Automated Pre-op Instructions in a Culture of Continuous Improvement

September/October 2011

Automated Pre-op Instructions in a Culture of Continuous Improvement

The benefits of providing patients with pre-operative instructions tailored specifically to their unique procedures, health status, and medications are well established. Patient safety perhaps tops this list. Healthcare providers have long recognized that offering clear, easily understandable instructions that cover requirements including fasting, discontinuing anticoagulants or blood pressure regulators, avoiding tobacco and alcohol, and more can enhance patient safety by reducing the chances of potentially life-threatening perioperative complications (Tea, 2010).

Pre-operative instructions that give patients a good sense of what to expect on the day of surgery and afterward can also improve patients’ subjective experience and clinical outcomes. Studies show that the simple act of offering detailed pre-operative information can reduce pre-operative anxiety, as well as post-operative pain and medication use—thus returning patients to daily function faster (Hathaway, 1986; Garretson, 2004; Makki et al., 2011; Blay et al. 2005). Pre-operative instructions that ensure patients are ready for surgery, and that provide clear contact information in case of questions or problems before the procedure, also reduce preventable surgery cancellations (Henderson et al., 2006; Pletta et al., 2008).

In fact, I believe the delivery of instructions is so important that it should be considered to be an integral part of the consent process. While these instructions do not need to be delivered by the surgeon, their importance cannot be overlooked or ignored.

From a surgeon’s, anesthetist’s, and OR scheduling team’s perspective, few circumstances are more frustrating than to enter the hospital for a scheduled procedure only to find that the case must be canceled due to failure of the patient to follow his or her pre-surgical directions. These situations can be equally disconcerting for the ill-prepared (and now angry and/or embarrassed) patient and patient’s family. He or she may have already scheduled time away from work, or insurance coverage may be a factor. Learning that a procedure needs to be rescheduled 6 weeks from when a patient originally expected can be devastating in terms of employment, reimbursement, or planned recuperative period.

Years ago I automated my practice in an effort to supply my patients with comprehensive packages of materials, some self-written and some supplied by the hospital, outlining all aspects of planned operations (Gottesman, 2005; Gottesman, 2008). My instructions clearly described what a patient should expect—this is particularly important for procedures when a patient is awake or only mildly sedated—and exactly what a patient needed to do to be ready for the test, treatment, or surgery. Forward-thinking hospitals, such as the Baltimore Veterans Affairs (VA) Medical Center, have developed similar strategies to avoid the challenges presented by inadequately prepared patients.

A colleague, Janet Pierce, RN, clinical informatics coordinator at the Baltimore VA Medical Center has described their efforts (2011) with computerizing the consenting process including the provision of preoperative instructions.
The Baltimore VA Medical Center is the acute medical and surgical care facility for the VA Maryland Healthcare System. This state-of-the-art teaching facility offers a full range of inpatient, outpatient, and primary care services.

However, through mid-2008, the process for providing pre-operative patient instructions and documenting that patients received and complied with them remained a paper-based one. Despite their use of the VA’s VistA Computerized Patient Record System (CPRS) electronic health record (EHR), this vestigial paper process risked creating inefficiencies that could contribute to delays in clearing patients for surgery, and in unnecessary clinic or emergency department visits, noted Pierce.

The Problem: Paper Is Hard to Access
While standardized paper forms were available for many procedures, they required nursing staff to locate them and then document any necessary details unique to the patient, often in the form of handwritten notes. Copies of the form were given to the patient, forwarded to the pre-op unit for verification on the day of surgery, and sent to medical records to be scanned into the electronic system.

Unfortunately, the records often were not scanned in a timely manner. So when patients contacted the system’s call center with questions, staff did not have access to the specific instructions. Nurses or physicians familiar with the case had to be tracked down for answers, or a clinic visit scheduled to clarify instructions.

The legibility of handwritten notes was also an issue, explained Pierce. In addition, on the day of surgery, locating a copy of the pre-procedure instructions was sometimes a problem. Between problems with patient compliance due to lost or difficult-to-read instructions and paperwork delays in the harried environment at the beginning of the surgical shift, the process involving pre-operative instructions contributed to some procedure delays and cancellations.

By contrast, the process for obtaining informed consent at the Baltimore VA Medical Center was fully electronic and integrated into the EHR. Customized consent forms by procedure were generated automatically using an automated informed consent application. Physicians had patients sign electronically and simply printed off the form for the patient to keep—reminding the patient of the risks and potential complications associated with his or her planned procedure. The signed consent forms automatically appeared in the patient’s electronic medical record without the need for scanning, making the detailed, procedure-specific consent available to all system users at any time.

Searching for a better answer to the challenges posed by the paper-based instruction process, nurses in the pre-op unit asked whether pre-operative instructions could be automated in a similar manner as their consent forms. Pierce took steps to do just that.

The Solution: Automating Pre-op Instructions
The task of automating pre-operative instructions proved less complex than expected. Nationally approved consent forms customized for most common procedures already existed in an automated consent application, and these forms included generic pre-operative instructions. Using these instructions as a template, Baltimore VA Medical Center staff added fields to enter patients’ active medications, specifics about their histories and physical exams that might affect instructions, and specific contact information.

Like the consent forms, offering the pre-op instructions via the automated digital system also allowed the functionality that provided for printing in larger fonts to accommodate the needs of older and visually impaired patients. Several surgical healthcare providers collaborated to create the form. Instructions typically include:

  • Procedure date
  • What to expect on the day of surgery and after
  • Pre-surgery fasting and nutrition requirements
  • Medication requirements (e.g., to discontinue use of medications such as blood thinners, or to maintain medications such as those for diabetes control)
  • Tobacco and alcohol requirements (e.g., no smoking 8 hours before surgery, no alcohol 24 hours before or after)
  • Any special hygiene requirements (e.g., pre-op shower with special soap, or a request to remove nail polish and makeup to enable adequate oxygenation assessments in patients undergoing anesthesia)
  • A request to report coughs, fevers, or other symptoms of illness or infection that occur prior to surgery
  • Contact information for the case manager and other pre-op contact staff

Because these are not consent documents, the pre-op instructions did not require approval at the national VA level. However, technical support personnel helped incorporate the instruction sheets into the existing consent software, which is fully integrated with the VistA CPRS system.

The instructions now are typically given to patients by nurse practitioners or nursing staff at a pre-operative clinic visit. A history and physical are taken, current medications are reviewed, and the instructions are the last step in the visit. Nursing staff go over the instructions in detail and answer any patient questions. Once satisfied that they understand their procedures, patients sign off electronically using a digitized signature capture pad similar to those for credit card transactions. The instructions are printed out and handed to the patient, but the completed form is also automatically appended to the patient’s electronic record. A separate note documenting provision of the instructions is posted in the EHR as well.

Many studies suggest that offering instructions in the clinic setting helps patients retain more information and improve compliance, and therefore may result in better outcomes (Ferschl et al., 2005; Kaye at al., 2010). At the Baltimore VA MedicaCenter, a high utilization rate has definitely had a positive impact on clinical workflow and patient care, stated Pierce.
Results and Lessons Learned
The automated pre-operative instruction program was introduced in October 2008, and was administered 423 times by the end of that year. In 2009, the form was submitted for 2,185 surgeries, and in 2010 for 2,099 surgeries, or 77% of surgeries performed. In some cases the forms are not appropriate—for in-patients undergoing procedures, for example—and occasionally there is not enough time to use the system before surgery.

While not in the 98 to 100% utilization range typically seen for use of the automated system to prepare consent forms, adoption of the electronic process for pre-op instructions has been excellent. This is especially notable given that preparing electronic pre-op instructions is not a requirement of the VA system. Moreover, Baltimore VA Medical Center staff report that the 77% rate is a huge improvement over the paper-based process, where it was difficult even to track utilization. Among the advantages observed:

  • The system assists clinicians with documenting the pre-op instruction process, freeing them to focus on the patient rather than noting exactly what was said and when.
  • Patients receive clear, customized instructions. If they are lost, they can be retrieved from the electronic record by any staff member and reproduced in seconds. This avoids wasting time tracking down paper documents or a clinician who can verify the instructions, increasing staff efficiency and preventing delays in giving patients the information they need.
  • The system enhances patient ownership of the preparation process, thus improving their chances of a good outcome and avoiding cancellations due to non-compliance with instructions. The signing requirement and the clear written instructions, in combination with the focused pre-surgery education visit, help engage patients in the process.
  • The automated process eliminates the need to search for misplaced documents in the pre-op area, reducing confusion before surgery. This avoids the prospect of having to re-instruct patients who may be anxious or lacking glasses (and maybe even teeth) in the minutes before surgery.
  • As a result of improved communication on conditions that might require a cancellation, patients are more likely to call in a day or two before surgery if they have cold symptoms or other problems. This reduces day-of-surgery cancellations and enables operating rooms to be used for “add-on” procedures for inpatients or emergent cases.

The automated process helps reduce late starts as well.

Even with all of the changes involved in implementing the automated pre-op instruction process, training on the new procedures was fairly straightforward. Most of the staff are conversant with electronic records and recognize the value of using them to streamline and improve care processes, explains Perce. In fact, residents from the University of Maryland School of Medicine, an academic affiliate connected to the Baltimore VA Medical Center—physicians who have had experience in other facilities—are particularly impressed with the VA’s EHR and automated informed consent and pre-op instruction programs.

One temporary snag they did encounter involved ensuring an adequate wireless infrastructure. The instruction process often is carried out with a laptop or tablet computer, and initially it was hindered in clinic and hospital locations that did not have adequate wireless signal strength. Pierce reports that the solution was obtained by adding extra Wi-Fi stations to eliminate dead zones. In addition, Baltimore VA Medical Center staff made sure to have printers available, close by, and networked with the system so that instructions can easily be printed for patients.

This project is a product of a “culture of continuous improvement” at the Baltimore VA Medical Center, noted Pierce. As with other efforts, it leverages information technology to make patients safer and improve outcomes. A large body of evidence suggests that customized pre-operative instructions delivered in a clinic setting help patients better prepare for common surgical procedures, improving the odds of better outcomes. By automating this system, the VA facility improved its “first-case-on-time” performance, providing more consistent service to its patients. The impact of this automation will continue to be studied, and Baltimore VA Medical Center intends to use those results to further improve their processes.

In Conclusion
Detailed, easy-to-understand pre-operative instructions accomplish three major objectives:

  1. They put patients at ease—my patients have historically been less anxious than they might otherwise be because they knew exactly what would happen to them from the moment they arrived at my office or hospital.
  2. They can make healthcare more efficient—it has not been unusual for me to explain to a patient that they would receive an ECG when they arrive at a hospital only to learn that they had just undergone that exact test in their internist’s office. Knowing that information well in advance results in test information being provided to the hospital and a redundant test or procedure eliminated.
  3. They improve outcomes—the patient who fails to discontinue anticoagulants (e.g. aspirin, ibuprofen) places him or herself at risk for post-surgical bleeding and related consequences. Likewise, the patient who fails to bathe with antibacterial soap, or who fails to take a prophylactic antibiotic precisely as directly, is at greater risk of a post-surgical infection. Strictly following pre-operative instructions is vital to minimizing the risk of treatment or surgical complications.

Like the Baltimore VA Medical Center, hospitals and physician practices can enhance safety and improve the overall delivery of care by investing in the processes that fully prepare their patients for treatments and procedures.

James Gottesman is a practicing urologist and frequent author and lecturer on the subject of informed consent and shared decision-making. Gottesman founded Dialog Medical, now a Standard Register Healthcare Company. He may be contacted at

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