FEBRUARY 1992, VOL 55, NO 2
AORN JOURNAL
Same Day Surgery COORDINATING THE EDUCATION PROCESS Nancy Haines, RN
P
rospective pricing has revolutionized health care delivery systems. The Center for Hip and Knee Surgery, Kendrick Health Care Center, Mooresville, Ind, is a research-oriented orthopedic hospital that has developed and implemented an alternative approach to preadmission testing and preoperative patient education. With the implementation of the prospective pricing system and diagnosis-related groups in 1983, hospital stays have decreased in length, and pressure to contain costs has increased. According to American Hospital Association figures, between 55% and 75% of all hospital admissions are surgery related.' Medicare, health maintenance organizations, and most third-party payment systems now are questioning why patients must be hospitalized the day before surgery. As a result, same day admission (ie, AM admission, day-of-surgery admission) for many procedures is becoming more common. This trend drastically reduces the amount of time in which crucial information can be delivered to and absorbed by the patient, and it creates a tremendous amount of pressure on nurses caring for the surgical patient. Nurses are responsible for the educational needs of the patient as well as for preparing the patient physically and emotionally for surgery. Additionally, nurses must ensure that all necessary consent forms and laboratory test results are in order. With less time to do all these things, nurses are experiencing increased pressure. The practice of providing surgical patients with information and instruction before their
operations began with the change in patient management strategy. Instead of confining patients to their beds for many days following surgery, nurses helped patients to ambulate immediately. Early resumption of physical activity became standard practice because it decreased the frequency of major physical postoperative complications.2 To reduce patients' fears and increase their willingness to participate in physical activity so soon after surgery, nurses and surgeons taught them about the
Nancy Haines, RN,C, M S N , i s a clinical research nurse, orthopedics, and an adult nurse practitioner at the Methodist Hospital of Indiana, Inc, Indianapolis. At the time this article was written, she was preadmission screening coordinator at the Center f o r Hip and Knee S u r g e r y , Kendrick Health C a r e C e n t e r , Mooresville, Ind. She earned her BSN degree from Indiana University, Indianapolis, and her MSN degree in adult primary health care from Indiana University at Indianapolis. 573
FEBRUARY 1992, VOL 5 5 , NO 2
AORN JOURNAL
Inherent in nursing practice is the belief that all individuals have the right to be treated with respect and dignity.
activities they were expected to perform. Most of the research on preparation of surgical patients stemmed from this change to early postoperative ambulation.‘
Does Educatioii Make a DifSerence?
F
or more than 20 years. nursing researchers have attempted to measure the effect of preoperative instruction on postoperative outcome. Results support the positive and beneficial effect preoperative instruction has on postoperative outcomes (eg, the risk of developing postoperative complications was reduced when patients were taught specific behaviors such as deep breathing, coughing. and leg exercises).4 Shorter hospital stays were reported following psycho-educational interventions.’ Other study results show that patients who receive preoperative instruction require less pain medication than those who d o not receive instruction.h One recurring theme is the increased effectiveness of preoperative teaching when psychotherapeutic and educational approaches are combined.7 Findings of one researcher’s metaanalysis of 68 studies, which examines the effects of preoperative instruction on postoperative outcomes, show that preoperative instruction has a positive and beneficial effect on postoperative outcomes.8 Numerous studies document how preoperative teaching helps relieve patients’ fears and anxieties, decrease their stress, enhance their psychologic well-being, and promote their postoperative recovery.‘ Two researchers categorized 50 studies by type of surgery (ie. abdominal, thoracic, orthopedic. gynecologic, other). and their meta-analysis results are evidence that patients with a broad range of conditions likely will benefit from preoperative education.’” Data from another study supports the conclusion that
patients who participate in preoperative teaching programs receive fewer doses of parented analgesics than those who do not participate. Patients in the experimental group (ie, those who received preoperative teaching) were hospitalized an average of 8.4 postoperative days, and those in the control group (ie, those who received no preoperative teaching) were hospitalized an average of 9.7 postoperative days.” Another study reviewed nearly 100 studies of arthritis patient education programs that suggest that certain education techniques, in selected arthritis patients, can help them manage their arthritis therapeutically. These randomized trials of education programs demonstrated decreases in patient pain, depression, and disability, and increases in patient compliance and other behaviors believed to affect arthritis positively. One researcher writes, “It appears that when using effectiveness criteria similar to those used in judging medication (ie, outcome measures, including patient-rated measures of pain, self-care, physical activity/mobility, role activities, mental health), arthritis patient education is therapeutically effective.”I3 According to another researcher, This evidence suggests that patient education can enhance the quality of patient care, particularly in improving adherence t o therapeutic regimens and in reducing postoperative complications. This does not mean that patient education is ah2ay effective, or that it is a ‘magic bullet,’ but rather it seems t o be an important and essential component of high quulity care.IJ Inherent in nursing practice is the belief that all individuals have the right to be treated with respect and dignity; the right to receive accessible, high-quality care; and the right to have understandable information about the choices available and their consequences. One researcher
FEBRUARY 1992, VOL 55, NO 2
AORN JOURNAL
explains nurses’ responsibility for patient education by saying that the court likely will see patient teaclng as a duty, just as obtaining informed consent from patients is a duty-especially when the right to know is critical to the patient’s health.15 Nurses’ commitment to patient education and to the challenge of learning about the effectiveness of their patient teaching subsequently evolved.
Preadmission Programs
B
y early 1984, the number of AM admission patients was increasing rapidly. By the time the admission process and the physical Surgeon discusses an upcoming procedure with a patient preparation of the patient was complet- during her initial office visit. ed, there was little time left for nurses to teach and for patients to learn. Patients’ patient involvement, which includes attending anxiety levels usually are high before surgery. preoperative education sessions and asking This also interferes with the learning process. questions about their surgery, contributes to the Because of these things, preadmission programs goals of preventing postoperative complicabegan to be implemented across the country. tions, decreasing the lengths of hospital stays, Literature supports numerous strategies and proand improving patients’ satisfaction and postgrams, which have a variety of names and educaoperative compliance. Our personalized preadtors teaching these surgical patients. Some exammission screening program has evolved in ples of other programs follow. At St Joseph’s stages since its inception in 1974. It soon Hospital, Albuquerque, the patient registration became apparent that screening patients 10 to and education program is run by the preadmission 14 days before they are admitted is crucial and coordinator in the patient and family services helps avoid last-minute surgery cancellations department.Ih due to unstable medical conditions. If a condiAt Albert Einstein Medical Center, tion is discovered during the screening and the Philadelphia, the short procedure unit is run by surgery must be cancelled, another patient usua nurse manager in cooperation with anesthesia ally can be scheduled for surgery. When a department personnel, and ambulatory surgery patient entered the hospital only 1 to 2 days nurses use a preoperative teaching checklist to before surgery and an unstable condition was ensure that teaching is ~ n i f 0 r m . lAlta ~ Bates discovered, it often was too late to schedule Hospital, Berkeley, Calif, established a preopanother patient for the reserved time. erative testing center separate from the OR. It is The Joint Commission on Accreditation of operated by the director of surgery and is Healthcare Organizations requires an assessstaffed by OR nurses.lX ment of the availability of appropriate services to meet patients’ post-hospitalization needs. Preadmission Screening Program The Joint Commission also requires the participation of physicians, nurses, social workers, t the Center for Hip and Knee Surgery, dieticians, utilization review staff members, preadmission screening personnel use a therapists, and pharmacists in discharge planmultidisciplinary approach. Active
A
575
AORN JOLRNAL
FEBRUARY 1992, VOL 55, NO 2
The nurse educator answers questions and explains procedures during the class.
ning.” Patients have a right to receive care and treatment. which includes individualized instruction and counseling about their post-hospitalization needs. Because the surgeons at the Center for Hip and Knee Surgery believe that late identification of discharge needs predisposes our patients to remain hospitalized for longer periods of time, they want the interdisciplinary. collaborative approach to discharge planning to begin no later than the day the patient is admitted to the hospital. Because Preadmission screening requires that the patient visit the hospital. we included other aspects of assessment, education. and discharge planning in the program. In 1974. patients were admitted to the hospital two days before their scheduled surgeries for laboratory tests. histories, and physical examinations by an orthopedist. Patients at the Center for Hip and Knee Surgery currently attend the preadmission screening program 10 to 14 days before surgery and are seen by an internal medicine specialist and a nurse patient educator who has a master’s degree in primary health care.
Truchiiig Strategies, Tools
T
he teaching process begins with the patient‘s initial visit to the orthopedic surgeon‘!, office. Once the diagnosis is
576
confirmed and surgery is indicated, the surgeon uses a picture booklet to discuss the diagnosis, the surgical procedure, and the involved risks with the patient and his or her family members. At this time, the surgeon also explains that the preadmission screening program is important and that the patient is expected to attend. The picture booklet explains the surgical procedure, the postoperative course, and the rehabilitation period. Of I43 patients surveyed between December 1988 and March 1989,89% reported that they read the booklet before attending the preadmission screening program.:(’ Research shows that patients forget half of what they are told within five minutes of when they hear it; patients recall more information if they read it as well as hear it.2i Another researcher showed that preparatory booklets and written information enhance the quality of presurgical communication.’?
Preadmission Day
A
t the Center for Hip and Knee Surgery, the preadmission coordinator/nurse educator is responsible for the preadmission education program. This person schedules patient appointments for admission, laboratory tests, x-rays, visits with thc internist, and education classes. He or she facilitates commu-
AORN JOURNAL
FEBRUARY 1992. VOL 5 5 , NO 2
A multidisciplinary conference. held the week before the patient is admitted, enhances the commitment to the complete care of each patient.
nication between support team members and c o n d u c t s the patient education c l a s s e s . Screening and education takes 4 to 5 hours. The patient is supposed to bring a spouse. relative. or friend to the program. We strongly support including family members because of their impact on patients‘ well-being. A patient representative and a patient transporter greet the patient and escort him or her to the various departments where preadmission laboratory work or tests are done. The patient spends approximately o n e h o u r with the internist. who takes a thorough history and performs a physical. The patient spends another hour with the nurse educator. who introduces and explains the purpose of the preadmission program. The patient watches a 30-minute video that was filmed at the Center for Hip and Knee Surgery and is narrated by the orthopedic surgeons who work there. This information is consistent with and reinforces the information provided in the i n s t r u c t i o n a I book 1e t s . The nurse educator provides procedural information about what will happen in the OR and sensory information. He or she reinforces important aspects of postoperative care and allows the patient ”hands-on” time with the equipment that will be used during surgery. In developing the curriculum for the educational classes. we reviewed books that were written by an expert in patient education. According to the author. patient education is 578
”a process of informing patients and their families about the illness and treatment, instructing them on how to adhere to the regimen, and helping them change their behavior.”” The author’s three-step approach to patient education includes establishing rapport and reducing patients’ anxiety and fear; teaching patients about their illnesses and the treatment plans; and overcoming obstacles to patient behavior, including fear, denial, secondary gains, inadequate social support, or lack of knowledge about the disease process. Because members of the target population are between 40 and 90 years old, we considered the characteristics of adult learners when formulating the curriculum, and we included characteristics of high-quality patient education programs. Characteristics of high-quality, patient education programs include active participation by both the patient and his or her family members; a focus on the individual’s learning needs; class content that stresses what the patient should do and know; and a combination of educational methods (eg, written, visual, personal c o m m ~ n i c a t i o n ) .Groups ~~ are kept small (eg, 2 to 4 patients) so that each patient receives individualized attention. The total class size is 4 to 8 people, including the patients’ f r i e n d s or f a m i l y members. W e attempt to give each patient who is scheduled for revision surgery the extra time and reassurance he or she may need by listening to any
FEBRUARY 1992, VOL 55, NO 2
questions or concerns and by providing accurate information in understandable terms. If we do not know the answer to a question, we tell the patient we will find out before he or she leaves the class. The concerns each patient voices on this day are documented on a teaching record, which is on the patient’s hospital chart, for all surgical team members to review. The climate our team members create is one of friendliness, interest, and reassurance. This environment helps us establish a trusting relationship with each patient. To promote this feeling of camaraderie, all patients and guests are invited to stay at the hospital for a complimentary lunch. This gives the patients another opportunity to share feelings and gain reassurance from each other. A multidisciplinary conference, which is held the week before the patient is admitted, enhances our commitment to the complete care of each patient. Representatives from various departments discuss the information about the patient that was obtained during his or her preadmission screening. Health care team members then are able to anticipate and plan for problems. We attribute the success of the program to orthopedic surgeons, administrative personnel, ancillary department members, nurses, and other team members. Our patients agree. One patient said, “It eased the tension and gave me a more secure feeling.” Another patient said, “I went into surgery relaxed and confident.” Our center is fortunate to have the necessary support for our preadmission program. At facilities that do not have such support, preoperative teaching must be the responsibility of each and every nurse who has patient contact. Perioperative nurses are in a unique position to make valuable contributions to the improvement of the quality of care for each surgical patient and to expand the scientific base of knowledge of perioperative nursing through research, documentation, and publication of their findings. 1 Notes 1. P N Palmer, “Nurse educator conference
AORN JOURNAL
focuses on ‘How,”’ AORN Journal 49 (January 1989) 312-321. 2. D J Leithauser, H L Bergo, “Early rising and ambulatory activity after operation: A means of preventing complications,” Archives of Surgery 42 (June 1941) 1086-1093. 3. J E Johnson, “Coping with elective surgery,” Annual Review of Nursing Research 2 (1984) 107132. 4. R G Dumas, R C Leonard, “The effect of nursing on the incidence of postoperative vomiting,” Nursing Research 12 (Winter 1963) 12-15; C A Lindeman, B Van Aernam, “Nursing intervention with the presurgical patient: The effects of structured and unstructured preoperative teaching,” Nursing Research 20 (July/August 1971) 319-332; E Mumford, H J Schlesinger, G V Glass, “The effect of psychological intervention on recovery from surgery and heart attacks: An analysis of the literature,” A m e r i c a n Journal o f Public- Health 72 (February 1982) 141-151. 5. L Egbert et al, “Reduction of postoperative pain by encouragement and instruction of patients,” The New England Journal of Medicine (April 1964) 825-827; F E Schmitt, P J Wooldridge, “Psychological preparation of surgical patients,” Nursing Research 22 (Mxch/April 1973) 108-1 16; E C Devine, T D Cook, “A meta-analytic analysis of effects of psycho-educational interventions on length of postsurgical hospital stay,” Nursing Research 32 (SeptembedOctober 1983) 267-274. 6. Egbert et al, “Reduction of postoperative pain by encouragement and instruction of patients,” 825827; Schmitt, Wooldridge, “Psychological preparation of surgical patients,” 108-116. 7. Johnson, “Coping with elective surgery,” 107-132. 8. D Hathaway, “Effect of preoperative instruction on postoperative outcomes: A meta-analysis,” Nursing Research 35 (September/October 1986) 269-275. 9. E R Chansky, “Reducing patients’ anxieties: Techniques for dealing with crises,” AORN Journul 40 (September 1984) 375-377; A E Goulart, “Preoperative teaching for surgical patients,” Perioperative Nursing Quarterly 3 (June 1987) 813; R C Moss, “Overcoming fear: A review of research on patient, family instruction,” AORN Journal 43 (May 1986) 1107-1114; D Orr, “Reducing presurgical anxiety,” Canadian Operating Room Nursing Journal 4 (February 1986) 29-3 1 ; D M Raab, “Patient education relieves preop fears,” Health Care 27 (February 1985) 38-40; G R Simms, “Emotional stress and the surgical patient,” Surgical Rounds f o r Orthopaedics 2 (September 1988) 37-41. 10. Devine, Cook, “A meta-analytic analysis of 5-79
AORN JOURNAL
effects of psycho-educational intentions on length of post surgical hospital stay," 267-274. 1 1. S L Kosik. P J Reynolds, "A nursing contribution to cost containment: A group preoperative teaching program that shortens hospital stay." Journal of Nursing Staff Developinenr 2 (Winter 1986) 18-22. 12. K Lorig, L Konkol, V Gonzalez. "Arthritis patient education: A review of the literature," Parienr Educrrtion Corinrel 10 (December 1987) 207-252. 13. K Lorig. "Does patient education require a prescription'?'' Arrhriris Care and Research 2 (December 1989) 105-107. 14. E E Bartlett. "How can patient education contribute to improved health care under prospective pricing?" Health Policy 6 ( 1986) 283-293. 15. C E Smith, "Patient teaching: It's the law." Nursing 87 17 (July 1987) 67-68. 16. S B a r r o n , "Preadmission made easy." Americcrn Journal of Nirrsing87 (December 1987) 1690- 1691. 17. L Hoffman, "Preoperative teaching leads to satisfied nurses. relaxed patients" Scrtnr Dax Surgei;v 9 (March 1985) 31-33. 18. C A Connaway, D Blackledge. "Preoperative testing center: Central location to evaluate and educate patients," AORN Journal43 (March 1986) 666670. 19. E Corkery, "Discharge planning and home health care: What every staff nurse should know." Orthopaedic, Nuring 8 (NovemberlDecember 1989) 18-26. 20. N Haines, G Viellion, "A successful combination: Preadmission testing and preoperative education," Orrhoptredic Nursing 9 (MarcNApril 1990). 2 1. P Ley et al, "A method for increasing patients' recall of information presented by doctors," Psychological Medicine 3 (May 1973) 2 17-220. 22. L M Wallace. "Psychological preparation as a method of reducing the stress of surgery," Journril of Humuri Srress 10 (Summer 1984) 62-77. 23. E Bartlett, "From where I stand patient education is 1-2-3," Patient Education Ne\lslerter (June 1984) 1 1 . 23. Bartlett. "How can patient education contribute to improved health care under prospective pricing?" 283-293.
Suggested reading Anderson, R. Zinibra, C . "Same day surgery: Coordinating the admission process." Nursing Management 17 (December 1986) 23-25. Kasdan. A S; Kasdan, M L: Janes. C. "Taking the extra step: T h e nursing role in s a m e d a y surgery." Todiry's OR Nur.w 6 (December 1984) 1x-20.
FEBRUARY 1992, VOL 5 5 , NO 2
Kempe. A R. "Patient education for the ambulatory surgery patient." AORN Journal 45 (February 1987) 500-507. Kernaghan. S G. "Preadmission preoperative teaching: A promising option, but easier said than done." Promoting Health 6 (March/April 1985) 6-8. Worley. B. "Preadmission testing and teaching: M o r e satisfaction at less cost." Nursing Mmagemenr 17 (December 1986) 32-33.
FDA Begins Reform of Drug Review Process The US Department of Health and Human Services (HHS) announced in its Nov 13, 1991 , issue of HHS NEWS that the US Food and Drug Administration (FDA) has begun reforms that will speed the drug review process and make the development and availability of new medications faster. The improvements were proposed by the council on competitiveness, which is chaired by Vice President Dan Quayle, and are an attempt to make new drugs available to patients with serious or life-threatening diseases. The recent release of dideoxyinosine (DDI) is an example of a new drug that has reached acquired immune deficiency syndrome patients sooner because of recommendations from the group. The FDA will expand the drug review process, use non-government scientific experts to augment FDA reviewers, and eliminate existing backlogs of drug applications. Reviews will be given a 1SO-day deadline for completion, and the FDA will attempt to maximize a drug's potential for approval by taking into account the risks to life and health that would result if its release were delayed. In addition, the FDA will create new rules to accelerate the approval process, coordinate its review standards with those of other industrialized countries, and improve the process of scientific review.
AORN JOURNAL
Same Day Surgery COORDINATING THE EDUCATION PROCESS Nancy Haines, RN
P
rospective pricing has revolutionized health care delivery systems. The Center for Hip and Knee Surgery, Kendrick Health Care Center, Mooresville, Ind, is a research-oriented orthopedic hospital that has developed and implemented an alternative approach to preadmission testing and preoperative patient education. With the implementation of the prospective pricing system and diagnosis-related groups in 1983, hospital stays have decreased in length, and pressure to contain costs has increased. According to American Hospital Association figures, between 55% and 75% of all hospital admissions are surgery related.' Medicare, health maintenance organizations, and most third-party payment systems now are questioning why patients must be hospitalized the day before surgery. As a result, same day admission (ie, AM admission, day-of-surgery admission) for many procedures is becoming more common. This trend drastically reduces the amount of time in which crucial information can be delivered to and absorbed by the patient, and it creates a tremendous amount of pressure on nurses caring for the surgical patient. Nurses are responsible for the educational needs of the patient as well as for preparing the patient physically and emotionally for surgery. Additionally, nurses must ensure that all necessary consent forms and laboratory test results are in order. With less time to do all these things, nurses are experiencing increased pressure. The practice of providing surgical patients with information and instruction before their
operations began with the change in patient management strategy. Instead of confining patients to their beds for many days following surgery, nurses helped patients to ambulate immediately. Early resumption of physical activity became standard practice because it decreased the frequency of major physical postoperative complications.2 To reduce patients' fears and increase their willingness to participate in physical activity so soon after surgery, nurses and surgeons taught them about the
Nancy Haines, RN,C, M S N , i s a clinical research nurse, orthopedics, and an adult nurse practitioner at the Methodist Hospital of Indiana, Inc, Indianapolis. At the time this article was written, she was preadmission screening coordinator at the Center f o r Hip and Knee S u r g e r y , Kendrick Health C a r e C e n t e r , Mooresville, Ind. She earned her BSN degree from Indiana University, Indianapolis, and her MSN degree in adult primary health care from Indiana University at Indianapolis. 573
FEBRUARY 1992, VOL 5 5 , NO 2
AORN JOURNAL
Inherent in nursing practice is the belief that all individuals have the right to be treated with respect and dignity.
activities they were expected to perform. Most of the research on preparation of surgical patients stemmed from this change to early postoperative ambulation.‘
Does Educatioii Make a DifSerence?
F
or more than 20 years. nursing researchers have attempted to measure the effect of preoperative instruction on postoperative outcome. Results support the positive and beneficial effect preoperative instruction has on postoperative outcomes (eg, the risk of developing postoperative complications was reduced when patients were taught specific behaviors such as deep breathing, coughing. and leg exercises).4 Shorter hospital stays were reported following psycho-educational interventions.’ Other study results show that patients who receive preoperative instruction require less pain medication than those who d o not receive instruction.h One recurring theme is the increased effectiveness of preoperative teaching when psychotherapeutic and educational approaches are combined.7 Findings of one researcher’s metaanalysis of 68 studies, which examines the effects of preoperative instruction on postoperative outcomes, show that preoperative instruction has a positive and beneficial effect on postoperative outcomes.8 Numerous studies document how preoperative teaching helps relieve patients’ fears and anxieties, decrease their stress, enhance their psychologic well-being, and promote their postoperative recovery.‘ Two researchers categorized 50 studies by type of surgery (ie. abdominal, thoracic, orthopedic. gynecologic, other). and their meta-analysis results are evidence that patients with a broad range of conditions likely will benefit from preoperative education.’” Data from another study supports the conclusion that
patients who participate in preoperative teaching programs receive fewer doses of parented analgesics than those who do not participate. Patients in the experimental group (ie, those who received preoperative teaching) were hospitalized an average of 8.4 postoperative days, and those in the control group (ie, those who received no preoperative teaching) were hospitalized an average of 9.7 postoperative days.” Another study reviewed nearly 100 studies of arthritis patient education programs that suggest that certain education techniques, in selected arthritis patients, can help them manage their arthritis therapeutically. These randomized trials of education programs demonstrated decreases in patient pain, depression, and disability, and increases in patient compliance and other behaviors believed to affect arthritis positively. One researcher writes, “It appears that when using effectiveness criteria similar to those used in judging medication (ie, outcome measures, including patient-rated measures of pain, self-care, physical activity/mobility, role activities, mental health), arthritis patient education is therapeutically effective.”I3 According to another researcher, This evidence suggests that patient education can enhance the quality of patient care, particularly in improving adherence t o therapeutic regimens and in reducing postoperative complications. This does not mean that patient education is ah2ay effective, or that it is a ‘magic bullet,’ but rather it seems t o be an important and essential component of high quulity care.IJ Inherent in nursing practice is the belief that all individuals have the right to be treated with respect and dignity; the right to receive accessible, high-quality care; and the right to have understandable information about the choices available and their consequences. One researcher
FEBRUARY 1992, VOL 55, NO 2
AORN JOURNAL
explains nurses’ responsibility for patient education by saying that the court likely will see patient teaclng as a duty, just as obtaining informed consent from patients is a duty-especially when the right to know is critical to the patient’s health.15 Nurses’ commitment to patient education and to the challenge of learning about the effectiveness of their patient teaching subsequently evolved.
Preadmission Programs
B
y early 1984, the number of AM admission patients was increasing rapidly. By the time the admission process and the physical Surgeon discusses an upcoming procedure with a patient preparation of the patient was complet- during her initial office visit. ed, there was little time left for nurses to teach and for patients to learn. Patients’ patient involvement, which includes attending anxiety levels usually are high before surgery. preoperative education sessions and asking This also interferes with the learning process. questions about their surgery, contributes to the Because of these things, preadmission programs goals of preventing postoperative complicabegan to be implemented across the country. tions, decreasing the lengths of hospital stays, Literature supports numerous strategies and proand improving patients’ satisfaction and postgrams, which have a variety of names and educaoperative compliance. Our personalized preadtors teaching these surgical patients. Some exammission screening program has evolved in ples of other programs follow. At St Joseph’s stages since its inception in 1974. It soon Hospital, Albuquerque, the patient registration became apparent that screening patients 10 to and education program is run by the preadmission 14 days before they are admitted is crucial and coordinator in the patient and family services helps avoid last-minute surgery cancellations department.Ih due to unstable medical conditions. If a condiAt Albert Einstein Medical Center, tion is discovered during the screening and the Philadelphia, the short procedure unit is run by surgery must be cancelled, another patient usua nurse manager in cooperation with anesthesia ally can be scheduled for surgery. When a department personnel, and ambulatory surgery patient entered the hospital only 1 to 2 days nurses use a preoperative teaching checklist to before surgery and an unstable condition was ensure that teaching is ~ n i f 0 r m . lAlta ~ Bates discovered, it often was too late to schedule Hospital, Berkeley, Calif, established a preopanother patient for the reserved time. erative testing center separate from the OR. It is The Joint Commission on Accreditation of operated by the director of surgery and is Healthcare Organizations requires an assessstaffed by OR nurses.lX ment of the availability of appropriate services to meet patients’ post-hospitalization needs. Preadmission Screening Program The Joint Commission also requires the participation of physicians, nurses, social workers, t the Center for Hip and Knee Surgery, dieticians, utilization review staff members, preadmission screening personnel use a therapists, and pharmacists in discharge planmultidisciplinary approach. Active
A
575
AORN JOLRNAL
FEBRUARY 1992, VOL 55, NO 2
The nurse educator answers questions and explains procedures during the class.
ning.” Patients have a right to receive care and treatment. which includes individualized instruction and counseling about their post-hospitalization needs. Because the surgeons at the Center for Hip and Knee Surgery believe that late identification of discharge needs predisposes our patients to remain hospitalized for longer periods of time, they want the interdisciplinary. collaborative approach to discharge planning to begin no later than the day the patient is admitted to the hospital. Because Preadmission screening requires that the patient visit the hospital. we included other aspects of assessment, education. and discharge planning in the program. In 1974. patients were admitted to the hospital two days before their scheduled surgeries for laboratory tests. histories, and physical examinations by an orthopedist. Patients at the Center for Hip and Knee Surgery currently attend the preadmission screening program 10 to 14 days before surgery and are seen by an internal medicine specialist and a nurse patient educator who has a master’s degree in primary health care.
Truchiiig Strategies, Tools
T
he teaching process begins with the patient‘s initial visit to the orthopedic surgeon‘!, office. Once the diagnosis is
576
confirmed and surgery is indicated, the surgeon uses a picture booklet to discuss the diagnosis, the surgical procedure, and the involved risks with the patient and his or her family members. At this time, the surgeon also explains that the preadmission screening program is important and that the patient is expected to attend. The picture booklet explains the surgical procedure, the postoperative course, and the rehabilitation period. Of I43 patients surveyed between December 1988 and March 1989,89% reported that they read the booklet before attending the preadmission screening program.:(’ Research shows that patients forget half of what they are told within five minutes of when they hear it; patients recall more information if they read it as well as hear it.2i Another researcher showed that preparatory booklets and written information enhance the quality of presurgical communication.’?
Preadmission Day
A
t the Center for Hip and Knee Surgery, the preadmission coordinator/nurse educator is responsible for the preadmission education program. This person schedules patient appointments for admission, laboratory tests, x-rays, visits with thc internist, and education classes. He or she facilitates commu-
AORN JOURNAL
FEBRUARY 1992. VOL 5 5 , NO 2
A multidisciplinary conference. held the week before the patient is admitted, enhances the commitment to the complete care of each patient.
nication between support team members and c o n d u c t s the patient education c l a s s e s . Screening and education takes 4 to 5 hours. The patient is supposed to bring a spouse. relative. or friend to the program. We strongly support including family members because of their impact on patients‘ well-being. A patient representative and a patient transporter greet the patient and escort him or her to the various departments where preadmission laboratory work or tests are done. The patient spends approximately o n e h o u r with the internist. who takes a thorough history and performs a physical. The patient spends another hour with the nurse educator. who introduces and explains the purpose of the preadmission program. The patient watches a 30-minute video that was filmed at the Center for Hip and Knee Surgery and is narrated by the orthopedic surgeons who work there. This information is consistent with and reinforces the information provided in the i n s t r u c t i o n a I book 1e t s . The nurse educator provides procedural information about what will happen in the OR and sensory information. He or she reinforces important aspects of postoperative care and allows the patient ”hands-on” time with the equipment that will be used during surgery. In developing the curriculum for the educational classes. we reviewed books that were written by an expert in patient education. According to the author. patient education is 578
”a process of informing patients and their families about the illness and treatment, instructing them on how to adhere to the regimen, and helping them change their behavior.”” The author’s three-step approach to patient education includes establishing rapport and reducing patients’ anxiety and fear; teaching patients about their illnesses and the treatment plans; and overcoming obstacles to patient behavior, including fear, denial, secondary gains, inadequate social support, or lack of knowledge about the disease process. Because members of the target population are between 40 and 90 years old, we considered the characteristics of adult learners when formulating the curriculum, and we included characteristics of high-quality patient education programs. Characteristics of high-quality, patient education programs include active participation by both the patient and his or her family members; a focus on the individual’s learning needs; class content that stresses what the patient should do and know; and a combination of educational methods (eg, written, visual, personal c o m m ~ n i c a t i o n ) .Groups ~~ are kept small (eg, 2 to 4 patients) so that each patient receives individualized attention. The total class size is 4 to 8 people, including the patients’ f r i e n d s or f a m i l y members. W e attempt to give each patient who is scheduled for revision surgery the extra time and reassurance he or she may need by listening to any
FEBRUARY 1992, VOL 55, NO 2
questions or concerns and by providing accurate information in understandable terms. If we do not know the answer to a question, we tell the patient we will find out before he or she leaves the class. The concerns each patient voices on this day are documented on a teaching record, which is on the patient’s hospital chart, for all surgical team members to review. The climate our team members create is one of friendliness, interest, and reassurance. This environment helps us establish a trusting relationship with each patient. To promote this feeling of camaraderie, all patients and guests are invited to stay at the hospital for a complimentary lunch. This gives the patients another opportunity to share feelings and gain reassurance from each other. A multidisciplinary conference, which is held the week before the patient is admitted, enhances our commitment to the complete care of each patient. Representatives from various departments discuss the information about the patient that was obtained during his or her preadmission screening. Health care team members then are able to anticipate and plan for problems. We attribute the success of the program to orthopedic surgeons, administrative personnel, ancillary department members, nurses, and other team members. Our patients agree. One patient said, “It eased the tension and gave me a more secure feeling.” Another patient said, “I went into surgery relaxed and confident.” Our center is fortunate to have the necessary support for our preadmission program. At facilities that do not have such support, preoperative teaching must be the responsibility of each and every nurse who has patient contact. Perioperative nurses are in a unique position to make valuable contributions to the improvement of the quality of care for each surgical patient and to expand the scientific base of knowledge of perioperative nursing through research, documentation, and publication of their findings. 1 Notes 1. P N Palmer, “Nurse educator conference
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focuses on ‘How,”’ AORN Journal 49 (January 1989) 312-321. 2. D J Leithauser, H L Bergo, “Early rising and ambulatory activity after operation: A means of preventing complications,” Archives of Surgery 42 (June 1941) 1086-1093. 3. J E Johnson, “Coping with elective surgery,” Annual Review of Nursing Research 2 (1984) 107132. 4. R G Dumas, R C Leonard, “The effect of nursing on the incidence of postoperative vomiting,” Nursing Research 12 (Winter 1963) 12-15; C A Lindeman, B Van Aernam, “Nursing intervention with the presurgical patient: The effects of structured and unstructured preoperative teaching,” Nursing Research 20 (July/August 1971) 319-332; E Mumford, H J Schlesinger, G V Glass, “The effect of psychological intervention on recovery from surgery and heart attacks: An analysis of the literature,” A m e r i c a n Journal o f Public- Health 72 (February 1982) 141-151. 5. L Egbert et al, “Reduction of postoperative pain by encouragement and instruction of patients,” The New England Journal of Medicine (April 1964) 825-827; F E Schmitt, P J Wooldridge, “Psychological preparation of surgical patients,” Nursing Research 22 (Mxch/April 1973) 108-1 16; E C Devine, T D Cook, “A meta-analytic analysis of effects of psycho-educational interventions on length of postsurgical hospital stay,” Nursing Research 32 (SeptembedOctober 1983) 267-274. 6. Egbert et al, “Reduction of postoperative pain by encouragement and instruction of patients,” 825827; Schmitt, Wooldridge, “Psychological preparation of surgical patients,” 108-116. 7. Johnson, “Coping with elective surgery,” 107-132. 8. D Hathaway, “Effect of preoperative instruction on postoperative outcomes: A meta-analysis,” Nursing Research 35 (September/October 1986) 269-275. 9. E R Chansky, “Reducing patients’ anxieties: Techniques for dealing with crises,” AORN Journul 40 (September 1984) 375-377; A E Goulart, “Preoperative teaching for surgical patients,” Perioperative Nursing Quarterly 3 (June 1987) 813; R C Moss, “Overcoming fear: A review of research on patient, family instruction,” AORN Journal 43 (May 1986) 1107-1114; D Orr, “Reducing presurgical anxiety,” Canadian Operating Room Nursing Journal 4 (February 1986) 29-3 1 ; D M Raab, “Patient education relieves preop fears,” Health Care 27 (February 1985) 38-40; G R Simms, “Emotional stress and the surgical patient,” Surgical Rounds f o r Orthopaedics 2 (September 1988) 37-41. 10. Devine, Cook, “A meta-analytic analysis of 5-79
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effects of psycho-educational intentions on length of post surgical hospital stay," 267-274. 1 1. S L Kosik. P J Reynolds, "A nursing contribution to cost containment: A group preoperative teaching program that shortens hospital stay." Journal of Nursing Staff Developinenr 2 (Winter 1986) 18-22. 12. K Lorig, L Konkol, V Gonzalez. "Arthritis patient education: A review of the literature," Parienr Educrrtion Corinrel 10 (December 1987) 207-252. 13. K Lorig. "Does patient education require a prescription'?'' Arrhriris Care and Research 2 (December 1989) 105-107. 14. E E Bartlett. "How can patient education contribute to improved health care under prospective pricing?" Health Policy 6 ( 1986) 283-293. 15. C E Smith, "Patient teaching: It's the law." Nursing 87 17 (July 1987) 67-68. 16. S B a r r o n , "Preadmission made easy." Americcrn Journal of Nirrsing87 (December 1987) 1690- 1691. 17. L Hoffman, "Preoperative teaching leads to satisfied nurses. relaxed patients" Scrtnr Dax Surgei;v 9 (March 1985) 31-33. 18. C A Connaway, D Blackledge. "Preoperative testing center: Central location to evaluate and educate patients," AORN Journal43 (March 1986) 666670. 19. E Corkery, "Discharge planning and home health care: What every staff nurse should know." Orthopaedic, Nuring 8 (NovemberlDecember 1989) 18-26. 20. N Haines, G Viellion, "A successful combination: Preadmission testing and preoperative education," Orrhoptredic Nursing 9 (MarcNApril 1990). 2 1. P Ley et al, "A method for increasing patients' recall of information presented by doctors," Psychological Medicine 3 (May 1973) 2 17-220. 22. L M Wallace. "Psychological preparation as a method of reducing the stress of surgery," Journril of Humuri Srress 10 (Summer 1984) 62-77. 23. E Bartlett, "From where I stand patient education is 1-2-3," Patient Education Ne\lslerter (June 1984) 1 1 . 23. Bartlett. "How can patient education contribute to improved health care under prospective pricing?" 283-293.
Suggested reading Anderson, R. Zinibra, C . "Same day surgery: Coordinating the admission process." Nursing Management 17 (December 1986) 23-25. Kasdan. A S; Kasdan, M L: Janes. C. "Taking the extra step: T h e nursing role in s a m e d a y surgery." Todiry's OR Nur.w 6 (December 1984) 1x-20.
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Kempe. A R. "Patient education for the ambulatory surgery patient." AORN Journal 45 (February 1987) 500-507. Kernaghan. S G. "Preadmission preoperative teaching: A promising option, but easier said than done." Promoting Health 6 (March/April 1985) 6-8. Worley. B. "Preadmission testing and teaching: M o r e satisfaction at less cost." Nursing Mmagemenr 17 (December 1986) 32-33.
FDA Begins Reform of Drug Review Process The US Department of Health and Human Services (HHS) announced in its Nov 13, 1991 , issue of HHS NEWS that the US Food and Drug Administration (FDA) has begun reforms that will speed the drug review process and make the development and availability of new medications faster. The improvements were proposed by the council on competitiveness, which is chaired by Vice President Dan Quayle, and are an attempt to make new drugs available to patients with serious or life-threatening diseases. The recent release of dideoxyinosine (DDI) is an example of a new drug that has reached acquired immune deficiency syndrome patients sooner because of recommendations from the group. The FDA will expand the drug review process, use non-government scientific experts to augment FDA reviewers, and eliminate existing backlogs of drug applications. Reviews will be given a 1SO-day deadline for completion, and the FDA will attempt to maximize a drug's potential for approval by taking into account the risks to life and health that would result if its release were delayed. In addition, the FDA will create new rules to accelerate the approval process, coordinate its review standards with those of other industrialized countries, and improve the process of scientific review.
