Empowering Patients: Simplifying Discharge Instructions

BACKGROUND: Studies have shown that many patients leave the ED with partial comprehension of their visit and discharge instructions. Patients who are not adequately informed as to their discharge plans have decreased compliance with medications and treatment plans, decreased patient safety, increased Emergency Department (ED) recidivism, and poor patient satisfaction. The fast-paced and unpredictable environment of the ED makes thorough communication a challenge, so it is especially important to ensure that patients are given accessible and easy-to-understand information given the acuity and urgency of these patients' conditions. LOCAL PROBLEM: This project's objective is to develop and implement a method to assess and improve patient understanding of treatment and discharge plan at the Clements University Hospital Emergency Department, an academic urban hospital ED that sees approximately 43,500 patients per year. Written instructions provided to patients at the beginning of the study were found to be long and tedious, and important information was often difficult to find. METHODS: The PDSA (Plan, Do, Study, Act) cycle was employed throughout the project. Planning occupied a large portion of the project, with the determination of stakeholders, mapping of the current state, and developing an algorithm for assessment of patient understanding. ED discharge process was mapped with a flow diagram to understand the process of educating patients upon discharge from Clements University Hospital. The authors developed a questionnaire to assess patient knowledge using CMS OP-19 Transfer Record and Joint Commission recommendations, areas of communication deficits reported in other papers, and ED staff and provider input. A baseline study was conducted with fifty patients to measure patient understanding of their discharge instructions (Do). Responses from patient interviews were then scored against the medical record (Study). Three scorers graded all patient responses, and inter-rater reliability was calculated using the kappa statistic. INTERVENTIONS: Based on patient scores in the baseline study, stakeholder interviews, and fishbone diagrams examining reasons for lower scores, a decision matrix was created to decide on the most effective intervention (Act, Plan). The intervention chosen was creating a new, short discharge document. We developed the one-page Simplified Information Page (SIP) targeted to teach patients their most relevant discharge instructions. Next, we tested the SIP on one hundred eighteen patients to see its effect on patient understanding (Do). RESULTS: None (0%) of the fifty patients in the initial survey had complete comprehension of their ED visit and discharge instructions, although most patients stated they understood their discharge instructions and thought that their discharge instructions were useful. The lowest scoring questions were medication instructions (dosing and frequency) and indications to return to the ED. Median score improved after implementation of the SIP, with statistically significant changes in score distribution across all questions assessed with the Wilcoxon signed-rank test. Repeated measures ANOVA did not reveal any significant relationship between improvement in scores and any demographic criteria. Inter-rater reliability between scorers was high (kappa = 0.84). CONCLUSION: 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. We found that the majority of patients do not fully comprehend their ED discharge instructions. Our project has shown that a simple, easy-to-read page with patient input significantly improved ED discharge knowledge.