9 Patient Education Abstract Evidence has shown that appropriate preoperative patient education prior to minimally invasive spine surgery can be very beneficial in terms of patient satisfaction and clinical outcomes. In the past, patient education prior to surgery consisted of a short, quick speech given by the surgeon or his or her assistant in the office, usually during the same visit as the initial preoperative office consultation. Patients usually have not found this very helpful, mostly because of the hurried nature of the speech and fear of asking questions. This chapter demonstrates the advantages of preoperative education programs compared to the more traditional “surgeon’s office” education. Specifically, we examine a computer-assisted education program, where patients can review slides on a computer at their own pace, and a preoperative education class offered at the hospital where the surgery will be performed. Advantages of each approach are discussed along with a review of why such programs are beneficial to the patient, the patient’s family, the hospital staff, and the surgeon. In our program, because of our preoperative patient education program, we have found a significant improvement in terms of length of stay as well as patient satisfaction surveys. Keywords: preoperative spine surgery, patient education Historically, spine surgery for patients meant several weeks of a long recovery and restricted activity. Minimally invasive spine surgery has led to a paradigm shift for patients to have a shorter recovery period with a faster return to normal activity. Furthermore, since most patients have preconceived notions about spine surgery and the associated risks, benefits, recovery times, and long-term implications, it is imperative that surgeons and their support staff properly educate patients to help make patient expectations congruent with the new reality. In 2008, Keulers et al1 demonstrated that surgeons often underestimate their patients’ desire to receive extensive information prior to surgery. The study also found that surgeons and patients had differing opinions regarding the educational priorities. As one might predict, surgeons tended to focus on details of the surgery, while patients were more interested in receiving details on anesthesia, the postoperative course, and self-care. Patients considered these issues approximately 25% more important than their surgeons did. In other words, each party was most interested in what they perceived to be most important. Additionally, Keulers et al1 found that women demonstrated a significantly greater need for information than men. Women visit doctors more often, require more emotional support, often ask more questions, and are engaged in more conversation with health care providers than men. For many years, the medical literature has supported the fact that improved patient education results in improved clinical outcomes.2,3,4 The orthopaedic field has been able to demonstrate a decrease in length of stay for joint replacement patients who attend a preoperative class on joint replacements. The patient’s level of knowledge can quickly decline from the initial consultation despite supportive measures. This illustrates the need for a comprehensive spine education program prior to surgery. The first priority is the method by which patient education will be delivered. Traditionally, the surgeon, together with office staff, has provided the majority of preoperative education in the office at the time of consultation. Unfortunately, patients seem to remember only a few basic points by the time they have their surgery. The brief nature of this “traditional” patient education, coupled with the high level of patient anxiety at that particular time, would clearly lead to decreased retention of the facts. Traditionally, surgeons provide basic education to their patients in the form of a brief discussion of what to expect pre-, peri-, and postoperatively, possible complications and risks, pain management, and how long it will take to heal and resume normal activities. Some surgeons do this in the form of a 5- to 10-minute didactic speech in their office; some utilize a nurse, midlevel provider, or another office employee; some rely on printed literature and brochures; and many use some combination of the above. The problem is that all forms of traditional patient education require passive learning on the part of the patient. Either someone is lecturing him or her, or the patient is asked to read or watch something with no way of determining the patient’s comprehension of the material. Additionally, anecdotally, patients have expressed that they are often too intimidated to interrupt the physician to ask “a stupid question” or afraid that the doctor is short on time and do not want to bother him or her to spend more of their time explaining. In contrast, a computer program controlled by the patient would help to standardize the educational material and ensure that all topics are covered, and the patient would ultimately control the pace of the learning. A trial by Keulers et al5 compared patient education by a doctor versus a patient engaging computer program and concluded the computer program can be at least equally effective, and possibly more effective, than the physician. Interestingly, patients actually learned more by using the computer program but were also equally satisfied with either education they received. For many patients, an interactive computer program would be less intimidating and would allow patients to control the pace at which they learned. Preconceived notions of a physician-led education might lead patients to believe the physician would be less patient if they had questions or needed to slow down the flow of information. Another option is to offer a preoperative spine class taught by a midlevel provider or office nurse. We currently offer such a class weekly at Beaumont Hospital in Royal Oak, MI, for all patients and their family members who are scheduled for both neurosurgery and orthopaedic spine surgery. The class has been very well received by the patients since it is taught by an experienced midlevel provider who describes each step of spine surgery starting with where to park on the day of the surgery and ending with what to expect following hospital discharge. The class has unexpectedly become a “peer support group” for some patients, as there are often patients and/or family members attending the class who have had spine surgery in the past. These people often give reassurance to first-time spine surgery patients, as it is always comforting for people to meet others who have undergone the same procedure. In fact, sometimes patients with spine surgery experience can be more helpful than the health care professionals. This preoperative spine class was developed using a multidisciplinary approach with input from spine surgeons, anesthetists, bedside nurses, midlevel providers, physical therapists, and discharge planning nurses. Based on prior patient satisfaction surveys, the group was able to identify the most common spine patient complaints and concerns, which were pain control, fear of anesthesia, fear of Foley catheter, fear of mobilization after surgery, and fear of going home too soon. The foundation for the class was built upon these complaints and concerns. The class lasts approximately 1 hour and 30 minutes to accommodate all patients’ questions and concerns. Spine anatomy is reviewed at the beginning of the class using slides along with models of the normal and pathologic spine. It is notable that the patients really enjoy and appreciate the spine models, as they allow a hands-on, interactive experience. The class also has other interactive props including an incentive spiro-meter, sequential compression device, Jackson Pratt (JP) and hemovac drains, cervical collars, and back braces. Pictures of the hospital areas as well as a hospital scrub color guide are included in the class. Patients have stated the photos and hands-on props from the class decrease their level of anxiety prior to their spine surgery since they have a better idea of what to expect. The majority of the class is dedicated to pain control and a review of the pharmacologic and nonpharmacologic methods. Intravenous pain medication is compared to oral pain medication with respect to duration of each drug and the importance of transitioning to oral medication as soon as possible. Patients are taught that they will not be “pain free” after surgery, as they will have incisional pain. Most likely their preoperative, neuropathic pain will be resolving if not gone immediately after surgery. Additionally, patients are given reassurance that incisional pain is normal, and nurses will work closely with them to help control their pain. They are instructed to notify the nurse when pain is moderate and not to wait for it to be intolerable. Patients are also reminded they will have less postoperative pain with the minimally invasive spine technique compared to the traditional open spine technique. Early mobility is also highly emphasized in the class since minimally invasive spine surgery allows patients to return to activity faster than the traditional open spine technique. Patients are instructed that they will be out of bed on the same day of surgery, which in turn decreases muscle spasms and pain along with a shorter length of hospital stay. Patients are often surprised but happy to hear they will be out of bed on the same day of surgery. Spine precautions are explained in detail several times throughout the class to remind the patient to avoid bending, twisting, driving, and lifting until cleared by their spine surgeon. Patients are also reminded to consider alternative measures for caring for their pets after surgery since pets often weigh more than 10 pounds. Constipation and proper nutrition are also discussed in the class. Patients are instructed to maintain a healthy diet with protein for proper wound healing, and high fiber and adequate water intake is recommended to prevent constipation. Patients are also instructed to begin a bowel regimen, stool softener, and/or polyethylene glycol 3350 prior to surgery since constipation following spine surgery can cause a great deal of pain and potential surgical problems. Patients are also instructed to continue some kind of bowel regimen after surgery and to pay attention to their bowel movements as constipation could occur once they are at home. Specifically, patients are informed how opiate pain medications, anesthesia, decreased mobility, and decreased fluid and/or fiber intake can all lead to constipation. The question and answer session at the end of the session has been one of the patients’ favorite sections of the class. Many patients stated that they benefited greatly from listening to questions of other patients and the subsequent answers. A few frequently asked questions include: • “When will I be put to sleep and will I hear anything in the OR?” • “How far will I have to be pushed down the hall to go into the OR?” • “Will I be asleep when the Foley catheter is placed?” • “What will I be wearing into the OR?” These are just a few examples of information the spine surgeon would most likely not address as part of the traditional education given during a preoperative office consultation. The class welcomes any and all questions, many of which patients might feel uncomfortable asking their surgeon.
9.1 Introduction
9.2 Method of Patient Education
9.2.1 Traditional Patient Education
9.2.2 Computer-Assisted Education
9.2.3 Preoperative Education Class
9.2.4 Introductory Education
Pain Management
Postoperative Education
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