A Picture Is Worth a Thousand Words: Pictographs to Improve Understanding of Discharge Instructions

Crowdsourcing the Impact of Illustration in Cleft Surgery Education

OBJECTIVE

This study aimed to (1) assess layperson preferences for how surgical information is presented; (2) evaluate how the format of visual information relates to layperson comfort with undergoing surgery, perceptions of surgeon character traits, and beliefs about artistic skill impacting plastic surgery practice; and (3) identify sociodemographic characteristics associated with these outcomes.

DESIGN

A survey was developed in which one of five standardized sets of information depicting a unilateral cleft lip repair was presented as (1) text alone, (2) quick sketches, (3) simple drawings, (4) detailed illustrations, or (5) photographs.

SETTING

Online crowdsourcing platform.

PARTICIPANTS

Raters aged 18 years and older from the United States.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

After viewing the surgical information, participants answered three sets of Likert scale questions. Ratings were averaged to produce three composite scores assessing (1) comfort with undergoing surgery (2) perceptions of surgeon character traits, and (3) beliefs about plastic surgery and artistry.

RESULTS

Four hundred seventy-nine participants were included. Surgeon character traits score was highest among participants who viewed detailed illustrations at 4.46 ± 0.59, followed by photographs at 4.43 ± 0.54, text alone at 4.28 ± 0.59, simple drawings at 4.17 ± 0.67, and quick sketches at 4.17 ± 0.71 (p = 0.0014). Participants who viewed detailed illustrations rated surgical comfort score and plastic surgery and artistry score highest, although differences did not achieve statistical significance.

CONCLUSIONS

Viewing detailed cleft lip repair illustrations was significantly associated with positive perceptions of surgeon character traits. Our data help to contextualize methods of communication and education valued by the public when seeking cleft care.

A Quality Improvement Initiative to Improve Pediatric Discharge Medication Safety and Efficiency

Medication errors are a leading safety concern, especially for families with limited English proficiency and health literacy, and patients discharged on multiple medications with complex schedules. Integration of a multilanguage electronic discharge medication platform may help decrease medication errors. This quality improvement (QI) project's primary aim (process measure) was to increase utilization in the electronic health record (EHR) of the integrated MedActionPlanPro (MAP) for cardiovascular surgery and blood and marrow transplant patients at hospital discharge and for the first clinic follow-up visit to 80% by July 2021.

Methods

This QI project occurred between August 2020 and July 2021 on 2 subspecialty pediatric acute care inpatient units and respective outpatient clinics. An interdisciplinary team developed and implemented interventions, including integration of MAP within EHR; the team tracked and analyzed outcomes for discharge medication matching, and efficacy and safety MAP integration occurred with a go-live date of February 1, 2021. Statistical process control charts tracked progress.

Results

Following the implementation of the QI interventions, there was an increase from 0% to 73% in the utilization of the integrated MAP in the EHR across the acute care cardiology unit-cardiovascular surgery/blood and marrow transplant units. The average user hours per patient (outcome measure) decreased 70% from the centerline of 0.89 hours during the baseline period to 0.27 hours. In addition, the medication matching between Cerner inpatient and MAP inpatient increased significantly from baseline to postintervention by 25.6% (P < 0.001).

Conclusion

MAP integration into the EHR was associated with improved inpatient discharge medication reconciliation safety and provider efficiency.

Impact of Illustrated Postoperative Instructions on Knowledge and Retention During a Cleft Lip and Palate Surgical Mission

OBJECTIVE

To determine the impact of illustrated postoperative instructions on patient-caregiver knowledge and retention.

DESIGN

Prospective study with all participants receiving an educational intervention.

SETTING

Pediatric plastic surgical missions in Guatemala City, Guatemala, between 2019 and 2020.

PARTICIPANTS

A total of 63 majority-indigenous Guatemalan caregivers of patients receiving cleft lip and/or palate surgery.

INTERVENTION

Illustrated culturally appropriate postoperative care instructions were iteratively developed and given to caregivers who were surveyed on illustration-based and text-based information at preoperative, postoperative, and four-week follow-up time points.

MAIN OUTCOME MEASURE

Postoperative care knowledge of illustration-based versus text-based information as determined by the ability to answer 11 illustration- and 8 text-based all-or-nothing questions, as well as retention of knowledge as determined by the same survey given at four weeks follow-up.

RESULTS

Scores for illustration-based and text-based information both significantly increased after caregivers received the postoperative instructions (+13.30 ± 3.78 % SE, + 11.26 ± 4.81 % SE; P < .05). At follow-up, scores were unchanged for illustration-based (-3.42 ± 4.49 % SE, P > .05), but significantly lower for text-based information (-28.46 ± 6.09 % SE, P < .01). Retention of text-based information at follow-up correlated positively with education level and Spanish literacy, but not for illustration-based.

CONCLUSIONS

In the setting of language and cultural barriers on a surgical mission, understanding of illustration-based and text-based information both increased after verbal explanation of illustrated postoperative instructions. Illustration-based information was more likely to be retained by patient caregivers after four weeks than text-based information, the latter of which correlated with increased education and literacy.

Definitions and measurement of health literacy in health and medicine research: a systematic review

OBJECTIVES

The way health literacy is understood (conceptualised) should be closely linked to how it is measured (operationalised). This study aimed to gain insights into how health literacy is defined and measured in current health literacy research and to examine the relationship between health literacy definitions and instruments.

DESIGN

Systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

DATA SOURCES

The MEDLINE, PsycINFO, ERIC and CINAHL databases were searched for articles published during two randomly selected months (March and October) in 2019.

ELIGIBILITY CRITERIA

We included articles with a quantitative design that measured health literacy, were peer-reviewed and original, were published in the English language and included a study population older than 16 years.

DATA EXTRACTION AND SYNTHESIS

Six researchers screened the articles for eligibility and extracted the data independently. All health literacy definitions and instruments were considered in relation to category 1 (describing basic reading and writing skills, disease-specific knowledge and practical skills) and category 2 (social health literacy competence and the ability to interpret and critically assess health information). The categories were inspired by Nutbeam's descriptions of the different health literacy levels.

RESULTS

120 articles were included in the review: 60 within public health and 60 within clinical health. The majority of the articles (n=77) used instruments from category 1. In total, 79 of the studies provided a health literacy definition; of these, 71 were in category 2 and 8 were in category 1. In almost half of the studies (n=38), health literacy was defined in a broad perspective (category 2) but measured with a more narrow focus (category 1).

CONCLUSION

Due to the high degree of inconsistency between health literacy definitions and instruments in current health literacy research, there is a risk of missing important information about health literacy considered be important to the initial understanding of the concept recognised in the studies.

PROSPERO REGISTRATION NUMBER

CRD42020179699.

Tailoring nutrition and cancer education materials for breast cancer patients

OBJECTIVE

Many breast cancer patients are vulnerable to poor nutritional status and may benefit from nutrition education, but existing materials are not generally tailored to the needs of low-literacy immigrant and minority patients.

METHODS

With nutritionist guidance, we developed a nutrition presentation for breast cancer patients. English- (n = 29) and Spanish-speaking (n = 19) patients were recruited from 5 safety-net hospitals, an academic cancer center, and a Latina cancer support organization. Materials were tested using multiple rounds of cognitive interviewing (with an adapted USDA interview guide), followed by study team reviews and modifications, until saturation.

RESULTS

Seven rounds of interviews per language were needed. Approximately 25% of interviewees had less than a high school education. Changes included adapting to regional lexicons and resolving vague/confusing phrasing. Specific food examples needed cultural tailoring. Text color coding (red/bad, green/good) was requested. Labeled images enhanced participants' understanding of concepts. Spanish speakers expressed a desire to understand nutrition labeling, and this was emphasized in the Spanish slides.

CONCLUSION

Cognitive interviews were an important tool for creating a nutrition curriculum tailored to the needs of low-literacy, mostly immigrant patients.

PRACTICE IMPLICATIONS

Cultural and linguistic factors should be considered for nutritional education materials in diverse patient populations.

Parent Perceptions and Experiences Regarding Medication Education at Time of Hospital Discharge for Children With Medical Complexity

BACKGROUND

Children with medical complexity (CMC) often require complex medication regimens. Medication education on hospital discharge should provide a critical safety check before medication management transitions from hospital to family. Current discharge processes may not meet the needs of CMC and their families. The objective of this study is to describe parent perspectives and priorities regarding discharge medication education for CMC.

METHODS

We performed a qualitative, focus-group-based study, using ethnography. Parents of hospitalized CMC were recruited to participate in 1 of 4 focus groups; 2 were in Spanish. Focus groups were recorded, transcribed, and then coded and organized into themes by using thematic analysis.

RESULTS

Twenty-four parents participated in focus groups, including 12 native English speakers and 12 native Spanish speakers. Parents reported a range of 0 to 18 medications taken by their children (median 4). Multiple themes emerged regarding parental ideals for discharge medication education: (1) information quality, including desire for complete, consistent information, in preferred language; (2) information delivery, including education timing, and delivery by experts; (3) personalization of information, including accounting for literacy of parents and level of information desired; and (4) self-efficacy, or education resulting in parents' confidence to conduct medical plans at home.

CONCLUSIONS

Parents of CMC have a range of needs and preferences regarding discharge medication education. They share a desire for high-quality education provided by experts, enabling them to leave the hospital confident in their ability to care for their children once home. These perspectives could inform initiatives to improve discharge medication education for all patients, including CMC.

Syncope in the Emergency Department: A Guide for Clinicians

Syncope is a common presenting symptom to emergency departments, but its evaluation and initial management can be challenging for ED practitioners and particularly urgent in the presence of high-risk features that increase the likelihood of cardiac etiology. Even after thorough clinical evaluation, syncope may remain unexplained. In such instances, practitioners' clinical judgment and risk assessments are critical to guide further management. In this article, evidence-informed strategies are outlined to approach the diagnosis of syncope and provide an overview of syncope clinical decision rules and shared decision-making. By incorporating risk stratification and shared decision-making into syncope care, practitioners can more confidently engage patients and families in disposition decisions to organize appropriate outpatient and follow-up care, observation, or admission.

The Effectiveness of Pictorial Discharge Advice Versus Standard Advice Following Discharge From the Emergency Department: A Systematic Review and Meta-Analysis

INTRODUCTION

Failure to provide adequate discharge advice to patients on leaving the emergency department can lead to poor understanding of and noncompliance with discharge instructions and consequently postdischarge complications or hospital readmissions. The use of pictographs to complement discharge advice has the potential to enhance patient recall and comprehension. The purpose of this paper was to determine the effectiveness of pictorial discharge advice compared with standard discharge advice in the emergency department.

METHODS

A systematic review and meta-analysis was conducted. CINAHL, MEDLINE, ASSIA, and EMBASE were searched from inception to March 1, 2020, combining terms related to the emergency room, pictogram, and randomized trials as appropriate. Randomized trials reporting on the use of pictorial discharge advice in the emergency department were eligible for inclusion. Outcome measures were comprehension, compliance with advice, satisfaction with advice and the ED visit, and reattendance rates. The Cochrane risk of bias tool was used to assess bias in the included studies.

RESULTS

Four studies were identified as eligible and included in the review. Pictorial discharge advice improved comprehension, compliance, and patient satisfaction with the advice, but not satisfaction with the ED visit when compared with standard discharge advice. None of the included studies measured reattendance rates.

DISCUSSION

The results of this systematic review support the use of pictorial discharge advice. However, few studies exist; none had a low risk of bias overall, and 3 were published over 12 years ago. This finding highlights a need for further research to inform evidence-based best practices on optimal methods for providing quality discharge advice in the emergency department.

Emergency department discharge instruction for mild traumatic brain injury: Evaluation on readability, understandability, actionability and content

INTRODUCTION

Emergency departments (EDs) routinely provide discharge instructions due to a large number of patients with mild traumatic brain injury (mTBI) being discharged home directly from ED. This study aims to evaluate the quality of available mTBI discharge instructions provided by EDs of Malaysia government hospitals.

METHODS

All 132 EDs were requested for a copy of written discharge instruction given to the patients. The mTBI discharge instructions were evaluated using the Patient Education Materials Assessment-Printable Tool (PEMAT-P) for understandability and actionability. Readability was measured using an online readability tool of Malay text. The content was compared against the discharge instructions recommended by established guidelines.

RESULTS

49 articles were eligible for the study. 26 of the articles met the criteria of understandability, and 3 met the criteria for actionability. The average readability level met the ability of average adult. Most of the discharge instructions focused on emergency symptoms, and none contained post-concussion features.

CONCLUSION

Majority of the discharge instructions provided were appropriate for average people to read but difficult to understand and act upon. Important information was neglected in most discharge instructions. Thus, revision and future development of mTBI discharge instruction should consider health literacy demand and cognitive ability to process such information.

Giving Voice to Parents in the Development of the Preemie Prep for Parents (P3) Mobile App

BACKGROUND

Parents at risk for preterm birth frequently receive prematurity education when the mother is hospitalized for premature labor. Parental ability to learn and consider the information is limited because of the stress of the hospitalization. A promising approach is dissemination of information to at-risk parents before the birth hospitalization.

PURPOSE

This article describes formative research used to develop smartphone-based prematurity education app for parents at-risk for preterm birth.

METHODS

Stakeholders were parents with a prior preterm birth. Using stakeholder meeting transcripts, constant comparative analysis was used to reflect upon the parental voice.

RESULTS

The parents named the app, Preemie Prep for Parents (P3). Parent perspectives revealed desire for information in the following 5 categories. (1) Power in knowledge and control: parents want autonomy when learning information that may influence medical decision-making. (2) Content and framing of information: they desire information from a trusted resource that helps promote prenatal health and provides neonatal intensive care information. (3) Displaying content: parents want personalization, push notifications, photographs displaying fetal development, and easy-to-understand statistics. (4) Providing information without causing harm: they desire non-value-laden information, and they do not support "gamifying" the app to enhance utilization. (5) Decision making: parents want information that would benefit their decision making without assuming that parents have a certain outlook on life or particular values.

IMPLICATIONS FOR PRACTICE

These findings support the need for the P3 App to aid in decision making when parents experience preterm birth.

IMPLICATIONS FOR RESEARCH

The findings highlight the need to study the effects of smartphone-based prematurity education on medical decision-making.

Awareness of diagnosis and follow up care after discharge from the Emergency Department

BACKGROUND

Patients currently receive discharge summaries including investigation results, medical assessment and follow up requirements with health professionals on discharge from the emergency department (ED). This study aimed to evaluate if a simplified discharge information card in addition to current care improved patients' awareness of their discharge diagnosis and requirements for follow-up appointment.

METHODS

A prospective pre-post design interventional study was conducted. The pre-intervention phase collected data from patients who did not receive the discharge card. The post-intervention phase occurred after implementing the discharge card. Participants underwent brief interviews to assess awareness of diagnosis and follow-up appointment requirements after discharge. Responses were compared to the plan in the medical notes and concordance determined.

RESULTS

There were 112 patients in the pre-intervention group and 117 in the post-intervention group. Awareness of discharge diagnosis improved from 73.2% (95% CI: 64.3-80.5) of pre-interventions participants to 89.7% (95% CI: 82.9-94.0) for participants receiving the discharge card (p<0.001; NNT 6.1 patients). Statistically significant improvements were observed regarding knowledge of follow-up destination and timing.

CONCLUSION

A short discharge information card improved awareness of discharge diagnoses and follow-up requirements. Such interventions that empower patients with knowledge about their health, should be considered prior to discharge from EDs.