Video Education Provides Effective Wound Care Instruction Pre- or Post- Mohs Micrographic Surgery

Monica M. Van Acker, DO; MArk A. Kuriata, DO,FAOCD

Disclosure: The Authors report no relevant conflicts of interest.

Abstract
Objective: The objective of this study was to determine if delivery of wound care instruction pre-Mohs micrographic surgery versus the typical, post-Mohs surgery would allow for greater patient retention. Design: A non-blinded, randomized, controlled trial receiving institutional review board exemption from Michigan State University was conducted over a three-month period. Patients scheduled for Mohs surgery on 13 selected days were randomized into pre- versus post-procedure groups to receive wound care education. Setting: This study was conducted at a dermatology practice in Saint Joseph, Michigan. Participants: Fifty cognitive and literate patients greater than 18 years of age were evaluated in this study. Measurements: Participants’ ability to recall instructions delivered by a Mohs surgeon in the form of digital media was assessed by a 10-question, multiple-choice exam. Additional analyses were conducted on patient’s disposition around medical professionals, past experience with Mohs surgery, preference for digital media versus human instruction, and desire for home access. Results: Pre- (n=24; score=77±14%) versus post- (n=26; 83±11%) procedure education displayed no significant difference (p=0.13) in overall questionnaire performance. Seventy-four percent of participants preferred video delivery as opposed to provider instruction. Thirty-four percent reported being intimidated by healthcare workers. Participant performance showed no significant change (p=0.78) with previous exposure (79±19%) to Mohs surgery versus a first-time encounter (80±11%). Conclusion: Video education prior to or post-Mohs surgery serves as an effective mechanism for patient education and improvement of time management in clinical practice. (J Clin Aesthet Dermatol. 2014;7(4):43–47.)

Recently, a new emphasis has been placed upon evaluation of the standard methods of wound care instruction to patient’s post-dermatological procedures. To date, no study has evaluated the ideal timing for delivery of instruction in wound management after dermatological surgery for adequate patient comprehension. This study was designed to assess optimal timing for conveyance of wound care instruction, pre- versus post-procedure, to Mohs micrographic surgery (Mohs surgery) patients for proper retention.

Mohs surgery, an effective technique employed by dermatologists, spares healthy skin surrounding cancer by removing narrow margins of tissue until pathological clearance is determined. With minimal complications, such as dehiscence, bleeding, and infection, proper wound education plays a pivotal role in the further prevention of postsurgical complications.[1–3] Procedures in medicine requiring wound care education typically deliver instruction after surgery is completed. This method fails to consider the role postsurgical stress may play in a patient’s overall ability to understand and retain the communicated information. To our knowledge, a limited number of studies have evaluated the ability of an anxiety-influenced patient to follow preoperative instruction given for postsurgical care.[4,5] Among the studies reported, all involving highly invasive surgeries, preoperative education demonstrated a better overall patient empowerment for optimal recovery.[4,6–9]

Previous studies have demonstrated high-definition video modules to be an effective mechanism for delivery of wound care instruction and informed consent for patients undergoing Mohs surgery.[10,11] Additionally, digital media has served as a preferred method of instructional delivery, maintaining patient satisfaction similar to that of delivery by a healthcare provider.[8]

In this study, the authors analyzed the ability of 50 patients to recall wound care instructions when delivered prior to Mohs surgery compared to wound care instruction delivered to a patient after Mohs surgery. In each instance, education was delivered by means of digital media. Herein, the authors present their findings concerning the timing of wound care instructions for Mohs surgery in consideration of adequate patient retention and wound care management.

Methods
Patient recruitment. Data collection for this three- month study was conducted at a dermatology clinic in Saint Joseph, Michigan. This study, deemed “quality improvement” by Michigan State University’s Institutional Review Board, required no further exemption or ethical clearance.

A total of 51 patients (males:females; 27:24) diagnosed with squamous and basal cell carcinoma receiving treatment by Mohs surgery were enrolled in this study. Ninety-eight percent of participants identified themselves as Caucasian with the remaining two percent Hispanic/Latino. The average age of enrolled patients was 70 (70±21 years). Ninety-four percent of participants received a high school education or greater while the remaining six percent received an eighth grade education or below. Thirty-eight percent had previously been treated with Mohs surgery. Exclusion criteria for this study included inability to pass a mental status exam or illiteracy. One female participant was excluded from the reported results for inadequate completion of their exam answering 2 of 10 questions (Table 1).

Survey conduction. Patients undergoing Mohs surgery on 13 selected days were randomized into pre- versus post- Mohs surgery groups, and wound care instruction was delivered based upon this division. The same Mohs surgeon performed all participant surgeries. Different nurses were assigned to participants, yet consistency in delivery of instruction was maintained using digital media. A video delivered by a Mohs surgeon discussing patient restrictions and adequate wound care was shown to all participants. These guidelines were specific to standard of care provided at the study location. At the completion of the video a healthcare provider asked participants if any clarification was needed concerning the video. Seventy-four percent of patients were accompanied during their appointment by a significant other, family member, and/or friend.

Participants were then asked to independently complete a questionnaire consisting of demographic (4), dichotomous yes or no (4), and multiple-choice (10) questions (Figure 1). The 10 multiple-choice questions assessed participants’ retention of video guidelines and were scored to evaluate optimal timing for delivery of wound care instruction in this population.

Questions were evaluated for difficulty level and ranged from fair to very easy; no scores representing severe difficulty or language confusion were obtained. Each multiple choice question was worth 10 percent of the exam. Score adjustments occurred if all questions were not answered reflecting a total score out of answered questions. Half credit was awarded to participants who selected the correct answer plus an additional option. After questionnaire completion, participants were given typed wound care instructions pertinent to the video and debriefed on the overall experience.

Statistical Analysis. Sample size collection was determined by power analysis and comparison to similar studies in which statistically significant data were reported Data were analyzed using computer software SPSS by method of two-tailed t-tests (significance level p<0.05), ANOVA, and linear regression. Results were confirmed by Michigan State University’s Center for Statistical Training and Consulting.

Results
The data collected from 50 participants’ questionnaires were evaluated for statistical significance (p<0.05) (Table 2). The authors found timing of instruction delivery, pre- (n=24; score=77±14%) versus post- (n=26; 83±11%) procedure, played no significant (p=0.13) role in participant performance.

Seventy-four percent of participants preferred watching the wound care instructional video as opposed to a health professional delivering instructions after Mohs surgery. Only 34 percent of participants reported being nervous around healthcare providers, or having “white coat syndrome” (WCS). This factor played no significant (p=0.97) role in participant performance (80±11%) when compared to participants without WCS (80±14%). Sixty- five percent of patients with WCS preferred the video compared to teaching delivered by a healthcare provider. Twenty percent of the participants preferred having access to the instructional video at home than compared to typical alternatives, such as a pamphlet or calling their physician’s office. Six percent of the participants had an eighth grade level of education or below, scoring 90, 85, and 70 percent. No significant difference (p=0.79) was demonstrated in participant performance if they had previously experienced Mohs surgery (79±15%) versus a first-time encounter (80±11%). Similarly, video preference (p=0.58) over healthcare professional instruction, age (p=0.15), patient accompaniment (p=0.70), education level (p=0.08), gender (p=0.684), or number of stages participants underwent for Mohs (p=0.9) did not play a significant role in overall questionnaire performance.

Summary of Results (Table 2)

Discussion
Mohs surgery is a proficient modality employed by dermatological surgeons in the treatment of cutaneous cancer.[12] With more than 3.5 million cases annually,16 skin cancer is the number one diagnosed malignancy.[13] With this in mind, proper wound care management concurrent with appropriate patient instruction is important in prevention of postsurgical infection and achievement of cosmetically acceptable results.[14,15]

Although this study was not able to establish an optimal time for instruction to improve patient retention, a larger sample size may be of clinical interest to corroborate this hypothesis. Data from our study reiterates patients’ approval for the use of digital media in the healthcare setting,[9,16–18] regardless of timing in delivery. The post-video multiple-choice exam provides further assessment of patient comprehension and provoked patient questions that may not have otherwise been posed. Digital media has proven to be beneficial in teaching patients with limited education.[19,20] This finding can be appreciated in our data. Ultimately numerous methods should be employed to achieve patient comprehension and satisfaction in Mohs surgery for optimal wound healing.

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