Introduction

The hospital-to-home surgical transition period includes the predischarge, discharge and postdischarge (ie, 3 months after discharge) periods, and it is a vulnerable time for patients due to their increased risk of mortality and morbidity.1 2 This is also a time when they may have poor patient experience.1 Surgical patients are especially vulnerable during care transitions due to the risk of adverse outcomes following discharge.1 Adverse outcomes following discharge home for surgical patients can differ from those with other medical conditions due to their increased risk of readmissions for avoidable complications such as wound infections.3 Our scoping review will focus solely on colorectal surgery due to the high incidence of colorectal cancer in Canada.4 Colorectal cancer is the second most commonly diagnosed type of cancer, with an increase in incidence among both men and women under the age of 50.4

Hospitals have adopted pathways, such as Enhanced Recovery After Surgery (ERAS) for various surgical procedures, to promote early discharge, improve perioperative care, expedite the postoperative recovery period and shorten a patient’s length of hospital stay5 through methods such as early mobilisation after surgery and the avoidance or minimal use of opioids to produce fewer complications.6 These surgical pathways can also have implications for improving patient experiences, including readiness for discharge.5 In many countries, ERAS has become the standard of surgical care with numerous Canadian institutions successfully implementing the pathway.7 Optimising the discharge transition requires careful consideration of surgical patients’ experiences, including a thorough understanding of reported challenges during the transition period.8 Patients tend to rely on their family members, friends or supplemental paid caregivers to meet their care needs after transitioning home from the hospital, which raises concerns about the accessibility and coordination of home care in countries such as Canada, where formal home care is publicly funded.9 10

Patient experience is important to measure and can help better understand the associations between patient-reported outcomes measures, such as adverse events or complications and health service use.11 With shorter length of stays in hospital following surgery,5 patients often rely on educational tools that help them prepare for postdischarge and recovery.12 Patients have noted that they desire more information about their recovery and how to receive professional care services in the home if they feel they require it.13 The delivery of early educational materials has the potential to improve outcomes by allowing patients the opportunity to appropriately plan and gain a better understanding of their procedure and recovery.12 14 The quality and types of educational resources given to patients influence their level of engagement in the management of their care postdischarge.12 Despite advances in innovation to improve patients’ transition experiences, it is unclear—in the context of colorectal surgery—what elements of patient education and care could provide the greatest benefit to patient experiences and clinical outcomes.15 This knowledge gap necessitates a comprehensive synthesis of the challenges experienced by adult colorectal surgical patients during hospital-to-home transitions which this scoping review seeks to identify.

Methods and analysis

This paper presents a protocol for a scoping review of existing literature from countries with publicly funded health systems (ie, Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, the United Kingdom and the USA) on colorectal surgery patients’ challenges when transitioning home from the hospital.16 These countries were selected because they have similar health systems to Canada and are in accordance with the Canadian Institute for Health Information benchmarking for international comparisons as peer countries with comparable economies and levels of resources that can be used towards healthcare.17 This review will be guided by the Arksey and O’Malley18 framework and will adhere to the following five stages: (1) identify the research question, (2) identify relevant studies, (3) study selection, (4) chart the data and (5) collate, summarise and report the results.18 Preliminary literature searching began in June 2021 on the University of Toronto library database using search terms of colorectal surgery and experience to familiarise ourselves with some of the literature that has been published and identify relevant search terms. The primary search will be conducted in April 2023 with expected data extraction completed by January 2025. We anticipate that this review will be completed in full by February 2025.

Patient and public involvement

Patients or the public were not involved in the design of this scoping review protocol.

Stage 1: identify the research question

This scoping review seeks to improve current knowledge of colorectal surgical care transitions from hospital to home by answering the following primary research questions:

What type of literature has been published in countries with publicly funded health systems (ie, Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, the United Kingdom and the USA) on colorectal surgery patients’ challenges with regard to the standard of care (ie, ERAS pathway) when transitioning home from the hospital?16

What challenges have been reported by colorectal surgery patients during their transition home from the hospital regarding the standard of care (ie, ERAS pathway)?

Stage 2: identifying relevant studies

A comprehensive search strategy will be developed in collaboration with a librarian using a combination of database-specific subject headings and text words for the main concepts of colorectal surgery and hospital-to-home transition/patient-reported outcome measures/patient education. Results will be limited to adult human studies in the English language from 2012 to present. Search results from 2012 onwards were chosen as this is when ERAS was starting to be widely adopted in provinces such as Ontario (Canada) and has become the standard of surgical care in the country.19 Only English language articles will be included due to resource constraints. In addition, these date limits will be imposed to ensure the review will capture current and contextually relevant educational materials and surgical experiences. Challenges experienced during patients’ colorectal surgical transition period will include any point from predischarge to 3-month postdischarge and will be recorded. This time constraint will be imposed because the first 3 months after surgery is crucial for patients as it is indicative of any potential postoperative complications.12 Conference proceedings and books will be removed where applicable. We will search the following databases, which our team deemed the most appropriate to capture literature pertaining to our study topic: Ovid MEDLINE; Ovid Embase; Cochrane Database of Systematic Reviews (Ovid) and Cochrane Central Register of Controlled Trials (Ovid). In addition to database searches, the reference lists of a sample of included studies will be searched and considered for inclusion to identify studies that might have been missed. A preliminary search was conducted on PubMed in 2022 that produced 93 results to help further inform the inclusion criteria. Please see the full search strategy in the appendix.

As shown in table 1, this review will include peer-reviewed qualitative, quantitative, theoretical and empirical studies. Empirical studies should entirely consist of a colorectal surgery sample to be included in this scoping review. Theoretical papers (without samples) should focus on colorectal surgery populations. Studies will be excluded if they are unavailable in English, are not peer reviewed or include participants under the age of 18 years or participants discharged from hospital for reasons other than surgery or any location other than their home. Randomised control trials that compare interventions to the standard of care will be removed in order to capture the typical experience of a colorectal surgery patient (ie, those who receive surgical care that uses ERAS guidelines). Review of the literature will include reporting on the type of pathway and care that colorectal surgery patients receive in order to ascertain whether the challenges were experienced while receiving the standard of care that would be typical in Canada (ie, the ERAS protocol).

Table 1

Inclusion criteria

Stage 3: study selection

Search results will be uploaded and deduplicated using Covidence and then undergo title and abstract screening, followed by full-text review.

Title and abstract screening

Two reviewers will independently screen the title and abstracts using inclusion and exclusion criteria (see table 1). The criteria will be pilot tested using a random sample of studies prior to screening to ensure inter-rater agreement. Any study that meets the inclusion criteria will undergo a full-text review. Conflicts will be resolved through discussion with two or more members of the study team.

Full-text review

Two reviewers will independently complete the full-text review to verify whether a study meets the inclusion criteria. Any uncertainties or conflicts concerning the eligibility of a study will be resolved through team discussion.

Stage 4: charting the data

A data extraction form will be used to record relevant data from the studies. After reviewing the preliminary included studies, the research team will determine the systematic structure of data extraction. The type of data extracted will relate to the research questions.

To address research question 1, we will extract data related to the type of literature on the challenges experienced by colorectal surgery patients during their transition home from the hospital, such as:

Study characteristics (eg, publication year and study location)

Contextual information (eg, country, hospital type)

Sample characteristics (eg, age, sex, gender (if available), ethnicity, comorbidities, socioeconomic status, education level, health literacy, primary language)

Colorectal surgical procedure (eg, type of surgery)

Study methodology (eg, quantitative or qualitative tools used to capture patient experience)

Study objective/aim

To address research question 2, we will extract data related to the challenges that have been reported by colorectal surgery patients during their transition home from the hospital, such as:

The type of challenge(s) (eg, informational challenges related to completeness or timeliness of information, inconsistent information with healthcare providers, other reasons for poor or good patient experience)

Who identified the challenge(s)

The time at which the challenge was experienced (eg, prehospital discharge, during discharge or postdischarge, making note of exact timing when available)

Possible reason(s) why each challenge was experienced

Details of any solutions to address the challenge (eg, educational interventions, communication strategies, processes solutions and who/which healthcare providers were involved, the timing of delivery and value, etc)

During the pilot testing phase, two team members will trial the data extraction form on the same two studies to ensure that there are not any discrepancies in extracted data and improve the comprehensiveness of data captured within the form. Once discrepancies are resolved and there is a consistent understanding of the data extraction methodology, AS will extract the remaining studies independently.

Stage 5: collating, summarising and reporting the results

Data related to the type of literature on colorectal surgery patients’ care challenges will be analysed numerically (eg, frequency counts) and presented using descriptive summaries.

In addition, data related to the challenges reported by colorectal surgery patients during their transition home from the hospital will be descriptively analysed using a deductive content analysis. First, the extracted related to the challenges will be reviewed and then grouped into categories of the International Classification of Functioning, Disability and Health (ICF).20 The ICF is a framework that classifies physical and psycho-social health at an individual and population level.21 Using the ICF framework to categorise the identified challenges will enable a holistic understanding of the contextual factors that influence patients’ health and health experiences, including the social and physical environment from which these experiences occur.21 Specifically, the ICF framework will be used to categorise identified challenges into the following health-related domains20:

Body structures: any challenge impacting a surgical patient’s bodily structure,20 such as their limbs and organs

Body functions: any challenge impacting a surgical patient’s physiological bodily functions (eg, cognitive, sensory, pain, communication, movement-related, psychological)20

Activities and participation limitations: any challenge limiting a surgical patient’s activity (ie, ‘execution of a task or action’)20 or restricting them from participating in any aspect of their life

Environmental factors: any challenge related to a surgical patient’s physical, social and attitudinal environment20

The challenges will further be grouped according to the surgical transition trajectory (eg, predischarge, during discharge and postdischarge). Mapping patient pathways aids in identifying when the best point in the patient journey is the best to implement improved practices as well as achieve patient-centred care.22 We anticipate that a comprehensive list of challenges that colorectal surgery patients experience during transitions home from the hospital will be generated from this analysis. Any solutions identified from the included studies will be linked to the specific challenges they address. A summary table will be generated to illustrate the number of studies reporting each challenge, along with the methodology used to identify the challenge. In addition, data analysis for quantitative studies will include types of outcome measures used to document impact and describe the type of impact. The strengths, weaknesses and validity of the studies will be recorded to identify potential confounders or explain results.23 Furthermore, team discussions will take place throughout the data analysis phase to identify gaps in the literature that can inform future research directions. Our team includes clinicians (general surgery and internal medicine) and health service researchers who have content expertise on this research topic, including experience and expertise in surgical transitions, patient education and scoping reviews.

Strengths and limitations

This scoping review will have some limitations. First, contextual restrictions must be considered. As only English-language studies will be included in this review, we will not capture findings in non-English speaking contexts. Additionally, this review will be limited to countries with publicly funded healthcare systems. While this will enable us to enhance the relevancy and transferability of our findings to the Canadian healthcare delivery where this review is being conducted, the findings will not report transitional challenges experienced by surgical patients in countries with private health systems. The second limitation is that our research questions will focus on patient-related challenges, not caregivers’ experiences. Caregiver experiences are important to consider and warrant further research. Our study is unique in that it focuses on the type of literature that has been published on challenges that colorectal surgery patients face throughout their perioperative journey and will identify these challenges from the patient perspective. Our team also consists of content experts to inform analysis and potentially improve the utility of our findings and knowledge translation activities.