This study documents current post-operative physiotherapy management of patients following UAS.
Despite not seeing patients pre-operatively, physiotherapists currently undertake post-operative screening utilising a variety of assessment tools, and treat patients with a combination of early mobilisation and respiratory interventions post-operatively. The mean age of participants was 35 years, with the majority of respondents having practiced physiotherapy for greater than 10 years, with more than 5 years’ experience in general surgical wards. This provides confidence that the received responses are from highly experienced physiotherapists with considerable knowledge and experience within UAS practice.
Screening patients for pre-existing and post-operative risk factors prior to commencing treatment
Pre-existing risk factor screening
This study identified that the majority of physiotherapists surveyed do not currently perform routine pre-operative screening or interventions on patients prior to their UAS. Early reports from the LIPSMAck POP trial [14] suggest that pre-operative interventions have the potential to positively influence patient outcomes post-operatively. This indicates that a significant change in practice will need to be undertaken across Australia in order to ensure the key research findings are translated into practice. Improved access to patients pre-operatively will also provide opportunities for pre-operative screening. This encourages the identification of high-risk patients, allowing them to be prioritised post-operatively, ensuring the best allocation of physiotherapy resources and a potential to further reduce PPC rates.
Despite not pre-operatively screening patients, Australian physiotherapists are assessing patients early post-operatively for pre-existing risk factors for PPC development. Physiotherapists used advanced age, respiratory and cardiac co-morbidities, and smoking history as primary pre-existing parameters to screen whether their patient was at high risk of a PPC, with the majority of respondents suggesting that past respiratory history was a factor related to PPCs. These factors are reflective of those described by Haines et al. [10] and Scholes et al. [15], and assist clinicians’ ability to screen for high-priority patients that are at greater risk of PPC development in the post-operative period. This is important to ensure physiotherapy interventions are allocated and targeted to those who are most likely to benefit [15].
Coincidently, the risk factors commonly identified by clinicians equate to an ASA score greater than two [15]. Despite this, use of the ASA scoring system as a screening tool was not common amongst respondents. This could indicate a lack of awareness of the ASA scoring system as a well-documented, validated assessment and predictive tool for PPCs, or that physiotherapists do not regard it as relevant to their practice. Additionally, clinicians failed to comment on other factors used to screen patients, such as pre-operative exercise capacity and pre-existing neurological conditions. This is despite them being identified as having an impact on respiratory function and patient outcomes post-operatively [15].
Post-operative risk factor screening
The development of diagnostic criteria specific to UAS (such as those of Scholes et al. [15]) assists physiotherapists in the identification of variables that place patients at higher risk of PPC development post-operatively. Clinicians did not identify ‘high temperature’ or ‘sputum classification’ as frequently used screening tools, despite being recommended measures to identify infection post-operatively [15]. Despite its potential to reduce mobility, ‘non-compliance’ did not prove to be an indicator used by physiotherapists to recognise someone at high-risk of complications. Likewise, clinicians did not recognise ‘duration of surgery and anaesthesia’ as influences to PPC development. Nevertheless, physiotherapists identified ‘chest x-ray’, ‘auscultation’ and ‘decreased SpO2’ as common screening tools which reflect those mentioned by Scholes et al. [15].
Various diverse screening tools are being used throughout clinical practice to identify a patient at risk of developing a PPC. This calls for additional work to form an agreed consensus on the key assessment tools available to clinicians within the UAS patient population. This is likely to improve physiotherapists’ efficiency at screening and prioritising treatment to high-risk patients, reducing the severity and impact of PPCs, and allowing for the appropriate allocation of resources [15].
Respiratory intervention
Results from this survey suggest that physiotherapists are currently implementing respiratory interventions into their practice; more than half combining chest treatments and mobilisation as their standard practice. This is despite recent evidence supporting the use of mobilisation as a standalone treatment, concluding that the addition of DBEx and coughing provides no additional benefit [9].
The majority of respondents specified an aim to perform routine chest treatment on day one, with results indicating that physiotherapists universally prescribed DBEx and supported coughs. It is evident that positioning and TEEs are also favourable interventions, with over half of clinicians consistently implementing them. These results are reflective of Hanekom et al. [1] who recommended that respiratory interventions are warranted for patients post-UAS. These recommendations are purely based on clinical experience, as the current literature remains somewhat inconclusive. A further study found adherence to mobilisation and chest therapy was effective at reducing the incidence of atelectasis to 0% [4], but continued research is necessary to validate this claim.
Despite conflicting evidence, clinical experience may be the primary driver behind why physiotherapists continue to use chest treatment as standard practice and not as per required. Although clinical experience is not necessarily unreliable, it needs to be acknowledged as a potential factor in resistance to change and should be integrated with evidence from high quality studies to promote best practice for patients undergoing UAS.
Further research to clarify the role of standard respiratory interventions and translation of evidence-based practice within UAS has the potential to encourage physiotherapists to agree and consistently implement interventions that are validated and most beneficial to this patient population, whilst best utilising valuable physiotherapy resources. That being said, there was no indication throughout this study that physiotherapists were using respiratory techniques as a standalone treatment, as mobilisation was universally accepted as the optimal choice of treatment in this patient population.
Mobilisation
Hanekom et al. [1] reported early mobilisation to be a beneficial intervention for patients following UAS. This is further validated by Silva and colleagues [9] emphasising the benefits of early mobilisation away from the bedside when performed at sufficient intensities, whilst Haines et al. [10] established that delaying early mobilisation caused an increase in PPCs.
This study demonstrated a positive link between a majority of milestones clinicians expected patients to achieve post-operatively and the physiotherapy treatment actually delivered over consecutive days. Following day one, physiotherapists indicated that when their patients were medically stable, providing no limitations to physiotherapy management, they mobilised their patients away from the bedside. This is in line with physiotherapists’ expectations and primary focus that from day one onwards, all patients should be mobilising away from the bedside. These findings are similar to the pre-existing literature of Silva et al. [9] and Haines et al. [10] concluding that the implementation of mobilisation alone provided an adequate reduction in PPC rates. This suggests recent literature is being translated into current practice as Australian physiotherapists demonstrated an awareness of mobilising away from the bedside as an effective treatment post-operatively.
Stair climbing was not necessarily being prescribed as an intervention despite physiotherapists expecting patients to achieve it as a milestone. Respondents also indicated that cycle pedals are an uncommon intervention post-operatively despite Bhatt and colleagues [6] determining that early aerobic exercise through the use of cycle pedals halved the rate of respiratory infection and length of stay. This was, however, a small single-centre study that needs to be validated prior to translation into standard physiotherapy practice in upper abdominal surgery patients.
Overall, this study’s results suggest that physiotherapists are implementing early mobilisation and that it reflects recent literature within this patient population. Despite all physiotherapists identifying early mobilisation as the primary focus of treatment, a small percentage of physiotherapists acknowledged that it was not implemented on every occasion, suggesting that barriers to ideal treatment exist.
Barriers to treatment
Findings of this survey indicate that a variety of patient-dependent factors limit the commencement of physiotherapy treatment post-operatively. ‘Pain’ was the most prominent barrier reported, followed by ‘fatigue’ and ‘patient readiness’, all having the capacity to reduce mobility and hence increasing the risk of a PPC. Similarly, ‘non-compliance’ was an evident barrier to treatment despite not previously being recognised as a post-operative risk factor for PPC development and delayed mobility.
The barriers identified by physiotherapists in this study are reflective of those previously reported by Browning et al. [16], in particular ‘availability of staff’ and ‘assistance to mobilise’ were both found to affect the amount of ‘uptime’ patients receive post-operatively following UAS. ‘Patient condition’ and ‘patient compliance’ were also reported as factors impacting the commencement and frequency of treatment, especially mobility, in this study.
Strong, validated evidence could give physiotherapists the opportunity to become more autonomous in the prescription of interventions post-operatively, assisting them to overcome external barriers such as ‘physician instruction’. There could be additional value in finding ways to support knowledge translation beyond physiotherapy cohorts and outwards to the wider field of the multi-disciplinary team to enhance physiotherapy management of patients post-UAS.
Barriers to treatment was not a focus of this study, therefore as a consequence of these incidental findings, it is unclear as to whether barriers such as pain and fatigue limit the efficiency and desired outcome of physiotherapy interventions or if it prevents the commencement of treatment completely. These findings provide avenue for further investigation into the impact of these barriers on commencing treatment and the strategies physiotherapists use to overcome them, creating the foundation of future studies to discover ways to facilitate treatment.
Limitations
Despite piloting, the length of the survey was the primary limitation of this study, with only two-thirds of those commencing survey completing (38/57). Not all questions were universally answered, with some respondents commenting that various questions were not applicable and/or repetitive, despite such issues not being apparent with piloting. Additionally, respondents may have perceived the questions differently to what was intended, again despite face validity being a focus of the piloting. Not all question responses were mandated in order to proceed through the survey, possibly accounting for varied response rates per question; providing opportunities for ‘not applicable’ answer options may be appropriate for future projects. The survey was anonymous potentially allowing multiple people to contribute from one facility. Likewise, the rotational nature of physiotherapy jobs may have hindered the response rate. Nevertheless, reminder emails worked to increase response rates to an adequate number with desirable representation Australia wide. Useful information was obtained throughout the survey making it a reflective summary of current practice in the UAS population.
Recommendations for future work
Continued research is necessary to determine whether the addition of respiratory interventions to early mobilisation confers any additional benefit to mobilisation alone in preventing PPCs. Further discussion is necessary to establish whether formalising an agreed minimal dataset of core screening tools could be a potential solution for prioritising resources. Also, further investigation into the barriers to treatment need to be completed. This has the potential to reduce PPC rates, improve patient-related outcomes and encourage the appropriate use of physiotherapy resources.