A Question of Protocol?: How a Patient Education Process Enhances Practice & Betters Business

Effective patient education leads to improved informed consent, decreased preoperative anxiety and better postoperative pain management. Whether allocating office and hospital resources for patient education results in more cost-effective medicine is a more complicated issue.  

Few would argue that an emphasis on patient education prior to cardiac surgery or a catheter-based intervention is good practice. Patients have become increasingly interested in learning about their therapeutic options and participating in decision-making about cardiac interventions. How, when and where to deliver patient education are complex questions that require the participation of many members of the surgical care team as well as discussion about the optimal use of practice and hospital resources.


Many options, mixed results

Many forms of patient education have been implemented prior to all types of surgery and medical procedures. These include pure preoperative verbal instruction by physicians or ancillary care personnel, written pamphlets, preoperative instruction videos, audio presentations and combinations of these. In fact, patient information booklets and other materials are an industry in themselves, lining the countertops and walls of physician offices, clinics and even intensive care and coronary care units.

In addition, patients now have a vast amount of information available to them via the internet. Online content tends to be both informative and promotional, such as that provided by the Mayo Clinic or national disease-based organizations, including the American Heart Association. The Society of Thoracic Surgeons (STS) recently launched ctsurgerypatients.org, a comprehensive patient information website aimed at educating patients regarding a wide variety of cardiac and thoracic surgical diseases, including therapeutic options and what to expect with surgery. The website is presented in lay terms in both English and Spanish, contains a biweekly blog and features images and videos.  

Patient retention and comprehension of knowledge regarding disease processes, therapeutic options and procedural risks and benefits are notoriously poor after leaving physician offices. To be effective, patient education should be offered early in the process, be repeated and take place in multiple settings (Int J Evid Based Healthc 2012;10[4]:309-23). Otherwise, merely “modernizing” the patient education format has yielded disappointing results. For example, researchers who compared web-based education with face-to-face education in preoperative orthopedic surgery found no difference in pre-, intra-, or postoperative costs between the two groups (Orthop Nurs 2011;30[1]:20-8). Similarly, there was no difference in postoperative stays, pain scores or use of pain medication in a study on the effect of adding patient education videos to written and verbal education before colorectal surgery (Colorectal Dis 2013;15[11]:436-41). Only when such information is provided in lay terms and repeated in different venues by office staff, nurse practitioners, physician assistants (PAs) and hospital nurses does it make a difference in clinical results. Patients also need the ability to have questions answered that may not occur to them at the time of the educational sessions. An increasing number of physicians provide an e-mail address to patients for the purpose of answering preoperative questions and addressing postoperative issues. This seems practical, but may be limited by privacy and record-keeping concerns. 


Protocol pays off

At Huntington Hospital in Pasadena, Calif., we follow a cardiac surgery patient education protocol that begins in the original consultation, when the surgeon describes the disease process, therapeutic options, his or her recommendations and possible risks. Educational materials, including models of the heart, are used. Patients are referred to the STS website and are provided with a written pamphlet for further information.

Patients then attend an independent session with a PA, who describes a routine hospital stay, including the usual length of stay and goals to be met each day until discharge. Pain management strategies also are discussed. During the postoperative hospital stay, physicians and ancillary care personnel review care strategies with patients and their families on a daily basis. On the day of discharge, patients have a discharge education session with a PA, view an instructional discharge video and discuss discharge instructions with a nurse.

This educational strategy has resulted in consistently reduced hospital stays and readmission rates, both of which have been applauded by the hospital and payers. 


Robbin G. Cohen, MD, MMM, is an associate professor of cardiothoracic surgery at the University of Southern California Keck School of Medicine in Los Angeles and the medical director of cardiothoracic surgery at Huntington Hospital in Pasadena.