At the Louis Stokes Cleveland Department of Veteran Affairs Health Care System (LSCDVAHC), in Cleveland, Ohio, the staff of the cardiology section has engaged in a systematic education program focusing on veterans and their families. The goal is to enhance the patient’s knowledge and encourage family involvement prior to cardiac procedures. The department has utilized planned teaching methods such as the use of instructional DVDs (with closed-captioned option for the hearing impaired), pamphlets, visual aids and direct conversation with the veterans. This innovation was designed to enhance understanding of the scheduled procedure, with a focus on the veteran and their family unit. This innovation also includes measures to decrease costs and encourage safe and effective utilization of resources. The LSCDVAHC Cardiology Department has implemented this innovation by educating our veterans prior to any procedure. The educational session is then documented in our computerized patient record system (CPRS) and becomes part of the patient’s permanent medical record.
After reviewing results from a 2009/2010 satisfaction survey, it was clear that LSCDVAHC veterans would benefit from an enhanced pre-procedure education program.1,2 Some of the patients’ questions to be addressed from the satisfaction survey were as simple as “What is a cardiac catheterization?” or “When can I return to work?”. Based on the survey results, our nurses and the cardiology team recognized a need for improved pre-procedure education, and the need for a nurturing environment while waiting (hospitality). Utilizing a web of causation model (Figure 1), we confirmed the need for early education to improve involvement of the patient and family.3 The Cardiology Department worked to create an innovative educational system, which has been in use since January 1, 2009, as a regular part of patient care.
We began our education program with a simple telephone call to the patient for an introduction and education, but wanted to do more. We sought to more efficiently utilize resources to decrease patient anxiety by educating them prior to a cardiac procedure. Our efforts arose both as a response to the Planetree model (www.planetree.org, a non-profit organization that provides education and information to create patient-centered care in healing environments), and the fact that the Joint Commission of Accreditation was scheduled to visit sometime that year. After ensuring the guidelines from the Joint Commission were met or exceeded, our department decided to develop a patient education initiative. As we looked toward the future, we also saw medication reconciliation as a forthcoming Joint Commission guideline, and our department decided to implement medication reconciliation simultaneously with patient education. The medication reconciliation is obtained from the patient pre procedure and documented in the Computer Patient Record System (CPRS). Post-procedure education consisted of complications of the procedure to watch for and restricted activities due to sedation.
The initiative followed a poster based on the ideals of shared governance. For the education of all staff, the poster design covered patient education, hospitality, safety, environment of care, and situation, background, assessment and recommendation (SBAR).4 The poster was developed by literature reviews of peer-reviewed articles and rewritten by our staff to meet our organization’s needs. From the poster, a Plan Do Check Act (PDCA) system was devised to reinforce the poster’s main points of emphasis. We were able to prove that our implementation of patient education prior to the procedure was a great asset to the facility by the results of the PDCA plan.
One of our primary concerns was to meet the goal of the VA’s Strategic Plan, which focuses on educating and empowering our veterans and their families. Our division supervisor, cardiologists and nursing staff came together in several meetings to plan a strategy and protocol related to this project. The cardiology staff was acutely aware of the learning level required and used a knowledge base that the veterans and their families could easily understand.
Change involves patience and perseverance, as well as the unity of a team to create and define the changes we wish to make. Change is often difficult and met with resistance, but is a necessary part of continued growth. We are fortunate that the LSCDVAHC has an environment of support that empowers every nurse to create and develop innovative ideas. Nursing administration encourages nurses to actively participate in organizational decision-making. This involves creating a collaborative structure with multidisciplinary team involvement. The cardiology nurses, in conjunction with the cardiologists and the electrophysiologist, developed an educational DVD to be viewed by the veteran prior to his or her procedure. Creating a video helps ensure that all patients are educated, including the hearing impaired.
By involving our chief of cardiology, the innovation grew to include a number of cardiology physicians, nurses and technologists.2 It was through the diversity and focus of this dynamic team that the entire scope of the patient education innovation successfully became a regular part of our daily process.
The department utilized available resources, including the hospital intranet, librarian, and medical media. Topics for pre-procedure education were divided among the physicians based on their cardiology specialties, including cardiac catheterization, electrophysiology, imaging and echocardiography. Individual cardiologists’ roles were defined and the dialogue was written by each physician prior to taping the DVD.
Patients often report feeling stressed, rushed, coerced or overwhelmed prior to their procedure. It is our goal to ensure that our patients are educated prior to their procedure, resulting in the reduction of stress and anxiety.3 During our review of the satisfaction surveys, it was also noted that family members became frustrated, and many times, emotional, when not updated in a timely manner. In response to this, a pager system was developed. The family member is given a pager, and the pager alerts them when the physician is ready to discuss findings and interventions. We also page family members if a procedure lasts longer than expected. This provides a bridge of information to the family during the procedure, and results in better-informed and less anxious family members.
We have found decreased costs as a result of increasing patient satisfaction and decreased need for service recovery. Costs have also been decreased by patients not requiring as much sedative medication, a result of reduced anxiety. Patient readmission rates have also decreased, freeing bed usage. These patients are typically readmitted overnight. Further cost has been saved because our system has reduced workload and overtime pay. We have found that by increasing patient satisfaction, patient retention is easier and return visits more likely, due to an established trust relationship. Return visits increase patient volume, revenue and workload. Our established trust relationships arise out of focused, factual education for patients and the well-educated staff providing the teaching.
We include educational pamphlet information, hospitality bags and stress-relieving recordings to decrease patient and family member anxiety. The list below includes all of the tools that we use, and a card that we give to all our patients is laid out as follows:
You had a procedure in Cardiology today.
My name is: (Nurse name here)
If you have any questions, concerns or complaints about your Cardiology experience, please feel free to contact my supervisor @ _______________
We also provide the patient with:
• Questions regarding anxiety pre procedure and post:
– What was your anxiety prior to the procedure?
– Were you offered a choice of music to listen to during the procedure?
– Were you able to have the music you requested?
– Did the music help to relieve you anxiety?
• An Understanding Cardiac Catheterization pamphlet
• Cardiology care bags
– Cardiology bags are printed with: “Cardiology cares”
– Teddy bears with a “Cardiology cares” button
– Additional cardiac catheterization pamphlets
– Disposable walkmans with relaxation music
• Magazines: Jet, Time, Popular Science, Home Journal
• Audio tapes focusing on reducing stress and anxiety
• Headphones with jazz, pop, and piano concerto music
A primary nurse then follows the patient during their procedure. This ensures each patient can develop a therapeutic relationship with their primary nurse.
The mission of the Cardiology Department is: “We do what is best for the service of our veterans.”
Creating the Educational DVD
The DVD teaches the veteran about their upcoming procedure and explains what he or she may expect upon arrival to the Cardiology Department. The veteran has the opportunity to view the DVD prior to their procedure, either in our department or in their room. This video is also available for viewing in all of the community-based outpatient clinics (CBOCs) in Veterans Integrated Service Network (VISN) 10. Pre-viewing the DVD enables the veteran to address questions about their procedure — whether a question about preparation for, during, or post procedure — before they arrive in the cardiac catheterization or electrophysiology lab. Their questions can then be addressed directly with their primary cardiology nurse or their physician. Each DVD contains information about different procedures, including cardiac catheterization, electrophysiology, stress testing and transesophageal echocardiograms. The veteran can easily choose which portion of the DVD will be relevant and helpful. Through many hours of follow-up phone calls, our nursing staff has discovered that educating our veterans prior to their procedure not only reduces anxiety, but provides the veteran with increased confidence and self assurance upon arrival to the Cardiology Department.
Our team consisted of the following: 2 cardiologists; 1 electrophysiologist/ cardiologist; 1 certified clinical nurse specialist; 3 registered nurses with a BSN; 1 registered nurse with a Masters in Education; 1 certified radiography technician; 1 certified nurse practitioner.
Each team member provided input into this project.
Educating the patient and the family prior to the procedure decreases fear and the patient’s anxiety levels, leading to a more successful outcome. The aim of every cardiologist is to have positive patient outcomes and increase patient satisfaction. The LSCVAMC staff is seeking to promote high patient satisfaction and customer service, while encouraging the development of self-efficacy. Self-efficacy focuses on one’s expectations and beliefs about one’s own ability to competently perform specific actions that will produce desired outcomes.5 A long-term goal is to have the patient change lifestyle habits, such as diet, exercise and smoking cessation. This information is noted when the patient reports to the follow-up clinic. Various studies have supported the idea that patients who work alongside their physician to improve their own health feel a sense of self-importance, as well as a higher drive to promote positive clinical outcomes.6,7 One of the main objectives is to encourage active patient participation via discussion, pamphlets, and the LSCVAMC intra-facility television system. We have included all family members by giving them a pager to alert them when the case is over. The pagers have decreased their anxiety by giving families a feeling of security, knowing they were just a page away from the patient, rather than the uncertainty of not knowing when or by whom they may be contacted.
The DVD was initially viewed by cardiology patients, followed by electrophysiology, stress and finally, transesophageal patients. It is seen on a pre-arranged, scheduled time slot. Patients needing education view the material at their own initiative. Presently, we are educating the patients in the clinic, and with the support of our physicians, we are also educating and meeting patients at the bedside, as well as prior to the procedure.8 The nurse programs the DVD to the cardiac catheterization procedure and the physician performing the procedure educates the patient through the DVD. The efforts of the cardiology team ensure that the patient will have continuity of care. The nurse who educates the patient will be the nurse to administer the sedation medications. We are also providing patients with a quiet environment and a sense of comfort, as well as trust.
With the patient being the focus, we all meet to ascertain the needs of the patient and any questions or concerns prior to the start of a procedure.8 In general, the goal of the LSCVAMC Cardiology Department is to provide high-quality, evidence-based practice to ensure good, patient-centered care. The overall goal is to provide evidence of positive patient support and care, advancing the knowledge of our patient population. A study in Australia indicated that when the needs of patients’ families are met, they are more capable of caring for the patient at home.5 Our goal is to improve patient care and outcomes by enhancing patient knowledge, utilizing technology for patients as well as families, while supporting the care of the patients.9
The impact of educating the patient and their families became apparent with the results of our satisfaction surveys. Survey results following implementation of our education innovation indicated an increase in the number of positive responses from veterans. These performance improvement results reflected an increase in satisfaction over a one-year period.2 Our surveys were created by our dynamic team, and were submitted to Quality Management for approval. The surveys focused on the educational material as well as meeting our objectives for hospitality improvement. Following is a brief look at some of our findings:
- 68% of patients reported “being nervous” prior to the procedure.
- 84% of patients reported that music assisted them with relaxation.
- 84% of patients preferred music during their procedure; 16% preferred no music during their cardiac catheterization.
- Overall, 53% of patients responded positively to our educational and music innovation.
During the survey, questions were asked such as: “What is your music preference?” and “Do you think music would help relax you during your procedure?” We found that the questions asked were easy for the patient to think through and answer. Some of the challenges encountered included providing privacy to the patient, a quiet environment, and communicating patient flow in the work area.10
Our team’s efforts included a multifaceted approach to educating our patients, using pamphlets, verbal communication/education, and concrete procedural information. The results of this specific education revealed a substantially reduced amount of stress and anxiety for the patients and their families prior to their scheduled procedure. In January of 2009, 67 cardiology patients received music and innovative education as described above. These therapies were received in such a positive way by our patients that we increased our efforts, and the following month, 87 patients received the same information.
To be included, the patient had to be scheduled for a cardiac catheterization or electrophysiology procedure. As the initiative grew, the stress testing lab and the echocardiogram department adopted the same innovative procedures, with the same positive results. This innovation was kept specific to the cardiology department. Other areas of the hospital were excluded from this innovation.
Finally, it was decided that any patient who received a stent in our catheterization lab would be sent home with a teddy bear. The cuddly bear served to provide the veteran with comfort and a sense of hospitality following their procedure. Again, these were well received, resulting in a distribution of 240 bears total thus far.
Every day, we are faced with unique challenges while caring for the veterans in our medical center. Since the beginning of our innovation, we have had > 900 patients receiving pre-procedural education, comforts such as music, bears, and take-home bags, and proper medication reconciliation. We are committed to continuously improving the care, education, and hospitality that we provide to our veterans.
The authors can be contacted at Tammy.Chandler@va.gov.
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