Pt DC instructions: How to deliver?

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Specializes in ER.

When you are a patient, it gives you a better perspective of healthcare. I had recent outpatient surgery. There was a real deficiency in the instruction process. It got me to thinking about how to improve, both my own practice, and the deficiency in our current system, generally.

I did not have a general, but a local and some Versed and Fentanyl. I was awake throughout, but high as a kite in recovery. The nurse first handed me a written sheet, which had the protocol of a different doctor. It talked about a splint, etc, and I asked about this. She said, oh we don't have your doctor's protocol yet (I'd had this surgeon before and followed him to his new clinical site).

On DC, the nurse read the DC instructions verbatim. My friend was there with me. It basically went through one ear and out the other. I really liked my nurse by the way, she was very nice.

On reading the instructions at home I found them basically useless, even aside from the fact that the protocol was different. These information sheets seem to be packed with too much irrelevant information. It seems that we rely, too much, on a one sized fits all, click of a button print out that seems to be designed to protect us legally, but not the most effective for actual teaching.

In the ER where I work, we also rely on these types of instruction sheets. For instance, we have a general, abdominal pain one. It's packed with so much general information, covering every type of possibility, as to be useless. I always let the patient know that not everything on the sheet pertains to them. I try to customize my instructions for their situation. But, verbal instructions given to someone who just got opiates aren't really reliable. Their designated driver is probably not paying much attention either.

I did let my dear surgeon know, on my follow up, that I was very confused by what to do after surgery, he said others have told him the same. And, when I had called the office, they had told me that my Dr wasn't in that day, and the person who answered actually gave me incorrect advise, I found out. Our system is so rushed, I think that's the root of the problem.

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We're pushing the teach back method with our staff as well as promoting use of demonstration versus only verbal and written instructions, which as you've observed are not easily retained.

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Specializes in orthopedic/trauma, Informatics, diabetes.

I had the same problem as a pt. I had a same day shoulder arthroscopy. My husband was there for instructions. I was so proud of my self for getting the steri strips off in the shower. (head slap). We are also encouraging teach back or demonstraton AND having a family member present. It is inevitable that they call because they don't understand something. I highlight, circle, anything I can to stress what is important.

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Specializes in Critical care.

I try to be as specific as possible, but this is a good reminder that what is clear to the nurse might not be for the patient and/or family. We don't get many post-op patients on my unit, so major incision/wound care isn't big. My unit gets chest tubes, pna, COPD exacerbations, respiratory viruses, cardiac caths, and others. I go through and highlight the important points and always try to wait for family so there are two sets of ears. I also literally go through and physically write out when exactly each medication is next due (date and time) to avoid any issues.

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I wish you would give specifics of what wasn't made clear.

I have plenty of time and go over discharge instructions thoroughly with the patient and their ride home. They sign them and take them home. Yet it is not unusual when we call the patient the next day for the patient to ask basic question that are clearly covered on their discharge paper.

It doesn't bother me, I understand they had surgery, anesthesia, a lot of worries and concerns on their mind.

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Some things that patients p/caregivers come home not remembering..

to understand the importance to read their dc instructions. Have seen many who "didn't have time yet" to read them and missed important meds such as aspirin for 2 days since discharge post joint replacement.

The importance of that silly incentive spirometer at the bottom of the hospital bag and why/how it will prevent pooling of secretions with patient's pain related reduced mobility. "Your dad is at high risk for post op pneumonia and doing this IS exercise every hour will help prevent it".

You have a new rx waiting at your pharmacy for nebulizer meds, make sure that is picked up and started today. It is be taken every 6 hrs not prn. DO YOU HAVE A NEBULIZER AT HOME? (Can't tell you how many times that detail is missed.)

Getting up frequently and moving around means get up every hour and walk for a few minutes around your house to prevent pressure sore, DVT and PNA. That does not mean resume chores or sitting up at your computer for hours, you will have too much swelling and more pain if you do.

Your medications have changed. You will need to eliminate everything not on this list until your follow up appt. No, it's okay to resume your inhalers for COPD, those were just inadvertently left off the list, the Advair is important. If you use a mediplanner, you will need to have the discontinued meds or any not on this list removed, if not you could be getting double of meds for your BP and HR and that would be DANGEROUS.

If you have a referral to home health, they may not see you for 48hrs and a lot can go wrong if you don't follow these instructions until then.

If your ride is not your caregiver, these instructions must be given and read by your caregiver. Don't let your ride takes these home or put in an obscure place and making home health nurse request a copy from medical records because they were also not included in the referral pkt, too much can go wrong until then..

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Specializes in ER.
I wish you would give specifics of what wasn't made clear.

Activity limitations, timetable for follow up with OT, bathing, etc. Then I had a week of nausea, I had used a scopalmine patch left over from previous problems with same, then the side effects from that bothered me too much, so I just stopped taking my pain pills since I don't tolerate too many meds combined with NPO apparently, and it lasts for days. I had asked the nurse maybe to try Phenergan already, since Zofran doesn't work for me, so I didn't bother to try calling them at that point, just drank ginger ale, I had my daughter home to help.

Then, when all that was done I had questions about some activities and follow up, couldn't figure out anything from written instructions which were another surgeons protocol, and crammed with stop smoking advice and do daily weights if you have heart failure. When I called the office to ask if a certain activity was allowed, she said my Dr wasn't in the office, but that sounded ok, which turned out to be incorrect.

I told my Dr that I finally just started looking online for information. He's going to advocate for a better process. One thing though, I'm very pleased with the outcome at this point, but had some anxiety and confusion at the time.

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There is research that shows what is the most effective way to deliver health information. The discharge information I have received as a patient followed none of the guidelines.

Some of the guidelines include:

- sentences should be no more than 8-10 words

- the number of letters in a line should be 40-50 (in other words 2 columns on a page)

- you should use action words not passive

- paragraphs should be 3-5 sentences

- tell the patient what you want them to do not what you don't want them to do.

- bullets are better than paragraphs

- put the most important information first

- use 12-14 point font

- Serif font is easier to read than Sans Serif

- try to use 1 or 2 syllable words

- provide necessary information. Eliminate nice to know information.

To take an example provided by a PP, it doesn't follow what research shows is most effective for the average patient. (I don't mean to be critical of Libby1987, because for me her instructions would be perfect.)

"Your dad is at high risk for post op pneumonia and doing this IS exercise every hour will help prevent it." The sentence is too long. It is passive voice, and it contains "nice to know" information (i.e. "Your dad is at high risk for post op pneumonia.")

According to research it is better to say, "Use this once an hour to prevent pneumonia."

I think for scheduled surgeries/treatments, the discharge instructions should be given to the patient when they schedule surgery. The nurse could review it with the patient when the patient is not under the influence of pain meds or anesthesia and relatively non-stressed.

The patient could read the information at home prior to surgery. They could be encouraged to write down any questions they have.

Then the discharge nurse could answer their questions, review the instructions again after surgery, and make any changes that might be necessary.

If the hospital really wanted to improve discharge education, the pre-op nurse would also review the information with the patient. My education trained family members say that you need to teach something 3 times for most people to get it.

I had 1 physician provide post-op instructions when I scheduled the surgery. I was told to bring the information with me to the hospital. The discharge nurse reviewed the instructions with me again. It was very helpful to have the information ahead of time.

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There is research that shows what is the most effective way to deliver health information. The discharge information I have received as a patient followed none of the guidelines.

Some of the guidelines include:

- sentences should be no more than 8-10 words

- the number of letters in a line should be 40-50 (in other words 2 columns on a page)

- you should use action words not passive

- paragraphs should be 3-5 sentences

- tell the patient what you want them to do not what you don't want them to do.

- bullets are better than paragraphs

- put the most important information first

- use 12-14 point font

- Serif font is easier to read than Sans Serif

- try to use 1 or 2 syllable words

- provide necessary information. Eliminate nice to know information.

To take an example provided by a PP, it doesn't follow what research shows is most effective for the average patient. (I don't mean to be critical of Libby1987, because for me her instructions would be perfect.)

"Your dad is at high risk for post op pneumonia and doing this IS exercise every hour will help prevent it." The sentence is too long. It is passive voice, and it contains "nice to know" information (i.e. "Your dad is at high risk for post op pneumonia.")

According to research it is better to say, "Use this once an hour to prevent pneumonia."

I think for scheduled surgeries/treatments, the discharge instructions should be given to the patient when they schedule surgery. The nurse could review it with the patient when the patient is not under the influence of pain meds or anesthesia and relatively non-stressed.

The patient could read the information at home prior to surgery. They could be encouraged to write down any questions they have.

Then the discharge nurse could answer their questions, review the instructions again after surgery, and make any changes that might be necessary.

If the hospital really wanted to improve discharge education, the pre-op nurse would also review the information with the patient. My education trained family members say that you need to teach something 3 times for most people to get it.

I had 1 physician provide post-op instructions when I scheduled the surgery. I was told to bring the information with me to the hospital. The discharge nurse reviewed the instructions with me again. It was very helpful to have the information ahead of time.

Less words makes sense. Instructing them in shorter sentences would be a better delivery at Hosp discharge. In the HH setting we also have the luxury of being able to sit down at eye level and have the time to wait for them to demonstrate their understanding. If one way doesn't work then we go to another.

My point though was more specific to content. There are a lot of things in general that can be prevented but in my experience with teaching patients they respond differently when they buy into how it will actually affect them. For instance most patients realize that post op aspirin is a "bold thinner" but too often delay obtaining it or they just resume a previous low dose. So many have gone 48 hrs without having it in the house because even though they know it was ordered. They minimize it because what they don't often realize is that their ortho surgery makes them likely to develop a blood clot if they aren't anticoagulated. Before that they thought it was just good measure and could wait until someone made a trip to the store. So if you say, "Take your aspirin twice a day to prevent a blood clot" it doesn't always bring the point home.

I completely agree about pre op teaching, the practices that have classes before elective surgeries have the best information retention and comprehension, in my anecdotal experience.

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It is very difficult that's for sure.

Many times I have asked the surgeon about discharge instructions. They often say, "I, or my nurse, went over that, the patient has their instructions at home.". I return to the patient and they say they lost them, don't remember, etc.

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PS....at our out patient surgery clinic it is mandatory to call the patient within 48 hours after discharge to check on them, do they have any questions, do they understand their discharge instructions, etc.

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Specializes in ER.
Good points. At our hospital the total joint patients are required to go to a class beforehand to go over what to expect and how to recover. It is a calm and encouraging environment in which to ask questions, take your time, and initiate some familiarity with the process.

Wow, that's a great idea! I'm getting some fantastic ideas here, I will include them on the feedback form.

1) They need to have the correct protocol for the correct doctor.

2) The forms need to be decluttered of superfluous information.

3) The forms need to be simplified into small paragraphs, simple sentences, using the bullet format, bolding the most important points.

4) The information needs to be given ahead of time, then reinforced at the time of discharge.

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