Article
Reference
Introduction of a specialized consultation prior to insertion of totally implantable access venous devices: Impact on cancellation rate and
patient satisfaction
COLUCCI, Nicola, et al .
Abstract
Preoperative consultation is usually not performed before insertion of a totally implantable venous access device (TIVAD). In our experience, an incomplete preoperative assessment, a predictable medical condition contraindicating surgery, or no-show patients the day of surgery led to several surgery cancellations. Therefore, we introduced a specific preoperative surgical consultation for TIVAD that took place shortly before surgery. The aim of the present study is to evaluate the patients' satisfaction and to establish the rate of cancellation after the adoption of this strategy. Methods: Two-hundred and four patients who benefited from the preoperative consultation before TIVAD insertion from August 2014 to August 2016 were included.
Satisfaction of patients and cancellation rate were documented. Results: With that strategy, no TIVAD insertion was either delayed or cancelled. The overall level of satisfaction was high (91.8%); 184 patients (90.2%) judged the consultation useful in preparation for the surgery.
The surgical procedure met their expectations in 92.2% of cases. Patients known for a psychiatric comorbidity [...]
COLUCCI, Nicola, et al . Introduction of a specialized consultation prior to insertion of totally implantable access venous devices: Impact on cancellation rate and patient satisfaction.
Vascular , 2020, p. 1708538120930470
DOI : 10.1177/1708538120930470 PMID : 32508290
Available at:
http://archive-ouverte.unige.ch/unige:137343
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VASCULAR
Title: INTRODUCTION OF A SPECIALIZED CONSULTATION PRIOR TO INSERTION OF TOTALLY IMPLANTABLE ACCESS VENOUS DEVICES: IMPACT ON CANCELLATION RATE AND PATIENT SAT- ISFACTION
Authors: Dr. Nicola Colucci, MD 1-2
Dr. Adrien Gregoris 3
Dr. Jeremy Meyer, MD, MD-PhD 1 Dr Surennaidoo Perumal Naiken, MD 1 Dr. Wojciech Staszewicz, MD 1 Dr. Eleftherios Gialamas, MD 4 Prof. Christian Toso, MD, PhD, PD 1 Dr. Ziad Abbassi, MD 1
Affiliations: 1. Department of Surgery Division of Visceral Surgery University Hospitals of Geneva Rue Gabrielle-Perret-Gentil 4 1211 Genève 14
Switzerland
2. Department of Clinical-Surgical, Diagnostic and Pediatric Sciences University of Pavia
Via Ferrata 5 27100 Pavia Italy
3. Department of Surgery Riviera-Chablais Hospital Route du Vieux Séquoia 20 1847 Rennaz
Switzerland
4. Department of Surgery Neuchâtel Hospital Rue de la Maladière 45 2000 Neuchâtel Switzerland
Corresponding author: Dr. Ziad Abbassi, MD Division of Digestive Surgery
University Hospitals of Geneva Rue Gabrielle-Perret-Gentil 4
1211 Genève 14 Switzerland
E-mail: [email protected] Phone: +41.22.379.52.52
Conflicting interests:
None.
Funding: None.
Informed consent: Written informed consent was obtained from all subjects before the study.
Ethical approval: Ethical approval for this study was obtained from Cantonal Research Ethics Committee - Geneva, Switzerland.
Contributorship: NC performed literature research, analysed the data, designed the figures and tables and wrote the ma- nuscript. AG, JM and ZA did statistical analysis, did critical appraisal and helped writing the manuscript. SPN, WS and EG performed literature research, designed the study and obtained ethical clearance. CT provided critical intellectual input in constructing and finalizing the manuscript.
Acknowledgements: None.
ABSTRACT
Background
Preoperative consultation is usually not performed before insertion of a totally implantable venous access device (TIVAD). In our experience, an incomplete preoperative assessment, a predictable medical condition contraindicating surgery, or no-show patients the day of surgery led to several surgery cancellations. Therefore, we introduced a specific preoperative surgical consultation for TIVAD that took place shortly before surgery. The aim of the present study is to evaluate the patients’ satisfaction and to establish the rate of cancellation after the adoption of this strategy.
Patients and methods
Two-hundred and four patients who benefited from the preoperative consultation before TIVAD insertion from August 2014 to August 2016 were included. Satisfaction of patients and cancellation rate were documented.
Results
With that strategy, no TIVAD insertion was either delayed or cancelled. The overall level of satisfaction was high (91,8%); 184 patients (90,2%) judged the consultation useful in preparation for the surgery. The surgical procedure met their expectations in 92,2% of cases. Patients known for a psychiatric comorbidity were more likely to express dissatis- faction.
Conclusion
The introduction of a specific preoperative surgical consultation for TIVAD insertion led to a high level of patients’ sat- isfaction. After the preoperative consultation, no cancellation was recorded. Special approaches have to be considered for patients with a psychiatric comorbidity.
Keywords : Vascular access devices; patient satisfaction; surgery cancellation rate; preoperative period; referral and consultation.
MANUSCRIPT
Background
Totally implantable venous access devices (TIVAD) are widely used to provide long-term access to central venous cir- culation, notably for administration of chemotherapeutic agents, hyperosmolar solutions and extreme pH drugs in the setting of oncological or chronic illnesses, therefore improving venous access reliability and overall patients’ quality of life (1). Although insertion of TIVAD is generally considered a minor procedure, early complications can occur due to injury to adjacent structures during catheter insertion and reservoir implantation (2-6), which might alter patient’s satis- faction.
Ideally, the surgeon inserting the TIVAD should perform a physical examination, explain the different implantation techniques and the potential complications, and perform a venous ultrasonography at the intended implantation site (8).
In reality, that step is usually skipped for time reason, with a patient seen directly in the operative room and the con- sequent inability of the surgeon to give exhaustive information and to establish an adequate therapeutic relationship.
Further, the patient does not have the time to give an informed consent or to change his mind. As a consequence, pa- tients might cancel the surgery in the very last minute (9), resulting in mobilization in resources and patients’ dissatis- faction.
Therefore, we introduced a preoperative surgical consultation for TIVAD insertion that took place the week before the planned surgery. The aim of the present study was to evaluate the patient’s satisfaction after the consultation and to es- tablish the rate of cancellation after the adoption of this strategy.
Methods
Patients’ inclusion
Patients aged more than 18 years with an indication for TIVAD insertion were prospectively included for the period 08.2014-08.2016. Ethical committee clearance was obtained from the Geneva Cantonal Research Ethics Committee. Of note, informed written consent was obtained from each of the participants.
Preoperative consultation
The consultation took place the week before the surgery. The physician checked the patient’s file for surgical indication, previous TIVAD implantation, history of breast, shoulder or clavicle surgery, prescription of antiagregant and/or antico- agulant drug, blood platelet concentration, and performed physical examination. The site and the technique of implanta- tion were chosen. A standardized form was filled. Then, the physician provided a comprehensive explanation to the pa- tient on the surgical indication, surgical procedure, post-operative recovery, potential complications and schedule of the surgery day. The consultation was conducted by senior general surgery residents and lasted 20 minutes on average. Ap- propriate supporting material was used (vascular anatomy flashcards, a port with his catheter and a Huber needle) and described to the patient.
Surgical procedure
Surgery was mostly performed under local anaesthesia (94.6%), on an outpatient basis. When deep sedation was nee- ded, it was performed using either propofol alone or using a combination of propofol and fentanyl. General anaesthesia was used only in two cases (1%). We used polysulphone ports with silicone catheters (Celsite® Access Port, B. Braun Medical Ltd). Our technique was similar to the one described by Di Carlo et al. (10). A single skin incision of 4 cm was made at the Mohrenheim fossa, followed by isolation of the cephalic vein for at least 2 cm. The vein was ligated distally and partially cut to insert the catheter. Correct positioning of the distal tip of the catheter in the superior vena cava was achieved by fluoroscopic control. The catheter was fixed by tightening a polypropylene ligature around the vein. The port was then placed medially to the incision, by creating a prepectoral subcutaneous space. A test puncture to check patency and flow through the system was then performed. In case of failure, we used external jugular vein cut-down, percutaneous puncture of internal jugular or subclavian veins (11).
The evaluation form
The evaluation form was translated and reproduced in Appendix A. The evaluation form was handed out to patients the day of the consultation and collected the day of surgery, before discharge. The evaluation form was composed by 10 items inquiring about both preoperative consultation (time spent in waiting room, doctor’s welcome, explication about surgical indication, information regarding surgery procedure, supporting material during the consulting, information regarding risks and complications of the surgery) and surgery (surgeon’s answers immediately before the surgery, time between the consulting and the surgery, usefulness of consulting in preparation for surgery, if surgery met patients ex-
pectations made during consulting). The rating about each statement was expressed on a 5-point Likert scale: totally satisfied (= 5), very satisfied (= 4), quite satisfied (= 3), dissatisfied (= 2) and very dissatisfied (= 1).
Statistical analysis
We dichotomized Likert scale variables by grouping negative responses (1 and 2) as expression of dissatisfaction and positive responses (3 through 5) as expression of satisfaction. Unanswered questions were considered as expression of dissatisfaction, e.g. ahead of lack of information or unavailability of the supporting material during the consultation as reported in a comment section at the end of the questionnaire. Thus, two groups of satisfied and unsatisfied patients were created for every item of the evaluation form.
Continuous variables were expressed as means ± SD. Categorical variables were expressed as numbers (proportions).
Continuous variables were compared using the two-sided Student’s t test. A p-value <0.05 was considered as statistic- ally significant.
A comprehensive analysis of the characteristics of every dissatisfied samples (item-by-item) was conducted, by compar- ing them to the characteristics of the whole population.
All analyses were conducted on STATA, version 13 (STATAcorp, USA).
Results
Two hundred and four patients aged 21 to 86 (mean 60), predominantly females (1.6:1), who benefited from a specific preoperative surgical consultation for venous access ports from August 2014 to August 2016 were included in the present study [see Table 1]. No exclusion criteria were applied.
In this series, none of the 204 enrolled patients presented clinical conditions contraindicating or delaying the surgery that was consequently confirmed and scheduled in the 7 days following the consultation. All of the 204 patients were present on the expected day of surgery. As a result, the cancellation rate was 0%.
The overall level of satisfaction, obtained by calculating the mean of all 10 items satisfaction percent score, was high (91.76% ± 2.29). Time elapsed from the consultation to surgery was the highest satisfactory subscale (97.55% ± 2.13), followed by doctor’s welcome, caring and concern (96.57% ± 2.5). Despite the information regarding surgery procedure was considered complete by the largest part of the sample (95.1% ± 2.97), the information regarding risks and complic-
ations was among the least satisfactory subscales (87.75% ± 4.5) along with the supporting material used during the consultation (86.76% ± 4.66).
Concerning the surgery, patients considered the consultation useful in preparation for surgery (90.2% ± 4.09), which met patient expectations in 92.65% (± 3.58) of the sample [see Table 2].
Patients known for a psychiatric comorbidity were more likely to express dissatisfaction. T-test analysis showed a stat- istically significant difference in prevalence of psychiatric disorders in patients who were unsatisfied about the informa- tion regarding surgery procedure (60±16% vs 27±3%, P = 0.0238), about the information regarding risks and complica- tions (48±10% vs 27±3%, P = 0.0291) and about their expectations on surgery (50±13% vs 27±3%, P = 0.0499). In the same way, a younger population found a discrepancy between reality and their expectations about surgery (51±4y vs 60±1y, P = 0.0107). A higher prevalence of men were also found in the sample which expressed dissatisfaction about the time spent in the waiting room (59±11% vs 37±3%, P = 0.0415). No other statistically significant associations were find.
Discussion
The introduction of a specific pre-operative surgical consultation for TIVAD insertion led to a high level of patients’
satisfaction, related to a better understanding of the procedure, to the establishment of a relationship with the perform- ing surgeon and to the well-balanced timing between the consultation and the surgery, leaving the patients the time to think about the information that was given. When effected during the week preceding surgery, the consultation did not postpone the procedure; nevertheless, it potentially permits to detect acute conditions constituting a contraindication that would lead to surgery cancellation. As a consequence, we believe that the cancellation rate for these patients is sig- nificantly lower. Cancellation on the day of surgery is costly for patients and healthcare providers. In the UK, the cost in lost operating theatre time is as high as £400 million per year (12). In our sample, none of the procedures were aborted:
an advantageous cost/benefit ratio could be speculated. Future studies need to be conducted to investigate the benefit derived from the reduction in cancellation rate compared to the cost of running this preoperative consultation.
On the other hand, the survey allowed us to understand what needed to be improved. As reported above, the satisfaction rates about information regarding surgery’s risks and complications and about the supporting material were among the lowest. The introduction of multimedia materials like 3D anatomy reconstructions or surgery animation videos could primarily enhance the satisfaction about the supporting material and secondarily the understanding of the surgery (13).
An in-depth analysis of the population that expressed dissatisfaction showed a higher prevalence of patients presenting a psychiatric comorbidity. Of note, failure to attend appointment was shown to be higher in patients with social diffi- culties (14). Personal experience of surgery could be stressful, especially in an oncological setting: we strongly believe that a preoperative anxiety assessment should be integrated in the preoperative consultation. Patients suffering of preop- erative anxiety could benefit from non-pharmacological methods, such as cognitive therapy and music therapy and re- laxation (15). For example, it has been demonstrated that perioperative music reduced pain, pain medication, anxiety, and blood pressure and heart rate in patients undergoing procedures with local and regional anaesthesia (16), that re- flects our setting. For more complex cases, like patients with severe psychiatric comorbidities, multimodal interdiscip- linary approaches should be suggested, including a psychological accompaniment (15).
This study has several limitations, including the lack of blinding and the absence of a control group permitting compar- isons with the period prior to the introduction of the specialized consultation. However, we were able to demonstrate the high level of satisfaction of patients requiring a port device when a specialized preoperative consultation takes place. A cost/benefit analysis needs to be conducted to investigate the possible economic advantage derived from the introduc- tion of this strategy.
Conclusion
Introduction of a specialized consultation prior to insertion of TIVAD led to a high satisfaction’s rate of patients. This consultation allowed to illustrate the surgical procedure and its risks, and to establish a profitable surgeon-patient rela- tionship. Further, it gave the time to patients to think about the procedure and to obtain a 0% cancellation rate.
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Table 1
Table 2
