A service evaluation exploring time on physiotherapy caseload following lung lobectomy surgery

Introduction

In 2016 more than 77% of all lung resections for lung cancer were lobectomy or bilobectomy procedures (Royal College of Physicians 2017). The number of lung lobectomy or bilobectomy surgeries performed annually continues to increase in the UK (Jones et al. 2013; Royal College of Physicians 2016) from 4,498 in 2015 to 4,905 in 2016 (Royal College of Physicians 2017). This leads to increased pressure on thoracic surgical hospital beds. Following lung cancer and lobectomy surgery individuals can experience a loss of independence and functional decline (Granger et al. 2012). Physiotherapy is considered a crucial component of the management of patients following lobectomy surgery (Ahmed 2018). Physiotherapy after lobectomy can facilitate early independence, functional recovery and help to reduce hospital length of stay reducing bed pressures (Tait et al. 2021). Time on physiotherapy caseload and factors influencing this following lobectomy surgery have not been explored and measured within existing research. The aim of the service evaluation was to explore whether age, gender, type of surgical incision, day first mobilised and chest drain duration affected time on physiotherapy caseload following lobectomy surgery.

Method

Lobectomy is the most common type of thoracic surgery performed at our UK teaching hospital and most of the existing research features individuals who have undergone lobectomy surgery. To allow comparison with existing literature, only individuals who underwent lobectomy were analysed in this service evaluation.

This service evaluation was registered with and approved by the Blackpool Teaching Hospitals NHS Foundation Trust’s Research and Development team. Ethical approval was not required in line with the Trust policy on undertaking service evaluations.

The cardiothoracic physiotherapy team routinely assess all individuals postoperatively following lobectomy surgery. Postoperative physiotherapy assessment includes respiratory function, shoulder joint range of movement and mobility assessments. Physiotherapy interventions following lobectomy surgery typically include: chest clearance techniques including incentive spirometry and wound supported cough; shoulder exercises; mobilisation; static exercise bike and a stair assessment prior to discharge (if clinically indicated). Individuals who undergo lobectomy surgery are reviewed on day one postoperatively and continue to receive physiotherapy treatment until discharged from physiotherapy. To be discharged from physiotherapy individuals should be at a level of mobility where they are able to safely manage at home, independently clear pulmonary secretions, have a chest radiograph (CXR) approved by the multidisciplinary team, maintain their target oxygen saturations on room air (unless on home oxygen) and, if applicable, safely manage to climb stairs. Referral to physiotherapy follow-up services following hospital discharge is not routinely made.

A retrospective service evaluation was conducted. Data were collected over a 12 month period from 1st July 2015–30th June 2016 for all individuals reviewed by the cardiothoracic physiotherapy team following lobectomy surgery.

Data were collected retrospectively from individuals’ physiotherapy ward sheets, CXR and an electronic patient database.

Data collected included:

• Date of surgery.

• Day discharged from physiotherapy.

• Age.

• Gender.

• Type of surgical incision.

• Day first mobilised.

• Day chest drains removed.

(Day = number of days post-operatively with day of operation = day 0). Mobilisation was defined as ambulation away from the bed space.

The distribution of the data for the number of days on physiotherapy caseload, day first mobilised postoperatively and day chest drains removed postoperatively was assessed using histograms. The data did not have normal distribution. Median and interquartile range values were used due to the skewed distribution of data.

Univariate analysis was performed for each variable (age, gender, type of incision, day first mobilised, chest drain duration) separately compared with the time on physiotherapy caseload using a single linear regression model. A multivariate analysis linear regression model was then used to analyse whether there was any association between age, gender, type of incision, day first mobilised, chest drain duration and time on physiotherapy caseload. All assumptions for linear regression were checked and where the assumptions were not met, log transformation was used.

Results

Data were obtained for 135 individuals (78 female, 57 male) following lobectomy surgery with a median (range) age of 68 (63–75) years. For 2 patients there was no available information on incision performed, whilst 68 individuals underwent a thoracotomy incision and 65 individuals underwent a VATS incision. The first day that patients mobilised postoperatively was 3 (2–5) days. Chest drains were removed after 3 (2, 5) days. Patients were on the physiotherapy caseload for 6 (4–8) days.

The results of univariate analysis for each variable and time on physiotherapy caseload showed that age was not found to have a statistically significant impact on time on physiotherapy caseload SE 0.03 (p = 0.105). Gender was found to be statistically significant with females spending an extra 1.91 days on physiotherapy caseload in comparison to males SE 0.59 (p = 0.002).

Incision type was found to also be statistically significant with VATS incision decreasing time on physiotherapy caseload by 1.99 days SE 0.56 (p <0.001). The day first mobilised was statistically significant for each day later first mobilised time on physiotherapy caseload was increased by 0.82 days SE 0.12 (p <0.001). Chest drain duration was statistically significant as for each extra day chest drains remained in situ time on physiotherapy caseload by 0.355 days SE 0.06 (p <0.001).

Table 1 shows the results of the multivariate regression model for time on physiotherapy caseload. Of the variables used gender, incision type and chest drain duration had a statistically significant impact on time on physiotherapy caseload, whereby being female and chest drain duration increased time on physiotherapy caseload and having a VATS incision decreased it. Gender (female) increased time on physiotherapy caseload by 1.07 days CI 0.16, 1.98 (p = 0.02) and for each 2.7 days the chest drain(s) remained in situ the time on physiotherapy caseload increased by 1.98 days CI 1.30, 2.66 (p <0.001). Conversely having a VATS incision decreased time on physiotherapy caseload by 0.74 days CI -1.20, -0.32 (p = 0.001). No other variables were significant. The R2 value was 0.51 so 51% of the variance can be explained suggesting that there were other factors affecting time on physiotherapy caseload that were not measured.

Table 1: Results of multivariate analysis regression model for time
on physiotherapy caseload.

*VATS = video assisted thoracoscopic surgery.

Discussion

In this service evaluation there was no significant association between age and time on physiotherapy caseload. However, the sample size in this service evaluation may have been too small to detect a significant association between age and time on physiotherapy caseload. It was anticipated that with increased age patients would have a longer time on physiotherapy caseload. Suggested reasons for the risk of longer time on physiotherapy caseload with advanced age following thoracic surgery include: increased risk of postoperative morbidity and postoperative complications due to increased incidence of comorbidities and decline in cardiopulmonary function associated with aging (Okami et al. 2009).

In this service evaluation only age, gender, type of surgical incision, day first mobilised and chest drain duration were explored. It is likely that there are other factors not explored by this service evaluation that influence time on physiotherapy caseload also. It is possible some of these factors may have influenced the finding that increased age was not significantly associated with time on physiotherapy caseload.

Female gender was significantly associated with a longer time on physiotherapy caseload. Smoking history and the presence of underlying medical conditions could account for why males tended to be more at risk of longer LOS following lobectomy surgery (Wright et al. 2008); however, these aspects where not captured in data collection and is an area that warrants research focus. In this service evaluation male and females were comparable in terms of most characteristics (including postoperative chest drain duration, age, type of surgical incision), although females tended to mobilise a day later postoperatively. In this Trust the cardiothoracic wards are usually single-sex therefore males and females tend to be cared for on different wards. It is possible that differences in ward culture, routine and staffing between these wards, rather than gender, may have influenced differences in time on physiotherapy caseload between males and females. This may be an area for further research exploration.

Time on physiotherapy caseload was also significantly longer for individuals who underwent a thoracotomy than for individuals following a VATS incision. Possible reasons for shorter time on physiotherapy caseload following VATS include shorter duration of surgery, therefore less time under anaesthetic, smaller size of incision which potentially leads to less pain reducing analgesia requirements and allowing patients to engage earlier in postoperative breathing exercises and postoperative mobilisation (Flores et al. 2009; Jeon et al. 2013; Medbery et al. 2016; Farjah et al. 2016).

The postoperative day first mobilised was found to be an independent predictor of time on physiotherapy caseload in the univariate analysis but when adjusting for other variables in the multi-variate regression model there was no significant association between day first mobilised and time on physiotherapy caseload. This suggests that other factors were more important predictors of time on physiotherapy caseload than day first mobilised postoperatively. It was anticipated that early postoperative mobilisation may reduce time on physiotherapy caseload by improving lung expansion, reducing the risk of developing postoperative pulmonary complications (PPC) and encouraging earlier independence with mobility (Agostini et al. 2014; Yeung 2016; Tait et al. 2021).

In this service evaluation, individuals with longer chest drain(s) durations had a significantly longer time on physiotherapy caseload. The presence of chest drains can limit postoperative mobilisation and likely results in patients taking longer to reach their mobility goals (Rathinam et al. 2011; Tait et al. 2021). The presence of chest drains may also increase postoperative pain potentially increasing the risk of developing PPCs (Rathinam et al. 2011; Bjerregaard et al. 201; Mesa-Guzman et al. 2015). The main reason chest drains remain in situ following lobectomy surgery is due to an air leak visible in the drain indicating the lung has not re-expanded. Prolonged air leak therefore is a likely cause of prolonged chest drain duration that may also lengthen the requirement for physiotherapy intervention (Mesa-Guzman et al. 2015).

There were several strengths to this service evaluation. We explored an area of physiotherapy practice in our service that has not yet been extensively investigated I the research. Statistical analysis was used to ascertain the significance of patient characteristics and surgery details on time on physiotherapy caseload following lobectomy surgery. The service evaluation was limited by the retrospective collection of data from the physiotherapy ward sheets. This is reliant on accurate data being collected at the time as omissions and abnormalities are hard to check retrospectively. Only patients who received in-patient physiotherapy were included in this service evaluation therefore not all data for patients who underwent lobectomy surgery were captured.

The clinical implications of the current project are for exploration within the service as to whether there are any differences in ward routine and culture between the different cardiothoracic wards. In addition, there is a need to consider providing more intensive physiotherapy input into individuals undergoing lobectomy via thoracotomy incision to help reduce time on physiotherapy caseload. This may involve treating individuals more frequently (twice daily), using the static exercise bike and encouraging early postoperative mobilisation. It may also be beneficial to review chest drain removal procedures and review the type of drains that are being used within the Trust to ascertain whether chest drain duration could be reduced to help patients to mobilise earlier and reduce time on physiotherapy caseload.

Conclusion

Time on physiotherapy caseload was higher for females and for patients with longer chest drain durations. Time on physiotherapy caseload was reduced by having a VATS incision. It was not affected by age.

Reviewing chest drain removal practices, encouraging earlier postoperative mobility and providing more intensive physiotherapy input to individuals following thoracotomy incision are worth exploration to ascertain whether these interventions could reduce time on physiotherapy caseload following lobectomy surgery.

Acknowledgements

Thank you to the Cardiothoracic Physiotherapy Team for their hard work. Thank you to all the thoracic surgeons, medical staff and cardiothoracic nursing staff. Thank you to the Library services, Research and Development Department and the trust statistician at Blackpool Teaching Hospitals NHS Foundation Trust.

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