Preparation of adolescents for outpatient surgery: using an Internet program

AORN Journal,  Feb, 2008  by Susan O'Conner-Von

• E-mail
• Print
• Link

Since the 1980s, dramatic changes have taken place in the delivery of health care in the United States. One major change has been the shift from inpatient to outpatient surgery for children. This change has occurred in response to advances in surgical technology, improvement in anesthetic agents, and the need to cut medical costs. (1,2)

Historically, surgery necessitated lengthy hospitalization. Now, children often are admitted one to two hours before surgery and are discharged within four to six hours after surgery. For the child, outpatient surgery offers several advantages that help to reduce the psychological stress of surgery. These include a shorter stay in the health care setting, decreased separation from family, and less disruption in daily routine. (3) Furthermore, outpatient surgery has been found to decrease the risk of health care-associated infections, be more cost effective, and reduce the number of health care professionals needed per patient. (4) Although there are many benefits of outpatient surgery for children, more responsibility has been placed on parents for presurgery preparation and postoperative care at home. (5)

LITERATURE REVIEW

This study focuses on presurgical preparation of adolescents who will undergo tonsillectomy. A literature search was conducted using the terms tonsillectomy and presurgical preparation.

TONSILLECTOMY. According to Lalakea et al, (6) the shift to outpatient surgery for tonsillectomy began as a result of a 1968 retrospective case review of 40,000 outpatient tonsillectomy procedures conducted by Chiang et al. (7) These researchers found few resultant complications and no deaths from the outpatient procedures. (7) Continued research in the United States and worldwide revealed outpatient tonsillectomies to be a safe procedure for children when performed with strict selection criteria and competent care. (8-12)

Although tonsillectomy with or without adenoidectomy has been one of the most common surgeries for children, (13,14) no research has been published regarding the preparation needs of adolescents undergoing outpatient tonsillectomy. Arguably, "the success of the outpatient experience depends on adequate preparation." (4(p21)

PRESURGICAL PREPARATION. During the past five decades, research has indicated that presurgical preparation benefits children by preventing or reducing their negative responses to surgery. In 1952, a study involving 200 children examined the effects of psychological preparation and parental involvement for the experimental group (n = 100) compared to routine care for the control group (n = 100). (15) Post-discharge negative reactions such as sleep disturbance, tantrums, separation anxiety, and aggressive behavior were seen in 92% of the control group compared to 68% of the experimental group.

In the 1960s, most presurgery preparation programs provided basic information about surgery and encouraged the expression of emotions. (16) The classic studies in 1975 by Visintainer (17) and Wolfe (18) examined the effects of presurgery preparation on the stress response of child patients and their parents, along with adjustment after hospitalization.

Since the mid 1970s, preparation programs using coping models, procedural and sensory information, and medical play have resulted in less anxiety, increased knowledge, and enhanced coping skills in children undergoing surgery. (19-22) Further research has indicated that preparation programs need to be designed to meet the needs of the child's coping style, cognitive and developmental level, and past experience with health care. (23-26) Although some researchers have indicated that it is cost-effective to prepare only those children at high risk for anxiety,

   most professionals in fields related to the psychosocial care of
   children, such as nursing, child life, and social work, agree that
   all children should receive preoperative care. (19(p36))

Results of an integrative review examining preparation of children for surgery revealed that a majority of the studies involved preparation strategies developed for preschool and school-aged children undergoing inpatient surgery. (27) Few studies addressed presurgery preparation considering the developmental needs of adolescents between the ages of 10 and 16 years, such as their

* developing mental awareness,

* ability to process information,

* focus on body image, and

* desire for privacy and self-control.

Although many preparation strategies have been shown to be effective in reducing anxiety for inpatients, few strategies solicit information about patient and parent satisfaction with the method of preparation or use a means to evaluate the effectiveness of the method, especially in outpatient populations. Results of the integrative review confirmed the advantages of preparation before inpatient surgery but revealed a gap in the research addressing the methods of preparation for outpatient surgery in general and for adolescents in particular. The experimental study described in this article was designed to address this gap.