Incorporating the Distress Thermometer into Preoperative Vital Signs in Patients Undergoing Ambulatory Oncology Surgery: A Pilot Feasibility Study

Abstract

Background

Despite the extensive literature supporting distress screening at relevant transitions of care, the implementation of distress screening remains limited in ambulatory surgery settings. Our multidisciplinary team completed a pilot study to assess the feasibility and acceptability of including a standardized psychosocial assessment, the Distress Thermometer (DT), with the collection of admission vital signs by Patient Care Technicians (PCTs) in patients undergoing oncology surgery.

Methods

We assessed feasibility by the response rate and acceptability through discussions with the PCTs.

Results

Of the 189 men who underwent radical prostatectomy at our center, 71 were approached with the DT scale, and all patients who were approached completed the DT with no missing data. The staff reported no issues with data collection. A total of 21/71 (30%; 95% CI 19%, 42%) reported a clinically relevant distress DT ≥ 4.

Conclusion

Our results demonstrated that incorporating the DT into vital sign collection was feasible, acceptable, and provided a valuable assessment.

Introduction

Patients describe the time between diagnosis and lead-up to surgery as a profoundly stressful period¹. Not only are they coping with a cancer diagnosis, but they may also experience anxiety and fear regarding the surgery and anesthesia, hospitalization, pain, and recovery^2–4. In fact, patients with preoperative anxiety are also more likely to experience higher rates of postoperative nausea and vomiting and unplanned overnight admissions^5,6. Furthermore, cancer patients with high distress levels before surgery also experience higher distress and pain during the recovery period, which in turn can impact healing and recovery^7,8.

The National Comprehensive Cancer Network (NCCN) Guidelines (v.2.2023) on Distress Management emphasizes that “patients should be screened for distress at every medical visit as a hallmark of patient-centered care²”. However, the implementation is limited in the outpatient surgical setting because integrating psychosocial assessments into the busy preoperative time period due to insufficient time with patients and other logistical concerns such as privacy^9–11.

The NCCN Distress Thermometer—a one item 11-point numerical rating scale of distress—is an ideal tool to screen for distress in this type of setting. The instructions are straightforward, it does not take long to complete, and it is available in 71 different languages. It has been validated in patients with different cancers and to detect cancer-specific distress, particularly close to diagnosis¹².

The purpose of our pilot study was to assess the feasibility and acceptability of including a standardized psychosocial assessment, the Distress Thermometer (DT), with the collection of admission vital signs by Patient Care Technicians (PCTs) in patients undergoing oncology surgery using iPad tablets optimized for data collection.

Methods

Patient Recruitment

All patients undergoing robotic-assisted laparoscopic prostatectomy for prostate cancer at our center were eligible for distress screening.

Staff Recruitment

We assembled a multidisciplinary steering committee of stakeholders and discussed the ideal staff to complete the distress screening at a point in time that would not disrupt the busy, task-filled, limited time frame immediately before surgery. After exploring the options, the nursing leaders identified the patient care technicians (PCT) as the ideal staff to collect the distress thermometer data at the same time as they collect the vital signs. All PCTs were trained by the health care team on the distress screening protocol, both during an in-person meeting and were also e-mailed the directions. After soliciting volunteers, one of the PCTs volunteered to be responsible for communicating any issues with implementation reported by the staff to the larger team. We then scheduled weekly check-ins with the PCT leader throughout the 4-month period.

Technology

Our team included experts in technology to facilitate a streamlined and secure collection. We used iPads configured in a kiosk format with a customized home screen that opened directly to the screening tool.

Data Collection

The unit secretary screened the operating room schedule to identify eligible patients and added a colorful sticky note to the patients’ chart to instruct the PCT to complete a distress screening during their vital sign collection. The PCT then retrieved the iPad from a locked cabinet. In addition to the Distress Thermometer, participants provided their birth date and initials so the staff could follow-up if needed, depending on the reported score. Participants also reported their preferred language. Selecting a language other than English prompted re-directory on the iPad to an optional on-demand mobile app for Video Remote Interpreting and Over-the-Phone Interpreting Services in over 300 languages. After each patient use, the iPad was cleaned with a disinfecting wipe per institutional protocol.

Results

Feasibility & Acceptability

During the 4-month period, between March 7 and July 5, 2023, there were 189 men who underwent minimally invasive radical prostatectomy at our center. Of these, 71 were approached with the Distress Thermometer scale, corresponding to an uptake of implementation of 38% (95% CI 31%−45%). The initial uptake was slightly lower than anticipated but the rate increased after all of the PCTs completed the training, and the iPad technical issue was resolved.

All patients who were approached completed the Distress Thermometer corresponding to a 100% (71/71, one-sided 97.5% lower bound 95%) response rate, i.e., penetration of implementation among eligible patients. with no missing data on any of the 5 survey items. The staff reported no issues with data collection.

Distress Outcome

The median Distress Thermometer score was 2 (quartile 1, quartile 3: 0, 4). A total of 21/71 (30%; 95% CI 19%, 42%) reported clinically relevant distress (Distress Thermometer score ≥ 4). We followed our standard institution protocols for distress referrals, which includes a referral to social work or psychiatry as needed. The highest score reported was 8. No patient reported severe distress requiring immediate intervention (scores 9–10).

Language

The preferred language for most patients, 67/71 (94%; 95% CI 86%, 98%), was English. Four patients reported Bengali, Mandarin, Spanish and Twi as their preferred languages. Among these, none required a translator; the caregiver assisted two patients and the PCT assisted two patients. All patients were offered the on-demand mobile app for interpreting services, but no patient required its use.

Barriers

The implementation required a staff training meeting and additional follow-up meeting to provide training to the PCTs not present at the initial meeting. The PCTs were initially concerned that the data collection would interrupt their busy clinical workflow, however after they discussed it in the group, they decided to hand the iPad to the patient while collecting vital signs and reported no disruptions in their productivity. One-month into the data collection, the iPad froze, but was successfully reset after the PCT contacted the champion who alerted the IT team, and with no issues after this single event.

Opportunities for improvement identified during a debriefing with the multidisciplinary team include: improved procedures for flagging eligible patients including automatized identification of eligible patients and integrated documentation in the electronic medical record at the time of vital sign collection, optimized communication between the unit secretary and PCT to approach eligible patients on the day of surgery, and regular check-in and reminders from the project champion.

Facilitators

The multidisciplinary Nurse Scientist-led team was a crucial facilitator in the success of the pilot. Additionally, the ongoing check-ins provided opportunities to troubleshoot any unexpected issues. The Nurse Scientist was well familiar with the processes and staff members and was able to easily navigate the situation and prepare for any obstacles. In addition, the nursing leadership was critical in identifying the ideal staff and helping to develop the logistical process for data collection. Identifying a lead PCT and implementing the ongoing check-ins also provided opportunities to troubleshoot any obstacles the PCTs may have encountered as well as serving as a reminder to continue to collect to the data as the workflow as updated.

Discussion

This innovative pilot was the first opportunity for PCTs to collect additional data as a part of the vital sign collection in the preoperative setting. Our results demonstrated that incorporating the DT into vital sign collection was feasible, acceptable, and provided a valuable assessment. Encouragingly, 100% of the patients approached agreed and completed the Distress Thermometer and additional survey questions. Notably, one in three patients reported distress levels ≥ 4, demonstrating the importance of distress screening at this time point to provide support.

Our study demonstrated a successful example of team science that included a multidisciplinary team with expertise in clinical workflow, technology, social work, and psychiatry to identify the staff members to collect the data, the appropriate screening tool, and the ideal time point. However, only 38% of patients eligible were approached. Future direction includes modifying and refining our implementation approach, addressing barriers and facilitators, and reassessing feasibility.

Conclusion

Distress Screening can be implemented into the preoperative setting on the day of surgery during the collection of vital signs. We welcome other institutions to use this framework, including the utilization of a nursing scientist-led multidisciplinary team, to incorporate distress screening at this important time point on the surgical patient’s journey.