Total Joint Arthroplasty Patient Education:What Should Be Taught and When? Jack Davis, MSN, RN, ONC Manager, Patient Education Programs Hospital for Special Surgery Conflict of Interest No financial affiliation with products discussed Current role as Manager, Patient Education Programs for Hospital for Special Surgery (HSS) influences my views on the subject on which I am presenting Objectives Identify 3 educational topics that focus on setting realistic expectations Manage self-care Manage pain Prevent complications Discuss 3 teaching strategies that facilitate understanding across the continuum Written materials Classroom instruction Multimedia tools 1
Poll Question How are your arthroplasty patients taught? 1. Pre-op education class 2. Video instruction 3. One-on-one session 4. Combined approach 5. Other Health Education Health education is designed to assist individuals to make informed decisions and take action that positively affects their health outcome (Simonds, 1971). Would You Agree? Patient education is critical to helping patients successfully cope with and recover from illness and injury (arthroplasty surgery) 2
Some Evidence to Support Pre-op Patient Education Reduced anxiety Greater satisfaction Patients more prepared for surgery Improved ability to control pain (Kearney, Jennrich, Lyons, Robinson, & Berger, 2011) Patient Education Framework Provide health information Facilitate knowledge & understanding Engage patients to take an active role in care management Effect physical and mental health outcomes Patient Education is more than just having the nurse review discharge instructions prior to leaving the hospital, it is a means for the nurse to assist the patient in the enhancement and expansion of his ability to provide effective self-care (Bastable, 2006). 3
Self-management Model used in chronic disease (OA) Problem solving and decision making Patients engage in daily process to manage own care Use family, health team & community to manage consequences of health conditions (Richard & Shea, 2011) A Challenge Research shows that patients remember and understand less than half of what clinicians explain to them. (Ley, 1988) Barriers to Learning Patient health status Medications Anxiety Teaching environment Learning styles 4
Individual Learning & Retention 10% of what is read 26% of what is heard 30% of what is seen 50% of what is seen & heard 70% of what they say 90% of what they say as they do something (Felder & Silverman, 2002) Competency Commitment Nurses Need Effective Tools Time A way to check that the intervention is effective Teach-back is Asking patients to repeat in their own words what they need to know or do, in a non-shaming way. NOT a test of the patient, but of how well you explained a concept. A chance to check for understanding and, if necessary, re-teach the information. 5
Teach-back is Evidence-based Asking that patients recall and restate what they have been told is one of 11 top patient safety practices based on the strength of scientific evidence. (AHRQ, 2001 Report, Making Health Care Safer) Poll Question Do you use the Teach back technique 1. Never 2. Sometimes 3. Routinely Even if Teaching is Good, Will It Influence Behavior? Education occurs if learning takes place with a resultant change in behavior, skill or attitude. (Falvo, 1994) 6
What Do Arthroplasty Patients Need to Learn? Hospital processes? JCO & other safety initiatives? Detailed surgery and treatment plans? General vs specific knowledge? Nurses Should Understand Learning Principles Active involvement Readiness to learn Conducive environment Perceived relevance Repetition General info Pleasant experience Begin with known topics & move to unknown Present at appropriate rate (DeYoung, 2009) Poll Question How long does your pre-op class take? 1. Less than 30 minutes 2. 30 to 60 minutes 3. 60 to 90 minutes 4. Greater than 90 minutes 7
Are We Teaching at the Right Time? Before surgery Access to information after consults? During the hospital stay when taking medications? Reminders sent after discharge? Across all transitions of care? Orthopaedic Transitions Out Patient office consult Operating Room Post op follow up Primary care Internist Anesthesia Other Consultant Surgical Service Medical Service Post Surgery Pre Surgery PACU In-patient Home Rehab Patient Education Admission Nutrition Holding Teaching Across Transitions Involves multiple caregivers Communication Interdisciplinary services Promotes safety 8
Navigating Transitions Avoidable readmissions and reimbursement? Target discharge instructions Meds, diet & who to follow-up with Post op calls Web-based patient portal Optimal time to teach? Poll Question Is anyone involved in meaningful use initiatives? Yes No Meaningful Use? The American Recovery and Reinvestment Act (ARRA) Use of Electronic Health Record (EHR) in meaningful manner EHR to exchange health info to improve quality EHR to submit quality reporting and other measures 9
EHR Benefits? Reduced paperwork Expanded access & Improved quality Prevention of medical errors Decreased costs Increased efficiencies Engagement of Pt/families in own care Case Study Example Pt education program Orthopaedic specialty institution Speaker s experience HSS Background Musculoskeletal specialty hospital est 1863 No. 1 ranking for orthopaedics Magnet recognition Academic center Research division 10
HSS Organization Overview ~205 beds ~35 OR suites ~26,000 surgical procedures/yr Adult Reconstructive Joint Replacement Service/yr ~3800 THA ~500 hip resurfacing ~3600 TKA Focus on Expectations Encourage patient/family participation in self care Promote safety Manage pain Increase mobility Prevent complications Skin, falls, infection & VTE Patient Education Conceptual Model HSS Context Information Knowledge Application: Self Management Health Behaviors Health Outcomes Individual factors 11
Patient Education Council Oversight Office practice Service lines Classroom Written Revise content Condition & process Patient Education Knowledge retention Press Ganey Outcomes Multimedia Web-based & other Interactive formats Classroom 10 arthroplasty classes/week 5 Hip, 5 Knee 10 to 15 in class 3200 3100 3000 2900 2800 2700 2600 2500 2400 2009 2010 2011 THR TKR Written Materials Reviewed by Patient Education Council THR, TKR, Spine, ACL, Arthroscopic knee, Shoulder & Pediatric conditions Coumadin therapy, Pain management, Smoking cessation, Falls prevention, Case management, Nutrition, Patient safety 12
Health Literacy the ability to read, understand, and use health information to make appropriate healthcare decisions and follow instructions for treatment AMA & AMA Foundation, 2003 Multimedia A/V classroom environment Interactive animations Understand.com HSS website Link all materials to www.hss.edu www.hss.edu Multimedia in Class 13
Evaluation of Patient Education Measurement Patient Safety Outcomes -Falls -Med errors Continuum of Care - Length of Stay - Payor reports - Transitions Patient Satisfaction Press Ganey -Information overall -Teach instructions -Care experience Self-Management -Pain Control -Patient Knowledge Teach back Discharge instructions Medication management MD follow up Patient Satisfaction In Summary: We Focus on Expectations Encourage patient/family participation in self-care Promote safety Manage pain Increase mobility Prevent complications Skin, infection & VTE 14
We Reinforce Across Transitions Pre- to Post-op With written materials In the classroom At every nurse-patient care encounter With links to the hospital website Next Steps? Develop Teach back competencies Offer live webinars to pt/family Expand EHR and Meaningful Use Implement transitional care models? Research every aspect References American Medical Association Health literacy tool kit available online at www.ama-assn.org AHRQ, 2001 Report, Making Health Care Safer Bastable, S.B. (Ed.). (2008). Nurse as educator: Principles of teaching and learning for nursing practice (3rd ed.). Burlington, MA: Jones and Bartlett DeYoung, S. (2009). Teaching Strategies for Nurse Educators. Philadelphia: Prentice Hall Falvo, D. (1994). Effective Patient Education: A guide to Increased Compliance, 2nd ed. Maryland: Aspen Publishers. Felder, R., and Silverman, L. K. (2002). Learning and Teaching Styles in Engineering Education, Engr. Education, 78(7), 674-681 (1988). Kearney, M., Jennrich, M. K., Lyons, S., Robinson, R., & Berger, B. (2011). Effects of Preoperative Education on Patient Outcomes after Joint Replacement Surgery. Orthopaaedic Nursing, 391-396. Ley, P. (1988)Communicating with Patients. London: Chapman and Hall. Richard, A, & Shea, K (2011). Delineation of self-care and associated concepts. Journal of Nursign Scholarship, 43,255-264. Simonds, S. (1971) Patient education vital, but more research needed. Geriatrics, Vol. 26, Issue 8 15
Acknowledgements Lisa Briskie, BS, RN, ONC Regina Cannon-Drake, MA, RN, ONC Patricia Quinlan, DNSc, MPA, RN, CPHQ HSS Patient Education Council Patient Education Council Oversight Office practice Service lines Classroom Written Revise content Condition & process Patient Education Knowledge retention Press Ganey Outcomes Multimedia Web-based & other Interactive formats Total Joint Arthroplasty Patient Education: What Should Be Taught and When? Jack Davis, MSN, RN, ONC Manager, Patient Education Programs Hospital for Special Surgery davisj@hss.edu 16