Original Article Effect of a Nursing Case Management Model on the Uncertainty in Recovery in Patients with Vascular Crisis After Finger Replantation

Int J Clin Exp Med 2021;14(1):407-414 www.ijcem.com /ISSN:1940-5901/IJCEM0118334

Original Article Effect of a nursing case management model on the uncertainty in recovery in patients with vascular crisis after finger replantation

Qiaoli Mo1, Risheng Qiu1, Songhe Cheng2, Xiaomin Chen1, Aiping Peng1

1Department of Hand Surgery, Affiliated Xiaolan Hospital, Southern Medical University, Zhongshan 528415, Guangdong Province, China; 2Department of Pain Management, Affiliated Xiaolan Hospital, Southern Medical University, Zhongshan 528415, Guangdong Province, China Received July 17, 2020; Accepted November 5, 2020; Epub January 15, 2021; Published January 30, 2021

Abstract: Objective: To investigate the effect of a nursing case management model (NCMM) on the uncertainty in illness recovery in patients with vascular crisis after finger replantation. Methods: The clinical data of 109 patients who underwent finger replantation in our hospital were collected retrospectively. Patients were divided into two groups according to the manner of intervention. Group A received routine health education and group B received NCMM on the basis of care give to group A. The scores of Mishel Uncertainty in Illness Scale (MUIS), Self-rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS) and Visual Analogue Scale (VAS), the survival rate of the replanted fingers, treatment and nursing comfort, and nursing satisfaction were compared between the two groups before and after intervention. Results: After intervention, patients in group B exhibited lower scores than patients in group A in 4 dimensions including unpredictability, inconsistency, complexity and ambiguity, SDS, SAS, and VAS (P<0.05). The survival rate of the replanted fingers in group B was 96.36%, which was higher than that of 72.22% in group A (P<0.05). Patients in group B showed a higher high-comfort rate (50.91% vs. 29.63%), a higher moderate- comfort rate (47.27% vs. 27.78%) and a reduced low-comfort rate (1.82% vs. 42.39%) than those in group A, with a significant difference (P<0.05). The scores of nursing attitude, nursing responsibility, nursing professional skills and nursing professional knowledge in group B were higher than those in group A (P<0.05). Conclusions: NCMM is able to reduce the uncertainty in illness recovery in patients with vascular crisis after finger replantation and is a valuable method to improve the mental status and nursing comfort and satisfaction.

Keywords: Nursing case management model, finger replantation, vascular crisis, uncertainty in illness

Introduction ological and pathological changes caused by the hemodynamic disorders of anastomosed Finger replantation refers to reattaching and arteries and veins after finger replantation [4, replanting the nerves, vessels and other tis- 5]. Individuals who have self-injury behaviors, sues of amputated fingers by means of micro- smokers, pregnant women, children and fe- surgical technique, which is one of the treat- males are more likely to develop vascular crisis ment techniques in clinical surgery [1]. With the after finger replantation [6]. There are a variety continuous improvement of microsurgical tech- of clinical methods to deal with vascular crisis, niques, China has been in a leading position of including venous perfusion, anticoagulation by finger replantation in the world this treatment heparin sodium and bloodletting, prostaglandin plays an essential role in the survival and func- E1, urokinase, surgical exploration and hyper- tion of amputated fingers. The survival rate of baric oxygen [7, 8]. Although the above meth- replanted fingers is closely correlated to the ods have certain therapeutic effects for vascu- blood circulation of repaired vessels [2, 3]. lar crisis, patients not only suffer from fear about their amputated fingers but also worry As a common complication after finger replan- about the surgical outcomes of finger replanta- tation, vascular crisis refers to a series of physi- tion, leading to negative emotions such as anxi- Effect of NCMM in patients with vascular crisis after finger replantation ety, fear and uneasiness [9]. Moreover, when tive and mental disorders; patients combined vascular crisis occurs after finger replantation, with serious organ diseases such as in the liver, patients are prone to uncertainty in their recov- kidney and heart; or communication disorders. ery due to lack of surgical knowledge [10, 11]. Studies have shown that uncertainty about Methods recovery has a significant impact on patients’ psychological adaptability and adjustment abil- Patients in group A received routine health edu- ity. In addition, patients’ negative emotions and cation. A primary nurse strengthened health mental stress may also be aggravated, and dis- education orally, to patients, including the rupt the patients’ ability to reaming positive causes of vascular crisis after finger replanta- about healing, thus leading to treatment inter- tion, treatment and nursing methods, ward ruption or depression [12]. Therefore, a scien- environment, etc. tific and reasonable intervention nursing model Patients in group B received NCMM on the is necessary to reduce the uncertainty in ill- basis of treatment in group A. A specialized ness in patients with vascular crisis after finger case management team was established, whi- replantation. ch consisted of a nutritionist, psychological Previous intervention methods usually give pa- consultant, rehabilitation therapist, specialist tients routine health education to enrich their nurse and specialist doctor. All members were knowledge of disease and surgery, however, required to have a bachelor’s degree or above, this care often lacks flexibility and individua- more than 10 years of clinical work experience, lization, making patients especially vulnerable and strong communication and organizing abil- to the uncertainty in their recovery [13, 14]. ity. Additionally, they needed to have unified Nursing case management model (NCMM) is a and professional case management training. novel nursing model that has emerged in recent Finally, only after passing an examination could years which integrates planning, coordination, they provide nursing services for patients. service, evaluation and monitoring, and pro- Implementation process: (1) Evaluation: First, vides segmented care for patients [15]. As re- members of the case management team com- ported, NCMM exhibits satisfactory application prehensively evaluated the patient’ knowledge value in improving patients’ negative emotions level, mental and social status and acceptabili- and relieving uncertainty in recovery [16]. In vi- ty, and then established a file for each patient. ew of this, our study is innovative and feasible (2) Plan: Members of the case management in the application of NCMM to nursing interven- team made a feasible and individualized inter- tion for patients with vascular crisis after finger vention plan for each patient based on his/her replantation. evaluation results. (3) Service: Based on the Materials and methods acceptability and cultural background of each patient, members of the case management Materials team explained to the patient the knowledge related to vascular crisis after finger replanta- The clinical data of 109 patients who under- tion, from the superficial to the complex (includ- went finger replantation in our hospital were ing risk factors, mechanism, clinical manifesta- collected retrospectively. Patients were divided tions, treatment, prevention methods of com- into group A (n=54) and group B (n=55) accord- plications and related matters needing atten- ing to the intervention manner. Group A received tion), strengthened targeted health guidance routine health education and group B received and encouraged patient’s families to actively NCMM in addition to the treatment of group A. participate in the nursing process. Family mem- (1) Inclusion criteria: Patients were informed bers were told to give love and care and were and agreed to treatment protocols; patients instructed to provide a high level of mental and were in a normal mental state; patients had social support to the patients. Furthermore, surgical indications of replantation of a severed combined with the actual situation of the char- finger; this study was approved by the Medical acteristics of each patient with vascular crisis Ethics Committee; patients had normal com- after finger replantation, intuitive and informa- munication ability; patients voluntarily partici- tive health knowledge brochures were made pated in the research. (2) Exclusion criteria: to transmit recovery-related knowledge to the Withdrawal; surgical contraindications; cogni- patients and improve their perception, in the

408 Int J Clin Exp Med 2021;14(1):407-414 Effect of NCMM in patients with vascular crisis after finger replantation forms of cartoon images, pictures and words. Self-rating Anxiety Scale (SAS) score and Self- Patients were allowed to record their questions rating Depression Scale (SDS) score [18]: SAS in the note area reserved in brochure, and th- and SDS were used to evaluate anxiety and en the case management members explained depression in both groups before and after these questions in detail. Members of the case intervention. The critical score for SAS and SDS management team made full use of their empa- is 50 and 53, respectively, and a higher score thy to analyze patients’ charming personality indicates more severe anxiety and depression. characteristics and formulated a targeted mental intervention plan and supporting strategy Visual Analogue Scale (VAS) score [19]: VAS to ensure the patients mental health, which in was used to evaluate pain in both groups be- turn promoted their physical health. By this fore and after intervention. 11 numbers from 0 means, patients could build solid confidence in to 10 represent different degrees of pain, with treatment, actively overcome anxiety and fear, 0 for painless and 10 for very severe pain. leading to a higher survival rate of the replant- Higher scores indicate more severe pain. ed fingers. (4) Coordination: The leader of case management team coordinated with the differ- The survival rate of replanted fingers was com- ent departments to ensure that, the whole pared in both groups, and survival criteria de- team worked well together, and patients were note that ruddiness at the end of the replanted willing to actively cooperate with imaging and fingers, with normal capillary reaction, normal laboratory examinations during treatment. Al- temperature, and moderate tension [20]. so, the leader strengthened the communica- Treatment and nursing comfort [21]: American tion with the case management members to Kolcaba general comfort questionnaire (GCQ) promote good health outcomes. (5) Monitoring: was used to evaluate treatment and nursing A good communication platform was built to comfort in both groups after intervention. GCQ insist on tracing patients’ rehabilitation condi- has a total score of 112. A score above 90 is tions by outpatient follow-up combined with considered as high comfort, ≤90 as moderate telephone follow-up. Members of case manage- comfort, and ≤60 as low comfort. ment team discussed the specific follow-up plan with patients, provided comprehensive Nursing satisfaction [22]: Nursing satisfaction guidance in medication, rehabilitation, exer- was evaluated in both groups after interven- cise, treatment and diet, patiently listened to tion, including nursing attitude, nursing respon- patients’ questions, and answered carefully. (6) sibility, nursing professional skills and nursing Evaluation: On one hand, the case manage- professional knowledge. Each item is evaluated ment team performed follow-up nursing care with a centesimal system, and higher scores throughout the care, evaluated the nursing effi- indicate higher nursing satisfaction. cacy, solved patients’ problems in a timely manner during the treatment process, and Statistical analysis developed mutual trust and harmonious nurse-patient relationship with both patients and SPSS 22.0 software was used to perform sta- their families. On the other hand, the case man- tistical analysis. Measurement data were ex- agement team also guided patients to make pressed by mean ± standard deviation (mean ± needed adjustments and reduced their mental SD). Normally distributed data were analyzed stress and negative emotions, so as to ensure by t-test, and non-normally distributed data the best recovery. were analyzed by Mann-Whitney U test. Co- unting data were expressed by n (%). Chi- Observation index squared test was used to analyze the count data between groups. P<0.05 was considered Mishel Uncertainty in Illness Scale (MUIS) score statistically significant. [17]: MUIS was used to evaluate uncertainty in illness recovery in both groups before and after Results intervention, including 4 dimensions, namely, unpredictability (5 items), inconsistency (7 Comparison of general data between the two items), complexity (7 items) and ambiguity (13 groups items). All the items are rated on a 5-point Likert scale, and a higher score indicates high- The proportion of male and female patients in er uncertainty in illness recovery. group A was 57.41% and 42.59%, respectively,

409 Int J Clin Exp Med 2021;14(1):407-414 Effect of NCMM in patients with vascular crisis after finger replantation

ference between groups (P> Table_ 1. Comparison of general data between the two groups n (%)/( x ± s) 0.05). Patients of the two Group A Group B groups showed no significant Materials t/X2 P (n=54) (n=55) difference in age, nature of injury and amputation site Gender (case) 0.076 0.783 (P>0.05) (Table 1). Male 31 (57.41) 33 (60.00) Female 23 (42.59) 22 (40.00) Comparison of MUIS scores Age (years) 42.28±1.35 42.32±1.31 0.157 0.876 between the two groups Nature of injury (case) Incised injury 15 (27.78) 17 (30.91) 0.018 0.859 There was no significant difference in the scores of 4 dimen- Crush injury 18 (33.33) 19 (34.55) sions, including unpredictabil- Avulsion injury 16 (29.63) 13 (23.64) ity, inconsistency, complexity Others 5 (9.26) 6 (10.91) and ambiguity, between the Amputation site (case) two groups before interven- Thumb 12 (22.22) 11 (20.00) 0.159 0.996 tion (P>0.05). Compared with Middle finger 15 (27.78) 13 (23.64) scores before intervention, th- Index finger 13 (24.07) 15 (27.27) ese scores were decreased Ring finger 8 (14.81) 9 (16.36) significantly in the two groups Little finger 6 (11.11) 7 (12.73) after intervention (P<0.05). Pa- tients in group B had lower scores of the 4 dimensions (unpredictability, inconsistency, complexity and ambiguity) than those in group A after intervention (P<0.05) (Figure 1).

Comparison of SDS scores and SAS scores between the two groups

The two groups showed no significant difference in SDS and SAS scores before intervention (P>0.05). The scores of SDS and SAS decreased significantly in both groups after intervention (P<0.05), and group B showed lower scores of SDS and SAS than group A after intervention (P<0.05) Figure 1. Comparison of MUIS scores between the two groups. (A) The com- (Figure 2). parison of unpredictability score between the two groups before intervention, with P>0.05, and group B has lower unpredictability score than group A after Comparison of VAS scores intervention, with P<0.05; (B) Shows the comparison of inconsistency score between the two groups between the two groups before intervention, with P>0.05, and group B has a lower inconsistency score than group A after intervention, with P<0.05; the comparison of complexity score between the two groups before intervention The VAS score of group A was is shown in (C) with P>0.05, and group B has a lower complexity score than not significantly different from group A after intervention, with P<0.05; (D) Comparison of ambiguity score that of group B before inter- between the two groups before intervention, with P>0.05, and group B has a vention (P>0.05), but both gr- lower ambiguity score than group A after intervention, with P<0.05; * refers oups showed decreased VAS to P<0.05 compared with group A. scores after intervention (P< 0.05). The VAS scores in group and that in group B was 60.00% and 40.00%, B were lower than those in group A after inter- respectively, with no statistically significant dif- vention (P<0.05) (Figure 3).

410 Int J Clin Exp Med 2021;14(1):407-414 Effect of NCMM in patients with vascular crisis after finger replantation

Comparison of treatment and nursing comfort between the two groups

Patients in group B had a higher high-comfort rate (50.91% vs. 29.63%), a higher moderate-comfort rate (47.27% vs. 27.78%) and a reduced low-comfort rate (1.82% vs. 42.39%) than those in group A, showing a significant differ- Figure 2. Comparison of SDS scores and SAS scores between the two groups. (A) comparison of SAS score between the two groups before inter- ence (P<0.05) (Table 3). vention, with P>0.05, and group B has a lower SAS score than group A after intervention, with P<0.05; (B) comparison of SDS score between the two Comparison of nursing sat- groups before intervention, with P>0.05, and group B has a lower SDS score isfaction between the two than group A after intervention, with P<0.05; * refers to P<0.05 compared groups with group A. Patients in group B had significantly higher scores for nursing attitude, nursing responsibility, nursing professional skills and nursing professional knowledge than those in group A (P<0.05) (Table 4).

Discussion

Vascular crisis is a common complication after finger replantation with various inducing factors. It is closely correlated with age, gender, amputation level, ischemia time, cause of injury, smoking history, etc. [23]. From the injury perspective, long-term ischemia, crush and avulsion injury and distal segment amputation are the main risk factors of vascular crisis [24]. Secondly, sudden trauma can cause nervous tension, coupled with tolerance for very severe pain, which is extremely easy to produce negative emotions such as anxiety and depression. However, negative emotion may in turn stimulate the sympathetic nervous system, leaving it Figure 3. Comparison of VAS scores between the an excited state and a consequent release of two groups. The figure shows the comparison of VAS Catecholamines, which trigger vasoconstric- scores between the two groups before intervention, with P>0.05, and group B has a lower VAS score than tion or spasms and slow the blood flow of anas- group A after intervention, with P<0.05; * refers to tomosis, then thrombus forms and vascular P<0.05 compared with group A. crisis occurs [25]. Too low or too high temperature in the ward can promote vasoconstriction and accelerate tissue oxygen consumption and Comparison of the survival rate of replanted metabolism, leading to vascular crisis. Pain can fingers between the two groups induce the stress response, stimulate an enor- mous release of injury factors, promote vaso- Group A had 39 patients with survival of the constriction, and eventually cause vascular cri- amputated fingers, with a survival rate of sis [26]. 72.22%, while group B had 53 patients with survival of amputated fingers, with an overall Although vascular crisis has various treatment survival rate of 96.36%. Thus, the survival rate methods in the clinic, which can significantly of group A was lower than that of group B improve the therapeutic effect and the survival (72.22% vs. 96.36, P<0.05) (Table 2). rate of replanted fingers, some patients seri-

411 Int J Clin Exp Med 2021;14(1):407-414 Effect of NCMM in patients with vascular crisis after finger replantation

Table 2. Comparison of the survival rate of replanted fingers between tion were higher than th- the two groups n (%) ose in group A, indicat- Group Case The survival rate of replanted fingers ing that NCMM can alleviate uncertainty in illne- Group A 54 39 (72.22) ss recovery in patients Group B 55 53 (96.36)* with vascular crisis after 2 X 12.064 finger replantation, im- P 0.001 prove patients’ mental Note: *refers to P<0.05 compared with group A. status, nursing comfort and satisfaction. Wan et al. [29] also found that Table 3. Comparison of treatment and nursing comfort between the two the level of uncertainty groups n (%) in illness of patients in Group Case High comfort Moderate comfort Low comfort the case nursing man- Group A 54 16 (29.63) 15 (27.78) 23 (42.59) agement group at dis- Group B 55 28 (50.91)* 26 (47.27)* 1 (1.82)* charge, 1 month and 2 X2 5.126 4.413 26.382 months after discharge P 0.024 0.036 0.000 was lower than that in Note: *refers to P<0.05 compared with group A. the control group, which was similar to this study to some extent, proving Table_ 4. Comparison of nursing satisfaction between the two groups that the case manage- ( x ± s, score) ment model was condu- Nursing cive to reducing uncer- Nursing Nursing Nursing Group professional tainty in illness of pa- attitude responsibility professional skills knowledge tients. The possible me- Group A (n=54) 71.15±1.25 70.09±2.29 73.25±1.18 71.16±1.08 chanisms are discussed Group B (n=55) 89.96±2.36* 91.25±2.36* 96.36±1.08* 95.12±2.88* as follows. First, NCMM t 51.859 47.495 106.694 57.303 is a novel clinical medical and nursing mana- P 0.000 0.000 0.000 0.000 gement system, which Note: *refers to P<0.05 compared with group A. advocates regarding patients as the priority, fo- ously lack multi-aspect knowledge and under- cusing on service and integration and adopting standing of vascular crisis, such as pathogene- a coordinated, holistic and continuous nursing sis and prognosis. Moreover, these patients model, so as to provide comprehensive care for are afraid of the impact of treatment failure on patients, ensure patients’ access to high-quali- their normal life in the future, and these factors ty nursing services and improve nursing servic- contribute to uncertainty in illness recovery es quality. Next, this nursing model can also [27]. Previously, patients with vascular crisis help alleviate patients’ mental stress and en- after finger replantation usually receive routine hance their sense of security and belonging. health education, however, its content is too Meanwhile, NCCM increases nurses’ sense of mechanistic and lacks flexibility and individual- achievement and responsibility, and effectively ization, so that patients often do not fully under- encourages inproved nurse-patient communi- stand the occurrence and progression of the cation and relationships. By this means, pa- recovery, and are full of fear about the com- tients will have less uncertainty in illness and plex treatment process, followed by uncertainty mental stress and burden, and the nursing in illness [28]. Therefore, our study adopted comfort during the nursing process is corre- NCMM to care for patients with vascular crisis spondingly improved. In addition, NCMM can after finger replantation. The results showed improve nursing efficacy and economic benefit that the scores of 4 dimensions in MUIS, SDS, through multi-department and multi-disciplin- SAS and VAS in group B were lower than those ary communication, coordination and coopera- in group A, while the survival rate of the re- tion among case management members. In the planted fingers, nursing comfort and satisfac- nursing process, the whole-course and com-

412 Int J Clin Exp Med 2021;14(1):407-414 Effect of NCMM in patients with vascular crisis after finger replantation prehensive evaluation of patients and the es- [5] Chung KC, Yoon AP, Malay S, Shauver MJ, tablishment of a bridge of friendly communica- Wang L and Kaur S. Patient-reported and func- tion between nurses and patients are benefi- tional outcomes after revision amputation and cial to increase patients’ compliance and medi- replantation of digit amputations: the FRAN- CHISE Multicenter International Retrospective cal experience, so as to alleviate their negative Cohort Study. JAMA Surg 2019; 154: 637-646. emotions [30]. [6] Barbato B and Salsac AV. Finger and thumb replantation: from biomechanics to practical sur- To sum up, NCMM is beneficial to decrease the gical applications. Hand Surg Rehabil 2020; uncertainty in illness in patients with vascular 39: 77-91. crisis after finger replantation, improve their [7] Nakanishi A, Omokawa S, Kawamura K, Iida A, mental status, and increase nursing comfort Kaji D and Tanaka Y. Tamai zone 1 fingertip and satisfaction. amputation: reconstruction using a digital artery flap compared with microsurgical replan- Despite our results, our study still has the limi- tation. J Hand Surg Am 2019; 44: 655-661. tation of a small sample size, which requires [8] Tuzun HY, Turkkan S, Arsenishvili A and Kurklu M. A new technique for metacarpophalangeal further analysis with a larger sample size, a lon- joint replantation after four-finger amputation. ger term and a more comprehensive research Hand Surg Rehabil 2020; 39: 235-237. in the future. [9] Mokhtar K, Culnan DM and Lineaweaver WC. Evolving antibiotic resistance of aeromonas Acknowledgements species in finger replantation. Surg Infect (Larchmt) 2020; 21: 158-160. This work was supported by “Painless Ward” [10] Khan N, Rashid M, Ur Rashid H, Ur Rehman for Reducing Vascular Crisis after Finger Sarwar S, Khalid Choudry U and Khurshid M. Replantation (No. 2019j239). Functional outcomes of secondary procedures in upper extremity replantation and revascular- Disclosure of conflict of interest ization. Cureus 2019; 11: e5164. [11] Charpentier K, Loisel F, Menu G, Feuvrier D, None. Obert L and Pluvy I. Long-term functional results of digital replantation: a survey of 28 pa- Address correspondence to: Aiping Peng, Depart- tients. Hand Surg Rehabil 2019; 38: 375-380. [12] Pickrell BB, Daly MC, Freniere B, Higgins JP, ment of Hand Surgery, Affiliated Xiaolan Hospital, Safa B and Eberlin KR. Leech therapy following Southern Medical University, No. 65, Jucheng digital replantation and revascularization. J Avenue Middle, Xiaolan Town, Zhongshan 528415, Hand Surg Am 2020; 45: 638-643. Guangdong, China. Tel: +86-18928101974; E-mail: [13] Sahin MS, Cakmak G and Birtay T. Comparison [email protected] of single-dose infraclavicular brachial plexus block and continuous infraclavicular brachial References plexus block applications in the treatment of finger amputations. J Hand Microsurg 2019; [1] Yoon AP, Mahajani T, Hutton DW and Chung 11: 134-139. KC. Cost-effectiveness of finger replantation [14] Saito T, Nezu S, Matsuhashi M, Nakahara R, compared with revision amputation. JAMA Shimamura Y, Noda T, Yumoto T, Nakao A and Netw Open 2019; 2: e1916509. Ozaki T. The trend of treatment and convey- [2] Woo SH. Practical tips to improve efficiency ance system for upper extremity replantation and success in upper limb replantation. Plast in Japan: a nationwide population-based study Reconstr Surg 2019; 144: 878e-911e. from the Japan trauma data bank. J Orthop Sci [3] Maruccia M, Marannino PC, Elia R, Ribatti D, 2020; S0949-2658(20)30077-4. Tamma R, Nacchiero E, Manrique OJ and Giu- [15] Vonderlind HC, Zach A, Eichenauer F, Kim S, dice G. Treatment of finger degloving injury Eisenschenk A and Millrose M. Proximal inter- with acellular dermal matrices: functional and phalangeal joint arthrodesis using a compres- aesthetic results. J Plast Reconstr Aesthet sion wire: a comparative biomechanical study. Surg 2019; 72: 1509-1517. Hand Surg Rehabil 2019; 38: 307-311. [4] Wang Z, Zhu L, Kou W, Sun W, He B, Wang C, [16] Kayalar M, Güntürk ÖB, Gürbüz Y, Toros T, Shen Y, Wang Y, Zhu Z and Liang Y. Replanta- Sügün TS and Ademoğlu Y. Survival and com- tion of cryopreserved fingers: an “organ bank- parison of external bleeding methods in artery- ing” breakthrough. Plast Reconstr Surg 2019; only distal finger replantations. J Hand Surg 144: 679-683. Am 2020; 45: 256.e251-256.e256.

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