Application of a standardized early activity program on enhanced recovery after surgery in patients after surgery for pulmonary nodules

Abstract

BACKGROUND:

Early postoperative activity, an important part of enhanced recovery after surgery (ERAS) in clinical practice, is considered to be a significant component of postoperative quality care.

OBJECTIVE:

To evaluate the effect of a standardized early activity program on ERAS in patients after surgery for pulmonary nodules.

METHODS:

A total of 100 patients with pulmonary nodules who underwent a single-port thoracoscopic segmental resection or a wedge resection of the lung were selected for the present study. These patients were divided into a control group ( $n=$ 50) and an intervention group ( $n=$ 50) by a digital random method. The patients in the control group received routine perioperative nursing intervention for thoracic surgery due to lung cancer, and those in the intervention group received an intervention using a standardized early activity program along with routine nursing care. The evaluation indexes in both groups included postoperative indwelling time of the closed chest drainage tube, the time to the first off-bed activity after surgery, the incidence of postoperative pulmonary complications, the length of postoperative hospital stay, and patient satisfaction.

RESULTS:

The postoperative indwelling time of the closed chest drainage tube and the time to the first off-bed activity in the intervention group were less than in the control group. The length of the postoperative hospital stay in the intervention group was shorter than in the control group, and the patient satisfaction in the intervention group was higher than in the control group. The difference for these evaluation indexes were statistically significant ( $P<$ 0.05). The number of cases of postoperative complications was four and eight in the intervention group and the control group, respectively, and the difference was not statistically significant ( $P>$ 0.05).

CONCLUSION:

A standardized early activity program is a safe and effective nursing measure for ERAS for patients after surgery for pulmonary nodules, which can promote earlier off-bed activity, shorten the postoperative indwelling time of the closed chest drainage tube, shorten the postoperative hospital stay, improve patient satisfaction, and promote rapid recovery.

Keywords

Early activity program pulmonary nodules postoperative enhanced recovery after surgery single-port thoracoscopy

1. Introduction

The concept of fast-track surgery has gradually evolved into the concept of enhanced recovery after surgery (ERAS) with the recent developments in medical science, and the emergence of minimally invasive technology has promoted the growth and realization of the ERAS concept [1, 2, 3]. Early postoperative activity, an important part of ERAS in clinical practice, is considered to be a significant component of postoperative quality care [4]. Studies have reported [5, 6] that early off-bed activity of patients after surgery can reduce the length of the postoperative hospital stay, reduce hospitalization costs, prevent venous thrombosis of the lower limbs, benefit patients’ physical and mental health, and accelerate recovery. However, many patients refuse to get out of bed early due to psychological changes, pain, and other post-surgical factors, thus slowing their recovery. Therefore, it is particularly important for medical staff (especially the nursing care team) to carry out activity intervention for postoperative patients. There are studies on early postoperative activity in lung cancer patients who receive thoracoscopic surgery, but there are no specific standards for the time, form, and frequency of the early postoperative activity, and there are few reports on the specific scheme of the early activity in clinical practice. In addition, the lack of awareness of early activity and how it affects ERAS by both doctors and patients results in its lack of or inconsistent use. Therefore, it is necessary to develop a safe and effective early activity program to guide the postoperative activity of patients after surgery for pulmonary nodules to improve their clinical outcome and prognosis. Liu et al. [7] conducted a quantitative activity program in gastric cancer patients after surgery to guide their postoperative activities based on the ERAS concept and achieved good results. Therefore, this study investigates the effect of a standardized early activity program on the ERAS in patients after surgery for pulmonary nodules.

2. Materials and methods

2.1 Subjects

A total of 100 patients with pulmonary nodules, treated from September 2020 to April 2021, were selected as the subjects using the convenience sampling method. These patients were divided into the control group ( $n=$ 50) and the experimental group ( $n=$ 50) by a digital random method. The surgeries and post-operative nursing care were completed by the same group of surgeons and the same group of nurses, respectively, for the patients in the two groups. The patients in the two groups were compared for baseline data including gender, age, occupation, education level, marital status, proposed surgical method, and proposed surgical site; the differences were not statistically significant ( $P>$ 0.05) and were comparable. This study was conducted in accordance with the Ceclaration of Helsinki and approved by the Ethics Committee of Chongqing University Cancer Hospital. Written informed consent was obtained from all participants.

1) Inclusion criteria:

⟀ Patients with pulmonary nodules and surgical indications;

⟁ The surgical method was thoracoscopic segmental resection or wedge resection of the lung;

⟂ Age: $\geqslant$ 18 and $<$ 65 years old;

⟃ Patients who quit smoking for more than one week before surgery;

⟄ Patients who understood and agreed to this study and who could take care of themselves, comprehend information, and communicate normally before surgery; and

⟅ Patients who did not receive neoadjuvant chemotherapy before surgery.

2) Exclusion criteria:

⟀ Patients with a movement disorder before surgery, or patients with complications of serious blood diseases, organ dysfunction of the heart, lung, liver, or kidney, or muscle weakness;

⟁ Patients who were transferred to the ICU for treatment due to intraoperative or postoperative complications; and

⟂ Patients who changed surgical methods to lobectomy or pneumonectomy.

2.2 Specific measures

2.2.1 Control group

Based on the ERAS concept, patients underwent routine perioperative nursing intervention of thoracoscopic lobectomy according to the nursing system and procedures of our department, with the following specific measures:

•
(1) Education on admission: Personnel introductions (i.e., the attending physician and nurse, the section head, and the nursing supervisor); introduction of the ward environment and the ward management system. (2) Evaluation on admission: Pain assessment; psychological assessment; fall/falling-down-from-bed risk assessment; nutritional risk assessment; and other related knowledge education. (3) The doctor informed patients of the harm of smoking to their disease and instructed them to quit. (4) The primary nurse delivered the health education contents about the preoperative examination precautions and objectives as well as the preoperative and postoperative coordination points through the medical wisdom system to establish a good nurse-patient relationship and improve patient compliance.
•
Lung rehabilitation exercises: (1) The doctor introduced the knowledge and precautions of surgery and explained the possible respiratory complications caused by general anesthesia; therefore, patients were made aware of the importance and necessity of pulmonary rehabilitation exercises and would have less anxiety. (2) The doctor instructed the patients to start pulmonary function rehabilitation training before surgery (i.e., respiratory function training exercises, specifically pursed-lips breathing, shoulder and arm movement, chest expansion, abdominal respiration, and effective cough training) and informed and emphasized the benefits and methods of early postoperative activity. Patients were directed to follow the step-by-step principle during training. In case of any uncomfortable reaction, such as dizziness or chest tightness, they were told to suspend training immediately and report to the supervising physician right away.
•
Early-stage eating: Patients could drink a small amount of water 4 h after awakening from general anesthesia, and they could eat light and easy-to-digest food 6 h after surgery if no choking, vomiting, or other uncomfortable symptoms were present.
•
Analgesic management: A postoperative analgesic pump was used, and oral analgesics were prophylactically administered to patients (i.e., a dexketoprofen capsule, 25 mg, three times a day, by mouth, within 3 days after the surgery). Meanwhile, the pain site, nature, degree, and duration in patients were consistently evaluated, and the patients were encouraged to express their feelings to participate in their pain management. Per our protocols, the education of pain-related knowledge was completed, the patients and their families were taught to correctly score postoperative pain using the NRS [8], and a 5-mg dezocine injection was given intramuscularly when the patient’s postoperative NRS score was higher than three points. The specific assessment frequency and record was in accordance with the pain management regulations of our hospital.
•
Keeping the respiratory tract unobstructed: The patients were placed in the supine position with their head tilted to one side before awakening from general anesthesia to ensure that the respiratory tract remained unobstructed. After they were awake and their vital signs were stable, the patients were assisted to a semireclining position. After aerosol inhalation (four times/day as directed), the patients were instructed to cough effectively. In addition, the patients were administered 24-hour continuous oxygen and ECG monitoring. The patients were directed to do activities with the help of family members and under the supervision of the primary nurses. The patients and their family members were also given the instructions on diet, medication, and activity, while the time and frequency of activity were determined based on the patient’s conditions to ensure patient safety. All activities were closely monitored.
•
Tube protection: Each tube was properly fixed, and the closed chest drainage bottle was approximately 60–100 cm lower than the chest outlet. Each drainage tube was kept unobstructed and prevented from distortion, folding, or compression. The importance and necessity of tube indwelling were explained to the patients and their families, and cooperation was obtained from all parties. The closed chest drainage bottle was replaced daily in a strict aseptic manner.
•
Education at discharge: The patients were instructed to alternate work with rest, keep up their respiratory function exercises and the functional exercises of the affected upper limb, and gradually perform an increasing number of daily living activities without assistance. They were also provided with instructions on their diet and medication, were asked to follow the doctor’s advice, and were directed to receive regular follow-up examinations.

2.2.2 Intervention group

The patients in the intervention group received the same treatment and nursing care as the patients in the control group did; however, they also received early activity program intervention, with the following specifics:

•
Development of the early activity program: After an extensive overview of local and global literature, we invited the medical and nursing experts from the department of thoracic surgery to discuss the whole study protocol according to the characteristics and actual situation of the patients with this disease in our department based on the ERAS concept. Then, the preliminary experiment was performed to identify any issues, after which the early activity program was developed for patients who underwent surgery for pulmonary nodules through repeated consulting, discussion, revision, and improvement.
•
The early activity program was then performed in clinical practice, with the following specific measures:

–
Stage I (day of surgery)

*
Bed activities: Before awakening in the ward after surgery, the head of the patient was tilted to one side to keep the respiratory tract unobstructed. After awakening (approximately 4–6 h postoperative), the patient was placed in a semireclining position, and the head of the bed was raised to 30 ${}^{\circ}$ –45 ${}^{\circ}$ when the vital signs were stable. The primary nurse and the project team members began to guide the patient to do early bed activities, including respiratory function rehabilitation training and limb function rehabilitation training, as follows: ⟀ Abdominal respiration: relax the shoulders, put the left hand on the chest and the right hand on the abdomen; make the abdomen bulge during inhalation through the nose; keep the abdominal muscles tight, breath out through pursed-lips, and feel the abdominals contract; complete this training five to seven times a day according to the individual’s body tolerance, 5–15 min each time. ⟁ Pursed-lip breathing: inhale through the nose, and then slowly exhale by pursing lips (like whistling) while contracting the abdomen, with an inhalation/exhalation time ratio of 1:2 or 1:3, at a frequency of seven to eight times a day, 10–15 min each time; the patient should not experience any dizziness during this exercise. ⟂ Assistance in sputum excretion: assist the patient to a semireclining position, knock on the patient’s back for 2–3 min, and instruct the patient to lean the upper body slightly forward. The patient should press on the incision with or without the help of the nurse, breathe deeply and slowly two to three times, and then take a deep breath and hold it for a few seconds. Next, the patient should make short and powerful coughs two to three times to promote drainage and sputum excretion; this exercise should be performed for 5–10 min each time. ⟃ Limb function training: ankle pump and straight leg raise, flexion, and extension every 2–3 h, 5–10 min each time. ⟄ General movement in bed: teach patients to independently turn over in the bed with a multi-functional rehabilitation belt [9], change the appropriate position, and complete muscle strength training of the affected limb. Ensure that the range of activity is not too large or too fast to prevent severe pain caused by incision pulling, and observe whether the patient has any adverse reactions.
*
Bedside sitting: If the patient had no obvious discomforts at 6–12 h after surgery, the primary nurse, the project team members, and the family members assisted the patient to sit up for 1 min; if there were no discomfort symptoms while sitting, such as dizziness and palpitations, they assisted the patient to brush their teeth and wash their face in bed. They also encouraged the patient to try bedside sitting for 5 min (legs sagging) and bedside standing for 1 min if there was no obvious discomfort.
*
Off-bed activity: If the following conditions were met within 24 h after surgery, the patient communicated with the attending physician for a joint evaluation and was permitted to do off-bed activity (pending the evaluation results) [10]: ⟀ Stable vital signs, and no anesthesia reactions, such as dizziness and vomiting; ⟁ Properly fixed tube, unobstructed drainage, and no effusion of blood at the incision site; ⟂ Pain score $<$ 4 points; ⟃ Medication: no sedatives or hypnotics used; ⟄ Muscle strength: muscle strength $\geqslant$ grade 4; and ⟅ Barthel index score [11] $\geqslant$ 55 points.

Per this protocol, the tubes and infusion bags should be properly fixed on the multi-functional booster rehabilitation device designed by our department. When patients get out of bed, family members should assist and accompany them. Patients should get out of bed following the “trilogy” (lying 30 s, sitting 30 s, standing 30 s) and then walking. Sequence of off-bed activity: sitting and standing at the edge of the bed $\to$ standing bedside $\to$ doing off-bed activity to a limited extent with the help of a walking aid $\to$ doing activity in the room $\to$ doing activity in the ward. An activity tracker, such as a wireless smart bracelet, should be worn to monitor the patient’s physical activity level [12, 13], which should be 200, 560, and 890 steps on the first, second, and third days after surgery, respectively, as long as there are no uncomfortable symptoms.
–
Stage II (1–3 days after surgery)

Patients should be encouraged to complete daily activities independently, such as brushing their teeth, washing their face, dressing, and eating. At 1–3 days after surgery, the doctor should arrange activities according to the patient’s disease conditions and physical condition three times a day (in the morning, afternoon, and evening) before and after infusions. The project team members should urge and guide patients to complete their daily activities. In addition, the patient’s physical activity level should be gradually increased according to the patient’s specific conditions; moreover, patients should do respiratory function training and limb function exercises on the affected side.
–
Precautions

The risk of falling from the bed should be dynamically assessed over time [14]. Patients should do activities with the help of a multi-functional rehabilitation walking aid, accompanied by family members. Patients should wear non-slip slippers and clothes of appropriate length. The ground should be kept clean and dry. For a patient at a high risk of falling, it is necessary to add a safe guard, use a red wristband, and hang a warning sign at the head of the bed that states: “Beware of fall and falling down from bed.” This will help to inform the patient and their family of the precautions related to falling and may prevent patients from falling. When patients are instructed to do early off-bed activities after surgery, the level and time of the physical activity should be gradually increased, and the heart rate and blood oxygen saturation of the patients during any activity should be monitored by a mobile finger pulse oximeter. When their heart rate was $>$ 100 bpm and their SPO ${}_{2}$ was $<$ 90%, the patient was advised to rest and complete the remainder of the activity later. In addition, the activity should be terminated immediately if the patient complains of chest tightness, shortness of breath, dyspnea, dizziness, fatigue, sweating, a pain score of $>$ 4 points, and other intolerance conditions. The project team members should immediately assist the patient to have a rest at the bedside or in bed, evaluate the patient’s vital signs, and take the treatment measures as instructed by the doctor, such as oxygen inhalation, ECG monitoring, and pain alleviation when necessary. The team should also check for oozing of blood at the incision site, and any changes in the color, nature, and quantity of the drainage fluid.

2.3 Evaluation indexes

1)
Postoperative indwelling time of the closed chest drainage tube;
2)
Time to the first off-bed activity after surgery;
3)
Incidence of any postoperative pulmonary complications (e.g., atelectasis, pulmonary infection, and pleural effusion);
4)
Length of postoperative hospital stay; and
5)
Patient satisfaction.

2.4 Statistical treatment

SPSS 26.0 software was used for statistical description. The measurement data were expressed as the mean $\pm$ standard deviation ( $\bar{\chi}$ $\pm$ SD), and the enumeration data were expressed as frequency (%).

Baseline and effect comparison: The enumeration data were subject to the chi-square test ( $\chi^{2}$ ). The measurement data were subject to the normality test and homogeneity test for variance. When there was normal distribution and homogeneous variance, the independent sample $t$ -test was used. When the data violated normal distribution and homogeneity of variance, the rank-sum test was used. For abnormal distribution, the Wilcoxon signed-rank test in non-parametric tests was used. A value of $P<$ 0.05 indicated a statistically significant difference.

3. Results

A comparison between the two groups of postoperative indwelling time of the closed chest drainage tube and the time to the first off-bed activity (Table 1).

Table 1
Comparison between the two groups in terms of postoperative indwelling time of closed chest drainage tube and time to first off-bed activity

Item	Control group ( $n=$ 50)	Intervention group ( $n=$ 50)	$T$	$P$
Indwelling time of closed chest drainage tube (d)	3.04 $\pm$ 1.08	2.13 $\pm$ 0.79	$-$ 5.31	0.00
Time to first off-bed activity (h)	26.54 $\pm$ 5.43	19.62 $\pm$ 3.67	$-$ 7.47	0.00

Table 2

Comparison of the incidence of postoperative pulmonary complications between the two groups ( $n$ , %)

Item	Control group ( $n=$ 50)	Intervention group ( $n=$ 50)	$\chi^{2}$	$P$
Pulmonary infection	2 (8%)	2 (8%)
Atelectasis	3 (6%)	1 (2%)
Pleural effusion	3 (6%)	1 (2%)
Total	8 (16%)	4 (8%)	1.52	0.22

Table 3

Comparison of postoperative hospital stay and patient satisfaction between the two groups

Item	Control group ( $n=$ 50)	Intervention group ( $n=$ 50)	$T$	$P$
Postoperative hospital stay (d)	6.84 $\pm$ 1.35	5.56 $\pm$ 1.05	$-$ 5.30	0.00
Satisfaction (%)	98.08 $\pm$ 1.22	99.01 $\pm$ 0.84	4.45	0.002

The indwelling time of the closed chest drainage tube in the intervention group was shorter than that in the control group, and the difference was statistically significant ( $P<$ 0.05). The time to the first off-bed activity after surgery in the intervention group was significantly less than that in the control group, and the difference was statistically significant ( $P<$ 0.05).

A comparison of the postoperative pulmonary complications between the two groups (Table 2).

There were no statistically significant differences between the two groups in terms of the incidence of postoperative complications ( $P>$ 0.05).

A comparison of the length of the postoperative hospital stay and patient satisfaction between the two groups (Table 3).

The length of the postoperative hospital stay in the intervention group was shorter than it was in the control group, and the difference was statistically significant ( $P<$ 0.05). The postoperative patient satisfaction in the intervention group was higher than in the control group, and the difference was statistically significant ( $P<$ 0.05).

4. Discussion

Studies have shown that patients show insufficient recognition of early postoperative activity to a varying degree, they do not know the time and method of recommended activities, and they worry about accidents occurring during activities (e.g., falls or medical equipment failures) [15, 16]. A standard early activity program was developed in this study based on the ERAS concept, which was then refined and quantified under the premise of patient safety. Risk management was conducted in advance, and all patients in the intervention group were urged, assisted, and guided to do early activities to improve compliance and promote rapid recovery.

During off-bed activities, patients and their families were taught to properly fix the tubes to a multi-functional walking aid, and the patients were assisted with early postoperative activities. The time to the first off-bed activity for the patients in the intervention group was significantly less than that of the patients in the control group (19.62 $\pm$ 3.67 versus 26.54 $\pm$ 5.43 h), and the difference was statistically significant ( $P<$ 0.01). There were no adverse events (i.e., falls, falling down from the bed, or the tube falling off during the early off-bed activity) in the intervention group, indicating that the early activity program was safe and feasible.

The indwelling time of the closed chest drainage tube and the length of the postoperative hospital stay in the intervention group were significantly shorter than in the control group, and the differences were statistically significant ( $P<$ 0.01). Thus, the implementation of the early activity program promoted the discharge of fluid and gas in the pleural cavity of the patients after surgery and effectively promoted pulmonary reexpansion; this shortened the indwelling time of the closed chest drainage tube, relieved patient pain, and improved patient comfort level. If a patient had no discomfort (e.g., chest tightness, shortness of breath, and dyspnea) in the 1–2 days of early observation after extubation, discharge was considered to effectively shorten the hospital stay, accelerate the bed rotation of the department, and reduce the economic burden to the patient’s family.

The incidence of postoperative pulmonary complications in the intervention group was lower than in the control group (8% versus 16%); however, the difference was not statistically significant ( $P>$ 0.05). This may be associated with the fact that some ERAS-based perioperative care was implemented in both groups, including education on admission, lung rehabilitation exercises, analgesia management, and early eating and general activity guidance, which could have prevented the occurrence of pulmonary complications [17, 18, 19].

In the standard early activity program, the activity form was refined, and the patients were personally guided and assisted to do postoperative physical activity as planned. This not only ensured patient safety and improved patient satisfaction but also improved the quality of care.

There were some limitations in the present study. This study is a single-center, small sample size study, and the findings are subject to further validation in future multicenter studies with larger sample sizes.

5. Conclusion

The results of the study indicate that the standardized early activity program is safe and effective in patients who receive surgery for pulmonary nodules. Its use can promote the rapid recovery of patients.

Footnotes

Conflict of interest

The authors declare no conflict of interest.

Funding

This study was supported by the Project of Municipal Health Commission (No. 2022WSJK070) and Shapingba District Decision Consultation and Management Innovation Project (No. JCD202121).

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Application of a standardized early activity program on enhanced recovery after surgery in patients after surgery for pulmonary nodules

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Materials and methods

2.1 Subjects

2.2 Specific measures

2.2.1 Control group

3. Results

Table 1 Comparison between the two groups in terms of postoperative indwelling time of closed chest drainage tube and time to first off-bed activity

5. Conclusion

Footnotes

Conflict of interest

Funding

References

Table 1
Comparison between the two groups in terms of postoperative indwelling time of closed chest drainage tube and time to first off-bed activity