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Postoperative Phone Calls: Is There Another Way?
CLINICAL CLIPS
Postoperative Phone Calls: Is There Another Way? Barbara Godden, MHS, RN, CPAN, CAPA SINCE THE EARLY DAYS of outpatient surgery, perianesthesia nurses have been completing postoperative phone calls to follow-up on patients in their care. These phone calls have taken a variety of formats, with facilities creating their own forms and questions to ask the patients. The ASPAN Clinical Practice Network receives a number of questions related to postoperative phone calls. Many nurses ask if this is a regulatory requirement, whereas others ask about the best practices related to phone calls, e.g., what questions should they ask, how many questions should they ask, and when is the best time to call a patient. Others ask whether there are any alternatives for follow-up in place of phone calls, such as a survey sent to a patient’s home. Still others ask whether postoperative calls really make a difference or if this is a sacred cow.
Regulatory Requirements Postoperative phone calls are not a requirement of any regulatory agency, including The Joint Commission. What The Joint Commission requires is that reassessment is done on all patients at intervals determined by the facility.1 Reassessment is necessary to evaluate response to care and treatment.1 For ambulatory care, The Joint Commission requires that the organization defines in writing its reassessment parameters.2 The ASPAN Standards state: ‘‘The Registered Nurse will adhere to institutional policy for patient reassessment following
Barbara Godden, MHS, RN, CPAN, CAPA, is a Clinical Nurse Coordinator, Sky Ridge Medical Center, Lone Tree, CO. Address correspondence to Barbara Godden, 9320 Erminedale Drive, Lone Tree, CO 80124; e-mail address: bagodden@ comcast.net. Ó 2010 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 doi:10.1016/j.jopan.2010.09.004
discharge.’’3 Although most facilities complete phone calls with a nurse calling the patient, other facilities have implemented automated phone calls. Still, other facilities complete their patient follow-ups with a hospital or facility survey, or even a department-specific mailed survey. All of these methods meet the requirements of regulatory agencies. Anyone who has been through a Joint Commission or other regulatory survey, knows that surveyors many times ask how the facility performs follow-up and reassessment on outpatients. So even if it is not written in so many words, follow-up of some sort is required. What is most important is that institutional policy is followed.
Advantages of a Postoperative Phone Call To meet the reassessment requirement, the postoperative phone call is an important element in closing the loop of the nursing process. The perianesthesia nurse implements this nursing process by including assessment, planning, intervention, and evaluation. Nurses go through this process multiple times in the care of pre- and postanesthesia patients. However, the final evaluation for the ambulatory patient cannot be completed until the patient is at home. This is when the nurse can evaluate the care provided and determine whether the interventions taken were effective. Phone calls allow the nurse to reinforce postoperative teaching, as well as provide reassurance and relieve anxiety. Postoperative phone calls complete the continuum of care. Ambulatory surgery has grown exponentially in the last several decades. Facilities are seeing increasingly complex patients and procedures in their ambulatory settings. Many of these patients are not only compromised physically, but also emotionally, educationally, and socially. These additional factors are other reasons to follow-up on
Journal of PeriAnesthesia Nursing, Vol 25, No 6 (December), 2010: pp 405-408
405
406
patients once they leave our care, to see how they are coping in their homes. Follow-up calls are an important method to ensure patient safety once they leave the health care facility.4 Other advantages of postoperative calls include obtaining information for process improvements, both related to patient care and facility practices. This information can also be obtained from a written survey, but surveys are often delayed in getting to the people who can implement the change. The postoperative phone call provides immediate and timely feedback for improvement. The personal contact is an important factor in giving patients the opportunity to ask questions as well as providing feedback. Flanangan5 states that we should not assume we know what improvements are needed without the patient’s feedback. In addition, the postoperative phone call is an important tool to evaluate whether the patient’s preoperative teaching had an impact on her or his experience.5 Postoperative phone calls can be an important marketing tool. Favorable impressions can be created with a caring, compassionate call. Patients then share with friends and family, as well as with their physicians, that they received a phone call after they returned home. In many cases, a postoperative call may reduce a facility’s liability if a patient is unhappy with some aspect of the care he or she received. It is more difficult to be angry with someone when they show caring and compassion in a postoperative phone call. Nurses, as well as other health care workers, love positive feedback. The feeling of having done a job well creates a sense of satisfaction and a positive work attitude. No one intentionally starts out wanting to do a bad or mediocre job, and receiving positive feedback enhances one’s self esteem and sense of professionalism, and increases job satisfaction.5
Elements of the Postoperative Phone Call For HIPAA-related reasons, it is best to obtain permission to call as well as leave a message. This is also a good time to verify the patient’s phone number, or the number he or she would like you to call. Many patients now prefer to have the postoperative call made to their cell phones.
BARBARA GODDEN
Before the call, information should be obtained that includes the surgical procedure performed, as well as any postanesthesia or postoperative problems during the patient’s stay. This information is important so that the nurse can have an appropriate conversation with the patient. Content of the patient phone call should include questions such as: How are you doing in general? How is your pain? (Have the patients provide a pain score.) If you are still having pain, are you taking your pain medication as directed? Are you able to eat and drink? Are you experiencing any nausea or vomiting? What does your surgical site look like? Is there any redness or bleeding? Do you have or have you had a fever? For extremity procedures, is your circulation, motion, sensation intact? Are you having any difficulty voiding? (This question is especially important with certain procedures and anesthesia types.) Are you able to get around in your home? Are there any limitations? Have you had to contact your physician for any reason, or return to the emergency department? Did you have any issues while in our care? Have you made your follow-up appointment? Were your discharge instructions clear and helpful, or do you have additional questions? How was your overall satisfaction with your experience? Were there any areas of concern or feedback that would allow us to improve? Is there anything we could have done to make your stay better? Were there any particular employees you wanted to mention? Allow for any other comments/concerns that the patients want to share.6 Documentation of the phone call is important, whether on paper or in the patient’s electronic record. Documentation should include responses to the above questions as well as interventions that were used. These could include supportive listening, review of medications, review of discharge teaching, review of appointments, review of treatment, and/or referral to a physician. The Joint
CLINICAL CLIPS: POSTOPERATIVE PHONE CALLS
Commission also requires that any communication with the patient, including phone calls, are documented in the patient record.2 Many facilities attempt to call patients two to three times, whereas other facilities continue to call until they reach the patient. Again, this is important to provide closure in the nursing process loop. Nurses should not be providing medical advice, but the critical thinking skills and answers to patient questions are best handled by a registered nurse rather than allied personnel.
Timing of the Postoperative Phone Call One school of thought regarding postoperative phone calls is not to let too much time pass because this only decreases the opportunity to intervene if needed. A delay in follow-up may also decrease patient satisfaction and promote a negative feeling from the patient about his or her experience. In this scenario, the postoperative phone call is completed within 24 hours of the patient’s surgery. This is a good time to assess whether the patient is experiencing any problems or whether clarification of discharge instructions is needed. When calls are made the next day, timely interventions can be implemented to facilitate resolution or to allay any anxiety related to a patient’s concerns and possible complications. Patients should be given an idea of when to expect a postoperative phone call. Again, it is important to follow your policy. Many facilities state in their policies that they complete postoperative calls on the next business day. This works for facilities that are closed on weekends and holidays. There are also increasing data to support more than one postoperative phone call to each patient. In a study published in 2007 following outpatient tonsillectomy, two postoperative calls were made— the first one the day after surgery, and the second one between the ninth and twelfth day postoperatively. This study found that the first call served to meet additional instructional needs that the patient/parents had, and the second call was needed for emotional support and to ascertain whether the patient was on the right track in her or his recovery. This study also found that a postoperative phone call on the day after surgery led to decreased use
407
of outside resources, and increased patient/parent confidence in caring for the child.7 In another study reported in 2004, patients were contacted daily for three days after surgery. The findings from this study suggest that the first day may not be the best time to contact patients, especially early in the day, because patients reported not feeling well enough to talk on the phone and often did not remember the calls. However, when patients were called on the first postoperative day, the study found that late afternoon or early evening was the best time to call. In this study, the patients did not always remember the discussion from the phone calls on the first or second day, but they did report remembering the third-day call, and at that time had specific questions to ask. Many patients also did not remember receiving written discharge instructions when called on the first day. In the study, researchers also found that very specific instructions were needed; for example, not just to drink plenty of fluids, but exactly how much and when. In this study, many misconceptions about pain were identified. These misconceptions included pain and activity, the reason for not driving when taking pain medications, avoiding pain, side effects including constipation, addiction due to taking opioids, and amount of pain medications to take. In these cases, the postoperative calls helped to dispel the misconceptions.8
Factors Contributing to the Successful Completion of Postoperative Phone Calls Time is the biggest barrier that perianesthesia nurses feel prevents them from completing calls in a timely manner. The culture of the unit and the leadership team need to support and stress the importance of postoperative phone calls. The routine of the unit should allow a minimum of one to two people to make the calls away from the busiest area of the unit. This is important so that the patient does not sense that the nurse is in a hurry with the call and allows for more participation from the patient. Listening is important. Calls can be made anytime during the day. Many facilities start making calls after 9:00 AM, during down time, and some reserve their call time for the evening. The evening is often better for patients as well, because it has been at least 24 hours and they are often starting to feel better.
BARBARA GODDEN
408
Another contributing factor to successful completion of phone calls is a standardized format for postoperative calls. The format should allow for individualization, but keep the nurse on track with the patient to obtain important information. Specific scripting for unique situations also allows the nurse to feel more comfortable when something unusual comes up in the conversation.
What to Do With the Information Collected The postoperative call feedback should be a permanent part of the record. This can take the form of paper, or many facilities have a postoperative call screen in their electronic documentation. Information obtained from the postoperative phone call is invaluable in determining effectiveness and quality of care, to identify areas for improvement in such areas as communication and discharge teaching, to obtain information related to areas for improvement for other departments, or to hear what one does well. Employee satisfaction is enhanced when a nurse receives positive feedback about the care he or she provided. This information can be shared with the unit manager for the employee’s file. Many facilities also keep a log form for postoperative call information. This log is used to track the number of patients called; the number of patients reached; and the number of problems identified such as postoperative nausea and vomiting, bleed-
ing, returns to the emergency department, communication concerns, and interventions taken. Trends can be identified and actions taken when necessary. This log can serve as an ongoing unit performance improvement project.
Conclusions Although not specifically required, the postoperative phone call is an important element in reassessment and follow-up to complete the nursing process. Today, ambulatory patients are sicker, with more complex problems, and they undergo increasingly complex procedures. A solid followup program is needed to ensure that patients are doing well once they leave the comfort and safety of a health care facility. The best timing for the phone call is still debatable. Questions develop as the patient is recovering, and the first postoperative day may not be the best time to call. Also, some patients may not remember or absorb information the first postoperative day. If calls are made on the first postoperative day, waiting a full 24 hours seems to be best. From 24 to 48 hours seems optimal to make initial contact for follow-up and determine whether the patient requires any additional information or an intervention is needed. The postoperative phone call is also an important time to clarify and reinforce instructions to decrease the use of additional health care resources after discharge.
References 1. The Joint Commission. Standard PC.2.150. In: Hospital Accreditation Standards. Chicago, IL: The Joint Commission; 2010. 2. The Joint Commission. Ambulatory Health Care Accreditation Program. Available at: http://www.jointcommission.org/Ac creditationPrograms/AmbulatoryCare/. Accessed August 22, 2010. 3. American Society of PeriAnesthesia Nurses. Standards of Perianesthesia Practice 2008-2010. Cherry Hill, NJ: ASPAN; 2008:66. 4. Ead H. From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery. J Perianesth Nurs. 2006;21:259-267. 5. Flanagan J. Postoperative telephone calls: Timing is everything. AORN J. 2009;90:41-51.
6. Fossum S. Discharge planning: Extended observation, home and follow-up care. In: Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing, 2nd ed. St Louis, MO: Saunders/ Elsevier; 2010:1410-1416. 7. Le T, Drolet J, Parayno E, et al. Follow-up phone calls after pediatric ambulatory surgery for tonsillectomy: What can we learn from families? J Perianesth Nurs. 2007;22: 256-264. 8. Dewar A, Scott J, Muir J. Telephone follow-up for day surgery patients: Patient perceptions and nurses’ experiences. J Perianesth Nurs. 2004;19:234-241.
Postoperative Phone Calls: Is There Another Way? Barbara Godden, MHS, RN, CPAN, CAPA SINCE THE EARLY DAYS of outpatient surgery, perianesthesia nurses have been completing postoperative phone calls to follow-up on patients in their care. These phone calls have taken a variety of formats, with facilities creating their own forms and questions to ask the patients. The ASPAN Clinical Practice Network receives a number of questions related to postoperative phone calls. Many nurses ask if this is a regulatory requirement, whereas others ask about the best practices related to phone calls, e.g., what questions should they ask, how many questions should they ask, and when is the best time to call a patient. Others ask whether there are any alternatives for follow-up in place of phone calls, such as a survey sent to a patient’s home. Still others ask whether postoperative calls really make a difference or if this is a sacred cow.
Regulatory Requirements Postoperative phone calls are not a requirement of any regulatory agency, including The Joint Commission. What The Joint Commission requires is that reassessment is done on all patients at intervals determined by the facility.1 Reassessment is necessary to evaluate response to care and treatment.1 For ambulatory care, The Joint Commission requires that the organization defines in writing its reassessment parameters.2 The ASPAN Standards state: ‘‘The Registered Nurse will adhere to institutional policy for patient reassessment following
Barbara Godden, MHS, RN, CPAN, CAPA, is a Clinical Nurse Coordinator, Sky Ridge Medical Center, Lone Tree, CO. Address correspondence to Barbara Godden, 9320 Erminedale Drive, Lone Tree, CO 80124; e-mail address: bagodden@ comcast.net. Ó 2010 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 doi:10.1016/j.jopan.2010.09.004
discharge.’’3 Although most facilities complete phone calls with a nurse calling the patient, other facilities have implemented automated phone calls. Still, other facilities complete their patient follow-ups with a hospital or facility survey, or even a department-specific mailed survey. All of these methods meet the requirements of regulatory agencies. Anyone who has been through a Joint Commission or other regulatory survey, knows that surveyors many times ask how the facility performs follow-up and reassessment on outpatients. So even if it is not written in so many words, follow-up of some sort is required. What is most important is that institutional policy is followed.
Advantages of a Postoperative Phone Call To meet the reassessment requirement, the postoperative phone call is an important element in closing the loop of the nursing process. The perianesthesia nurse implements this nursing process by including assessment, planning, intervention, and evaluation. Nurses go through this process multiple times in the care of pre- and postanesthesia patients. However, the final evaluation for the ambulatory patient cannot be completed until the patient is at home. This is when the nurse can evaluate the care provided and determine whether the interventions taken were effective. Phone calls allow the nurse to reinforce postoperative teaching, as well as provide reassurance and relieve anxiety. Postoperative phone calls complete the continuum of care. Ambulatory surgery has grown exponentially in the last several decades. Facilities are seeing increasingly complex patients and procedures in their ambulatory settings. Many of these patients are not only compromised physically, but also emotionally, educationally, and socially. These additional factors are other reasons to follow-up on
Journal of PeriAnesthesia Nursing, Vol 25, No 6 (December), 2010: pp 405-408
405
406
patients once they leave our care, to see how they are coping in their homes. Follow-up calls are an important method to ensure patient safety once they leave the health care facility.4 Other advantages of postoperative calls include obtaining information for process improvements, both related to patient care and facility practices. This information can also be obtained from a written survey, but surveys are often delayed in getting to the people who can implement the change. The postoperative phone call provides immediate and timely feedback for improvement. The personal contact is an important factor in giving patients the opportunity to ask questions as well as providing feedback. Flanangan5 states that we should not assume we know what improvements are needed without the patient’s feedback. In addition, the postoperative phone call is an important tool to evaluate whether the patient’s preoperative teaching had an impact on her or his experience.5 Postoperative phone calls can be an important marketing tool. Favorable impressions can be created with a caring, compassionate call. Patients then share with friends and family, as well as with their physicians, that they received a phone call after they returned home. In many cases, a postoperative call may reduce a facility’s liability if a patient is unhappy with some aspect of the care he or she received. It is more difficult to be angry with someone when they show caring and compassion in a postoperative phone call. Nurses, as well as other health care workers, love positive feedback. The feeling of having done a job well creates a sense of satisfaction and a positive work attitude. No one intentionally starts out wanting to do a bad or mediocre job, and receiving positive feedback enhances one’s self esteem and sense of professionalism, and increases job satisfaction.5
Elements of the Postoperative Phone Call For HIPAA-related reasons, it is best to obtain permission to call as well as leave a message. This is also a good time to verify the patient’s phone number, or the number he or she would like you to call. Many patients now prefer to have the postoperative call made to their cell phones.
BARBARA GODDEN
Before the call, information should be obtained that includes the surgical procedure performed, as well as any postanesthesia or postoperative problems during the patient’s stay. This information is important so that the nurse can have an appropriate conversation with the patient. Content of the patient phone call should include questions such as: How are you doing in general? How is your pain? (Have the patients provide a pain score.) If you are still having pain, are you taking your pain medication as directed? Are you able to eat and drink? Are you experiencing any nausea or vomiting? What does your surgical site look like? Is there any redness or bleeding? Do you have or have you had a fever? For extremity procedures, is your circulation, motion, sensation intact? Are you having any difficulty voiding? (This question is especially important with certain procedures and anesthesia types.) Are you able to get around in your home? Are there any limitations? Have you had to contact your physician for any reason, or return to the emergency department? Did you have any issues while in our care? Have you made your follow-up appointment? Were your discharge instructions clear and helpful, or do you have additional questions? How was your overall satisfaction with your experience? Were there any areas of concern or feedback that would allow us to improve? Is there anything we could have done to make your stay better? Were there any particular employees you wanted to mention? Allow for any other comments/concerns that the patients want to share.6 Documentation of the phone call is important, whether on paper or in the patient’s electronic record. Documentation should include responses to the above questions as well as interventions that were used. These could include supportive listening, review of medications, review of discharge teaching, review of appointments, review of treatment, and/or referral to a physician. The Joint
CLINICAL CLIPS: POSTOPERATIVE PHONE CALLS
Commission also requires that any communication with the patient, including phone calls, are documented in the patient record.2 Many facilities attempt to call patients two to three times, whereas other facilities continue to call until they reach the patient. Again, this is important to provide closure in the nursing process loop. Nurses should not be providing medical advice, but the critical thinking skills and answers to patient questions are best handled by a registered nurse rather than allied personnel.
Timing of the Postoperative Phone Call One school of thought regarding postoperative phone calls is not to let too much time pass because this only decreases the opportunity to intervene if needed. A delay in follow-up may also decrease patient satisfaction and promote a negative feeling from the patient about his or her experience. In this scenario, the postoperative phone call is completed within 24 hours of the patient’s surgery. This is a good time to assess whether the patient is experiencing any problems or whether clarification of discharge instructions is needed. When calls are made the next day, timely interventions can be implemented to facilitate resolution or to allay any anxiety related to a patient’s concerns and possible complications. Patients should be given an idea of when to expect a postoperative phone call. Again, it is important to follow your policy. Many facilities state in their policies that they complete postoperative calls on the next business day. This works for facilities that are closed on weekends and holidays. There are also increasing data to support more than one postoperative phone call to each patient. In a study published in 2007 following outpatient tonsillectomy, two postoperative calls were made— the first one the day after surgery, and the second one between the ninth and twelfth day postoperatively. This study found that the first call served to meet additional instructional needs that the patient/parents had, and the second call was needed for emotional support and to ascertain whether the patient was on the right track in her or his recovery. This study also found that a postoperative phone call on the day after surgery led to decreased use
407
of outside resources, and increased patient/parent confidence in caring for the child.7 In another study reported in 2004, patients were contacted daily for three days after surgery. The findings from this study suggest that the first day may not be the best time to contact patients, especially early in the day, because patients reported not feeling well enough to talk on the phone and often did not remember the calls. However, when patients were called on the first postoperative day, the study found that late afternoon or early evening was the best time to call. In this study, the patients did not always remember the discussion from the phone calls on the first or second day, but they did report remembering the third-day call, and at that time had specific questions to ask. Many patients also did not remember receiving written discharge instructions when called on the first day. In the study, researchers also found that very specific instructions were needed; for example, not just to drink plenty of fluids, but exactly how much and when. In this study, many misconceptions about pain were identified. These misconceptions included pain and activity, the reason for not driving when taking pain medications, avoiding pain, side effects including constipation, addiction due to taking opioids, and amount of pain medications to take. In these cases, the postoperative calls helped to dispel the misconceptions.8
Factors Contributing to the Successful Completion of Postoperative Phone Calls Time is the biggest barrier that perianesthesia nurses feel prevents them from completing calls in a timely manner. The culture of the unit and the leadership team need to support and stress the importance of postoperative phone calls. The routine of the unit should allow a minimum of one to two people to make the calls away from the busiest area of the unit. This is important so that the patient does not sense that the nurse is in a hurry with the call and allows for more participation from the patient. Listening is important. Calls can be made anytime during the day. Many facilities start making calls after 9:00 AM, during down time, and some reserve their call time for the evening. The evening is often better for patients as well, because it has been at least 24 hours and they are often starting to feel better.
BARBARA GODDEN
408
Another contributing factor to successful completion of phone calls is a standardized format for postoperative calls. The format should allow for individualization, but keep the nurse on track with the patient to obtain important information. Specific scripting for unique situations also allows the nurse to feel more comfortable when something unusual comes up in the conversation.
What to Do With the Information Collected The postoperative call feedback should be a permanent part of the record. This can take the form of paper, or many facilities have a postoperative call screen in their electronic documentation. Information obtained from the postoperative phone call is invaluable in determining effectiveness and quality of care, to identify areas for improvement in such areas as communication and discharge teaching, to obtain information related to areas for improvement for other departments, or to hear what one does well. Employee satisfaction is enhanced when a nurse receives positive feedback about the care he or she provided. This information can be shared with the unit manager for the employee’s file. Many facilities also keep a log form for postoperative call information. This log is used to track the number of patients called; the number of patients reached; and the number of problems identified such as postoperative nausea and vomiting, bleed-
ing, returns to the emergency department, communication concerns, and interventions taken. Trends can be identified and actions taken when necessary. This log can serve as an ongoing unit performance improvement project.
Conclusions Although not specifically required, the postoperative phone call is an important element in reassessment and follow-up to complete the nursing process. Today, ambulatory patients are sicker, with more complex problems, and they undergo increasingly complex procedures. A solid followup program is needed to ensure that patients are doing well once they leave the comfort and safety of a health care facility. The best timing for the phone call is still debatable. Questions develop as the patient is recovering, and the first postoperative day may not be the best time to call. Also, some patients may not remember or absorb information the first postoperative day. If calls are made on the first postoperative day, waiting a full 24 hours seems to be best. From 24 to 48 hours seems optimal to make initial contact for follow-up and determine whether the patient requires any additional information or an intervention is needed. The postoperative phone call is also an important time to clarify and reinforce instructions to decrease the use of additional health care resources after discharge.
References 1. The Joint Commission. Standard PC.2.150. In: Hospital Accreditation Standards. Chicago, IL: The Joint Commission; 2010. 2. The Joint Commission. Ambulatory Health Care Accreditation Program. Available at: http://www.jointcommission.org/Ac creditationPrograms/AmbulatoryCare/. Accessed August 22, 2010. 3. American Society of PeriAnesthesia Nurses. Standards of Perianesthesia Practice 2008-2010. Cherry Hill, NJ: ASPAN; 2008:66. 4. Ead H. From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery. J Perianesth Nurs. 2006;21:259-267. 5. Flanagan J. Postoperative telephone calls: Timing is everything. AORN J. 2009;90:41-51.
6. Fossum S. Discharge planning: Extended observation, home and follow-up care. In: Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing, 2nd ed. St Louis, MO: Saunders/ Elsevier; 2010:1410-1416. 7. Le T, Drolet J, Parayno E, et al. Follow-up phone calls after pediatric ambulatory surgery for tonsillectomy: What can we learn from families? J Perianesth Nurs. 2007;22: 256-264. 8. Dewar A, Scott J, Muir J. Telephone follow-up for day surgery patients: Patient perceptions and nurses’ experiences. J Perianesth Nurs. 2004;19:234-241.