Feasibility of digital application-based information and follow-up in day-care surgery

Globally, a notable surge has been seen in the introduction of digital, electronic and mobile-health solutions over the past decade, with mounting evidence of digital follow-up after hospital treatment being primarily positive. This encompasses patient interest in follow-up through applications [1], satisfaction with digital application-based follow-up [2, 3], technical feasibility [4, 5], staff willingness to engage in digital care [6], cost-effective utilization of hospital resources [7-9], improved personalised pain management [10] and the potential to reduce readmissions [11].

A qualitative study exploring patients' experiences with post-operative recovery after day care surgery emphasised the importance of patients feeling safe, reassured and acknowledged during the post-operative recovery period [12]. The study found this feasible with sufficient support and information from their healthcare organisation. Additionally, the use of a mobile app, both for assessment and to facilitate contact with the day surgery unit during the post-operative recovery period, improved cohesion of care and alleviated feelings of post-operative isolation [12]. Systematic e-assessment can enhance patients' subjective sense of recovery and identify key areas for improvement in perioperative care [13]. Additionally, allowing patients to autonomously decide when and if they need contact and support does not increase the frequency of contacts [14].

Following the implementation of a novel interactive mobile health platform for evaluating functional outcomes and pain, Khanwalkar et al. achieved a response rate of 85.6% from patients who reported outcome measures digitally [15], whereas other studies found response rates in the 35-70% range [16]. Warren-Stomberg et al. found that, despite expressed interest in digital follow-up, the non-response in clinical testing accounted for half of the patients included [1].

Evidence supports the potential of mobile apps to enhance compliance, facilitate more frequent and timely collection of patient-reported outcomes with minimal resource use and seamless integration into daily care routines [17]. Furthermore, these apps have demonstrated improvements in outcome measures compared to standard care discharge, reinforcing their potential to enhance overall patient care [18].

To our knowledge, this is the only integrated post-operative pain assistant developed for use within an already existing charting system, where all data and communication are captured and handled alongside all other charting data. Furthermore, we found no published studies of Danish mobile pain-based follow-up or any formal scientific knowledge on overall patient experience of pain and minor comforts immediately after discharge from day-care surgery in Denmark. Furthermore, if feasible, this solution has the potential to continuously obtain data on patient-reported outcomes and pain experiences.

As the international experiences suggest that e-health solutions are highly viable, our primary aim was to evaluate whether the implementation of a digital smartphone application is a feasible follow-up tool after ambulatory surgery. Our secondary aim was to investigate whether it may be implemented within the existing charting system, Sundhedsplatformen (the Danish version of Epic), workplace organisational structures and staff resources.

Methods

Study design

This feasibility study adheres to the framework outlined by Bowen et al. [19], incorporating defined feasibility domains, measures and criteria to determine success. Domains were chosen and adapted to this setting within the areas of “Population”, “Acceptance”. “Integration”. “Practicality”, “Critical Adaptation”, “Demand”, “Adherence” and “Implementation”. Furthermore, the success criteria were determined by discussion in the study group before the study was conducted (Table 1).

Participants

Inclusion: Patients 15 years or older, scheduled for ear-nose-throat same-day procedures at an outpatient surgery ward at a tertiary university hospital in Eastern Denmark. Inclusion required possession of a private smartphone with an activated MinSP app.

Procedures: Three primary categories: sinus, otologic and auditory implantation surgery.

Exclusion: Patients who did not wish to or were unable to participate (non-Danish speaking, surgery cancelled).

Intervention

A digital pain application was automatically allocated to all eligible patients in the charting system (Sundhedsplatformen), including an application (MinSP) allowing patients to access their own chart and communicate with staff. The intervention (see Appendix A) was developed by a pain unit and offered video-based patient information, post-operative inquiries on pain, analgesics, nausea, whether the patient could handle the pain and whether the patient required a phone call from staff within seven post-operative days after discharge.

All patients received standard follow-up care. Digital follow-up was offered as an additional option.

Data collection

Data were drawn anonymously and in aggregated form from the reporting system in Sundhedsplatformen, so individual patient charts were not accessed. As formal hospital leadership approval of the project was obtained, hospital policy allows for the analysis and presentation of data. Informed consent was not required.

Statistical analysis

Simple, transparent mathematical processing with numbers and percentages for meeting set the criteria. Demographic descriptions of age (average and range) were recorded, as were binary judicial gender.

Practical execution of the study

The study was executed following a detailed plan, involving leadership meetings, workflow adaptation, educational sessions and comprehensive information dissemination through accessible channels. Patient and staff manuals were developed and tested for electronic designated workflows. On-site and tele-support were provided, and quick access to building teams was ensured for the correction of flaws and errors. Execution was overseen and driven by the Pain Unit.

Staff workflow

Ambulatory office nursing staff played a pivotal role in patient information and follow-up on post-operative days 2-7 (see Appendix B). Access to the charting system was used only for follow-up and to document actions.

Daycare nursing staff were designated to remind patients of the digital follow-up upon arrival and discharge from the hospital on the day of surgery and to handle follow-up on the first post-operative day.

Results

A total of 491 patients met the inclusion criteria. Among these, 201 wished to participate and were given access to the solution (Figure 1). Due to an unknown error in the SP workflows, 279 patients were not automatically given access to the solution as expected. This unfortunately had a negative impact on our overall allocation results. Looking into the proposed domains for feasibility, the chosen criteria for success were not met, as illustrated by the result on complete implementation. Thus, the proportion of patients meeting the domains of Practicality, Demand, Critical adaption and Adherence was as low as 7.7% (Table 2).

When focusing on the included patients who did have access to the solution (n = 201), both men and women were included almost equally, with an average age of 31 years (Table 3); 18.9-27.9% viewed the information videos about digital follow-up, and 29.4-42.8% viewed the health-related videos (Table 3). In all, 137 patients (68.1%) completed at least one inquiry or questionnaire within the seven-day follow-up period (63.8 within the first three post-operative days). Among these patients, 54 (26.9%) requested a phone call and 13 (6.2%) answered that they “could not cope with post-operative pain”, which also elicited a phone call. A total of 67 patients received a phone call. All requests for a phone call from staff were met and documented (Table 3).

Discussion

The conversion of surgical procedures into ambulatory surgery represents a strategic approach to optimising hospital resources, thereby increasing the capacity to accommodate a larger number of patients. Escalation in the complexity of ambulatory procedures underscores the need for effective post-operative follow-up and information, particularly in the immediate post-operative period. During this phase, patients are discharged and expected to assume responsibility for their post-surgery care, diverging from the traditional model of hospitalisation with continuous care of healthcare professionals. Given that direct contact with health professionals is primarily initiated by patients in the immediate post-operative period, executing high-flow, same-day surgery demands viable means of disseminating patient information, ensuring accessible communication and instilling a sense of security. A digital application, as proposed by this pain assistant, may represent a feasible means to provide patients with easy access to staff and report outcomes when at home, as they appeared able to navigate and utilise the features of the digital solution and content to engage in digital follow-up.

Although 491 patients met the inclusion criteria, only 201 (41.9%) were included. Assuming that automatic allocation based on defined patient- and procedure-specific criteria would secure allocation to all eligible patients proved misleading. The initial edition of the pain assistant in Sundhedsplatformen was built to capture all eligible patients based on set age criteria, booking type and surgical field and validated by the builders in a subtext of the system. However, during the study, automatic allocation was inconsistent and several patients were missed due to an unknown error.

This technical error adversely affected the feasibility outcomes, as detailed in Table 2. Technical feasibility is therefore limited, unless this issue is addressed in future implementations. However, among patients who had access to the solution, feasibility outcomes were more favourable, although the implementation did not fully meet the success criteria defined by the study group. However, patients showed considerable interest in the solution, with a high acceptance rate (201/212 = 95%), although this rate might have been lower had all the patients been allocated the solution. These response rates were broadly consistent with international experiences [16]. Although they were slightly lower than those reported by Khanwalkar et al. [20], our results indicate that patients recognised the application’s functionality and opportunities and, to a large extent, were able to utilise its features as needed.

No formal registration of work hours was conducted for analogue patient-initiated follow-up before implementation of the digital solution; staff subjectively reported that digital follow-up was performed without requiring additional resource. Furthermore, they deemed all inquiries for a phone call to be relevant.

Among allocated patients, use of the features varied: some completed one or more health questionnaires or requested phone calls, but they did not systematically watch all videos or complete all questionnaires. We interpret this to mean that the patients only used the possibility and information if they perceived it to be necessary. This corresponds with Stomberg et al. [5] who found that although expressed interest in digital follow-up was high, this was not fully reflected in a clinical study testing a mobile app for post-operative follow-up. In an era of abundant, easily accessible online information, we found the interaction noteworthy, demonstrating the need for interaction with the staff. We therefore argue that the application is a feasible solution. However, to document this, the feasibility criteria must be revised for validity to accommodate user variance and relevance.

As part of separate studies on patient satisfaction, we concurrently conducted a voluntary, web-based, validated questionnaire survey. The survey assessed satisfaction with digital follow-up, the video-based content of the application and overall satisfaction with the care pathway. While the results will form the basis of a future publication, preliminary findings showed that patients were generally very satisfied with the digital pathway and its content. However, participants reported several technical issues related to functionality and expressed a need for more information about the surgical procedure, specific operative details and guidelines regarding the surgical site and wound care.

Promoting the activation of “MinSP” by all patients remains a continuous focus in both regions. Over time, we expect electronic health literacy in the population to improve, supporting a wider adoption of digital and application-based tools in healthcare. The proposed solution is readily applicable across most surgical fields and patient groups, free of charge and feasible within existing personnel resources.

Further studies are in progress as we aim to validate the solution in a randomised clinical trial, where the solution will be used by a group of patients undergoing surgery at a secondary spine unit.

Conclusions

Converting standard procedures for post-operative follow-up on pain and minor discomforts in the immediate period after discharge into a digital, systematic application-based solution may be feasible and implemented within the hospital system's existing digital structures and staff resources; however, further research and technical assistance are required to validate the solution.

Staff commonly reported that follow-up did not require more attention than previously, and that the amount and content of patient inquiries were considered relevant. However, ensuring patient access to the solution is fundamental for successful implementation.

Data sharing statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.