The Role of Patient Education in Emergency Department Visits After Otolaryngologic Surgery

Hospitals track their 30-day readmissions as a quality indicator. Under the value-based care system, hospitals may not be paid for these readmissions. Consequently, avoiding preventable readmissions is of paramount importance. Prior studies in the otolaryngology literature have attempted to identify the causes and frequency of readmissions following otolaryngologic surgery. Murray, et al.,(1) used analysis of the Pediatric Health Information System database to show that readmission rates after pediatric otolaryngology surgery were low overall but were higher in patients with chronic medical conditions, low socioeconomic status, and certain procedure types.(1)

Other studies have focused on reasons for readmission following specific procedure types. McKeon, et al.,(2) showed readmission following endoscopic sinus surgery most commonly occurred due to epistaxis, with nausea/vomiting, respiratory infections, and sinusitis noted as less-common causes. Risk factors for readmission among these patients included age younger than 3 years, asthma diagnosis, and cystic fibrosis diagnosis.(2) Similarly, Chang, et al.,(3) looked to correlate severity of preoperative sleep-disordered breathing with readmission rates after adenotonsillectomy and found no correlation.

Murray, et al.,(1) calculated a 2.3% readmission rate following pediatric otolaryngology surgery, a rate much lower than that seen in adults. However, with approximately 1.3 million pediatric otolaryngology procedures performed annually, approximately 30,000 patients are still readmitted annually.(1) Current research has not focused on how many of these hospital revisits were avoidable. This study intended to identify the role that suboptimal patient communication and education (leading to poor parental understanding and retention) has in revisits to the emergency department (ED) following otolaryngologic (ENT) surgery.

Quantifying the portion of ED revisits that could be avoided with improved communication will help clinicians and hospital leadership understand the scope of the problem and ascertain if improvements to patient education would be valuable in decreasing post-surgical ED visits.

Methodology

This study used data from the pediatric otolaryngology service of a single children’s hospital. Institutional review board exemption was obtained before data collection began. The hospital already tracks and generates a monthly report for patient visits to the ED within 30 days of any surgical procedure as part of its Performance Improvement and Patient Safety program. Reports for the pediatric otolaryngology service were obtained from January 2018 to March 2019.

After patients who were readmitted within 30 days following ENT surgery were identified, individual charts were reviewed to identify whether the subsequent ED visits were related to the prior surgery or for an independent reason. Among those patients who presented to the ED for a reason related to their ENT surgery, charts were further assessed to identify if a failure of patient education regarding the treatment plan or postoperative recovery symptoms could be identified as the cause for the visit.

The above methodology of categorizing and grouping patients was used to calculate the percentage of readmissions attributable to breakdowns in patient communication. Among the ED visits for communication failures, the nature of the failure was also identified to assess for frequency. A two-tailed chi-square test was used to compare the composition of the two patient groups based on various demographic factors including race, insurance coverage, and need for English language interpretation. Race was determined by what the parent had identified during initial registration, when a list of options is offered that included “other” and “decline to answer.” Additionally, US Census Data were used to identify the median household income for each patient’s zip code.(4) Income data were compared between groups using a two-tailed student’s t-test.

Main Findings

From January 2018 through March 2019, 330 patients who visited the ED within 30 days of their ENT surgery were identified. Of these, 97 (29.4 percent) returned to the ED as a result of their surgery, while the remaining 233 (70.6 percent) visited the ED for unrelated reasons. The most common reasons for unrelated revisits were viral illnesses and traumatic injuries.

Among the 97 patients who returned to the ED for reasons related to their ENT surgery, 48 visits (49.5 percent) were identified as a consequence of lapses in patient communication. The remaining 49 visits (50.5 percent) were determined to be unavoidable despite appropriate patient education. The unavoidable readmissions typically occurred as a result of surgical complications such as wound infection, post-tonsillectomy bleeding, or dehydration despite appropriate adherence to prescribed pain medication (see Figure 1).

Figure 1. Surgery-related emergency department visits within 30 days after otolaryngologic surgery and portion of those visits associated with failure in patient education

When gaps in patient communication were identified, they were categorized into two groups: 1) confusion over expectations for the postoperative recovery course, and 2) failure to follow the recommended postoperative medication regimen. The second category, which was significantly less common, included confusion over how to administer otic drops and under-dosing or omission of pain medications following adenotonsillectomy.

For families who had inappropriate expectations of their child’s postoperative recovery, common areas of misunderstanding focused on expectations for duration and severity of pain following tonsillectomy, timing for return to normal oral intake after tonsillectomy, meaning and treatment of otorrhea following bilateral myringotomy with tubes, timing for improvement in congestion after adenoidectomy, and presence of fever after any surgery. Additionally, families in this group sometimes presented for expected associated symptoms such as ear or jaw pain following tonsillectomy or bad breath following adenoidectomy.

Comparisons between patients visiting the ED for unavoidable reasons and those visiting the ED due to lapses in education were conducted to determine if any demographic differences were present between groups. There was no significant difference in insurance coverage between the two groups (p = 0.3384 [see Figure 2]). Among patients unavoidably readmitted, 51.1 percent were privately insured and 48.9 percent were on public insurance. Among patients readmitted for communication failures, 43.2 percent were privately insured and 56.8 percent were on public insurance.

Figure 2. Private versus public insurance status among patients visiting the emergency department within 30 days after otolaryngologic surgery for unavoidable reasons versus those visiting for reasons related to gaps in patient communication

Statistically significant differences were noted between the racial compositions of the two groups (p = 0.0006 [see Figure 3]). Among patients unavoidably readmitted, 20 percent were Black, 66.7 percent were White, 8.9 percent were Latino, and 4.4 percent were Asian. Among patients readmitted for communication failures, 32.4 percent were Black, 43.2 percent were White, 24.3 percent were Latino, and 0 percent were Asian.

Figure 3. Racial demographics of patients visiting the emergency department within 30 days after otolaryngologic surgery for unavoidable reasons versus those visiting due to gaps in patient communication

The need for English language interpretation also showed a statistically significant difference between the two groups (p = 0.0001). Among patients unavoidably readmitted, 2.2 percent requested an interpreter and 97.8 percent declined an interpreter. Among patients readmitted for communication failures, 16.2 percent requested an interpreter and 83.8 percent declined an interpreter. All families requesting an interpreter identified their primary language as Spanish (see Figure 4).

Figure 4. The need for English language interpretation among patients visiting the emergency department within 30 days after otolaryngologic surgery for unavoidable reasons versus those visiting for reasons related to gaps in patient communication

Statistically significant differences were also noted for median household income by zip code between the two groups (p = 0.0481 [see Figure 5]). The average median household income by zip code for patients who were unavoidably readmitted was $71,688.22. The average median household income by zip code for patients who were readmitted because of communication failures was $59,502.81.

Figure 5. Median household income by zip code among patients visiting the emergency department within 30 days after otolaryngologic surgery for unavoidable reasons versus those visiting for reasons related to gaps in patient communication

Limitations

This study does have limitations. Data were collected from a single hospital, so it cannot be claimed to represent the readmission profile of all children’s hospitals nationwide. Additionally, the information contained in the ED provider note (used to determine if a failure in patient communication existed) was non-standardized, which may have obfuscated the findings.

For example, some ED provider notes clearly commented on the home pain regimen of patients with post-tonsillectomy pain, while other notes did not specify the pain medications used prior to presentation in the ED. This lack of clarity could have caused some patients to be misclassified. Furthermore, multivariate analysis, which would have allowed for assessment on collinear variables, could not be accurately performed due to small sample size.

Discussion

Providers and health systems frequently attempt to provide patient education but may be unaware that they are failing to communicate effectively. Often, information may be provided as verbal or written instruction and too much information may be given at one time. Additionally, retention of this material may be limited, especially among parents who may feel stressed about their child undergoing a surgical procedure.

In the current study’s institution, all areas that noted parental confusion are covered in the handout parents receive on the day of their clinic appointment and on the day of surgery. Despite these interventions in addition to verbal communication, a significant portion of parents are not receiving the information in a way that avoids unnecessary ED visits. This suggests that the information being provided is not being supplied in a way such that families can use and apply when caring for their children.

Additionally, data collected suggest that Black and Latino families may be especially vulnerable for gaps in communication, based on the fact that these populations were overrepresented among patients presenting to the ED for communication lapses when compared with patients presenting for unavoidable reasons.

Patients requiring English language interpretation were also overrepresented in the group presenting to the ED for communication failures. As all patients requesting interpretation in this study were Spanish-speaking and identified as Latino, this language effect may account for part of the reason Latinos were so significantly overrepresented among patients seen as a result of communication failures. In a larger sample, multivariate analysis could be used to better assess the potential collinearity of these variables.

The effect of socioeconomic status remains unclear. The median household income by zip code for communication failures was lower on average than the median household income by zip code for unavoidable visits to the ED. However, there was no statistically significant difference between the compositions of the groups according to private versus public insurance status. Both of these measures are proxies for actual income, and further research will be needed to define the true effect of socioeconomic status.

Prior studies looking at parental recall, even after a formal discussion like informed consent, have shown poor recall rates. Wasserzug, et al.,(5) queried parents of tonsillectomy patients with a 16-question multiple-choice quiz based on information they received before signing surgical consent. The average score on the quiz was 76.3 percent correct responses. The question defined as “essential” by the investigators — that parents recognize that they should go to the nearest ED if their child began bleeding orally — was answered incorrectly by 21.6 percent of parents.(5) Handouts have been shown to improve patient recall, but recall rates are still low. Papsin, et al., surveyed 50 parents of pediatric otoplasty patients. Half of the parents were given a handout detailing the seven major risks of the procedure along with the verbal consent discussion; the control group received only the verbal consent discussion. Parents who received the verbal discussion alone recalled an average of 2.8 risks; those who received a handout recalled an average of 3.9 risks. While the difference between groups was statistically significant, even parents who received the handout were unable to recall three of the seven risks on average.(6)

While hospitals, clinicians, and medical societies have devoted significant effort to designing more readable and patient-centered handouts, it is unclear how readily these handouts are used by patients. In a study of adult patients with allergic rhinitis, Camilleri showed that while 90 percent of patients think leaflets are a good idea, only 75 percent of patients actually read and used the leaflets provided.(7)

Although a majority of patients did use the handouts, a significant number admitted to disregarding the written instructions. This study did not look for any correlations between adherence to the treatment regimen, symptom improvement, and illness severity and the use of handouts.

This failure of verbal instructions and handouts to provide effective patient communication suggests a new way to provide information is needed. Prior guidance on patient education has focused on techniques such as “teach back,” where parents are asked to repeat back their understanding of the most important instructions, and providing limited amounts of information during each patient encounter.(8) Current modes of care provision do not allow most pediatric otolaryngologists to have multiple visits prior to routine procedures, necessitating a large transfer of information in a single visit.

Some investigators have studied timed text messages as an alternate mode of communication that would allow for the provision of smaller amounts of information at more frequent intervals.(9,10) Newton and Sulman conducted a pilot study(9) among families with a child planning to undergo a tonsillectomy. The families received a series of informational text messages containing videos beginning two weeks before surgery and ending nine days after surgery. The investigators postulated that providing small amounts of information at pertinent time points during the patient’s postoperative recovery would be more useful than a handout given out at the time of surgery. When surveyed, all five families felt the information was useful, and none called the nurses’ line to ask additional questions.(9)

If parents are provided small amounts of information at the times when they need it, they will not need to use additional resources such as the nurses’ line or the ED to obtain routine postoperative information. The authors’ follow-up study of 85 families showed that no families visited the ED and only 25 percent of families called the nurses’ line postoperatively.(10)

Conclusions

This study seeks to identify the role that failures in communication play in ED visits after otolaryngologic surgery. Data collected showed that failures of communication, such as misunderstandings with respect to postoperative recovery symptoms and prescribed treatment regimens, account for approximately half of related ED visits occurring within 30 days of surgery. Given the high volume of pediatric otolaryngology procedures performed in the United States annually, even a low overall readmission rate affects a large number of patients and families.

Further investigation should be targeted at identifying risk factors for poor patient communication such as primary language, ethnic background, and socioeconomic status. Additionally, strategies to improve patient communication should be considered to help reduce these avoidable visits and decrease costs while improving quality of care. Investigators plan to initiate a postoperative text message program for common otolaryngologic procedures to reduce ED revisits and phone calls to the nurse line while improving the quality of care.

References

1. Murray R, Logvinenko T, Roberson D. Frequency and cause of readmissions following pediatric otolaryngologic surgery. Laryngoscope. 2016;126(1):199–204.

2. McKeon M, Medina G, Kawai K, Cunningham M, Adil E. Readmissions Following Ambulatory Pediatric Endoscopic Sinus Ssurgery [published online March 1, 2019]. Laryngoscope. doi:10.1002/lary.27898

3. Chang IS, Kang KT, Tseng CC, et al. Revisits After Adenotonsillectomy in Children with Sleep-disordered Breathing: A Retrospective Single-institution Study. Clin Otolaryngol. 2018; 43(1):39-46.

4. US Census Bureau. American Fact Finder. Available at: https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?fpt=table . Accessed July 8, 2019.

5. Wasserzug O, Fishman G, Sternbach D, et al. Informed Consent for Tonsillectomy: Do Parents Comprehend the Information We Provide? Int J Pediatr Otorhinolaryngol. 2016;88: 163–67.

6. Papsin E, Haworth R, Chorney JM, Bezuhly M, Hong P. Pediatric Otoplasty and Informed Consent: Do Information Handouts Improve Parental Risk Recall? Int J Pediatr Otorhinolaryngol. 2014; 78(12):2258–61.

7. Camilleri AE. Information Leaflets in the Rhinitis Clinic? J Laryngol Otol. 1991;105(4):282–84.

8. Doak C, Doak L, Root J. Teaching Patients with Low Literacy Skills. 2nd Edition. Philadelphia: JB Lippincott Co.;1996.

9. Newton L, Sulman C. A Pilot Program: Using Text Messaging to Improve Timely Communication to Tonsillectomy Patients. ORL Head Neck Nurs. 2016; 34(2):6–10.

10. Newton L, Sulman C. Use of Text Messaging to Improve Patient Experience and Communication with Pediatric Tonsillectomy Patients. Int J Pediatr Otorhinolaryngol. 2018; 113:213–17.