Visual guidelines and tutoring in pediatric urological surgery

Abstract

Background

The aim of this prospective randomized study was to evaluate the impact of visual guidelines (picture book) and parents tutoring on pediatric urological surgery on parent’s stress and anxiety, the number of postoperative contacts, and complications.

Materials and methods

Following institutional ethical committee approval, a special picture book reflecting different stages of the convalescent period following multiple types of pediatric urological surgery was developed. Parents were randomly divided into 2 groups in which 33 parents in Group 1 received the picture book in addition to routine instructions prior to the surgery and 31 in Group 2 received only routine postoperative instructions. The parents were asked to answer a questionnaire (Amsterdam Preoperative Anxiety and Information Scale) regarding the level of anxiety before surgery and immediately after surgery in the recovery room. The number of postoperative parent’s calls, nonplaned emergency room visits, and complications were recorded.

Results

No statistically significant difference in perioperative parental anxiety was found (p = 0.88). The visual tutoring group had a significantly lower rate of emergency room admissions (6.6% vs. 18.6%, p = 0.0433), however parents from this group made a higher number of postoperative calls (9.9% vs. 3.1%, p = 0.38). Two (6.6%) from the tutoring group expressed their desire to omit visual counseling in future surgical preparation and 4 (13.2%) did not have an opinion. Overall satisfaction with regards to the preoperative counseling and information and the number of postoperative complications was similar in both groups.

Conclusions

Visual tutoring does not add any value to parental anxiety but seems helpful in reducing postoperative emergency room visits. Some parents preferred to exclude visual information from future preoperative counseling.

1. Introduction

Parental education before pediatric urological surgery is an important tool that helps reducing parent’s anxiety levels.^[1–3] There were a small number of studies regarding family’s visual education.^[1,4–8] Most of them were related to pediatric anesthesia or pain management^[5–8] After discharge from the department, the patient and family are responsible for monitoring the postoperative recovery, identifying abnormal events or conditions, and determining whether healing is progressing normally. These responsibilities may be particularly challenging for parents of young children undergoing surgery, and this responsibility, along with a lack of knowledge and experience, can be a source of stress and anxiety. Nelson et al.^[1] used a visual atlas of normal penile healing after circumcision and circumcision revision for better understanding “normal” surgical recovery by parents, in order to avoid unnecessary stress and anxiety and to reduce the number of postoperative contacts between hospital staff and the family. The authors concluded that parental education utilizing a visual atlas leads to a significant decrease in postsurgical telephone calls, but parental postoperative anxiety did not measurably change. McEwen et al.^[8] explored the influence of a short 8 minute video describing anesthesia induction and recovery periods on parental anxiety levels before anesthesia and reported a significant reduction in anxiety and desire for information in the intervention group compared with the control group.

We hypothesized that preoperative instruction with visual tutoring may decrease perioperative anxiety and avoid unnecessary emergency department visits. Therefore, the aim of the study was to determine whether visual information could reduce parental perioperative anxiety levels, postoperative emergency department visits, and the telephone contact rate.

2. Materials and methods

After institutional ethical committee approval, we prospectively recruited parents of 76 consequent children aged 2–168 months, who were candidates for surgery in our department from April 2014 to June 2016. In the study, we included patients with American Society of Anesthesiologists physical status I or II, who were scheduled for elective penile surgeries, groin procedures, and open pyeloplasty. Children with two or more surgical areas and re-do cases were excluded. All parents were randomly divided into 2 groups (38 patients in each group). In Group 1, parents received a computerized picture book with photos of the surgical site or wounds in different healing periods in addition to routine preoperative education. Parents from Group 2 underwent only routine preoperative instruction without any visual tutoring.

The randomization was performed utilizing the blocked method of randomization. A block size of 6 was used in order to allocate an equal number of patients into both groups. In Group 1 the computerized picture book was an integral part of the preoperative preparation and in Group 2 only routine preoperative instruction without any visual tutoring was given. Following block allocation, the information was sealed in an opaque envelope and opened by the practitioner nurse at the beginning of the preoperative clinic.

Preoperative preparation was done during assessment in the preoperative clinic by the same nurse practitioner with good clinical experience. Parents of children candidates for pyeloplasty received an explanation about postoperative tubes and drains, and parents of children before hypospadias repair were instructed about urethral catheters.

2.1. Generation of image catalog

We used the same methodology as Nelson et al.^[1] with small modifications. Photographs were taken by a physician on postoperative days 0, 3, 7, 14 using a 12 megapixel digital camera. All identifiers were destroyed after the photo sequence was complete for each subject. No identifying marks were present in any images. Pictures were loaded into an institutional computer that the staff nurse used for parenteral education prior to the surgery.

The parents were asked to answer the Amsterdam Preoperative Anxiety and Information Scale before surgery in the waiting area and after surgery in the recovery room. We recorded parent’s calls to the hospital staff and non-planed emergency room visits. In addition, they filled out a satisfaction questionnaire.

Amsterdam Preoperative Anxiety and Information Scale is a self-reporting measure which is simple and practical to use in the preoperative setting as we showed in our previous publication.^[9,10] It consists of 6 items designed to assess anxiety levels and need for information before surgery (Appendix 1). The satisfaction questionnaire contains 4 questions (Appendix 2).

2.2. Statistical analysis

An a priori study sample size calculation was performed based upon previously reported observed 40% difference in the incidence of the anxiety status between clown group patients versus the control group. Applying an uncorrected x² test with an a of 0.05, a sample size of 38 would be expected to have 80% power to detect a minimum 40% difference between two such treatment groups. Commercially available software GraphPad Prism version 6.02 for Windows (GraphPad software, San Diego, CA) was used. Mann–Whitney and Fisher tests were utilized for statistical evaluation, considering a p value of <0.05 as significant.

3. Results

Following institutional ethical committee approval, 76 children who were scheduled for penile (hypospadias repair, chordee repair, circumcision), groin (orchidopexy and inguinal hernia repair), and renal surgery (pyeloplasty and partial nephrectomy) were included in this study. A total of 33 parents from Group 1 and 31 parents from Group 2 completed the study survey. The remainder of the 76 initially included patients dropped out due to lack of interest in completing the study. However all reported full satisfaction with the surgical outcome and preoperative preparation. Clinical data on the included study patients are presented in Table 1. We did not find any statistically significant difference in the perioperative anxiety level between the 2 groups. There was no difference in the total Amsterdam Preoperative Anxiety and Information Scale score (Fig. 1), in anesthesia- related anxiety (Fig. 2), surgery related anxiety (Fig. 3), and in the information-desire component (Fig. 4). The visual education group had a statistically significant lower rate of emergency admissions (p= 0.043) (Fig. 5), however they made more calls to the hospital staff after the surgery although this did not reach statistical significance (p= 0.38) (Fig. 6). Overall parental satisfaction from preoperative education was similar in both groups. Two parents from the visual education group preferred to avoid visual counseling in future surgical preparation if needed and four had no opinion (Table 2).

Table 1.

Patient’s clinical data.

Surgery type	Group 1 (visual education)		Group 2 (routine)
	Median age (mo)	n	Median age (mo)	n
Penile	8	19	22	14
Groin	24	9	16	13
Renal	3	5	2.5	4

Figure 1.

APAIS score. APAIS = Amsterdam Preoperative Anxiety and Information Scale.

Figure 2.

Anesthesia-related anxiety. A = Anesthesia-related anxiety (before/after surgery).

Figure 3.

Surgery-related anxiety.

Figure 4.

Information-desire component. S = satisfaction – information-desire component (before/after surgery).

Figure 5.

Rate of emergency room admissions. ER = Emergency room visits after surgery.

Figure 6.

Calls to the hospital staff. Mom’s calls = Parent’s calls to the hospital staff after the surgery.

Table 2.

Parent’s satisfaction questionnaire.

Answers	Group 1 (visual education)			Group 2 (routine)
	Good	Bad	No opinion	Good	Bad	No opinion
Overall satisfaction	24	6	1	24	7	0
Education was helpful	28	0	5	30	0	1
Opinion about visual tutoring	27	2	4	20	4	7
Continue with visual education	27	2	4	30	0	1

4. Discussion

Recently, most surgical procedures in pediatric urology have transitioned from inpatient to ambulatory care.^[1,3,11] Even those procedures that require inpatient hospitalization have evolved and the patients are often discharged home with catheters and drains in place and asked to return to the outpatient facility to have them removed. While this trend has benefits regarding efficiency and cost, a significant number of postoperative care responsibilities have been transferred from the trained staff of the hospital to the child’s parents or other caregivers.^[2,12] Most of these parents have little or no medical training, and their experience with postoperative management of incisions, dressings, and other surgical facts of life is likely to be minimal.

The result of this transition is that, after surgery, parents are primarily responsible for evaluating the patient’s postoperative status and making potentially critical decisions regarding the need for further evaluation of possible problems. For many parents, this responsibility is a source of stress and anxiety.^[12]

The lack of knowledge and experience can result in unnecessary discomfort and adverse outcomes. Although life threatening situations are rarely reported, sometime the parents are not able to recognize serious complication related to the surgery which in turn could lead to undesirable outcomes.

Efforts to improve parental education and understanding, and to reduce parental stress have consistently demonstrated that these approaches could result in better transmission of information to parental caregivers with resulting improvements in care of the pediatric patient after discharge.^[4–6]

Better quality surgical care requires good and safe communication with parental caregivers.^[3]

Some of studies with regards to visual parental education prior to procedure or surgery, showed improvement in parental anxiety.^[4,7,8] We also expected to see lower perioperative anxiety levels in the visual tutoring group. It should be pointed out that our aim was to show pictures with operative wounds and the operative site area, in order to decrease the surgery-related anxiety component and information desire component. We did not expect any influence on anesthesia-related anxiety.

On the perioperative surveys of parental anxiety, there was no significant difference in overall summary scores between responses. Like Boston’s group study, we did not find any difference in any component of the anxiety scale.^[1] The patients from the visual tutoring group made less visits to the emergency room following surgery, however they also made more calls to the hospital staff after the surgical procedure. The patients from the education group expressed more confidence in dealing at home with surgical related events and made the phone calls just to support their initial confidence. Moreover, they felt that they had more tools to deal with postoperative problems at home without jeopardizing the surgical outcome. Furthermore, none of our patients developed surgery related complication due to parent’s negligence or not showing up to the emergency room following surgery.

Most of our patient’s caregivers felt positive with regards to the visual guidelines on surgical procedures and were interested in this tutoring in future surgeries. However, we had some feelings that some parents developed preoperative fear due to postoperative pictures during tutoring which could increase their anxiety even before the surgery. This fact should not be overlooked therefore it is advisable that the team which is counseling parents upon scheduled surgery should apply visual education on an individual basis.

This study has some limitations that should be mentioned. The patient included in the study underwent different heterogeneous urological procedures, however they reflect the “bread and butter” of common urological practice and are part of the daily urological practice of almost every pediatric urologist. Not all patients completed the study protocol. However, overall the number of patients fitted the minimal number of participants required for a study of this kind and was in prior agreement with the study statistic calculation. It has to be mentioned that all those patient’s caregivers who were not interested in continuing with the postoperative survey were satisfied with the treatment outcome and declined to participate due to some reasons unrelated to the study.

5. Conclusions

Our data showed that visual tutoring does not add any value to parental anxiety but seems helpful to reduce postoperative emergency room visits. Since some parents preferred omitting visual information from future preoperative counselling, it should be offered to the parents and patients on an individual basis during perioperative counseling.

Conflict of interest statement

The authors declare that they have no conflicts of interest.