Exploring outcomes in adults after major abdominal surgery - a mixed methods study.

Major Upper Abdominal Surgery (MUAS): Upper abdominal surgery (UAS) is defined as any surgical procedure performed to the abdomen through an incision that is superior to or extends superior to the level of the umbilicus. Upper abdominal surgery involves opening the abdomen in order for a surgeon to examine the contents and, where possible, remedy any pathology. Major upper abdominal surgery (MUAS) is defined as an upper abdominal procedure requiring general anaesthetic for more than one hour and a post-operative hospital length of stay of more than 24 hours. Common pathologies addressed via MUAS include viscus organ perforation, mesenteric ischemia, haemorrhage, cancer-related pathologies, and bowel obstructions. Patients/participants in the study will be under observation for a period of approximately 3 months. Recruitment Potential participants were identified by a physiotherapist who is a member of the treating team at Royal Perth Hospital (RPH) on Ward 6G (abdominal surgery ward) immediately following their surgery. A physiotherapist screened for patients meeting inclusion criteria daily and consulted with the medical team to ensure the potential participants were deemed capable of consent. Participants were approached by a physiotherapist to consent to participate in the study. Two forms of contact were obtained at this point in order to arrange for the three-month follow-up interview. Method Participants Once written informed consent of the participant was obtained, the physiotherapist completed the data collection form. Details on this form include two methods of contacting the patient, the patient’s Clinical Frailty Score (CFS) (this was already calculated as part of routine clinical care) and the Lawton’s instrumental activities of daily living (IADL) scale. Data collection forms were stored in a secure, locked cupboard within the Physiotherapy Department of RPH. At patient discharge the remaining details of the data collection form were completed (length of surgery, surgery procedure, complications during hospital stay, length of hospital stay) by a member of the study team. Participants were allocated a unique study number. The participant’s name and study number were recorded in a master log. The master log linking the participant details with the unique study number was securely stored at WA Health (W:\ Drive) and was not made available to Curtin University. Data was entered into REDCap (central database) in coded format by the (site) study coordinator. At three months post surgery, participants were contacted by telephone to arrange an appropriate date and time to have their follow up interview. At the scheduled follow-up interview via phone call, participants completed the post-operative questionnaires which collected the following data: CFS, MoCA Blind test, the Lawton’s IADLs, NPRS and FSS. Participants were also asked if they would like to participate in a seperate interview where a series of open-ended questions regarding their experience during recovery after MUAS will be asked. This interview occurred on a seperate date and time by another researcher and was aimed to take less than 30 minutes. The data gathered from the questionnaires were entered directly into the REDCap system. Interviews were recorded and transcribed verbatim. Data integrity and completeness was optimised by making a maximum of 2 follow-up phone calls to participants with missing or incomplete post-operative data. Remaining participants with missing or incomplete data were considered non-responders. Caregivers At the second interview involving open-ended questions, the study investigator asked if the primary caregiver of the participant would be willing to partake in the interview. Verbal consent was recorded at this time and a written consent form was mailed with a reply-paid envelope attached to the caregiver to obtain formal written consent. Only when written consent was obtained was information obtained be used. The interviewer asked caregivers about their experiences caring for someone who had undergone MUAS and any burden this placed upon them. Guiding principles for the interviews The interviews focused on broad categories, informed by the literature, and comprise open-ended questions exploring functional recovery following surgery. Activities were grouped as basic activities of daily living (e.g. eating, bathing dressing toileting, mobility and grooming) and activities that require more complex planning such as more complex activities such as meal preparation, domestic chores, paying bills and taking medication. Both perceived barriers and enablers to these tasks were sought. A discussion was facilitated on points of disagreement between the participants and caregiver, with clarification sought to understand the nature of these areas of discord in lived experiences. Responses from the participants and caregivers interview transcripts were entered into NVivo10 (QSR International Pty Ltd, version 10, 2012) to facilitate data organisation, coding, and management. Data collection and analyses will be performed concurrently to monitor the emergence of new themes. Inductive thematic analysis will be used to identify codes and themes that reflected participants’ perceptions and experiences. To enhance the trustworthiness of the analysis, individual data and interpretations will be independently reviewed by a second investigator experienced with thematic analysis. Medical notes information: In addition to these outcome measures, patients contact details were recorded at the time of consent. At patient discharge, the following data was collected from the medical records: indication for why the surgery is being carried out, pathologies associated with the surgery, emergency or elective status, pre-operative haemoglobin, pre-operative pH level, pre-operative base excess, pre-operative lactate level, Portsmouth-Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSOM) risk score, Australia and New Zealand Emergency Laparotomy Audit (ANZELA) risk score, surgical procedure name, length of surgery, complications during hospital stay and length of hospital stay. Participant participation: The process has been practiced and timed and is likely to take approximately 15 minutes for the questionnaires and less than 30 minutes for the patient interview or 15 minutes for the caregiver interview. This will be explained upfront to participants.