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Follow-up Phone Calls After Pediatric Ambulatory Surgery for Tonsillectomy
Follow-up Phone Calls After Pediatric Ambulatory Surgery for Tonsillectomy: What Can We Learn From Families?Thao Le, RN, BSc(N), Julie Drolet, RN, BSc(N), Elvie Parayno, RN, BSc(N), Christina Rosmus, RN, MSc, Sonia Castiglione, RN, MSc(A)The purpose of this quality improvement study was to describe families’ responses regarding the adequacy of the preoperative preparation provided in the Preoperative Assessment Clinic, and the necessity of two follow-up phone calls after pediatric ambulatory surgery for tonsillectomy with or without adenoidectomy (T A). Using a questionnaire developed for the study, 90 families were contacted by phone on the ?rst postoperative day and, of them, 73 were contacted a second time between the ninth and twelfth postoperative days. Families’ responses were reported in four categories: (1) concerns, (2) use of resources, (3) adequacy of the preoperative teaching, and (4) necessity of the two postoperative phone calls. Results showed that, at the ?rst phone call, a sore throat was reported as the most important concern followed by a decreased oral intake (ie, ?uid, food, medicine), vomiting, and fever or “perceived fever.” During the second phone call, a sore throat remained the most important concern followed by a decreased intake. Earache was the third highest concern and vomiting was then reported of concern by a minority of families. The most frequently consulted resource person for concerns was the physician on call for the otolaryngology service. Eighty-seven percent of families felt the preoperative preparation was adequate. For reasons of instructional and/or emotional support, 94% of families who responded reported that the ?rst phone call was necessary and 68% reported that the second call was as well. Keywords: research, pediatrics, ambulatory surgery, tonsillectomy. ? 2007 by American Society of PeriAnesthesia Nurses.Thao Le, RN, BSc(N), is a Nurse Clinician in the Preoperative Assessment C Julie Drolet, RN, BSc(N), is a Nurse Clinician in the Preoperative Assessment C Elvie Parayno, RN, BSc(N), is Head Nurse in the Preoperative Assessment Clinic, Postanesthesia Care Unit and Day Surgery C Christina Rosmus, RN, MSc, is a Nursing Research Associate in the Nursing Research D and Sonia Castiglione, RN, MSc(A), is a Research Assistant in the Nursing Research Department, The Montreal Children’s Hospital, Montreal, Quebec, Canada. Address correspondence to Thao Le, RN, BSc(N), Nurse Clinician, Preoperative Assessment Clinic, McGill University Health Centre-The Montreal Children’s Hospital, 2300 Tupper Street B247, Montreal, Quebec, H3H 1P3, C e-mail address: thao.le@muhc.mcgill.ca. ? 2007 by American Society of PeriAnesthesia Nurses. /.00/0 doi:10.1016/j.jopan.256Journal of PeriAnesthesia Nursing, Vol 22, No 4 (August), 2007: pp 256-264FOLLOW-UP PHONE CALLS257AMBULATORY SURGERY is de?ned as “a surgical procedure that requires minimum postoperative care, which can be given at home with appropriate instruction.”1 At the pediatric university teaching hospital where this study was carried out, 4,735 surgical cases per year were performed a of those, 663 were tonsillectomies with or without adenoidectomies (T A). At the time of this study, there was no formally established nursing follow-up for these patients as part of routine care. ASPAN standards recommend providing follow-up for extended care as indicated and providing additional resources to contact if problems arise.2 To improve the nursing care delivered to the children undergoing ambulatory T A, a quality improvement study was undertaken to explore families’ perspectives of the adequacy of the preoperative preparation in the Preoperative Assessment Clinic and the necessity of follow-up phone calls postoperatively. The postoperative care given at home by families can be anxiety provoking.3,4 This intense period of recovery needs to be addressed when planning the care of ambulatory patients and their families. For preoperative teaching to be most effective, it must occur during the optimal time for learning and retaining information, determined to be within the two weeks preceding the surgery.3,5,6 Preoperative teaching offers families information and strategies to care for children so that they can better understand and cope with what to expect before and after surgery. This will help families make arrangements and prepare for the postoperative period.7 Follow-up phone calls are regarded as an ef?cient means of monitoring families’ concerns, to determine patient well-being, and to appraise the quality of care received8 compared with other methods such as e-mail.9 These calls are also useful to evaluate any potential problems or complications to ensure that postoperative instructions are being followed correctly and to demonstrate the institution as “caring.”8,10-14 In addition, Norinkavich et al15 revealed that fam-ilies of children who underwent T A were less concerned about going home on the same day when informed that they would receive a phone call from the nurse within 24 hours of discharge. The present quality improvement study was undertaken to assess whether the preoperative teaching was adequate to prepare families for the postoperative period and if they would bene?t from follow-up phone calls.PurposeThe purpose of this quality improvement study was twofold: to describe families’ responses regarding the adequacy of the preoperative preparation provided at the Preoperative Assessment Clinic and to explore the necessity of two follow-up phone calls after their child’s T A ambulatory surgery.MethodsStudy GroupThe study group consisted of families whose children underwent ambulatory surgery for T A. These children were categorized as class 1 or 2 (low risk) according to the American Society of Anesthesiologists Physical Status.16 The children were between 3 and 18 years of age (children under the age of 3 years were admitted to the hospital per institutional practice presently supported by the literature).17 The Montreal Children’s Hospital (McGill University Health Centre), Quality Improvement Studies does not require approval from the Research Ethics Committee. Informed consent was obtained from the families for the quality improvement study. Families were included in the study if: their child had undergone ambulatory surgery for T A and was discharged home the same day, they were able to communicate in English or French, and the mother and/or father had attended the Preoperative Assessment Clinic with their child.ProcedureDuring the preoperative visit, which usually took place 1 to 14 days before surgery, the258LE ET ALfamily was shown a video presentation that described the general pre and postoperative events. Families also received a standardized preoperative preparation from the nurse. The visit included history taking, a physical examination, and if indicated, laboratory work-up. In addition, the pre and postoperative T A teaching, both verbal and written, were given during the same clinic visit and reinforced in the PACU where the parents were present. Topics reviewed were pain management, diet and hydration, prevention and recognition of complications such as bleeding and infection, side effects of anesthesia such as nausea and vomiting, fever, activities permitted, and any other concerns brought up by the families. The families had been instructed by the surgeon to keep their child at home for at least 10 days postoperatively and to monitor the occurrence of possible complications such as bleeding, dehydration, and infection (according to the otolaryngology [OTL] department’s protocol). On the day of the surgery, in the PACU the families were asked if they would agree to participate in a telephone survey regarding the postoperative care at home. Before discharge from the PACU, the families were asked to sign the discharge checklist, indicating that the postoperative instructions had been received and explained to their satisfaction. Families were instructed to use the hospital’s 24-hour telephone number to reach the OTL physician on call or to come to the hospital’s emergency department for additional assistance. Each family received two phone calls made by the same nurse. A questionnaire developed for this study was used during the phone calls (Fig 1). This questionnaire was piloted for comprehension and readability with 21 separate families. No changes to the questionnaire were deemed necessary. The ?rst call was made on postoperative day one to assess the concerns of the ?rst 24 hours and to ascertain the adequacy of the preopera-tive preparation. The second call was made to obtain data indicating the developments over the 10-day convalescent period. The second call was scheduled on the ninth or tenth day postoperatively, but was made on the eleventh or twelfth day if the ninth or tenth day fell on a weekend or the families could not be reached on the scheduled day. The nurse addressed any concerns raised by the families.ResultsData collection was carried out over a period of ?ve months. Ninety ?ve families met the inclusion criteria. Ninety families (95%) were reached for the ?rst postoperative call, and 73 (77%) for the second (42/73 on postoperative day 9 and 10, 31/73 on postoperative day 11 and 12). Families spoke English (75%) or French (25%); 81% of the children were between three an 63% of the children were boys and 37% were girls. Families’ responses were reported in four categories: (1) concerns, (2) use of resources, (3) adequacy of the preoperative teaching, and (4) necessity of the two postoperative phone calls.Families’ Concerns During Phone CallsTable 1 shows the concerns brought up by the families during the ?rst and second phone calls and how many of them reported contacting a resource person for advice. The most common concerns reported by families on the ?rst postoperative day included sore throat (91%), decreased intake (71%), vomiting (59%), and fever or “perceived fever” (29%). During the second phone call, families remained concerned about the child’s pain lasting 4 to 11 days (63%) and decreased oral intake (40%), but were less concerned about vomiting (5%). Earache was the third highest concern, reported by 33% of families compared with 8% during the ?rst phone call. Families reported that earaches of varying intensity often occurred between days three and nine postoperatively. The earache lasted from three to eight days. TheFOLLOW-UP PHONE CALLS259Fig 1.Questionnaire administered to parents and referred to during the follow-up phone calls.next three prevalent concerns, only reported during the second phone call, were bad breath (16%), weight loss (14%), and a change in voice (10%). Families described a change in voice, such as low pitch, highpitch, and muf?ed or nasal speech. A few families reported that their child had lost weight, as much as eight pounds. Five families said they would have preferred that their child stay overnight in the hospital.260LE ET AL Table 1. Postoperative Concerns and Number of Families Who Contacted A Resource Person for AdviceConcerns Call 1 (n 90) Contact for Advice (Call 1) Call 2 (n 73) Contact for Advice (Call 2)Sore throat Decreased oral intake Vomiting Fever/Perceived fever* Mouth breathing/Snoring Change in sleep pattern Bleeding Drooling/Not swallowing/Gagging Earache Bad breath Weight loss Change in voice *Perceived fever “hot to touch.”82 64 53 26 12 9 9 9 7 0 0 03 2 10 1 0 0 3 0 0 0 0 046 29 4 8 1 3 7 4 24 12 10 76 8 0 1 0 0 2 0 7 3 2 1Use of Resources by FamiliesFamilies reported using the following resources postoperatively: the physician on call for the OTL service, the OTL surgeon, the pharmacist, the local clinic, the emergency department, friends, and relatives. The most frequently consulted resource person was the physician on call for the OTL service, as instructed during the pre and postoperative teaching (Table 2). During the ?rst phone call, the results showed that, although a sore throat and a decreased intake were the two most frequently expressed concerns, it was the vomiting that prompted 10 families to consult a resource person. This represented the highest number of calls (Table 1).Before the families received the ?rst phone call, eight had already consulted someone with respect to analgesics, as opposed to concerns about their child’s symptoms. By the time the second phone call occurred, the three main reasons for consulting were decreased oral intake, earache, and sore throat by a total of 21 families. Table 1 shows other reasons why families contacted a resource person.Was the Preoperative Teaching Adequate?During the two postoperative calls, 78% of the parents for the ?rst call and 92% for the second call responded to the question regarding adequacy of the preoperative teaching to help with postoperative care of their child. One parent onTable 2. Resources Used by FamiliesResources Call 1 (n 90) Call 2 (n 73)Physician on call for the OTL service OTL surgeon (during follow-up appointment or by telephone) Pharmacist Relative/Friend Emergency department visit (of the hospital where surgery was done) Family pediatrician Local clinic Student nurse (during home visit) Other families (during follow-up appointment)15 4 5 3 2 1 1 0 017 11 3 0 1 3 3 1 1FOLLOW-UP PHONE CALLS261the ?rst call and two on the second call did not answer the questions. Eighteen parents at the time of the ?rst phone call and three parents at the time of the second call were not asked if the preoperative teaching was adequate because (1) they were overwhelmed and concentrated on speci?c concerns, or (2) they were busy with other tasks and terminated the interview before being asked the question. During both calls, 87% of the parents stated that the preoperative teaching was adequate and felt that the written and verbal instructions were very helpful in preparing them. Thirteen percent of the parents would have liked more detailed information regarding the intensity and duration of the pain and what to do if they were unable to give the medications. Two parents also mentioned that they had not anticipated how much care would be required for the 10 postoperative days.Were the First and Second Phone Calls Necessary?hospital, had they not been expecting our call. Four parents did not feel that the ?rst phone call was necessary because their child was doing well and they were able to manage the child’s care. One of those families had two other children who had previously undergone the same surgery. Another family had received support from an outreach service. When the parents were asked to give reasons why the second call was necessary, 43% said it was necessary for instructional support and 86% for emotional support. One parent was reluctant to consult a resource and was waiting for our call. Thirty-two percent of parents did not feel that the second call was necessary, although, during the call, many still expressed concerns, asked questions, or verbalized their feelings. Several said they felt the call would have been necessary if their child had been having problems. Although their child was doing well, all the parents welcomed the call for emotional support. Four of them felt that the call was also necessary for instructional support. Five parents suggested that the second phone call would have been more helpful between the fourth and seventh day after the surgery. Parents stated that communicating with the nurse offered them reassurance, eg, “to hear that I am on the right track.” It was also an opportunity to ask questions as stated by a parent, eg, “within 24 hours the call is crucial since the stay in the hospital was short and we need to ask questions.” Table 3 shows some statements made by parents in this regard.The ?rst phone call was deemed necessary by 94% of parents and the second call by 68% of them. Eight families were not asked if the phone calls were necessary because the child was being taken care of by a family caregiver other than a parent, and three parents were not asked for the same reasons as stated in the previous section. In analyzing the reasons given for whether the follow-up phone calls were necessary, the responses were divided into two categories: instructional support (clari?cation, validation, reinforcement, recon?rming, advice, guidance, and asking questions) and emotional support (reassurance, encouragement, personalization, decreasing anxiety, ventilating, and “keeping in touch.”) Of the parents who felt the ?rst phone call was necessary, 81% stated it was for instructional support and 76% for emotional support. Parents may have identi?ed the phone call as being necessary for reasons in one or both of these two categories. Five parents stated that they would have called theDiscussionDuring the follow-up of 90 families with children who had undergone ambulatory surgery for T A, the families identi?ed several issues regarding postoperative care. In the present quality improvement study, a postoperative phone call was found to be an effective means to evaluate the adequacy of the preoperative teaching and identify the concerns of the families after an ambulatory T A procedure. The262LE ET AL Table 3. Examples of Emotional and Instructional SupportParents’ Cited Reason for the Necessity of the CallsStatements of ParentsEmotional supportInstructional support“Reassuring to hear that I am on the right track” “It eased my mind to know you would call” “It’s hard to see your child in so much pain” [The call is a] “Nice personal touch” “Shows you care about our child” “Honest to God, it’s overwhelming, even mentally” “I’m exhausted from taking care of my child, your reassurance and answers to my questions were very helpful” “Less afraid to forget asking a question, knowing you’ll call” “I like the call to see if everything is OK [. . .] and to check up on me” “Within 24 hours the call is crucial since the stay in the hospital was short and we need to ask questions” “Suggestions are well appreciated” “I’m a strong believer in follow-ups for . . . discussion and asking questions” “It was a traumatic experience, your teaching guided us well to care for our child” “Good to make sure I understood what we were told in the hospital” “The call is good to verify everything, since we leave so soon after surgery”?ndings of this study suggest that after a T A, two follow-up phone calls from a nurse were necessary. The ?rst phone call was necessary more for instructional support and could still be made on the day after the surgery. The second phone call was needed more for emotional support, and feedback from families indicated that it could be scheduled between the fourth and seventh day postoperatively, while the concerning issues were current. As reported in most other studies, families expressed concerns related to pain, diet, fever, hydration, and bleeding. Randall and Hoffer18 stated that a “sore throat occurs in almost all patients after surgery,” and it seemed to contribute to a decrease in ?uid intake.19 In the present study, a signi?cantly high percentage of families were concerned about their child’s sore throat and decrease in oral intake (ie, ?uid, food, medicine), as was also reported by Sutters and Miaskowski.20 The results of the study showed that the majority of families who had postoperative concernsdid not contact a resource person for advice. Kanerva et al21 reported a similar ?nding with their T A population. A possible explanation might be that this study group was expecting follow-up phone calls postoperatively and were waiting for them to express their concerns. This may re?ect the bene?t of a follow-up phone call in decreasing the need for families to contact a resource person. During the ?rst phone call, the families problem-solved with the nurse, and this may have led to a decreased need to use one of the suggested resources. In that way, it appears that the nurse may have had a positive impact on families’ ability and con?dence to care for their child. Another potential reason for not seeking advice could be that families were indecisive as to when to call regarding their concerns. The majority of families found the preoperative teaching adequate. Although verbal and written instructions were given preoperatively, families stated that more detailed written instructions could have been bene?cial in decreasing their concerns when taking care of their child. A study by Oberle et al6 also reported that familiesFOLLOW-UP PHONE CALLS263requested more written information even though they had received both written and verbal instruction preoperatively. Although parents reported that the preoperative preparation was adequate, the telephone calls illustrated that they still had many concerns regarding the care of their child, thus the usefulness of these calls. In the present study, families were not asked about the desire to have their child stay overnight, but ?ve families stated a preference for an overnight stay instead of ambulatory surgery because they felt overwhelmed taking care of the child at home. Between 1994 and 2003, the percentage of families preferring an overnight stay has decreased from 80%22 to 5.5%.21 Perhaps when ambulatory surgery was a novelty, families were more anxious to take their child home on the same postoperative day. Today, it might be routine thinking to be discharged home on the same day after minor surgery. As a result of this quality improvement study, changes in practice have already been implemented. From what was learned from the families in the study, the discharge teaching sheet was expanded to a booklet detailing and improving the written instructions for T A. These instructions are discussed with the families during their preoperative visit and are reviewed with them before discharge, after surgery. To see if this booklet decreases the need for instructional and emotional support, hence the follow-up phone calls, a more formal evaluation will be needed in the future. The study had some limitations. One limitation was that the families volunteered the data. For example, they may have chosen to mention their more serious concerns but not necessarily all of them. They reported their perceptions of how the recovery was progressing. Because the data wereobtained by telephone, it was not possible to validate the accuracy of the information obtained. In this study, posing open-ended questions was a strength because it helped to identify the scope of concerns. In the future, a semistructured follow-up phone call could be developed based on data collected in this study. Another important limitation is related to the nurse eliciting information regarding the helpfulness of the phone calls and the adequacy of the preoperative teaching. Families may have been hesitant to tell the nurse what they really felt. Finally, parents who did not answer or were not asked the questions concerning the necessity of phone calls may have been different than the parents who fully participated in the study and may have provided different data.ConclusionThe families of ambulatory surgery patients for T A stated that the preoperative preparation was adequate to help them care for their child postoperatively. The majority felt that the ?rst follow-up phone call was necessary for instructional and emotional support and more than two thirds of the families stated that the second call was bene?cial for the family. This family survey provided important feedback that could be used to improve the care of children undergoing ambulatory T A procedures. As nurses, the merits of acknowledging families’ concerns allows for important changes in practice that bene?t the care of their children.AcknowledgmentsWe thank the children and their families for their participation in this study. We also acknowledge the contribution of the nursing staff in the Post-Anesthesia Care Unit, McGill University Health Centre, The Montreal Children’s Hospital. We are also grateful to Judy Collinge, RN, MBA, and former Director of Nursing Research at the Montreal Children’s Hospital for her advice and guidance. Last, we thank Peggy Jensen, RN, for her participation in the pilot study.References1. Granell J, Gete P, Villafruela M, et al. Safety of outpatient tonsillectomy in children: A review of 6 years in a tertiary hospital experience. Otolaryngol Head Neck Surg. -387. 2. American Society of PeriAnesthesia Nurses. 2004 Standards of Perianesthesia Nursing. Cherry Hill, NJ: The American Society of PeriAnesthesia N 2004.264LE ET AL13. Dewar A, Scott J, Muir J. Telephone follow-up for day surgery patients: Patient perceptions and nurses’ experiences. J Perianesth Nurs. -241. 14. Sutherland M, Bruce B. Same-day pediatric surgery. Can Nurs. -39. 15. Norinkavich KM, Howie G, Cario?les P. Quality improvement study of day surgery for tonsillectomy and adenoidectomy patients. Pediatr Nurs. -344. 16. American Society of Anesthesiologists. ASA Physical Status Classi?cation System. Available at: http://www.asahq.org/clinical/ physical status.htm. Accessed December 5, 2006. 17. Ross AT, Kazahaya K, Tom LWC. Revisiting outpatient tonsillectomy in young children. Otolaryngol Head Neck Surg. -31. 18. Randall DA, Hoffer ME. Complications of tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg. -68. 19. Hamers JPH, Abu-Saad HH. Children’s pain at home following (adeno) tonsillectomy. Eur J Pain. -219. 20. Sutters KA, Miaskowski C. Inadequate pain management and associated morbidity in children at home after tonsillectomy. J Pediatr Nurs. -185. 21. Kanerva M, Tarkkila P, Pitkaranta A. Day-case tonsillectomy in children: Parental attitudes and consultation rates. Int J Pediatr Otorhinolaryngol. -784. 22. Schloss MD, Tan AKW, Schloss B, et al. Outpatient tonsillectomy and adenoidectomy: Complications and recommendations. Int J Pediatr Otorhinolaryngol. -122.3. Kain ZN. Perioperative information and parental anxiety: The next generation. Anesth Analg. -239. 4. Tonz M, Herzig G, Kaiser G. Quality assurance in day surgery: Do we do enough for the families to prevent stress? Eur J Pediatr. -988. 5. Hellier WPL, Knight J, Hern J, et al. Day case paediatric tonsillectomy: A review of three years experience in a dedicated day case unit. Clin Otolaryngol. -212. 6. Oberle K, Allen M, Lynkowski P. Follow-up of same day surgery patients. AORN J. 6-1025. 7. Kankkunen P, Vehvilainen-Julkunen K, Pietila AM, et al. Is the suf?ciency of discharge instructions related to children’s postoperative pain at home after day surgery? Scand J Caring Sci. 372. 8. Ireland D. Legal issues in ambulatory surgery. Ambul Surg. -476. 9. Goldman RD, Mehrotra S, Pinto RT, et al. Follow-up after a pediatric emergency department visit: Telephone versus email? Pediatrics. -991. 10. Burden N. Telephone follow-up of ambulatory surgery patients following discharge is a nursing responsibility. J Postanesth Nurs. -261. 11. Rosbe KW, Jones D, Jalisi S, et al. Ef?cacy of postoperative follow-up telephone calls for patients who underwent adenotonsillectomy. Arch Otolaryngol Head Neck Surg. -722. 12. Bonhomme S, Guerra C, Nimijean W. Telephone follow-up of gynecology day surgery patients. On line for quality and continuity of care. In?rm Que. -16.
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