{"paper_id":"2df3ab01-0645-482a-9630-8d12cf18f6fa","body_text":"Focus on Comfort - The effect of focus language on postoperative hospital stay compared to the NRS in children receiving postoperative care – A before-after study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Focus on Comfort - The effect of focus language on postoperative hospital stay compared to the NRS in children receiving postoperative care – A before-after study Ariana Angenent, Jolanda M. Maaskant, Laura Nieland, Charlotte L. Hoedjes, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8428158/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Apr, 2026 Read the published version in European Journal of Pediatrics → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose This study evaluates the effect of comfort assessment using focus language compared with pain assessment using the Numeric Rating Scale (NRS) on the postoperative length of stay (LOS), analgesic use and patient and parental satisfaction. Methods This prospective before-after study was conducted on a general pediatric ward at Emma Children’s Hospital. During the pre-intervention period pain was assessed using NRS. After implementation of focus language, comfort was assessed using the new communication approach. Eligible participants were children ≥6 years receiving postoperative care for >24 hours, able to report a NRS. Primary outcome was LOS (hours). Secondary outcomes were analgesic use (hours) and patient and parental satisfaction. Multivariable linear regression was used to adjust for baseline differences, potential confounding and effect modification. Results Pre-intervention 93 patients were included and post-intervention 99. The adjusted mean LOS in the post-intervention group (94.29 hours) was statistically significantly higher than the pre-intervention group (74.13 hours): expβ=1.27, p<0.01. Additional analyzes showed the estimated LOS was significantly higher post-intervention, suggesting more complex surgeries were performed during that period. Therefore, we analyzed the difference between estimated and actual LOS; no statistical significant difference was found. Analgesic use and patient and parental satisfaction were comparable. Conclusion When healthcare professionals focused on comfort during postoperative care, the difference between the estimated actual LOS was not statistical significant, patients received comparable number of analgesics, and patients and parents were equally satisfied. Shifting from pain-focused to comfort-focused communication appears a safe, feasible and promising approach for pediatric postoperative care. Patient comfort pain management pain measurement comfort assessment postoperative care pediatrics Figures Figure 1 What is Known – What is New What is known • The NRS is commonly used to assess pain in children ≥6 years. • Pain-related communication may influence the perception of pain. • Language used by clinicians can modulate pain and analgesic effects What is new • Comfort assessment instead of NRS did not change analgesic use or patient/parent satisfaction. • Longer LOS post-intervention was likely due to surgical heterogeneity, not the intervention. • Comfort-focused communication appears safe and feasible in pediatric postoperative care. Introduction The measurement of pain using the Numerical Rating Scale (NRS) is widely used in verbal children aged six years and older, yet its validity and potential unintended effects are increasingly debated [1-4]. Although valued for its simplicity, repeatedly asking children to rate their pain may heighten pain perception, fear, avoidance of activities, and functional disability [5-8]. These effects can be amplified by caregivers’ distress and focus on pain, while non–pain related factors such as depression may also influence NRS scores [9-12]. Pain and distress are significant clinical problems, associated with elevated metabolism, immune suppression, and impaired brain development [3; 13]. In surgical patients, these problems are common and can prolong hospital stay [14-18]. Accurate assessment is therefore essential for guiding treatment and evaluating its effectiveness. However, growing evidence highlights the role of communication in shaping pain perception, suggesting that assessment methods themselves may influence outcomes [9; 10; 12]. Focus language is a psychological approach that shifts the conversation from pain and its reduction, to comfort and its improvement [19]. Similar interventions—such as medical hypnosis, breathing techniques, distraction, and positive language—have been shown to reduce pain and distress in children during medical procedures [19-21]. Moreover, in adults, studies have shown that the words used by healthcare providers can modulate analgesic effects and affect patients’ anxiety and pain experience. For example, Bingel et al. [22] showed that when administering a powerful painkiller to healthy volunteers exposed to a painful stimulus, the effect of the medication was influenced by the raised expectation. When participants were told they were receiving a very powerful painkiller, they reported less pain compared to those who were told that the drug might not help. Dutt-Gupta et al. [23] found that placement of an peripheral intravenous catheter might be less painful and better tolerated when no warning of a sting is given. Chooi et al. [24] conducted a randomized trial comparing pain and comfort scores in women after caesarean section. Their results show more discomfort and analgesia use when women were asked to rate pain instead of comfort, suggesting that the wording of assessment scales can influence patients’ pain perception [24]. Despite these promising findings in adults, the effectiveness of focus language in pediatric postoperative care remains unstudied. We therefore designed a study evaluating the differences between comfort assessment using focus language and pain assessment using the NRS, on postoperative length of stay, analgesic use, and patient and parental satisfaction in postoperative children 6-18 years old. Materials and methods Study design and setting This prospective before–after study was conducted at a general pediatric ward of Emma Children’s Hospital, Amsterdam UMC. It comprised three phases: pre-intervention, implementation, and post-intervention. Participants We included children aged 6–18 years, receiving >24h postoperative care, able to self-report pain or comfort and fluent in Dutch (patient and/or parents). Outcomes The primary outcome of this study is postoperative length of stay (LOS, hours). The secondary outcomes are the difference between the estimated LOS and the actual LOS (delta LOS, hours), the duration of analgesic use (hours), and patient and parent satisfaction with pain management. Procedures Pre-intervention (Sept 2021–July 2022): Patients assessed pain using the NRS (0=no pain, 10=worst pain imaginable) every 8 hours during the first 72 hours post-surgery. Nurses assessed a nurse observed NRS as well, based on their observation of the patient. Both scores were documented in the electronic patient file (EPF). Implementation (Aug–Sept 2022): All healthcare professionals of the participating ward involved in the care of the children were trained in focus language. The training was provided during clinical lessons and daily evaluation moments by members of the research team. The following healthcare professionals were trained: nurses, physician assistants, surgeons, nurse practitioners, physiotherapists, dietitians, and pain specialists. In addition, reminder cards with a decision tree about the use of focus language and how to conduct a comfort score were handed out to the healthcare professionals, and posters with supportive information were placed in the ward. See supplementary Figure 1. Post-intervention (Sept 2022–Oct 2023): Patients assessed comfort using the comfort score (0=worst day, 10=best day) every 8 hours during the first 72 hours post-surgery. Pain was not actively mentioned by healthcare professionals. If the patient gave a comfort score ≤5, causes and supportive interventions were discussed. Pain was only addressed if raised by the patient. Nurses assessed a nurse observed NRS, conform pre-intervention period. The comfort score and the NRS were both documented in the EPF. Sample size Based on mean LOS of the participating ward in 2020 of 4.6 days (110 hours) and a 15% reduction (α=0.05, power=80%), 108 participants were required per group (nQuery version 8.5.1.). Ethics The Institutional Review Board of Amsterdam University Medical Center (UMC) confirmed the study was not subject to the Medical Research Involving Human Subjects Act (WMO) (W21_342#21.379). Data were pseudonymized, stored securely, and analyzed in compliance with General Data Protection Regulations. Consent was not required as the study was conducted in compliance with the Dutch law on Quality of Healthcare and evaluated quality of care. Data collection Data were extracted from the EPF by three researchers; a random sample of 10% was independently verified by the head researcher. Sample characteristics The following sample characteristics were collected from the EPF: age (years), gender, type of surgery and medical specialism. We collected the highest and the lowest nurse observed NRS per participant. These scores from the pre-intervention and post-intervention period were used to explore the pain levels of the patients during both periods, in order to assess whether the groups were comparable. Additionally, we collected the highest and the lowest patient reported NRS per participant (pre-intervention) and the highest and lowest comfort scores per participant (post-intervention). Outcome measures Length of postoperative stay (LOS) The LOS (hours) was defined as the time the patient arrived at the Post Anesthesia Care Unit (PACU) until the time that the patient was discharged from the hospital. When the time of arriving at the PACU was not registered in the EPF, the time of departing the Operating Room was used to note a LOS as accurate as possible. Delta LOS Additional to the actual LOS , the delta LOS (hours) was defined as: the difference between the expected length of postoperative stay and the actual length of postoperative stay. The expected LOS was estimated pre-hospitalization and registered in the EPF. Analgesics use The duration of analgesic use (in hours) for every type of analgesic was measured from the moment the participants arrived at the PACU until the last gift of the analgesic, or until the moment of discharge. The type of analgesics was noted, as well as the method of medication administration. The duration of analgesics use was reported for different subgroups: parenteral analgesics, enteral analgesics, parenteral opioids, and enteral opioids. Satisfaction The Netherlands Federation of University Medical Centers (NFU) survey was used to explore the satisfaction of the patients and their parents or caregivers about the postoperative pain management. The NFU survey is a national survey which is sent to every patient or their parent who has been hospitalized in a Dutch University Medical Centre to monitor the experiences of patients and parents [25]. The survey includes a question regarding pain management, addressing the patients (aged 8-17 years) and the parents (patients aged 0-8 years). Confounders and effect modifiers The following potential confounders were collected: (post-)surgery complications, (registered) psychiatric problems, and the presence of a chronic condition associated with chronic pain. We used the following definitions: (Post-)surgery complications: (internal) bleeding, (wound) infection, urinary tract infection, anastomotic leakage after bowel surgery, postoperative ileus, pneumonia, and any situation that needed a re-intervention. Psychiatric problems: mental health problems which daily affects the way a person thinks, feels and behave, e.g. anxiety disorder, depression, posttraumatic stress disorder, attention deficit hyperactivity disorder, and autism spectrum disorder. Chronic conditions associated with chronic pain, e.g., inflammatory bowel disease, therapy resistant constipation, medically unexplained symptoms, hereditary motor and sensory neuropathy, and arthritis as these conditions may change the pain experience and management [4; 14]. Patients with (post-)surgery complications, tend to need longer postoperative care due to the complication. This may affect the primary outcome. Regarding patients with psychiatric problems and patients with chronic conditions associated with chronic pain, it is clinically plausible these subgroups were affected differently by the focus language as these patients often need specific treatment during postoperative care [4; 14]. Regarding the use of analgesics, we considered LOS an effect modifier. When the LOS is longer, it is plausible the duration of analgesic use is longer as well. Additional subgroup analyses are reported in supplementary Table 1. Statistical analysis Descriptive statistics of continuous values were expressed as mean and standard deviation (SD). If not normally distributed, median and interquartile range (IQR) were used. Baseline differences between the pre- and post-intervention groups were explored using the Fisher exact test (dichotomous data), the Chi-square test or the Wilcoxon-rank sum test (categorical data), or the unpaired T-test (continuous data). The assumptions (normal distribution and homoscedasticity) were tested using the Shapiro Wilkinson test, the Levene’s test and by visual inspection of the histograms, QQ-plots and boxplots of the data. If the data were not normally distributed, the variable was log-transformed. If the data did not have homoscedasticity, the Yates correction was considered for the unpaired T-test. The Wilcoxon-rank sum test was used in case both assumptions were not met. We considered p<0.05 statistically significant. All analyses were performed in R Studio (v4.0.4). Missing data Only complete cases were included. For complications, psychiatric problems, and chronic conditions, absence in the EPF was interpreted as not present. NFU survey data were analyzed as available; missingness could not be assessed. Results Baseline characteristics of the participants During the pre-intervention period 93 patients were included and during the post-intervention period 99 patients (Figure 1). The following sample characteristics showed no statistically significant differences between the pre- and post-intervention periods: age, gender and type of medical specialism (Table 1). Length of postoperative stay (LOS) The mean LOS was statistically significant longer post-intervention 115.9h (SD 10.98) compared to pre-intervention 84.3h (SD 10.35; expβ=1.38, p<0.01). After adjustment for confounding, this remained statistically significant (mean 94.3h vs. 74.1h; expβ=1.27, p<0.01;). See Table 2a. Difference between estimated and actual LOS The mean delta LOS was not statistically significant different for patients in the post-intervention group: 42.95h (SD 10.82) compared to the pre-intervention group: 37.78h (SD 10.31, expβ=1.04, p=0.64). After adjustment for confounding, this remained not statistically significant (mean 23.60h vs. 26.20h; expβ=0.97, p=0.77). See Table 2b. To perform the delta LOS analyses, two participants in the post-intervention group were excluded due to missing preoperative estimated LOS in the EPF. Analgesic use We adjusted the following analyses for effect modification. The mean duration of parenteral analgesics use (opioids and non-opioids) was not statistically significant different for patients in the post-intervention group compared to the pre-intervention group: 18.94h (SD 12.03) versus 20.99h (SD 11.52), p=0.59. The mean duration of enteral analgesics use (opioids and non-opioids) was not statistically significant different for the patients in the post-intervention group compared to the pre-intervention group: 51.58h (SD 11.56) versus 38.61h (SD 11.10), p=0.05. The mean duration of parenteral opioids use for the patients in the post-intervention group remained not statistically significant different from the pre-intervention group: 1.13h (SD 13.09) versus 1.01h (SD 14.63), p=0.67. The mean duration of enteral opioids use for the patients in the post-intervention group was not statistically significant different from the pre-intervention group: 10.87h (SD 14.65) versus 5.79h (SD 18.51), p=0.11. See Table 2c. Satisfaction NFU surveys were completed by 16 patients and 61 parents pre-intervention, and 18 patients and 89 parents post-intervention. Satisfaction scores regarding pain management were not statistically significant different. Patient satisfaction: median 3 [IQR 3–3] in pre- and post-intervention period (p=0.56). Parental satisfaction: median 3 [IQR 3–3] in pre- and post-intervention period (p=0.06). See Table 2d. Post-hoc analyses A statistically significant difference in surgery type was observed between pre- and post-intervention groups. A total of 130 types of surgeries were performed during this study, of which 9 types of surgeries were performed in both the pre- and post-intervention period. See supplementary Table 2 for an overview of the most commonly performed operations in the pre- and post-intervention group. Discussion Main findings Contrary to expectations, we found that LOS was longer when comfort assessment was done with focus language instead of with the NRS. Furthermore, we found that analgesic use and patient/parental satisfaction in children receiving postoperative care were not influenced by the use of focus language. We hypothesize that LOS might not be the right outcome measure to investigate the effect of focus language. First of all, the longer LOS in the intervention group may reflect variations in surgery types between the pre- and post-intervention groups rather than the intervention’s effect. During the pre-intervention period, the COVID-19 pandemic affected scheduling, which caused catch-up surgeries during the post-intervention period, likely increasing heterogeneity in surgery types [26]. Since LOS is influenced by surgery type, this complicates the interpretation of our results [27]. The estimated LOS was significantly higher post-intervention, suggesting that more complex surgeries requiring longer LOS were performed during that period. To address the surgical heterogeneity, we focused on the difference between estimated and actual LOS (Delta LOS) additional to the primary outcome. As Delta LOS did not statistically significantly differ between groups, this suggests the intervention did not adversely affect LOS. Second, LOS has dramatically decreased in the period 2005-2012, but has been stable the past 13 years. For children 0-19 years the LOS has been approximately 4 days since then [28]. Clinical care has been optimized to meet discharge criteria in the most efficient manner and it is possible that there is not much room for reduction anymore. Although we did not find an effect of focus language on reduction of LOS, the intervention itself might reduce stress and enhance comfort. This was observed by staff of the anesthesia providing the post-operative pain management on the pediatric wards. The staff were so pleased with the new approach that it was implemented throughout the hospital before the results of this study were available [29]. Recently, Van Dorp et al. [30] & Edwards et al. [31] found that in adults visiting the emergency department because of pain, pain scores and comfort scores did not significantly differ. Therefore, pain and comfort scores might be interchangeable, supporting the safety of studying the effect of cognitive reframing and the use of comfort scores. This positive attitude towards the new approach is supported by the finding that patients and parents remained equally satisfied about pain management, although they were never questioned about pain [32; 33]. Furthermore, patients received the same amount of painkillers in the intervention group, suggesting that patients’ needs were still adequately recognized and treated. Inconsistent with our results were the findings of Chooi et al. [24] regarding their study among women receiving postoperative care after a caesarean section. They found that women in the comfort group requested even less painkillers compared to women in the standard NRS group. They also found that the negative suggestions used in the NRS group seem to have resulted in an increased number of patients reporting that their post-operative sensations were unpleasant, more bothersome, and perceived as tissue damage and injury rather than healing and recovery as mentioned in het comfort group Chooi et al. [24]. Limitations This study has several limitations. As mentioned above, when selecting the before-after design, we did not anticipate heterogeneity in surgery types, given the duration of inclusion during pre- and post-intervention period (11-14 months) and the homogeneity of the specialisms. The heterogeneity in surgery types may explain the difference in LOS rather than the effect of focus language. Secondly, the sample size was smaller than originally calculated due to missing data. The before–after design, the heterogeneity in surgical procedures, and the smaller-than-planned sample size, may limit the interpretability of the observed effect. Furthermore, the uncertain fidelity of the focus language implementation may have affected internal validity. At the end of the implementation period of this research, no measurements were conducted regarding how well the focus language was used during practical care. This limitation results in uncertainty about protocol adherence; whether the healthcare professionals used the focus language as described. This uncertainty also introduces the potential for contamination bias. Because patients in the intervention group may have occasionally received elements of standard care, and patients in the control group may have been inadvertently exposed to components of the intervention, the distinction between groups may have been reduced. Such contamination can dilute the true effect of the intervention, resulting in an underestimation of the results. Additionally, the relatively low response rate to the NFU survey (25%) lacks power and therefore can only be seen as an exploration of the patient/parental satisfaction. Finally, the study was conducted in a single center, which may limit the generalizability of the findings. Future research Future studies should use homogeneous surgical populations and consider outcomes more directly related to pain and distress rather than LOS, as this may provide a clearer understanding of the intervention’s true effect. As we did not administer any (additional) patient questionnaires, our insight into the patient experience is limited. Administering questionnaires and conducting interviews—such as measures of patient satisfaction, perceived control, or procedural anxiety—could provide more in-depth insight into outcomes that are relevant from the patient’s perspective. Subgroups (e.g. children with psychiatric or chronic pain conditions, or different age groups) may respond differently to focus language, as our exploratory analyses suggested shorter LOS in patients with chronic pain or psychiatric conditions. Conclusion Shifting from pain-focused to comfort-focused communication may be a safe and feasible approach in pediatric postoperative care. Patients and parents remain satisfied, analgesic use is unaffected, and the method shows promise for enhancing the patient experience. Future research should target homogeneous populations and explore the perspectives of both patients and healthcare professionals to maximize benefits. Abbreviations EPF: Electronic Patient File IQR: Interquartile Range LOS: postoperative length of hospital stay NFU: Netherlands Federation of University Medical Centers NRS: Numeric Rating Scale PACU: Post Anesthesia Care Unit SD: Standard Deviation UMC: University Medical Center VATS: Video Assisted Thoracoscopic Surgery WMO: Medical Research Involving Human Subjects Act Statements & Declarations Acknowledgments The authors thank the ESPR for providing a nursing grant and all nurses of the general nursing wards of the Emma Children’s Hospital for their cooperation in this study. Funding This work was supported by a nursing grant from the European Society for Paediatric Research (ESPR). Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions All authors contributed to the study conception and design. Material preparation and data collection were performed by Ariana Angenent, Charlotte Hoedjes, Linda Klaassen and Laura Nieland. Analyses were performed by Ariana Angenent. The first draft of the manuscript was written by Ariana Angenent, Jolanda Maaskant and Tessa Sieswerda-Hoogendoorn and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics approval The IRB confirmed the study was not subject to the Medical Research Involving Human Subjects Act (WMO) and has confirmed that no ethical approval is required. Data were pseudo-anonymized, stored securely, and analyzed in compliance with GDPR. Consent was not required as the study evaluated quality of care. Consent to participate Not applicable. Consent to publish Not applicable. 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Patient Educ Couns 80:293–299 https://doi.org/10.1016/j.pec.2010.05.033 Tables Table 1 – Sample characteristics Characteristics Pre-intervention group (NRS) Post-intervention group (focus language) P-value 1 Participants, n 93 99 - Age (in years) Median [IQR # ] 13.16 [11.00; 16.00] 13.42 [12.00; 15.00] 0.82 2 Gender 0.47 3 Male, n (%) 56 (60.2) 54 (54.5) Female, n (%) 37 (39.8) 45 (45.5) Type of medical specialism 0.08 3 General pediatric surgery, n (%) 47 (50.5) 46 (46.5) Pediatric plastic surgery, n (%) 7 (7.5) 9 (9.1) Pediatric orthopedic surgery, (n (%) 23 (24.7) 39 (39.4) Pediatric pulmonology, n (%) 3 (3.2) - Trauma surgery, n, (%) 4 (4.3) 3 (3.0) Pediatric gastroenterology, n (%) 1 (1.1) - General pediatrics, n (%) 1 (1.1) - Pediatric urology, n (%) 4 (4.3) 1 (1.0) Pediatric oral and maxillofacial surgery, n (%) 2 (2.2) - Neurosurgery, n (%) 1 (1.1) - Otorhinolaryngology, n (%) - 1 (1.0) Types of surgery, n 68 71 <0.01 3 Complications 0.24 3 No, n (%) 86 (92.5) 86 (86.9) Yes, n (%) 7 (7.5) 13 (13.1) Confounders and effect modifiers Diagnosed psychiatric problems OR chronic conditions associated with chronic pain, n (%) 15 (16.1) 24 (24.2) 0.28 3 Diagnoses chronic conditions associated with chronic pain, n (%) 14 (15.1) 23 (23.2) Diagnosed psychiatric problems, n (%) 2 (2.2) 2 (2.0) Comfort and pain assessment Highest NRS by nurse, median [IQR # ] 4 [3; 6] 4 [3; 5] 0.94 2 Lowest NRS by nurse, median [IQR # ] 0 [0: 1] 1 [0; 2] <0.01 2 Highest NRS by patient, median [IQR # ] 6 [4; 7] - Lowest NRS by patient, median [IQR # ] 0 [0; 1] - Lowest comfort score by patient, median [IQR # ] - 5 [4; 6] Highest comfort score by patient, median [IQR # ] - 8 [7.25; 9] # IQR = Interquartile range. 1 A p-value <0.05 was considered statistically significant. 2 Wilcoxon-rank sum test. 3 Fisher exact test. Table 2a – Results of multivariable linear regression analyses for postoperative length of stay (LOS) Pre-intervention group (n=93) Post-intervention group (n=99) Primary Outcome Mean SD * Exp(SE ○ ) 1 Mean SD * Exp(SE ○ ) 1 Exp(β-Coeff) 1 P-value 2 Length of postoperative hospital stay (in hours) without adjustment for confounders 84.28 10.35 1.07 115.92 10.98 1.10 1.38 <0.01 Length of postoperative hospital stay (in hours) with adjustment for confounders 3 74.13 10.31 1.07 94.29 10.89 1.09 1.27 <0.01 *SD = Standard Deviation, ○ SE = Standard Error 1 The dependent variable was log-transformed to meet the assumptions of the linear regression. 2 A p-value <0.05 was considered statistically significant. 3 Corrected for the variable: psychiatry or chronic pain and complications. Table 2b – Results of additional multivariable linear regression analyses for delta LOS Pre-intervention group (n=93) Post-intervention group (n=97) Primary Outcome Mean SD * Exp(SE ○ ) 1 Mean SD * Exp(SE ○ ) 1 Exp(β-Coeff) 1 P-value 2 Delta length of postoperative hospital stay (in hours) without adjustment for confounders 37.78 10.31 1.07 42.95 10.82 1.10 1.04 0.64 Delta length of postoperative hospital stay (in hours) with adjustment for confounders 3 26.20 10.29 1.07 23.60 10.77 1.09 0.97 0.77 *SD = Standard Deviation, ○ SE = Standard Error 1 The dependent variable was log-transformed using (log(y+α)) to meet the assumptions of the linear regression. 2 A p-value <0.05 was considered statistically significant. 3 Corrected for the variable: psychiatry or chronic pain and complications. Table 2c – Results of multivariable linear regression analyses for analgesic use Pre-intervention group (n=93) Post-intervention group (n=99) Secondary Outcomes Mean SD * Exp(SE ○ ) 1 Mean SD * Exp(SE ○ ) 1 Exp(β-Coeff) 1 P-value 2 Duration of parenteral analgesic use (in hours) without adjustment for confounders or effect modifier 46.92 11.20 1.16 56.74 12.25 1.23 1.21 0.36 Duration of parenteral analgesic use (in hours) with adjustment for confounders and effect modifier 3 20.99 11.52 1.19 18.94 12.03 1.21 0.90 0.59 Duration of enteral analgesic use (in hours) without adjustment for effect modifier 78.13 10.88 1.13 132.25 11.76 1.18 1.69 <0.01 Duration of enteral analgesic use (in hours) with adjustment for effect modifier 4 38.61 11.10 1.15 51.58 11.56 1.16 1.34 0.05 Duration of parenteral opioid use (in hours) without adjustment for confounders or effect modifier 7.14 11.82 1.23 12.11 13.31 1.34 1.70 0.07 Duration of parenteral opioid use (in hours) with adjustment for confounders and effect modifier 3 1.01 14.63 1.52 1.13 13.09 1.32 1.12 0.67 Duration of enteral opioid use (in hours) without adjustment for effect modifier 11.32 12.84 1.33 23.89 14.46 1.45 2.11 0.05 Duration of enteral opioid use (in hours) with adjustment for effect modifier 4 5.79 18.51 1.92 10.87 14.65 1.47 1.88 0.11 *SD = Standard Deviation, ○ SE = Standard Error 1 The dependent variable was log-transformed to meet the assumptions of the linear regression. 2 A p-value <0.05 was considered statistically significant. 3 Corrected for the variables: “psychiatry or chronic pain”, “complications” and “length of postoperative stay”. Restricted cubic splines with 3 knots was applied on the variable “length of postoperative stay”. 4 Corrected for the variable: “length of postoperative stay”. Restricted cubic splines with 3 knots was applied. Table 2d- Results non-parametric test analysis for patient and parental satisfaction Pre-intervention group Post-intervention group Secondary Outcomes N Median IQR # N Median IQR # W-value 1 P-value 2 Patient satisfaction – NFU Survey 16 3 [3; 3] 18 3 [3; 3] 127.5 0.56 Parental satisfaction – NFU Survey 61 3 [3; 3] 89 3 [3; 3] 2995 0.06 # IQR = Interquartile range. 1 W-value of the Wilcoxon Rank sum test. 2 A p-value <0.05 was considered statistically significant. Additional Declarations No competing interests reported. Supplementary Files Supplementarytablesandfigures301225.docx Cite Share Download PDF Status: Published Journal Publication published 27 Apr, 2026 Read the published version in European Journal of Pediatrics → Version 1 posted Editorial decision: Revision requested 25 Feb, 2026 Reviews received at journal 24 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviews received at journal 20 Jan, 2026 Reviewers agreed at journal 07 Jan, 2026 Reviewers invited by journal 07 Jan, 2026 Editor assigned by journal 07 Jan, 2026 Submission checks completed at journal 07 Jan, 2026 First submitted to journal 22 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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08:32:04\",\"extension\":\"jpeg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":605502,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFlow diagram of the participants in the pre- and post-intervention group.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8428158/v1/7f25e60e5b2120f2cbbe792e.jpeg\"},{\"id\":108437589,\"identity\":\"fefc4f9d-7f74-4736-b655-cdd0cb07d305\",\"added_by\":\"auto\",\"created_at\":\"2026-05-04 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hospital stay compared to the NRS in children receiving postoperative care – A before-after study\",\"fulltext\":[{\"header\":\"What is Known – What is New\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eWhat is known\\u003c/strong\\u003e\\u003cbr\\u003e\\u0026nbsp;• The NRS is commonly used to assess pain in children ≥6 years.\\u003cbr\\u003e\\u0026nbsp;• Pain-related communication may influence the perception of pain.\\u003c/p\\u003e\\n\\u003cp\\u003e• Language used by clinicians can modulate pain and analgesic effects\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eWhat is new\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e• Comfort assessment instead of NRS did not change analgesic use or patient/parent satisfaction.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;• Longer LOS post-intervention was likely due to surgical heterogeneity, not the intervention.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;• Comfort-focused communication appears safe and feasible in pediatric postoperative care.\\u003c/p\\u003e\"},{\"header\":\"Introduction \",\"content\":\"\\u003cp\\u003eThe measurement of pain using the Numerical Rating Scale (NRS) is widely used in verbal children aged six years and older, yet its validity and potential unintended effects are increasingly debated [1-4]. Although valued for its simplicity, repeatedly asking children to rate their pain may heighten pain perception, fear, avoidance of activities, and functional disability [5-8]. These effects can be amplified by caregivers’ distress and focus on pain, while non–pain related factors such as depression may also influence NRS scores [9-12].\\u003c/p\\u003e\\n\\u003cp\\u003ePain and distress are significant clinical problems, associated with elevated metabolism, immune suppression, and impaired brain development [3; 13]. In surgical patients, these problems are common and can prolong hospital stay [14-18]. Accurate assessment is therefore essential for guiding treatment and evaluating its effectiveness. However, growing evidence highlights the role of communication in shaping pain perception, suggesting that assessment methods themselves may influence outcomes [9; 10; 12].\\u003c/p\\u003e\\n\\u003cp\\u003eFocus language is a psychological approach that shifts the conversation from pain and its reduction, to comfort and its improvement [19]. Similar interventions—such as medical hypnosis, breathing techniques, distraction, and positive language—have been shown to reduce pain and distress in children during medical procedures [19-21]. Moreover, in adults, studies have shown that the words used by healthcare providers can modulate analgesic effects and affect patients’ anxiety and pain experience. For example, Bingel et al. [22] showed that when administering a powerful painkiller to healthy volunteers exposed to a painful stimulus, the effect of the medication was influenced by the raised expectation. When participants were told they were receiving a very powerful painkiller, they reported less pain compared to those who were told that the drug might not help. Dutt-Gupta et al. [23] found that placement of an peripheral intravenous catheter might be less painful and better tolerated when no warning of a sting is given. Chooi et al. [24] conducted a randomized trial comparing pain and comfort scores in women after caesarean section. Their results show more discomfort and analgesia use when women were asked to rate pain instead of comfort, suggesting that the wording of assessment scales can influence patients’ pain perception [24].\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eDespite these promising findings in adults, the effectiveness of focus language in pediatric postoperative care remains unstudied. We therefore designed a study evaluating the differences between comfort assessment using focus language and pain assessment using the NRS, on postoperative length of stay, analgesic use, and patient and parental satisfaction in postoperative children 6-18 years old.\\u003c/p\\u003e\"},{\"header\":\"Materials and methods\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eStudy design and setting\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis prospective before\\u0026ndash;after study was conducted at a general pediatric ward of Emma Children\\u0026rsquo;s Hospital, Amsterdam UMC. It comprised three phases: pre-intervention, implementation, and post-intervention.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eParticipants\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe included children aged 6\\u0026ndash;18 years, receiving \\u0026gt;24h postoperative care, able to self-report pain or comfort and fluent in Dutch (patient and/or parents).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eOutcomes\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe primary outcome of this study is postoperative length of stay (LOS, hours). The secondary outcomes are the difference between the estimated LOS and the actual LOS (delta LOS, hours), the duration of analgesic use (hours), and patient and parent satisfaction with pain management.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eProcedures\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003ePre-intervention (Sept 2021\\u0026ndash;July 2022):\\u003c/u\\u003e Patients assessed pain using the NRS (0=no pain, 10=worst pain imaginable) every 8 hours during the first 72 hours post-surgery. Nurses assessed a nurse observed NRS as well, based on their observation of the patient. Both scores were documented in the electronic patient file (EPF).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eImplementation (Aug\\u0026ndash;Sept 2022):\\u003c/u\\u003e All healthcare professionals of the participating ward involved in the care of the children were trained in focus language. The training was provided during clinical lessons and daily evaluation moments by members of the research team. The following healthcare professionals were trained: nurses, physician assistants, surgeons, nurse practitioners, physiotherapists, dietitians, and pain specialists. In addition, reminder cards with a decision tree about the use of focus language and how to conduct a comfort score were handed out to the healthcare professionals, and posters with supportive information were placed in the ward. See supplementary Figure 1.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003ePost-intervention (Sept 2022\\u0026ndash;Oct 2023):\\u003c/u\\u003e Patients assessed comfort using the comfort score (0=worst day, 10=best day) every 8 hours during the first 72 hours post-surgery. Pain was not actively mentioned by healthcare professionals. If the patient gave a comfort score \\u0026le;5, causes and supportive interventions were discussed. Pain was only addressed if raised by the patient. Nurses assessed a nurse observed NRS, conform pre-intervention period. The comfort score and the NRS were both documented in the EPF.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eSample size\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eBased on mean LOS of the participating ward in 2020 of 4.6 days (110 hours) and a 15% reduction (\\u0026alpha;=0.05, power=80%), 108 participants were required per group (nQuery version 8.5.1.).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eEthics\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe Institutional Review Board of Amsterdam University Medical Center (UMC) confirmed the study was not subject to the Medical Research Involving Human Subjects Act (WMO) (W21_342#21.379). Data were pseudonymized, stored securely, and analyzed in compliance with General Data Protection Regulations. Consent was not required as the study was conducted in compliance with the Dutch law on Quality of Healthcare and evaluated quality of care.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData collection\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eData were extracted from the EPF by three researchers; a random sample of 10% was independently verified by the head researcher.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eSample characteristics\\u0026nbsp;\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe following sample characteristics were collected from the EPF: age (years), gender, type of surgery and medical specialism. We collected the highest and the lowest nurse observed NRS per participant. These scores from the pre-intervention and post-intervention period were used to explore the pain levels of the patients during both periods, in order to assess whether the groups were comparable. Additionally, we collected the highest and the lowest patient reported NRS per participant (pre-intervention) and the highest and lowest comfort scores per participant (post-intervention).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eOutcome measures\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eLength of postoperative stay (LOS)\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe LOS (hours) was defined as the time the patient arrived at the Post Anesthesia Care Unit (PACU) until the time that the patient was discharged from the hospital. When the time of arriving at the PACU was not registered in the EPF, the time of departing the Operating Room was used to note a LOS as accurate as possible.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eDelta LOS\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAdditional to the \\u003cstrong\\u003eactual LOS\\u003c/strong\\u003e, the \\u003cstrong\\u003edelta LOS\\u003c/strong\\u003e (hours) was defined as: the difference between the expected length of postoperative stay and the actual length of postoperative stay. The \\u003cstrong\\u003eexpected LOS\\u003c/strong\\u003e was estimated pre-hospitalization and registered in the EPF.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eAnalgesics use\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe duration of analgesic use (in hours) for every type of analgesic was measured from the moment the participants arrived at the PACU until the last gift of the analgesic, or until the moment of discharge. The type of analgesics was noted, as well as the method of medication administration. The duration of analgesics use was reported for different subgroups: parenteral analgesics, enteral analgesics, parenteral opioids, and enteral opioids.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eSatisfaction\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe Netherlands Federation of University Medical Centers (NFU) survey was used to explore the satisfaction of the patients and their parents or caregivers about the postoperative pain management. The NFU survey is a national survey which is sent to every patient or their parent who has been hospitalized in a Dutch University Medical Centre to monitor the experiences of patients and parents [25]. The survey includes a question regarding pain management, addressing the patients (aged 8-17 years) and the parents (patients aged 0-8 years).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eConfounders and effect modifiers\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe following potential confounders were collected: (post-)surgery complications, (registered) psychiatric problems, and the presence of a chronic condition associated with chronic pain. We used the following definitions:\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003e(Post-)surgery complications: (internal) bleeding, (wound) infection, urinary tract infection, anastomotic leakage after bowel surgery, postoperative ileus, pneumonia, and any situation that needed a re-intervention.\\u003c/li\\u003e\\n \\u003cli\\u003ePsychiatric problems: mental health problems which daily affects the way a person thinks, feels and behave, e.g. anxiety disorder, depression, posttraumatic stress disorder, attention deficit hyperactivity disorder, and autism spectrum disorder.\\u003c/li\\u003e\\n \\u003cli\\u003eChronic conditions associated with chronic pain, e.g., inflammatory bowel disease, therapy resistant constipation, medically unexplained symptoms, hereditary motor and sensory neuropathy, and arthritis as these conditions may change the pain experience and management [4; 14].\\u0026nbsp;\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003ePatients with (post-)surgery complications, tend to need longer postoperative care due to the complication. This may affect the primary outcome. Regarding patients with psychiatric problems and patients with chronic conditions associated with chronic pain, it is clinically plausible these subgroups were affected differently by the focus language as these patients often need specific treatment during postoperative care [4; 14]. Regarding the use of analgesics, we considered LOS an effect modifier. When the LOS is longer, it is plausible the duration of analgesic use is longer as well. Additional subgroup analyses are reported in supplementary Table 1.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eStatistical analysis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eDescriptive statistics of continuous values were expressed as mean and standard deviation (SD). If not normally distributed, median and interquartile range (IQR) were used. Baseline differences between the pre- and post-intervention groups were explored using the Fisher exact test (dichotomous data), the Chi-square test or the Wilcoxon-rank sum test (categorical data), or the unpaired T-test (continuous data). The assumptions (normal distribution and homoscedasticity) were tested using the Shapiro Wilkinson test, the Levene\\u0026rsquo;s test and by visual inspection of the histograms, QQ-plots and boxplots of the data. If the data were not normally distributed, the variable was log-transformed. If the data did not have homoscedasticity, the Yates correction was considered for the unpaired T-test. The Wilcoxon-rank sum test was used in case both assumptions were not met. We considered p\\u0026lt;0.05 statistically significant. All analyses were performed in R Studio (v4.0.4).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eMissing data\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eOnly complete cases were included. For complications, psychiatric problems, and chronic conditions, absence in the EPF was interpreted as not present. NFU survey data were analyzed as available; missingness could not be assessed.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003cu\\u003eBaseline characteristics of the participants\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eDuring the pre-intervention period 93 patients were included and during the post-intervention period 99 patients (Figure 1). The following sample characteristics showed no statistically significant differences between the pre- and post-intervention periods: age, gender and type of medical specialism (Table 1).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eLength of postoperative stay (LOS)\\u0026nbsp;\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe mean \\u003cstrong\\u003eLOS\\u003c/strong\\u003e was statistically significant longer post-intervention 115.9h (SD 10.98) compared to pre-intervention 84.3h (SD 10.35; expβ=1.38, p\\u0026lt;0.01). After adjustment for confounding, this remained statistically significant (mean 94.3h vs. 74.1h; expβ=1.27, p\\u0026lt;0.01;). See Table 2a.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eDifference between estimated and actual LOS\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe mean \\u003cstrong\\u003edelta\\u003c/strong\\u003e \\u003cstrong\\u003eLOS\\u003c/strong\\u003e was not statistically significant different for patients in the post-intervention group: 42.95h (SD 10.82) compared to the pre-intervention group: 37.78h (SD 10.31, expβ=1.04, p=0.64). \\u0026nbsp;After adjustment for confounding, this remained not statistically significant (mean 23.60h vs. 26.20h; expβ=0.97, p=0.77). See Table 2b. To perform the delta LOS analyses, two participants in the post-intervention group were excluded due to missing preoperative estimated LOS in the EPF.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eAnalgesic use\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe adjusted the following analyses for effect modification. The mean duration of \\u003cstrong\\u003eparenteral analgesics\\u0026nbsp;\\u003c/strong\\u003euse (opioids and non-opioids) was not statistically significant different for patients in the post-intervention group compared to the pre-intervention group: 18.94h (SD 12.03) versus 20.99h (SD 11.52), p=0.59. The mean duration of \\u003cstrong\\u003eenteral analgesics\\u003c/strong\\u003e use (opioids and non-opioids) was not statistically significant different for the patients in the post-intervention group compared to the pre-intervention group: 51.58h (SD 11.56) versus 38.61h (SD 11.10), p=0.05. The mean duration of \\u003cstrong\\u003eparenteral opioids\\u003c/strong\\u003e use for the patients in the post-intervention group remained not statistically significant different from the pre-intervention group: 1.13h (SD 13.09) versus 1.01h (SD 14.63), p=0.67. The mean duration of \\u003cstrong\\u003eenteral opioids\\u003c/strong\\u003e use for the patients in the post-intervention group was not statistically significant different from the pre-intervention group: 10.87h (SD 14.65) versus 5.79h (SD 18.51), p=0.11. See Table 2c.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eSatisfaction\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNFU surveys were completed by 16 patients and 61 parents pre-intervention, and 18 patients and 89 parents post-intervention. Satisfaction scores regarding pain management were not statistically significant different. \\u003cstrong\\u003ePatient satisfaction:\\u003c/strong\\u003e median 3 [IQR 3–3] in pre- and post-intervention period (p=0.56). \\u003cstrong\\u003eParental satisfaction:\\u003c/strong\\u003e median 3 [IQR 3–3] in pre- and post-intervention period (p=0.06). See Table 2d.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003ePost-hoc analyses\\u003c/u\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA statistically significant difference in surgery type was observed between pre- and post-intervention groups. A total of 130 types of surgeries were performed during this study, of which 9 types of surgeries were performed in both the pre- and post-intervention period. See supplementary Table 2 for an overview of the most commonly performed operations in the pre- and post-intervention group.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003e\\u003cu\\u003eMain findings\\u003c/u\\u003e\\u003cbr\\u003e\\u0026nbsp;Contrary to expectations, we found that LOS was longer when comfort assessment was done with focus language instead of with the NRS. Furthermore, we found that analgesic use and patient/parental satisfaction in children receiving postoperative care were not influenced by the use of focus language.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eWe hypothesize that LOS might not be the right outcome measure to investigate the effect of focus language. First of all, the longer LOS in the intervention group may reflect variations in surgery types between the pre- and post-intervention groups rather than the intervention’s effect. During the pre-intervention period, the COVID-19 pandemic affected scheduling, which caused catch-up surgeries during the post-intervention period, likely increasing heterogeneity in surgery types [26]. Since LOS is influenced by surgery type, this complicates the interpretation of our results [27]. The estimated LOS was significantly higher post-intervention, suggesting that more complex surgeries requiring longer LOS were performed during that period. To address the surgical heterogeneity, we focused on the difference between estimated and actual LOS (Delta LOS) additional to the primary outcome. As Delta LOS did not statistically significantly differ between groups, this suggests the intervention did not adversely affect LOS.\\u003c/p\\u003e\\n\\u003cp\\u003eSecond, LOS has dramatically decreased in the period 2005-2012, but has been stable the past 13 years. For children 0-19 years the LOS has been approximately 4 days since then [28]. Clinical care has been optimized to meet discharge criteria in the most efficient manner and it is possible that there is not much room for reduction anymore.\\u003c/p\\u003e\\n\\u003cp\\u003eAlthough we did not find an effect of focus language on reduction of LOS, the intervention itself might reduce stress and enhance comfort. This was observed by staff of the anesthesia providing the post-operative pain management on the pediatric wards. The staff were so pleased with the new approach that it was implemented throughout the hospital before the results of this study were available [29]. Recently, Van Dorp et al. [30] \\u0026amp; \\u0026nbsp;Edwards et al. [31] found that in adults visiting the emergency department because of pain, pain scores and comfort scores did not significantly differ. Therefore, pain and comfort scores might be interchangeable, supporting the safety of studying the effect of cognitive reframing and the use of comfort scores.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThis positive attitude towards the new approach is supported by the finding that patients and parents remained equally satisfied about pain management, although they were never questioned about pain [32; 33]. Furthermore, patients received the same amount of painkillers in the intervention group, suggesting that patients’ needs were still adequately recognized and treated. Inconsistent with our results were the findings of Chooi et al. [24] regarding their study among women receiving postoperative care after a caesarean section. They found that women in the comfort group requested even less painkillers compared to women in the standard NRS group. They also found that the negative suggestions used in the NRS group seem to have resulted in an increased number of patients reporting that their post-operative sensations were unpleasant, more bothersome, and perceived as tissue damage and injury rather than healing and recovery as mentioned in het comfort group Chooi et al. [24].\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eLimitations\\u003c/u\\u003e\\u003cbr\\u003e\\u0026nbsp;This study has several limitations. As mentioned above, when selecting the before-after design, we did not anticipate heterogeneity in surgery types, given the duration of inclusion during pre- and post-intervention period (11-14 months) and the homogeneity of the specialisms. The heterogeneity in surgery types may explain the difference in LOS rather than the effect of focus language. Secondly, the sample size was smaller than originally calculated due to missing data. The before–after design, the heterogeneity in surgical procedures, and the smaller-than-planned sample size, may limit the interpretability of the observed effect.\\u003c/p\\u003e\\n\\u003cp\\u003eFurthermore, the uncertain fidelity of the focus language implementation may have affected internal validity. At the end of the implementation period of this research, no measurements were conducted regarding how well the focus language was used during practical care. This limitation results in uncertainty about protocol adherence; whether the healthcare professionals used the focus language as described. This uncertainty also introduces the potential for contamination bias. Because patients in the intervention group may have occasionally received elements of standard care, and patients in the control group may have been inadvertently exposed to components of the intervention, the distinction between groups may have been reduced. Such contamination can dilute the true effect of the intervention, resulting in an underestimation of the results.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAdditionally, the relatively low response rate to the NFU survey (25%) lacks power and therefore can only be seen as an exploration of the patient/parental satisfaction. Finally, the study was conducted in a single center, which may limit the generalizability of the findings.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cu\\u003eFuture research\\u003c/u\\u003e\\u003cbr\\u003e\\u0026nbsp;Future studies should use homogeneous surgical populations and consider outcomes more directly related to pain and distress rather than LOS, as this may provide a clearer understanding of the intervention’s true effect. As we did not administer any (additional) patient questionnaires, our insight into the patient experience is limited. Administering questionnaires and conducting interviews—such as measures of patient satisfaction, perceived control, or procedural anxiety—could provide more in-depth insight into outcomes that are relevant from the patient’s perspective. Subgroups (e.g. children with psychiatric or chronic pain conditions, or different age groups) may respond differently to focus language, as our exploratory analyses suggested shorter LOS in patients with chronic pain or psychiatric conditions.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eShifting from pain-focused to comfort-focused communication may be a safe and feasible approach in pediatric postoperative care. Patients and parents remain satisfied, analgesic use is unaffected, and the method shows promise for enhancing the patient experience. Future research should target homogeneous populations and explore the perspectives of both patients and healthcare professionals to maximize benefits.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEPF:\\u003c/strong\\u003e\\u0026nbsp; Electronic Patient File\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eIQR:\\u003c/strong\\u003e\\u0026nbsp; Interquartile Range\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLOS:\\u003c/strong\\u003e\\u0026nbsp; postoperative length of hospital stay\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eNFU:\\u003c/strong\\u003e\\u0026nbsp; Netherlands Federation of University Medical Centers\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eNRS:\\u003c/strong\\u003e\\u0026nbsp; Numeric Rating Scale\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePACU:\\u003c/strong\\u003e\\u0026nbsp; Post Anesthesia Care Unit\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSD:\\u003c/strong\\u003e\\u0026nbsp; Standard Deviation\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eUMC:\\u003c/strong\\u003e\\u0026nbsp; University Medical Center\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eVATS:\\u003c/strong\\u003e\\u0026nbsp; Video Assisted Thoracoscopic Surgery\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eWMO:\\u003c/strong\\u003e\\u0026nbsp; Medical Research Involving Human Subjects Act\\u003c/p\\u003e\"},{\"header\":\"Statements \\u0026 Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgments\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors thank the ESPR for providing a nursing grant and all nurses of the general nursing wards of the Emma Children’s Hospital for their cooperation in this study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis work was supported by a nursing grant from the European Society for Paediatric Research (ESPR).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting Interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors have no relevant financial or non-financial interests to disclose.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors contributed to the study conception and design. Material preparation and data collection were performed by Ariana Angenent, Charlotte Hoedjes, Linda Klaassen and Laura Nieland. Analyses were performed by Ariana Angenent. The first draft of the manuscript was written by Ariana Angenent, Jolanda Maaskant and Tessa Sieswerda-Hoogendoorn and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics approval\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe IRB confirmed the study was not subject to the Medical Research Involving Human Subjects Act (WMO) and has confirmed that no ethical approval is required. Data were pseudo-anonymized, stored securely, and analyzed in compliance with GDPR. Consent was not required as the study evaluated quality of care.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent to publish\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003cbr\\u003e\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eBirnie KA, Hundert AS, Lalloo C, Nguyen C, Stinson JN (2019) Recommendations for selection of self-report pain intensity measures in children and adolescents: a systematic review and quality assessment of measurement properties. Pain 160:5\\u0026ndash;18 http://dx.doi.org/10.1097/j.pain.0000000000001377\\u003c/li\\u003e\\n\\u003cli\\u003eThong ISK, Jensen MP, Mir\\u0026oacute; J, Tan G (2018) The validity of pain intensity measures: what do the NRS, VAS, VRS, and FPS-R measure? Scand J Pain 18:99\\u0026ndash;107 https://doi.org/10.1515/sjpain-2018-0012\\u003c/li\\u003e\\n\\u003cli\\u003eBrummelte S, Grunau RE, Chau V, Poskitt KJ, Brant R, Vinall J, Gover A, Synnes AR, Miller SP (2012) Procedural pain and brain development in premature newborns. Ann Neurol 71:385\\u0026ndash;396 https://doi.org/10.1002/ana.22267\\u003c/li\\u003e\\n\\u003cli\\u003eFranck LS, Bruce E (2009) Putting pain assessment into practice: why is it so painful? Pain Res Manag 14:13\\u0026ndash;20 https://doi.org/10.1155/2009/856587\\u003c/li\\u003e\\n\\u003cli\\u003eChooi CS, Nerlekar R, Raju A, Cyna AM (2011) The effects of positive or negative words when assessing postoperative pain. Anaesth Intensive Care 39:101\\u0026ndash;106 https://doi.org/10.1177/0310057X1103900117\\u003c/li\\u003e\\n\\u003cli\\u003eLang EV, Hatsiopoulou O, Koch T, Berbaum K, Lutgendorf S, Kettenmann E, Logan H, Kaptchuk TJ (2005) Can words hurt? Patient-provider interactions during invasive procedures. Pain 114:303\\u0026ndash;309 https://doi.org/10.1016/j.pain.2004.12.028\\u003c/li\\u003e\\n\\u003cli\\u003eOtt J, Aust S, Nouri K, Promberger R (2012) An Everyday Phrase May Harm Your Patients The Influence of Negative Words on Pain During Venous Blood Sampling. Clin J Pain 28:324\\u0026ndash;328 https://doi.org/10.1097/AJP.0b013e3182321cc3\\u003c/li\\u003e\\n\\u003cli\\u003eVarelmann D, Pancaro C, Cappiello EC, Camann WR (2010) Nocebo-induced hyperalgesia during local anesthetic injection. Anesth Analg 110:868\\u0026ndash;870 https://doi.org/10.1213/ANE.0b013e3181cc5727\\u003c/li\\u003e\\n\\u003cli\\u003eBearden D, Feinstein A, Cohen L (2012) The influence of parent preprocedural anxiety on child procedural pain: mediation by child procedural anxiety. J Pediatr Psychol https://doi.org/10.1093/jpepsy/jss041\\u003c/li\\u003e\\n\\u003cli\\u003eBrown E, Young A, Kimble R, Kenardy J (2019) Impact of Parental Acute Psychological Distress on Young Pain-Related Behavior Through Differences in Parenting Behavior During Pediatric Burn Wound Care. J Clin Psychol Med Settings 26:516\\u0026ndash;529 https://doi.org/10.1007/s10880-018-9596-1\\u003c/li\\u003e\\n\\u003cli\\u003eHeathcote LC, Simons LE (2020) Stuck on pain? Assessing children\\u0026apos;s vigilance and awareness of pain sensations. Eur J Pain 24:1339\\u0026ndash;1347 https://doi.org/10.1002/ejp.1581\\u003c/li\\u003e\\n\\u003cli\\u003eOommen S, Shetty A (2020) Does parental anxiety affect children\\u0026apos;s perception of pain during intravenous cannulation? Nurs Child Young People 32:21\\u0026ndash;24 https://doi.org/10.7748/ncyp.2019.e1187\\u003c/li\\u003e\\n\\u003cli\\u003eStoddard FJ, Ronfeldt H, Kagan J, Drake JE, Snidman N, Murphy JM, Saxe G, Burns J, Sheridan RL (2006) Young burned children: the course of acute stress and physiological and behavioral responses. Am J Psychiatry 163:1084\\u0026ndash;1090 https://doi.org/10.1176/ajp.2006.163.6.1084\\u003c/li\\u003e\\n\\u003cli\\u003eAndersen RD, Olsson E, Eriksson M (2021) The evidence supporting the association between the use of pain scales and outcomes in hospitalized children: A systematic review. Int J Nurs Stud 115:103840 https://doi.org/10.1016/j.ijnurstu.2020.103840\\u003c/li\\u003e\\n\\u003cli\\u003eLeeds IL, Boss EF, George JA, Strockbine V, Wick EC, Jelin EB (2016) Preparing enhanced recovery after surgery for implementation in pediatric populations. J Pediatr Surg 51:2126\\u0026ndash;2129 https://doi.org/10.1016/j.jpedsurg.2016.08.029\\u003c/li\\u003e\\n\\u003cli\\u003eSchlatter MG, Nguyen LV, Tecos M, Kalbfell EL, Gonzalez-Vega O, Vlahu T (2019) Progressive reduction of hospital length of stay following minimally invasive repair of pectus excavatum: A retrospective comparison of three analgesia modalities, the role of addressing patient anxiety, and reframing patient expectations. J Pediatr Surg 54:663\\u0026ndash;669 https://doi.org/10.1016/j.jpedsurg.2018.12.003\\u003c/li\\u003e\\n\\u003cli\\u003eShinnick JK, Short HL, Heiss KF, Santore MT, Blakely ML, Raval MV (2016) Enhancing recovery in pediatric surgery: a review of the literature. J Surg Res 202:165\\u0026ndash;176 https://doi.org/10.1016/j.jss.2015.12.051\\u003c/li\\u003e\\n\\u003cli\\u003eVagnoli L, Bettini A, Amore E, De Masi S, Messeri A (2019) Relaxation-guided imagery reduces perioperative anxiety and pain in children: a randomized study. Eur J Pediatr 178:913\\u0026ndash;921 https://doi.org/10.1007/s00431-019-03376-x\\u003c/li\\u003e\\n\\u003cli\\u003eBirnie KA, Noel M, Chambers CT, Uman LS, Parker JA (2018) Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev 10:Cd005179 https://doi.org/10.1002/14651858.CD005179.pub4\\u003c/li\\u003e\\n\\u003cli\\u003eLang EV, Benotsch EG, Fick LJ, Lutgendorf S, Berbaum ML, Berbaum KS, Logan H, Spiegel D (2000) Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial. Lancet 355:1486\\u0026ndash;1490 https://doi.org/10.1016/s0140-6736(00)02162-0\\u003c/li\\u003e\\n\\u003cli\\u003eLoeffen EAH, Mulder RL, Font-Gonzalez A, Leroy P, Dick BD, Taddio A, Ljungman G, Jibb LA, Tutelman PR, Liossi C, Twycross A, Positano K, Knops RR, Wijnen M, van de Wetering MD, Kremer LCM, Dupuis LL, Campbell F, Tissing WJE (2020) Reducing pain and distress related to needle procedures in children with cancer: A clinical practice guideline. Eur J Cancer 131:53\\u0026ndash;67 https://doi.org/10.1016/j.ejca.2020.02.039\\u003c/li\\u003e\\n\\u003cli\\u003eBingel U, Wanigasekera V, Wiech K, Ni Mhuircheartaigh R, Lee MC, Ploner M, Tracey I (2011) The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Sci Transl Med 3:70ra14 https://doi.org/10.1126/scitranslmed.3001244\\u003c/li\\u003e\\n\\u003cli\\u003eDutt-Gupta J, Bown T, Cyna AM (2007) Effect of communication on pain during intravenous cannulation: a randomized controlled trial. Br J Anaesth 99:871\\u0026ndash;875 https://doi.org/10.1093/bja/aem308\\u003c/li\\u003e\\n\\u003cli\\u003eChooi CS, White AM, Tan SG, Dowling K, Cyna AM (2013) Pain vs comfort scores after Caesarean section: a randomized trial. Br J Anaesth 110:780\\u0026ndash;787 https://doi.org/10.1093/bja/aes517\\u003c/li\\u003e\\n\\u003cli\\u003eUMCNL (2025) Pati\\u0026euml;ntervaringsmonitor (PEM). https://www.umcnl.nl/projecten/patientervaringsmonitor-pem/ Accessed 9 November 2025\\u003c/li\\u003e\\n\\u003cli\\u003eNeethirajan SGR, Manickam A (2020) Scheduling elective surgeries following COVID-19: Challenges ahead. J Anaesthesiol Clin Pharmacol 36:291\\u0026ndash;296 https://doi.org/10.4103/joacp.JOACP_317_20\\u003c/li\\u003e\\n\\u003cli\\u003eBaniasadi T, Kahnouji K, Davaridolatabadi N, Hosseini Teshnizi S (2019) Factors affecting length of stay in Children Hospital in Southern Iran. BMC Health Serv Res 19:949 https://doi.org/10.1186/s12913-019-4799-1\\u003c/li\\u003e\\n\\u003cli\\u003eRIVM (2025) Ziekenhuiszorg - Gebruik - Ligduur. https://www.vzinfo.nl/ziekenhuiszorg/gebruik/ligduur Accessed 9 November 2025\\u003c/li\\u003e\\n\\u003cli\\u003eAmsterdamUMC (2023) Nieuw protocol: pijnscore wordt comfortmeting. https://tulpintranet.nl/nieuws/nieuw-protocol-pijnscore-wordt-comfortmeting.htm Accessed 9 November 2025\\u003c/li\\u003e\\n\\u003cli\\u003eVan Dorp TIB, Kwant M, Lameijer H (2023) Could we use the comfort score instead of the numeric rating pain score? Am J Emerg Med:64\\u0026ndash;67 https://doi.org/10.1016/j.ajem.2023.01.015\\u003c/li\\u003e\\n\\u003cli\\u003eEdwards CM, Veenje S, Visser E, Dammers D, de Haan-Lauteslager MI, Lameijer H (2025) Comfort scores instead of pain scores as a possible tool for pain and analgesia reduction in the emergency department: A randomized controlled clinical trial. nt Emerg Nurs https://doi.org/10.1016/j.ienj.2025.101657\\u003c/li\\u003e\\n\\u003cli\\u003eBenedetti F, Lanotte M, Lopiano L, Colloca L (2007) When words are painful: unraveling the mechanisms of the nocebo effect. Neuroscience 147:260\\u0026ndash;271 https://doi.org/10.1016/j.neuroscience.2007.02.020\\u003c/li\\u003e\\n\\u003cli\\u003eBensing JM, Verheul W (2010) The silent healer: the role of communication in placebo effects. Patient Educ Couns 80:293\\u0026ndash;299 https://doi.org/10.1016/j.pec.2010.05.033\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003cstrong\\u003eTable 1 \\u0026ndash; Sample characteristics\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCharacteristics\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePre-intervention group\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(NRS)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePost-intervention group\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(focus language)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eP-value\\u003csup\\u003e1\\u003c/sup\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eParticipants, n\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e93\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e99\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAge (in years)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003eMedian [IQR\\u003csup\\u003e#\\u003c/sup\\u003e]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cbr\\u003e\\u0026nbsp;13.16 [11.00; 16.00]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e13.42 [12.00; 15.00]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e0.82\\u003csup\\u003e2\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eGender\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e0.47\\u003csup\\u003e3\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eMale, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e56 (60.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e54 (54.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eFemale, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e37 (39.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e45 (45.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u003csup\\u003e\\u0026nbsp;\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eType of medical specialism\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e0.08\\u003csup\\u003e3\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eGeneral pediatric surgery, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e47 (50.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e46 (46.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003ePediatric plastic surgery, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e7 (7.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e9 (9.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003ePediatric orthopedic surgery, (n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e23 (24.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e39 (39.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003ePediatric pulmonology, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e3 (3.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eTrauma surgery, n, (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e4 (4.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e3 (3.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003ePediatric gastroenterology, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e1 (1.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eGeneral pediatrics, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e1 (1.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003ePediatric urology, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e4 (4.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e1 (1.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003ePediatric oral and maxillofacial surgery, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e2 (2.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eNeurosurgery, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e1 (1.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eOtorhinolaryngology, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e1 (1.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTypes of surgery, n\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e68\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e71\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026lt;0.01\\u003csup\\u003e3\\u003c/sup\\u003e\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eComplications\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e0.24\\u003csup\\u003e3\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eNo, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e86 (92.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e86 (86.9)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eYes, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e7 (7.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e13 (13.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eConfounders and effect modifiers\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eDiagnosed psychiatric problems OR chronic conditions associated with chronic pain, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e15 (16.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e24 (24.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e0.28\\u003csup\\u003e3\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eDiagnoses chronic conditions associated with chronic pain, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e14 (15.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e23 (23.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eDiagnosed psychiatric problems, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e2 (2.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e2 (2.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eComfort and pain assessment\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eHighest NRS by nurse, median [IQR\\u003csup\\u003e#\\u003c/sup\\u003e]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e4 [3; 6]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e4 [3; 5]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e0.94\\u003csup\\u003e2\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eLowest NRS by nurse, median [IQR\\u003csup\\u003e#\\u003c/sup\\u003e]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e0 [0: 1]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e1 [0; 2]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026lt;0.01\\u003c/em\\u003e\\u003csup\\u003e2\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eHighest NRS by patient, median [IQR\\u003csup\\u003e#\\u003c/sup\\u003e]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e6 [4; 7]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eLowest NRS by patient, median [IQR\\u003csup\\u003e#\\u003c/sup\\u003e]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e0 [0; 1]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eLowest comfort score by patient, median [IQR\\u003csup\\u003e#\\u003c/sup\\u003e]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e5 [4; 6]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003eHighest comfort score by patient, median [IQR\\u003csup\\u003e#\\u003c/sup\\u003e]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e8 [7.25; 9]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 75px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e#\\u003c/sup\\u003e IQR = Interquartile range.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e1\\u003c/sup\\u003e A p-value \\u0026lt;0.05 was considered statistically significant. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e2\\u0026nbsp;\\u003c/sup\\u003eWilcoxon-rank sum test.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e3\\u0026nbsp;\\u003c/sup\\u003eFisher exact test.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 2a \\u0026ndash; Results of multivariable linear regression analyses for postoperative length of stay (LOS)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cdiv align=\\\"center\\\"\\u003e\\n \\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"659\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 105px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" valign=\\\"top\\\" style=\\\"width: 203px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePre-intervention group\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(n=93)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" valign=\\\"top\\\" style=\\\"width: 202px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePost-intervention group\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(n=99)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 105px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePrimary Outcome\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 65px;\\\"\\u003e\\n \\u003cp\\u003eMean\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 53px;\\\"\\u003e\\n \\u003cp\\u003eSD\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eExp(SE\\u003csup\\u003e○\\u003c/sup\\u003e)\\u003csup\\u003e1\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 64px;\\\"\\u003e\\n \\u003cp\\u003eMean\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 53px;\\\"\\u003e\\n \\u003cp\\u003eSD\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eExp(SE\\u003csup\\u003e○\\u003c/sup\\u003e)\\u003csup\\u003e1\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003eExp(\\u0026beta;-Coeff)\\u003csup\\u003e1\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003eP-value\\u003csup\\u003e2\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 105px;\\\"\\u003e\\n \\u003cp\\u003eLength of postoperative hospital stay (in hours) without adjustment for confounders\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 65px;\\\"\\u003e\\n \\u003cp\\u003e84.28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 53px;\\\"\\u003e\\n \\u003cp\\u003e10.35\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1.07\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 64px;\\\"\\u003e\\n \\u003cp\\u003e115.92\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 53px;\\\"\\u003e\\n \\u003cp\\u003e10.98\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1.10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e1.38\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026lt;0.01\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 105px;\\\"\\u003e\\n \\u003cp\\u003eLength of postoperative hospital stay (in hours)\\u003c/p\\u003e\\n \\u003cp\\u003ewith adjustment for confounders\\u003csup\\u003e3\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 65px;\\\"\\u003e\\n \\u003cp\\u003e74.13\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 53px;\\\"\\u003e\\n \\u003cp\\u003e10.31\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1.07\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 64px;\\\"\\u003e\\n \\u003cp\\u003e94.29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 53px;\\\"\\u003e\\n \\u003cp\\u003e10.89\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1.09\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e1.27\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026lt;0.01\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003e*SD = Standard Deviation, \\u003csup\\u003e○\\u003c/sup\\u003eSE = Standard Error\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e1\\u0026nbsp;\\u003c/sup\\u003eThe dependent variable was log-transformed to meet the assumptions of the linear regression.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e2\\u0026nbsp;\\u003c/sup\\u003eA p-value \\u0026lt;0.05 was considered statistically significant.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e3\\u003c/sup\\u003e Corrected for the variable: psychiatry or chronic pain and complications.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 2b \\u0026ndash; Results of additional multivariable linear regression analyses for delta LOS\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cdiv align=\\\"center\\\"\\u003e\\n \\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"659\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 105px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" valign=\\\"top\\\" style=\\\"width: 203px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePre-intervention group\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(n=93)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" valign=\\\"top\\\" style=\\\"width: 202px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePost-intervention group\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(n=97)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 105px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePrimary Outcome\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 65px;\\\"\\u003e\\n \\u003cp\\u003eMean\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 53px;\\\"\\u003e\\n \\u003cp\\u003eSD\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eExp(SE\\u003csup\\u003e○\\u003c/sup\\u003e)\\u003csup\\u003e1\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 64px;\\\"\\u003e\\n \\u003cp\\u003eMean\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 53px;\\\"\\u003e\\n \\u003cp\\u003eSD\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eExp(SE\\u003csup\\u003e○\\u003c/sup\\u003e)\\u003csup\\u003e1\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003eExp(\\u0026beta;-Coeff)\\u003csup\\u003e1\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003eP-value\\u003csup\\u003e2\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 105px;\\\"\\u003e\\n \\u003cp\\u003eDelta length of postoperative hospital stay (in hours) without adjustment for confounders\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 65px;\\\"\\u003e\\n \\u003cp\\u003e37.78\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 53px;\\\"\\u003e\\n \\u003cp\\u003e10.31\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1.07\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 64px;\\\"\\u003e\\n \\u003cp\\u003e42.95\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 53px;\\\"\\u003e\\n \\u003cp\\u003e10.82\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1.10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e1.04\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e0.64\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 105px;\\\"\\u003e\\n \\u003cp\\u003eDelta length of postoperative hospital stay (in hours)\\u003c/p\\u003e\\n \\u003cp\\u003ewith adjustment for confounders\\u003csup\\u003e3\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 65px;\\\"\\u003e\\n \\u003cp\\u003e26.20\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 53px;\\\"\\u003e\\n \\u003cp\\u003e10.29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1.07\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 64px;\\\"\\u003e\\n \\u003cp\\u003e23.60\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 53px;\\\"\\u003e\\n \\u003cp\\u003e10.77\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1.09\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e0.97\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e0.77\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003e*SD = Standard Deviation, \\u003csup\\u003e○\\u003c/sup\\u003eSE = Standard Error\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e1\\u0026nbsp;\\u003c/sup\\u003eThe dependent variable was log-transformed using (log(y+\\u0026alpha;)) \\u0026nbsp; to meet the assumptions of the linear regression.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e2\\u0026nbsp;\\u003c/sup\\u003eA p-value \\u0026lt;0.05 was considered statistically significant.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e3\\u003c/sup\\u003e Corrected for the variable: psychiatry or chronic pain and complications.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 2c \\u0026ndash; Results of multivariable linear regression analyses for analgesic use\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cdiv align=\\\"center\\\"\\u003e\\n \\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"614\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 141px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" valign=\\\"top\\\" style=\\\"width: 180px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePre-intervention group (n=93)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" valign=\\\"top\\\" style=\\\"width: 180px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePost-intervention group (n=99)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 141px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSecondary Outcomes\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003eMean\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003eSD\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003eExp(SE\\u003csup\\u003e○\\u003c/sup\\u003e)\\u003csup\\u003e1\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003eMean\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003eSD\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003eExp(SE\\u003csup\\u003e○\\u003c/sup\\u003e)\\u003csup\\u003e1\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003eExp(\\u0026beta;-Coeff)\\u003csup\\u003e1\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003eP-value\\u003csup\\u003e2\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 141px;\\\"\\u003e\\n \\u003cp\\u003eDuration of parenteral analgesic use (in hours) without adjustment for confounders or effect modifier\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e46.92\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e11.20\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.16\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e56.74\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e12.25\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.23\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e1.21\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e0.36\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 141px;\\\"\\u003e\\n \\u003cp\\u003eDuration of parenteral analgesic use (in hours) with adjustment for confounders and effect modifier\\u003csup\\u003e3\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e20.99\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e11.52\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.19\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e18.94\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e12.03\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.21\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e0.90\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e0.59\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 141px;\\\"\\u003e\\n \\u003cp\\u003eDuration of enteral analgesic use (in hours) without adjustment for effect modifier\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e78.13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e10.88\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e132.25\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e11.76\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.18\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e1.69\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026lt;0.01\\u0026nbsp;\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 141px;\\\"\\u003e\\n \\u003cp\\u003eDuration of enteral analgesic use (in hours) with adjustment for effect modifier\\u003csup\\u003e4\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e38.61\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e11.10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.15\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e51.58\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e11.56\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.16\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e1.34\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e0.05\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 141px;\\\"\\u003e\\n \\u003cp\\u003eDuration of parenteral opioid use (in hours) without adjustment for confounders or effect modifier\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e7.14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e11.82\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.23\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e12.11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e13.31\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.34\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e1.70\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e0.07\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 141px;\\\"\\u003e\\n \\u003cp\\u003eDuration of parenteral opioid use (in hours) with adjustment for confounders and effect modifier\\u003csup\\u003e3\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e1.01\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e14.63\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.52\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e1.13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e13.09\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.32\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e1.12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e0.67\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 141px;\\\"\\u003e\\n \\u003cp\\u003eDuration of enteral opioid use (in hours) without adjustment for effect modifier\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e11.32\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e12.84\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.33\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e23.89\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e14.46\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.45\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e2.11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e0.05\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 141px;\\\"\\u003e\\n \\u003cp\\u003eDuration of enteral opioid use (in hours) with adjustment for effect modifier\\u003csup\\u003e4\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e5.79\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e18.51\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.92\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e10.87\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 47px;\\\"\\u003e\\n \\u003cp\\u003e14.65\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.47\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e1.88\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e0.11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003e*SD = Standard Deviation, \\u003csup\\u003e○\\u003c/sup\\u003eSE = Standard Error\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e1\\u0026nbsp;\\u003c/sup\\u003eThe dependent variable was log-transformed to meet the assumptions of the linear regression.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e2\\u003c/sup\\u003e A p-value \\u0026lt;0.05 was considered statistically significant.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e3\\u0026nbsp;\\u003c/sup\\u003eCorrected for the variables: \\u0026ldquo;psychiatry or chronic pain\\u0026rdquo;, \\u0026ldquo;complications\\u0026rdquo; and \\u0026ldquo;length of postoperative stay\\u0026rdquo;. Restricted cubic splines with 3 knots was applied on the variable \\u0026ldquo;length of postoperative stay\\u0026rdquo;.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e4\\u0026nbsp;\\u003c/sup\\u003eCorrected for the variable: \\u0026ldquo;length of postoperative stay\\u0026rdquo;. Restricted cubic splines with 3 knots was applied.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 2d- Results non-parametric test analysis for patient and parental satisfaction\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cdiv align=\\\"center\\\"\\u003e\\n \\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"671\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" valign=\\\"top\\\" style=\\\"width: 227px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePre-intervention group\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" valign=\\\"top\\\" style=\\\"width: 227px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePost-intervention group\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSecondary Outcomes\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003eN\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003eMedian\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003eIQR\\u003csup\\u003e#\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003eN\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003eMedian\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003eIQR\\u003csup\\u003e#\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003eW-value\\u003csup\\u003e1\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003eP-value\\u003csup\\u003e2\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003ePatient satisfaction \\u0026ndash;\\u0026nbsp;NFU Survey\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e16\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e[3; 3]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e18\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e[3; 3]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e127.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e0.56\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003eParental satisfaction \\u0026ndash;\\u0026nbsp;NFU Survey\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e61\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e[3; 3]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 38px;\\\"\\u003e\\n \\u003cp\\u003e89\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e[3; 3]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e2995\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 57px;\\\"\\u003e\\n \\u003cp\\u003e0.06\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e#\\u003c/sup\\u003eIQR = Interquartile range.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e1\\u0026nbsp;\\u003c/sup\\u003eW-value of the Wilcoxon Rank sum test.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e2\\u003c/sup\\u003e A p-value \\u0026lt;0.05 was considered statistically significant.\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"european-journal-of-pediatrics\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ejpe\",\"sideBox\":\"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)\",\"snPcode\":\"431\",\"submissionUrl\":\"https://submission.nature.com/new-submission/431/3\",\"title\":\"European Journal of Pediatrics\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"Patient comfort, pain management, pain measurement, comfort assessment, postoperative care, pediatrics\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8428158/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8428158/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003ePurpose\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study evaluates the effect of comfort assessment using focus language compared with pain assessment using the Numeric Rating Scale (NRS) on the postoperative length of stay (LOS), analgesic use and patient and parental satisfaction.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis prospective before-after study was conducted on a general pediatric ward at Emma Children’s Hospital. During the pre-intervention period pain was assessed using NRS. After implementation of focus language, comfort was assessed using the new communication approach. Eligible participants were children ≥6 years receiving postoperative care for \\u0026gt;24 hours, able to report a NRS. Primary outcome was LOS (hours). Secondary outcomes were analgesic use (hours) and patient and parental satisfaction. Multivariable linear regression was used to adjust for baseline differences, potential confounding and effect modification.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003ePre-intervention 93 patients were included and post-intervention 99. The adjusted mean LOS in the post-intervention group (94.29 hours) was statistically significantly higher than the pre-intervention group (74.13 hours): expβ=1.27, p\\u0026lt;0.01. Additional analyzes showed the estimated LOS was significantly higher post-intervention, suggesting more complex surgeries were performed during that period. Therefore, we analyzed the difference between estimated and actual LOS; no statistical significant difference was found. Analgesic use and patient and parental satisfaction were comparable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWhen healthcare professionals focused on comfort during postoperative care, the difference between the estimated actual LOS was not statistical significant, patients received comparable number of analgesics, and patients and parents were equally satisfied. Shifting from pain-focused to comfort-focused communication appears a safe, feasible and promising approach for pediatric postoperative care.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Focus on Comfort - The effect of focus language on postoperative hospital stay compared to the NRS in children receiving postoperative care – A before-after study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-01-12 08:31:58\",\"doi\":\"10.21203/rs.3.rs-8428158/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-02-25T20:51:04+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-25T02:43:16+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"9498078086292508537409632455450111998\",\"date\":\"2026-02-02T16:20:54+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-01-20T11:50:43+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"279349344113065779835545442498099165857\",\"date\":\"2026-01-07T20:32:31+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-01-07T18:10:27+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-01-07T12:08:01+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-01-07T08:49:55+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"European Journal of Pediatrics\",\"date\":\"2025-12-22T20:04:56+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"european-journal-of-pediatrics\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ejpe\",\"sideBox\":\"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)\",\"snPcode\":\"431\",\"submissionUrl\":\"https://submission.nature.com/new-submission/431/3\",\"title\":\"European Journal of Pediatrics\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"916786c4-5801-48f2-b082-f6ebe84cf8ef\",\"owner\":[],\"postedDate\":\"January 12th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-05-04T15:59:20+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-8428158\",\"link\":\"https://doi.org/10.1007/s00431-026-06932-4\",\"journal\":{\"identity\":\"european-journal-of-pediatrics\",\"isVorOnly\":false,\"title\":\"European Journal of Pediatrics\"},\"publishedOn\":\"2026-04-27 15:57:23\",\"publishedOnDateReadable\":\"April 27th, 2026\"},\"versionCreatedAt\":\"2026-01-12 08:31:58\",\"video\":\"\",\"vorDoi\":\"10.1007/s00431-026-06932-4\",\"vorDoiUrl\":\"https://doi.org/10.1007/s00431-026-06932-4\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8428158\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8428158\",\"identity\":\"rs-8428158\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}