Kenny T, Wilson RG, Purves IN A PIL for every ill? Patient information leaflets (PILs): a review of past, present and future use. Fam Pract. 1998; 15:471-479 https://doi.org/10.1093/fampra/15.5.471
Sustersic M, Gauchet A, Foote A, Bosson JL. How best to use and evaluate patient information leaflets given during a consultation: a systematic review of literature reviews. Health Expect. 2017; 20:531-542 https://doi.org/10.1111/hex.12487
Parker RM, Ratzan SC, Lurie N. Health literacy: a policy challenge for advancing high-quality health care. Health Aff (Millwood). 2003; 22:147-153 https://doi.org/10.1377/hlthaff.22.4.147
Kliegl R, Smith J, Heckhausen J, Baltes P. Mnemonic training for the acquisition of skilled digit memory. Cognition and Instruction. 1984; 4:203-223
Ravindra P, Barrett C. Compliance with pre-operative instructions for procedures with conscious sedation: a complete audit cycle. Br Dent J. 2012; 212 https://doi.org/10.1038/sj.bdj.2012.99
Mayer RE. The Cambridge Handbook of Multimedia Learning.New York: Cambridge University Press; 2009
Meppelink CS, van Weert JC, Haven CJ, Smit EG. The effectiveness of health animations in audiences with different health literacy levels: an experimental study. J Med Internet Res. 2015; 17 https://doi.org/10.2196/jmir.3979
Shaw MJ, Beebe TJ, Tomshine PA A randomized, controlled trial of interactive, multimedia software for patient colonoscopy education. J Clin Gastroenterol. 2001; 32:142-147 https://doi.org/10.1097/00004836-200102000-00010
Newsom E, Lee E, Rossi A Modernizing the Mohs surgery consultation: instituting a video module for improved patient education and satisfaction. Dermatol Surg. 2018; 44:778-784 https://doi.org/10.1097/DSS.0000000000001473
Winter M, Kam J, Nalavenkata S The use of portable video media vs standard verbal communication in the urological consent process: a multicentre, randomised controlled, crossover trial. BJU Int. 2016; 118:823-828 https://doi.org/10.1111/bju.13595
Michalski A, Stopa M, Miśkowiak B. Use of multimedia technology in the doctor-patient relationship for obtaining patient informed consent. Med Sci Monit. 2016; 22:3994-3999 https://doi.org/10.12659/msm.894147
Limbruno U, Ebert AG, Casarosa F Utilità di un supporto audiovisivo nella preparazione del paziente alle procedure di cardiologia invasiva [Usefulness of an audiovisual support to informed consent before percutaneous coronary intervention procedures]. G Ital Cardiol (Rome). 2008; 9:726-32
Bostock S, Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study. BMJ. 2012; 344 https://doi.org/10.1136/bmj.e1602
Chestnutt IG, Reynolds K. Perceptions of how the Internet has impacted on dentistry. Br Dent J. 2006; 200:161-165 https://doi.org/10.1038/sj.bdj.4813195
Hanna K, Brennan D, Sambrook P, Armfield J. Third Molars on the internet: a guide for assessing information quality and readability. Interact J Med Res. 2015; 4 https://doi.org/10.2196/ijmr.4712
Nason K, Donnelly A, Duncan HF. YouTube as a patient-information source for root canal treatment. Int Endod J. 2016; 49:1194-1200 https://doi.org/10.1111/iej.12575
A patient information video for treatment under intravenous conscious sedation: considerations, challenges and prospects Harjit Tagar Omesh Modgill Jashme Patel Julie Edwards Olamide Obisesan Dental Update 2024 48:9, 707-709.
This article describes the use of a newly developed animation for the delivery of patient information pertinent to dental treatment performed under intravenous conscious sedation, and provides an understanding of how digital health-related information impacts upon the patient experience. This article provides insight into the rationale for using animation as a means to deliver healthcare-related information, the process undertaken to develop this animation and how the themes and imagery in the animation can be used more broadly to further enhance the patient experience in primary and secondary dental care settings.
CPD/Clinical Relevance: This article outlines the process of developing an animation for patient information and the impact animation can have upon patient experience locally as an aid to delivering instructions.
Article
Approximately 7000 adult dental treatment episodes under intravenous conscious sedation with midazolam (IVS) are performed annually at Kings College Dental Hospital (KCH). Upon receipt of referral, patients are triaged to the appropriate dental specialty for outpatient assessment and treatment planning. As part of the informed consent process, options for different treatment modalities are discussed and those patients considering treatment under IVS are provided verbal and written information as per the Intercollegiate Advisory Committee for Sedation in Dentistry guidance.1 Information provided includes the sedation technique that will be used, fasting regimens, continuation or omission of medications, avoidance of alcohol and recreational drugs, and general aftercare instructions.
Evidence suggests that patient information leaflets (PILs) improve patient compliance by aiding the recall of advice given.2 While the use of PILs in an outpatient setting is widespread, they should serve only to reiterate information delivered verbally.3
Healthcare literacy is defined as the ‘degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions’.4 Several factors influence each patient's healthcare literacy and their ability to comprehend written information. Consequently, while guidance now exists for developing PILs5,6 there is no guarantee that a PIL will comprehensively facilitate patient's understanding of healthcare-related information.
Information delivered in an animated form may be considered more advantageous than that provided verbally and within a PIL, given that ideas presented graphically are easier to remember than written information.7 The Department of Oral Surgery and Department of Community Special Care Dentistry at King's College Hospital, London initiated, planned and delivered a concise animation to reinforce information relevant to a treatment episode under IVS. The aim of this project was to provide a means to facilitate the delivery of patient information conveyed by a PIL and verbally. The animation is not intended as a direct substitute for information provided via verbal discussion and a PIL, but rather another means to deliver information in a more engaging manner.
Each patient considering treatment under IVS was given the opportunity to watch the animation during their outpatient assessment and provided with a text link to access the animation via YouTube outside the clinical setting. The animation is available via an internal server in every department offering adult treatment under intravenous sedation within the dental hospital.
The approach to developing and delivering this animation and initial data of the patient experience following its use during outpatient assessment are described.
Developing a patient information animation
There are several stages to developing a patient information animation. These include, but are not limited, to:
Needs assessment;
Patient involvement;
Business planning and tendering;
Animation design;
Implementation;
Assessment of patient experience.
Needs assessment
A prospective log of cases performed under IVS kept at the Department of Oral Surgery provided insight into the reasons for on-the-day cancellations. During a 6-month period, 251 patients had been cancelled on the day of surgery. Of these, 55 patients (22%) attended without an appropriate chaperone, 10 patients (4%) attended with a child and 15 patients (6%) had smoked cannabis within 48 hours. Our department cancellation data were comparable to that published previously by another UK tertiary dental teaching hospital.8 Locally, therefore, there was a clear need for facilitating patient's understanding of the pre- and post-operative requirements for treatment under IVS.
Patient Involvement
Early in the development of this animation, patient involvement identified potential benefits for the provision of animated information and how such information may be accessed by patients. The majority of patients responded positively to the suggestion of receiving patient information via an animated video during outpatient assessment. Most of the patient cohort involved had access to internet and/or mobile data and stated that their chaperone would benefit in watching the animation to clarify their role before, during and after the treatment episode. The findings are summarized in Figure 1.
Figure 1. Summary of the patient involvement survey.
Business planning and tendering
Following needs assessment and patient involvement, a business plan was formulated and agreed upon locally. It was decided that the animation should relay the following messages:
Pre- and post-operative sedation instructions for adult patients attending for treatment under IVS;
Reiterate that treatment is not being carried out under general anaesthetic;
An explanation to patients as to how they might feel on the day;
Instructions for going home;
Specific advice for patients who are pregnant or breastfeeding;
Clarification of the requirements and role of a patient chaperone.
The tendering process commenced with the patient communication team, consultants from the aforementioned dental specialties and local dental managers who identified and secured the services of a media company to develop the animation. Following a competitive tendering process, Senate Media were ultimately commissioned for the delivery of this project. The commissioning of the animation was delivered at a cost of approximately £6000.
Animation design
An initial consultation with representatives from Senate Media outlined an agreed concept for the animation. The Department of Oral Surgery provided a framework to guide the creative process, including formulating and refining the animation script. Six vital considerations for successful design were discussed at length with animation consultants.
Time
The script was edited to ensure an animation length of approximately 2 minutes to reflect an evidence base that suggests this is an optimal length for relaying information through video.9 A longer duration is associated with a significant decrease in audience engagement (Figure 2).
Figure 2. Engagement mapped against video length. Published with permission from Wistia.9
Language
An essential requirement was to ensure that all language was simple and jargon-free to reduce the barriers to access for those with reduced healthcare literacy. Subtitles were placed and confined to the lower border of the screen to ensure that no part of the animation was obscured. Subtitling was intentionally limited to two lines to avoid distraction from the animation, and ensure written information could be read quickly. Subtitles were kept as a permanently enabled feature.
Voiceover
Several voiceover artist samples were peer reviewed by the dental team who subsequently agreed upon a tone that reflected a professional manner but was also of a soft and reassuring nature.
Visual tone
A number of character designs were considered, ranging from those with realistic facial features to more abstract depictions. A conscious decision was made to use cartoon-like characters with some level of facial detail, allowing a degree of warmth and empathy to be expressed in facial expression, while also ensuring that the visual tone did not appear overly clinical. Furthermore, the ethnic mix of the local community and staff, including receptionists, nurses and clinicians, was incorporated to further help the animation resonate with patients. The colour scheme currently used in PILs at KCH was incorporated within the animation to maintain synergy with colours historically associated with the hospital trust. Aqua blue has been associated with protection and emotional healing and was therefore used as a background throughout the animation. Patients in the animation were intentionally dressed in different shades and hues of purple to reflect the demonstrated association between purple and calmness.10 The use of thought bubbles was included to reinforce to patient's their responsibility to remember instructions.
Story line
This was intentionally written to mirror the patient journey in real life, while also providing a clear narrative to the patient, delivering messages in a clear, logical order and including the responsibility of the patients' nominated chaperone.
Uniform resource locator (URL)
A shortened URL was created using Bitly (Bitly Inc), a free URL shortening service. This was to allow the URL to be more easily typed by patients and allowed for greater customization of the URL to bit.ly/kingsdentalsedation
Implementation
The intravenous sedation PIL was modified to include a thumbnail and URL (Figure 3). A written reminder was added to request patients to watch the animation via a link to YouTube. Double-sided A6-sized reminder cards were created (Figure 4) to be given with written confirmation of a patient's appointment. The cards were similarly styled with selected images based on the most common reasons for on-the-day IVS cancellations. Additionally, posters in waiting areas were redesigned to continue the theme of the animation and guide patients to report to reception (Figure 5). The process of rebranding written information aimed to further develop patient's familiarity with the animation and further acquaint patients with departments in which treatment under IVS is performed.
Figure 3. Updated KCH PIL for patients attending for dental treatment under intravenous sedation.Figure 4. A6 appointment reminder cards incorporating characters and imagery from the animation.Figure 5. Updated waiting room posters continuing the theme of the animation.
The animation was officially launched in January 2019. The video is hosted on an internal server at KCH, and a desktop shortcut via an icon was created to allow quick access to the video in the clinical setting. While initially used within the Department of Oral Surgery, the animation was subsequently shown to clinical leads in all departments within Kings College Dental Hospital, and is now used routinely in all departments carrying out dental treatment under IVS.
Assessment of patient experience
A 10-point patient experience questionnaire was formulated following collaboration between an oral surgery registrar, consultant oral surgeon and the head of patient experience at KCH.
The questionnaire was designed according to the Likert scale in which five responses were proposed for each question. The questionnaire was written in English, populated in Microsoft Word and provided to patients as a printed handout. Responses were collected over a 6-month period from January 2019 to June 2019, inclusive.
Patients attending for any minor oral surgery procedure under IVS at the Department of Oral Surgery, KCH, were requested to complete the patient experience questionnaire immediately pre-operatively and to return a completed copy to attending reception staff.
Completed patient questionnaires were stored in a secure facility. Responses were collated and analysed using an encrypted Microsoft Excel spreadsheet.
Responses
In total, 226 questionnaires were handed out and 197 (87%) responses were returned.
Of the respondees, 185 (94%) patients considered the video to be a very helpful or helpful medium for the delivery of information relating to treatment under IVS, while 147 (74.6%) patients felt that the video was clear to follow and 159 (80.7%) patients felt it helped them to better understand how to prepare for treatment under IVS. There were 88 (44.6%) patients who watched the animation at least once outside the clinical setting.
In total, 73 (37%) chaperones watched the animation at least once. In these cases, 72 (98.6%) patients found it reassuring that their escort had watched the animation. Of those chaperones who watched the animation, 41 (56%) found the animation helpful in clarifying their role before, during and after the treatment episode.
Most patients (195, 98.9%) said they would recommend other patients to watch the animation before attending for treatment under IVS.
Discussion
Mayer's cognitive theory of multimedia learning11 proposes that individuals learn through the combined interpretation of visual and auditory information, as opposed to understanding these elements in a mutually exclusive fashion. Individuals are assumed to have two separate ‘channels’ for the receipt of auditory and visual information. Each channel has a finite memory capacity and can be overloaded if the processing demands of a learning task are greater than the processing capacity of the brain. The key principles of this theory underpinned the development of our animation.
Animations that use both visual and auditory information are less likely to cause cognitive overload in the receiver, and are associated with significant recall of information when compared with the use of animation alone.12
The use of patient-centred multimedia tools to assist with the informed consent process has been described13 and shown to improve comprehension and patient satisfaction with the informed consent process.14,15,16 When used correctly, these tools reduce the impact of the varying healthcare literacy of the population, and improve the overall quality of patient education17 while also enhancing recall of essential information among patients.18
A significant challenge in the success of a PIL to relay information is an individual patient's healthcare literacy. Factors correlating with poor healthcare literacy include increasing age, ethnicity and degree of education.19 In England, 42% of working-age adults are unable to understand and make use of healthcare-related information. This figure rises to 61% if numeracy skills are needed to understand information.20 Furthermore, one-third of elderly patients have difficulty reading and understanding basic healthcare-related information.21 To further compound such challenges, stigma and embarrassment may deter patients from seeking further information or clarification.22
Healthcare-related information is increasingly available on the internet.23 Patients are, therefore, increasingly likely to access healthcare-related information via search engines, social media websites and healthcare applications if uncertainty remains after consultation. Ideally, healthcare professionals should be able to direct patients to appropriate online sources. However, evidence suggests that the quality of information available via online platforms is variable.24 Furthermore, little information specifically relevant to treatment under IVS currently exists online. The animation sought to overcome these potential barriers to access to information pertaining to treatment under IVS with midazolam.
One-third of adults with internet access in the UK and US access YouTube on a daily basis. Consequently, the video was uploaded to YouTube and patients were provided with a link (bit.ly/kingsdentalsedation) by both text message and on the rebranded PIL. At the time of publication, the animation has had over 47,000 views on YouTube.
The animation was designed to facilitate the informed consent process rather than act as a replacement for a tailored discussion with a patient. Consequently, the voiceover and subtitles were delivered only in English and shown to each patient only after a detailed discussion of all treatment options had been conducted. It was felt that if a patient could not understand a verbal discussion in English, providing them with access to a video dubbed in their native language would be inappropriate and not in keeping with the principles of Montgomery consent because patients would not subsequently have the opportunity to ask questions relevant to IVS.
Early data suggested that the animation enhanced the patient experience with 94% of those who responded to the questionnaire indicated that the animation was a very helpful or helpful medium for the delivery of information relating to IVS, and vindicated the use of animation to deliver information. Most patients who responded (80.7%) stated that the video helped them to better prepare for sedation, providing further justification for the use of animation to facilitate and consolidate the understanding of information provided verbally and in written form. The animation was developed in line with established principles of human learning and used the best available evidence for developing an engaging patient information video. Given that this resulted in approximately 75% of patients who responded to the questionnaire stating that the video was clear to follow, the development process of this animation may provide a template for how future patient-related information videos can be designed to enhance patients' knowledge.
Further work is required to improve chaperone viewership of the animation. While a text link can be sent directly to a patient prior to attending for their treatment under IVS, such an approach to contact chaperones is impractical since their details are often not known. Additionally, chaperones do not always attend the outpatient clinic with patients, which potentially further limits the opportunity to introduce chaperones to the video. We can also speculate that patients may instead verbally relay information relevant to the patient's chaperone.
Repeated viewing of the animation is likely to reinforce understanding of necessary instructions and is, therefore, desirable. Given that KCH serves a largely underprivileged patient demographic, repeat viewing figures may be low because of barriers to accessing the internet or a mobile device.
The animation was formally launched in January 2019, and its effect upon patient compliance to pre- and post-operative instructions for IVS has yet to be fully elucidated. Overall, early data suggest that the animation has been well received by patients and enhanced the overall patient experience for those who watched the animation at least once.
Conclusion
As the use of mobile technology to access healthcare-related information becomes more widespread, a more tailored approach is preferable to improve patient knowledge regarding treatment. We have provided some insight into how animated media can be an engaging means of delivering information relating to treatment under intravenous sedation. Future work is needed to determine how patients and chaperones access and interact with this animation, and its overall impact on the efficiency of care. Early signs show promise that the use of digital media commands more attention than the sole use of verbal and written information. Dental Update readers can view the animation at:
