Browsing by Author "Whelan, Megan"

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    The impact of preoperative education on postoperative outcomes in patients with colorectal cancer in Johannesburg, South Africa
    (2024) Whelan, Megan
    The global burden of cancer has increased over the past few decades. Colorectal cancer is one of the most frequently reported cancer types globally. There are a number of lifestylerelated factors described in the literaure linked to risk of colorectal cancer and survival. Surgery remains the top treatment choice (when appropriate) for patients diagnosed with colorectal cancer. Furthermore, patients who have undergone a variety of different cancer treatment methods may experience fatigue and muscle weakness resulting in reduced physical function. There is literature describing the use of preoperative physiotherapy interventions (rehabilitation and education strategies) for patients undergoing abdominal surgery for various pathologies. However, there is a paucity of literature describing the use of preoperative education by physiotherapists for patients undergoing abdominal surgery for coloretal cancer specifically. This thesis describes the profile of patients with colorectal cancer in urban Johannesburg South Africa and further describes those who underwent surgical resection. Secondly, a physiotherapy preoperative education programme was developed using a variety of research methods. Finally the impact and feasibility of the programme was tested in a randomised pilot study for patients who underwent colorectal cancer resection at a private hospital in Johannesburg South Africa. Paper 1 (Chapter 3) includes a secondary analysis and retrospective review of a database of patients who were diagnosed with colorectal cancer at institutions forming part of the University of the Witwatersrand Academic Teaching Complex. The aim was to determine the demographic, functional and clinical profile of the patients included in the database. The review further aimed to identify modifiable factors linked with colorectal cancer and to determine the relationship between these risk factors and survival. Data from the public sector was compared with data from the private sector. The results showed that patients in the private sector cohort were older, had earlier stages of cancer, had a higher percentage of alcohol consumption and had higher survival rates than the public sector cohort. Furthermore, waist circumfrence was shown to have a large-strength effect on survival across the whole cohort. Paper 2 (Chapter 4) aimed to further investigate the patients included in the database who had surgical resection for their colorectal cancer in the private sector cohort. The surgical and functional profiles of the patients were identified. Predictors of post-surgical outcomes were determined using regression analysis statistics. One hundred and twenty five patients were included in the review. Postoperative paralytic ileus and surgical site infections accounted for the most postoperative complications that were reported. Preoperative vigorous-intensity exercise and functional performance status were the significant predictors of hospital length of stay and incidence of postoperative complications in patients who underwent abdominal surgery for colorectal cancer at one private hospital in Johanesburg, South Africa. Paper 3 (Chapter 5) describes the start of the development of a physiotherapy preoperative education programme framework for patients undergoing abdominal surgery for colorectal cancer. Firstly, five databases were screened and a narrative review was performed to determine the evidence available regarding the timing, content, mode of delivery and setting of preoperative education delivered by physiotherapists for patients who underwent abdominal surgery for various pathologies. Seventeen studies were included in the review. The content included in the programmes described in the literature inclues breathing exercises, coughing techniques, verbal advice, physical exercises, surgical information, postoperative pain management, nutritional support, relaxation techniques and information about postoperative complications. Secondly, physiotherapists working in surgical intensive care units and high care units in Johannesburg were purposively sampled to participate in a focus group session. The nominal group technique was used with the goal to reach consensus on the proposed content of a preoperative education programme for patients undergoing abdominal surgery for colorectal resection. The author used the results of the narrative review and the focus group session to develop a famework for preoperative physiotherapy education for this patient population. Paper 4 (Chapter 6) describes the use of a modified Delphi study to obtain expert insight into the content of peoperative education that could be provided to patients undergoing colorectal cancer resection. A panel consisting of international physiotherapy clinicians and academics working in the field of surgery, oncology or a combination of both were invited to participate in a two-round Delphi study. The survey developed was based on information gathered from the retrospective database review, narrative review and the focus group session. Consensus was set at 70%. The initial survey consisted on 36 statements. Statements not achieving consensus after the first round were modified and new statements added to the second round survey depending on patient feedback. Seventeen experts were invited to participate. Eight responded to the first round survey and seven responded to the second round survey. Thirty one stataments reached consensus after both rounds which fell under the following categories: wound/pain, rehabilitation, respiratory considerations, cancer considerations, medical and surgical journey, and other consideratons. Paper 5 (Chapter 7) describes the use of a pilot study to test the impact and feasibility of a preoperative physiotherapy education programme for patients undergoing abdominal surgery for colorectal cancer. Firstly, a reliability study was perfomed to establish interrater reliability of the research assistants who were to assist with data collection in the pilot study. Three research assistants performed assessments using two outcome measures on five healthy control participants. Interrater reliability was measured using the intraclass correlation coefficient using Cronbach’s alpha. The results showed that two of the three research assistants demonstrated excellent interrater reliability using the Six minute walk test and the Short Physical Performance Battery. Secondly, a randomised pilot study was perfomed on patients who underwent open abdominal surgery at a private hospital in Johannesburg. Participants who met the inclusion criteria were randomised into one of three groups: a control group, intervention group one (patients received a written education pamphlet) and intervention group two (patients received a written educaton pamphlet as well as a face-toface education session). Assessments were performed preoperatively, at discharge from the intensive care unit and at hospital discharge. Outcomes measured were hospital length of stay and postoperative complications that developed. Due to very low recruitment rates over the five-month study period, only one patient was included in the pilot study. The patient was randomised into the control group which meant that the impact of the education programme could not be assessed. However, the feasibility of the programme was assessed addressing the practicality and integration aspects. A number of limitations of the various studies were identified and described in the relevant chapters in the thesis. In conclusion, the profile of South African patients with colorectal cancer described in this thesis highlighted risk factors associated with survival and poor postoperative outcomes. A preoperative physiotherapy education programme was developed and tested. Issues were identified regarding the feasibility of implementing the programme in patients undergoing colorectal cancer resection at a private academic hospital in Johannesburg, South Africa
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    The use of the CPAX tool in a South African intensive care unit: clinical outcomes and physiotherapists' perceptions
    (2017) Whelan, Megan
    Background: There is limited research available on the use of outcome measures in intensive care units (ICU) in a South African setting.The Chelsea Critical Care Physical Assessment tool (CPAx) is a measure of morbidity related to physical function and assesses respiratory function and functional abilities of critically ill patients. Objectives: The objectives of this study were to establish the effect of the use of the CPAx tool on ICU and hospital length of stay (LOS) in the care of critically ill patients; to establish the usefulness of the CPAx tool according to patient admission diagnosis; to determine if a relationship exists between CPAx scores and severity of illness or general morbidity during ICU admission; and to establish physiotherapists’ perceptions and views towards the use of the CPAx tool in their daily clinical practice in ICU. Design: The study consisted of two parts. Part one was a quasi-experimental design with a historical matched control group. Part two was a survey-based design. Methods: The study took place in a South African public sector hospital. Twenty six participants each were recruited into the experimental and control groups. Participants from the control group were matched with participants in the experimental group according to age, gender, diagnosis and acute physiology and chronic health evaluation (APACHE) II scores. CPAx scores and sequential organ failure assessment (SOFA) scores were calculated for participants in the experimental group on alternate weekdays during their ICU stay. Comparisons of ICU and hospital LOS between the study participants and historical control group were done using an independent t-test. Pearson’s correlation coefficient was used to determine if a relationship existed between CPAx scores, APACHE II scores or SOFA scores. A p-value ≤ 0.05 was deemed statistically significant. A questionnaire was developed and was completed by the research assistants who administered the CPAx tool to participants in the experimental group in order to determine their perceptions of the tool. Results: The mean age for the CPAx group was 37.88 (±13.37) years and for the control group was 37.81 (±12.21) years. The CPAx group consisted of 14 (53.8%) participants who underwent surgical procedures and 12 (46.2%) participants with traumatic orthopaedic injuries. The control group consisted of 14 (53.8%) participants who underwent surgical procedures and 12 (46.2%) participants with traumatic orthopaedic injuries. The mean initial SOFA score for the CPAx group was 2.42 (±1.79) and for the control group was 4.15 (±2.6). A p=0.03 indicates that there was a statistically significant difference between the two groups with regards to initial SOFA scores. The mean SOFA score at ICU discharge for the CPAx group was 1.80 (±0.42) and for the control group was 2.87 (±1.81). A p=0.05 indicates that there was a statistically significant difference between the two groups with regards to SOFA scores at ICU discharge. The mean initial CPAx score for the experimental group was 29.73 points (±14.81) and the mean CPAx score at ICU discharge was 36.15 (±8.33). The mean CPAx scores changed by 9.45 points between admission and discharge from ICU for participants who underwent surgical procedures and the mean CPAx scores changed by 3.9 points between admission and discharge from ICU for participants who sustained traumatic orthopaedic injuries. The mean ICU LOS for the CPAx group was 5.84 days (±7.43) and for the control group was 4.56 days (±5.25). The mean hospital LOS for the CPAx group was 17.43 (±16.68) days and for the control group was 19.31 days (±15.79); however, in both cases differences were not statistically significant. APACHE II scores had a very weak negative correlation with initial CPAx scores. APACHE II scores had a very weak positive correlation with CPAx scores at ICU discharge. There was a statistically significant difference between the two groups with regards to initial SOFA scores (p=0.05). Initial SOFA scores had a statistically significant moderate negative correlation with initial CPAx scores (r=-0.45, p=0.02). Initial SOFA scores had a weak negative correlation with CPAx scores at ICU discharge. Initial CPAx scores had a moderate positive correlation with SOFA scores at ICU discharge. CPAx scores at ICU discharge had a very strong statistically significant positive correlation with SOFA scores at ICU discharge (r=0.80, p=0.05).The CPAx tool proved to be more responsive in a surgical population than in a trauma population. Clinicians had positive perceptions of the CPAx tool in the management of critically ill patients. Discussion: Participants in the CPAx group were well matched with those in the historical control group with regards to age, gender, diagnoses and severity of illness. Those in the CPAx group had lower extent of organ dysfunction than those in the control group which might account for their shorter period of hospitalisation. Patients with a higher risk for mortality on admission into the ICU displayed lower functional abilities and, in turn, lower CPAx scores were measured. A greater change in CPAx scores was observed for participants recovering from surgical interventions compared to those recovering from traumatic orthopaedic injuries. Participants with low morbidity at the time of ICU admission seemed to have a greater ability to perform functional activities during their ICU stay. Limitations of the study included a small patient sample, a limited number of research assistants as well as lack of content validation of the questionnaire used. A multi-centre trial on the use of CPAx in ICU patient management could yield a wider perception of physiotherapists regarding the usefulness of the tool in daily clinical practice. Measuring the effect of the CPAx tool on participants’ length of mechanical ventilation could also be an interesting clinical outcome to consider. Conclusion: The data presented in this study show that the use of the CPAx tool does not have an influence on ICU and hospital LOS in a small sample of surgical and trauma participants. The tool appears to be more useful when used in the care of patients who are recovering from surgical procedures rather than those who sustained complex traumatic injuries. Physiotherapy clinicians that participated in the study supported the use of the CPAx tool in this single-centre trial and generally had positive perceptions towards the use of the tool.