Readability of patient discharge instructions with and without the use of electronically available disease-specific templates

The Development and Implementation of an Evidence-Based Tumescent Liposuction Protocol, Online Educational Course for Perioperative Staff, and Discharge Instructions: A Quality Improvement Project

PURPOSE

The purpose of this quality improvement project was to improve perioperative management of patients undergoing tumescent liposuction (TL) through the development and implementation of a perioperative evidence-based protocol, educational course for perioperative staff, and patient discharge instructions.

DESIGN

The TL protocol was validated using the modified Delphi process. The educational course and discharge instructions used a pre and postimplementation design.

METHODS

An evidence-based protocol, an educational course for perioperative staff, and readable discharge instructions for patients undergoing TL were developed in accordance with best practice guidelines. The protocol was validated by subject matter experts at the facility and submitted for adoption. The evidence-based educational course was implemented, and the effectiveness of the course was evaluated for improving providers' knowledge and self-confidence. The evidence-based discharge instructions were implemented and evaluated for patient satisfaction and readability.

FINDINGS

Three items were removed from the protocol, 2 items were modified, and 25 items were accepted with no change from modified Delphi analysis. Provider knowledge scores improved from 85.7% ± 16.18 to 97.1% ± 4.88; however, this was not statistically significant (P = .066). There was a trend toward improved confidence scores (P = .180). Overall patient satisfaction scores slightly improved postimplementation; results were not statistically significant (P > .05).

CONCLUSIONS

All three phases of perioperative care in patients receiving TL were evaluated, reflecting best practice guidelines and successful adoption. There was no statistically significant improvement in provider knowledge, provider self-confidence, or patient satisfaction. A small sample size was a significant limiting factor.

Improving patient understanding on discharge from the short stay unit: an integrated human factors and quality improvement approach

This intervention used a systems approach to improve patient understanding on discharge from the adult acute medicine short stay unit (SSU). Patient understanding was assessed across five domains: diagnosis, medication changes, follow-up care, return instructions and knowing who their consultant was. The aim of this approach was that at least 90% of patients achieved near-complete understanding (score >4) on questionnaire across all five discharge domains by the end of April 2021. Pre-intervention most patients received verbal instructions and only a minority received written information. Through staff interviews, we identified the electronic discharge document (EDD) as a practical source of written information. However, testing with patients showed that the format required substantial redesign to be written in patient-friendly language, using signposting, spacing information out and avoiding jargon. The effect of this intervention was assessed with a structured telephone questionnaire, which included both a patient self-rated score and a comparative understanding score to assess true patient understanding of the revised EDD. Pre-intervention 29 discharged patients were interviewed across 10 days and post-intervention 10 patients were interviewed in 7 days. Patients consistently over-rated their understanding of discharge information. Only one patient achieved the aim of comparative understanding >4 across all domains post-intervention. Understanding improved across all but one of the domains, the exception being medication changes. An important unanticipated consequence was that interviews identified inconsistencies in EDD information and gaps in patient understanding, which required escalation to the SSU team. In summary, this intervention improved patient understanding across four of the five domains. However, further work is required on process reliability for the redesigned EDD and on improving understanding of medication changes. Furthermore, the interviews revealed clinically important inconsistencies in EDD information and gaps in patient understanding.

Overcoming Health Literacy Barriers by Developing Standardized Surgical Discharge Instructions

INTRODUCTION

Approximately one-third of surgical patients exhibit low health literacy, and 39% of our patients are primary Spanish speakers. We first evaluated the current content of our arteriovenous fistula/graft discharge instruction (DCI) templates. Using the Plan-Do-Study-Act cycle quality improvement methodology, we then aimed to optimize the readability and formally translate new DCI and evaluate usage and inappropriate bouncebacks following implementation.

METHODS

Current arteriovenous fistula/graft template content was reviewed by the literacy department for readability and vascular faculty for completeness and accuracy. The literacy department edits were categorized by word choice, added/removed content, format change, and grammatical errors. Two vascular surgeons rated completeness and accuracy on a Likert scale (1-5). Retrospective chart review was performed for telephone calls and emergency department bouncebacks for 3 mo flanking new DCI implementation.

RESULTS

Of the 10 templates, all were in English and word count ranged from 192 to 990 words. Despite each template including all necessary subcategories, the median number of edits per 100 words was 9.2 [7.0-9.5]. Approximately half of the edits (5.4 [5.1-5.5]) were word choice edits. Overall, experts rated completeness at 3.9 [3.2-4.2] and accuracy at 4.0 [3.7-4.1]. Highest template utilization occurred during post-implementation months 1 (90%) and 3 (100%) with orientation sessions. There was a significant increase in concordant Spanish DCI use (P < 0.01) and no inappropriate bouncebacks after implementation.

CONCLUSIONS

Our study demonstrated notable variability in the content and readability of our vascular access instruction templates. New DCI had strong usage and language concordance; continued use may decrease bouncebacks.

Efficacy of Digital Health Tools for a Pediatric Patient Registry: Semistructured Interviews and Interface Usability Testing With Parents and Clinicians

Background

Acute respiratory infection (ARI) in childhood is common, but more knowledge on the burden and natural history of ARI in the community is required. A better understanding of ARI risk factors, treatment, and outcomes will help support parents to manage their sick child at home. Digital health tools are becoming more widely adopted in clinical care and research and may assist in understanding and managing common pediatric diseases, including ARI, in hospitals and in the community. We integrated 2 digital tools—a web-based discharge communication system and the REDCap (Research Electronic Data Capture) platform—into the Pragmatic Adaptive Trial for Acute Respiratory Infection in Children to enhance parent and physician engagement around ARI discharge communication and our patient registry.

Objective

The objective of this study is to determine the efficacy and usability of digital tools integrated into a pediatric patient registry for ARI.

Methods

Semistructured interviews and software interface usability testing were conducted with 11 parents and 8 emergency department physicians working at a tertiary pediatric hospital and research center in Perth, Western Australia, in 2019. Questions focused on experiences of discharge communication and clinical trial engagement. Responses were analyzed using the qualitative Framework Method. Participants were directly observed using digital interfaces as they attempted predetermined tasks that were then classified as success, failure, software failure, or not observed. Participants rated the interfaces using the System Usability Scale (SUS).

Results

Most parents (9/11, 82%) indicated that they usually received verbal discharge advice, with some (5/11, 45%) recalling receiving preprinted resources from their physician. Most (8/11, 73%) would also like to receive discharge advice electronically. Most of the physicians (7/8, 88%) described their usual practice as verbal discharge instructions, with some (3/8, 38%) reporting time pressures associated with providing discharge instructions. The digital technology option was preferred for engaging in research by most parents (8/11, 73%). For the discharge communication digital tool, parents gave a mean SUS score of 94/100 (SD 4.3; A grade) for the mobile interface and physicians gave a mean usability score of 93/100 (SD 4.7; A grade) for the desktop interface. For the research data management tool (REDCap), parents gave a mean usability score of 78/100 (SD 11.0; C grade) for the mobile interface.

Conclusions

Semistructured interviews allowed us to better understand parent and physician experiences of discharge communication and clinical research engagement. Software interface usability testing methods and use of the SUS helped us gauge the efficacy of our digital tools with both parent and physician users. This study demonstrates the feasibility of combining qualitative research methods with software industry interface usability testing methods to help determine the efficacy of digital tools in a pediatric clinical research setting.

Improving Discharge Instructions Following a Concussion Diagnosis in the Pediatric Emergency Department: A Pre-post Intervention Study

Introduction

Many children are discharged from the pediatric emergency department (PED) with incomplete or inappropriate instructions following a concussion. Our objective was to evaluate the effectiveness of a simple intervention in improving discharge instruction disbursement and completeness following PED diagnosis of concussion.

Methods

A pre/post intervention study of 935 patients (375 preintervention and 560 postintervention) ages 5-19, diagnosed with a concussion and discharged from the PED between July 2016 and November 2019, was performed at a single United States pediatric tertiary-care center. Dedicated provider education sessions were held, and a consensus guideline-based set of discharge instructions were implemented in the electronic health record. Primary outcomes included the presence of return-to-play (RTP) instructions, return-to-learn (RTL) instructions, follow-up recommendations, and "complete" discharge (ie, all 3 components present). Statistical process control charts were generated and tested for special cause variation.

Results

More patients received instructions for RTP (87% versus 59%) and RTL (60% versus 3%), and a complete discharge was more frequent (45% versus 2%), following the conclusion of the intervention. Only the improvement in RTP instructions was completely sustained into the following academic year, whereas RTL and complete discharge rates declined to 27% and 20%, respectively.

Conclusions

A simple, low-cost intervention such as peer-to-peer education and consensus guideline-based discharge instruction templates can significantly improve discharge readiness after pediatric concussion. Further work is needed to maintain progress and continue improvements, at our large academic trauma center.

A Scoping Review on How to Make Hospitals health Literate Healthcare Organizations

The concept of health literacy is increasingly being recognised as not just an individual trait, but also as a characteristic related to families, communities, and organisations providing health and social services. The aim of this study is to identify and describe, through a scoping review approach, the characteristics and the interventions that make a hospital a health literate health care organisation (HLHO), in order to develop an integrated conceptual model. We followed Arksey and O’Malley’s five-stage scoping review framework, refined with the Joanna Briggs Institute methodology, to identify the research questions, identify relevant studies, select studies, chart the data, and collate and summarize the data. Of the 1532 titles and abstracts screened, 106 were included. Few studies have explored the effect of environmental support on health professionals, and few outcomes related to staff satisfaction/perception of helpfulness have been reported. The most common types of interventions and outcomes were related to the patients. The logical framework developed can be an effective tool to define and understand priorities and related consequences, thereby helping researchers and policymakers to have a wider vision and a more homogeneous approach to health literacy and its use and promotion in healthcare organizations.

Student-Novice Nurse Preparation: Addressing Barriers in Discharge Teaching

AIM

The aim of this article was to assess how and to what degree nursing students are prepared for patient discharge teaching (DT).

BACKGROUND

The process of discharging patients has become more complex. Despite the expectation that nursing students will be competent in providing effective DT upon graduation, the preparation of new graduates is a problem for hospitals.

METHOD

A review of the literature was conducted.

REVIEW

The review showed that novice nurses enter the workforce unprepared to provide adequate DT due to limited communication and limited time during their education, which led to low confidence and limited knowledge.

CONCLUSION

Methods to overcome current barriers in DT, including simulation practices, the teach-back method, dedicated education units, collaborative efforts, discharge checklists, and health literacy identification, are presented as recommendations for nursing education.

Impact of a Health Information Technology Intervention on the Follow-up Management of Pulmonary Nodules

Lung cancer is the leading cause of cancer deaths in the USA. The most common abnormalities suspicious for lung cancer on CT scan include pulmonary nodules. Recommendations to improve care for patients with pulmonary nodules require follow-up management. However, transitions in care, especially for patients undergoing transitions to ambulatory care sites from the emergency department (ED) and inpatient settings, can exacerbate failures in follow-up testing and compromise patient safety. We evaluate the impact of a discharge module that includes follow-up recommendations for further management of pulmonary nodules on the study outcome and follow-up management of patients with pulmonary nodules within 1 year after discharge. After IRB approval, we collected data on all patients undergoing chest or abdominal CT exams over a 12-month baseline and 12-month intervention period at an academic medical center. The inpatient discharge module was implemented in November 2011; the ED module was implemented in May 2012. Multivariable logistic regression was performed to account for care setting, imaging modality, recommendations, and patient demographics. Implementation of a discharge module resulted in improved follow-up of patients with pulmonary nodules within 1 year after discharge (OR = 1.64, p = 0.01); the ED implementation resulted in better follow-up compared to the inpatient module (OR = 2.24, p < 0.01). Twenty-seven percent of patients with pulmonary nodules received follow-up management, which, although significantly improved from the 18% baseline, remains low. An electronic discharge module is associated with improved follow-up management of patients with pulmonary nodules, and may be combined with interventions to further improve management of these patients.

Testing a Photo Story Intervention in Paper Versus Electronic Tablet Format Compared to a Traditional Brochure Among Older Adults in Germany: Randomized Controlled Trial

BACKGROUND

To increase effective communication in primary care consultations among older adults in Germany, the photo story is considered to be a useful tool based on Bandura's social cognitive theory. With information technology helping to increase effective communication, the use of tablets is gaining attention in health care settings, especially with older adults. However, the effectiveness of tablet technology and photo stories has rarely been tested.

OBJECTIVE

The aim is to compare the effectiveness of a photo story intervention to a traditional brochure. Both were delivered either in paper or tablet format.

METHODS

A trial was conducted with 126 older adults, aged 50 years and older, who were approached and recruited by researchers and administrative staff from senior day care, doctors in rehabilitation centers, and trainers in sports clubs in Germany. Open and face-to-face assessment methodologies were used. Participants were randomly assigned to one of four intervention conditions: traditional brochure in paper format (condition 1) and tablet format (condition 2), and photo story in paper format (condition 3) and tablet format (condition 4). Each participant received a questionnaire and either the traditional brochure or photo story in a paper or tablet version. To evaluate the effectiveness of each intervention, participants completed evaluation questionnaires before and after each intervention. The second part of the questionnaire measured different indicators of health literacy, communication skills, health measurements, and possible underlying mechanisms.

RESULTS

Compared to the traditional brochure, participants considered the photo story easier to understand (t₁₂₄=2.62, P=.01) and more informative (t₁₂₄=-2.17, P=.03). Participants preferred the paper format because they found it less monotonous (t₁₂₄=-3.05, P=.003), less boring (t₁₂₄=-2.65, P=.009), and not too long (t₁₂₄=-2.26, P=.03) compared to the tablet format. Among all conditions, the traditional brochure with a tablet (condition 2) was also perceived as more monotonous (mean 3.07, SD 1.08), boring (mean 2.77, SD 1.19), and too long to read (mean 2.50, SD 1.33) in comparison to the traditional brochure in paper format (condition 1). Moreover, the participants scored significantly higher on self-referencing on the traditional brochure in paper format (condition 1) than tablet format for both types of the brochure (conditions 2 and 4).

CONCLUSIONS

Traditional brochures on a tablet seem to be the least effective communication option in primary care consultations among all conditions for older adults. The findings might be specific for the current generation of older adults in Germany and need to be replicated in other countries with larger sample sizes. Although information technology brings advantages, such as effective interventions in different fields and settings, it may also come with several disadvantages, such as technical requirements of the users and devices. These should be considered when integrating information technology into wider situations and populations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02502292; https://clinicaltrials.gov/ct2/show/NCT02502292 (Archived by Webcite at http://www.webcitation.org/747jdJ8pU).

Discharge communication practices and healthcare provider and patient preferences, satisfaction and comprehension: A systematic review

Purpose

To systematically review the available evidence about hospital discharge communication practices and identify which practices were preferred by patients and healthcare providers, improved patient and provider satisfaction, and increased patients' understanding of their medical condition.

Data sources

OVID Medline, Web of Science, ProQuest, PubMed and CINAHL plus.

Study selection

Databases were searched for peer-reviewed, English-language papers, published to August 2016, of empirical research using quantitative or qualitative methods. Reference lists in the papers meeting inclusion criteria were searched to identify further papers.

Data extraction

Of the 3489 articles identified, 30 met inclusion criteria and were reviewed.

Results of data synthesis

Much research to date has focused on the use of printed material and person-based discharge communication methods including verbal instructions (either in person or via telephone calls). Several studies have examined the use of information technology (IT) such as computer-generated and video-based discharge communication practices. Utilizing technology to deliver discharge information is preferred by healthcare providers and patients, and improves patients' understanding of their medical condition and discharge instructions.

Conclusion

Well-designed IT solutions may improve communication, coordination and retention of information, and lead to improved outcomes for patients, their families, caregivers and primary healthcare providers as well as expediting the task for hospital staff.

Patient and Public Outreach Initiatives in Chronic Rhinosinusitis from the Canadian Sinusitis Working Group: Support for Affected Patients and Extending an Understanding of CRS to the General Public

Chronic rhinosinusitis is an important disease entity that affects patients worldwide, yet there is limited public awareness regarding the disease. The Canadian Rhinosinusitis Working Group, a group of diverse medical professionals, has made a multitude of efforts to help improve the health literacy of patients and important stakeholders, as well as the quality of life of patients with chronic rhinosinusitis. This review will aim to outline these initiatives.

Readability assessment of patient-provider electronic messages in a primary care setting

BACKGROUND

The high prevalence of limited health literacy among patients threatens the success of secure electronic messaging between patients from diverse populations and their providers.

OBJECTIVE

The purpose of this study is to generate hypotheses about the readability of patient and provider electronic messages.

METHODS

We collected 31 patient-provider e-mail exchanges (n = 119 total messages) from a safety-net primary care clinic. We compared the messages' mean word count and Flesch-Kincaid Grade Levels (FKGLs), calculated the frequency of provider messages below an FKGL = 8, and assessed readability concordance between patients' and providers' messages.

RESULTS

Patients used more words in their initial e-mails compared to providers, but the FKGLs were similar, and 68% of provider messages were written below an FKGL = 8. Of 31 exchanges, 9 (29%) contained at least one patient message with an FKGL > 3 grade levels lower than the corresponding provider message(s).

CONCLUSION

Our study demonstrates that most providers are able to respond to patient electronic messages with a matching reading level.