Background
Improving the patient experience, controlling pain with nonopiate therapies, and preparing for value-based reimbursement are increasingly important foci for both physicians and hospitals.
Objective
We aimed to determine whether the addition of music and a natural landscape image to postoperative hospital rooms would result in improved pain and satisfaction scores among inpatients undergoing pelvic reconstructive surgery.
Study Design
This randomized controlled trial was approved by an Institutional Review Board. Eligible candidates were 18–85 years old, English speaking, and scheduled to undergo native tissue vaginal vault suspension for symptomatic pelvic organ prolapse. Patients with history of a chronic pain or substance abuse were excluded. Subjects were advised that the purpose of the study was to assess the effect of changes to the hospital environment on patient experience but were blinded to their group and intervention details. Changes included a landscape image mounted to the wall and access to a speaker with preprogrammed music selections. The intervention group was instructed to listen to their preferred music for a minimum of 2 30-minute sessions postoperatively. The control group had a standard hospital room, without music or landscape. All patient rooms were private. The primary outcome was the visual analog scale for pain in the morning of postoperative day 1. Secondary outcomes included narcotic use, likelihood to refer family to the same hospital facility, satisfaction with care and the hospital, and perception of a healing environment. A sample size of 43 subjects per arm was calculated to detect a difference of 10 mm in visual analog scale pain score.
Results
A total of 133 subjects were enrolled; primary outcome data were available for 92 (46 per arm). The mean age was 63.8 (standard deviation, 9.5) years, median Charlson comorbidity score was 2 (min, 0; max, 7), and 94.6% of subjects were white. On postoperative day 1, median visual analog scale pain scores were low (28.8 mm [0, 86]; 24.5 mm [0, 81]) and did not differ between intervention and control, respectively ( P =.57). Total morphine equivalents ( P =.817) and nursing pain scores ( P =.774) were also similar. However, the intervention group displayed a higher likelihood to refer family members to the hospital (98 mm (47, 100); 96 mm (65, 100); P =.037). At postoperative 2 weeks, the intervention group indicated higher satisfaction with their care (98 mm, (34, 100); 95 mm (42, 100); P =.032), the hospital (98 mm (71, 100); 94 mm (6, 100); P =.004), and the healing environment provided during their stay (98 mm; 92 mm (19, 100); P =.020) than those in the standard hospital rooms.
Conclusion
In this randomized trial, we found music and landscape imagery did not substantially affect postoperative pain scores; however, they had a positive effect on the postoperative experience. Furthermore, this effect appeared to broaden 2 weeks after surgery. Given the importance of value-based care, interventions such as these should be emphasized to enhance patient satisfaction, quality scores, and overall well-being.
In the late 1800s, Florence Nightingale wrote about the importance of supportive spaces for patient care and recovery. More recently, the Institute of Medicine formed the Committee on Quality of Health Care in the United States. The committee aimed to redefine the definition of quality healthcare by introducing the following 6 “domains of care”: safe, effective, patient-centered, timely, efficient, and equitable. Their recommended framework for improving the quality of healthcare in the United States has since become an integral part of healthcare delivery.
Why was this study conducted?
This study aimed to determine whether music and landscape imagery during the postoperative period would improve patient pain and satisfaction.
Key findings
Subjects exposed to music and landscape imagery postoperatively indicated similar pain scores; however, they were more likely to refer their family to the hospital and reported higher satisfaction with both their care and the hospital.
What does this add to what is known?
Simple and inexpensive changes to the postoperative environment positively change the patient experience and could potentially improve patient impressions of the hospital.
Efforts in medical research have historically focused on markers of disease pathology, such as treatment effectiveness. Patient-centered care has allocated the patients’ experience with a similar significance. Reinforcing this, patient satisfaction surveys, such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, are directly tied to insurance reimbursements. , Furthermore, patient satisfaction has been found to improve adherence to care plans, reduce 30-day readmission rates, and decrease overall mortality. , To enhance the patient experience, studies have focused on the postoperative environment and its effect on healing. A recent review in the Lancet suggested that music consistently reduces pain, anxiety, and analgesic utilization and can help improve patient satisfaction with their care. Fostering the patient surroundings with attractive imagery has been found to improve patients’ vital signs, clinical outcomes, and cortisol levels. Moreover, patients seem more likely to refer others to seek care at facilities that display art.
There is no randomized controlled trial that has assessed the effect of environmental changes in a urogynecologic population. Hence, we aimed to describe the effect of music and art incorporation into the postoperative environment after pelvic organ prolapse surgery using visual analog scales (VAS) for pain and satisfaction compared with controls experiencing standard care.
Methods
This randomized single-blind controlled trial was performed at the TriHealth Good Samaritan Hospital and Bethesda North Hospital in Cincinnati, OH, between May 2018 and June 2019. The study was approved by the TriHealth Institutional Review Board (IRB) (December 5, 2017) and registered with the national clinical trials registry (NCT03379753). Written informed consent was obtained from all participants before study enrollment. Funding was provided by the TriHealth Medical Education Quality Improvement Fund.
Subjects eligible for participation were women undergoing planned native tissue vaginal vault suspension for pelvic organ prolapse, with or without additional concomitant procedures. All procedures were performed by board-certified Female Pelvic Medicine and Reconstructive Surgery specialists, in conjunction with fellows. Vault suspension procedures included either uterosacral ligament suspension or sacrospinous ligament fixation. Surgical technique, suture number, and material were similar between surgeons. In addition, all subjects received general endotracheal anesthesia. Exclusion criteria included a physical or mental impairment, such as deafness, blindness, or dementia, that would preclude them from utilizing the modified postoperative environment. Furthermore, subjects were not eligible if they were actively taking daily narcotics, being treated for a chronic pain syndrome, non-English speaking, or planning to undergo an endoscopic reconstructive procedure or had a history of drug or alcohol dependence.
Patients meeting inclusion criteria were approached for enrollment in the preoperative holding area by their surgeon, a fellow, or the nurse coordinator. Potential participants were informed that small changes would be made to the environment of their hospital room; however, they were not advised regarding the nature of those changes. Thus, both groups were blinded to their group assignments. Enrolled participants were randomized using a random number table with block randomization, and participant group assignment was made with sequentially numbered, opaque, sealed envelopes.
Intervention group participants were assigned to a modified postoperative environment that included music and a natural landscape image. Music was accessed by using a Bluetooth-capable speaker. Four playlists were provided that offered selections of romantic big band jazz, new age spa, contemporary soul, and piano. Subjects could also play selections from their personal playlists. Subjects were asked to listen to music for a minimum of 2 30-minute sessions, although no maximum limit was enforced. Their assigned floor nurse ensured that the participants listened for 30 minutes. Individuals were instructed how to use the Bluetooth speaker and the music was turned on for them during afternoon and morning rounds.
A canvas print of a natural landscape was hung on the wall near the foot of the patient bed. The natural landscape was selected using a convenience sample of 100 volunteers in the surgery waiting area over 2 days. These 100 volunteers were asked to select their 3 preferred landscape images from 20 options. Through repeating the polling process, a single landscape was selected for study application.
The control group participants were provided a standard hospital room without any changes. All subjects were admitted for overnight observation to the same nursing units and received private rooms with private bathrooms. Subjects were cared for by nurses trained and familiar with the procedures and goals of the study. Beds were assigned by availability. Postoperative care among the intervention group and control group, including medications, voiding trials, activity, and diet, were standardized, although no expedited recovery protocol was implemented. This standard order set included scheduled dose of 30-mg Toradol IV for 24 hours; all other pain medications were provided as needed or per request.
On postoperative day (POD) 1, at breakfast time, , subjects were asked to rate their current pain and most intense pain they experienced using a VAS from 0–100 mm, 0 indicating “no pain” and 100 indicating “severe pain.” Before discharge they were asked to complete another series of VAS-based questions. Regarding pain, they were asked to indicate their current pain, the most intense pain they experienced, and their average pain level over the course of the day. Furthermore, they were asked to specifically indicate their average pain level with activity and rest. Patient experience was evaluated by asking their satisfaction with the hospital and the care they received, whether they felt the hospital room provided a healing environment, and how likely they were to choose the hospital again for future care. A modified version of questions 21 and 22 from the HCAHPS survey was also presented in a VAS format. Because of regulations associated with this questionnaire, we could not provide an exact copy of the survey. Subjects were asked how likely they were to recommend the hospital to family and friends and how they would rate the hospital compared with other hospitals. Subjects were provided a space in which they could write additional comments.
The intervention group answered specific questions before discharge regarding music and the landscape. The questions were formatted using a Likert scale. Regarding music they were asked, “How beneficial did you find the music to be to your recovery?” Considering the landscape they were asked, “How beneficial did you find the natural landscape on the wall to be to your recovery?” Subjects were also asked whether they would be interested in having music and landscapes available to them in the future if they again required inpatient care.
At the 2-week postoperative visit, subjects were asked to answer the same VAS questions with 2 exceptions. The VAS questions modeled after the HCAHPS survey were presented in their original, unaltered format. In addition, subjects were asked to complete question 1 of the Patient Global Impression of Improvement (PGI-I) and the Decision Regret Scale for pelvic floor disorders. The intervention group answered again the same questions concerning the helpfulness of music and landscape to their recovery.
Demographics including age, ethnicity, body mass index (BMI), controlled substance exposure, and diagnoses associated with the Charlson Comorbidity Index were collected from the patient chart. Use of medications provided for treatment of pain, including amitriptyline, doxepin, nortriptyline, nonsteroidal anti-inflammatories, opiates, acetaminophen, gabapentin, pregabalin, lamotrigine, duloxetine, venlafaxine, and carbamazepine was recorded. Preoperative pelvic organ prolapse quantification (POP-Q) measurements were identified from presurgical office visits. Surgical details including concomitant procedures, length of stay, estimated blood loss, and intraoperative complications were collected. Postoperatively, voiding trial results, total morphine equivalents, nursing pain scores, and complications within the 30-day period were recorded.
Our primary outcome was the VAS for pain “right now” and “most intense pain” on POD1 at breakfast time, comparing intervention and control groups. We selected pain scores as our primary outcome because of measurability and strong previous data. , , To establish a meaningful clinical difference for our primary outcome, we performed a literature review of similar work. Research on effects of music in other surgical specialties indicated an average decrease in the VAS score of 7–26 mm. , Similarly, a Lancet review article reported on 73 randomized trials and described a mean overall difference in pain scores of 23 mm among the intervention and control groups. Finally, the most similar study design to ours provided music to cardiac intensive care unit patients for 30 minutes and reported a difference in VAS pain scores of 10 mm. Therefore, we selected 10 mm as representing a meaningful clinical difference in pain.
Secondary outcomes included VAS pain scores before discharge, nursing recorded pain scores, and total morphine equivalents between groups. Furthermore, we aimed to compare patient satisfaction of their care, the hospital, and the healing environment of their inpatient room, responses to HCAHPS related questions regarding referral of family and friends, and overall impression of the hospital. To determine whether environmental changes had a lasting influence on the patient experience, we compared these same data points 2 weeks postoperatively. Finally, length of stay, rates of urinary retention, scores on the Decision Regret Scale, PGI-I, and complications within the first 30 days were also compared among groups.
Based on the anticipated difference of 10 mm in VAS pain scores among groups, a sample size of 43 per group was planned, with a power of 90% and standard deviation of 14 mm. Total enrollment was initially set at 102, planning for a 15% attrition rate. However, soon after beginning enrollment, our research coordinator left her position. Immediate study audit noted incomplete data collection for 11 subjects from the intervention arm. The audit further revealed a data loss rate of 20%, which was higher than our original estimates. On that basis, we calculated the number of additional subjects required to meet our original enrollment for statistical power. Forthwith, a study modification was submitted to the IRB to increase enrollment to a total of 132 subjects, with newly constructed ratio of 1:3 (control to intervention) randomization table to achieve our set sample size. Because of this change, demographics were compared between those with and without primary outcome data.
Descriptive statistics were calculated for all continuous and categorical data. Continuous variables are summarized as mean (SD) or median (range). Categorical variables are presented as frequency (percentage). Student’s t-test and Mann-Whitney U test (Wilcoxon rank-sum test) were implemented to evaluate for substantially differences in pain and satisfaction scores and narcotic use between intervention and control groups. For categorical data, chi-square or Fisher’s exact test was used to test the association. SPSS version 22 (Armonk, NY) was used for statistical analysis.
Results
A total of 170 patients were screened for eligibility, 133 of whom met inclusion criteria and consented. One subject failed to be appropriately randomized. Of the 132 randomized patients, 61 received a standard hospital room (control), and 71 received a modified room (intervention). In the control group, 2 subjects withdrew, 2 were excluded, and 12 had missing primary outcome data. In the intervention group, 1 subject withdrew, 2 were excluded, and 22 had missing primary outcome data. Thus, 46 subjects in each group were included in final analysis ( Figure 1 ). Subjects were enrolled between May 2018 and June 2019.
Demographics are presented in Table 1 . The average age was 63.8 (9.5) years, average BMI was 27.6 (4.6) kg/m 2 , and 94.6% patients were white. Only a small proportion of patients had a diagnosis of depression (19.5%). Medications associated with pain treatment were taken by a small group of patients and for indications other than chronic pain ( Table 1 ). The groups did not differ in their parity, sexual activity, or alcohol consumption. The health of both groups was similar, and all had a prolapse of stage 2 or greater. Considering incomplete data, we did not find any substantially differences between participants included in the final analysis and those who were not included as a result of missing data. Finally, for 11 patients who did not provide responses during their 2-week follow-up, their demographics were also similar to those who completed the questionnaires (data not indicated).
| Characteristics | Standard (n=46) | Music and landscape (n=46) |
|---|---|---|
| Age, mean (SD), y | 63.6 (9.6) | 64 (9.4) |
| BMI, mean (SD), kg/ <SPAN role=presentation tabIndex=0 id=MathJax-Element-1-Frame class=MathJax style="POSITION: relative" data-mathml='m2′>m2m2 m 2 | 27.8 (4.9) | 27.5 (4.3) |
| Race | ||
| White | 43 (93.5) | 44 (95.7) |
| Black/African American | 2 (4.3) | 1 (2.2) |
| Hispanic | 1 (2.2) | 0 (0.0) |
| Asian | 0 (0.0) | 1 (2.2) |
| Parity, median (min, max) | 3 (1, 6) | 3 (1, 6) |
| Vaginal deliveries, median (min, max) | 3 (1, 6) | 2 (0, 4) |
| Cesarean deliveries, median (min, max) | 0 (0, 2) | 0 (0, 2) |
| Sexually active | 20 (44.4) | 18 (39.1) |
| Alcohol use | 26 (56.5) | 25 (54.3) |
| Charlson comorbidity, median (min, max) | 2 (0, 7) | 2 (0, 6) |
| Depression | 10 (21.7) | 8 (17.4) |
| Chronic pain | 3 (6.5) | 2 (4.3) |
| Medication | ||
| NSAIDs | 5 (10.9) | 8 (17.4) |
| Opiates | 1 (2.2) | 0 (0) |
| Tylenol | 3 (6.5) | 1 (2.2) |
| Gabapentin | 1 (2.2) | 3 (6.5) |
| Duloxetine | 0 (0.0) | 2 (4.3) |
| Venlafaxine | 2 (4.3) | 2 (4.3) |
| Greatest stage of prolapse | ||
| 2 | 18 (39.1) | 24 (52.2) |
| 3 | 25 (54.3) | 16 (34.8) |
| 4 | 3 (6.5) | 6 (13) |
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