Significance Of Early-in-hospital Mobilization Practice Standards And Approaches In Post-operative Patients After Abdominal And Thoracic Surgeries

Early Mobilization and Postoperative Care

Early mobilization is considered as an essential aspect in postoperative care. Dr. Emil Ries was the one of the first surgeons to explain the idea of early mobilization in post-operative care facilities. In spite of the documentation published by Ries, the clinical practice of mobilization after surgical event was slow in order to achieve favor in North America and healthcare professionals still preferred to keep the patients on strict bed rest following their surgery for some weeks with an objective to reduce pain and ensure sufficient wound healing. However, early mobilization was started being adapted by some health professionals; more specifically by surgeons by the 1940s as some of observational studies recommended that this clinical practice was comparatively more beneficial and not harmful for patients in their post-operative stage. Apart from that, evidence on negative impacts of immobilization in post-surgical period (e.g. pneumonia, risk of thromboembolism, physical deconditioning and muscle wasting) also came into the hand, reinforcing the advantages of ignoring prolonged and strict bed rest of patients after their surgery.

Within the last two decades, a significant advancement is there in perioperative care facilities along with the advancement and implementation of ‘standardized enhanced recovery pathways’ (ERPs). It is known to amalgamate many different components of care in intraoperative, perioperative as well as postoperative phases and objective to decrease morbidity, reduce duration of hospital stay and develop recovery of patients after their surgical event. ERPs are contained up to 25 individual interventions based on current evidences in the perioperative phase; though, the comparative contribution of all the stated components to the post-surgical recovery process was not clear. In this aspect, it has also been shown that early mobilization can be considered to be a major element of ERPs, consistent with aims of assisting the initial reestablishment of usual function (3). Policies and regulations for perioperative care processes from the ‘enhanced recovery after surgery society’ provided a concrete recommendation for early mobilization to be implemented and/or followed in case of post-operative patients. It has also been suggested that practice of early mobilization within an ERP is an essential as well as independent determinant of initial recovery specifically after surgery of colon cancer (3). Poor availability of evidence in the literature on relevant strategies to facilitate adherence to early mobilization as well as relevant differences in objectives associated with mobilization between programs. A systematic approach to enhance compliance is by utilizing a particular mobilization standard assisted by personnel specifically dedicated to mobilizing individuals for example, an occupational therapist or physiotherapist; though the additional advantages of this approach is not clearly known.

Enhanced Recovery Pathways

Therefore, the main aim of this rapid review, is to summarize and discuss the evidence on the significant impact of early-in-hospital mobilization practice standards and approaches on post-operative results after abdominal and thoracic surgery in comparison with standard care approach. To proceed with the process, in this study a total of nine different articles have been chosen from electronic databases like PubMed, CINAHL and MEDLINE. Most of the studies chosen to establish the rapid review were retrospective cohort studies and RCTs where mainly the impact of early mobilization intervention was specifically investigated in the patients who have undergone abdominal surgery. All the chosen research elicits both similar and varying findings in regards of the implementation of early mobilization intervention to enhance mobility of patients after their abdominal and thoracic surgery. For example, the study of Lockstone et al. (2020) performed a prospective pre-post cohort in order to investigate abdominal surgery patients including pre-cohort participants and post-cohort participants and found significant decrease in incidence of PPC following the said intervention. The findings of this study was found almost very similar to the findings of another study performed by Boden et al. (2018) where the authors have performed pragmatic, prospective, patient and accessor blinded randomized controlled trial. In this study, participants of the intervention groups elicited a positive result in term of reduction of Post-operative pulmonary complication. In this study, thematic analysis has been followed, where post-operative complications have been characterized in three different groups such as, post-operative pulmonary complications, physical mobility of patients with or without assistance and duration of hospital stay of the patients after accomplishment of their surgery. In all the chosen entities however, implementation of evidence-based intervention showed a positive outcome in term of reducing average total duration of hospital stay of patients who have undergone oesophagogastrectomy and total gastrectomy as well. The study of Rounlin et al. also found very similar findings where implementation of enhanced recovery for patients significantly helped in reducing total duration of hospital stay. Immobilization is a very common incident elicited by patients who have undergone abdominal and thoracic surgery (12). In order to increase mobility and working ability of the patients, different interventions for example, physiotherapy, yoga and meditation helped in increasing mobility of the patients that also had significant impact on overall wellbeing of the patients along with reduced need for assistance from healthcare professionals during their movement (25).

In this study, the assessment report of nine different articles along with information obtained from study findings was analysed in a proper manner using thematic approach of data analysis in order to focus specifically on each predictors of physiological wellbeing of patients including duration of hospital stay, post-operative pulmonary complication and ability to move independently. All the chosen articles showed positive impact of intervention supported by confidence interval. Limitations and advantages of all the chosen studies have also been precisely discussed as well where common major advantages of the studies included to develop this rapid review are participants selection from different demographics, large size of population studied, well-defined control and intervention study group and statistical significance. However, disadvantages of the chosen literatures are lack of standardization of the intervention followed in order to investigate their impact on patients’ wellbeing after their surgery and varying interventions in the chosen studies. 

Evidence of Early Mobilization in ERPs

Do the early-in-hospital mobilization practice standards and approaches have clinical significance in improving patients’ mobilization who have gone through abdominal or thoracic surgery in comparison with standard care approach?

The rapid review was conducted in accordance with the JBI methodology for scoping reviews, using a cross-section design. A total of nine studies were included. The articles that were included in the study were either randomized controlled trials or cohort studies. Main basis for choosing articles with above mentioned study methodology is to ensure unbiased and authentic research findings considering evidence of hierarchy.

This review will consider a cross-sectional design from 7 databases Medline, Cochrane Library, ProQuest, Cinahl, Web of Science, Scopus and PsycInfo library. There is limited evidence from April 2016 to November 2021. (Systematic review not included).

Guidance for authors: Patients who have gone through abdominal and thoracic surgery.

Guidance for authors: Post-operative patients (e.g. abdominal and/or thoracic surgery) and implementation of early-in hospital mobilization practice standards and approaches.

Guidance for authors:  Participants were chosen irrespective of their gender and age specificities. Participants selected in the study were not from any specific location and hence, reflected a broad image of post-operative complications of patients of different geographical location and cultural background. Restriction on language was there however (e.g. English).

E-databases like PubMed, CINAHL, Google Scholar, Medline, PsychINFO.

This scoping review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion.

Qualitative studies will also be considered that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research and feminist research.

In addition, systematic reviews that meet the inclusion criteria will also be considered, depending on the research question.

Text and opinion papers will also be considered for inclusion in this raped review

Edit Set Text As Appropriate:

The search strategy will aim to locate both published and unpublished studies. A three-step search strategy will be utilized in this review.  First an initial limited search of MEDLINE (PubMed) and CINAHL (EBSCO) change as appropriate was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for report the name of the relevant databases/information sources (see Appendix A). The search strategy, including all identified keywords and index terms, will be adapted for each included database and/or information source. The reference list of all included sources of evidence will be screened for additional studies. Specify the types of references examined (eg, references of studies included in the systematic review, or references of systematic reviews on the same or similar topic.

Strategies to Facilitate Adherence to Early Mobilization

Study Source 

figure 1

The conclusion of this Rapid review was assessed for quality by a single independent reviewer. Methodology quality assessment using (JBI) for the critical appraisal tool. Nine studies were included.

This rapid review was assessed for quality by a single independent reviewer; nine studies were critically appraised; no studies were excluded based on methodological quality using the (JBI) Critical Appraisal Checklist. Overall quality scores were between high and low quality. The chosen articles in this study are scored according to pre-determined criteria (Yes=2, No=0, and N/A=1) and rated as high (66-100%), moderate (34-65%) or low quality (0-33%). The highest score was 100 %, and the lowest score was 77.7%. Considering the quality of methodology used in the chosen studies, it was considered that almost all the studies meet high score (e.g. moderated to rated as high).

Data will be extracted from papers included in the scoping review by two or more independent reviewers using a data extraction tool developed by the reviewers. cite the tool to be used or append the data extraction tool if an existing tool has been modified or a new tool developed any modifications to existing tools should be described in the text  The data extracted will include specific details about the participants, concept, context, study methods and key findings relevant to the review question/s.

A draft extraction form is provided (see reference list). The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included evidence source. Modifications will be detailed in the scoping review. Any disagreements that arise between the reviewers will be resolved through discussion, or with an additional reviewer/s. If appropriate, authors of papers will be contacted to request missing or additional data, where required.

Data Synthesis

The literature search yielded a total of 378 studies initially following the removal of duplicates. Considering both inclusion and exclusion criteria, of the said 378 articles a total of 40 articles were incorporated in the records. All 40 records were retrieved ultimately. Eligibility assessment of the 40 chosen articles was performed and considering the assessment, it has been found that 4 articles had ineligible intervention, 2 articles had ineligible comparator, 6 articles had ineligible outcomes and 15 articles had ineligible study design. Therefore, a total of 37 studies were excluded from the records as not meeting the above mentioned criteria. Of the 13 articles left, performing further assessment, a total of 9 articles were included in the record to perform a rapid review.

Rapid Review Findings

Eight studies incorporated patients undergoing abdominal surgical event and 1 study incorporated patients undergoing thoracic surgery. Some common issues associated with study methodology identified in the studies included were poor availability of information on external validity, poor documentation, lack of appropriate blinding strategy and high risk of systematic bias as appropriate blinding strategy was not followed. All the said factors had significant impact on validity of study findings and reliability as well. In four of the nine chosen articles, randomized controlled trial (RCT) method was followed, authors of one study performed a multicenter international cohort, two among nine chosen articles were prospective cohort and three articles were retrospective cohort.

In the study of Lockstone et al. (2020), the authors have performed Prospective, pre-post cohort, observational and single-centre study recruiting a total of 182 participants of abdominal surgery including both pre-cohort and post-cohort participants. Incidence of postoperative pulmonary complications (PPC) was considered as the main primary outcome where the authors of the study have found that PPC incidence was comparatively less in the group of intervention in comparison with control group (e.g. No NIV). Average time of first session of NIV was 18.6 hours with a total of 74% of patients receiving NIV within 24 hours of surgical event. No major critical incidences were found in this experiment. Next in the study of Boden et al. (2018), the authors have performed a pragmatic, prospective, patient and accessor blinded, multicentre, parallel group, randomised placebo controlled superiority trial experiment recruiting a total of 441 adult individuals who have went through an upper abdominal surgery. The primary outcome of the research was PPC and the authors have found that significant reduction in CPP was observed in the participants of treatment group. For example, the incidence of primary outcome was 9 in treatment group and in control group the CPP score was 21 along with an appropriate risk reduction of 22%. Each patients in the treatment group were able to follow the exercise event (at least for partially); however, the performance among the participants were not at all homogenous. A parallel-arm, single blinded randomized trial was performed by De Almeida EP et al. (2018) with an objective to investigate the impact of early-in hospital intervention on mobilization of post-operative patients. Total number of enrolled patients in this study were 108. Among the total number of participants a total of 54 were allocated in intervention group, were they were provided with supervised aerobic exercise and rest 54 were allocated in control group where they were provided with standard post-operative care. Significant reduction in CPP was observed in the participants of treatment group. For example, the incidence of primary outcome was 9 in control group and treatment group the CPP score was 21 along with an appropriate risk reduction of 22%. Each patients in the treatment group were able to follow the exercise event (at least for partially); however, the performance among the participants were not at all homogenous. Patients with gastric and oesophageal cancer surgery were recruited in the retrospective cohort study of Gatenby et al. (2015). In this study the authors have found that the average total duration of hospital stay was decreased by 3 days after oesophagogastrectomy and total gastrostomy. The mean duration of stay of the patients on the CCU remained the very same for every patients. Jonsson et al. (2019), recruited participants undergoing thoracic surgery due to advancement of lung cancer. Primary outcome of research and/or evaluation was performed by measuring activity degree in hospital and physical capacity after surgical event. The findings of the study suggested that the patients who received physiotherapy intervention in hospital elucidated elevated extent of physical activity in time of the initial days following lung cancer surgery in comparison with control group (untreated). No significant impact on spirometric entities and six-minute walk test was found. Patients undergoing high-risk abdominal surgical event were included in this study of Jønsson et al. (2018). A total of 50 patients undergoing abdominal surgery were allocated in this study and a prospective cohort study methodology was followed. Patients who have gone through AHA surgery have very restricted ability for physical activities in the initial week of post-operative phase mostly due to abdominal pain and fatigue. Patients aged 65 years and more than that who went through clinical emergency abdominal surgical event were recruited in the prospective cohort study of Pederson et al. (2020). Primary outcomes considered in this study were 30 day and 6-month-every-caause re-admission to healthcare centers and demise after discharge event following surgery. Delayed mobilization has independent association with elevated risk of 30-day readmission in healthcare facilities or morbidity. The data was not statistically significant when it was considered in term of 6-months period. A Multicenter international cohort study was performed by Roulin et al. (2020) where, the study was dependant on prospective database, including every consecutive individuals/ participants undergoing robotic or laparoscopic elective and open PD. Implementation of enhanced recovery for PD was significantly difficult, specifically in the postoperative phase. Overall adherence with ERAS protocol, more than 70% participants was linked with reduced complications and stay duration. A total of 214 participants were recruited consecutively who have gone through an elective robot associated or open laparoscopic in the study of Svensson-Raskh et al. (2021), where the primary outcome of research was based on variabilities in arterial blood oxygen pressure and peripheral oxygen saturation level. Considering data of intention-to-treat analysis, participants of treatment group who received both breathing exercises and mobilization exercises had improved both oxygen partial pressure and oxygen saturation level.

Review Question

Considering the rapid review findings, as discussion, it can be stated that reduction of PPC may be possible with non-invasive ventilation after upper abdominal surgery. As the study of Lockstone et al. (2020), suggested that incidence of PPC was considerably less in the treatment group, where participants were administered with 30-minute-session of NIV in comparison with the participants of control group who did not receive the stated treatment. However, very little consensus is there on the standardised dosage of NIV in order to experience a clinically relevant advantage with extensive heterogeneity amongst studies (15). A previous study in this specific aspect provided guidance for choosing 30-minute NIV session in the experiment performed by Lockstone et al. (2020) (16). Apart from the previous intervention, in another study performed by Boden et al. (2018), the advantage of performing pre-operative physiotherapy for 30 minutes has also shown significant improvement in incidence of PPCs in case of a general patients’ population enlisted for elective upper abdominal surgical event (7). A similar experiment was also performed in Pakistan, where the researchers included a total of 224 participants in there research and reported that preoperative education while delivered by medical registrars, it results in earlier post-operative mobilisation and as well as around 76% decrease in incidences of PPCs (17). Therefore, it can be stated that in case of participants of upper abdominal surgery, in order to ensure mobilization, physical activity and ensure significant decrease in incidences of PPCs both post-operative NIV administration and pre-operative 30 minutes physiotherapy training and education plays a very important role. The result of the study of Boden et al. (2018) is considered essential enough as it includes some important and evidence-based interventions that help in inhibiting PPCs are pre-habilitation, inspiratory muscle training, postoperative chest physiotherapy and incentive spirometry utilization. De Almeida EP et al. (2018), highlighted some essential aspects on advantage of using early mobilization program to improve functional capacity of in-patients following surgery of major abdominal cancer. In this study, the researchers involved a total of 108 patients who underwent a major abdominal cancer surgery and an initial mobilization program depending on some supervised physical activities and/or exercises performed two times a day. This intervention significantly helped in resulting in a huge proportion of in-patients able to move from one place to another without assistance of any health professionals and other persons on the fifth day after completion of the surgical event (8).This finding of the study was also consistent with a similar study performed before that evaluated the impact of an early mobilization approach and intervention on the functional capability of participants undergoing major abdominal surgery. Though, this study has significant advantages on ensuring quick recovery and mobilization of patients after their major surgery, most of the studies have experimented and found the strategy for early mobilization as a major part of set of therapeutic or clinical interventions specifically in a multidisciplinary approach of rehabilitation, also called enhanced recovery or fast-track recovery after surgical event (8). Gatenby et al. (2015), has performed a study as mentioned above to investigate the impact of an enhanced recovery programme in gastric and oesophageal cancer surgery (9). In this aspect, it has been shown that proper implementation of ERAS approach is significant enough to gastric cancer and oesophageal cancer patient (18). The basis of all similar studies performed before has already been the positioning of an agreed standard, which is carefully followed throughout the pathway of patient (18). Despite, achieving success in this experiment, to date, poor availability of data on this field raise some potent challenges and difficulties. Jonsson et al. (2019), also has designed, developed and performed a research along with his co-researchers and colleagues, the main objective of this study was to investigate whether in-hospital physiotherapy intervention can bring positive change in improvement level of physical activity and advancement of lung cancer (10). The main finding indicated in the study is that patients or participants who receive physiotherapy in time of the very first post-operative days were comparatively more physiologically active in time of their stay in hospital (10). The participants of the treatment group significantly reached more foot-steps and/or counts per hour than the participants in the control group (e.g. they did receive standard post-operative care to the patients. However, before this study, global research on the stated topic, published two different reports. The study of Agostini et al. (2011) reported a very low physical activity degree; the patients took an average of 170 steps on the very second day of their postoperative period and a total of 233 foot steps on the third day of post-operative phase. This value; however, were somewhat lower than the participants in the study performed by Jonsson et al. (2019). On the other hand, as per the study of Esteban et al. (2013), the participants were very active in time of their hospitalization event, taking an average of around 7200 and 8900 steps on the second and third day respectively. Therefore, a difference has been identified in this specific aspect, and it is mostly due to challenge in standardizing the protocol as number of published, peer-reviewed articles are less in this topic (19). A prospective cohort study was performed by in order to investigate the impact of physical activities and/or performance after acute high-risk abdominal surgery among the patients. According to the statements of authors, a total of fifty patients were identified undergoing AHA surgery. In the finding section, the authors of this paper stated that, patients who go through an AHA surgical event, have very restricted physical performance in the very first week of post-operative phase. Barriers that have been identified to independent movement and mobilization of elderlies are abdominal pain and merely fatigue (20). Lastly, a study has been performed by (11), shown that implementation of enhanced recovery for pancreatoducodenectomy is very challenging, specifically in the postoperative phase. Overall adherence with protocol of ERAS was linked with reduced challenges and duration of healthcare stay. The common themes identified in all the chosen articles are impact on intervention on mobility, reduction in hospital stay and reduction in symptoms of post-operative pulmonary complication. Both similarities and differences are found in the findings of the chosen articles in term of the impact of intervention. For example, in the study of Lockstone et al. (2020), the impact of intervention resulted in reduction of PPC incidence of less than half of the total number of participants participated in the research. Where as in the study of Boden et al. (2018) with similar intervention, almost half reduction of PPCs was achieved in the participants of intervention group. However, difference was there in the two above mentioned studies in term of standardization of intervention and approach or methodology followed. The study of Ep et al. (2018) was able to reduce risk of the same event by around 22%; however, in this study the performance among participants was not similar however. Similarities between the findings of study performed by Gatenby et al. (2015), Jonsson et al. (2019) found similar result in the aspect of reduction of hospital stay duration. Some other studies are also there that specifically focus on similar issues and found similar findings in this aspect. The study of Hoogeboom (2014), found significant improvement in mobility of post-operative patients implementing physiotherapy as intervention pattern. Deep-breathing along with physiotherapy also helps in reducing post-operative anxiety, pain and enhance confidence to move and perform self-activities.  The study of Muehling (2008), specifically focused on intervention to reduce post-operative PCC in after thoracic surgery in lung cancer patients. In this study, the authors were able to optimize a specific patient care program for patients undergoing thoracic surgery and the findings suggested significant impact of optimized patient care program on the reduction of PC. The findings of this study significantly correlate with findings of literature used in this rapid review. 

Methods

The advantage of this rapid review incorporates utilizing the standardized JBI critical appraisal tool of quantitative studies. Appraisal tool is considered very essential for appraising article to check its’ validity, reliability and authentication before using its’ information for evidence-based practices. To date, different critical appraisal tools are available such as CASP appraisal tool for quantitative article and JBI critical appraisal instrument. However, in this case, JBI critical appraisal instrument was used considering instruction. Thorough analysis of the articles helped in extracting most relevant information from the chosen articles and to put them in this research to enhance its’ credibility and validity (Munn et al. 2014). Apart from that systematic flow of the review study is another advantage that will help reader to understand the topic.  On the other side, some restriction also requires to be acknowledged. Primarily, the review was accomplished by single independent reviewer. Therefore, it may increase risk of systematic biases due to having error in data handling, data analysis and data incorporation. Review or cross-check by another author increases transparency and credibility of research that was not followed in case of this systematic review article.  Second, all the including studies were published in English. Therefore, other articles published in language other than English were skipped though they may contain some relevant information that could increase the significance of the study. Considering the subject matter of all the chosen articles, it has not been possible to conduct a thematic analysis due to not having overlap in findings and different interventions and comparators used in the articles (e.g. physiotherapy, NIV, physiotherapy education etc.) Due to this reason, it may raise some confusion as instead of providing a specific message on ensuring mobility for patients after their surgical event, this systematic review provides a broad overview on currently available interventions that can be chosen by healthcare facilities to ensure muscle strength, walking ability and lastly, mobility of the individuals. Third, most studies were cross-sectional in design. According to hierarchy of evidence, systematic review ranks highest and extracting information from systematic review does not impose high risk of potential bias. However, in case of RCTs and cohort studies, if conditional aspects are not considered properly (e.g. blinding approach, treat-to-analysis method, statistical analysis), then it increases risk of potential bias; mostly in case of quantitative study.  Fourth, Limited access to seven databases. While developing systematic review or rapid review, it is very essential to develop a record that contains vast array of research and then further exclusion is to be performed considering inclusion and exclusion criteria. It requires good analytical sense and team-work. To develop this study, limited source of research have been extracted from above mentioned journals and databases. As the obtained data are not from different countries, it also may raise some queries regarding generalizability of the findings. Fifth, articles that were published between April 2016 to November 2021 chosen to develop this systematic review; therefore, it is also a major drawback, as many articles might be there published before the given range put significant contribution in strengthening this study. Sixth, the researches differed with different age groups, and in this regard my review is from 5 to 18 years old. Homogenous population was not there in nine different articles, therefore, response of individuals may significantly differ against the interventions. Therefore, it requires further investigation where the interventions are providing similar outcome from both aged participants (aged more than 18 years and below 18 years).The seventh and last limitation was the ethical consideration. It is considered very essential in research studies as publishing participants actual data may raise legal activities as well as also may cause harm to the participants.

Types of Articles

Conclusions   

The rapid review examined the evidence based on the findings of nine peer reviewed articles obtained from seven different e-databases such as CINAHL, PubMed, Google Scholar, Medline and PsychoINFO. Among nine different articles in the fifth one, RCTs was followed and in rest of the articles cohort study was performed where the authors and/or researchers found many evidence-based interventions as effective enough to be ensure mobility in patients who have undergone surgery. Interventions like physiotherapy training, physiotherapy education, yoga and aerobic and NIV help in building muscle strength, bone strength and brain strength. Despite availability of many theoretical research on such interventions, limited data are available on the standardized guideline and/or policy that needs to be followed in order to successfully implement the program within care facilities. Studies included in this systematic review, used their standardized protocol considering the standard used in previous researches. However, limitation is still there, as the intervention was locally administered and the participants were not homogenously utilized them all either due to having difference in age, exposure and education on using the devices and tools. Considering this issue, though it cannot be stated that the data obtained and analysed in this rapid review project is validate and generalizable; however, as many studies have suggested implementation of the stated interventions bring change and success in case of post-operative patients; clinical sectors need to think further on it as disability, immobility and surgery associated disability are increasing gradually across the world. Further study needs to be performed developing specific research question; that will provide specific insight on a particular domain in-stead of providing an overview of all currently available interventions to manage the issue in healthcare and/or surgical unit.

As already stated that administration of optimal dosage of NIV facilitates achieving a clinically significant advantage with extensive heterogeneity among studies, it needs to be implemented in healthcare facilities for clinical practice. To implement this service in clinical facilities, staff training needs to be arranged stimulating the involvement of internal and external stakeholders. The study of Lockstone et al. (2020), suggests that appropriately trained physiotherapists can be skilled in the implementation of NIV. Apart from trained physiotherapists, nurse practitioner can also gain his/her practical experience, expertise and knowledge on the said domain; and hence, can facilitate implementation of the program in clinical practice to ensure mobility of the patients who had undergone surgery. Apart from NIV, as breathing exercise in peri-operative and post-operative care facility has shown significant benefit, it can also be implicated in healthcare sectors by providing education on this particular to the patients. Standardization of intervention protocol is considered very essential. Ambulation associated with post-operative facilities needs to be standardised precisely, as development in hospital stay duration are independently attributed to early mobilization events after major surgical event. In this specific aspect, early ambulation is also united as a probable intervention to prohibit PPCs. Therefore, proper staff training and ensuring infrastructure availability will help in promoting ambulation within healthcare and reducing PPCs. Another study used in this systematic review has shown that physiotherapy is quite beneficial after surgical event for increasing stay duration. In clinical facilities, duration of stay significantly depends on factors and/or determinants other than physiological status of patients only. Therefore, ensuring a patient’s wellbeing following surgical event demands incorporation of all the above mentioned tools/protocols that will further determine, mobility, muscle strength, emotional and psychological status, confidence and psychological abilities. Aerobic and yoga are also found beneficial in ensuring muscle and bone flexibility, strength and integrity that helps in mobilization of patient and reduce risk for post-operative complications. Successful implementation of such programs within healthcare require approval from management and nurse leader. As all the above mentioned clinical practice measures are non-clinical, it will not impose any serious risks for side-effects; however, precise learning and developing skills on showing empathetic behaviour and approach to the patients significantly help in developing the condition. Occupational therapists and physiotherapists are considered internal stakeholders in that aspects; therefore, active participation of them is assumed to develop the situation further. Allowing grant or fund will also help in developing infrastructure of healthcare facilities by arranging tools and devices essential for providing post-operative mobility care the patients. A method or tool of evaluation is also considered very essential to investigate the progression of the intervention; therefore, if local (e.g. primary care and secondary care healthcare sectors) can take the above mentioned decision, it will be very helpful. 

Inclusion Criteria

Lastly, I am thankful and knowing my gratitude to all my professors as they have provided me immense support by sharing resource, tools and options to evaluate research quality and discussing method for developing rapid review. I am also thankful to my peers as they also have provided support by sharing me some essential resources that helped me to develop and/or synthesis this research study.

Report which of the following are publicly available and where they can be found: template data collection forms, data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review #N.B. unmodified JBI forms (ie, critical appraisal and data extraction) are publicly available in JBI SUMARI and in the JBI Manual for Evidence Synthesis or the a priori protocol. Other required details may be posted as recommended in the PRISMA guidelines or available upon request. 

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