584391
research-article2015
NCPXXX10.1177/0884533615584391Nutrition in Clinical PracticeEmery et al
Clinical Research
Voiceover Interactive PowerPoint Catheter Care Education for Home Parenteral Nutrition
Nutrition in Clinical Practice Volume XX Number X Month 201X 1–6 © 2015 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533615584391 ncp.sagepub.com hosted at online.sagepub.com
Dorothy Emery, ADN, RN1; Annette Pearson, BSN, RN1; Rocio Lopez, MS2; Cindy Hamilton, MS, RD, LD1; and Nancy M. Albert, PhD, RN, CCNS, CCRN3
Abstract Background: In home infusions via tunneled catheter/peripherally inserted central catheter (TC/PICC) the risk of catheter-related bloodstream infection (CRBSI) and complications contribute to rehospitalization and costs. It is unknown if voiceover interactive PowerPoint (VOIPP) via digital video disc education improves clinical outcomes. Materials and Methods: In a quaternary care medical center and using a randomized, controlled, 2-group design, hospitalized patients with TC/PICC received usual care education or usual care (UC) plus VOIPP education prehospital discharge. A multiple-choice 6-item knowledge questionnaire was administered preeducation, immediately posteducation, and 7–10 days postdischarge. At 90 days, patients were assessed for CRBSI incidence rates per 1000 catheterdays, rehospitalization, CRBSI-related hospitalization, non-CRBSI complications and patient calls to the home parenteral nutrition (HPN) clinicians. Analysis of variance, Pearson χ2, and Kruskal-Wallis test were used to compare results between groups. Results: Of 51 patients (UC, n = 27; UC+VOIPP, n = 24), mean ± SD age was 46.3 ± 14.3 years, 68.6% were female, HPN duration was 2.2 ± 1.01 months, and time to postdischarge test completion was 11.5 ± 5.2 days. There were no baseline differences between groups. Between-group knowledge and changes in knowledge were similar at preeducation, immediate posteducation, and postdischarge (P = .88, 0.30, and 0.37, respectively). There were no differences in CRBSI incidence, rehospitalization, CRBSI-related rehospitalization rates, and non-CRBSI complications between groups. The UC+VOIPP group had more patient calls than did the UC group (21.8 vs 7.7 calls/1000 catheter-days, P < .001). Conclusion: Recorded education led to more patient calls to the HPN clinicians; however, there were no differences between groups in other outcomes. (Nutr Clin Pract. XXXX;xx:xx-xx)
Keywords nutritional support; home parenteral nutrition; home infusion therapy; patient education; central venous catheters; infection
Background Home parenteral nutrition (HPN) allows patients with intestinal failure to maintain an adequate nutrition status in an outpatient setting.1–5 Patients who require HPN have complex care needs requiring ongoing communication and collaboration between inpatient and outpatient clinicians to minimize complications.6 However, complications have been reported. The most frequent complication (75%) was catheter-related bloodstream infections (CRBSIs).7 Catheter complications (lowgrade fever to sepsis)8 account for a major cause of rehospitalizations and costs. The most effective method for the prevention of CRBSI is patient education9 that involves strict adherence to hand hygiene and aseptic techniques.8 In research, interactive educational interventions using videos reduced infective complications.7 Patient and family education is an essential component of predischarge preparation for patients with HPN. Education includes increasing patient and family knowledge about complications.4–6,10,11 It is unknown if technology associated with Microsoft (Redmond, WA) PowerPoint (PP) presentation can be used to educate patients about HPN catheter care. Nutrition support team (NST) nurses are responsible for teaching patients
about catheter care prior to discharge. In-room education involved receiving 2–3 didactic lessons on catheter care and home self-monitoring. Patients received a catheter care manual and a television video on home self-monitoring was also available. An effective tool that could streamline catheter care education, enhance patient knowledge, and decrease serious catheter associated complications is warranted. The purpose of this research study was to determine the clinical effects of an educational voiceover interactive PowerPoint (VOIPP) and usual care education vs usual care education alone in patients with a tunneled catheter or peripherally inserted central catheter (TC/PICC) who required From the 1Center for Human Nutrition, Digestive Disease Institute; 2 Quantitative Health Sciences; and 3Nursing Institute, Office of Research and Innovation, Cleveland Clinic, Cleveland, Ohio. Financial disclosure: None declared. Corresponding Author: Dorothy Emery, ADN, RN, Center for Human Nutrition, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Mail Code TT-204, Cleveland, OH 44195, USA. Email: [email protected]
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catheter care education in preparation for hospital discharge to home. The specific aims of this study were to determine if there were differences in clinical outcomes between VOIPP and usual care education vs usual care education alone in catheter care knowledge, CRBSI incidence, 90-day all-cause rehospitalization rate, CRBSI-related rehospitalization rate, non-CRBSI complications, and number of patient calls.
Methods This research was a prospective, randomized, controlled pilot study. The institutional review board approved this study prior to initiation, and all procedures met the ethical standards of the institutional review board.
Setting and Sample The research was conducted in a 1200-bed quaternary care medical center in northeast Ohio. The center’s NST consists of multidisciplinary care providers, including nurses and dietitians. The NST services all hospitalized patients who receive parenteral nutrition (PN). Hospitalized patients with a TC/PICC who were scheduled for hospital discharge on home parenteral nutrition (HPN) were eligible for enrollment. Inclusion criteria were that patients had not been receiving HPN in the past 6 months, were expected to be discharged home, were able (or caregivers were able) to demonstrate safe management of HPN catheter care procedures, had a DVD player, and had a catheter inserted during the hospital episode. Exclusion criteria were discharge to a facility other than home (ie, skilled nursing facility, extended care facility, subacute facility, long-term acute care, or hospice care), receiving hospice care at home, or in an acute or chronic delusional or confused state.
presentation content was 25 (PICC) to 30 (tunneled catheter) minutes in length and contained audio and visual information on catheter care and when to contact HPN clinicians for advice. A practice presentation format was used that showed real people completing catheter care behaviors, including hand washing, changing a TC dressing, changing an end connector, and securing a catheter. Patients received a DVD of the VOIPP presentation to take home and rewatch. Patients were instructed to view the DVD within 7–10 days of hospital discharge.
Outcomes and Measurement Catheter care knowledge was assessed using an investigatordeveloped 6-item knowledge questionnaire that had a 4-option, multiple-choice response set. Themes of each question were as follows: proper length of time to clean the end connector; proper length of time to wash hands before initiating PN procedures; preferred solution to clean work surfaces; the first step to take when a crack or hole is found in a catheter; of 4 situations, which one does not require notification of the HPN service; and which step is important in preventing accidental removal of the catheter. Scores ranged from 1–6, and higher scores reflected better knowledge. Content validity was assessed by 8 clinical experts in nutrition and catheter care for HPN. Using the Lynn method,12 the content validity index was 1.0, reflecting strong content validity at a P < .05 level. The incidence of CRBSI was assessed from data retrieved from an HPN database on CRBSI incidence. Database data collectors used medical record review and postdischarge patient communication to obtain data on all patients with tunneled catheters and PICCs. Data on 90-day allcause rehospitalization, CRBSI-related rehospitalization, nonCRBSI complications, and number of patient calls to clinicians were retrieved from the HPN database.
Data Collection
Intervention Usual care and intervention education was delivered by 2 registered nurse (RN) members of the NST. Usual care education was completed 48–72 hours prior to home discharge. Education consisted of a one-on-one nurse-led, predischarge-delivered lesson on HPN catheter care, potential complications of HPN, and monitoring for potential complications. The lesson also included catheter care and maintenance involving dressing changes for TC and an assessment of the PICC insertion site. Education was delivered verbally. Patients received a written instruction manual. Patients had an opportunity to return demonstration of changing dressings (tunneled catheters only), flushing catheters, changing end connectors, and emergency clamping using a 3-dimensional model of a chest, neck, and arm. Patients were instructed to contact HPN clinicians for complications or advice. Intervention education consisted of all usual care education and viewing of VOIPP on a laptop computer. The VOIPP
After verbal informed consent, patients were randomly assigned to an education group. Tunneled catheter and PICC knowledge were assessed preintervention and immediately postintervention by 2 NST nurses. The baseline knowledge test (before education or usual care) and first posttest (immediately after education or usual care) were completed by pen and paper in the hospital. Knowledge was assessed by telephone at 7–10 days postdischarge by HPN clinicians who were not blinded to the study group. At the follow-up phone calls, 3 additional questions were asked of patients randomized to the usual care plus VOIPP group to assess if they viewed the DVD (yes/no), number of times the DVD was viewed, and number of days since discharge before the DVD was viewed.
Statistical Analysis Data are presented as mean ± standard deviation or number (%). Univariable analysis was performed to assess differences
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Table 1. Patient Characteristics. Factor Age, mean ± SD, y Female sex, No. (%) HPN duration, mean ± SD, mo Catheter type, No. (%) PICC Hickman Lumens (number), No. (%) 1 2
Overall (n = 51)
Usual Care Education (n = 27)
VOIPP Education (n = 24)
46.3 ± 14.3 35 (68.6) 2.2 ± 1.01
44.4 ± 14.0 18 (66.7) 2.1 ± 1.08
48.4 ± 14.6 17 (70.8) 2.4 ± 0.90
14 (27.5) 37 (72.5)
11 (40.7) 16 (59.3)
3 (12.5) 21 (87.5)
36 (70.6) 15 (29.4)
16 (59.3) 11 (40.7)
20 (83.3) 4 (16.7)
P Value .33a .75b .16a .024b .060b
HPN, home parenteral nutrition; PICC, peripherally inserted central catheter; SD, standard deviation; VOIPP, voiceover interactive PowerPoint. a Analysis of variance. b Pearson χ2 test.
Table 2. Knowledge Test Scores Preeducation, Immediate Posteducation, and Delayed Posteducation. Mean ± SD Test Score Preeducation test score Immediate posteducation 7–10 Days posteducation
Overall (n = 51)
Usual Care Education (n = 27)
4.4 ± 0.96 5.6 ± 0.96 5.4 ± 1.4
4.3 ± 1.1 5.8 ± 0.58 5.5 ± 0.78
VOIPP Education (n = 24) 4.4 ± 0.77 5.5 ± 1.3 5.2 ± 1.9
P Valuea .88 .30 .37
SD, standard deviation; VOIPP, voiceover interactive PowerPoint. a Analysis of variance.
between the 2 groups; analysis of variance (ANOVA) was used to compare continuous variables, Kruskal-Wallis tests were used for ordinal factors, and Pearson χ2 tests were used for categorical data. The CRBSI incidence rates, all-cause readmission, CRBSIrelated readmission, non-CRBSI complications, and patient call rates/per 1000 catheter-days were estimated for each group by dividing the number of observed events by the total number of catheter days contributed by each group. The difference in incidence rates between the groups and corresponding 95% confidence interval are reported. A P < .05 was considered statistically significant. SAS (version 9.2; SAS Institute, Cary, NC) and R (version 3.0.1; The R Foundation for Statistical Computing, Vienna, Austria) were used for all analyses.
Results In total, 51 patients were randomized to receive usual care (n = 27) or usual care plus VOIPP (n = 24). Medical diagnoses varied; the most frequent were Crohn’s disease or ulcerative colitis (29.4%), different cancers (17.6%), and obesity (9.8%). Reasons for HPN also varied; the most frequent were postoperative ileus and other obstructions (39.2%), intestinal fistulas (23.6%), and malabsorption (23.5%). Mean ± SD patient age was 46.3 ± 14.3 years, and 68.6% were female. Mean ± SD
HPN duration was 2.2 ± 1.0 months. Usual care plus VOIPP patients were more likely to have Hickman catheters than those in the usual care education group (88% vs 59%; P = .024; see Table 1). Overall, 8 of 24 patients (mean ± SD frequency, 33.3% ± 48.1%) viewed the DVD at home. Of the 8 patients who viewed the DVD, mean ± SD time to viewing it was 4.25 ± 4.3 days, and only 2 patients (mean ± SD, 1.25 ± .46) watched it more than one time.
Knowledge Scores Between Groups Of patients, knowledge scores about HPN catheter care were lowest at baseline, and both the usual care and intervention groups had similar scores. Knowledge increased immediately after education in a similar manner in both groups. Furthermore, at 7–10 days after hospital discharge, there were no between-group differences in knowledge scores (see Table 2).
Clinical Outcomes at 90 Days Numerically, there were more CRBSIs, hospital readmissions, and CRBSI-related hospital readmissions in the usual care education group than in the usual care plus VOIPP
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Table 3. Clinical Outcomes. Factor CRBSI, No. (%) All-cause readmissions, No. (%) All-cause readmission (occurrences), No. (%) 0 1 2 3 CRBSI-related readmission, No. (%) Non-CRBSI complications, No. (%) Non-CRBSI complications, occurrences, No. (%) 0 1 2 3 No. of patients who initiated calls, No. (%) Number of calls received, mean ± SD
Overall (n = 51)
Usual Care Education (n = 27)
VOIPP Education (n = 24)
5 (9.8) 23 (45.1)
4 (14.8) 14 (51.9)
1 (4.2) 9 (37.5)
28 (54.9) 14 (27.5) 8 (15.7) 1 (2.0) 5 (9.8) 17 (38.6)
13 (48.1) 9 (33.3) 4 (14.8) 1 (3.7) 4 (14.8) 8 (34.8)
15 (62.5) 5 (20.8) 4 (16.7) 0 (0.0) 1 (4.2) 9 (42.9)
27 (61.4) 13 (29.5) 2 (4.5) 2 (4.5) 17 (33.3)
15 (65.2) 7 (30.4) 1 (4.3) 0 (0.0) 9 (33.3) .48 (0.75)
12 (57.1) 6 (28.6) 1 (4.8) 2 (9.5) 8 (33.3) 1.6 (3.0)
P Value .35a .30a .37b .35a .58a .45b .99a .57b
CRBSI, catheter-related bloodstream infection; SD, standard deviation; VOIPP, voiceover interactive PowerPoint. a Pearson χ2 test. b Kruskal-Wallis test.
usual care plus VOIPP patients made calls about the catheter itself to HPN clinicians. Rationale for all phone calls is provided in Table 4.
Discussion
Figure 1. Clinical outcomes between usual care (n = 27) and usual care plus voiceover interactive PowerPoint (VOIPP) (n = 24) groups. CRBSI, catheter-related bloodstream infection.
group; however, there were no statistically significant differences between groups (all 3, P = .16). Non-CRBSI complications, such as intake and output issues, PN formula or other medication issues, and weight or diet changes, were similar between groups. The usual care plus VOIPP group had more patient calls (21.8 calls/1000 catheter-days) compared with the usual care group (7.7 calls/1000 catheterdays, P < .001; Table 3 and Figure 1). Numerically, more
In this pilot study that compared usual care education and usual care plus VOIPP education to engage and educate patients with HPN, there was no superiority in patient knowledge or in 90-day clinical outcomes (all-cause readmission, CRBSIs, CRBSI readmission, non-CRBSI complications). Not all education technologies provide superiority. In a meta-analysis of 9 randomized controlled trials, instruments and technologies differed, but researchers found small effect sizes and equivocal effect sizes when satisfaction was studied.13 In a systematic review of multimedia educational interventions to inform consumers about over-the-counter medications, there were no differences in outcomes based on education interventions used.14 Finally, in a systematic review that focused on video-assisted education, some of which were a practice presentation format similar to VOIPP, not all were effective in achieving clinical outcomes.15 Only one-third of this study’s usual care plus VOIPP group reviewed the DVD at home. It is unknown if results would have differed if more patients chose to review education content after hospital discharge. Ultimately, it might be important to deliver education content through multiple strategies, thereby allowing patients to learn and retain knowledge from different styles in a way that optimizes clinical practices.
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Table 4. Themes of Patient-Initiated Phone Calls to Home Parenteral Nutrition Clinicians.a Theme Catheter itself (eg, site problem; occlusion or break in the catheter; dressing problem) Intake, output, weight, swelling, diarrhea, vomiting, dizziness, nausea Parenteral nutrition formula, medications, diet changes Serum laboratory work; general, blood cultures, and glucose Fever, shakes, chills, coughing Shortness of breath Pump issues Dental J-tube issue Outside hospital admission General question Urinary tract infection symptoms
Usual Care Education (n = 27), No. (%)
VOIPP Education (n = 24), No. (%)
9 (33)
27 (112)
11 (40) 8 (30) 2 (7) 11 (40) 0 5 (18) 0 0 0 0 1 (3)
19 (79) 5 (21) 5 (21) 3 (12) 3 (12) 2 (8) 2 (8) 1 (4) 1 (4) 1 (1) 0
VOIPP, voiceover interactive PowerPoint via digital video disc. a Totals do not equal 100% as individual patients could have made multiple calls and/or had more than one discussion themes.
In HPN guidelines,4,5 patient education is expected and may involve computers, computer discs/DVDs, print materials, demonstration, and verbal instructions.10 Although participants in this study received teaching strategies previously shown to be effective, there might have been patient, process, and system factors that prevented the intervention from achieving superiority over usual care education. For both groups, patient factors could have included lack of adherence to expected hand-washing behaviors and variation in handwashing techniques used. Furthermore, participants were young and appeared cognitively intact; however, their ability to remember the totality of education delivered could have been overwhelming, especially for the usual care plus VOIPP education group who had an extra education step. It could be that too much education delivered in a short period of time did not add knowledge. Rather, it might have decreased patients’ focus and attention on education. Cultural norms and expectations may have also played a role in patients’ ability to translate education into usual care at home. For example, attitudes about personal hygiene, self-image, and modesty could have affected patients’ ability to retain information learned and, more importantly, carry out HPN procedures as instructed.10 From a process and systems perspective, education depth and breadth by trained NST nurses and resources used in delivering education (eg, the written instruction manual) could have been superior in the usual care group, preventing the intervention from having an additional effect. It was surprising that the usual care plus VOIPP group had more patient calls to clinicians for advice, since investigators hypothesized that VOIPP would lead to less need for advice. More calls for catheter care advice might be a surrogate for education attentiveness or for a desire to optimize catheter care skills. The usual care group may have relied on the
written instruction manual to answer questions about catheter care, and the usual care plus VOIPP group might have relied on the visual and voice cues from real people and repetition in messages about calling HPN clinicians for suspected complications. In signaling theory, repetition frequency is a cue for judgments about a message.16 Although most research for signaling theory and repetition involved advertising messages, repetition influenced perceptions of quality.17 Patients may have been more likely to contact clinicians if they believed the repeated messages about contacting the HPN clinician were important. Furthermore, the repeated messages may have increased patient confidence in making phone calls. Alternately, exposure to education content via DVD education might have led to new questions about catheter care. In this study, investigators did not ask participants to provide education format preference. It might be that VOIPP captured the attention of patients in a different manner and stimulated questions. A trend in benefit in the usual care plus VOIPP group in CRBSI, all-cause readmission, and CRBSI-related readmission compared with the usual care education group could have been due to self-care actions carried out by real people, visual cues, and repeated messages patients received via the VOIPP presentation. Although nonsignificant in this small study, when a VOIPP contains the features of live action, visual cues, and repeated messages, patients might have a heightened awareness of the potential for CRBSI and be prompted to carry out catheter care behaviors in a way that lowers complications and rehospitalization rates. Further research, using a randomized controlled study design and a large multicenter sample, is needed to determine if CRBSI, all-cause readmission, and CRBSI-related readmission can be reduced when using this simple education strategy.
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Limitations There are a few limitations of this research. It was a singlecenter study and had a small sample size. Not all enrolled patients provided full study data. No assessment was made to determine if those who did not complete research processes had the same characteristics of those who completed all research processes. The knowledge questionnaire was administered 2 times in a short period, and although answers were not reviewed with patients, content was provided in both usual care education and by VOIPP. Sensitization to questionnaire content could be a threat to internal validity, and external validity was threatened by administering both a preand posttest. Obtaining longer term follow-up at 90 days would have minimized threats to internal and external validity. The intervention was a bundled intervention that included usual care education, usual care plus VOIPP education, and receiving DVD education materials. It may be that usual care plus VOIPP (on DVD) alone would have been sufficient to achieve goals. Also, results might have differed if more usual care plus VOIPP patients chose to view the DVD postdischarge. The usual care and intervention groups could have been too similar (they both included verbal education and receiving an HPN instruction manual). A novel education intervention or use of VOIPP with a different format or teaching style might have a greater effect size and lead to greater differences between groups.
Conclusions Usual care and usual care plus VOIPP education had similar results, reflecting that the intervention provided adequate education. It is unknown if VOIPP or DVD alone would provide similar results. Patient calls to HPN clinicians were higher in the usual care plus VOIPP group and may have been due to repeated VOIPP messages to contact the HPN clinician for suspected complications. Trends of fewer CRBSI and allcause rehospitalizations among usual care plus VOIPP patients need to be confirmed in a more robust multicenter sample of patients.
Acknowledgments We acknowledge Mandy L. Corrigan, MPH, RD, LD, CNSC, and Kristen Roberts, PhD, LD, RD, for their support of this study and assistance in study conduct.
Statement of Authorship D. Emery, C. Hamilton, and N. M. Albert contributed to the conception/design of the research; A. Pearson and R. Lopez contributed to the design of the research; R. Lopez contributed to the analysis of the data; C. Hamilton and N. M. Albert contributed to the interpretation of the data; D. Emery and A. Pearson contributed
to the acquisition, analysis, and interpretation of the data; D. Emery, A. Pearson, and N. M. Albert drafted the manuscript. All authors critically revised the manuscript, agree to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript.
References 1. Jeppesen PB. Spectrum of short bowel syndrome in adults: intestinal insufficiency to intestinal failure. JPEN J Parenter Enteral Nutr. 2014;38(1) (suppl):8S-13S. 2. Shatnawei A, Habib M, Hamilton C, et al. The association between home parenteral nutrition and patients with FAP-associated intra-abdominal desmoids: a retrospective study. JPEN J Parenter Enteral Nutr. 2013;37: 683-688. 3. Rhoda KM, Suryadevara S, Steiger E. Home parenteral nutrition support for intestinal failure. Surg Clin North Am. 2011;91:913-932. 4. Staun M, Pironi L, Bozzetti F, et al. ESPEN guidelines on parenteral nutrition: home parenteral nutrition (HPN) in adult patients. Clin Nutr. 2009;28:467-479. 5. Gillanders L, Angstmann K, Ball P, et al. AuSPEN clinical practice guideline for home parenteral nutrition patients in Australia and New Zealand. Nutrition. 2008;24:998-1012. 6. Kumpf VJ, Tillman EM. Home parenteral nutrition: safe transition from hospital to home. Nutr Clin Pract. 2012;27:749-757. 7. Smith CE, Curtas S, Kleinbeck SV, et al. Clinical trial of interactive and videotaped educational interventions reduce infection, reactive depression, and rehospitalizations for sepsis in patients on home parenteral nutrition. JPEN J Parenter Enteral Nutr. 2003;27:137-145. 8. Miller DL, O’Grady NP; Society of Interventional Radiology. Guidelines for the prevention of intravascular catheter-related infections: recommendations relevant to interventional radiology for venous catheter placement and maintenance. J Vasc Interv Radiol. 2012;23:997-1007. 9. Moller T, Borregaard N, Tvede M, Adamsen L. Patient education—a strategy for prevention of infections caused by permanent central venous catheters in patients with haematological malignancies: a randomized clinical trial. J Hosp Infect. 2005;61:330-341. 10. Gifford H, Delegge M, Epperson LA. Education methods and techniques for training home parenteral nutrition patients. Nutr Clin Pract. 2010;25:443-450. 11. Fitzgerald SA, Macan Yadrich D, Werkowitch M, Piamjariyakul U, Smith CE. Creating patient and family education web sites: design and content of the home parenteral nutrition family caregivers web site. Comput Inform Nurs. 2011;29:637-645. 12. Lynn MR. Determination and quantification of content validity. Nurs Res. 1986;35:382-385. 13. Gysels M, Higginson IJ. Interactive technologies and videotapes for patient education in cancer care: systematic review and meta-analysis of randomised trials. Support Care Cancer. 2007;15:7-20. 14. Ciciriello S, Johnston RV, Osborne RH, et al. Multimedia educational interventions for consumers about prescribed and over-the-counter medications. Cochrane Database Syst Rev. 2013;4:CD008416. 15. Abu Abed M, Himmel W, Vormfelde S, Koschack J. Video-assisted patient education to modify behavior: a systematic review. Patient Educ Couns. 2014;97:16-22. 16. Magloff L. Repetition as an advertisement technique. Chron.com. Businesshttp://smallbusiness.chron.com/repetition-advertisement-technique-24437.html. Accessed August 12, 2014. 17. Moorthy S, Hawkins SA. Advertising repetition and quality perception. J Business Res. 2005;58:354-360.
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research-article2015
NCPXXX10.1177/0884533615584391Nutrition in Clinical PracticeEmery et al
Clinical Research
Voiceover Interactive PowerPoint Catheter Care Education for Home Parenteral Nutrition
Nutrition in Clinical Practice Volume XX Number X Month 201X 1–6 © 2015 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533615584391 ncp.sagepub.com hosted at online.sagepub.com
Dorothy Emery, ADN, RN1; Annette Pearson, BSN, RN1; Rocio Lopez, MS2; Cindy Hamilton, MS, RD, LD1; and Nancy M. Albert, PhD, RN, CCNS, CCRN3
Abstract Background: In home infusions via tunneled catheter/peripherally inserted central catheter (TC/PICC) the risk of catheter-related bloodstream infection (CRBSI) and complications contribute to rehospitalization and costs. It is unknown if voiceover interactive PowerPoint (VOIPP) via digital video disc education improves clinical outcomes. Materials and Methods: In a quaternary care medical center and using a randomized, controlled, 2-group design, hospitalized patients with TC/PICC received usual care education or usual care (UC) plus VOIPP education prehospital discharge. A multiple-choice 6-item knowledge questionnaire was administered preeducation, immediately posteducation, and 7–10 days postdischarge. At 90 days, patients were assessed for CRBSI incidence rates per 1000 catheterdays, rehospitalization, CRBSI-related hospitalization, non-CRBSI complications and patient calls to the home parenteral nutrition (HPN) clinicians. Analysis of variance, Pearson χ2, and Kruskal-Wallis test were used to compare results between groups. Results: Of 51 patients (UC, n = 27; UC+VOIPP, n = 24), mean ± SD age was 46.3 ± 14.3 years, 68.6% were female, HPN duration was 2.2 ± 1.01 months, and time to postdischarge test completion was 11.5 ± 5.2 days. There were no baseline differences between groups. Between-group knowledge and changes in knowledge were similar at preeducation, immediate posteducation, and postdischarge (P = .88, 0.30, and 0.37, respectively). There were no differences in CRBSI incidence, rehospitalization, CRBSI-related rehospitalization rates, and non-CRBSI complications between groups. The UC+VOIPP group had more patient calls than did the UC group (21.8 vs 7.7 calls/1000 catheter-days, P < .001). Conclusion: Recorded education led to more patient calls to the HPN clinicians; however, there were no differences between groups in other outcomes. (Nutr Clin Pract. XXXX;xx:xx-xx)
Keywords nutritional support; home parenteral nutrition; home infusion therapy; patient education; central venous catheters; infection
Background Home parenteral nutrition (HPN) allows patients with intestinal failure to maintain an adequate nutrition status in an outpatient setting.1–5 Patients who require HPN have complex care needs requiring ongoing communication and collaboration between inpatient and outpatient clinicians to minimize complications.6 However, complications have been reported. The most frequent complication (75%) was catheter-related bloodstream infections (CRBSIs).7 Catheter complications (lowgrade fever to sepsis)8 account for a major cause of rehospitalizations and costs. The most effective method for the prevention of CRBSI is patient education9 that involves strict adherence to hand hygiene and aseptic techniques.8 In research, interactive educational interventions using videos reduced infective complications.7 Patient and family education is an essential component of predischarge preparation for patients with HPN. Education includes increasing patient and family knowledge about complications.4–6,10,11 It is unknown if technology associated with Microsoft (Redmond, WA) PowerPoint (PP) presentation can be used to educate patients about HPN catheter care. Nutrition support team (NST) nurses are responsible for teaching patients
about catheter care prior to discharge. In-room education involved receiving 2–3 didactic lessons on catheter care and home self-monitoring. Patients received a catheter care manual and a television video on home self-monitoring was also available. An effective tool that could streamline catheter care education, enhance patient knowledge, and decrease serious catheter associated complications is warranted. The purpose of this research study was to determine the clinical effects of an educational voiceover interactive PowerPoint (VOIPP) and usual care education vs usual care education alone in patients with a tunneled catheter or peripherally inserted central catheter (TC/PICC) who required From the 1Center for Human Nutrition, Digestive Disease Institute; 2 Quantitative Health Sciences; and 3Nursing Institute, Office of Research and Innovation, Cleveland Clinic, Cleveland, Ohio. Financial disclosure: None declared. Corresponding Author: Dorothy Emery, ADN, RN, Center for Human Nutrition, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave, Mail Code TT-204, Cleveland, OH 44195, USA. Email: [email protected]
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catheter care education in preparation for hospital discharge to home. The specific aims of this study were to determine if there were differences in clinical outcomes between VOIPP and usual care education vs usual care education alone in catheter care knowledge, CRBSI incidence, 90-day all-cause rehospitalization rate, CRBSI-related rehospitalization rate, non-CRBSI complications, and number of patient calls.
Methods This research was a prospective, randomized, controlled pilot study. The institutional review board approved this study prior to initiation, and all procedures met the ethical standards of the institutional review board.
Setting and Sample The research was conducted in a 1200-bed quaternary care medical center in northeast Ohio. The center’s NST consists of multidisciplinary care providers, including nurses and dietitians. The NST services all hospitalized patients who receive parenteral nutrition (PN). Hospitalized patients with a TC/PICC who were scheduled for hospital discharge on home parenteral nutrition (HPN) were eligible for enrollment. Inclusion criteria were that patients had not been receiving HPN in the past 6 months, were expected to be discharged home, were able (or caregivers were able) to demonstrate safe management of HPN catheter care procedures, had a DVD player, and had a catheter inserted during the hospital episode. Exclusion criteria were discharge to a facility other than home (ie, skilled nursing facility, extended care facility, subacute facility, long-term acute care, or hospice care), receiving hospice care at home, or in an acute or chronic delusional or confused state.
presentation content was 25 (PICC) to 30 (tunneled catheter) minutes in length and contained audio and visual information on catheter care and when to contact HPN clinicians for advice. A practice presentation format was used that showed real people completing catheter care behaviors, including hand washing, changing a TC dressing, changing an end connector, and securing a catheter. Patients received a DVD of the VOIPP presentation to take home and rewatch. Patients were instructed to view the DVD within 7–10 days of hospital discharge.
Outcomes and Measurement Catheter care knowledge was assessed using an investigatordeveloped 6-item knowledge questionnaire that had a 4-option, multiple-choice response set. Themes of each question were as follows: proper length of time to clean the end connector; proper length of time to wash hands before initiating PN procedures; preferred solution to clean work surfaces; the first step to take when a crack or hole is found in a catheter; of 4 situations, which one does not require notification of the HPN service; and which step is important in preventing accidental removal of the catheter. Scores ranged from 1–6, and higher scores reflected better knowledge. Content validity was assessed by 8 clinical experts in nutrition and catheter care for HPN. Using the Lynn method,12 the content validity index was 1.0, reflecting strong content validity at a P < .05 level. The incidence of CRBSI was assessed from data retrieved from an HPN database on CRBSI incidence. Database data collectors used medical record review and postdischarge patient communication to obtain data on all patients with tunneled catheters and PICCs. Data on 90-day allcause rehospitalization, CRBSI-related rehospitalization, nonCRBSI complications, and number of patient calls to clinicians were retrieved from the HPN database.
Data Collection
Intervention Usual care and intervention education was delivered by 2 registered nurse (RN) members of the NST. Usual care education was completed 48–72 hours prior to home discharge. Education consisted of a one-on-one nurse-led, predischarge-delivered lesson on HPN catheter care, potential complications of HPN, and monitoring for potential complications. The lesson also included catheter care and maintenance involving dressing changes for TC and an assessment of the PICC insertion site. Education was delivered verbally. Patients received a written instruction manual. Patients had an opportunity to return demonstration of changing dressings (tunneled catheters only), flushing catheters, changing end connectors, and emergency clamping using a 3-dimensional model of a chest, neck, and arm. Patients were instructed to contact HPN clinicians for complications or advice. Intervention education consisted of all usual care education and viewing of VOIPP on a laptop computer. The VOIPP
After verbal informed consent, patients were randomly assigned to an education group. Tunneled catheter and PICC knowledge were assessed preintervention and immediately postintervention by 2 NST nurses. The baseline knowledge test (before education or usual care) and first posttest (immediately after education or usual care) were completed by pen and paper in the hospital. Knowledge was assessed by telephone at 7–10 days postdischarge by HPN clinicians who were not blinded to the study group. At the follow-up phone calls, 3 additional questions were asked of patients randomized to the usual care plus VOIPP group to assess if they viewed the DVD (yes/no), number of times the DVD was viewed, and number of days since discharge before the DVD was viewed.
Statistical Analysis Data are presented as mean ± standard deviation or number (%). Univariable analysis was performed to assess differences
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Table 1. Patient Characteristics. Factor Age, mean ± SD, y Female sex, No. (%) HPN duration, mean ± SD, mo Catheter type, No. (%) PICC Hickman Lumens (number), No. (%) 1 2
Overall (n = 51)
Usual Care Education (n = 27)
VOIPP Education (n = 24)
46.3 ± 14.3 35 (68.6) 2.2 ± 1.01
44.4 ± 14.0 18 (66.7) 2.1 ± 1.08
48.4 ± 14.6 17 (70.8) 2.4 ± 0.90
14 (27.5) 37 (72.5)
11 (40.7) 16 (59.3)
3 (12.5) 21 (87.5)
36 (70.6) 15 (29.4)
16 (59.3) 11 (40.7)
20 (83.3) 4 (16.7)
P Value .33a .75b .16a .024b .060b
HPN, home parenteral nutrition; PICC, peripherally inserted central catheter; SD, standard deviation; VOIPP, voiceover interactive PowerPoint. a Analysis of variance. b Pearson χ2 test.
Table 2. Knowledge Test Scores Preeducation, Immediate Posteducation, and Delayed Posteducation. Mean ± SD Test Score Preeducation test score Immediate posteducation 7–10 Days posteducation
Overall (n = 51)
Usual Care Education (n = 27)
4.4 ± 0.96 5.6 ± 0.96 5.4 ± 1.4
4.3 ± 1.1 5.8 ± 0.58 5.5 ± 0.78
VOIPP Education (n = 24) 4.4 ± 0.77 5.5 ± 1.3 5.2 ± 1.9
P Valuea .88 .30 .37
SD, standard deviation; VOIPP, voiceover interactive PowerPoint. a Analysis of variance.
between the 2 groups; analysis of variance (ANOVA) was used to compare continuous variables, Kruskal-Wallis tests were used for ordinal factors, and Pearson χ2 tests were used for categorical data. The CRBSI incidence rates, all-cause readmission, CRBSIrelated readmission, non-CRBSI complications, and patient call rates/per 1000 catheter-days were estimated for each group by dividing the number of observed events by the total number of catheter days contributed by each group. The difference in incidence rates between the groups and corresponding 95% confidence interval are reported. A P < .05 was considered statistically significant. SAS (version 9.2; SAS Institute, Cary, NC) and R (version 3.0.1; The R Foundation for Statistical Computing, Vienna, Austria) were used for all analyses.
Results In total, 51 patients were randomized to receive usual care (n = 27) or usual care plus VOIPP (n = 24). Medical diagnoses varied; the most frequent were Crohn’s disease or ulcerative colitis (29.4%), different cancers (17.6%), and obesity (9.8%). Reasons for HPN also varied; the most frequent were postoperative ileus and other obstructions (39.2%), intestinal fistulas (23.6%), and malabsorption (23.5%). Mean ± SD patient age was 46.3 ± 14.3 years, and 68.6% were female. Mean ± SD
HPN duration was 2.2 ± 1.0 months. Usual care plus VOIPP patients were more likely to have Hickman catheters than those in the usual care education group (88% vs 59%; P = .024; see Table 1). Overall, 8 of 24 patients (mean ± SD frequency, 33.3% ± 48.1%) viewed the DVD at home. Of the 8 patients who viewed the DVD, mean ± SD time to viewing it was 4.25 ± 4.3 days, and only 2 patients (mean ± SD, 1.25 ± .46) watched it more than one time.
Knowledge Scores Between Groups Of patients, knowledge scores about HPN catheter care were lowest at baseline, and both the usual care and intervention groups had similar scores. Knowledge increased immediately after education in a similar manner in both groups. Furthermore, at 7–10 days after hospital discharge, there were no between-group differences in knowledge scores (see Table 2).
Clinical Outcomes at 90 Days Numerically, there were more CRBSIs, hospital readmissions, and CRBSI-related hospital readmissions in the usual care education group than in the usual care plus VOIPP
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Table 3. Clinical Outcomes. Factor CRBSI, No. (%) All-cause readmissions, No. (%) All-cause readmission (occurrences), No. (%) 0 1 2 3 CRBSI-related readmission, No. (%) Non-CRBSI complications, No. (%) Non-CRBSI complications, occurrences, No. (%) 0 1 2 3 No. of patients who initiated calls, No. (%) Number of calls received, mean ± SD
Overall (n = 51)
Usual Care Education (n = 27)
VOIPP Education (n = 24)
5 (9.8) 23 (45.1)
4 (14.8) 14 (51.9)
1 (4.2) 9 (37.5)
28 (54.9) 14 (27.5) 8 (15.7) 1 (2.0) 5 (9.8) 17 (38.6)
13 (48.1) 9 (33.3) 4 (14.8) 1 (3.7) 4 (14.8) 8 (34.8)
15 (62.5) 5 (20.8) 4 (16.7) 0 (0.0) 1 (4.2) 9 (42.9)
27 (61.4) 13 (29.5) 2 (4.5) 2 (4.5) 17 (33.3)
15 (65.2) 7 (30.4) 1 (4.3) 0 (0.0) 9 (33.3) .48 (0.75)
12 (57.1) 6 (28.6) 1 (4.8) 2 (9.5) 8 (33.3) 1.6 (3.0)
P Value .35a .30a .37b .35a .58a .45b .99a .57b
CRBSI, catheter-related bloodstream infection; SD, standard deviation; VOIPP, voiceover interactive PowerPoint. a Pearson χ2 test. b Kruskal-Wallis test.
usual care plus VOIPP patients made calls about the catheter itself to HPN clinicians. Rationale for all phone calls is provided in Table 4.
Discussion
Figure 1. Clinical outcomes between usual care (n = 27) and usual care plus voiceover interactive PowerPoint (VOIPP) (n = 24) groups. CRBSI, catheter-related bloodstream infection.
group; however, there were no statistically significant differences between groups (all 3, P = .16). Non-CRBSI complications, such as intake and output issues, PN formula or other medication issues, and weight or diet changes, were similar between groups. The usual care plus VOIPP group had more patient calls (21.8 calls/1000 catheter-days) compared with the usual care group (7.7 calls/1000 catheterdays, P < .001; Table 3 and Figure 1). Numerically, more
In this pilot study that compared usual care education and usual care plus VOIPP education to engage and educate patients with HPN, there was no superiority in patient knowledge or in 90-day clinical outcomes (all-cause readmission, CRBSIs, CRBSI readmission, non-CRBSI complications). Not all education technologies provide superiority. In a meta-analysis of 9 randomized controlled trials, instruments and technologies differed, but researchers found small effect sizes and equivocal effect sizes when satisfaction was studied.13 In a systematic review of multimedia educational interventions to inform consumers about over-the-counter medications, there were no differences in outcomes based on education interventions used.14 Finally, in a systematic review that focused on video-assisted education, some of which were a practice presentation format similar to VOIPP, not all were effective in achieving clinical outcomes.15 Only one-third of this study’s usual care plus VOIPP group reviewed the DVD at home. It is unknown if results would have differed if more patients chose to review education content after hospital discharge. Ultimately, it might be important to deliver education content through multiple strategies, thereby allowing patients to learn and retain knowledge from different styles in a way that optimizes clinical practices.
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Table 4. Themes of Patient-Initiated Phone Calls to Home Parenteral Nutrition Clinicians.a Theme Catheter itself (eg, site problem; occlusion or break in the catheter; dressing problem) Intake, output, weight, swelling, diarrhea, vomiting, dizziness, nausea Parenteral nutrition formula, medications, diet changes Serum laboratory work; general, blood cultures, and glucose Fever, shakes, chills, coughing Shortness of breath Pump issues Dental J-tube issue Outside hospital admission General question Urinary tract infection symptoms
Usual Care Education (n = 27), No. (%)
VOIPP Education (n = 24), No. (%)
9 (33)
27 (112)
11 (40) 8 (30) 2 (7) 11 (40) 0 5 (18) 0 0 0 0 1 (3)
19 (79) 5 (21) 5 (21) 3 (12) 3 (12) 2 (8) 2 (8) 1 (4) 1 (4) 1 (1) 0
VOIPP, voiceover interactive PowerPoint via digital video disc. a Totals do not equal 100% as individual patients could have made multiple calls and/or had more than one discussion themes.
In HPN guidelines,4,5 patient education is expected and may involve computers, computer discs/DVDs, print materials, demonstration, and verbal instructions.10 Although participants in this study received teaching strategies previously shown to be effective, there might have been patient, process, and system factors that prevented the intervention from achieving superiority over usual care education. For both groups, patient factors could have included lack of adherence to expected hand-washing behaviors and variation in handwashing techniques used. Furthermore, participants were young and appeared cognitively intact; however, their ability to remember the totality of education delivered could have been overwhelming, especially for the usual care plus VOIPP education group who had an extra education step. It could be that too much education delivered in a short period of time did not add knowledge. Rather, it might have decreased patients’ focus and attention on education. Cultural norms and expectations may have also played a role in patients’ ability to translate education into usual care at home. For example, attitudes about personal hygiene, self-image, and modesty could have affected patients’ ability to retain information learned and, more importantly, carry out HPN procedures as instructed.10 From a process and systems perspective, education depth and breadth by trained NST nurses and resources used in delivering education (eg, the written instruction manual) could have been superior in the usual care group, preventing the intervention from having an additional effect. It was surprising that the usual care plus VOIPP group had more patient calls to clinicians for advice, since investigators hypothesized that VOIPP would lead to less need for advice. More calls for catheter care advice might be a surrogate for education attentiveness or for a desire to optimize catheter care skills. The usual care group may have relied on the
written instruction manual to answer questions about catheter care, and the usual care plus VOIPP group might have relied on the visual and voice cues from real people and repetition in messages about calling HPN clinicians for suspected complications. In signaling theory, repetition frequency is a cue for judgments about a message.16 Although most research for signaling theory and repetition involved advertising messages, repetition influenced perceptions of quality.17 Patients may have been more likely to contact clinicians if they believed the repeated messages about contacting the HPN clinician were important. Furthermore, the repeated messages may have increased patient confidence in making phone calls. Alternately, exposure to education content via DVD education might have led to new questions about catheter care. In this study, investigators did not ask participants to provide education format preference. It might be that VOIPP captured the attention of patients in a different manner and stimulated questions. A trend in benefit in the usual care plus VOIPP group in CRBSI, all-cause readmission, and CRBSI-related readmission compared with the usual care education group could have been due to self-care actions carried out by real people, visual cues, and repeated messages patients received via the VOIPP presentation. Although nonsignificant in this small study, when a VOIPP contains the features of live action, visual cues, and repeated messages, patients might have a heightened awareness of the potential for CRBSI and be prompted to carry out catheter care behaviors in a way that lowers complications and rehospitalization rates. Further research, using a randomized controlled study design and a large multicenter sample, is needed to determine if CRBSI, all-cause readmission, and CRBSI-related readmission can be reduced when using this simple education strategy.
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Limitations There are a few limitations of this research. It was a singlecenter study and had a small sample size. Not all enrolled patients provided full study data. No assessment was made to determine if those who did not complete research processes had the same characteristics of those who completed all research processes. The knowledge questionnaire was administered 2 times in a short period, and although answers were not reviewed with patients, content was provided in both usual care education and by VOIPP. Sensitization to questionnaire content could be a threat to internal validity, and external validity was threatened by administering both a preand posttest. Obtaining longer term follow-up at 90 days would have minimized threats to internal and external validity. The intervention was a bundled intervention that included usual care education, usual care plus VOIPP education, and receiving DVD education materials. It may be that usual care plus VOIPP (on DVD) alone would have been sufficient to achieve goals. Also, results might have differed if more usual care plus VOIPP patients chose to view the DVD postdischarge. The usual care and intervention groups could have been too similar (they both included verbal education and receiving an HPN instruction manual). A novel education intervention or use of VOIPP with a different format or teaching style might have a greater effect size and lead to greater differences between groups.
Conclusions Usual care and usual care plus VOIPP education had similar results, reflecting that the intervention provided adequate education. It is unknown if VOIPP or DVD alone would provide similar results. Patient calls to HPN clinicians were higher in the usual care plus VOIPP group and may have been due to repeated VOIPP messages to contact the HPN clinician for suspected complications. Trends of fewer CRBSI and allcause rehospitalizations among usual care plus VOIPP patients need to be confirmed in a more robust multicenter sample of patients.
Acknowledgments We acknowledge Mandy L. Corrigan, MPH, RD, LD, CNSC, and Kristen Roberts, PhD, LD, RD, for their support of this study and assistance in study conduct.
Statement of Authorship D. Emery, C. Hamilton, and N. M. Albert contributed to the conception/design of the research; A. Pearson and R. Lopez contributed to the design of the research; R. Lopez contributed to the analysis of the data; C. Hamilton and N. M. Albert contributed to the interpretation of the data; D. Emery and A. Pearson contributed
to the acquisition, analysis, and interpretation of the data; D. Emery, A. Pearson, and N. M. Albert drafted the manuscript. All authors critically revised the manuscript, agree to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript.
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