Examining patient comprehension of emergency department discharge instructions: Who says they understand when they do not?

The Use of Teach Back at Hospital Discharge to Support Self-Management of Prescribed Medication for Secondary Prevention after Stroke-Findings from A Feasibility Study

The study aimed to investigate whether a structured discharge letter and the use of the person-centred communication method Teach Back for sharing information at hospital discharge could support perceived understanding and knowledge of and adherence to prescribed medication for secondary prevention after stroke. Data from a feasibility study of a codesigned care transition support for people with stroke was used. Patients who at discharge received both a structured discharge letter and participated in the person-centred communication method Teach Back (n = 17) were compared with patients receiving standard discharge procedures (n = 21). Questionnaires were used to compare the groups regarding perceived understanding of information about medical treatment, knowledge of information about medical treatment and medication adherence at 1 week and 3 months. There was a statistically significant difference in perceived understanding of information about medical treatment (p > 0.01) between the groups in favour of those who participated in Teach Back at the discharge encounter. No differences between groups were found regarding understanding health information about medical treatment and medication adherence. The results indicate that the use of Teach Back at the discharge encounter positively impacts perceived understanding of information about medical treatment in people with stroke. However, considering the nonrandomised study design and the small sample size, a large-scale trial is needed.

A Scoping Review of Emergency Department Discharge Risk Stratification

INTRODUCTION

Although emergency department (ED) discharge presents patient-safety challenges and opportunities, the ways in which EDs address discharge risk in the general ED population remains disparate and largely uncharacterized. In this study our goal was to conduct a review of how EDs identify and target patients at increased risk at time of discharge.

METHODS

We conducted a literature search to explore how EDs assess patient risk upon discharge, including a review of PubMed and gray literature. After independently screening articles for inclusion, we recorded study characteristics including outcome measures, patient risk factors, and tool descriptions. Based on this review and discussion among collaborators, major themes were identified.

RESULTS

PubMed search yielded 384 potentially eligible articles. After title and abstract review, we screened 235 for potential inclusion. After full text and reference review, supplemented by Google Scholar and gray literature reviews, we included 30 articles for full review. Three major themes were elucidated: 1) Multiple studies include retrospective risk assessment, whereas the use of point-of-care risk assessment tools appears limited; 2) of the point-of-care tools that exist, inputs and outcome measures varied, and few were applicable to the general ED population; and 3) while many studies describe initiatives to improve the discharge process, few describe assessment of post-discharge resource needs.

CONCLUSION

Numerous studies describe factors associated with an increased risk of readmission and adverse events after ED discharge, but few describe point-of-care tools used by physicians for the general ED population. Future work is needed to investigate standardized tools that assess ED discharge risk and patients' needs upon ED discharge.

Discharge communication study: a realist evaluation of discharge communication experiences of patients, general practitioners and hospital practitioners, alongside a corresponding discharge letter sample

OBJECTIVES

To develop a programme theory for the intervention of patients receiving discharge letters.

DESIGN

We used a realist evaluation approach and captured multiple perspectives of hospital discharge to refine our previously developed programme theory. General practitioner (GP), patient and hospital clinician views of a single discharge event in which they were all involved were collected using semi-structured interviews and surveys. These were then triangulated to match the corresponding discharge letter. Data were qualitatively synthesised and compared in meta-matrices before interrogation with realist logic of analysis to develop the programme theory that maps out how patients receiving discharge letters works in specific contexts.

SETTING

14 GP practices and four hospital trusts in West Midlands, UK.

PARTICIPANTS

10 complete matched cases (GP, patient and hospital practitioner), and a further 26 cases in which a letter was matched with two out of the three participants.

RESULTS

We identified seven context mechanism outcome configurations not found through literature searching. These related to the broad concepts of: patient preference for receiving letters, patient comprehension of letters, patient-directed letters, patient harm and clinician views on patients receiving letters. 'Patient choice' was important to the success (or not) of the intervention. Other important contexts for positive effects included: letters written in plain English, lay explanations for jargon, verbal information also provided, no new information in letter and patient choice acknowledged. Three key findings were: patient understanding is perhaps greater than clinicians perceive, clinician attitudes are a barrier to patients receiving letters and that, negative outcomes more commonly manifested when patients had not received letters, rather than when they had.

CONCLUSIONS

We suggest how patients receiving discharge letters could be improved to enhance patient outcomes. Our programme theory has potential for use in different healthcare contexts and as a framework for policy development relating to patient discharge.

Implementing teach-back during patient discharge education

AIM

To determine how registered nurses understood the teach-back method and whether such understanding translated to better evaluation of patients' understanding of discharge instructions.

BACKGROUND

The teach-back method helps nurses confirm whether the information provided to patients is understood. The current literature indicates the benefits of teach-back; however, nurses do not apply the method adequately during discharge teaching.

DESIGN

This study used a qualitative pretest-posttest design with an educational session.

METHODS

A consecutive sampling method was used. Twelve nurses were interviewed using a discussion guide to gauge their understanding of the teach-back method during the period July to August 2016. This was followed by an educational session on the teach-back method. Nurses then implemented the method on the medical/surgical unit. A second interview was conducted using a questionnaire to evaluate participants' understanding of the method. Data were analyzed using Atlas.ti 7 software.

RESULTS

Participants' knowledge of the teach-back method increased. Participants identified benefits associated with the method, but time constraint was a concern.

CONCLUSION

The findings contribute to an understanding of the teach-back method by nurses. Patient care will benefit if the method is reinforced among nurses through continuing in-service education.

Quality of acute internal medicine: A patient-centered approach. Validation and usage of the Patient Reported Measure-acute care in the Netherlands

Background

Providing high quality care is important and has gained more attention since the introduction of value-based healthcare. Value should be measured by outcomes achieved, relevant for patients. Patient-centeredness is one domain for quality improvement determined by the Institute of Medicine, aiming to deliver care responsive to the patient. The development and implementation of patient reported outcome- and experience measures can be used for this goal. Recently, we developed the Patient Reported Measure (PRM)-acute care, based on five relevant domains to evaluate and improve the quality of care in the Emergency Department (ED).

Objective

To validate the PRM-acute care, in order to evaluate and improve patient-centered care in the ED.

Methods

We performed a prospective questionnaire-based study. Patients ≥18 years presenting for internal medicine in the ED were eligible. The validity of the PRM-acute care was evaluated according to the COSMIN-criteria. We performed hypotheses testing to evaluate construct validity. The perceived quality of care was evaluated by statistical analysis.

Results

Face- and content validity was evaluated based on previously performed research and deemed good. Construct validity was supported by demonstrated differences between subgroups; patients with severe symptoms had a higher perceived quality of care. The correlation between overall satisfaction and the total mean score of the PRM-acute care (r = 0,447, p = 0.01) was significant. Overall, patients reported a mean perceived quality of care of 4.67/6.0.

Conclusion

The PRM-acute care is a valid instrument to measure the perceived quality of care in an acute setting for internal medicine patients. Additionally, patients reported a good perceived quality of care in the ED with scores ranging from moderate to well for each of the relevant domains. Therefore, we believe that the PRM-acute care can be implemented in daily practice to evaluate the perceived quality of care and to improve the quality of acute care.

The impact of teach-back on patient recall and understanding of discharge information in the emergency department: the Emergency Teach-Back (EM-TeBa) study

Background

Previous research has demonstrated that patients leaving the emergency department (ED) have poor recall and understanding of their discharge information. The teach-back method is an easy technique that can be used to check, and if necessary correct, inaccurate recall. In our study, we aimed to determine the direct and short-term impact of teach-back as well as feasibility for routine use in the ED.

Methods

A prospective cohort study in an urban, non-academic ED was performed which included adult patients who were discharged from the ED with a new medical problem. The control group with the standard discharge was compared to the intervention group using the teach-back method. Recall and comprehension scores were assessed immediately after discharge and 2–4 days afterward by phone, using four standardized questions concerning their diagnosis, treatment, follow-up care, and return precautions.

Results

Four hundred eighty-three patients were included in the study, 239 in the control group, and 244 in the intervention group. Patients receiving teach-back had higher scores on all domains immediately after discharge and on three domains after 2–4 days (6.3% versus 4.5%). After teach-back, the proportion of patients that left the ED with a comprehension deficit declined from 49 to 11.9%. Deficits were most common for return precautions in both groups (41.3% versus 8.1%). Teach-back conversation took 1:39 min, versus an average of 3:11 min for a regular discharge interview.

Conclusion

Teach-back is an efficient and non-time-consuming method to improve patients’ immediate and short-term recall and comprehension of discharge information in the ED.

Implementation of a mobile app for trauma education: results from a multicenter study

Background

In an era of shared decision making, patient expectations for education have increased. Ideal resources would offer accurate information, digital delivery and interaction. Mobile applications have potential to fulfill these requirements. The purpose of this study was to demonstrate adoption of a patient education application (app: http://bit.ly/traumaapp) at multiple sites with disparate locations and varied populations.

Methods

A trauma patient education application was developed at one trauma center and subsequently released at three new trauma centers. The app contains information regarding treatment and recovery and was customized with provider information for each institution. Each center was provided with promotional materials, and each had strategies to inform providers and patients about the app. Data regarding utilization was collected. Patients were surveyed about usage and recommendations.

Results

Over the 16-month study period, the app was downloaded 844 times (70%) in the metropolitan regions of the study centers. The three new centers had 380, 89 and 31 downloads, while the original center had 93 downloads. 36% of sessions were greater than 2 min, while 41% were less than a few seconds. The percentage of those surveyed who used the app ranged from 14.3% to 44.0% for a weighted average of 36.8% of those having used the app. The mean patient willingness to recommend the app was 3.3 on a 5-point Likert scale. However, the distribution was bimodal: 60% of patients rated the app 4 or 5, while 32% rated it 1 or 2.

Discussion

The adoption of a trauma patient education app was successful at four centers with disparate patient populations. The majority of patients were likely to recommend the app. Variations in implementation strategies resulted in different rates of download. Integration of the app into patient education by providers is associated with more downloads.

Level of evidence

Level III care management.

Patient Preference for Medical Information in the Emergency Department: Post-Test Survey of a Random Allocation Intervention

INTRODUCTION

Health literacy can create barriers for ED staff attempting to communicate important information to patients. Video discharge instructions may address some of these barriers by improving patients' comprehension of medical information and addressing health literacy challenges.

METHODS

One hundred ninety-six patients diagnosed with either hypertension, asthma, congestive heart failure, or diabetes were randomly assigned to 1 of 2 interventions: watching video medical information followed by reviewing written discharge instructions or written instructions first, followed by video education. After the interventions, patients from both groups completed surveys assessing their preferences for receiving medical information.

RESULTS

We found that 44% (n = 86/196) of ED patients preferred receiving medical information in video format, whereas 18% (n = 35/196) favored the written format, and 38% (n = 75/196) of the sample preferred receiving both formats. Fifty-five percent of men (n = 38/69) preferred the video format, whereas 42% (n = 51/122) of women indicated a preference for both video and written formats. Learning something new from the video was associated with patient preference for receiving medical instructions, (χ2 [1] = 9.39, P = 0.01) and the desire to watch medical videos or read information at home via the Internet (χ2 [1] = 18.46, P < 0.001).

DISCUSSION

The majority of ED patients in this study preferred medical information in video or video plus written formats, compared with written-only format.

Improved Concussion Discharge Instructions in a Pediatric Emergency Department

Pediatric concussions are common and many children seek care in emergency departments. Providing concussion discharge instructions to patients and families is part of routine standard of care. The objective of this study was to determine whether the use of the Acute Concussion Evaluation-Emergency Department Discharge Instructions (ACE-ED DI) improves the caregiver's knowledge of injury management, specifics about returning to school and sports activities, and outpatient follow-up. This was a quasi-experimental study conducted in an urban Level 1 trauma center pediatric emergency department (PED). A convenience sample of caregivers of children aged 5-18 years who presented to the PED with a concussion was recruited and consented to participate. Caregivers completed a 16-item survey to assess overall understanding of concussion management after instructions were given. Caregivers received the standard discharge instructions (SDIs) in Phase 1 and SDIs plus the ACE-ED DI in Phase 2. Descriptive statistics were used for demographic variables and t-test to compare groups. Sixty-three of 68 (93%) caregivers participated; 30 in the SDI group and 33 in the SDI plus ACE-ED DI group. Demographic characteristics were similar between groups. Caregivers who received the ACE-ED DI reported a 24% increase in helpfulness of written materials (p < 0.001), a 25% increase in perceived understanding about concussion injury and management (p < 0.001), a 23% increase in understanding about returning to school activities (p < 0.001), and were 17% more likely to follow up with their primary care provider (p < 0.001). The ACE-ED DI used in a PED was found to be more effective at increasing caregivers' perceived knowledge of concussion management, specifics about returning to school and sports activities, and outpatient follow-up.