Patient Education in Wound Care and Hyperbaric Oxygen Therapy

Last updated on 2/10/20 | First published on 8/19/19 | Literature review current through Jun. 2020 [cite]

Authors: Erin Tharalson DNP, RN, ANP-BC, CWS, Elaine Horibe Song MD, PhD, MBA, Tiffany Hamm BSN, ACHRN, CWS, Jeff Mize RRT, CHT, CWCA, Topic editors: Eugene Worth MD, M.Ed., FABA, ABPM/UHM,

ABSTRACT

Patient and caregiver education is central to patient-centered, value-based care. It can be a differentiating factor for wound care and hyperbaric oxygen therapy (HBOT) services looking to offer the highest standards of clinical practice. This topic provides an update on the importance and benefits of patient education in wound care and HBOT, current gaps, commonly used methods, and resources to develop patient education programs in wound care and HBOT. It lists 5 tools that can be implemented today to streamline patient education at the point-of-care, and provides a downloadable framework with best practices on patient education in wound care and HBOT.

INTRODUCTION

Background

Definitions

Patient education is defined as the utilization of an organized process or program by healthcare professionals to provide patients with health information to facilitate learning.[1] Patient education is more than informing or giving information - it includes teaching (Figure 1). Teaching consists of modalities and strategies to facilitate and enhance patients' ability to incorporate what they learn into self-care.[1]
The goal of patient education is to help individuals improve their health, increase knowledge, and/or influence attitudes.[2] As an outcome, the patient is empowered to manage their condition autonomously to prevent illness, disease, and complications.

Figure 1. Patient education is more than informing or giving information; it includes teaching

Relevance

from a Clinical perspective

Patients who are fully informed regarding their care and condition(s) are equipped with the knowledge and know-how to be engaged partners in their healthcare.
Additionally, incorporating patient education into practice:

Improves patient engagement
Supports patient-centered care
Ensures informed decision-making by the patient
Encourages adherence to prescribed regimens
Improves health-related outcomes
Fosters self-care/self-management
Drives health literacy through improved understanding

from a Quality and safety perspective

In the U.S., eligible providers are required to participate in the Centers for Medicare and Medicaid (CMS) Quality Payment Program to avoid CMS payment deductions. Among the high priority quality measures that providers can choose from for their performance assessment is the “Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey”. The Survey, filled out by patients, includes questions related to “Health Promotion & Education”, “Shared Decision Making”, among others. Verbal and written patient education is essential for providers to perform well in this measure.[3]
Patient education is also a requirement for accreditation of healthcare facilities.[4][5] See Table 1.

Table 1. Patient Education Standards for Accreditation by The Joint Commission [4]

Patient Education Standards for Accreditation by The Joint Commission

The organization provides patient education and training based on each patient's needs and abilities (PC.02.03.01).
The organization performs a learning needs assessment for each patient, which includes the patient's cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication (EP 1).
The organization respects the patient's right to receive information in a manner he or she understands (RI.01.01.03)

What happens if patients are not educated or improperly educated?

The lack of adequate patient education may result in care and treatment misunderstandings. These misunderstandings may lead to reduced treatment adherence, increased adverse events, medical errors, and the continuation or worsening of symptoms.[6]
The lack of adherence to medication or treatment regimens is associated with poor clinical outcomes, reduced quality of life, increased hospitalizations, and rising healthcare costs.[6]

PATIENT EDUCATION IN WOUND CARE AND HYPERBARIC OXYGEN THERAPY

What are the current gaps in patient education in wound care and hyperbaric oxygen therapy?

Specific problems in wound care and hyperbaric oxygen therapy (HBOT) patient education include gaps related to limited availability of educational materials, variability in patients’ literacy levels, and complexity of interventions, as described below:

1. There is limited availability of educational materials in wound care and HBOT:

Many available resources lack educational visual aids supporting the teaching of unique/individualized dressing regimens
Educational materials in languages other than English are limited
Not many resources use simplified language with visuals that explain the underlying condition and how HBOT supports healing of the condition
There are limited resources with literacy-supportive wound pictures that demonstrate wound care basics such as wound cleansing and dressing application methods

2. Variability in patients’ literacy levels implies that many patients have low literacy skills.

Low literacy skills may inhibit understanding of the patient's own condition and care plan.

Literacy includes the ability to read and write, as well as comprehend, problem solve, and reason.[1] Patient education visual aids ideally should be created at a fifth-grade reading level or less and include simple pictorials and limited words.[7]

Low literacy skills may impede adherence to the wound care plan and consequently delay wound closure.

Health literacy is defined as the capacity to process, understand, and obtain health information and services and act on that information.[8] Patients with low to moderate health literacy skills struggle with self-management. In other conditions with similar multi-step self-care regimens (e.g. diabetes, heart failure), lower health literacy is associated with reduced disease knowledge, self-efficacy, and self-care behaviors.[9][10] Within wound care, health literacy research is limited to a single prospective cohort study. This study reported that patients with lower health literacy had larger and older wounds compared to those with higher health literacy.[11]

3. Complexity of many wound care/ HBOT interventions require that patients who perform self-care at home be knowledgeable and skilled:

Advancements in wound care technology coupled with improved dressing application methods have led to multi-step dressing regimens individualized to a patient’s specific wound characteristics. As a result, dressing change regimens require multiple steps, are scheduled at specific intervals, and require knowledge and skill in removal and application.
Increasingly, patients (and family members and caregivers) are responsible for performing these complex regimens themselves in the home. If not performed correctly, patients are at risk for adverse outcomes such as infection, delayed healing, and increased dressing costs.
Healthcare professionals must teach these complex regimens in an effective manner that supports the development of dressing skills, knowledge of complications (ex. infection monitoring), and adherence to the dressing change regimen.

What are the most commonly used methods for patient education?

Typical patient and family education strategies include print, audio-visual methods, demonstration, and verbal instruction.[5] Among these strategies, verbal education is used in virtually every patient-provider encounter. When effective, verbal patient education has been shown to improve the patient’s ability to care for him or herself after discharge, thus reducing morbidity and mortality.[5] However, not all patients learn effectively through verbal instructions. Different people learn differently, and providers need to adapt their teaching style to the patient’s needs.[5]

For all patients/ caregivers, especially patients whose preferred learning style is not verbal communication, pictures on paper or on a screen may serve as simple visual aids to supplement verbal education.[5][12]

Systematic reviews have shown that:

Caregivers/ patients who receive written and verbal information are more knowledgeable and satisfied than those that receive verbal education alone.[13]
Written information provided as new patient information packages or booklets improved patient knowledge and reduced confusion.[14]
The use of customized print material resulted in better information recall than did general print materials, and evidence-based brochures increased knowledge compared to no brochures.[15]

The Brigham and Women’s Faulkner Hospital in Boston developed a model to facilitate verbal patient and family education. The EDUCATE model provides best practices for clinicians who need to educate patients and caregivers.[5] Figure 1 provides a framework based on the EDUCATE model, that wound care and HBOT clinicians can use to enhance verbal education in any care setting.

Patient Education Wound Care Hyperbaric Oxygen Therapy (HBOT)

Figure 2. Best Practices for Verbal Patient Education in Wound Care and HBOT. Adapted from Marcus, 2014[5]

How can patient education in wound care help improve outcomes?

Patient education has a direct relationship to adherence: research cites improved patient adherence as an outcome when effective education is given.[1][6]

Adherence to care plans has many forms and is important in all healthcare settings. Issues in adherence may appear in the form of non-adherence or limited adherence to medication, treatments, appointment keeping, dietary, and lifestyle measures.[1] Adherence is influenced by factors that are related to the healthcare system or the patient.

Healthcare factors that influence adherence include the lack of adequate or effective patient teaching, poor communication, a non-patient-centered approach, and a lack of consideration of the influence of the socio-cultural aspects of the patient.[1]
Patient-based factors associated with adherence include literacy, health literacy, psychosocial, environmental, developmental, cultural, and communication factors.[1]

Literature shows that educational interventions in wound self-care improve outcomes. Below we summarize studies that support the integration of patient education interventions to foster wound self-care. In general, findings of these studies suggest that patient education results in increased adherence to wound care plans and better outcomes:

A prospective study incorporating a home-based venous ulcer patient education program reported reduced venous ulcer recurrence rates and improved disease knowledge and self-care.[16]
In the emergency room setting, a 25-minute education program focused on wound self-care management of lacerations with practice on a prosthetic model and a booklet resulted in increased satisfaction in wound care, improved self-care, and reduced infection rates.[17]
Similarly, a wound education pilot that utilized individualized literacy-supportive visual aids and prosthetic models found a significant improvement in knowledge, dressing performance, and healing in English and Spanish-speaking patients with variable health literacy levels.[18]
In a randomized control trial by Chan and Lai [19], a patient education program that incorporated patient teaching and telephone follow-up for wound care in the home-setting by patients compared to dressing changes by professional nurses in an outpatient clinic showed no differences in wound healing.

Effective patient education improves adherence.

What factors should be considered when developing patient educational programs in wound care and/or HBOT?

When developing an educational program, factors to be considered include the needs of the target patient population, education content, and logistics of how/ when/ who will deliver the education intervention.

Teaching interventions that promote adherence includes: 1) assessment of the learning needs of each patient, 2) incorporation of best practices for information presentation, and 3) adjustment of the education to support patient-specific needs and circumstances.[1] (See Figure 2 above for details)
Teaching interventions should be patient-centered and address patient-related adherence issues that hinder proper self-care. A patient-centered approach encourages healthcare professionals to engage in shared-decision making.

WoundReference clinical and reimbursement decision support web-app offers a comprehensive set of tools and content to enhance verbal patient education and promote patient adherence. For a list of tools and content (Free and Premium), proceed to the section below.

CLINICAL DECISION SUPPORT AND PATIENT EDUCATION

WoundReference clinical and reimbursement decision support platform offers a comprehensive suite of features to facilitate patient education at the point-of-care and at the patient’s home. WoundReference’s solutions allow clinicians to enhance verbal education with written and visual aids, in order to improve patient knowledge, satisfaction, adherence and wound healing outcomes.[18][13]

WoundReference's Patient Education Features: 5 tools to enhance patient engagement

1. Dressing Change Brochure Editor

(Free Basic Plan and above)

The Dressing Change Brochure Editor in English and in Spanish is a digital tool was based on a paper-based visual aid that was previously piloted and optimized for English and Spanish-speaking populations, at a 5th grade level (Figure 3).[20][18]

Figure 3. Custom patient handout instantly created with the Dressing Change Brochure Editor

With this digital, point-of-care dressing education tool clinicians can:

Edit brochures on-the-fly and set their patients up for successful dressing changes at home. Select from ~50 different professional pictures to compose brochures specific to each patient.
Empower patients to engage in self-care through customized, pictorial, step-by-step instructions

A pilot multi-center evaluation has shown that 95% of the patients interviewed (n=20) found the brochure to be “very helpful” or ”helpful”. All clinicians interviewed (n=3) found the brochures to be “very helpful” or ”helpful” in supporting teaching and in increasing patient adherence to the treatment. See blog post "Promoting Patient Education and Self-care with the Dressing Change Brochure Editor".

2. Wound Poster "When is My Wound Going to Heal?"

(Free Basic Plan and above)

Patient Education Topic and Wound Poster "When is My Wound Going to Heal?": these resources help clinicians explain to patients how wounds heal, how to recognize infection, and what patients can do to help their wound heal. The poster may be printed out, shared with patients and/or displayed at healthcare facilities (Figure 4).

Figure 4. Wound Poster "When is My Wound Going to Heal?"

3. Instant Personalized Product Handouts

(Premium)

To adhere to care plans, patients need to know which products to purchase, where to obtain them, how much they cost, and how to use them.[21] The Instant Personalized Product Handouts Generator is a point-of-care digital tool allows clinicians to instantly generate product handouts with clinical, coverage, supplier information customized to patients (Figure 5).

Wound care clinicians have found our patients handouts to be “useful” or “very useful” in increasing patient adherence to the plan of care ~90% of the time.[22] See blog post " WoundReference publishes new study on Instant Personalized Product Handouts"

Figure 5. Sample product handout. Brand names have been blurred. WoundReference does not advertise or commercialize products used on patients

4. Custom Patient Education Handouts with the Wound Care and/or HBOT Program’s Logo

(Premium)

This point-of-care, digital education tool automatically adds the Program’s logo to WoundReference’s evidence-based wound care brochures. Examples include "Venous Leg Ulcer" and "Diabetic Foot Ulcer"

Evidence-based brochures improve patient knowledge, reduce confusion and increase satisfaction.[14][15][13]
Branded brochures backed by evidence and updated as needed reinforces the Program’s authority and reputation among patients, caregivers, and healthcare professionals.

5. Patient Education Handouts for Patients Undergoing HBOT in English and Spanish

(Premium)

The WoundReference Editorial Team has been creating patient education handouts for the most common HBOT indications. The growing library contains illustration-rich handouts in English and Spanish written at a 5th grade level, to facilitate comprehension by patients and caregivers. Handouts can be printed with a regular printer at the point-of-care or digitally shared with patients and caregivers. For a list of available handouts, see "HBO Education Materials for Patients".

OTHER RESOURCES

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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.