Empowering patients: simplifying discharge instructions

Abstract

Patients who do not have enough information about their discharge plans have decreased treatment compliance, decreased patient safety, increased emergency department (ED) recidivism, and poor satisfaction. This project aimed to develop and implement a method to assess and improve patient understanding of treatment and discharge plan in the ED. The authors developed a questionnaire to assess patient knowledge using Centers for Medicare and Medicaid Services and Joint Commission recommendations, areas of communication deficits reported in other manuscripts, and ED staff and provider input. Responses from patient interviews were then scored against the medical record. Three trained scorers graded all responses, and inter-rater reliability was calculated using the kappa statistic.Baseline observations found that written discharge instructions were long and tedious, and important information was difficult to find. Based on initial patient scores, stakeholder interviews, and fishbone diagrams, the team developed a one-page simplified information page (SIP) targeted to inform patients their most relevant discharge instructions. Next, the SIP was tested on 118 patients to measure its effect on patient understanding. At the baseline study, no patients had complete understanding of their discharge instructions. The areas of lowest scores were medication instructions and indications to return to the ED. Implementation of the SIP resulted in statistically significant changes in score distribution across all questions assessed with the Wilcoxon signed-rank test. Interrater reliability between scorers was high (kappa=0.84). We incorporated the concept of the SIP to the cover page of our standard discharge instructions.Healthcare providers often spend valuable time educating their patients, and it is important to assess the effectiveness of this teaching to identify areas in which we may improve health literacy and patient understanding. This project has shown that a simple, easy-to-read, concise page developed with patient input significantly improved ED discharge instruction knowledge.

Keywords: electronic health records; emergency department; health literacy; medical education; patient education.

Figure 1

Baseline Patient Questionnaire Scores. Baseline discharge knowledge of 50 emergency depatment (ED) patients was assessed in six domains: indications to return to the ED, information about medications (frequency and duration), diagnosis, other postdischarge treatment (wound care, etc), tests and procedures performed in the ED, and follow-up (clinics to follow up with after discharge from the ED). The answers were graded as correct, partially correct or incorrect. The counts for each of these answers are presented here.

Figure 2

Simplified information page. Our one-page discharge summary document written at a Flesch-Kincaid grade 5 level includes simple pictograms to act as a memory aid.

Figure 3

Patient Questionnaire Scores preintervention and postintervention. Discharge knowledge questionnaire scores of 118 patients preintervention and postintervention after using the SIP via a teach-back method. The same domains of knowledge and scoring method were used as in the baseline questionnaire. SIP, simplified information page.