Background to the Study
Orthopaedic surgical procedures have some of the highest rates for postoperative deep vein thrombosis (DVT), with rates between 40% to 60% (Falck-Ytter et al., 2012; Geerts et al., 2008). Anticoagulant treatment is critical for these patients, and aspirin is generally recognized as being an effective treatment to prevent DVT in this patient population (Mont & Jacobs, 2011). In addition, aspirin is listed in the updated 2012 guidelines by American College of Chest Physicians and by the American Academy of Orthopedic Surgeons as an acceptable anticoagulant treatment choice for patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA).
Patients undergoing TKA and THA patients are typically discharged on aspirin for 30 days, prescribed as an oral anticoagulant, not as an antipyretic, anti-inflammatory, or analgesic. It is extremely important that patients appreciate these differences, as their previous experience, education, and practices related to aspirin administration may be inappropriate for this purpose. For example, if patients are using aspirin as an anti-inflammatory, they may omit a dose without serious consequences; this may not be true when it is used as an anticoagulant.
Patient education is an essential component in the management of patients who are discharged on anticoagulants. Appropriate education is imperative for the prevention of postoperative DVT after patients are discharged from the acute care setting. Because it is time consuming and may be considered common knowledge, patient education for the use and administration of aspirin as an anticoagulant may be deficient (Wooford, Wells, & Singh, 2008). This would seem to be particularly true for a common medication such as aspirin that is used for multiple purposes.
In January 2009, the Joint Commission implemented a National Patient Safety Goal intended to reduce harm associated with the use of anticoagulation therapy (The Joint Commission, 2013). To meet this goal, most hospitals developed education programs for anticoagulants such as warfarin and heparin. Even with this mandate, reports continue to appear indicating that healthcare providers sometimes fail to educate patients regarding discharge medications, in particular, anticoagulant therapy (Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS], 2013; American Society of Consultant Pharmacists, 2014). Furthermore, studies based on HCAHPS indicate a strong positive correlation between patients' perception of care, such as their perception of education regarding medication administration, and measures of hospital quality and safety (HCAHPS, 2013; Isaac, Zaslavsky, Cleary, & Landon, 2010).
To our knowledge, there have not been specific studies examining patients' knowledge regarding the importance and proper use of aspirin as an anticoagulant after orthopaedic procedures. Nor were the authors able to locate specific educational material for aspirin as an anticoagulant or a specific questionnaire to measure knowledge regarding this medication.
The two complementary purposes for this study were to (a) pilot a novel knowledge assessment tool regarding the use of aspirin as an anticoagulant in a sample of postoperative joint replacement patients and (b) evaluate the effect of a focused educational approach for discharge teaching regarding the use of aspirin as anticoagulant on knowledge level after joint replacement surgery.
Research Hypothesis
A focused educational approach will improve knowledge regarding aspirin as an anticoagulant in TKA and THA patients having joint arthroplasty in a hospital setting.
Methods
Study Design
This was a one-group pretest, posttest pilot study. The predictor variable was presence or absence of the structured educational program; the outcome variable, knowledge related to the use of aspirin for anticoagulation, was evaluated using an investigator-developed quiz. Control variables included patients' age, race/ethnicity, gender, and type of surgery (see Table 1).
Setting and Participants
After receiving institutional review board approval, a convenience sample of 28 subjects was recruited from an orthopaedic hospital in north central Georgia. Subjects for this study were TKA and THA patients between the ages of 18 and 80 years who were able to speak, read, and write English and who were having a single TKA or THA and were able to provide consent.
Participant recruitment and enrollment occurred in the preadmission testing area. Because the intervention occurred after the surgery, sometimes as much as 2 weeks after the consent procedure, patients were reminded of their enrollment and given an opportunity to reassent to participate or withdraw before beginning study procedures.
Procedure
Preintervention
Approximately 24 hours after surgery, the nurse provided discharge education to the patient per usual care. Usual care consisted of reviewing the prescription and post-discharge plan of care and giving the patient a written discharge document downloadable from the computer summarizing the aspirin protocol as shown in Appendix A. The nurse answered questions and clarified any areas of concern, and then he or she administered the Aspirin Quiz for Time 1 as the pretest (see Table 2).
Intervention
On the day of discharge, the nurse provided the intervention. The intervention consisted of a review of the prescription and provision of the printed focused educational material regarding aspirin specifically as an anticoagulant. This was developed by staff nurses on the basis of directions for the use of aspirin as an anticoagulant. The instructions were designed to be clear, concise, and straightforward. (See Appendix B for the focused education material.)
Postintervention
The Aspirin Quiz was then administered for a second time as the posttest. Both tests were scored prior to patient discharge and additional teaching was providing as indicated. In addition to the ASA quiz, participant demographics and pertinent hospitalization characteristic data were also collected.
Measures
A short ASA Quiz was developed by the study team to measure patients' knowledge of aspirin as an anticoagulant (Appendix C). Items were devised by the team on the basis of the hospital-approved instructions on the use of aspirin as an anticoagulant. The ASA Quiz was designed to test knowledge of the purpose for which the ASA was ordered, the dosage, frequency, and duration of administration, and recognition and appropriate actions related to serious side effects. There were also feedback questions regarding the usefulness of the quiz.
Experienced nurses reviewed the ASA quiz to help establish its face validity. As a pilot, this project lays the framework for further development and validation of an instrument for testing aspirin knowledge relative to discharge instructions after TKA. A critical consideration in developing this quiz was to keep it as simple as possible to ensure patients' willingness to complete it prior to discharge.
Fidelity to the intervention was established through training led by the principal investigator (PI). All research nurses were trained individually by the PI using verbal instructions and clearly printed directions, followed by demonstrations. The PI was present for approximately half of the data collection and provided ongoing monitoring of compliance to the research protocol. The data collectors were part of the research team and were intimately acquainted with the protocol. The first ASA education discharge instruction was routine discharge information for ASA; the research team was instructed and encouraged to be faithful to the "usual care" process.
Data Analysis
Data were reviewed for completeness, distributional assumptions, and potential discrepancies prior to analyses. One of the 29 original subjects was excluded because it was apparent from the way questions were answered that he or she did not understand the quiz. Means and standard deviations for the remaining 28 subjects were calculated for continuous normally distributed measures such as age. However, the median and range (minimum and maximum) were reported for skewed data (quiz scores). Frequencies and relative percentages were reported for categorical and ordinal data. The Wilcoxon rank sum test was used to test for the paired changes in the scores from Quiz 1 to Quiz 2. McNemar's test was used on the individual quiz questions to test for significant changes in the percentages of subjects who had previously gotten a question incorrect on Quiz 1 to getting it correct on Quiz 2 and vice versa.
Results
There were 28 subjects aged 53-80 years, with an average age of 66.7 (SD = 7.7) years. Slightly more than half (53.6%) were female and Caucasian (67.9%). The majority (78.6%) had some college-level education or a college degree. There were no significant associations between any demographic variables on either pre- or postintervention scores or the differences between them.
For the pretest, the median number of items answered correctly on the Aspirin Quiz was 5.5 out of 7, resulting in scores averaging 74.0% (SD = 21.7%). The lowest score on the pretest was 28.6% (2/7) and the highest was 100% (7/7). On the posttest, after the educational intervention, the median number of items answered correctly was 7, resulting in scores averaging 92.3% (SD = 13.7%). The lowest score on the posttest was 42.9% (3/7) and the highest was 100% (7/7). Looking at the changes between the pre- and posttest, the majority (20/28 = 71.4%) got at least one more correct on posttest than on the pretest, which was a statistically significant improvement (Wilcoxon rank sum test Z = 3.880, p < .001). Only one subject actually did worse, getting one fewer correct on the posttest than on the pretest. The range of changed scores was from 1 item worse to 4 items better.
The pilot test provided information about question comprehension, sensitivity, and the difficulty of the questions. The interviewer evaluations of the pilot test did not define any particular question as problematic. The pilot did not lead to modification of materials or procedures.
Discussion
To our knowledge, this is the first study to assess patient knowledge of aspirin as an anticoagulant. Aspirin is a common medication that is prescribed for many reasons other than as a blood thinner or anticoagulant. Because patients may fail to understand the instructions for the use of aspirin as an anticoagulant, or the importance of taking it precisely as directed, our nurses created a tool to assess the knowledge of aspirin as an anticoagulant. We tested the patient's knowledge after general "usual care" instructions were provided. Then we provided a focused education, using the instructions for aspirin as an anticoagulant developed by the nurses and retested.
There was statistically significant improvement in the mean knowledge score after the education. This improvement was noted although our population was relatively well educated with many (48%) having attended college or obtaining a college degree (31%). Gender, race, and ethnicity were not associated with the quiz results.
It seems that most patients, regardless of their educational level, could benefit from the focused approach. Test scores improved from 74% prior to the focused educational intervention to 92% after the education. The three questions with the most improvement addressed the reason for the medication, length of time it was prescribed, and how often it is taken. This has critical clinical relevance to patients' recovery and prevention of coagulopathies. Patient education related to medication administration needs to include instruction in the importance of understanding why the medication is prescribed, how to take the medication properly, possible side effects, and when it may be necessary to contact the provider.
There were several limitations in this research study. First, the sample size was small. Second, we used the subjects themselves as controls so as not to change the routine standard of care for discharge for patients who were prescribed aspirin. Third, the knowledge test, that is, the Aspirin Quiz, was not a validated tool or test instrument as it was part of the pilot. While it had face validity and was reviewed by several psychometric experts, there were no further attempts to authenticate its validity. Finally, the retesting of the patient soon after the initial test (within a day) and the additional education may have biased the outcome toward improved scores; we do not know if it had any impact on retention of the knowledge or adherence to the prescribed medication regimen after discharge.
Conclusion and Implications
Patient teaching and preparation for discharge are important nursing activities. Patients' understanding and knowledge about the need for their medication and its proper administration may increase the probability that patients will follow the proper medication regimen, thereby deriving the maximum therapeutic benefit. This study clearly indicates a need to focus education on the use of aspirin as an anticoagulant, as opposed to its use as an analgesic or antipyretic. More globally, nurses cannot assume patients understand the specific purposes for which common medications are prescribed, and how adherence to instructions affects the level of benefits patients can expect from those medications. Patient education demands careful consideration, proper instruction, time, and effort; the education component is essential for optimal patient outcomes. The current study results indicate that the focused education session was effective in improving patients' knowledge related to aspirin as an anticoagulant.
As a result of information gained from this study, the shared governance councils at the study hospital have adopted the focused aspirin education material as part of the medication instructions when aspirin is prescribed postoperatively as an anticoagulant. In addition, after further consideration, the nurses recommended a review of all discharge teaching material for medications that have multiple indications or purposes to ensure clarity and simplicity of instructions.
Additional research is needed to examine the patients' long-term adherence to using aspirin as an anticoagulant. A further study following patients for 2 weeks and 4 weeks after discharge could offer valuable information regarding the degree to which individuals retain knowledge regarding the use of aspirin as an anticoagulant, and the extent to which they completed the regimen as prescribed.
Acknowledgments
We thank Susan Shapiro, PhD, RN, FAAN, for assistance with study design and manuscript preparation and M. June Connor, MN, RN, NE-BC, for administrative support of nursing research.
References