Q&A What

What should be included in the instructions given to the postoperative patient before discharge?

Postoperative care is the care you receive after a surgical procedure. The type of postoperative care you need depends on the type of surgery you have, as well as your health history. It often includes pain management and wound care.

Postoperative care begins immediately after surgery. It lasts for the duration of your hospital stay and may continue after you’ve been discharged. As part of your postoperative care, your healthcare provider should teach you about the potential side effects and complications of your procedure.

Before you have surgery, ask your doctor what the postoperative care will involve. This will give you time to prepare beforehand. Your doctor may revise some of their instructions after your surgery, based on how your surgery went and how well you’re recovering.

Ask as many questions as possible before your surgery, and ask for updated instructions before you’re discharged from the hospital. Many hospitals provide written discharge instructions.

Ask your doctor questions such as:

How long will I be expected to remain in the hospital?
Will I need any special supplies or medications when I go home?
Will I need a caregiver or physical therapist when I go home?
What side effects can I expect?
What complications should I watch out for?
What things should I do or avoid to support my recovery?
When can I resume normal activity?

The answers to these questions can help you prepare ahead of time. If you expect to need help from a caregiver, arrange for it before your surgery. It’s also important to learn how to prevent, recognize, and respond to possible complications.

Depending on the type of surgery you have, there are many potential complications that can arise. For example, many surgeries put patients at risk of infection, bleeding at the surgical site, and blood clots caused by inactivity. Prolonged inactivity can also cause you to lose some of your muscle strength and develop respiratory complications. Ask your doctor for more information about the potential complications of your specific procedure.

After your surgery is complete, you will be moved to a recovery room. You’ll probably stay there for a couple of hours while you wake up from anesthesia. You’ll feel groggy when you wake up. Some people also feel nauseated.

While you’re in the recovery room, staff will monitor your blood pressure, breathing, temperature, and pulse. They may ask you to take deep breaths to assess your lung function. They may check your surgical site for signs of bleeding or infection. They will also watch for signs of an allergic reaction. For many types of surgery, you will be placed under general anesthesia. Anesthesia can cause an allergic reaction in some people.

Once you’re stable, you’ll be moved to a hospital room if you’re staying overnight, or you’ll be moved elsewhere to begin your discharge process.

Outpatient surgery

Outpatient surgery is also known as same-day surgery. Unless you show signs of postoperative problems, you’ll be discharged on the same day as your procedure. You won’t need to stay overnight.

Before you’re discharged, you must demonstrate that you’re able to breathe normally, drink, and urinate. You won’t be allowed to drive immediately following a surgery with anesthesia. Make sure you arrange transportation home, preferably ahead of time. You may feel groggy into the following day.

Inpatient surgery

If you have inpatient surgery, you’ll need to stay in the hospital overnight to continue receiving postoperative care. You may need to stay for several days or longer. In some cases, patients who were originally scheduled for outpatient surgery show signs of complications and need to be admitted for ongoing care.

Your postoperative care will continue after you’ve been transferred out of the initial recovery room. You will probably still have an intravenous (IV) catheter in your arm, a finger device that measures oxygen levels in your blood, and a dressing on your surgical site. Depending on the type of surgery you had, you may also have a breathing apparatus, a heartbeat monitor, and a tube in your mouth, nose, or bladder.

The hospital staff will continue to monitor your vital signs. They may also give you pain relievers or other medications through your IV, by injection, or orally. Depending on your condition, they may ask you to get up and walk around. You may need assistance to do this. Moving will help decrease your chances of developing blood clots. It can also help you maintain your muscle strength. You may be asked to do deep breathing exercises or forced coughing to prevent respiratory complications.

Your doctor will decide when you’re ready to be discharged. Remember to ask for discharge instructions before you leave. If you know that you’ll need ongoing care at home, make preparations ahead of time.

It’s very important that you follow your doctor’s instructions after you leave the hospital. Take medications as prescribed, watch out for potential complications, and keep your follow-up appointments.

Don’t overdo things if you’ve been instructed to rest. On the other hand, don’t neglect physical activity if you’ve been given the go ahead to move around. Start to resume normal activities as soon as you safely can. Most of the time, it’s best to gradually return to your normal routine.

In some cases, you may not be able to care for yourself for a while after your surgery. You may need a caregiver to help tend your wounds, prepare food, keep you clean, and support you while you move around. If you don’t have a family member or friend who can help, ask your doctor to recommend a professional caregiving service.

Contact your doctor if you develop a fever, increased pain, or bleeding at the surgical site. Don’t hesitate to contact your doctor if you have questions or aren’t recovering as well as expected.

Appropriate follow-up care can help reduce your risk of complications after surgery and support your recovery process. Ask your doctor for instructions before you have your surgery and check for updates before you leave the hospital. Contact your doctor if you suspect you’re experiencing complications or your recovery isn’t going well. With a little planning and proactive care, you can help make your recovery as smooth as possible.

A 42-year-old woman was diagnosed with a torn anterior cruciate ligament (ACL) in her left knee after a skiing accident. Before arthroscopic surgery, she had been given postoperative instructions for ACL repair, which included 50% weight bearing starting immediately. Upon examination of the knee under anesthesia and with visualization from the arthroscope, the surgeon determined that the ACL was only partially torn and that the joint had sufficient stability. Rather than ACL repair, the surgeon performed microfracture to address damage to the intraarticular cartilage as well as meniscus repair.

After the surgery, the surgeon briefed the patient in the post-anesthesia care unit (PACU) on his findings and the revised postoperative instructions. Because of the microfracture procedure, she was to be completely non-weight bearing for 6 weeks—a significant change from what had been originally anticipated. However, the patient was still groggy from the anesthesia and asked the doctor to give this information to her husband. The doctor called the number in the chart and made contact with the patient's mother-in-law who understood the surgeon to say that a second surgery would be required (rather than that a different type of surgery had been performed) and the patient should abide by the postoperative instructions he had given her. It was not understood by the mother-in-law that these instructions had in fact changed.

None of this was in writing. When the husband picked up the patient, the written discharge instructions from the surgeon were generic and personalized only with the handwritten phrase "do as instructed." Confused, the patient followed the original, now incorrect, postoperative instructions. The confusion was never discovered at two subsequent postop visits, in part because the surgeon never explained specifically how the rehabilitation guidelines had changed based on the new findings and change in plan during surgery. The patient pushed herself to bear weight several weeks after the surgery. When she experienced significant pain, she called the surgeon who then chastised her for not following the postoperative plan. Needless to say, the patient was upset and concerned that she may have harmed her chances for a full recovery.

This case addresses the important and challenging topic of patient–provider communication and specifically highlights the significance of these interactions during transitions in care. This commentary will review key factors that hinder communication, the implications of failures in this process, and strategies that may enhance information delivery and patient outcomes.

Transitions in care, such as those that occur at discharge from the emergency department (ED), day surgery clinic, or the hospital, are critical, high-risk moments during which patients and families assume care of a medical condition that is often new and unfamiliar. The quality of patient education and the coordination of care with outpatient providers in these situations are paramount for promoting self-care adherence and recovery while minimizing adverse events and unnecessary health care resource utilization.(1-3)

Unfortunately, communication failures during these moments of transition are common. Previous research in the ED and inpatient hospital settings reveals that many patients, like the one in this case, return home with an incomplete understanding of their care and instructions and, thus, are at risk for adverse events.(1,3-5) Studies of ED patients have found that more than 75% of patients demonstrate knowledge deficits in at least one domain of their discharge information and greater than 50% in two domains.(3,4) One study from an inpatient general medicine service found that nearly 20% of patients had adverse events within 3 weeks of discharge. The majority of these events were related to medications and nearly three-fourths could have been prevented or ameliorated.(5) Although little research has been done in the day surgery setting, significant parallels exist between these patient populations and some evidence suggests similar patterns.(6)

The origin of communication failures is multifactorial, with intersecting elements related to providers, patients, and the environment. By nature, the health care setting is inherently stressful, often chaotic, and frequently a source of anxiety and uncertainty for patients and families. Moreover, patients' physical and emotional symptoms, the direct effects of medication and treatment, as well as work-related, personal, and family stress may all negatively impact patients' opportunities to receive and process information.(7,8) At the same time, providers confront significant time constraints, as well as diagnostic uncertainty or unpredicted interruptions and events, which may undermine their efforts to communicate effectively.(7) Previous research indicates that written discharge instructions often exceed patients' health literacy levels (9), and verbal discharge instructions possess significant variability in content, frequent deficiencies, and rare opportunities to elicit patients' questions or confirm their understanding.(10)

In the featured case, it is evident that many of these factors played a role in the communication failures following the patient's day surgery. Postoperative care instructions that were given before surgery changed due to an unanticipated discovery in the operating room, the patient was unable to engage with the surgeon due to the effects of anesthesia (no written instructions on the updated recovery plan were provided), and subsequent communication occurred by phone with a family member who was not well-prepared to receive the new instructions. One can suspect that health literacy, as well as stress and other distractions, played a role in the ineffective communication between surgeon and mother-in-law, who was apparently at patient's home to provide help during the patient's surgery and initial recovery. Vague written instructions and follow-up verbal interactions were inadequate and, therefore, failed to uncover or address existing communication failures in subsequent weeks. It is readily apparent from this case that the breakdown in communication resulted from many interconnected factors. Likewise, strategies to improve this process should be multifaceted with several complementary components.

To meet the literacy needs of diverse populations, health care systems and providers should practice "universal precautions" by ensuring that all health information and discharge materials are written at or below a 6th grade reading level. In addition, the length, complexity, and visual presentation of information should be carefully considered. The cognitive factors theory emphasizes that the capacity of working memory is limited and constrains the amount of information that any individual can absorb and retain.(8) As such, effective communication is largely dependent on efforts to ensure that individuals have sufficient cognitive resources to process critical information. For written instructions, the length and complexity of sentences should be limited and attention should be given to the layout, font choice, and use of white space. In addition, the utilization of visual aids (pictures/diagrams) may augment written information and, thereby, reduce the load on working memory. For verbal communication with patients, it is important to limit the quantity of information that patients are given at any given time and to minimize distractions that may reduce available working memory at times of information delivery (e.g., pain and physical symptoms; medication effects; multiple activities at one time, such as electrocardiogram being done when information is provided). Redundancy and reinforcement of information at times after the initial interaction (when stress is typically reduced) may also facilitate the acquisition of new and complex information about a medical condition and its management.(11,12) In this case, the surgery team could have provided reinforcement of revised discharge instructions with a phone call to the patient and/or her husband soon after returning home. Additional strategies to support information delivery include opportunities to review, such as a teach-back, which have been shown to improve patient adherence and clinical outcomes in the outpatient setting.(13) In the inpatient setting, existing projects (e.g., Project RED and Project BOOST) have developed highly-structured approaches to the discharge process that involve numerous supporting elements, including nurse discharge advocates, a standardized After Hospital Care Plan, follow-up phone calls to reinforce home care instructions, and enhanced coordination of care between inpatient and outpatient providers.(14,15) Results from Project RED demonstrated a 30% reduction in readmission and ED visit rates after hospital discharge.(14) These inpatient projects can serve as meaningful models for the enhancement of discharge processes in other clinical settings.

In this case, the patient was given verbal instructions for recovery, which were significantly different from what had been communicated preoperatively. However, she received those new instructions while cognitively compromised by anesthesia. No one communicated the change to her husband (the designated caregiver), and the written discharge instructions did not specify the changes. In the same day surgery setting, it is important that the health care team have a reliable process in place by which both written and verbal instructions are given to the patient or their designee at a time when they can be understood. Above all, it is critical that health care providers maintain a high level of awareness regarding factors that can hinder communication and, at the same time, recognize that compromised information delivery is a complication of medical care that needs to be addressed aggressively and thoroughly. In the future, technology may be an important element in safeguarding information delivery processes by providing "backups" to our direct interpersonal interactions, in the form of online records and appropriate multimedia (an instructional video or perhaps the attending physician's recorded instructions) which are available when needed. Although we are still far away from such a vision, this case highlights the importance of pursuing innovative approaches that can enhance the quality and safety of our health care system.

Take-Home Points

Effective communication between providers, patients, families, and caregivers is a critically important aspect of patient care, which has significant implications for patient outcomes at times of transitions in care.
Communication with patients should be at or below a 6th grade reading level and the complexity and quantity of information should be limited.
Repetition and reinforcement of key information can provide patients the opportunity to receive and retain their instructions.
Opportunities to review (e.g., a teach-back), follow-up contact with a patient after discharge, and enhanced coordination of care with other providers may improve patient outcomes at times of transitions in care.
Providers should be sensitive to factors (related to the environment, patient, or themselves) that may make it difficult for a patient or family member to receive new information and consider approaches or interventions to minimize these challenges.

Kirsten Engel, MD Assistant Professor in Emergency Medicine Northwestern University Feinberg School of Medicine Chicago, IL

References

1. Clancy C. Finding your way: what to do before you leave the hospital. AARP Bulletin. December 17, 2008. [Available at]

2. Dunnion ME, Kelly B. From the emergency department to home. J Clin Nurs. 2005;14:776-785. [go to PubMed]

3. Engel KG, Buckley BA, McCarthy DM, Forth VE, Adams JG. Communication amidst chaos: challenges to patient communication in the emergency department. J Clin Outcomes Manag. 2010;17:449-452. [Available at]

4. Engel KG, Buckley BA, Forth VE, et al. Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest? Acad Emerg Med. 2012;19:E1035-E1044. [go to PubMed]

5. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-167. [go to PubMed]

6. Fayers T, Abdullah W, Walton V, Wilkins MR. Impact of written and photographic instruction sheets on patient behavior after cataract surgery. J Cataract Refract Surg. 2009;35:1739-1743. [go to PubMed]

7. Pytel C, Fielden NM, Meyer KH, Albert N. Nurse–patient/visitor communication in the emergency department. J Emerg Nurs. 2009;35:406-411. [go to PubMed]

8. Wilson EAH, Wolf MS. Working memory and the design of health materials: a cognitive factors perspective. Patient Educ Couns. 2009;74:318-322. [go to PubMed]

9. Herndon JB, Chaney M, Carden D. Health literacy and emergency department outcomes: a systematic review. Ann Emerg Med. 2011;57:334-345. [go to PubMed]

10. Vashi A, Rhodes KV. "Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions. Ann Emerg Med. 2011;57:315-322.e1. [go to PubMed]

11. Sudore RL, Schillinger D. Interventions to improve care for patients with limited health literacy. J Clin Outcomes Manag. 2009;16:20-29. [go to PubMed]

12. Watson PWB, McKinstry B. A systematic review of interventions to improve recall of medical advice in healthcare consultations. J R Soc Med. 2009;102:235-243. [go to PubMed]

13. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90. [go to PubMed]

14. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150:178-187. [go to PubMed]

15. Project BOOST. Society of Hospital Medicine. [Available at]

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Take-Home Points

Effective communication between providers, patients, families, and caregivers is a critically important aspect of patient care, which has significant implications for patient outcomes at times of transitions in care.
Communication with patients should be at or below a 6th grade reading level and the complexity and quantity of information should be limited.
Repetition and reinforcement of key information can provide patients the opportunity to receive and retain their instructions.
Opportunities to review (e.g., a teach-back), follow-up contact with a patient after discharge, and enhanced coordination of care with other providers may improve patient outcomes at times of transitions in care.
Providers should be sensitive to factors (related to the environment, patient, or themselves) that may make it difficult for a patient or family member to receive new information and consider approaches or interventions to minimize these challenges.