Optimizing the Effectiveness of Preoperative Education Part 1

Optimizing the Effectiveness of Preoperative Education Part 1
Dr. Luke Pedersen, PT, DPT, CSCS

It seems logical that preoperative education (PE) can have numerous benefits for patients and healthcare providers, and in many instances, it has been accepted as a vital part of clinical best practice. Yet, when you analyze the research, it becomes clear that these benefits are not definitive. There is no consensus in the literature regarding the benefits, or lack thereof, of PE.

Part of the problem is the heterogeneity of the PE provided. Differences include what information is provided, how it’s provided, when it’s provided, and who provides it. Additionally, patients receiving different surgeries or procedures and different patient populations require different types of PE and will be impacted differently by the education they receive.

Current trends in healthcare emphasize quality care that is appropriate and effective. It also emphasizes care that is efficient and focuses on patient engagement and empowerment. PE utilizes financial resources and staff’s time. If PE is to be a standard of clinical best practice and provide its full capacity of benefits, it’s imperative that hospitals and health systems determine optimal PE strategies and put these strategies into practice.

(Author’s note: I have tried to provide citations at least where most important, but by no means do I believe this article to have fully formatted and completely correct citations. I also fully understand that this article has not endured the rigors of formal peer-review. I merely hope to provide my synthesis of the numerous articles I have reviewed. Each article I cited in the references has contributed in some way, big or small, to my thoughts and conclusions.)

Characteristics of Preoperative Educations
Goals

Preoperative education can be defined as any educational intervention delivered before surgery that aims to improve people’s knowledge, health behaviors, and health outcomes (1). Here are the main goals of most PE programs. Further down, we’ll see how effective PE is at achieving these goals.

Provide adequate information regarding the entire surgical process including preoperative procedures, perioperative procedures, details of the actual surgery, and postoperative procedures including the hospital stay and rehab process

• Help patients know what to expect the day of surgery and while in the hospital
• Allow patients to meet the medical team and individuals that will work with them in the hospital
• Set realistic expectations and unify patient and surgeon expectations.
• Reduce pre-op anxieties, stresses, and fears.
• Maximize patients’ engagement in pre-op preparation
• Maximize patients’ confidence, motivation, and self-efficacy
• Address patients’ questions and concerns
• Maximize patient satisfaction
• Reduce medical costs via shorter hospital stays, increased chance of discharge directly home (instead of a rehab facility), and/or shorter course of post-op rehab
• Reduce the rate of post-op complications
• Reduce post-op pain levels, improve pain management, and reduce the utilization of pain medications

(References: 1, 2, 3, 4, 5, 6, 7, 8)

Delivery Methods
There are multiple means of delivering PE and the effectiveness of each method depends on a number of factors. Broadly speaking, PE can be divided into verbal, written, and audiovisual. Verbal delivery usually consists of group classes, small group discussions, or one-on-one education sessions. Written materials include instructional booklets, pamphlets, and other handouts. Audiovisual materials include video and audio delivered via different methods (online, CD, DVD, other software).

A relatively new method of PE delivery is via technology. This form of PE is delivered through a website, app, or other software that utilizes multimedia to educate patients. Online resources can include text, images, video, audio, and graphics to provide education. Resources can be interactive by answering and asking questions or by using graphics and images that can be moved and manipulated.

Content

The content varies widely between different PE programs, and what content is included or excluded may play a significant role in the effectiveness of a PE program, as will be discussed. Here is an overview of the different content covered in PE programs. (Realize that each PE program does not cover each of these topics in-depth as it would not be practical or effective):

• Aspects of pre-op and pre-admission procedures and preparation
• Aspects of perioperative treatment and specifics of the actual surgical procedure
• Discussion of anatomy including normal anatomy and pathoanatomy (e.g. arthritic knee or hip)
• What to expect during the hospital stay
• Aspects of rehab, rehab exercises, and post-op recovery
• Importance of mobility and improving post-op range of motion
• Post-op restrictions and precautions (e.g. hip precautions)
• Possible complications
• Aspects of anesthesia
• Use of pain medicine and nonpharmacological pain management strategies
• Pain neuroscience education
• Perspectives and advice from past patients
• Sensory and emotional information regarding what to expect after surgery
• Possible post-op experiences and dealing with stressful situations associated with surgery
• General reassurance and support
• Coping strategies such as cognitive-behavioral therapy, relaxation, hypnosis, and mental rehearsal
• Discussion and use of anatomical models, joint prosthetics (knee and hip replacements)
• Demonstration of exercises and specific skills (e.g. use of assistive device, transfers)
• Introduction to the medical support staff and their roles
• Tour of aspects of the hospital facility and where they’ll be staying
• Answering questions and addressing concerns

Other Logistics

Timing: The literature shows significant variability in terms of when PE is delivered. Timing varies between the day before surgery to within 6 months before surgery. The majority of literature focuses on a couple weeks before surgery in the range of 2-6 weeks pre-op.

Duration: This also varies greatly. The literature shows durations ranging from a 12-minute video to a 4 hour class. The majority of classes or individual sessions range from approximately 30 min to 90 minutes in duration. Of course, for written and online modes of education it’s difficult to determine the amount of time patients spend utilizing these resources prior to surgery.

Instructor: Often, the classes and individual sessions were provided by nurses, physical therapists, occupational therapists, or physicians/surgeons. Other professionals who provide PE include psychologists, psychiatrists, rheumatologists, anesthetists, case coordinators, or an interdisciplinary team of multiple professionals.

(References: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14)

References

1. McDonald, Steve, et al. "Preoperative education for hip or knee replacement." Cochrane Database of Systematic Reviews 5 (2014).
2. Jordan, R. W., et al. "Enhanced education and physiotherapy before knee replacement; is it worth it? A systematic review." Physiotherapy 100.4 (2014): 305-312.
3. Louw, Adriaan, et al. "Preoperative education addressing postoperative pain in total joint arthroplasty: review of content and educational delivery methods." Physiotherapy theory and practice 29.3 (2013): 175-194.
4. Johansson, Kirsi, et al. "Preoperative education for orthopaedic patients: systematic review." Journal of advanced nursing 50.2 (2005): 212-223.
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6. Papanastassiou, Ioannis, et al. "Effects of preoperative education on spinal surgery patients." SAS journal 5.4 (2011): 120-124.
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8. Ronco, Monica, et al. "Patient education outcomes in surgery: a systematic review from 2004 to 2010." International Journal of Evidence‐Based Healthcare 10.4 (2012): 309-323.
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