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From the *Department of Anesthesiology and Institute and Policlinic of Medical Psychology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
Address correspondence and reprint requests to Martin Schuster, MD, MA, Department of Anesthesiology and Intensive Care, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin. Address e-mail to martin.schuster{at}charite.de.
Abstract
BACKGROUND: Video-assisted patient education during the preanesthetic clinic visit is a new intervention to increase knowledge transfer to the patient regarding anesthesia procedure and risks. However, little is known about whether video-based patient education influences patient anxiety and the duration of the preanesthetic visit.
METHODS: Two hundred nine consecutive patients, who visited the anesthesia clinic before major operations, were randomly assigned to one of three groups: no-video (Group 1), video-before-interview (Group 2), and video-after-interview (Group 3). Anxiety levels were measured before and after the interview using the state trait anxiety inventory and a visual analog scale (anxiety). Patient knowledge regarding anesthesia technique, anesthesia-related risks, and patient satisfaction were assessed after the interview using standardized questionnaires.
RESULTS: There were no significant differences in anxiety levels and patient satisfaction among the three groups. Patient knowledge was significantly higher in the video groups compared with the no-video group. The duration of the preanesthetic interview was significantly extended in Group 2 (video-before) (23.1 ± 14.0 min), compared with Group 1 (no-video) (17.6 ± 7.2 min), and Group 3 (video-after) (18.3 ± 9.6 min). This difference was even more profound in subgroups of patients scheduled for anesthesia techniques with invasive monitoring.
CONCLUSION: Our study suggests that the use of a video for detailed anesthesia risk education does not change patient anxiety, but leads to a better understanding of the procedure and risks of anesthesia. When the video is shown before the preanesthetic interview, the interview is longer.
To give informed consent to any medical procedure, patients need to have adequate knowledge about the course and risks of the procedure. It is the physician’s duty to provide this information and to ensure the patient has understood explanations about procedures and associated risks.1 Most patients have a positive attitude toward receiving information,2 but during the preanesthetic interview (PAI), transfer of knowledge regarding anesthesia procedure and risks from the anesthesiologist to the patient is often limited.3 Adding written material (i.e., a brochure) to the PAI might increase the patient’s knowledge4 and is regarded as a helpful tool by patients.5 However, written material requires active cooperation and patient compliance.5 Several studies have shown that video-assisted patient education (VIP), compared with an interview alone or to an interview plus a brochure, results in better patient satisfaction6 and improves patient knowledge regarding the anesthesia procedures.7–9
Most patients experience preoperative anxiety, which is a major concern before surgery,10,11 and it has been suggested that the reduction in preoperative anxiety levels might be associated with better outcomes.12 Several studies have addressed the influence of videos on perioperative anxiety in patients undergoing general anesthesia (GA).9,12,13 However, the results have been mixed, and none of the previous studies focused explicitly on video-based risk education. Furthermore, none of the previous studies included patients undergoing regional anesthesia techniques or patients who underwent more invasive anesthesia techniques, such as the placement of invasive monitoring devices. Finally, it is unclear whether the placement of the video before or after the PAI is important.
In addition, we examined the influence of VIP on the duration of patient-to-physician-contact during the preanesthesia clinic visit. The PAI produces 5%-10% of the total costs of anesthesia.14 Whether the VIP will increase or decrease the time the anesthesiologist spends on patient education and obtaining informed consent has not been investigated.
METHODS
Approval of the ethics committee of the Chamber of Physicians, Hamburg, and written informed patient consent was obtained. The study was conducted as a randomized, prospective trial from October 2006 to December 2006 in the anesthesia clinic of the University Hospital Hamburg-Eppendorf. The patients visit the preanesthesia clinic for anesthesia evaluation before surgery. The anesthesia evaluation includes four steps: (a) studying the patient chart, including the written material of the surgical evaluation, documentation of the referring physician, radiology studies, electrocardiograms, etc., (b) taking or verifying the patient’s history, with special focus on topics relevant to anesthesia, (c) performing a physical examination if necessary, and (d) explaining the planned anesthesia procedure, related risks, and obtaining written consent. The anesthesia clinic is open 8 h a day and patients of the following surgical subspecialties are mainly seen in this anesthesia clinic: general surgery, traumatology/orthopedics, and urology. Patients of other surgical specialties are seen by anesthesiologists in other locations and clinics. Trauma and orthopedics are combined services in our hospital. Acute trauma patients are not seen in the anesthesia clinic where we conducted the study, therefore, the patients included from the trauma/orthopedics service were exclusively those who came for elective operations, such as complex removal of the internal fixation months after the initial trauma or joint surgery for chronic disease. Only approximately 20% of all patients of the trauma/orthopedics service are in this group. For urology and general surgery, approximately 90% of all patients are seen in the anesthesia clinic. The rest are patients who are too sick to walk to the clinic and are therefore seen by anesthesiologists in the ward preoperatively. A maximum of three offices are available and the anesthesiologists, including anesthesia residents, take turns in the anesthesia clinic.
All patients referred to the anesthesia clinic during the study period for preoperative evaluation were evaluated for inclusion and exclusion criteria. Patients were considered to be eligible to participate in the study if they met the following inclusion criteria: Adults (18 yr or older), undergoing an elective operation under one of the following anesthesia techniques: GA, GA plus invasive monitoring (GAIM) such as central venous catheter and intra arterial catheter, GAIM plus epidural catheter, spinal anesthesia (SP), or SP supplemented with GA. For subgroup analysis, we differentiated anesthesia technique with invasive monitoring (GAIM and GAIM plus epidural catheter) and anesthesia technique without invasive monitoring (GA, SP, and SP supplemented with GA). For practical purposes, we included only those patients with scheduled surgery within 2 wk after the clinic visit. The following exclusion criteria were applied: cognitive, visual or speech disorders or other reasons for inability to give written informed consent, watched and understood the video, or answer the questionnaires; expected postoperative stay in the intensive care unit or previous anesthesia evaluation and consent within the last 12 mo. Because we wanted to study patients undergoing major operations with a variety of anesthesia techniques and with a presumed higher incidence of perioperative anxiety, we excluded all procedures performed on an outpatient basis.
Two hundred forty-eight patients were asked to participate. The 212 patients who agreed to participate were randomly assigned to one of the following groups, using a closed envelope technique: no-video (Group 1), video-before-the-preanesthetic-visit (Group 2), or video-after-the-preanesthetic-visit (Group 3).
The videos used (medlinq, Hamburg, Germany) are commercially available for preanesthestic clinic visits and follow the recommendations of the German Society of Anesthesiology and Intensive Care regarding preoperative anesthesia patient education. They include general information about the anesthesia procedure, but then focus on detailed explanations regarding the risks of anesthesia procedures. The videos were shown to the patient using a PC with monitor and headphones. A brief description of the content of the five different videos used can be found in Appendix A.
The patient’s anxiety level before the PAI was measured using two different tools: the visual analog scale (VAS) and the state trait anxiety inventory (STAI). With the VAS, patients rated their anxiety using a visual scale similar to the VAS pain. The VAS used had possible scores between 0 (no anxiety at all) and 10 (highest possible anxiety level). The patients were asked to specifically focus on their anxiety regarding the anesthesia procedure and risks. In contrast, the STAI is a more general tool to assess anxiety levels and consists of two 20-item questionnaires for state and trait anxiety.15 We used the questionnaire for state anxiety in a well established and validated German translation,16 where high scores (minimum 20, maximum 80) indicate increased anxiety.
The study design is displayed in Figure 1. Depending on the study group, the patient either saw the video first or went directly to see the anesthesiologist for the PAI. All anesthesiologists working in the anesthesia clinic agreed to participate in the study, and in all study groups, the patients were always assigned to the next available anesthesiologist. The PAI took place in the anesthesiologists’ offices in the anesthesia clinic, separate from the investigators and video room. The anesthesiologists who did the PAI were not otherwise involved in developing or conducting this study. As much as possible, we tried to keep the anesthesiologists blinded to patient’s study group assignment. However, in order not to interfere with normal patient-physician-interaction we did not make any suggestions, neither for patients, nor for physicians, regarding their behavior during the PAI. Therefore in some cases, when patients saw the video before the PAI, they disclosed this fact by asking specific questions. One study investigator (C.S.) was present during all interviews and recorded their duration but was not otherwise involved in the PAI. After the PAI, patients completed the VAS and STAI again. Group 3 (video-after) patients watched the video directly after the interview and afterwards completed the VAS and STAI again. Next, patients had to answer multiple choice knowledge questions regarding the anesthesia procedure and risk. To assess knowledge transfer, we used questions from the previously published and validated questionnaire by Snyder-Ramos et al.17 The knowledge questions can be found in Appendix B. Only one answer for every question was correct. The percentage of correct answers was recorded for each patient. The patients were also asked to rate their overall satisfaction with the PAI, using a 6-point-Likert-scale. Demographic data, operating surgical specialty, anesthesia technique, and American Society of Anesthesiologists (ASA)-classification were obtained from the hospital chart and the patient.
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The data were analyzed in Microsoft Excel 2002 (Microsoft, Redmond, WA) and SPSS 13.0 (SPSS, Chicago, IL). If not otherwise stated, mean ± sd are displayed. Also confidence intervals were calculated for STAI, VAS, and the interview duration. For overall comparison of the three groups, the Kruskal-Wallis test was used. If this showed significant differences, the three groups were directly compared with each other using a Mann-Whitney U-test. A P value <0.05 was considered significant.
RESULTS
Of the 248 eligible patients who were asked, 212 patients consented to participate. Of these, three patients withdrew after the PAI and had to be excluded, all of them because of time constraints to complete the post-PAI questionnaires (Fig. 2). Twenty-seven different anesthesiologists performed PAIs during the study period. The average number of study patients seen by a single anesthesiologist was 7.7 (range, 1-31).
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As shown in Table 1, the majority of patients underwent general surgical or urological operations, but a few trauma patients with elective operations were also included. The average age was 57.5 ± 13.6 yr and approximately 81% of the study participants were ASA Group 1 or 2. The majority of patients belonged to the predefined subgroup of anesthesia technique without invasive monitoring. However, 23% were planned to receive invasive monitoring with or without additional epidural catheters. There were no significant differences among the three study groups regarding age, gender, operating surgical specialty, method of anesthesia, and ASA classification (Table 1). All patients showed high satisfaction levels with the PAI (mean satisfaction score of 5.7 ± 0.5, 6-point-likert-scale). There were no significant differences among the three groups. Patients who saw the video answered a higher percentage of questions correctly in the knowledge test than patients who did not see the video (Group 1 [no-video]: 81.0% ± 16.7%; Group 2 [video-before]: 88.3% ± 13.9%; Group 3 [video-after]: 87.1% ± 14.2%; P = 0.009).
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STAI and VAS were not altered by the PAI. There were no significant differences in anxiety levels among all three groups at each time point (Fig. 3).
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As demonstrated in Figure 4, the duration of the interview showed significant differences among the three groups. The mean duration of all interviews was 19.6 ± 10.8 min. The interview durations of Group 1 (no-video) and Group 3 (video-after) did not vary significantly. However, Group 2 (video-before) had a significantly longer duration of the interview compared with Group 1 (no-video) (P = 0.007) and Group 3 (P = 0.014). Subgroup analysis showed that the duration of the interview was especially long in patients with anesthesia technique with invasive monitoring, who had watched the video before the interview.
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DISCUSSION
In this randomized controlled trial, we examined the effect of VIP on patient satisfaction, patient knowledge, patient anxiety levels, and the duration of the PAI. Similar to previous studies on video intervention, patient satisfaction was generally very high in each group and there was no significant difference among the three groups.4,12 This is not unexpected, as satisfaction is generally very high in clinical trials and might be an effect of increased attention for the patient in this setting.18–20 This limits the ability to differentiate between interventions.21
VIP can significantly increase patients’ knowledge of medical procedures.6,22,23 In our study, we also identified a significant increase in patients’ knowledge and we were able to show that this effect is independent of the positioning of the video before or after the PAI. Sufficient information and reasonable involvement in decision making is a major factor influencing patient satisfaction with anesthesia care.24 Furthermore, the legal requirements regarding the extent of risk education before informed consent for anesthesia have increased considerably over the last decades, at least in Germany. Even extremely rare complications, such as paraplegia after SP due to spinal hematoma, are now a mandatory part of risk education25 and an increasing number of lawsuits against anesthesiologists are filed based on insufficient risk education. Because of this, anesthesia brochures and consent forms have increased in volume and complexity to an extent that, in our experience, many patients refuse to read the provided material. Under these circumstances, the use of video material might serve both physicians’ and patients’ interests.
However, it is possible that these explicit, risk-focused videos might have a negative effect by increasing patient anxiety. Therefore, a major focus of this study was the effect of detailed anesthesia risk information on perioperative patient anxiety. In our study, we did not find any significant effect of the video material on the STAI or VAS scores. Previous studies have shown that there is no significant change in anxiety levels after additional written information is provided to the patients.26–28 According to our study, this finding can be transferred to the use of video material with its more explicit and vivid depiction of anesthesia procedures and risks. In a recent study, Kain et al.29 showed that a multimodal approach including, among others, the provision of video material, an operating room visit preoperatively, and parent coaching can successfully reduce anxiety in pediatric patients and their parents. However, the situation for pediatric patients is structurally different than for adults, and it is unclear how much risk education was included in the video material.
Several possible limitations have to be considered. First, our methodology measuring anxiety might not have been adequate. The STAI is used as the "gold standard" for measuring preoperative anxiety and a difference of eight points is considered significant in the STAI.30 However, the test procedure is rather complex, so we doubt that it will ever become clinical practice to assess perioperative patients using this tool. The VAS anxiety is simple and easy to administer, and there is good evidence that it performs as well in the perioperative setting as the much more complex state trait anxiety.31–33 For further studies on patient anxiety it therefore might help researchers if both values are reported, which might also be of practical value for clinicians who wish to assess their patient’s anxiety in their daily practice.
Second, the interaction with the anesthesiologist might be the more important factor, with the video having only a minor effect on patient anxiety. However, we received several handwritten commentaries on our questionnaires in which patients stated explicitly that they highly valued the additional information in the videos. The third, and probably most convincing, reason for the small effect of the video and the PAI on patient anxiety is the general situation of the patient. The majority of patients in our study underwent major operations. We therefore assume that patients were much more worried about surgery, the surgical outcome and, in tumor operations, the clarification of the diagnosis, rather than about anesthesia risks and complications.31,34
Probably the most interesting finding of our study is that showing the video to the patient before the PAI significantly prolonged the duration of the PAI. This effect was most profound in patients scheduled to undergo an anesthesia technique with invasive monitoring, with or without the use of a thoracic epidural catheter for postoperative pain management. The reason for this finding might have been that the patients were less aware of these more invasive procedures performed by anesthesiologists and that the detailed description of the procedure itself and the associated risks in the videos led to more detailed questions from the patient. During the PAI, these techniques are certainly also explained; however, the explanations from the anesthesiologists might be too brief or complex, or might not be as illustrative as the video presentation, so patients are not able to fully understand and ask specific questions. This increase in PAI duration after the presentation of the video might negatively influence the economics of the preanesthesia clinic. However, we think it should be regarded as a chance to strengthen patient autonomy.
Is it of importance when the video is shown? Neither knowledge transfer, anxiety, or patient satisfaction was affected by the timing of the video. Therefore, if the main purpose of the video is knowledge transfer, it does not seem to be important to place the video before the PAI. If the workflow of the anesthesia clinic can be optimized by placing the video after the PAI, it seems prudent to do so. In the study group, very few patients had additional questions if they saw the video after the PAI; all of the questions could be answered easily by the clinic nurse and no repeated consultation of the anesthesiologist was necessary.
Some inherent limitations of this study should be mentioned. For obvious reasons, it was not possible to blind patients regarding the treatment group. Also, because we did not give instructions regarding the patients’ or physicians’ behavior during the PAI, patients were able to tell the anesthesiologist whether they had seen the video or not, and some patients did so. Therefore, some anesthesiologists were unblinded during the PAI. However, the principle of not intervening was of overriding importance to us. Furthermore, we studied the effects of the video on a specific, clearly defined set of anesthesia techniques. It is unclear whether the effects of the video can be transferred to other anesthesia techniques (i.e., peripheral nerve blocks). Further studies are needed which consider the specific situation of the patients. For example posttraumatic patients, whom we did not study, might have intrinsically higher anxiety levels than other patients, and therefore might react differently to the video intervention. There are also some patients who might refuse to use VIP because they do not want to see medical interventions on video and might react with panic if they are forced to. It is also important to note that we studied patients only from certain surgical specialties and that the large number of anesthesiologists who took part in our study might have increased the variability of the results. Most importantly, all previous studies on VIP used different videos. This might be an important limitation in comparing the results. With video material becoming commercially available, a broader variety of anesthesia departments might be able to use it, making multicenter studies easier. The videos we used focus on risk-education, because of its medico-legal importance. As VIP seems to be an interesting tool for empowering patients, in the sense of informed consent, specific guidelines from the respective national association of anesthesiologists regarding the video material are desirable to ensure comparable contents.
In summary, this study suggests that detailed risk-focused VIP does not increase patients’ anxiety but increases patients’ knowledge and the duration of the PAI if the video is shown before the PAI. This might have a negative impact on the economics of the preanesthesia clinic but, more importantly, should be regarded as an opportunity for intensified physician-patient interaction, and should therefore be valued positively.
ACKNOWLEDGMENTS
We thank the anesthesia residents and consultants of the Department of Anesthesiology who participated in the study. The study was financed solely by departmental resources. The video material was made available free of charge by medlinq, Hamburg, Germany. No further financial support was provided. Furthermore, medlinq did not have any influence on the study design, data gathering, data analysis, or manuscript preparation.
The procedures are depicted by real video sequences from the operating room showing the actual procedure. The explanations provided in all videos avoid medical terminology so that patients without medical education can easily understand the content. For simplicity, adequate medical terms are used in the following description.
General Anesthesia (Duration 7:47 min)
Procedure: Attachment of electrocardiogram, noninvasive arterial blood pressure monitoring and pulse oximetry; anesthesia induction via peripheral vein; mask ventilation; intubation; preoperative instructions about fasting guidelines.
Risks: cardiovascular failure and circulatory arrest, hypoxia, allergic reactions, allergic shock, damages from positioning on the operating room table (nerve compression, temporary hair loss, nerve damage, and paralysis), teeth damage, laryngeal damage, persistent hoarseness, aphonia, shortness of breath, aspiration pneumonia with postoperative stay in the intensive care unit, dysphagia, and postoperative nausea and vomiting.
General Anesthesia with Invasive Monitoring (Duration 13:08 min)
Procedures and risks as described above under general anesthesia. Additionally:
Central venous catheter: indication; possible locations for placement.
Risks: catheter embolism, bleeding, nerve damage, pneumothorax, pleural effusion, infection, thrombosis.
Intraarterial catheter: indication; possible locations for placement.
Risks: disturbed circulation, bleeding, hematoma, infections.
General Anesthesia with Invasive Monitoring and Epidural Catheter (Duration 17:35 min)
Procedures and risks as described above under general anesthesia with invasive monitoring. Additionally:
Epidural catheter: Anatomy of puncture site; puncture, placement, and fixation of catheter, injection.
Risks: persistent nerve damage; epidural hematoma, epidural abscess; paraplegia; cardiovascular failure and circulatory arrest; allergic reactions; respiratory failure; postdural puncture headache; temporary hearing and vision impairment; hypotonia with nausea and vomiting; pain and discomfort at puncture site; bladder dysfunction.
Spinal Anesthesia (Duration 8:20 min)
Procedure: Anatomy of puncture site; puncture, injection.
Risks: persistent nerve damage; epidural hematoma, epidural abscess; paraplegia; cardiovascular failure and circulatory arrest; allergic reactions; respiratory failure; postdural puncture headache; temporary hearing and vision impairment; hypotonia with nausea and vomiting; pain and discomfort at puncture site; bladder dysfunction.
Spinal Anesthesia Combined with General Anesthesia (Duration 14:38 min)
Procedures and risks as described above under general anesthesia and spinal anesthesia.
APPENDIX B: QUESTIONNAIRE REGARDING KNOWLEDGE TRANSFER
Please indicate only one letter for each question.
Footnotes
1In Germany anesthesia is only performed by physicians. 
2Each anesthesiologist in Germany takes care for one patient at a time—performance of two or more anesthesia simultaneously (even with the help of nurses) is illegal.
3The current recommendation for NPO is 6 hours for food and 2 hours for clear liquids. This is mentioned in the video and in the interviews.
Accepted for publication August 23, 2007.
REFERENCES
This article has been cited by other articles:
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  R. B. Gunderman and P. J. Mehta Continue Drawing Back the Curtain: Educating the Community About Radiology Am. J. Roentgenol., May 1, 2009; 192(5): 1388 - 1390. [Full Text] [PDF]
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