By Joy Daughtery Dickinson
Ambulatory surgery programs traditionally calmed patients by providing anti-anxiety medications and perhaps offering a tour ahead of time for pediatric patients. However, with the current focus on patient satisfaction and the need to eliminate unnecessary medications and their corresponding costs, many programs are going the extra mile by providing calming environments and amenities such as live music, videos, and even flowers and spa robes! Even the traditional tours have become more elaborate by allowing children to don gowns and ride gurneys through all of the departments they will visit on surgery day, including the OR.
Providers are finding that such changes pay off with increased patient satisfaction scores and, in some cases, less anxiety medication, reduced pain, and quicker recovery time.
Research at the University of Kentucky (UK), Lexington found that music exposure during and after surgery at its hospitals resulted in patients who were less anxious before the procedure and who recovered more quickly and satisfactorily.1 They also required less medication for sedation and were more satisfied with their medical experience. Calm, slow, gentle music produced the most positive results and facilitated relaxation and pain reduction.
In outpatient surgery at UK Lexington, music is primarily used preoperatively. Some of those patients also come in for wound care, which is an area that has seen significant positive results with music therapy, says Lori Gooding, PhD, MT-BC, director of music therapy and lead author of the research. "The amount of time spent in wound care visits goes by much more quickly," Gooding says. Through music, "we decrease patients' perception of pain and anxiety, which allows staff to more effectively do their jobs." UK Lexington offers several playlists and lets patients choose one based on their tastes, she says. The playlists cover many genres of music, Gooding says. Music therapists usually play the music live with guitars and sing. If there are any infection control concerns, recorded music can be played.
When the music therapists have the opportunity, they encourage patients to practice listening to music and relaxing before the surgery. Patients can perform breathing exercises to music or use guided imagery to relax. To address anxiety, patients are distracted with musical activities such as playing drums, singing, and rewriting songs into parodies. These activities help with anxiety because "for humans, it's difficult to focus on two things at same time," Gooding says.
The approach is winning over fans. One parent commented that she previously had the perception that UK staff members were lacking empathy, but she saw that the music therapy calmed her child. It changed her perception of the overall facility, Gooding says. "That's the goal: to provide patient/family-centered care," she says.
Videos cut anxiety at induction
Another medium, videos, has had a positive impact art IWK Health Centre in Halifax, Nova Scotia. A study showed allowing children to watch a video immediately before day surgery was helpful in reducing their anxiety during anesthesia induction.2 The videos shown by the hospital are pre-screened and selected based on what programs the children watch at home. The videos are approved by the patient's parent, and many are taken from YouTube.
The children can watch part of the videos in the preop area, but when they are wheeled into the OR, screens there also are showing the video. Children continue to watch the videos through anesthesia inductions. The screens had been installed previously to help residents and other surgeons view surgical cases.
Their experience is backed by other recently published research. That study showed that letting children watch a favorite cartoon was found to be an effective and safe way to reduce anxiety before anesthesia and surgery. Anxiety was rated low or absent for 43% of children who watched cartoons, compared to 23% of those who brought a toy and 7% with neither treatment.3
At IWK Health Centre, the results from showing videos to children were "striking," says Jill Chorney, PhD, psychologist at IWK Health Centre and assistant professor at Dalhousie University, also in Halifax. One-fourth of the children in the video group showed no distress at induction, compared only 5% of children in the group who didn't see the video. Also, children who watched the video shown no change in anxiety when moving from the preop area to the OR, but children who didn't watch the video had a significant increase in anxiety as they entered the OR, Chorney says.
She does offer this caveat, however: It takes time to talk to the patients about what video they want to see and to get the video set up, Chorney says. For that reason, the hospital now offers a limited list of choices. Another warning: "It's not the answer for every kid," Chorney says. For some children, the electronic stimulation can be overwhelming, and those children prepare better in a quiet environment, she says.
Finger Lakes Surgery Center in Geneva, NY, prepares children by offering a monthly tour that allows them to don hospital gowns, wear a head covering, and travel through all of the patient care areas of the center, including a ride to the OR on a gurney, according to a news story.4 The "trial run" includes transferring children from the gurney to the operating room table, where the child is allows to try on an oxygen mask and have other procedures explained.
The Kids Tour is held at the end of the center's workday, but the center is flexible about scheduling tours other times. The purpose is to help children and their parents feel prepared and relaxed before the day of surgery.
Unity Point Health Methodist in Peoria, IL, has made some changes that are allowing fewer children to be medicated for anxiety before they head to the operating room. Medication now is given in "rare instances," says Juli Zerwer, RNC, registered nurse in preop phase 2 recovery. "Before, we were having to give a lot of medication just to get them back through the door," Zerwer says.
Patient satisfaction scores have improved from about 85% to 100% over a three-month period, she says. The hospital has been able to maintain satisfaction scores above 95%, Zerwer says.
One reason for their success is allowing children to read a book in print or electronic format that has photographs of the facility where they will be treated and the staff who will be taking care of them. The "Let's Get Ready for Surgery at Methodist" was made internally in collaboration with a child life specialist, marketing representative, and a photographer. "It's important that when we educate our patients for surgery, they see who they will see [the day of surgery], the equipment they will see, and the environment they will see," Zerwer says. "When the 'sleep doctor' walks in the room, they know what they will do. There are no surprises."
The book is given by the surgeon's office to the patients when the procedure is scheduled so they can read it at home The book also is available on the hospital web site (http://bit.ly/19dQzAL).
Satisfaction rates up, medication is down
The hospital helps children feel more at ease by limiting the people who come in contact with children, Zerwer says. "There's not four or five people trying to get them ready," she says. Also, they work at a pace that allows children to understand what is happening, Zerwer adds. Preoperative tours also are available in which children are allowed to touch equipment and ask questions.
On the day of surgery, children are offered diversions including a computer pad with games, movies on DVDs, and a play room. Children are given choices; for example, they are allowed to select a surgical hat from among several made by volunteers. They also can choose how they want to travel from the prep room to the surgical suite. Options include walking, riding in a wheelchair, or driving a battery-operated child-size Hummer or pink Fisher-Price car. One "huge" satisfier for parents is reuniting them with their children as soon as possible after surgery, Zerwer says. The discharge education is handled before surgery, when parents are not as distracted, she says.
"The whole [pediatric process] deals with education, being prepared, making them feel they're part of decision-making, and building that trust," Zerwer says.
Patients won over with design and amenitiesPatients can become anxious for even the most minor procedures, as outpatient surgery employees know. In comparison, a spa setting is inviting, and part of the reason is the environment and the amenities. Now outpatient surgery providers are finding that if they can provide a similarly inviting environment, it reduces patient anxiety and increases satisfaction. Franciscan Point Surgery Center, part of Franciscan Saint Anthony Health, both in Crown Point, IN, is an example of an outpatient surgery program that has created such a peaceful environment. "From the moment you hit the door, it's very spacious," says Judith DeMario, RN, nurse manager for the surgery center. "There's warm lighting, warm colors and artwork," she says. "It doesn't feel very clinical." Natural lighting is used in the waiting room, hallways, and the OR suites. Walls are painted in "calming" earth tones. Having no overhead paging also contributes to the spa-like setting, DeMario says. Pediatric patients have a special area designed for them with a child-sized table, low bookshelf, and their own TV. Patients have private bays preop (and postop), decorated with artwork, where they sit in attractive recliners to have their IVs started. Most patients walk into the procedure rooms instead of being taken on gurneys. In phase 2 recovery, patients face high windows, instead of each other. The "spa" environment extends to amenities at the surgery center. For example, patients are given a heavy robe to use while at the center. The robes, which cost about $70 each, are embroidered with the name of the surgery center's owner. Additionally, patients in recovery select a carnation from a large multi-colored bouquet delivered weekly, which costs the surgery center about $35 per bouquet. Another "plus" for the center is a card sent to patients that is signed by each staff person who helped take care of them. All of these amenities have allowed the center to gain Press Ganey patient satisfaction scores that put them in the 97-98 percentile nationally. "It's from an amazing collaboration of patients and staff," DeMario says. Dolls used for comfort and education At Children's West Surgery Center in Knoxville, TN, amenities include handmade comfort dolls on which children can draw, according to a news story.1 The dolls are provided by a local Kiwanis group. The dolls are "stuffed" by an Alzheimers unit at a local facility. Playing with the dolls helps children to relax, the staff members say. Also, they use the dolls to explain where on the child's body the surgery will be performed. To distract the children, anesthesia staff members also interact with the dolls. At Finger Lakes Surgery Center in Geneva, NY, children doing a preop tour are given a popsicle plus a stuffed bear, provided by local colleges, a news story says.2They also are encouraged to bring the teddy bear back on the day of surgery along with a DVD to watch before and after surgery. A group that serves individuals with disabilities provides coloring books and crayons to distract the children. On the day of surgery, nurses often dress the teddy bears in caps and masks and put bandages on them. Such efforts help the children to not be so anxious, staff say. Having the right staff is key to helping patients relax, say sources interviewed by Same-Day Surgery. At Franciscan Point Surgery Center, "they are clearly experts at customer service," DeMario says. Being able to make an emotional connection with patients, by talking in quiet, calming tones, for example, is as important a quality as having a good clinical background, she says. "They're more than just comforting," DeMario says. "They make the experience a [positive] emotional one for patients." REFERENCES
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REFERENCES
- Gooding L, Swezey S, Zwischenberger JB. Using music interventions in perioperative care. South Med J 2012; 105(9): 486-490. Doi: 10.1097/SMJ.0b013e318264450c.
- Mifflin KA, Hackmann T, Chorney JM Streamed video clips to reduce anxiety in dhildren during inhaled induction of anesthesia. Anesth Analg 2012; 115:1,162-1,167. Doi:10.1213/ANE.0b013e31824d5224.
- Lee J, Lee J, Lim H, et al. Cartoon distraction alleviates anxiety in children during induction of anesthesia. Anesth Analg 2012; 115:1.168–1,173.
- Clark Porter S. A tour to ease fears: Trial run-through lets kids see what surgery will entail. Finger Lakes Times. June 16, 2013. Accessed at http://bit.ly/1bN5ZLD.)
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