Early patient schedules surgery, and the time they have












Early Implementation of Patient

Laurel Heimsness

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Winona State University- Rochester











In this paper, the importance of early
implementation of patient education will be discussed as it relates to next day
dismissal and same day dismissal, especially in the orthopedic setting.

Orthopedic surgery patients at the Methodist campus
typically wait in the preoperative area for two to five hours before they’re
called back for surgery. This can be a valuable time that can be used to start
the patient education process that is typically time consuming and involves
reintroducing the material multiple times and in multiple ways. However, the
immediate preoperative period can be filled with anxiety, so information can be
difficult to absorb for some individuals.

In addition, there are typically several
months between the time a patient schedules surgery, and the time they have the
surgery. Currently, the orthopedic units utilize this time to do what are called
preoperative education courses, but this doesn’t involve much of the postoperative
teaching that needs to be completed, it just involves a general guideline of
what to expect and what may occur. This is the norm in many other hospitals as
well. Some hospitals may also send out a generalized educational DVD regarding
the procedure.

According to research by Kearney, Jennrich,
Lyons, Robinson, & Berger, “Most patients receive a short verbal
explanation about their surgery and the expected postoperative course from the
presurgical testing nurses during a preoperative visit…” They discovered that
“patients who attended the preoperative education class reported feeling better
prepared for surgery and better able to control their pain after surgery”
(2011). The conclusion of the research done by Kearney et al. was that
“knowledge gained from the hospital’s preoperative education class did affect
patient experiences.” Statistics discovered by their research support
preoperative education. Although, they said it requires further investigation,
“only 4 of 88 patients with some type of structured preoperative education
experienced a complication, compared with 8 of 62 with no structured
education” (2011).

With more adequate education, patients are
less likely to be readmitted, which has been proven by the above statement
about fewer complications. These complications following surgery include, but are
not limited to, contractures, blood clots, infection, and pulmonary
complications. Research by Bergin, et al. has shown that postoperative
pulmonary complications are a leading cause of morbidity and mortality,
affecting up to 50% of patients (2014). In the orthopedic practice, education of
patients on the use of the incentive spirometer is a norm. However, this
information would better serve them if they had learned it preoperatively in
addition to their other needed information.

Research by Lucas, Cox, Perry, & Bridges
(2013) supports current practices of patient education that the orthopedic unit
participates in such as procedure specific booklets and videos. While the
existing preoperative and postoperative education has been proven to be helpful,
there is still more that could done by starting earlier. Patients that are in
the hospital need adequate education so they can adapt to their condition and
perform adequate self-care behaviors (Aghakhani, Nia, Ranjbar, Rahbar, &
Beheshti, 2012).

With already limited staffing resources, there
isn’t always time to provide the one-on-one instruction during the hospital
stay that some of our patients need in order to maximize their education and
learning. This is especially true in the orthopedic specialty when hospital
stays are getting much shorter. Several orthopedic nurses have brought conflict
this up in conversation ever since the orthopedic surgeons started a new
project called OASIS. The idea of OASIS is to shorten hospital stays for
primary hip and knee replacement patients by initiating physical therapy early.
Sometimes, this first session occurs within an hour of unit arrival, when the
patient is still under the effects of anesthesia and is not likely to remember all
of the information.

With next day dismissals, the patient is
usually too sedated following anesthesia to do teaching properly their first
night on the unit. This creates an issue when nurse and therapists are cramming
all the needed information into the patient, typically on the same day they are
supposed to leave in order to make up for lost time. This process does not
allow for adequate time to have information repeated to better enhance
learning, or to have the patient demonstrate teachback in a manner that isn’t

This new process has placed a greater strain
on nursing, physical therapy and occupational therapy in terms of completing
adequate education. Since this is the patient’s primary joint surgery, all of
the information they hear is new, yet they have less time to learn it than a
revision patient would, despite the fact that revision patients have
experienced the same surgery and instructions repeatedly. Feedback has been received
from our physical therapists, as well as fellow nurses that they think this new
project is not helpful for the patient and in makes education more difficult
and rushed. Research by Aghakhani et al., found that in some hospitals
facilities are not sufficient and that lack of time is the most important cause
of insufficient patient education (2012). “Patients’ education is a fundamental
aspect of patient care, and yet poor education is the most common source of
patient’s complaints…” (Aghakhani et al., 2012). Ben-Morderchai, Herman, Kerzman,
& Irony discussed how “structured patient education…improves patient
satisfaction, pain management, compliance with follow-up and better functional
status” (2010).

Both nurses and PT/OT could implement patient
education earlier. Nurses could start the education process on medications, the
post-operative process, recovery, and things to watch for such as blood clots
and infection when the patient is first told they need surgery, or when they
set up the appointment. Physical therapists could start working with patients
before surgery to prepare them for the physical recovery process. It would also
save time, because patients who haven’t had surgery before have a hard time
remembering the correct way to use a walker, and know how in advance would help
keep their dismissal on track after surgery. Kwok, Paton, & Haddad
“hypothesized that preoperative physiotherapy, often known as prehabilitation
should improve post-operative outcomes” (2015).

Implementing education earlier allows for
patients to be better prepared for their surgery and their recovery, and the
research provided proves this to be true. By implementing patient education
earlier, patients, nurses, physical therapists, and doctors would all benefit.


In order to determine if the early
implementation of patient education was successful, a set of outcomes was designed
that each patient would be able to meet. Each outcome is measured by the
ability of the patient to accurately answer questions that are asked both
preoperatively and before discharge.

·       At
preoperative admission, the patient will be able to verbalize at least 3 signs
and symptoms of a blood clot and at least 3 signs and symptoms of infection.

·       At
preoperative admission, the patient will be able to verbalize their
post-operative precautions for their surgery (bending past a certain degree,
twisting, keeping knees bent or apart, etc).

·       At
preoperative admission, the patient will be able to verbalize at least 1 way to
prevent a blood clot and at least 1 way to prevent infection.

·       At
hospital discharge, the patient will be able to provide teachback by
verbalizing their precautions, signs and symptoms of infection and blood clots
and ways to prevent them.

·       At
hospital discharge, the patient will be able to verbalize what medications they
are being discharged on that may cause constipation and how to prevent it.

Change Model

Action Plan

Disengagement Plan

















Aghakhani, N., Nia, H. S., Ranjbar, H., Rahbar,
N., & Beheshti, Z. (2012). Nurses’ attitude to

patient education barriers in educational
hospitals of Urmia University of Medical Sciences. Iranian Journal of
Nursing and Midwifery Research, 17(1), 12–15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3590688/

B., Herman, A., Kerzman, H., & Irony, A. (2010). Structured discharge

improves early outcome in orthopedic patients. International Journal of
Orthopaedic and Trauma Nursing, 14(2), 66-74.

C., Speroni, K. G., Travis, T., Bergin, J., Sheridan, M. J., Kelly, K., &
Daniel, M. G.

Effect of Preoperative Incentive Spirometry Patient Education on Patient
Outcomes in the Knee and Hip Joint Replacement Population. Journal Of
Perianesthesia Nursing, 29(1), 20-27.

M., Jennrich, M. K., Lyons, S., Robinson, R., & Berger, B. (2011). Effects

Education on Patient Outcomes After Joint Replacement Surgery. Orthopaedic
Nursing, 30(6), 391-396. doi: 10.1097/NOR.0b013e31823710ea.

I. Y., Paton, B., & Haddad, F. S. (2015). Does Pre-Operative Physiotherapy

in Primary Total Knee Arthroplasty? – A Systematic Review. Journal Of
Arthroplasty, 30(9), 1657-1663. doi:10.1016/j.arth.2015.04.013

B., Cox, C., Perry, L., & Bridges, J. (2013). Pre-operative preparation of
patients for total

replacement: An action research study. International Journal Of
Orthopaedic & Trauma Nursing, 17(2), 79-90.