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Knight J et al (2018) Effects of bedrest 1: introduction and the cardiovascular

system. Nursing Times [online]; 114: 12, 55-58.

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Knight J et al (2019) Effects of bedrest 2: respiratory and haematological

systems. Nursing Times; 115: 1, 44-47.

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Knight J et al (2018) Effects of bedrest 3: gastrointestinal, endocrine and

nervous systems. Nursing Times; 115: 2, 50-53.

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Knight J et al (2019) Effects of bedrest 4: renal, reproductive and immune

systems. Nursing Times; 115: 3, 47-50.

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Knight J et al (2019) Effects of bedrest 5: the muscles, joints and mobility.

Nursing Times; 115: 4, 54-57.

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Knight J et al (2019) Effects of bedrest 6: bones, skin, self-concept and

self-esteem. Nursing Times; 115: 5, 56-59.

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What is a Pressure Ulcer?

Pressure ulcers are commonly known as pressure sores or bed sores, and they most often affect people confined to bed or a chair. Pressure ulcers can vary in appearance and can be superficial or deep. Skin may be intact, appear as an abrasion or a deep opening in the skin. They usually occur over bony prominences such as the base of the spine, buttocks, heels or hips.

How is it caused?

Pressure ulcer forms where bones cause the greatest force on the skin. This results in localised damage to the skin and underlying skin, and is usually caused by:

Pressure - caused by sitting or lying in one position for too long

Shearing - caused by the body sliding down the bed or chair

Friction - caused by skin rubbing on the bed or chair.

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Pressure ulcers are commonly known as pressure sores or bed sores, and they most often affect people confined to bed or a chair. Pressure ulcers can vary in appearance and can be superficial or deep. Skin may be intact, appear as an abrasion or a deep opening in the skin.

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We and our partners use cookies to personalize your experience, to show you ads based on your interests, and for measurement and analytics purposes. By using our website and our services, you agree to our use of cookies as described in our Cookie Policy.

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Constipation: how nurses can help their patients

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Listen to this episode from Nursing Standard Podcast on Spotify. Head of gastrointestinal nurse education Jennie Burch speaks to senior nurse editor Richard Hatchett about the causes of constipation, preventive tips and how nurses can help their patients. See acast.com/privacy for privacy and opt-out information.

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Avoiding deconditioning - Arora A and Dolan B book chapter from 

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Avoiding deconditioning - Arora A and Dolan B book chapter from 

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O’Hanlon S, Smith M (2021) A Comprehensive guide to rehabilitation of the older adult 4th Ed Elsevier

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Early Ambulation versus Bed Rest for Patients with PE or DVT - Students 4 Best Evidence

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This is a summary of a systematic review on using early ambulation as a treatment for pulmonary embolism (PE) and deep vein thrombosis (DVT).

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All NICE products on constipation. Includes any guidance, advice, NICE Pathways and quality standards.

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DVT prevention - hospital advice example

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DVT prevention - hospital advice example

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Graduated Compression Stockings

Some patients benefit from wearing stockings, particularly after an operation.
These should be worn all the time you are immobile but should be removed at least daily to check that the skin underneath particularly on the heel is not becoming sore, and to allow for washing.

Oral Anticoagulants

For some conditions particularly hip and knee replacements you may be prescribed a tablet to take, to prevent blood clots from forming.

# data[].attributes.attachment_link.description
Graduated Compression Stockings Some patients benefit from wearing stockings, particularly after an operation. These should be worn all the time you are immobile but should be removed at least daily to check that the skin underneath particularly on the heel is not becoming sore, and to allow for washing.

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Unfortunately, chest infections can be more likely in people with asthma, and they can make your asthma symptoms worse because they make your airways inflamed.

Asthma causes inflammation anyway, so if you get a chest infection (like pneumonia or bronchitis) it leads to a double whammy of extra inflammation and coughing, wheezing and breathlessness.

That's why the best thing you can do is to use your preventer inhaler, as it's made to calm down the inflammation in your airways. Taking it every day as prescribed will reduce your asthma symptoms and may make your chest infection a lot more bearable.

Is it asthma or a chest infection?

Some chest infection symptoms can feel like asthma symptoms - like coughing, wheezing and breathlessness. So, it can be hard to tell whether you have a chest infection, or if it's your asthma symptoms getting worse (if your asthma symptoms do get worse, you need to take action, don't ignore them).

If you have some, or all, of these symptoms, it might be a chest infection:

A chesty wet cough

Lots of yellow or green phlegm that is thick, and may be smelly

Chest pain or discomfort

A high temperature of 38 degrees or above

Aching muscles

Tiredness

The difference between a chest infection cough and an asthma cough

In comparison to a dry asthma cough, a chest infection cough is wet and you might cough up phlegm. Some people with asthma say they feel a wet chest infection cough 'in their chest' more, whereas a dry 'asthma cough' irritates their throat.

The cough from a chest infection is usually the last symptom to go and could last up to three weeks. But if you have asthma, you might find you've still got a dry cough even after your chest infection has cleared up. This might be a sign that your airways are still inflamed, and it's worth seeing your doctor and being extra careful.

Your doctor will take your peak flow and ask whether your cough seems to get better when you take your asthma medication. This will help them work out whether the cough is due to asthma or the after-effects of the chest infection.

If you've not been diagnosed with asthma, and if you've had a cough for more than three weeks, it could be that you have asthma or another lung condition rather than a chest infection. They need different treatments, so it's important to get the right diagnosis - go and see your GP. Find out more about diagnosing asthma.

When else to see your doctor about a chest infection

If your chest infection is making your asthma symptoms worse. Your doctor might give you a course of steroid tablets to treat the flare up.

If your asthma is waking you at night.

If you feel like your chest infection has cleared up, but you're still having asthma symptoms, such as a cough, wheeze or breathlessness.

If your reliever medication isn't lasting for four hours, this is an emergency and you need to see a doctor right away.
Last updated February 2018 Next review due February 2021

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Chest infections can be more likely in people with asthma. Asthma causes inflammation anyway, so if you get a chest infection (like pneumonia or bronchitis) it leads to a double whammy of extra inflammation in your lungs and coughing, wheezing and breathlessness.

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pressure ulcers

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Pressure Ulcer Reporting and Investigation - All Wales Guidance Final NOV2017

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Megan Melnyk, MSc, MD, Rowan G. Casey, MBChB, MD, FRCS(Urol), Peter Black, MD, FRCSC, FACS, and Anthony J. Koupparis, MBChB MD FRCS(Urol)

Abstract

Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.

The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.

Introduction

Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Overall complication rates have been reported as high as 64% at 90 days, with an average in-patient stay of 17.4 days.

Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining pre-operative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. ⁻ Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes,, they challenge traditional surgical doctrine, and as a result their implementation has been slow. Although much of the data arise from colorectal surgery, the evidence is applicable to major urological surgery, in particular radical cystectomy. The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.

What is ERAS?

Initiated by Professor Henrik Kehlet in the 1990s, ERAS, enhanced recovery programs (ERPs) or "fast-track" programs have become an important focus of perioperative management after colorectal surgery, vascular surgery, thoracic surgery and more recently radical cystectomy.,, These programs attempt to modify the physiological and psychological responses to major surgery, and have been shown to lead to a reduction in complications and hospital stay, improvements in cardiopulmonary function, earlier return of bowel function and earlier resumption of normal activities., The key principles of the ERAS protocol include pre-operative counselling, preoperative nutrition, avoidance of perioperative fasting and carbohydrate loading up to 2 hours preoperatively, standardized anesthetic and analgesic regimens (epidural and non-opiod analgesia) and early mobilization (). There are relatively few reports on the use of ERAS in urological surgery. The introduction of ERAS in a centre in the United Kingdom lead to a significant reduction in hospital stay and equivalent morbidity in radical cystectomy patients, compared to traditional approaches., The protocol focused on reduced bowel preparation, standardized feeding schedule and standardized analgesic regimens (). Similar findings have been replicated in a small number of other urological publications.,

Table 1.

Day before radical cystectomy Day 3 and 4

- Remove epidural on day 3

- Continue to mobilize and encourage self-care

- Light diet as tolerated

- Start planning for discharge

- Normal breakfast

- Admit to hospital

- Unrestricted clear fluids

- Refer to dietician

- Stoma therapist to see patient

- Assess social circumstances and refer if needed

Day of radical cystectomy Day 5, 6 and 7

- Dietician to assess nutritional requirements on day 5

- If a patient is not eating or drinking after 5 to 6 days, but with bowel activity, then start nasogastric feeding

- If there is no bowel activity then start total parenteral nutrition

- Clear carbohydrate drinks up to 2 hours before surgery, then nil by mouth

- Restart clear fluids as tolerated when in recovery

- Start food chart

- Epidural analgesia in situ

After radical cystectomy: Day 1

- Free fluids as tolerated

- Female patients, remove vaginal pack

- Mobilize and refer to physiotherapist

- Ranitidine 3 times daily intravenously or twice daily orally

- Remove drain if draining <50 mL in 24 hours

- Flush 20 mL into neobladder, twice hourly for 12 hours and then 4 times hourly

Day 2 Day 11 to 14

- Light diet as tolerated

- Mobilize and encourage self-care (catheter care/flushing in neobladders, and stoma bag emptying in patients with a conduit)

Perioperative nutrition

Preoperative nutrition

It is well-known that poor nutrition is detrimental to outcomes postoperatively., It frequently occurs with comorbidities and with underlying disease processes, such as cancer. Inadequate nutrition, particularly for cancer patients undergoing surgery, is an independent risk factor for complications, increased hospital stay and costs. The importance of nutritional status in patients undergoing radical cystectomy has long been noted, with reported complications rates as high as 80% in patients with poor nutrition. More recently, data from Vanderbilt University demonstrate that nutritional deficiency preoperatively is a strong predictor of 90-day mortality and poor overall survival. It is therefore unsurprising that assessment and treatment of poor nutrition is an essential component of ERAS protocols. In terms of defining the problem, the European Society of Parenteral and Enteral Nutrition (ESPEN) defines "severe" nutritional risk as one or more of the following: weight loss >10% to 15% in 6 months, body mass index <18.5 kg/m2 or a serum albumin of <30 g/L. The British Association of Parenteral and Enteral uses similar parameters as part of the Malnutrition Universal Screening Tool (MUST) to risk stratify patients according to their nutritional level. What is interesting when considering the patients who undergo radical cystectomy is how many would be classified as high risk or severe nutritional risk after appropriate assessment. Correction of preoperative nutritional deficiencies may sometimes require prolonged parenteral, or a combination of parenteral and enteral nutrition depending on the severity of the problem and the patient's gastrointestinal function. However, in most cases patients can be managed with appropriate input from a dietician or nutritionist, and the use of a standard whole protein liquid nutritional supplement.

Carbohydrate loading and early enteral feeding

The stress response is initiated by a variety of physical insults, such as tissue injury, infection, hypovolemia or hypoxia. The ERAS program is aimed at attenuating the body's response to surgery which is characterized by its catabolic effect. Autonomic afferent impulses from the area of injury or trauma stimulate the hypothalamus-pituitary-adrenal axis and mediate the body's subsequent endocrine response. Increased cortisol levels stimulate gluconeogenesis and glyconeogenesis in the liver, with triglyercides being converted to glycerol and fatty acids providing the substrates for gluconeogensis. Adrenocorticotropic hormone and cortisol production leads to protein catabolism, weight loss, muscle (skeletal and visceral) wasting and nitrogenous loss. There is also a relative lack of insulin and peripheral insulin resistance occurs due to alpha-2-adrenergic inhibition of pancreatic B cells (facilitated by catecholamines) and defects in the insulin receptor/intracellular signalling pathway. Hyperglycaemia is therefore a significant finding after cystectomy, and the observed insulin resistance is a major variable influencing length of stay, poor wound healing and increased risk of infective complications. The degree of insulin resistance is associated with the extent of surgery, and if postoperative hyperglycaemia is controlled, mortality and morbidity can be reduced by half. Methods which reduce the insulin resistance include adequate pain relief,, avoiding a prolonged period when oral intake is interrupted, and the use of carbohydrate loading.

The practice of fasting patients from midnight is used to avoid pulmonary aspiration after elective surgery; however, there is no evidence to support this. Preoperative fasting actually increases the metabolic stress, hyperglycemia and insulin resistance, which the body is already prone to during the surgical process. Changing the metabolic state of patients by shortening preoperative fasting not only decreases insulin resistance, but reduces protein loss and improves muscle function. A review of 22 RCTs comparing different perioperative fasting regimens and perioperative complications revealed that there is no evidence to suggest a shortened fluid fast results in an increased risk of aspiration, regurgitation or related morbidity compared to the standard fasting from midnight policy. Furthermore, if patients are allowed to take solids up to 6 hours preoperatively and clear fluids up to 2 hours, there is no increase in complications,, which forms the basis of preoperative guidelines adopted by the Royal College of Anaesthetists and the American Society of Anesthesiologists.

As mentioned previously, the use of carbohydrate loading attenuates postoperative insulin resistance, reduces nitrogen and protein losses,, preserves skeletal muscle mass and reduces preoperative thirst, hunger and anxiety. ⁻ It involves the use of clear carbohydrate drinks the day prior to surgery and up to 2 hours before. In addition to the metabolic effects, it facilitates accelerated recovery through early return of bowel function and shorter hospital stay, ultimately leading to an improved perioperative well-being. ⁻ As a result, it is an important element of the nutritional aspects of ERAS and should replace the practice of overnight fasting.

Role of mechanical bowel preparation

The routine use of preoperative mechanical bowel preparation (MBP) has long been a tradition in colorectal surgery; due to the use of bowel segments, MBP is used routinely for radical cystectomy patients. The aim of MBP is to rid the large bowel of solid fecal contents and to lower the bacterial load, thereby reducing the incidence of postoperative complications. However, MBP liquefies solid faeces, which may increase the risk of intra-operative spillage of contaminant, and it is almost impossible to reduce the bacterial load in the bowel due to the vast number of micro-organisms present in the digestive tract.

The routine practice of MBP has been challenged for over 30 years. In 1972, Hughes originally questioned MBP and concluded that vigorous mechanical bowel preparation is unnecessary. Not only does MBP cause metabolic and electrolyte imbalance, dehydration, abdominal pain/bloating and fatique, ⁻ but it may actually have detrimental effects on surgical outcome. Multiple RCTs and meta-analyses have been published over the last decade suggesting that it is safe to abandon MBP. ⁻ One of the largest RCTs from Denmark was published in 2007. The primary objective was to assess the outcome of elective colorectal resections with or without MBP. The authors examined 1431 patients at 13 colorectal centres and found no difference in anastamotic leakage, septic complications, fascial dehiscence or mortality between the groups. In addition to an absence of benefit, MBP is also likely associated with an increased risk of complications, particularly anastamostic leakage. A meta-analysis of 10 trials and nearly 2000 patients published in 2007, not only found an increased incidence of anastamotic leaks and wound infections, but also a trend toward increased incidence of intra-abdominal abscesses and extradigestive complications. With this in mind, Slim and colleagues published an updated meta-analysis and review of the literature which included 14 RCTs and nearly 5000 patients. Although it did not confirm the harmful effect of MBP as previously suggested, it demonstrated that any kind of MBP can safely be omitted before colonic surgery.

In terms of radical cystectomy, Shafii and colleagues conducted a retrospective study assessing no bowel preparation versus bowel preparation before cystectomy and urinary diversion. They authors concluded that in the group who received MBP, there was a higher incidence postoperative ileus, slower commencement of diet, greater risk of wound dehiscence and longer hospital stay (31.6 vs. 22.8 days) compared to the group who did not receive MBP.

Postoperative nutrition

In addition to preoperative carbohydrate loading, early postoperative nutrition can ameliorate the metabolic response leading to less insulin resistance, lower nitrogen losses and reduce the loss of muscle strength., An assessment of gastrointestinal function and patient tolerability is essential when commencing postoperative oral intake. Multiple studies exist on the timing of post-operative nutrition. One of the early meta-analyses, although relatively small, found that there is no advantage in keeping patients nil by mouth after elective gastrointestinal resection and early feeding may actually be beneficial by reducing infectious complications and length of hospital stay. Lewis and colleagues demonstrated no detrimental effect with early feeding, but a trend towards a lower incidence of anastomotic dehiscence, wound infection, pneumonia, intra-abdominal abscess or mortality in patients who received early enteral feeding. A Cochrane review in 2006 found a direction of effect towards a reduction in complications and mortality rate, and in an update to their original metanalysis, Lewis and colleagues confirmed no benefit to keeping patients nothing by mouth (NBM) postoperatively, a reduction in complications and a reduced mortality rate; although, the mechanism for reduced mortality remains unclear.

Prevention of prolonged postoperative ileus

Bowel complications, and particularly paralytic ileus, are among the most common problems following radical cystectomy.,,, The etiology of postoperative ileus is multifactoral, with bowel function relying on a combination of the enteric and central nervous systems, hormonal influences, neurotransmitters and local inflammatory pathways. Surgical stress, bowel handling, opioids and intraoperative fluid resuscitation can disrupt these normal arrangements within the gastrointestinal tract and lead to postoperative ileus and impaired gastrointestinal absorptive function. Factors that help reduce this include epidural anesthesia, minimally invasive surgery, gentle tissue handling, avoiding of fluid overload and early feeding., Furthermore, the use of routine nasogastric decompression should be avoided after surgery as the incidence of fever, atelectasis and pneumoniae are increased in patients with nasogastric tube drainage, and any nasogastric tubes placed during surgery should be removed prior to extubation.,

Chewing gum has previously been used in an attempt to improve the postoperative recovery of bowel function in patients. Chewing gum in the postoperative period has been described as a form of sham feeding, whereby a food substance is chewed but does not enter the stomach. Gum is postulated to increase cephalo-vagal stimulation, leading to increased gastric motility and reduced inhibitory inputs from the sympathetic nervous system. Gastrointestinal hormones, such as gastrin, neurotensin, cholecystokinin and pancreatic polypeptide, are also increased and result in vagal stimulation of smooth muscle fibres. Chewing gum also increases secretion of saliva and pancreatic juices, and a recent study proposed that sorbitol and hexitol found in sugar-free gum may also play a role in the reduction of postoperative ileus. A number of studies exist which demonstrate the benefits in patients undergoing colorectal surgery.,,⁻ A meta-analysis of several RCTs evaluating the effect of chewing gum on postoperative ileus has subsequently been published. Although there are relatively low patient numbers and a significant heterogeneity of studies, chewing gum offers significant benefits by reducing the time to pass flatus and the time until first bowel movement. ⁻

The use of bowel segments in the reconstruction of the urinary tract after cystectomy lead Kouba and colleagues to examine the use of chewing gum following cystectomy. The time to flatus was shorter in patients who received gum compared with controls (2.4 vs. 2.9 days). Also, time to bowel movement was reduced in patients who received gum (3.2 vs. 3.9 days). There was no significant difference in length of hospital stay between gum-chewing patients and controls (4.7 vs. 5.1 days). A similar picture was noted by Koupparis and colleagues who examined the addition of chewing gum postoperatively to their established enhanced recovery program. The authors noted a significant reduction in the duration of postoperative ileus, but with only a trend towards a reduced in-patient stay.

Health economic benefits

The implementation of ERAS protocols represents a significant change in practice and a potential increase in the use of resources. Certain aspects, such as chewing gum, represent a simple and cheap intervention, which could potentially lead to significant cost savings. Schuster and colleagues estimated that the use of chewing gum following colectomy could save $118 828 000 per year in the United States. However, few studies have examined the impact of introducing an ERAS program on quality of life or health economic outcomes in the months after surgery. The benefits of ERAS will be markedly reduced if the costs are simply transferred to the community or if patients suffer a greater deterioration in quality of life than is experienced with conventional care. King and colleagues examined information regarding in-patient days, out-patient and general practitioner visits and the use of community services and estimated costs from national published figures. Direct medical and indirect non-medical costs were significantly lower in the ERAS group. Similarly, Sammour and colleagues have recently published a cost-analysis of ERAS in colorectal surgery. They evaluated whether costs saved by reduced postoperative resource utilization would offset the financial burden of setting up and maintaining such an ERAS program. There was a significant reduction in total hospital stay, intravenous fluid use, complications and duration of epidural use in the ERAS group. The implementation of an ERAS program costs about $102 000, but this was offset by costs saved in reduced postoperative resource utilization, with an overall cost-saving of roughly $6900 per patient.

An ongoing trial is the Tapas-study. It was conceived to determine which of the three treatment programs (open conventional surgery, open "ERAS" surgery or laparoscopic "ERAS" surgery for patients with colon carcinomas) is the most cost-effective. Primary outcome parameters are direct medical costs and indirect non-medical costs, with the aim of directing future investment appropriately.

Conclusions

Enhanced recovery after surgery protocols were initially described in open colorectal surgery, but have since been studied in a variety of surgical specialties, including urology. Although growing evidence from several RCTs, systematic reviews and meta-analyses suggest significant benefits from ERAS pathways, there are still major difficulties when introducing these evidence-based guidelines into routine practice.,, The fact that less than half of patients are involved in a postoperative care pathway suggests that perioperative care continues to resemble traditional and conventional attitudes., Many surgeons state that they have "never heard of ERAS," while others cite inadequate multidisciplinary and community support as an impediment to implementation.

In terms of barriers to introducing ERAS, even the simple measures discussed in this review still represent fundamental changes in practice, and can therefore be difficult to achieve. Kahokher and colleagues outlined the key aspects required for the implementation of an ERAS protocol. One of the most important aspects is the ERAS team, which includes pre-admission staff, dieticians, nurses, physiotherapists, social workers, occupational therapists and doctors. All team members must be familiar ERAS principles and be motivated to carry out the program; they must be able to overcome traditional concepts, teaching and attitudes towards perioperative care. In light of such compelling evidence, the evidence-based environment in which we practice demands that we review the perioperative management of radical cystectomy patients and alter it accordingly.

Footnotes

Competing interests: None declared.

This paper has been peer-reviewed.

References

36. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev. 2003:CD004423. [[ PubMed] Google Scholar]

37. Brady M, Kinn S, O'Rourke K, et al. Preoperative fasting for preventing perioperative complications in children. Cochrane Database Syst Rev. 2005:CD005285. [[ PubMed] Google Scholar]

38. Anaesthetists TRCo Guidance on the provision of anaesthesia services for Pre-operative Care. 2009 [ Google Scholar]

65. Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev. 2006:CD004080. [[ PubMed] Google Scholar]

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Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

# data[].attributes.attachment_link.description
Megan Melnyk, MSc, MD, Rowan G. Casey, MBChB, MD, FRCS(Urol), Peter Black, MD, FRCSC, FACS, and Anthony J. Koupparis, MBChB MD FRCS(Urol) Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer.

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Doctors and the public are at odds over the symptoms of constipation, leaving some people without the advice or treatment they need, researchers say.

While medics think infrequent bowel movements are an important sign, less than a third of the public does, a study found.

The King's College London team said a new definition for constipation was needed, based on patient experiences.

"This shows the poo taboo is over," charity Guts UK said.

Constipation is a very common condition, affecting around one in seven people who are otherwise healthy.

It means having difficultly opening or emptying the bowels, and passing stools - but the way it is diagnosed varies widely.

The researchers say this list of six groups of symptoms could help form a new definition of constipation:

abdominal discomfort, pain and bloating - clothes not fitting as well as usual

rectal discomfort - bleeding from pushing too hard, pain or burning sensation in the anal area

infrequent bowel movements and hard stools - normal can range from three times a day to three times a week

sensory dysfunction - not having the urge to go or a sense of incomplete evacuation

flatulence and bloating - noisy or smelly wind

faecal incontinence - uncontrolled leakage or rectal bleeding

What is this list based on?

The researchers surveyed 2,557 members of the public, 411 GPs and 365 gastroenterology specialists and published the results in the American Journal of Gastroenterology.

They found that what most people think of as symptoms of constipation aren't included in any official diagnostic criteria.

These include:

spending a long time on the toilet unable to pass a stool

straining

needing to use laxatives

While most people who said they had constipation had symptoms that matched the official criteria, one in three 'healthy' patients didn't recognise their symptoms of constipation at all.

And doctors and the public don't seem to agree on the signs to look out for either, the study found.

Medics placed lots of emphasis on infrequent bowel movements, as a symptom, but only half of people who said they had constipation actually experienced this symptom.

What do the researchers say?

Dr Eirini Dimidi, study author from King's College London, said: "Our research may indicate that people who seek help for symptoms of constipation don't always have them recognised, diagnosed or managed."

She said constipation was usually caused by a lack of fibre or fluid in the diet but it could also be a sign of another underlying problem, such as bowel cancer, diverticular disease or coeliac disease.

Dr Dimidi said it was "always important to consult your doctor if you experience gut symptoms".

What about other experts?

Listening to what patients say about constipation is important, said Julie Harrington, from charity Guts UK.

"Patients are the experts, by experience, and when they come together with specialists, that's the sweet spot."

Not all constipation is the same, and different people have different symptoms, she added.

"Bowel problems are less likely to be picked up than other problems because people wait 6-12 months out of fear and embarrassment.

"You have to tune into your body."

How often should we poo?

This is difficult to answer - it can vary dramatically from person to person.

In the study, seven bowel movements a week was the average among people who weren't constipated.

But experts say three bowel movements a day to three a week qualifies as normal.

So you need to know what's normal for you - and then look out for changes.

What are the treatment options?

Most people recognise the problem themselves and try to solve it by increasing the fibre in their diet and drinking more fluid, according to NHS advice.

Fibre is present in wholegrain bread, wholegrain pasta, fruit, nuts, pulses and cereals.

Taking more exercise and eating regular meals can also help.

You can buy laxatives from the chemist if diet and lifestyle changes aren't working.

But it's important to see your GP if the problem persists, and you have other symptoms.

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Doctors and the public are at odds over the symptoms of constipation, leaving some people without the advice or treatment they need, researchers say. While medics think infrequent bowel movements are an important sign, less than a third of the public does, a study found.

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Bowel movement: the push to change the way you poo

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The long read: Are you sitting comfortably? Many people are not - and they insist that the way we've been going to the toilet is all wrong

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Deep Venous Thrombosis and Pulmonary Embolism.pdf

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Use of Waterlow scoring in long term care facilities.pdf

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How could bedrail use contribute to deconditioning?

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Essential Elements of Pressure Ulcer Prevention  Management All Wales Guidance 2014 Final Version.pdf

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Deep breathing and coughing exercises demonstrated - also known as the  active cycle of breathing and forced expiratory techniques respectively.

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NHS University Hospitals Plymouth Physiotherapy

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Active Cycle of Breathing Technique (ACBT)

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From our physiotherapy colleagues

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Tips on a speedier recovery after surgery

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Tips on a speedier recovery after surgery

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Atelectasis | National Heart, Lung, and Blood Institute (NHLBI)

# data[].attributes.attachment_link.description
Atelectasis is very common after surgery. The medicine used during surgery to temporarily put you to sleep can decrease or stop your normal effort to breathe and urge to cough. Sometimes, especially after chest or abdominal surgery, pain may keep you from wanting to take deep breaths.

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Consider how this kind of care will decondition patients

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Dementia Care, 5 live Investigates - BBC Radio 5 live

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Care for dementia patients on acute hospital wards is 'failing.'.

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Providing blood clot (thrombosis) education to patients and health care professionals. Support for patients with deep vein thrombosis, pulmonary embolism, thrombophilia or taking anticoagulants.

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From point 6.50 on is related to the colon

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You know, we’ve been talking about a lot of serious stuff here lately.

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Digestive System, Part 3: Crash Course Anatomy & Physiology #35

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Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism | Guidance and guidelines | NICE

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Evidence-based recommendations on assessing and reducing the risk of venous thromboembolism (VTE) and deep vein thrombosis (DVT) in people aged 16 and over

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Join the campaign to end 'pyjama paralysis' - a 70 day challenge | NHS Improvement

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At NHS Improvement, our role is to support trusts on their quality improvement journeys. #EndPJParalysis is so inspiring because it is being led by frontline staff.

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Geriatric Deconditioning

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I have lost count of the number of times I have quoted this fact, I use it when teaching on frailty, and I have used it when assessing people in the emergency department to explain the risks of hospital induced deconditioning. I regularly hear other Geriatricians use this fact.

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Abstract

Background

The benefits of postoperative mobilization include decreased incidence of pulmonary complications, pressure ulcers, and progression of deep vein thrombosis. However, the complexity of certain spinal reconstructions and the patient's physiologic condition may preclude the possibility of early mobilization. Prolonged bed rest after spine surgery is controversial.

Questions/purposes

We evaluated the efficacy of prolonged bed rest after complex spine surgery to determine (1) patient characteristics that led to prescribing bed rest, (2) clinical and radiographic outcomes, (3) complications, and (4) estimated direct costs.

Methods

We retrospectively reviewed all 11 patients (median age, 50 years) who underwent complex spine surgery followed by prolonged bed rest between 2005 and 2010. All patients were deemed at high risk for developing pseudarthrosis or instrumentation failure without postoperative bed rest. One patient died of complications related to pulmonary tuberculosis at 4 months. The patients averaged 3 months of bed rest. Minimum followup was 24 months (median, 30 months; range, 4-52 months).

Results

All patients had (1) tenuous or limited fixation after correction of severe deformity, (2) previously failed spine reconstruction after early mobilization, or (3) limited treatment options if failure occurred again. No patient experienced pseudarthrosis, failure of instrumentation, thromboembolic disease, pressure ulcers, or pneumonia. One patient had a delayed union and one developed late urosepsis. The median cost of skilled nursing facilities during the period of bed rest was $16,702, while the median cost of home health nursing was $5712.

Conclusions

For patients with contraindications to early postoperative mobilization, prolonged bed rest may be useful to minimize the risk of complications that can occur with mobilization.

Level of Evidence

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Introduction

The benefits of early mobilization after surgery are well documented. These benefits include reduced risk of pneumonia, pulmonary failure, cardiovascular complications, perioperative infection, pressure ulcers, and progression of deep vein thrombosis (DVT) [ 1, 20, 22]. Moreover, early spinal stabilization and mobilization have been associated with an almost eightfold decreased risk of complications related to prolonged recumbency [ 20]. These complications include pneumonia, respiratory failure, DVT, and pulmonary embolus. For example, compared to delayed spinal stabilization and mobilization, the rates of pneumonia have been reduced from 20% to 4% [ 20] and the rates of pulmonary failure have been reduced from 18% to 9% [ 20]. However, the complexity of a spinal reconstructive procedure and the overall physiologic condition of a particular patient (eg, bone quality, medical comorbidities, and the severity of the spinal deformity) may render early mobilization unfeasible and long-term postoperative bed rest a useful adjuvant therapy, as evidenced by improvement in physical function, decreased pain, and radiographic evidence of healing [ 16, 18].

Short-term bed rest is a well-documented primary and adjuvant method of treatment for spinal and musculoskeletal conditions. Two days of bed rest is usually sufficient for the treatment of acute low back pain [ 7]. Four weeks of postoperative bed rest reportedly improves the maintenance of sagittal alignment of patients with thoracolumbar burst fractures treated with spinal fusion and instrumentation [ 5] compared to spinal fusion and instrumentation with early mobilization. Moreover, some authors reported nonoperative treatment with 4 to 6 weeks of recumbence followed by mobilization with a brace was generally superior to surgical approaches in treating spinal injuries [ 23]. However, the potential benefits of more prolonged bed rest are unclear.

The adverse physiologic effects of prolonged bed rest on muscle and bone are also well documented. Muscle at complete rest can lose 10% to 15% of its strength per week of immobilization [ 9]. The muscles of the lower extremities are often the first to reveal signs of atrophy [ 3], but spinal muscle atrophy is also substantial: atrophy of the multifidus and erector spinae muscles may occur after 60 days of bed rest [ 3]. The cross-sectional area of the multifidus decreases after 8 weeks of bed rest, which may destabilize the spine [ 12]. In addition, there are structural changes in bone that are directly related to the duration of immobilization. These changes are consistent with other scenarios leading to disuse osteopenia and may cause substantial cortical thinning and trabecular bone loss [ 24]. The reduction in bone mass may, in turn, increase the risk for pseudarthrosis. In addition to causing long-term physiologic deterioration of muscle and bone, bed rest has been associated with other systemic complications. Insulin resistance, pressure ulcers, pneumonia, thromboembolic disease, cardiac atrophy with decreased stroke volume and orthostatic intolerance, and changes in microvascular structure have all been associated with prolonged immobilization [ 4, 6, 9, 12, 24, 26, 28].

We therefore investigated the efficacy of a controversial adjuvant treatment option: prolonged bed rest after major reconstructive spine surgery for patients at high risk for developing postoperative failure of spinal instrumentation, progressive deformity, pseudarthrosis, or life-threatening complications if further surgery is required to resolve these problems. Treatment efficacy was defined as successful, albeit delayed, upright mobilization without serious side effects during the period of prolonged bed rest. To determine the efficacy of prolonged postoperative bed rest as adjuvant therapy, we evaluated (1) the characteristics of the patients that led to prescribing prolonged bed rest after major reconstructive spine surgery; (2) clinical evidence of healing, ie, decreased pain and improved function; (3) radiographic evidence of healing on plain radiographs and CT scans; (4) associated complications; and (5) estimated direct costs.

Patients and Methods

After institutional review board approval was obtained, we retrospectively reviewed the surgical records of a single fellowship-trained spine surgeon (RAWM) to identify all 11 patients treated with prolonged bed rest in the postoperative course of their therapy during the years 2005 to 2010. Prolonged (at least 2 months) postoperative bed rest was prescribed. The median age of the patients (five men, six women) was 50 years (range, 27-73 years). All patients had a minimum followup of 24 months except one patient who died of complications related to his pulmonary tuberculosis. Median followup was 30 months (range, 4-52 months). All 11 patients presented with multiple diagnoses, and six of 11 presented with neurologic deficits (Table ).

Table 1

We evaluated the total number of previous spine operations, neurologic status, duration of bed rest, and complications. All patients were at high risk for developing progressive deformity, failure of instrumentation, or pseudarthrosis if early upright mobilization was instituted.

Seven patients were treated with a planned staged surgical approach with stages separated by a median of 4 days (range, 3-21 days) (Table ). Six patients underwent a posterior spinal fusion with instrumentation with a combination of transverse and pedicle subtraction osteotomies. Five patients underwent a combined anterior and posterior instrumented fusion; of these five patients, four had a corpectomy during the anterior portion.

Bed rest was instituted immediately postoperatively. Occupational and physical therapy consultations were obtained during the period of acute postoperative hospitalization. All patients were transferred to skilled nursing facilities or in-home assisted living at a mean of 6 days (range, 2-11 days) for the duration of the prolonged bed rest. Patients were deemed clinically stable when they had normal vital signs, electrolytes, and hemoglobin without clinical signs of wound or systemic complications. Patients (as well as their caregivers) were advised to avoid supine positioning during the initial 4 weeks to decrease direct pressure on the posterior wound. Use of strict log-rolling technique was prescribed; patients were allowed to raise the head of bed up to 40° during meals; and bedpans and urinals were used. To help prevent the patients' twisting and pulling with the upper extremities, overhead trapezes were prohibited.

Throughout the bed rest period, each patient received mechanical DVT prophylaxis, which consisted of the use of thromboembolic deterrent (TED) hose and thigh-high sequential compression devices while in the hospital and TED hose after discharge. Venous duplex ultrasonography was ordered for all patients on Postoperative Days 3 and 14; in none of the 11 patients was DVT detected by the procedure. Three patients elected to have an inferior vena cava (IVC) filter placed postoperatively, while one patient had an IVC filter placed preoperatively. None of the patients developed symptomatic pulmonary emboli. Chemical thromboembolic prophylaxis was not routinely used. However, one patient received prophylactic warfarin (Coumadin ®; Bristol-Myers Squibb, New York, NY, USA) and one patient received prophylactic, subcutaneous low-molecular-weight heparin during the bed rest period. After spine surgery, the patients were treated with a median of 3 months (range, 2-6 months) of bed rest.

All patients were instructed to proceed with upright mobilization after completing the prescribed period of bed rest: progressive periods of prolonged sitting for patients who could only be mobilized using a wheelchair and progressive periods of sitting, standing, and walking for patients who were ambulatory.

After discharge from the hospital, patients were seen at 6 weeks, 3 months, 6 months, 12 months, and 24 months postoperatively. Plain radiographs were obtained at each visit to evaluate for evidence of instrumentation failure or failure of fixation, and CT scans were performed within a week of surgery to evaluate the placement of the instrumentation and before mobilizing to detect any evidence of fusion. An interbody was considered fused if there was trabecular bone in continuity bridging between the adjacent vertebral endplates as described by Wang et al. [ 29]. Posterolateral fusion was determined using the classification described by Lenke et al. [ 15]. Patients were allowed to mobilize when either interbody fusion was identified or solid big trabeculated bilateral fusion masses (Grade A) or a unilateral large fusion mass with contralateral small fusion mass (Grade B) was identified posterolaterally. All radiographs and CT scans were independently reviewed by two of us (RAWM, RMS).

From the charts, we extracted the total number of previous spine operations, neurologic status, length of bed rest, and complications. Complications were assessed based on the classification of surgical complications as outlined by Dindo et al. [ 8]. We used a 10-point VAS to assess pain [ 18, 30], whole-body pain diagrams [ 21], and patient questionnaire [ 18, 30] to assess functional outcomes related to pain, narcotic use, symptoms of depression, and work status. Patients were also asked to evaluate their functional status at their latest followup compared to their preoperative levels.

We used a t-test (SPSS ® Version 18; IBM Corp, Chicago, IL, USA) to determine differences in VAS pain score from preoperatively to last followup.

Results

All patients treated with prolonged bed rest after complex spine surgery had one or more of the following characteristics: (1) tenuous or limited fixation after correction of severe sagittal or coronal imbalance (Fig. ), (2) previously failed complex spine reconstruction with instrumentation and attempted early mobilization, or (3) limited treatment options if failure of complex spine reconstruction occurred (Fig. ). All 11 patients were at high risk for developing progressive deformity, failure of instrumentation, or pseudarthrosis if early upright mobilization had been instituted (Table ).

Table 2

Patient

Reason for bed rest*

Bed rest duration (days)

Complications of bed rest

Followup (months)

Change in pain

Change in function

Radiographic evidence of healing

The mean pain level decreased (p < 0.001) at last followup compared to preoperatively: VAS 4 versus 8, respectively. At last followup, 10 of the 11 patients reported decreased pain and improved function. Nine of the 11 patients were unemployed before surgery and all nine of these patients remain unemployed. One of the patients employed preoperatively returned to work, while one patient became unemployed. All 11 patients had radiographic evidence of healing at last followup, and all maintained coronal and sagittal alignment. No patient developed failure of instrumentation or instrument fixation.

Two patients developed complications during the period of prolonged bed rest. Patient 1 had delayed union (Grade 1), and Patient 7 developed urosepsis (Grade 4). Patient 1 had a previous attempt to repair a pseudarthrosis at L5-S1 and a positive sagittal balance of 35 cm. Despite complete surgical correction of his sagittal imbalance, prolonged bed rest was prescribed because the patient previously failed complex spine reconstruction with attempted early mobilization, and there were limited treatment options if reconstruction failed again. Additionally, the potential for normal healing in this patient appeared diminished because the L5 and S1 endplates were extremely sclerotic despite aggressive endplate preparation. CT scan demonstrated delayed union of the L5-S1 anterior fusion at the 12-month followup evaluation but ultimately demonstrated fusion on CT scan at the 24-month followup. Patient 7 was initially treated with 6 months of bed rest. She developed urosepsis 11 months after her operation and subsequently developed an infection at a level adjacent to her anterior construct. This patient had progressive paraparesis and osteomyelitis secondary to methicillin-resistant Staphylococcus aureus at the time of her initial presentation. She underwent a two-level corpectomy, with titanium mesh reconstruction and single-rod anterior spinal instrumentation from L2 to L5, and had been scheduled to then undergo a posterior spinal fusion and instrumentation. However, she sustained a hypotensive episode upon positioning in the prone position, perhaps due to volume shifting to her massive pannus protruding through the frame of the Jackson table. The hypotension resolved after the patient was returned to the supine position. Postoperative bed rest was prescribed due to the limited fixation and limited treatment options if failure of the anterior spinal fusion had occurred. This patient mobilized to a wheelchair after 6 months of bed rest. A Pseudomonas urosepsis infection then seeded the L2-3 disc space 11 months after the index operation. Anterior débridement of L2-3 and anterior spinal fusion without instrumentation were followed by posterior spinal fusion and instrumentation from T10 to the pelvis. The patient who had been followed for 4 months before he died had succumbed to complications related to an underlying tuberculosis infection. There were no documented reports of superficial or deep wound infections, DVTs, pressure ulcers, wound breakdown, or hospital-acquired pneumonia throughout the prolonged period of bed rest. One patient developed symptoms of depression during bed rest, and one had symptoms of depression preoperatively and throughout the bed rest period. Both of these patients denied symptoms of depression at last followup.

The average daily rate for a private nursing home in our region is $164 per day, while the average hourly rate for home health nursing is $34 per hour. Six of our patients completed the period of bed rest in a skilled nursing facility at an estimated median cost of $16,702; four completed it at home with the assistance of home health nursing at an estimated median cost of $5712; and one completed it at home without home health nursing.

Discussion

Prolonged bed rest has been used to treat patients with thoracolumbar fractures, scoliosis, spondylolisthesis, and tuberculosis [ 2, 17, 30, 31]. The use of modern spinal instrumentation has reportedly reduced the recumbency time and complications after surgery [ 13]. Early mobilization has also been associated with decreased likelihood of developing minor and major complications after spine surgery [ 20]. However, the complexity of certain spinal reconstructions and the overall physiologic condition of the patient may preclude the possibility of early mobilization. To determine the efficacy of prolonged postoperative bed rest after complex spine surgery, we evaluated (1) the characteristics of the patients that led to prescribing prolonged bed rest after major reconstructive spine surgery; (2) clinical evidence of healing, ie, decreased pain and improved function; (3) radiographic evidence of healing on plain radiographs and CT scans; (4) associated complications; and (5) estimated direct costs.

We acknowledge the limitations of our study. First is the lack of a comparable cohort of patients treated with early postoperative mobilization. It is thus impossible to determine whether prolonged bed rest provides improved fusion or decreased instrumentation failure, compared to early postoperative mobilization for this select group of patients. It is possible these patients may have had similar clinical improvement in function and radiographic evidence of healing if early mobilization was instituted. However, every patient in this study was deemed to be at high risk for failure of instrumentation or fusion because of the complex spinal surgery required to correct the underlying deformity or infection, combined with severe osteoporosis or poor fixation. Moreover, several patients had no other reasonable treatment options in the event of failure of this final attempt at spine reconstruction. Direct comparison of a cohort of patients treated with early postoperative mobilization seems imprudent, since the potential risks of reoperation and failure of fixation or fusion appear to greatly outweigh the potential risks of bed rest in patients who meet the inclusion criteria for postoperative prolonged bed rest. Second, we had limited methods to assess function. We used a VAS for pain, whole-body pain diagrams, and patient questionnaires to assess functional outcomes related to pain, narcotic use, symptoms of depression, and work status. However, more rigorous methodology for assessing function was not performed, which complicates direct comparison of our results to other studies. Third was the controversial use of CT scan evidence of healing before allowing mobilization. It is possible enough healing could have occurred to allow these patients to mobilize earlier; however, we believed it was prudent to continue bed rest until some evidence of bone healing was noted before mobilization.

Ordinarily, the use of spinal instrumentation should provide enough stability to allow patients to mobilize early while maintaining alignment and achieving acceptable fusion rates. The initial intent of our treatment was early postoperative mobilization. However, three primary factors contributed to our belief that early mobilization would lead to failure of the instrumentation or fusion: (1) tenuous or limited fixation after correction of severe sagittal or coronal imbalance, (2) previous failure of complex spine reconstruction with instrumentation and attempted early mobilization, and (3) limited treatment options if complex spine reconstruction failed again. All patients had one or more of these risk factors. Early mobilization after the planned complex reconstruction of the spine would have dramatically increased the likelihood of these patients developing progressive deformity, failure of instrumentation, or pseudarthrosis. For these reasons, the potential benefits of prolonged bed rest appeared to greatly outweigh the potential risks for these 11 patients. Similarly, patients with unstable fractures, high-grade spondylolisthesis, and severe tuberculosis-related kyphosis who are treated without instrumentation are more likely to develop progressive deformity, neurologic deficits, or pseudarthrosis if early mobilization is prescribed [ 2, 11, 13, 14, 17- 19, 27, 30, 31]. The addition of modern instrumentation to the surgical treatment of these disorders has allowed us to employ early mobilization postoperatively for most patients with these disorders. However, unlike the patients in our study, most patients with these disorders have sufficient, satisfactory bone for screw purchase and sufficient fixation above and below the area of instability. Additionally, most of these patients have not experienced previous failure of surgical intervention. For these reasons, we believe our patients are different from patients previously described in the literature.

After a median of 3 months of postoperative bed rest, 10 of the 11 patients reported decreased pain and improved function at last followup. Similarly, Weinstein et al. [ 30] and Mumford et al. [ 18] reported satisfactory pain control based on VAS scores after bed rest for treatment of thoracolumbar burst fractures (Table ). Mumford et al. [ 18] also reported 32 of 41 patients (78%) were working before treatment, while 26 of 32 patients (81%) returned to work after treatment with bed rest. However, only two of 11 patients in our study were working before surgery, and only one of these patients returned to work after surgery. These data may reflect the more complex and disabling nature of the underlying problems treated in our patients compared to patients with thoracolumbar burst fractures. The radiographic outcomes of our patients demonstrated maintenance of coronal and sagittal alignment in all 11 patients. In contrast, several authors reported the development of progressive deformity of greater than 5° of kyphosis or scoliosis after bed rest for the treatment of scoliosis, thoracolumbar fractures, and spondylolisthesis [ 2, 14, 18, 19, 27, 31]. All of our patients were treated with spinal fusion with instrumentation, correction of deformity, and bed rest, which may have contributed to the maintenance of postoperative alignment in these patients compared to patients in other studies who were treated with bed rest alone.

Table 3

Despite the well-known adverse effects of immobilization [ 2- 7, 9- 14, 16- 19, 21, 23- 28, 30, 31], only a few postoperative complications were identified. One patient had radiographic evidence of delayed union, whereas four of 11 patients had preoperatively documented pseudarthrosis. All patients demonstrated radiographic evidence of healing at last followup. None of our patients experienced failure of instrumentation or failure of fixation. These findings are particularly important in view of the high risk for failure of the fixation or fusion if early upright mobilization had been instituted. These results compare favorably to the 22% (12 of 55) incidence of pseudarthrosis after radical resection, fusion, and bed rest for patients with tuberculosis as reported by the Medical Research Council [ 17]. Throughout the bed rest period, each patient received mechanical DVT prophylaxis, which consisted of the use of TED hose and sequential compression devices while in the hospital and TED hose after discharge. No thromboembolic events were reported in this series. However, if prolonged bed rest is planned and the patient has other underlying risk factors for thromboembolic disease, an IVC filter or chemical prophylaxis may be helpful in decreasing the risk of pulmonary emboli. In addition, no patient developed pressure ulcers or wound breakdown during the period of bed rest. This complication is avoidable if special care is taken to limit the time a patient lies directly on his or her back. The psychologic effects of prolonged bed rest are potentially detrimental to the patient's mental state. Patient 11 developed depression during the 6 months of bed rest. Although we did not identify any other reports of the development of depression during bed rest for the treatment of spinal disorders, Arkin [ 2] cited emotional problems and difficulty in school as two of the reasons he no longer recommends prolonged recumbency for his patients with scoliosis.

The direct costs of prolonged bed rest ranged from an estimated median cost of $16,702 for a skilled nursing facility to an estimated median cost of $5712 for home health nursing. Two of our 11 patients were employed before instituting bed rest. One of these patients remains unemployed 52 months after surgery. The other patient lost 3 months of work during the bed rest period and now works part-time.

Bed rest can be a useful adjunct to complex reconstructive spine surgery in carefully selected patients who are at high risk for failure of instrumentation with early mobilization and who have limited treatment options after such surgery. Further studies would be helpful in formulating a protocol to help reduce the potential complications associated with postoperative immobilization.

Footnotes

One of the authors (RAWM) is a consultant for Synthes Spine (West Chester, PA, USA) and DePuy Spine (Raynham, MA, USA) and is on the Speakers' Bureau of DePuy Spine.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

References

2. Arkin AM. Correction of structural changes in scoliosis by corrective plaster jackets and prolonged recumbency. J Bone Joint Surg Am. 1964;46:33-52.

25. Slipman CW, Lipetz JS, Jackson HB, Vresilovic EJ. Deep venous thrombosis and pulmonary embolism as a complication of bed rest for low back pain. Arch Phys Med Rehabil. 2000;81:127-129.

31. Wiltse LL, Bateman G, Hutchinson RH, Nelson WE. The paraspinal sacrospinalis-splitting approach to the lumbar spine. J Bone Joint Surg Am. 1968;50:919-926.

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Prolonged Bed Rest as Adjuvant Therapy After Complex Reconstructive Spine Surgery

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The benefits of postoperative mobilization include decreased incidence of pulmonary complications, pressure ulcers, and progression of deep vein thrombosis. However, the complexity of certain spinal reconstructions and the patient's physiologic condition may preclude the possibility of early mobilization. Prolonged bed rest after spine surgery is controversial.

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Covid-19 will be followed by a deconditioning pandemic

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Months of isolation and reduced levels of activity at home will have an immense deconditioning effect on millions of people, say Muir Gray and William Bird

All healthcare does harm. Much publicity is given to the contribution of poor quality care and errors, but even evidence based healthcare delivered at high quality can cause harm. It is an inevitable consequence of the use of radiation, the prescription of powerful chemicals, interventions such as surgery, or even requiring people who are ageing to stay in their own homes for three, or possibly more, months.

The Academy of Medical Royal Colleges published a report in 2015 called Exercise the Miracle Cure, not only promoting the benefit of activity as a therapy in its own right, but also emphasising the dangers of inactivity. [1] While accepting that rest has a part to play in the acute phase of illness, this usually passes very quickly. What has emerged is that in the high pressure world of the hospital, people-particularly people with multiple health problems-have their acute problem diagnosed and managed quickly, but are then often tucked into bed, because they cannot be discharged, while the staff have to cope with the next wave of acute cases at the other end of the ward. The result is what has been called the "deconditioning syndrome," a side effect of hospital admission and a consequence of inactivity. [2]

Although less dramatic, the months of isolation at home as a result of the covid pandemic will have an immense deconditioning effect, affecting millions of people. The covid-19 shielding policy was aimed at people over 70 and people under 70 with long term conditions, but we now know that

the older you are the more activity you need

the more long term conditions you have, the more activity you need

It is clear that inactivity has a direct effect on mortality through its direct impact on cardiovascular disease, diabetes, and cancer. We calculated using the WHO HEAT Model that imposed sedentary behaviour for three months in those over the age 70 years, or with long term conditions, would result in an extra 7000 premature deaths.

But, it is the other impacts that isolation and inactivity have on older people that will be a greater burden to society, unless addressed urgently.

Spending months at reduced levels of activity will have an impact on all 4 aspects of physical fitness-strength, stamina, suppleness, and skill. It is important to appreciate also that there will be a loss of cognitive and emotional wellbeing as a result of isolation and loneliness, and this will increase the risk of dementia. [3] For those who are already housebound, the impact of quarantine may not be so dramatic physically, but with even fewer visits there will be considerable cognitive and emotional impact.

All of life requires us to balance risk and people certainly need advice on how to reduce the risk of coronavirus infection. However, months of isolation and physical, social, and cognitive inactivity, without giving people information, encouragement, support, and motivation to maintain-or indeed increase fitness-while at home, will increase the numbers needing social care in the years to come.

The harm resulting from the constraints on health service resources resulting in increased mortality from heart disease and cancer has received publicity, but the harm from social distancing will shorten healthspan and increase dependency, and this has not been so widely recognised. The covid-19 pandemic will be followed by a deconditioning pandemic and a reconditioning programme needs to be implemented as an emergency to support and facilitate a significant increase in physical, cognitive, and emotional activity particularly among people living alone. [4]

The first aim would be to reverse the effects of deconditioning, and prevent further harm. This might just lead very many people to rethink what is happening to them as they live longer and take action after the epidemic of covid-19 infection is over that will reduce their risk of dementia, frailty, and the need for social care. [5]
Muir Gray, is a visiting professor in the Nuffield Department of Primary Health Care at the University of Oxford. William Bird, is Honorary Senior Lecturer, European Centre of Environment and Human Health, University of Exeter Competing interests: WB is CEO of Intelligent Health which trains doctors about physical activity, and delivers Beat the Street that gets school children and their families more active. MG is Director of the Optimal Ageing Programme which provides learning programmes for older people and professionals about how to Live Longer Better References:

1. Academy of Medical Royal Colleges (2015), Exercise the Miracle Cure

2. 2 Arora A. (2019), Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis, https://www.bmj.com/content/366/bmj.l4185/rapid-responses

3. 3 Livingston G et al (2017), The Lancet Commission on "Dementia prevention, intervention, and care" Lancet 390: 2673-734

4. 4 Douglas M. et al (2020), Mitigating the wider effects of covid-19 pandemic response, BMJ; 369;141-143

5. 5 McNally, S. et al (2017), Focus on physical activity can help avoid unnecessary social care. BMJ Oct 17;359: j4609.

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Covid-19 will be followed by a deconditioning pandemic - The BMJ

# data[].attributes.attachment_link.description
Months of isolation and reduced levels of activity at home will have an immense deconditioning effect on millions of people, say Muir Gray and William Bird All healthcare does harm. Much publicity is given to the contribution of poor quality care and errors, but even evidence based healthcare delivered at high quality can cause harm.

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England's CNO to announce national drive to 'end PJ paralysis'

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Patient time is the most important currency in health and social care

The 70 day #EndPJparalysis Challenge aims to save a million days of patient time in the NHS by getting patients up, dressed and moving while in hospital.

Find Out More

Despite the hard work of caring staff, patients, particularly older people, get 'stuck' in hospitals, and the systems and silos in healthcare conspire to make this worse. This Website is about the most valuable currency in healthcare - patients' time. It would be fair to say that a significant proportion of people who get stuck in the health care system are in the last 1000 days of their life, so they are the very people who do not have time to waste.

By focussing on the last 1000 days, our aim is to help draw attention to where time is wasted, what could be done differently and to share some examples of successes. Time really is the key; if you are against the clock, trying to get several things actioned, looking at when various services are open, competing for theatre slots, investigation times or outpatients appointments, there is rarely enough time. On the other hand if you, or one of yours, is waiting for any of the above it's very easy to lose precious days.

However much we individually agree with the last 1000 days philosophy, nothing changes unless someone changes it. It's very easy to think you can't make a difference to a system, an organisation or a healthcare culture, and true you possibly won't impact the whole system in one go. The thing is, big changes - cultural shifts - all start somewhere, usually by one person, and then the next, making a stand of a small change to something they have influence over. All it takes is for each of us to be brave enough to make a stand about the things that matter to us. The TODAY model has been created to help you to make that stand.

.

.

TIME Is the most important currency in healthcare. How to maximise time, minimise wasted time and prioritise patients' time.

OWNERSHIP Is about taking responsibility, understanding what you can influence and gaining support

DIAGNOSTICS Is understanding what good looks like then being able to assess care and activity against that and identify potential problems

ACTIONS Identifies some of the things that are already prioritising patients' time. How to engage others in meaningful change

YOU Is about understanding yourself, the impact you can have and how to influence others to make change

Professor Brian Dolan

FRSA, MSc(Oxon), MSc(Nurs), RMN, RGN

Brian has a 30+ year career in various nursing, leadership, academic and consulting roles focusing on system redesign, culture change and patient flow. He is Director of Health Service 360 and works in New Zealand (where he is Director of Service Improvement in Canterbury District Health Board), the UK and Australia.

Brian is the originator of #Last1000days and #EndPJparalysis. He was awarded a Fellowship of the Royal Society of Arts in 2016 and is Honorary Professor of Leadership in Healthcare at University of Salford, Manchester and Visiting Professor of Nursing at Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford.

Contact Brian - brian@dolanholt.co.uk Tel +44 7977 226151

Lynda Holt

MA, RGN, FInstLM

Lynda is CEO Health Service 360, and a champion for brave leaders and difference makers. Her message is unequivocal, 'show up, be brave and do what you believe in'. She leads people towards making their own impact - big or small.

For the past decade, Lynda has supported health organisations to make tangible change through empowering people and focusing on patient experience. During her clinical and managerial career in the NHS - which spanned nearly two decades - she was also the RCN Chair of the Emergency Care Association.

Contact Lynda - lynda@dolanholt.co.uk Tel +44 1789 801190

Professor Brian Dolan and Lynda Holt are founding Directors of Health Service 360
Health Service 360 is an award winning consultancy company who have helped 1000's of health professionals to lead well, change practice and put patients first. we have been delivering results in health organisations for 16 years and our mission is simple:
"To help you deliver health care that lives up to your aspirations, that your people feel proud of, and that your patients deserve."

We work with you to:

Improve patient experience

Develop your people

Identify and implement solutions

360 feedback for the health sector

Develop leadership

Coach individuals and teams

Support organisational objectives

The Last 1000 Days is a vehicle for drawing attention to patients' time. It is widely recognised that the elderly, the chronically ill, and those with life limiting conditions are the same people who spend the most time in healthcare settings. These are the very people who have the least time to waste.

The Last 1000 days concept has been developed to help draw attention to where & how time is wasted, to reinforce the positioning of patient's time as the most important currency in health care and to create a sense of urgency.

By creating a sense of urgency, we prioritise what can be done, what's in the way and what needs to be different. Making an issue out of the Last 1000 Days is important because it galvanises us to act. It creates a cause, a thing we can all get behind and a common language for change that we can share.

Of course, creating models and talking about things doesn't change them, but raising awareness, giving people a compelling reason to change and the tools to make a difference does enable change to happen. As nurses, doctors, therapists or other people involved in the patient's journey through the health system, we strive to do the best by patients on a daily basis. Sometimes we fall short because we are paying attention to the wrong thing - the system and processes we are used to, the way things are currently done and the time scales we have come to accept. By putting patients' time at the centre of everything, by making it our most important currency, we create a new value system that enables us to pay attention to different things - the things that may get in the way of the care we want to give.

Two examples of this are #EndPJparalysis and #Red2Green. These will be discussed and used as examples as we showcase the TODAY model.

#EndPJparalysis (originated by Professor Brian Dolan 2016) is a simple concept that encourages patient to get up, dressed and moving while in hospital. Thus preventing complications of being immobile, including chest infections, muscle degeneration, clotting; as well as shifting patient's perceptions 'I'm sick' to 'I'm getting better'

#Red2Green (originated by Dr Ian Sturgess 2007) makes visible any delays in the patient's journey through the system, identifies fixes and values patients' time by not wasting it. Each is a compelling story that connects us to doing the right thing for patients, valuing their time and in doing so valuing staff time too.

Send your pictures of #EndPJparalyisis to brian@dolanholt.co.uk if you want to share your successes here (with permission of the picture owner of course)

References
Asher RAJ (1947) The Dangers of Going to Bed. British Medical Journal 2,967

Clark D, Armstrong M, Allan A et al (2014) Imminence of death among hospital patients: Prevalent cohort study. Palliative Medicine, 28, 6, 474-479

Gill TM, Allore HA, Guo Z (2004) The deleterious effects of bed rest among community-living older persons. Journal of Gerontology, 59a, 7, 755-761

Kortebein P, Symons TB, Ferrando A et al (2008) Functional impact of 10 days of bed rest in healthy older adults. Journal of Gerontology, 63a, 10, 1076-1081

Recommended Reading
Dolan B (2016) What happens when patient time becomes the most important currency in health care?

Fab NHS stuff website (http://fabnhsstuff.net/2016/07/04/the-last-1000-days-what-happens-when-patienttime- becomes-the-most-important-currency-in-healthca/)

Gawande A (2015) Being mortal, Profile Books Ltd

Gawande A (2011) The checklist manifesto, Profile Books Ltd

Grant A (2016) Originals: How non-conformists change the world, WH Allen

Heath C, Heath D (2011) Switch: How to change things when change is hard, Random House Business

Lodge C et al (2016) The new age of ageing: How society needs to change, Polity Press

Marquet LD (2015) Turn the ship around! A true story of turning followers into leaders, Portfolio Penguin

Patterson K et al (2011) Crucial Conversations: Tools for talking when stakes are high, McGraw Hill Education

Sinek S (2014) Start with Why: How great leaders inspire everyone to take action, Penguin

Want to know more about the today model?
Contact us about a copy of model

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Last1000days | Making patients' time the most important currency in healthcare

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The 70 day #EndPJparalysis Challenge aims to save a million days of patient time in the NHS by getting patients up, dressed and moving while in hospital. Find Out More Despite the hard work of caring staff, patients, particularly older people, get 'stuck' in hospitals, and the systems and silos in healthcare conspire to make this worse.

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Brian Dolan talks about the importance of patient time

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Collins and O'Brien Constipation in adults.pdf

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Venous thromboembolic diseases: diagnosis, management and thrombophilia testing | Guidance and guidelines | NICE

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Evidence-based recommendations on diagnosing and managing venous thromboembolic diseases (VTE, deep vein thrombosis, DVT, blood clots) in adults

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If you use assistive technology (such as a screen reader) and need a version of this document in a more accessible format, please email publications@phe.gov.uk. Please tell us what format you need. It will help us if you say what assistive technology you use.

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Constipation and people with learning disabilities

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If you use assistive technology (such as a screen reader) and need a version of this document in a more accessible format, please email publications@phe.gov.uk. Please tell us what format you need. It will help us if you say what assistive technology you use.

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Advances in Diagnosis and Treatment of Constipation

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Constipation is one of the most frequent problems clinicians are asked to deal with. Despite how common it is, constipation is frequently not treated adequately. In this podcast, Arnold Wald, MD, explains a stepwise approach to the management of constipation ranging from very simple measures to the most novel and complicated new medical therapies.

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are constipated and it's not getting better with treatment

are regularly constipated and it lasts a long time

are bloated and it lasts a long time

have blood in your poo

have lost weight without trying

are constipated and feel tired all the time

are taking medicine that's causing constipation - such as opioid painkillers

Speak to the GP before you stop taking any prescribed medicine.

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Constipation is common and it affects people of all ages. You can usually treat it at home with simple changes to your diet and lifestyle.

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Lorraine O'Brien Clinical nurse specialist, St Mark's Hospital, Harrow, England

Constipation is a common, often chronic, condition that is a health concern for providers of care. The condition can be distressing and although seldom life-threatening can lead to patient discomfort and debilitating effects on patients' quality of life. Initial management of chronic constipation should include lifestyle changes and increased fibre and fluids. More active interventions include the use of laxatives and other medications, irrigation and biofeedback therapy. Some patients may require surgery. This article provides an overview of the strategies used to prevent constipation in adults as well as the possible treatment options available.

Nursing Standard. 29, 32, 49-58. doi: 10.7748/ns.29.32.49.e9571

Correspondence

brigitte.collins@nhs.net

Peer review

This article has been subject to double blind peer review

Received: 02 September 2014

Accepted: 20 January 2015

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Prevention and management of constipation in adults

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Lorraine O'Brien Clinical nurse specialist, St Mark's Hospital, Harrow, England Constipation is a common, often chronic, condition that is a health concern for providers of care. The condition can be distressing and although seldom life-threatening can lead to patient discomfort and debilitating effects on patients' quality of life.

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NICE - treatment summary - constipation

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The NICE British National Formulary (BNF) site is only available to users in the UK, Crown Dependencies and British Overseas Territories.

If you believe you are seeing this page in error please contact us.

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The NICE British National Formulary (BNF) site is only available to users in the UK, Crown Dependencies and British Overseas Territories. If you believe you are seeing this page in error please contact us.

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Everything NICE has said on assessing, diagnosing, treating and reducing the risk of venous thromboembolism in adults in an interactive flowchart