Background: Approximately 20% of patients diagnosed with pancreatic cancer will be eligible for hepato-pancreatico-biliary (HPB) surgery. Studies indicate that high-quality patient education is pivotal in reducing anxiety, improving clinical and performance outcomes, and increasing patient satisfaction.
Objectives: This quality improvement project sought to determine the perceived level of preparedness for patients undergoing HPB surgery and to identify information and knowledge gaps in preoperative education.
Methods: Convenience sampling was used to collect postoperative information via questionnaire from 50 patients regarding areas of importance.
Findings: Preoperative information gaps for patient and family education were identified. Improving preparedness for HPB surgery has the potential to improve clinical outcomes, increase quality and patient satisfaction, decrease length of stay, and reduce time to adjuvant therapy.
About 57,600 individuals will be diagnosed with pancreatic cancer in 2020 (American Cancer Society [ACS], 2020). Another 11,980 will have gallbladder cancer or another biliary cancer (ACS, 2020). About 20% of these individuals will be eligible for potentially curative resectional hepato-pancreatico-biliary (HPB) surgery, because the majority of patients will have nonoperable, locally advanced disease or metastatic cancer at the time of diagnosis (Pucci et al., 2017; Raigani et al., 2014). Those with premalignant pancreatic lesions and benign conditions are also eligible for HPB surgery.
Studies indicate that high-quality patient education is pivotal for preoperative surgical candidates to reduce anxiety, improve clinical and performance outcomes, and increase patient satisfaction (Eller et al., 2018; Mesters et al., 2001). Studies have identified a relationship between anxiety, psychological stress, and surgery (Berg et al., 2006; Mitchell, 2003; SjÖling et al., 2003). Patients with HPB cancers and premalignant HPB disease experience considerable worry and anxiety (Barnes et al., 2018; Beesley et al., 2016). Patients with cancer desire health information, and their healthcare providers are their most trusted source of information (Papadakos et al., 2014; Shea-Budgell et al., 2014).
To support the quality improvement project, PubMed®, CINAHL®, and OVID® databases were queried from September 1 to October 30, 2019, for articles published between 2014–2019, using the following search terms: pancreas surgery, preoperative education, perceived preparedness, performance outcomes, and patient satisfaction. The studies selected from this review of the literature evaluated the level of patient preparedness for surgery, the type of information offered to patients preoperatively, and the most effective presentation.
Based on the literature review, a knowledge gap exists concerning the educational needs of patients undergoing HPB surgery. Eller et al. (2018) reported on the Preoperative Learning and Readiness in Surgery program, which is a one-hour, patient-centered instructional class for individuals scheduled to have a pancreaticoduodenectomy. Eighty-two percent of patients who attended the class felt prepared for surgery compared to 77% of patients who did not attend the class. Three other studies investigating patient preparedness for surgery were identified, including two cross-sectional descriptive studies and one retrospective study.
Gillespie et al. (2017) investigated the information needs of individuals undergoing surgery for HPB conditions. Their study examined patient responses preoperatively and six weeks postoperatively to six domains of information: medical, practical, physical, emotional, social, and spiritual needs. The adult patient population was English speaking with a confirmed cancer diagnosis of the liver, pancreas, gallbladder, or bile duct, and who had undergone surgery. The physical and medical domains were most highly rated in terms of information importance. Information regarding how to prepare for surgery, information about the actual surgical procedure, how to deal with pain, and how to care for yourself following surgery were also highly valued. Overwhelmingly, patients preferred receiving information in a one-on-one consultation with a healthcare provider. Audio methods and websites were popular alternatives. These findings provide guidance to healthcare providers in developing educational tools preoperatively.
Munigala et al. (2018) evaluated the impact of the National Pancreas Foundation’s online educational module, Animated Pancreas Patient (APP), which is available on the APP website and YouTube. In their retrospective study, Munigala et al. (2018) reported that online education modules improved patient education, assisted patients and family members with decision making, and promoted patient satisfaction. Study results confirmed that written patient education information has the potential to engage patients in their own care and to create a more open dialogue between patients and clinicians.
In a 2018 cross-sectional survey of six cancer specialties, Ronfeldt et al. (2018) assessed clinical practice guidelines (CPGs) that promote enhanced surgical recovery. All CPGs addressed nutrition, mobilization, pain management, and postoperative nausea and vomiting. Based on the survey, only 65% of the cancer specialties had well-defined discharge plans. Patient information leaflets (PILs) were used to supplement oral instructions by describing the postoperative period, possible complications, and recovery expectations. Two researchers with Whipple procedure expertise assessed the PILs and determined that the PILs provided fair or poor quality of information for patients undergoing surgery for cancer.
An opportunity exists to improve the preparation of patients for HPB surgery. Enhancing the learning experience in the preoperative period can lead to reduced patient and family anxiety, improved patient outcomes, increased patient satisfaction, enhanced understanding of the planned procedure, and more realistic postoperative expectations for the patient and the family regarding the recovery course. The overall objective of this quality improvement (QI) project was to determine the perceived level of surgery preparedness of patients at Thomas Jefferson University Hospital, a high-volume National Cancer Institute–designated cancer center in Philadelphia, Pennsylvania, specializing in surgery for HPB cancers and conditions. The project’s intent was to improve the quality of the patient experience and clinical outcomes and to evaluate the current preoperative educational material. This information will ultimately be used to implement appropriate interventions to fill the identified informational and educational gaps.
Quality Improvement Project Procedures
This project began as a unit council initiative on an inpatient unit, Pavilion 13, at Thomas Jefferson University Hospital. More than 300 HPB surgeries are performed at the center annually. The clinical RNs on this unit provide nursing care for patients who have had HPB surgery, usually after a brief postoperative stay in the intensive care unit. At a unit council meeting, the nursing staff discussed the challenges that patients experienced in the immediate postoperative period following HPB surgery, such as progressive ambulation, participating in their own pain control, and enduring being NPO (nothing by mouth) for two days before being advanced to a full liquid diet. Council members reached out to the outpatient surgical oncology nurse practitioners (NPs) who work exclusively with this HPB patient population for their input. A research interest group was formed and considered if patients with pancreatic cancer and related biliary tract cancers were currently getting the information that they needed before and after HPB surgery. The Preparedness for Surgery QI project was designed to assess the level of patient preparedness for HPB surgery, patient knowledge about the postoperative course, and patient expectations regarding hospital discharge and postdischarge care. The goal was to (a) identify information gaps in preoperative patient and family education, (b) improve the quality of the patient experience and clinical outcomes, and (c) evaluate the preoperative educational material. The information will be used to develop and implement appropriate interventions to reduce identified information and teaching gaps.
Preoperative Educational Materials
Patients with pancreatic, ampullary, and duodenal cancers and serious, benign conditions that included intraductal papillary mucinous neoplasms (IPMNs), cyst adenomas, pancreatic neuroendocrine neoplasms, and gastrointestinal (GI) stromal tumors undergoing major, potentially curative surgery were included. The following operations are performed to remove these tumors: pylorus-preserving pancreaticoduodenectomy, also known as the mini Whipple procedure; distal pancreatectomy; classic pancreaticoduodenectomy; and total pancreatectomy. The usual preoperative education starts at the time of the first office visit with the surgeon, advanced practice nurses, and clinical research coordinators. The book Navigating Pancreatic Cancer: A Guide for Patients and Caregivers (Lustgarten Foundation, 2019) is given to patients who are candidates for pancreatic surgery. The guideline discusses the planned operation, such as the anticipated length of hospital stay, potential complications related to the operation, the usual hospital recovery process, and the discharge plan and expected home recovery course. The discharge plan includes a discussion about possible rehabilitation facility stays, home nursing care, and physical therapy. Discharge medications are not discussed in detail at this time and have traditionally been discussed as part of the unit-based discharge process, primarily because not every patient undergoing pancreatic surgery has the same medication needs. The education process continues during the pre-admission testing visit, which includes a physical examination, routine preoperative blood work and medication verification, and a review of the planned surgery with an opportunity for the patient and/or family to ask questions. There is also an opportunity to ask questions on the day of surgery.
A cross-sectional study design was used for this QI project. The desired sample size was 50 patients. Information was collected via a specifically developed questionnaire regarding HPB patient preparedness for surgery. The electronic health record was used to obtain relevant clinical data. The questionnaire was developed and refined by the authors, who have clinical expertise in the nursing care of patients undergoing HPB surgery, with the input of an experienced HPB surgeon to ensure face and content validity. The institutional review board (IRB) determined that the planned survey constituted a QI initiative and, therefore, did not require formal IRB study board approval or informed consent. The project was approved as a QI initiative by the IRB in 2019.
Postoperative patients who underwent HPB surgery were identified on an inpatient unit at the Thomas Jefferson University Hospital and were approached for the survey if their preoperative diagnosis was determined to be an operable HPB cancer or a benign or premalignant HPB condition, such as an IPMN or a pancreatic cyst. Postoperative patients who did not have an HPB diagnosis were excluded.
Data Collection and Outcome Measures
Patients who underwent HPB surgery were queried postoperatively regarding their perceived level of surgery preparedness on areas of postoperative importance. These areas broadly included postoperative ambulation, pain management, dietary provisions and restrictions, discharge planning, involvement of a case manager, and specific discharge medications. The eight-item questionnaire (see Figure 1) queried patients on how well prepared they felt for their planned surgery, using a Likert-type scale on which the possible responses were 1 (not at all prepared), 2 (somewhat prepared), 3 (moderately prepared), and 4 (well prepared). The questionnaire was administered postoperatively to patients who underwent HPB surgery on a single, high-volume inpatient unit from December 2018 to April 2019. The questionnaire was presented near the end of the hospitalization on postoperative day 4 or 5. Patients completed the survey either independently or with the help of a family member in some instances.
The survey responses and descriptive medical information gathered from the electronic health record were tabulated and entered into a Microsoft Excel® database (password protected) and transferred to STATA®, version 15, for statistical analysis. Exploratory data analyses were conducted, and descriptive statistics were calculated for the demographic and clinical information.
Fifty individuals with HPB conditions were surveyed. The sample included 28 women and 22 men (determined by self-report) between the ages of 39 and 82 years, with a median age 64 years (see Table 1). All respondents were English speaking and cognitively competent, as determined by the nurse interviewer. Cancer was the primary indication for surgery, with pancreatic cancer accounting for 56% of cases, and ampullary cancer or a duodenal cancer accounting for 14%. Fifteen patients had benign but serious conditions, including a premalignant IPMN, cyst adenoma, pancreatic neuroendocrine tumor, or a GI stromal tumor. The pylorus-preserving pancreaticoduodenectomy was the procedure performed in 30 patients, followed by a distal pancreatectomy in 10 patients. The average postoperative length of stay (LOS) was 5.5 days. Forty-three patients had an associated operation performed as part of the planned surgery. A cholecystectomy was performed on 27 patients and a splenectomy on 15. The major preoperative comorbidities of the cohort included hypertension, cardiovascular disease, gastroesophageal reflux disease (GERD), diabetes, and a history of a previous cancer.
Forty respondents reported that they were either well or moderately well prepared for the planned procedure. Overall, more men (n = 13) reported that they were well prepared than did women (n = 9). The oldest patients (older than age 79 years, n = 6) reported that they were only somewhat prepared for surgery and the postoperative course. As shown in Table 2, all respondents reported that they were well informed about the likelihood of experiencing postoperative pain. The majority also reported understanding about managing pain with patient-controlled analgesia. Most respondents reported feeling moderately to well prepared about the need to be NPO for a few days, and that they would be expected to ambulate on the unit four times a day starting on postoperative day 1. Of the 10 areas queried, patients were least aware of the discharge planning process, including the involvement of a case manager and the need for long-term medication use, such as taking acid blockers and exogenous pancreatic enzymes. The lowest scoring item on the questionnaire was about the possibility of referral to a long-term care facility for physical rehabilitation after hospital discharge.
Ten patients responded only “somewhat informed” about the assistance of a case manager and that they would be receiving a routine postdischarge follow-up phone call from one of the surgical oncology NPs (see Figure 2). Several patients commented that they had received inconsistent and contradictory information from different healthcare providers along their journey. Other areas identified as having not been addressed in the preoperative information teaching included information on the mechanics of postoperative care (i.e., NPO status), indwelling abdominal drains and IV fluid lines, and needing insulin, anticoagulation therapy, or total parenteral nutrition and vaccination. Vaccines are to be administered to individuals who had a splenectomy as part of the distal pancreatectomy to ensure their future immunologic protection (Bonanni et al., 2017). The first doses of these vaccines are typically given prior to discharge on postoperative day 4, if they have not been administered preoperatively.
Individuals undergoing surgery for HPB cancers and other benign but serious conditions represent a group of patients with complex healthcare needs. Results from this study identified the effectiveness of preoperative education about HPB surgery, addressing patient information needs. Individual handwritten comments on the questionnaire indicate that there is room for improvement in the level of detail in the preoperative information that is provided, particularly in regard to discharge planning. Several studies have found that specific preoperative information regarding pain and postoperative management has a positive effect on patient outcomes, and that high-quality patient education allows patients to take a more active role in their care and is pivotal in improving clinical outcomes and increasing patient satisfaction (Berg et al., 2006; Kiyohara et al., 2004; Sjoling et al., 2003). Patients who are psychologically prepared for surgery have better outcomes than those who are inadequately prepared (Kiyohara et al., 2004). The optimal method by which to ensure patient preparedness in the preoperative period has not been demonstrated definitively in the literature, but targeted information in a format that patients and families can understand has been reported to lower anxiety and reduce depression (Carr et al., 2005; Kiyohara et al., 2004; Stuart, 2020). Healthcare providers assume that all patients can and will read the information given to them. However, a report from the Institute of Medicine (2004) indicated that 90 million American adults lack the reading skills required to fully understand and act on health information. In addition, anxious patients and older adult patients often lose the completeness and accuracy of information given to them verbally (Pritchard, 2011) Therefore, it is important that preoperative and discharge patient information be provided in a variety of formats. Using a combination of verbal (one-on-one), written, visual, and auditory (listening devices) methods is more effective than using only one method (Papadakos et al., 2014). Although much information is available on the Internet, patients should be cautioned to use verified, reliable sites (Pritchard, 2011). Internet information is not a substitute for communication between patients and their healthcare providers.
Results from this project and from previous studies indicate that healthcare professionals do not provide consistent preoperative education. Fitzpatrick and Hyde (2006) reported that nurse knowledge and practices were associated with patients receiving different levels of care and unevenness in preoperative education. Information given to patients varied by the healthcare providers’ level of knowledge and experience. Formal methods of educational preparation are recommended for healthcare providers who are involved in delivering preoperative information to patients.
Beesley et al. (2016) identified a tsunami of unmet needs in patients with pancreatic and ampullary cancers. Unmet physical and psychological needs of this cohort did not vary between those who were resectable and those who were not eligible for surgery. Information about and access to supportive care services and palliative care through an institution’s cancer center needs to be routinely included in the discharge plan (Beesley et al., 2016).
The limitations of this QI initiative include the relatively small sample size, convenience sampling and cross-sectional data collection, and the use of a questionnaire. Although a consensus of nurses, NPs, and a surgeon with expertise in the care and management of patients undergoing HPB surgery developed the questionnaire, it is possible that other important and informative questions were not identified and represent a missed opportunity. For example, study participants were not asked their format preference to receive preoperative or discharge planning information.
Implications for Practice
The findings from this QI project will be implemented to assist patients in achieving a better understanding of the planned procedure, which may, in turn, reduce their anxiety and improve performance outcomes. Increased focus on involving the family and a greater awareness of the special needs of older adults is warranted. Family members will be involved in discussions about the planned surgery and the postoperative period. Improving preparedness for HPB surgery has the potential to improve clinical outcomes, increase the quality of the patient experience and patient satisfaction, decrease LOS, and reduce complications that may delay the start of adjuvant therapy for those who are recommended chemotherapy or chemoradiation treatment.
This QI project was the result of a unit council shared-governance initiative in collaboration with the HPB surgical oncology NPs. To the authors’ knowledge, this is the first survey to directly assess HPB patients’ perception of preparedness for HPB surgery. It adds significantly to the literature in this field. Implementing the findings of this study has the potential to lead to improvements in the quality of the patient experience and to assist patients and caregivers during the perioperative course.
About the Author(s)
Kelly O’Connor, BSN, RN-BC, CCCTM, is a clinical nurse, Diane La Bruno, MSN, RN, ACNS-BC, CCCTM, is a clinical nurse specialist, and Jamie Rudderow, BSN, RN, CCCTM, is a clinical nurse, all on Pavilion 13; Shawnna Cannaday, MSN, AGACNP, FNP-BC, is a senior surgical oncology nurse practitioner and Charles J. Yeo, MD, FACS, is the Samuel D. Gross Professor and chair, both in the Department of Surgery; and Theresa P. Yeo, PhD, MPH, ACNP-BC, AOCNP®, is a surgical oncology nurse practitioner in the Department of Surgery and an adjunct associate professor of nursing in the Jefferson College of Nursing, all at Thomas Jefferson University Hospital in Philadelphia, PA. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Yeo can be reached at email@example.com, with copy to CJONEditor@ons.org. (Submitted February 2020. Accepted April 3, 2020.)
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