Ambulatory surgery continues to expand rapidly. An increasing number of patients with several comorbidities and advanced age are undergoing more complex procedures in ambulatory surgery centers (ASC). As these patients continue their postoperative recovery in the comfort of their own homes, the ASC practice places a great degree of responsibility on patients and their caregivers to follow discharge instructions. This has caused the practice of ambulatory anesthesia to evolve, allowing for rapid recovery and return to activities of daily living after surgical procedures of greater invasiveness. It has also placed specific emphasis on patient education because patients and caretakers become active participants in the postoperative care and rehabilitation process compared to inpatient surgical practice. In hospitalized patients, perioperative morbidity and mortality, hospital length of stay and readmission rate are measured to evaluate outcomes after surgery.1 Postoperative pain, nausea and vomiting in the brief postoperative in-hospital period have also been used as outcome measurements. While these outcome measures continue to have importance in the ASC practice, several other patient-centered outcome measures demand equal attention. Better patient-reported outcome measures not only correlate with lower patient-reported complications but also with better patient-reported experiences and, perhaps, litigation. To further elevate perioperative anesthesia care quality, patient education is crucial in improving outcomes and safety for patients and their caregivers.
Education Before Operation Is the Key
The Perioperative Surgical Home (PSH) model and enhanced recovery after surgery (ERAS) pathways emphasize the importance of patient education in improving outcomes such as preoperative anxiety, postoperative pain, quality of recovery and even wound healing. The preoperative clinic may appear to be the easiest or best place for disseminating patient education; however, the majority of ASCs generally do not have preoperative clinics. Due to faster operating room turnover times and higher volumes of surgical procedures performed each day, choosing one or more specific points of patient contact can help the process of patient education to be more efficient and impactful for the specific needs of each ASC (Table 1). Depending on the setup and resource availability of each ASC, printed brochures, website addresses, customized web-based education, phone conversations and/or face-to-face discussions of the perioperative care, including surgical procedure and the anesthetic plan, may be provided. Regardless of where the education materials come from and what type of materials are provided, anesthesiologists must be involved in the development of education material to ensure the quality and accuracy of information provided. The readability and comprehensibility of education materials is important to ensure clear understanding of the information. Providing materials that are written at a fifth- to six-grade reading level could improve overall comprehension of information for patients with poor health literacy. As online information can be provided by commercial manufacturers, news reporters and other entities, there is significant variability in quality, accuracy and readability. Unfortunately, such web-based materials are often advertisements geared toward attracting patients to choose certain medications or products. Many online patient education materials related to the anesthesiology field are written far above the recommended readability grade level.7
Improving Patient-Centered Outcome Measures With Patient Education
Clear Instructions: Instructions ranging from preoperative fasting and perioperative continuation of prescription medications to postoperative discharge summaries may be streamlined by the anesthesia team to ensure efficiency and effectiveness. Clearly scripted fasting instructions benefit patients by avoiding unnecessarily prolonged fasting times while benefiting the ASC by decreasing surgery delays and cancellations due to violations of fasting guidelines. Specific instructions outlining which prescription medications should be taken or held during the preoperative period must be clearly conveyed, as abrupt discontinuation of certain medications may have a negative impact on patient safety and outcomes. Educating patients about the concept of ambulatory surgery in terms of length of time spent in the postoperative period may set realistic expectations. For discharge instructions, it is important for both patients and caregivers to understand that most ASCs are required to discharge patients into the care of a responsible adult. Some centers may further mandate this responsible person stay with the patient for 24 hours after discharge. The immediate postoperative period is not the most impactful venue for the patient education process. While receiving important educational materials, a patient’s ability to comprehend information may be diminished due to the residual effects of anesthetic drugs, so the process would rely more heavily on the caregivers’ ability to comprehend the information provided. Valuable planning time for postoperative caregiver availability and a patient’s mental preparedness of perioperative expectations would be lost.
Each ambulatory anesthesiologist plays a critical role in creating and providing much-needed patient education before surgery. Pereira et al. showed that an empathic patient-centered preoperative interview can reduce anxiety, improve surgical recovery and even increase wound healing.
Postoperative Recovery: Patient satisfaction with the perioperative experience depends on experiences that match expectations. Education on perioperative surgical and anesthetic risks, postoperative activity limitations, the possible need for physical therapy and future follow-up appointments allows patients to have realistic expectations of their postoperative recovery and return of function. Clear instructions for both patients and caregivers on when to seek medical attention after discharge may go a long way toward improving patient outcomes and avoiding unnecessary emergency room visits.
Postoperative Pain and Symptom Management: In the ASC setting, opioid-sparing multimodal pain management, utilization of regional anesthetic techniques when appropriate and multimodal antiemetic prophylaxis have all been used to enhance earlier recovery while improving postoperative outcomes. As we continue to make improvements in the quality of patient recovery by managing perioperative pain and postoperative nausea and vomiting, a patient’s enhanced understanding of the degree of expected pain levels and other symptoms after their procedure may decrease the incidence of acute care revisits and hospital readmissions after discharge from the ASC.