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What is the effect of preoperative education on patient outcomes after joint replacement surgery?Principal Investigator: Marge Kearney APN, ONC1 Sub-Investigators: Mary Kay Jennrich RN, BSN1, Stephanie Russo DPT, MSCS1, Rochelle Robinson RN, ONC1,

Sheri Wilhelmi RN, BSN1, Stephanie Wink RN, BSN1, Dan Felice MPT1, Lisa Orlet MPT1, Barbara Berger PhD, RN2

1 Advocate Good Samaritan Hospital, 2 University of Illinois at Chicago

Abstract

Findings

Conclusions/Discussion

AcknowledgementsAnalysis

Findings (continued)

Contact information

The research team would like to thank the following for their support of this study: Marty Dietrich MPH, Ginger Diven MS, RN, Gail Conforti MS, RN, CGRN, Carol Rogers PhD, APRN, BC and the staff nurses and physical therapists of the Ortho/Trauma unit at Advocate Good Samaritan Hospital.

Introduction: This descriptive comparative study explored the effects of preoperative education on patient outcomes after total joint replacement surgery.

Methods: Subjective data were obtained from each enrolled patient through a survey about their expectations of, and experiences after, total joint replacement surgery. Objective data were identified through a retrospective chart review and a follow-up phone call 30 days after discharge. A total of 150 patients having single joint total knee or total hip replacement surgery were enrolled.

Results: Findings showed some statistically significant differences between patients who attended the structured class and those who did not attend. Patients who attended the structured class felt significantly better prepared for surgery and better able to control their pain after surgery. No differences were found in postoperative pain levels, complications, ambulation distances or length of stay (LOS).

Conclusions: Attending a structured preoperative class prior to total joint replacement surgery was beneficial.

Purpose/Research Questions

This research study compared outcomes of patients who attended a free face-to-face preoperative education class offered by the hospital with those who did not attend.

• Do patients who attend this class feel better prepared for surgery, have more realistic expectations regarding postoperative pain and exercises, and comply better with measures to prevent complications?

• Are there any significant differences in reported pain, ambulation distance, complication rate and LOS?

• Are there any significant differences in discharge disposition or level of confidence regarding pain control and required therapy after discharge?

Background Advocate Good Samaritan Hospital offers a structured preoperative education class for patients undergoing elective total knee or total hip replacement . A staff nurse and physical therapist teach this face-to-face two hour class which covers topics such as pain control, prevention of complications, exercises and discharge planning.

About 50% of eligible patients attend this class and many of the instructors feel that these patients do better postoperatively. Studying the effects of preoperative education on patient outcomes after joint replacement surgery was the basis for this descriptive comparative study.

Literature review found no evidence supporting use of preoperative education over and above the standard care to improve postoperative clinical outcomes with respect to pain, functioning, complications and LOS. There was evidence that preoperative education has a modest beneficial effect on preoperative anxiety.

Methods

Procedures: Patients were identified on admission to the orthopaedic unit and were screened by a sub-investigator. If they met criteria, their consent was obtained, they were assigned a study ID and they were asked to complete the survey. The patient’s medical record was reviewed to obtain clinical data. Patients were called 30 days after discharge to identify any postoperative complications.

Sample: A total of 150 patients were enrolled in this study. This sample size was determined by power analysis. Eligible patients were those who were having a single joint total knee or hip replacement, who had not had this type of surgery in the past 5 years, who could read and write English, were alert and oriented and were to be discharged from the orthopaedic unit.

Marge Kearney APN, ONCc/o Advocate Good Samaritan Hospital3815 Highland AvenueDowners Grove, IL 60515630-275-3599Marge.Kearney@advocatehealth.com

OPTIOALLOGS HERE

• Patients who attended the structured preoperative education class felt better prepared for surgery and better able to control their postoperative pain (Table 2). However, they did not have significantly different clinical outcomes after surgery (Table 3).

• Consistent with other research, this study found no significant difference in postoperative pain level, length of stay, or ambulation distance based on preoperative education. The data did show a trend toward significance for an association between either of two types of structured preoperative education and a decrease in postoperative complications (Table 4).

• This study validated the content of the current class for preparing patients for joint replacement surgery. However, only about half (51%) of the patients having total joint replacement attended the structured face-to-face class, many because they were unaware of it. Future plans include sharing results with surgeons to encourage them to send their patients to this structured class.

GSAM class attendance

TABLE 1 – DEMOGRAPHICS Yes No test statistic p value

Age Mean (SD)

n

67.25 (10.8)

77

64.5 (11.2)

73

t148df = .131 .081

Gender F M

42 35

48 25

X21df = 1.961 .161

Type of joint being replaced

Knee Hip

46 31

41 32

X21df = .197 .657

Past joint replacement

Knee Hip

Neither

11 3 63

5 9 59

X22df = 5.278 .071

Femoral block (knees only)

Yes No

40 5

36 6

X21df = .198 .656

Discharge disposition

home-self home health

rehab SNF/ECF

0 37 25 15

1 41 22 9

X23df = 2.792 .425

Item GSAM class? n mean (SD) Mann-Whitney U

p value Amount of pain was what you expected a

yes no

76 73

2.3 (1.0) 2.5 (1.0)

.327

Felt able to help control pain b

yes no

76 72

1.4 (0.6) 1.7 (0.8)

.001*

First Physical Therapy session was as expected b

yes no

77 73

1.6 (0.8) 1.6 (0.6)

.618

Performed breathing exercises b

yes no

77 73

1.5 (0.8) 1.6 (0.8)

.218

Performed DVT prevention techniques b

yes no

76 72

1.1 (0.3) 1.1 (0.3)

.525

Felt prepared for surgery b

yes no

76 72

1.2 (0.4) 1.4 (0.5)

.002*

a response scale: 1 = less than expected, 2 = about expected, 3 = more than expected, 4 = much more than expected. b response scale: 1 = very much so, 2 = somewhat, 3 = very little, 4 = not at all. * p < .05

TABLE 2 – PATIENT PERCEPTIONS

TABLE 3 – CLINICAL OUTCOMES

variable GSAM class? n mean (SD) Mann-Whitney U

p value Average pain POD1* (from 0 to 10)

yes no

77 72

3.4 (1.3) 3.6 (1.6)

.884

Average pain POD3* (from 0 to 10)

yes no

69 68

3.0 (1.6) 2.9 (1.4)

.626

Time to first oral pain medication (hrs)

yes no

77 73

36.3 (18) 36.4 (15)

.582

Furthest ambulation POD1* (ft)

yes no

77 73

54.7 (59) 45.0 (65)

.194

Furthest ambulation POD3* (ft)

yes no

68 67

139.4 (105) 133.0 (74)

.905

Length of stay (days) yes no

77 73

3.5 (1.0) 3.6 (1.3)

.848

*POD = postoperative day

Complications

Class attendance Yes No test statistic p value

Face-to-face (f2f) classNo class

48

7365

X21df = 1.692 .193

Structured education (f2f or on-line)No structured education

48

8454

X21df = 3.452 .063

TABLE 4 – COMPLICATIONS

Data were entered into a single data file and analyzed using SPSS. Following verification of data accuracy, descriptive statistics were evaluated for each variable. Distribution-free nonparametric procedures were used to test hypotheses (=.05) related to preoperative education and joint replacement outcomes.

The face-to-face (f2f) class offered by Advocate Good Samaritan Hospital is a structured course designed to help patients anticipate and prepare for surgery. Many of our participants indicated that they also obtained preoperative information from searching on-line sites, from their doctor, office staff or presurgical testing nurses, and/or from a specific on-line course. The following table compares the number of postoperative complications between those who received a structured education offering (f2f or specific on-line course) with those reporting no structured education.