Unstable Ankle Fractures; Factors That Impact on Foot Pump Compliance – A Qualitative Study
Background
Ankle fractures are a common occurrence within the UK, accounting for 9% of all fractures. Approximately 15,000 of these injuries require surgical fixation each year to ensure the best outcomes. The accompanying soft tissue injury often results in severe rapid swelling and it is vitally important for excessive swelling to be reduced before surgery takes place, due to increased risks. Operative management of these injuries can be delayed for up to 14 days while the patient is hospitalized for swelling reduction. Current literature indicates that A-V foot pumps (AVFP) are the most effective for swelling reduction. However there are reports of non-compliance, with no available literature exploring why.
Study Aim
The aim of this research study was to explore the views of patients and nurses on the management of ankle fractures using an AV foot pump.
Methods
Qualitative research methods were utilized to collect rich data. Semi-structured interviews collected data from 4 patients and 4 nurses who had experience of the device.
Results
A thematic analysis revealed two main themes, ‘Tolerance,’ and ‘Caring Experience.’
Tolerance as a theme includes three categories, ‘Pain,’ ‘Patient Partnership’ and ‘Patient Experience,’ they link together directly relating to the patients ability to tolerate the AVFP and the impact the AVFP had on the patients whilst in hospital.
The default setting for the AVFPs are 130mm Hg for 1 second every 20 seconds, which is the locally used setting. None of the participants were able to tolerated this level. This study identified the patients ability to tolerate the AVFP is directly linked to the intensity, with all patients requiring the device to be lowered. Therapeutic ranges of the AVFP have not been discussed in the literature for this patient population. Manufacturer instructions only stipulate that the pressure and duration should be specified by the prescribing physician, according to clinical judgement. The majority of studies have reported using the default settings, whereas others have either not stipulate the intensity or have used lower settings. Information on the therapeutic range would potentially improve the patients experience and impact positively on costs. Patients could be educated on the therapeutic range and identify a level they can tolerate. Currently the AVFP is being lowered without this information, if the level is not effective it wastes time, energy and costs.
Caring Experiences explores the patients and nurses perceptions on how the AVFP impacts upon the hospital stay. It consists of three sub-categories ‘Prevent Activities of Daily Living,’ ‘Sleep Disturbances’ and ‘Noise Disruptive.’ There were differing opinions between the nurses and patients. Nevertheless the nurses had experience caring for ankle fracture patients with and without the AVFP. Whereas the patients had only ever experienced an ankle fracture in hospital with a device. Potentially the AVFP was blamed for impacts that would have been present without the device.
Both the patients and nurses reported that the AVFP impacted on the patients’ ability to carry out simple tasks such as those outlined in the ‘Activities of Daily Living’. Due to the design of the AVFP the patients are essentially bedbound. Routine tasks often taken for granted such as eating, going to the bathroom making a phone call requires the nurse to unplug the device. Patients are unable to sit out of the bed, leave the ward to go to the shop, get fresh air, have a cigarette or meet friends outside of visiting hours. The above activities require unplugging the AVFP, suspending treatment, which the clinicians discourage. As a result patients reported feeling bored and annoyed, stripped of all independence and control.
The current literature does not examine the impact of the AVFP on patients’ independence. However the ankle is a major weight bearing joint and therefore any damage to its structure will impact upon mobility. Several studies prescribe bed rest after an ankle fracture, whether to control pain or to use other interventions for the reduction of swelling, such as, ice packs, cryotherapy and compression bandages. Early mobilisation is only encouraged post surgically in this patient population. Therefore mobility of the patients would still be restricted without the AVFP.
A couple of the patients admitted to disconnecting the device themselves enabling them to leave the ward and therefore disrupting their treatment. The effectiveness of mobile foot pump devices has been explored in postsurgical elective patients undertaking hip or knee arthroplasties, when compared to standard AVFPs the results were inconclusive. Further research is required to establish whether a mobile device is feasible, allowing patients to leave the bed area without interrupting treatment, increasing tolerance levels reducing the impact upon their hospital stay.
Considerations for Further Research
The interpretation of the research data identified a number of gaps within the literature resulting in the following recommendations for further research.
Tolerance of the device was directly associated with intensity levels but the therapeutic range of the AVFP is unknown.
- Establish the AVFPs therapeutic range for reduction of swelling in unstable ankle fracture patients.
Patients and staff highlighted how the AVFP impacted upon mobility, restricting the patients’ independence. Mobile AVFPs are available but have not been tested in this patient population.
- Ascertain feasibility of mobile AVFPs and whether tolerance and patient satisfaction is increased.
All patients reported severe pain at some point when using the AVFP, requiring the device to be turned down initially. Pain appeared to reduce as the swelling reduced. There are reports of ankle blocks being used in this period but this has not been adequately explored.
- Explore the use of ankle blocks in this patient population, focusing upon patient satisfaction and tolerance of the AVFP.
The analgesia effect of the device should be explored, establishing whether the intensity levels impact on this.
- Explore analgesia effect of AVFP, how prevalent is it and what impacts on it.
Fitting the AVFP at admission in the A&E department will potential expedite swelling reduction but not all patients require an AVFP and the integral slipper costs £20.
- Establish feasibility, length of stay and cost implications of applying the AVFPs at admission to the A&E department.
The Department of Health actively encourages the patient-nurse partnership however the research finding indicated the nurses maybe cautious in allowing the patient to become more actively involved with their care. Further research is required to establish the nurses concerns.
- Explore nurse – patient relationships, establish nurse and patients views.
Recommendations
Recommendations focus upon supporting patient-nurse partnership, empowering patients to become more active in their care. This involves ensuring the nurses have the tools and training to appropriately educate and inform the patients.
- Information leaflets for patients, these are not to replace the current verbal information delivered by the clinical team but rather to support it. Provided at admission they will allow the patients and their families to become fully informed with consistent and accurate information. Encouraging active involvement in their care. They should include;
What is a AVFP and why is it needed.
How to use the AVFP
Reassurance that noise levels do not disturb other patients
Information on the therapeutic range (will require further research)
Reassurance that pain often reduces over time
Realistic timeline of what to expect whilst in hospital; including approximate times for reduction of swelling, pain levels.
- Include at least one paper tape measure within the cast to allow a more accurate measurement of swelling reduction within clinical practice. This information can then be disseminated to the patient, involving them in their care and updating them of their progress.
Paper tape measures placed under the cast, modelled by author.
- Develop documentation to support nursing staff in evaluating the extent each patient wishes to become involved in their care and supporting the patient-nurse partnership. Shifting emphasise from compliance to concordance. This may include, tolerance levels, a progress report and pain scores.
- Training for nursing staff in the above documentation and patient education.
- Disseminate these findings to staff increasing understanding of patients’ perceptions. Which will also provide an effective rationale to introduce the above changes to practice.
Reflection
Funding kindly donated by NHS professionals, arranged through the Nightingale Foundation allowed me to complete the final year of my masters and enabled me to carry out a thorough analysis of the data I had collected.
This study has proved invaluable in developing me personally and professionally. As a previous research nurse I had experience in contributing to the implementation of research studies. However the opportunities afforded to me by the Florence Nightingale foundation and NHS Professionals enabled me to carry out a thorough analysis of my own study. The challenges of running and analysing such a study have impacting immensely on my personal and professional growth. Utilising decision making skills to ensure the appropriate information is analysed and interpreted correctly. Ensuring the patients and nurses voices were clearly heard above my own preconceptions and outside influences. I continue to face challenges in my attempt to disseminate the results effectively. Submissions are planned to the RCN and ‘British Orthopaedic Association’ conferences and I am in the process of submitting the results to an appropriate nursing journal. Which has been aided with courses supplied by the Florence Nightingale foundation.
Changes in practice have begun; tape measures are now being placed in the casts to give a more accurate account swelling. Yet there is still a lot to do and learn; I believe strongly in the benefit of a patient- nurse partnership. Focus should be on concordance of healthcare plans rather than compliance; this requires further research to explore the obstacles, implications and challenges.
In conclusion although the study has brought many challenges and sleepless nights, the invaluable experience continues to prepare me for all future studies and projects. I sincerely thank you for the opportunity.