsen DH, Bardram L et al (2005) Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Ann Surg 241(3): 416-23 Beaver K, Tysver-Robinson D, Campbell M et al (2009) Comparing hospital and telephone follow-up after treatment for breast cancer: randomised equivalence trial. BMJ 338: a3147 Burch J, Taylor C (2012) Patients need for nursing telephone follow-up after enhanced recovery. Gastrointestinal Nursing 10(4): 51-58 DAmore J, Murray J, Powers H, Johnson C (2011) Does telephone followup predict patient satisfaction and readmission? Popul Health Manag 14(5): 249-55

Implications for future practice

The findings from these follow-up calls have suggested that further changes are required to the existing written discharge paperwork. Patients do receive discharge information in the pre-assessment clinic as part of their written information; however, in an attempt to further reduce problems at home, this advice has been transcribed to a separate sheet for patients who no longer have the original leaflet. These are given out before discharge home and they include contact numbers in case of problems.

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Fiore JF Jr, Browning L, Bialocerkowski A, Gruen RL, Faragher IG, Denehy L (2010) Hospital discharge criteria following colorectal surgery: a systematic review. Colorectal Dis 14(3): 270-81 Gravante G, Elmussareh M (2012) Enhanced recovery for non-colorectal surgery. World J Gastroenterol 18(3): 205-11 Gray RT, Sut MK, Badger SA, Harvey CF (2010) Post-operative telephone review is cost-effective and acceptable to patients. Ulster Med J 79(2): 76-9 Harrison JD, Young JM, Auld S, Masya L, Solomon MJ, Butow PN (2011) Quantifying postdischarge unmet supportive care needs of people with colorectal cancer: a clinical audit. Colorectal Dis 13(12): 1400-6 Harrison PL, Hara PA, Pope JE, Young MC, Rula EY (2011) The impact of postdischarge telephonic follow-up on hospital readmissions. Popul Health Manag 14(1): 27-32. Epub 2010 Jeyarajah S, Adams KJ, Higgins L, Ryan S, Leather AJ, Papagrigoriadis S (2010) Prospective evaluation of a colorectal cancer nurse follow-up clinic.Colorectal Dis 13(1): 31-8 Kimman ML, Bloebaum MM, Dirksen CD, Houben RM, Lambin P, Boersma LJ (2010) Patient satisfaction with nurse-led telephone follow-up after curative treatment for breast cancer. BMC Cancer 10: 174 King PM, Blazeby JM, Ewings P, Kennedy RH (2008) Detailed evaluation of functional recovery following laparoscopic or open surgery for colorectal cancer within an enhanced recovery programme. Int J Colorectal Dis 23(8): 795-800. Epub Lassen K, Soop M, Nygren J et al (2009) Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 144(10):961-9 Lawlor M, Kealy S, Agnew M et al (2009) Early discharge care with ongoing follow-up support may reduce hospital readmissions in COPD. Int J Chron Obstruct Pulmon Dis 4: 55-60. Epub Mistiaen P, Poot E (2006) Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. Cochrane Database Syst Rev (4): CD004510 Mohn AC, Bernardshaw SV, Ristesund SM, Hovde Hansen PE, Rkke O (2009) Enhanced recovery after colorectal surgery. Results from a prospective observational two-centre study. Scand J Surg 98(3): 155-9 Strand E, Nygren I, Bergkvist L, Smedh K (2011) Nurse or surgeon follow-up after rectal cancer: a randomized trial. Colorectal Dis 13(9): 999-1003. Epub 2010 Taylor C, Burch J (2011) Feedback on an enhanced recovery programme for colorectal surgery. Br J Nurs 20(5): 286-90 Wennstrm B, Stomberg MW, Modin M, Skullman S (2010) Patient symptoms after colonic surgery in the era of enhanced recovery--a long-term followup. J Clin Nurs 19(5-6): 666-72 Wick EC, Shore AD, Hirose K et al (2011) Readmission rates and cost following colorectal surgery. Dis Colon Rectum 54(12): 1475-9

KeY POiNtS
n Enhanced

recovery can result in faster recovery after surgery and fewer complications follow-up is a good short-term method to review patients after discharge home and may also be suitable as a long-term method in this study were found to be generally coping well at home after surgery and advice on the telephone was able to address most concerns at home after colorectal surgery on the enhanced recovery pathways is good with few readmissions to hospital

n Telephone

n Patients

n Recovery

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