Construction of sensitive quality indicators for rapid rehabilitation care of patients after combined pancreaticoduodenectomy

We selected relevant healthcare experts who were engaged in tertiary hospitals in different regions of China and had rich clinical experience in the field of pancreatic diseases. The inclusion criteria were: ① Those holding an associate’s degree or above, or a master’s degree; ② Clinical nursing experts, nursing managers, medical experts, and rehabilitation experts with relevant working experience in pancreatic surgery; ③ Those with > 10 years of experience in pancreatic surgeries, and ④ Individuals with informed consent and voluntary participation. The exclusion criteria were: ① Those who withdrew in the middle of the correspondence and ② Experts who filled in the questionnaires incorrectly. Additionally, only 15–50 experts can participate in a Delphi expert consultation [24]. Considering the research resources and the actual demand for correspondence, we included 18 experts from different related fields. Among them, 6 (33.33%) were clinical care experts, 5 (27.78%) were care managers, 5 (27.28%) were medical experts, and 2 (11.11%) were rehabilitation experts. Table 1 shows the expert panel’s demographics from Delphi.

According to the elements of evaluation indicators obtained in the initial drafting, an expert correspondence questionnaire on sensitive quality indicators for rapid rehabilitation care after pancreaticoduodenectomy was formed, which consisted of two parts: the first part was an expert consultation form for the evaluation of the system of sensitive quality indicators for rapid rehabilitation care after pancreaticoduodenectomy, which included the introduction of the preamble and the rating scale for the importance of the entries; and the second part was a correspondence questionnaire for the experts’ relevant information, which included the general expert information, expert judgement basis questionnaire and expert familiarity questionnaire. The researcher distributed the questionnaires to the experts on-site or by email, and the experts rated the importance of each item on a 5-point Likert scale. In this study, two rounds of correspondence questionnaires were conducted. After the first round of correspondence questionnaires were collected, the second round of correspondence questionnaires was formed by members of the research team after fully discussing and modifying the relevant items according to the experts’ opinions, and the above constructed system of sensitive quality indexes of rapid rehabilitation nursing care after pancreaticoduodenal resection was further revised and improved with reference to the results of the correspondence questionnaires(The first and second rounds of correspondence questionnaires are described in more detail in Supplements 1 and 2, the supplementary materials to this paper). The inclusion criteria for the entries were set as follows: the mean number of importance assignment was > 3.5, and the coefficient of variation was < 0.25.

SPSS 22.0 statistical software was used for processing, and all data were entered by double entry. Descriptive analyses were expressed in terms of frequency, constitutive ratio, mean, and standard deviation; the degree of expert positivity was expressed by the effective recovery rate of the questionnaire; expert authority was judged by the basis of judgement and the expert’s familiarity with the issue; and the degree of coordination of expert opinions was expressed by the Kendall’s harmony coefficient.

Ethical approval: Not applicable. Participants provided their informed consent; moreover, participants were assured of the anonymity and confidentiality of their data.

In this study, 18 questionnaires were distributed in the two rounds of expert consultation. All of the questionnaires were successfully retrieved, with an effective recovery rate of 100%, indicating that the participating experts were highly motivated. The Cr value of the authority coefficient of the experts in the two correspondence rounds was ≥ 0.80, of which the Cr values of the first and second correspondence rounds were 0.859 and 0.872, respectively. This indicated that the experts’ authority was high, and the results were more credible.

Our results showed a high degree of harmonization of expert opinions, with coefficients of variation ranging from 0 to 0.157 for the two expert correspondence rounds, both < 0.25 as seen in Table 2.

At the end of the first expert consultation round, the indicators were organized based on the criteria for selecting indicators, the experts’ opinions, and the study group’s discussion results. (1) Revisions of four indicators: Revision of the secondary indicator’s “complication rate” to “complication rate after PD” and “unplanned readmission rate within three months” to “unplanned readmission rate within one month”; Revision of the secondary indicator’s “complication rate” to “unplanned readmission rate within one month” while “unplanned readmission rate within three months” was revised to “unplanned readmission rate within one month”; the tertiary indicator’s “medical care ratio” was revised to “bed care ratio”, “pancreatic specialty ratio” was changed to “bed care ratio”, and “The percentage of pancreatic specialist nurses was revised to “ERAS working group”; (2) Deletion of nine indicators: the deleted indicators were “implementation rate of continuing education for nursing staff on rapid rehabilitation of pancreatic cancer”, “norms and standards related to rapid rehabilitation nursing care after PD”, “functional room for rehabilitation training”, “patient’s high-risk medication”, “specification for safe management of patients’ high-risk drug administration”, “knowledge rate of wound care routines”, “coverage rate of specialized training”, “vital signs, 24 h in and out, drainage fluid observation and record”, and “pulmonary rehabilitation training implementation rate”; (3) Addition of eight indicators: the new indicators were “voluntary cough strength compliance rate”, “inpatient mortality rate”, “early activity implementation rate”, “risk assessment implementation rate”, “blood glucose management standard rate”, “airway management technology implementation rate”, “VTE prevention measures implementation rate”, and “nutritional target intake attainment rate”.

At the end of the second expert consultation round, all indicators met the screening criteria, and two indicators were revised per the experts’ recommendations, with the tertiary indicator, “dynamic monitoring and assessment of pain” revised to “implementation rate of pain assessment” and the secondary indicator “negative emotional guidance” revised to “rehabilitation guidance”. Furthermore, the level 3 indicator “dynamic monitoring and assessment of pain” was changed to “implementation rate of pain assessment”, and the level 2 indicator “guidance on negative emotions” was revised to “incidence of moderate to severe emotional distress”. Finally, we established a sensitive indicator system for patients’ rapid rehabilitation care after PD, including 3 primary, 12 secondary, and 23 tertiary indicators, respectively. Hierarchical analysis was applied to calculate the weights of all indicators, and their consistency ratios at each level were < 0.1, indicating that the weights were set reasonably. Table 3 shows the specific results of the indicator system for patients’ rapid rehabilitation.

The four secondary indicators, with the highest weighted indicator being human resources (0.059), highlight the important role played by the ERAS working group members in the management of rapid rehabilitation care after combined PD.

In clinical practice, an ERAS team can ensure that each program is duly implemented to provide accurate and personalized patient management, improve patient compliance, and facilitate patient recovery [27]. This is underpinned by other two secondary indicators, teaching and training (0.042) and environmental equipment (0.033), that showed that most nurses currently have an incomplete knowledge structure regarding ERAS [10], and the cognitive aspects of ERAS are still at an intermediate level. Therefore, nursing managers should provide nurses with specialty knowledge and skills training and regularly organize diversified continuing education training through a multidisciplinary collaborative ERAS working group. This can effectively promote their specialty knowledge framework and improve the standard of nursing skills to guide the scientific development of rapid rehabilitation nursing activities after PD effectively.

The process indicator had the largest weight (0.574) among the primary indicators while the secondary indicator with the highest weight was disease care (0.298), indicating that this component was an important part of the process indicator and agreeing with the current concept of rapid rehabilitation surgical care. The high complication and mortality rates after combined PD make postoperative disease care extremely important. Studies have shown that the implementation of a scientific postoperative nursing protocol for combined PD cases can effectively reduce postoperative mortality [28]. Apart from focusing on strengthening nurses’ specialty knowledge and evaluating practical skills, nursing managers should also strengthen nurses’ quality control during the disease care process and strictly follow the standardized and regulated nursing practice protocol for ensuring patient safety and improving the quality of care. After goal-directed fluid management is done, near-zero fluid balance and avoidance of salt, as well as water overload, can improve the outcomes. Hence, the promotion of early recovery of patients [29‐32] was included in the “Goal-Oriented Individualised Fluid Management Compliance Rate”. Thromboembolism is one of the major causes of death after carcinogenesis, and deep vein thrombosis (DVT) occurs in about 3–8% of PD patients [33]. Hence, VTE prophylaxis should be strictly implemented postoperatively. Postoperative hyperglycemia is also associated with postoperative complications in PD [34], and reducing the hyperglycemia rate in surgical patients can further diminish the incidence of complications [35, 36]. Since the early resumption of a normal diet postoperatively can reduce complication rates and enhance rapid recovery, an oral diet may be the preferred feeding routine after PD. Early oral feeding is a safe, feasible, and tolerable procedure without increasing postoperative complications in PD [37, 38], in combination with good nutrition-related guidance from nurses. The next two secondary indicators were rehabilitation guidance (0.142) and emotion management (0.134). Early postoperative care can prevent pain and bowel obstruction in patients and is also associated with improved functional independence, mental health, level of consciousness, and cardiovascular as well as respiratory function [39], so timely rehabilitation activities should be undertaken. The timely implementation of effective rehabilitation instructions can ensure that rapid patient recovery is achieved, and scientific rehabilitation measures can effectively reduce the risk of complications after combined PD. Although effective airway management techniques like pulmonary function rehabilitation, exercises, and nebulization therapy can promote the patient’s voluntary coughing with strength, they can greatly reduce the occurrence of postoperative lung infections. Since nursing practice measures are always a core element of nursing care; thus, the rate of early mobilization can be monitored quantitatively to prevent the development of VTE in combined PD cases. Health knowledge beliefs are a crucial basis for promoting health behaviors, and studies have shown that such patients and their families lack knowledge related to early postoperative activities, and overall compliance is low. Hence, nursing staff should improve their professional knowledge in their daily work, in addition to enriching the health promotion methods, to meet the health needs of patients, effectively prevent the occurrence of postoperative complications, and improve the quality of care.

The top three weights of the outcome indicators were mortality (0.062), satisfaction (0.060), and unplanned readmission rate (0.054), respectively. Firstly, adverse patient outcomes, as an important indicator of quality evaluation of nursing management, not only seriously threaten the lives and health safety of patients and aggravate the economic burden, but the patient mortality rate can also directly evaluate the effectiveness of postoperative care. Secondly, patient satisfaction, as an important indicator of quality assessment of quality nursing services, suggests that nursing staff, as the core of nursing practice, should always practice the service concept of “patient-centered” when implementing nursing services to effectively improve patient satisfaction. Furthermore, the unplanned readmission rate can effectively evaluate the nursing care quality. Therefore, nursing staff must devise relevant strategies that can be incorporated into their daily nursing work, block the admission risk factors, reduce admission rates, and follow up on patients who have already been readmitted to provide timely intervention and improve the patient’s quality of life.