Improving patient prep

Bunny Isgett-Lynn

The failure of patients to adequately prepare for surgery is a potentially serious problem for nearly every medical institution. It commonly leads to last-minute cancellations, poor procedure results and unnecessary complications. Consider the bleeding risks, for instance, to patients who have not properly discontinued certain medications such as aspirin or warfarin prior to surgery.

Inadequate prep is more than just a matter of wasted time on the part of providers and patients. Patient safety risks are compounded by inefficient use of institutional resources — medications, equipment, time in the surgical suite. Moreover, patients who walk away from a cancelled or suboptimal procedure may not come back a second time, increasing the probability that they will decide to forego vital care entirely.

Supplying pre-operative patient education materials is one well-documented strategy for improving patient outcomes and reducing preventable cancellations.1,2,3 Aware of the potential benefits, some facilities with the Department of Veterans Affairs (VA) health system have begun using an automated informed consent tool to provide individualized pre-procedure patient instructions.

Mired in the inefficiencies of paper

The VA Gulf Coast Veterans Health Care System (GCVHCS) serves veterans in the Gulf Coast region of Mississippi, Alabama and Florida. In addition to its main facility in Biloxi, Miss., it also includes four community-based outpatient clinics in Mobile, Ala.; Eglin, Fla.; Panama City, Fla.; and Pensacola, Fla. Together they serve more than 50,000 veterans.

Prior to 2009, the process used by GCVHCS to offer pre-procedure information was best described as “not optimal.” Nurses reviewed standardized instruction sheets with patients during pre-operative appointments, but just as in most other facilities, these paper pamphlets often had been copied so many times that they were difficult to read.

In addition, the signed documents then had to be scanned into GCVHCS' electronic health record (EHR). Unfortunately, this was not always an immediate process; it sometimes took significant time until the documentation was available in the EHR. This step not only consumed personnel assets and resources, it prevented immediate provider access to the information.

Perhaps most troublesome, however, was the fact that pre-printed instructions could not be tailored to each individual veteran. This inability to personalize information hampered efforts to foster a sense of accountability on the part of each patient for his or her own care. Furthermore, it opened the door to safety hazards. A patient on aspirin therapy reading through generic instructions, for example, might not accurately calculate the date on which to stop taking the aspirin prior to a procedure.

So, when GCVHCS first opened its Pensacola facility, new staff with new ideas helped spark fresh perspectives on the delivery of pre-procedure instructions. GCVHCS set about developing a series of instructions designed to better prepare patients for common procedures. The goal was to optimize the probability of obtaining optimal outcomes, while reducing the rate of cancelled surgeries and treatments due to patients arriving improperly prepared for their procedures.

Choosing an automated solution

The Joint Commission on Accreditation, national VA and local VHA policy, nursing practice standards and many national nursing and medical organizations all specify that patients be allowed to give “informed consent” regarding procedures. An effective informed consent process is more than just a documentation requirement; it should foster communication between providers and patients. Within the VA health system, the entire informed consent process has been standardized using an automated informed consent application (AICA) called iMedConsent from Dialog Medical.

As its new Pensacola surgical service began to come on line, GCVHCS took the opportunity to evaluate its methods for offering pre-procedure instructions. During a few brainstorming meetings, staff asked, “Why not use the consent application to additionally automate pre-procedure instructions?”

Three distinct motivations guided the decision to provide pre-procedure instructions via the AICA. They were the desire to:

1.    Offer patients more detailed, personalized pre-procedure instructions;

2.    Best document that patients received the correct pre-procedure instructions; and

3.    Verify receipt of instructions via patient signature.

Using templates to personalize instructions

GCVHCS' Biloxi and Pensacola staff worked together to develop an automated process aimed at educating patients to be fully knowledgeable about, and prepared for, their procedures. Templates proved to be the answer to personalizing information, and initial template creation focused on the procedures most commonly performed at GCVHCS: colonoscopy, bronchoscopy and esophagogastroduodenoscopy (EGD). Starting with the most commonly performed procedure, new sets of instructions were rolled out one at a time. About seven unique sets now are in daily use.

Here is how the process currently works: Instructions typically are prepared for patients by a nurse during pre-operative clinic visits. After the patient watches a short movie about the scheduled procedure, the nurse discusses it further and asks the patient to verbalize — in repeat-back fashion — what he or she understands.

At that point, providers open the AICA from within the EHR and select the “patient signature forms” option. They then choose the desired set of instructions from a list presented on the screen. For example, they might click “joint ambulatory care center (JACC) pre-op instructions.” A check box allows them to mark the correct procedure (e.g., bronchoscopy, colonoscopy, dilatation, EGD, sigmoidoscopy) and enter personalized details in specific fields that include:

•    The date of the procedure;

•    The date to expect a confirmation call;

•    Medications to take on the morning of the procedure;

•    The exact dates to stop taking any aspirin products or diabetic medications;

•    Which lab tests must be performed, if applicable; and

•    Whether other services (e.g., ECG, X-ray or pharmacy) are applicable.

All of this information is then compiled — legibly — into an instruction sheet clearly labeled with the warning, “Failure to follow the instructions can result in your procedure being cancelled.” The patient signs the instructions using a digital signature capture pad and is given a printed copy of the signed instructions.

A note documenting the exact date and time that the instructions were provided to the patient automatically is posted to the patient's medical record in the EHR. An image of the signed instruction document automatically is posted to the facility's document management system. This automated process ensures that providers can confirm immediately and easily that patients have received all necessary instructions.

Obtaining positive results

In 2009, a total of 1,152 sets of pre-procedure instructions were produced with GCVHCS' automated informed consent application and saved electronically in the EHR. In 2010, the number rose to about 1,857.

Since implementing this process, GCVHCS facilities have seen a significant increase in the number of patients fully prepared for their procedures. Not surprisingly, they also have experienced a corresponding decrease in the number of procedure cancellations, missed appointments, and missed lab work. During its survey of the Pensacola facility, The Joint Commission expressed approval of the clearly documented, personalized process for supplying pre-procedure instructions.

Nursing staff appreciate that they no longer are questioned about the instructions provided. All of the “dos” and “don'ts” discussed with patients are clearly documented in the chart. Should any questions arise later — whether for patient care or legal reasons — the information is legible, dated and signed.

By using an automated system to facilitate the distribution of pre-procedure instructions, GCVHCS also no longer has a cache of difficult-to-update paper documents stashed away in cabinets. Instead, copies of instructions can be printed and distributed as many times as needed, which goes a long way toward the mission objective of patient record portability legislation.

In addition, GCVHCS has further increased the utility of the application by tailoring it to automate other key processes. Among them:

•    Advance directives. These documents are electronically signed and posted to the record in the same manner as pre-procedure instructions.

•    Schedule II narcotics distribution. The pharmacy uses a template to capture electronic patient signatures acknowledging receipt of Schedule II narcotics.

•    Valuables inventory. Emergency department staff take inventory of any valuables (jewelry, cash, etc.) that arrive with patients. Patients electronically sign the checklist, which is then posted to the electronic record. This use of the application has helped GCVHCS avoid frivolous legal claims alleging lost or stolen items.

Transforming patient care

GCVHCS was lucky in one respect: The conversion from a paper-based to an automated pre-procedure process quickly garnered the support of all involved. Collaboration among surgeons, nursing staff, IT staff and even the application vendor was manifest from the outset. This likely was due, at least in part, to previous familiarity and comfort with the AICA. Other facilities considering a similar process transformation should consider the involvement of all constituencies — beginning with the planning process — to ensure staff buy-in.

For GCVHCS, however, the application has become an essential tool to document that patients have received the right instructions, for the right procedure and at the right time. It is a tool that engages veterans in their own care, leading to more positive outcomes.

From accountable care to patient-centered care, many national healthcare reform efforts emphasize the critical importance of empowering patients in their own healthcare decisions. By signing that they have received patient-specific and procedure-specific pre-operative instructions, patients at GCVHCS now shoulder a rightful piece of responsibility for their care. Individualization of the process reinforces providers' discussions, engages patients in their care and increases their odds of having a good experience and positive outcome.

1. Hathaway D. Effect of preoperative instruction on postoperative outcomes: a meta-analysis. J Nurse Res. 1986;35(5):269-75.

2. Henderson BA, et al. Incidence and causes of ocular surgery cancellations in an ambulatory surgical center. J Cataract Refract Surg. 2006;32(1):95-102.

3. Pletta C, et al. Incidence and causes of ocular surgery cancellations in an ambulatory surgical center. J Nucl Med. 2008;49(Supp 1):426P.

Bunny Isgett-Lynn, BSN, RN,
is clinical application coordinator for the
VA Gulf Coast Veterans
Health Care System
in Biloxi, Miss.
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