- Email: [email protected]
374 Evaluation of Patient Understanding of Emergency Department Discharge Instructions
Research Forum Abstracts study was to determine how information delivery method (text versuss video) affects patients’ understanding and preference for USGIV versus IO. We hypothesized that overall, patients would prefer USGIV over IO, but that patients randomized to video would have a higher rate of preference for IO than their text counterparts. Additionally, we hypothesized that patients with a history of DIVA would have greater comprehension and would be more likely to prefer IO than their non-DIVA counterparts. Methods: A convenience sample of DIVA and non-DIVA patients was randomized to video or text overview of USGIV and IO. The content of each overview was identical except that the video visually demonstrated each access modality. Comprehension and preference were then assessed via a multiple-choice quiz. Subjects were eligible for enrollment if they meet all the following criteria: > 17 years, hemodynamically stable, fluent in English, and able to give consent. Subjects in the DIVA group were those with 2 or more failed IV attempts or a history of difficult access and no visible or palpable veins. Subjects with none of these characteristics were categorized as non-DIVA. Groups were compared with t-tests, chi-squares, nonparametric trend tests, and multivariate linear regression. The study was powered (80% power, alpha 0.05) to detect a 15% difference in comprehension for USGIV versus IO. Results: A total of 545 patients were enrolled; 133 DIVA and 412 non-DIVA. DIVA patients were older (43.1 versus 37.7 years, P<.01) but did not differ in education (P¼.236) or income (P¼.477). Mean comprehension test scores did not differ between patients in DIVA and non-DIVA groups (64.5% versus 63.5%, P¼.46) or in video and text groups (64.7% versus 62.8%, P¼.09) After controlling for age, education, and income, there was no difference in comprehension between DIVA and non-DIVA patients (P¼.111) or between patients randomized to text or video (P¼.386). Randomization to text versus video did not affect preference for USGIV (64.9% versus 66.2% respectfully, P¼.962). Both DIVA and non-DIVA patients preferred USGIV (68.9% versus 64%, P¼.309). Higher education was associated with increased comprehension scores. Patients with high school, some college, college, or post-graduate education had average comprehension scores of 59.8%, 64.2%, 69.8%, and 70.3% (trend P<.01) respectively. Level of education was not associated with increasing preference for USGIV (69.4%, 62.2%, 76.0% and 74.4%,(P¼.062). Conclusion: In this study, video communication is equivalent to traditional text in resultant comprehension and clinical preference for USGIV versus IO. Prior history of DIVA did not affect comprehension or preference for an access modality. Higher education was associated with significantly increased comprehension but had no relation to preference. All groups preferred USGIV.
374
Evaluation of Patient Understanding of Emergency Department Discharge Instructions
Stevens LA, Langlois BK, Nam C, Monrose E, Feldman JA, Mitchell PM, Klyce V, James TL/Boston University School of Medicine, Boston, MA; Boston Medical Center, Boston, MA
Study Objectives: Failure to complete emergency department (ED) discharge (D/C) instructions can lead to return ED visits, hospitalizations, and other complications. ED patients must understand and be able to follow their D/C instructions. To date, few studies have assessed ED patients’ understanding of their D/C instructions. This study aimed to assess ED patients’ comprehension of care and D/C instructions, and awareness of comprehension deficiencies. Methods: This was an IRB-approved, cross-sectional survey of a convenience sample of ED patients at an urban, academic, level 1 trauma center. Inclusion criteria were: English speaking, age > 21, D/C from the ED from June 2012 to November 2012. Two study investigators independently assessed subjects’ comprehension by rating the degree of agreement (concordance) between objective data from chart review and subjects’ verbal explanation of 4 domains (diagnosis, ED care, post-ED care, return instructions). Concordance was rated as complete, near, partial, or none. Concordance discrepancies were reviewed by both investigators to reach a final concordance rating. Any final rating less than complete (ie, near, partial, or none) was considered a “comprehension deficiency.” In addition, subjects rated their perceived comprehension of and difficulty understanding the 4 domains using 5-point Likert scales. Scales were dichotomized to identify subjects who perceived any comprehension difficulties (defined as either “a little” difficulty). Self-awareness of comprehension deficits was assessed by examining how objective “comprehension deficiency” (as measured by investigators’ concordance ratings) corresponds to subjects’ “perceived comprehension difficulties.” Descriptive statistics were used for all analyses; all data analyzed with SAS 9.3. Results: A total of 130 subjects were enrolled. Eleven were dropped, 119 were included in analysis. Mean age was 44; 56% were male; 56% were black. Results are displayed in Tables 1-3. A total of 476 domains were scored (119 subjects x 4
S134 Annals of Emergency Medicine
domains). Of the total scored domains, 64% were rated “complete” concordance; 34% were considered to have a “comprehension deficiency.” Of the total with a comprehension deficiency, most were in ED care (35%, 58/164) and 64% (105/164) were not aware of the deficiency by subjects. Conclusion: Patients commonly misunderstand important aspects of their ED care and D/C instructions, yet are not aware of their comprehension deficiencies. Clinicians should assess patient understanding at time of D/C to improve D/C instruction compliance. Table 1. Concordance Ratings Concordance ratings
Total number scored (%)
Complete concordance Near concordance Partial concordance No concordance N/A (unable to assess) Total
305 80 63 21 7 476
(64) (17) (13) (4) (1) (100)
95% CI 60, 68 13, 20 10, 16 3, 6 0.4, 3
Table 2. Comprehension Deficiencies Comprehension deficiencies by domain of ED visit Diagnosis and cause ED care Post-ED care Return instructions Total
Total number deficient (%) 23 58 41 42 164
(14) (35) (25) (26) (100)
95% CI 9, 19 28, 43 18, 32 19, 32
Table 3. Awareness of Comprehension Difficulties
Awareness of comprehension deficiencies Domains with complete concordance Domains with less than complete concordance N/A (unable to assess) Total scored domains (119 pts. x 4 domains)
375
Total number
Number with perceived deficit/ difficulty (%); 95% CI
305
92 (30); 25, 35
164
59 (36); 29, 43
7 476
4 (57); 8, 100 155 (33); 28, 37
Tertiary Care Transfer Experience: One Month of Emergency Department Transfers
Black KP, Ko PY, Grant WD/SUNY Upstate Medical University, Evans Mills, NY
Study Objectives: Transfers to tertiary care emergency department (ED) centers provide beneficial effects to patient care due to the increased availability of medical specialists and services. Are there characteristics which help determine the appropriateness of these transfers? The objective of this study was to describe the nature of outside facility transfers to a tertiary care center ED. Methods: The charts of all hospital transfers to a tertiary care ED during August 2013 were examined. The orders and diagnosis of the transferring emergency physician were extracted from the electronic medical record. The orders and diagnosis of the emergency physician at the tertiary care center were also extracted. Results: There were 296 patients transferred from 30 different facilities (60.5% male, mean age 36.5 years, SD 27.2 years, 95% CI 33.4 to 39.6 years, range 3 months to 99 years). The primary diagnosis was related to injury or trauma for 167 patients (58.4%). The primary diagnosis was in a specialty surgical field 65.6% of the time (orthopedics 25.7%, Otolaryngology 17.6, trauma surgery 11.8% and neurosurgery 10.5%), with general surgery 7.4%, neurology 5.7%, general medicine 4.1%, and gastroenterology 3.4%. At the outside EDs, each patient had an average of 7.1 orders, 3.8 of which were labs and 2.2 radiographs. The tertiary care emergency physician had an average of 4.7
Volume 64, no. 4s : October 2014
374
Evaluation of Patient Understanding of Emergency Department Discharge Instructions
Stevens LA, Langlois BK, Nam C, Monrose E, Feldman JA, Mitchell PM, Klyce V, James TL/Boston University School of Medicine, Boston, MA; Boston Medical Center, Boston, MA
Study Objectives: Failure to complete emergency department (ED) discharge (D/C) instructions can lead to return ED visits, hospitalizations, and other complications. ED patients must understand and be able to follow their D/C instructions. To date, few studies have assessed ED patients’ understanding of their D/C instructions. This study aimed to assess ED patients’ comprehension of care and D/C instructions, and awareness of comprehension deficiencies. Methods: This was an IRB-approved, cross-sectional survey of a convenience sample of ED patients at an urban, academic, level 1 trauma center. Inclusion criteria were: English speaking, age > 21, D/C from the ED from June 2012 to November 2012. Two study investigators independently assessed subjects’ comprehension by rating the degree of agreement (concordance) between objective data from chart review and subjects’ verbal explanation of 4 domains (diagnosis, ED care, post-ED care, return instructions). Concordance was rated as complete, near, partial, or none. Concordance discrepancies were reviewed by both investigators to reach a final concordance rating. Any final rating less than complete (ie, near, partial, or none) was considered a “comprehension deficiency.” In addition, subjects rated their perceived comprehension of and difficulty understanding the 4 domains using 5-point Likert scales. Scales were dichotomized to identify subjects who perceived any comprehension difficulties (defined as either “a little” difficulty). Self-awareness of comprehension deficits was assessed by examining how objective “comprehension deficiency” (as measured by investigators’ concordance ratings) corresponds to subjects’ “perceived comprehension difficulties.” Descriptive statistics were used for all analyses; all data analyzed with SAS 9.3. Results: A total of 130 subjects were enrolled. Eleven were dropped, 119 were included in analysis. Mean age was 44; 56% were male; 56% were black. Results are displayed in Tables 1-3. A total of 476 domains were scored (119 subjects x 4
S134 Annals of Emergency Medicine
domains). Of the total scored domains, 64% were rated “complete” concordance; 34% were considered to have a “comprehension deficiency.” Of the total with a comprehension deficiency, most were in ED care (35%, 58/164) and 64% (105/164) were not aware of the deficiency by subjects. Conclusion: Patients commonly misunderstand important aspects of their ED care and D/C instructions, yet are not aware of their comprehension deficiencies. Clinicians should assess patient understanding at time of D/C to improve D/C instruction compliance. Table 1. Concordance Ratings Concordance ratings
Total number scored (%)
Complete concordance Near concordance Partial concordance No concordance N/A (unable to assess) Total
305 80 63 21 7 476
(64) (17) (13) (4) (1) (100)
95% CI 60, 68 13, 20 10, 16 3, 6 0.4, 3
Table 2. Comprehension Deficiencies Comprehension deficiencies by domain of ED visit Diagnosis and cause ED care Post-ED care Return instructions Total
Total number deficient (%) 23 58 41 42 164
(14) (35) (25) (26) (100)
95% CI 9, 19 28, 43 18, 32 19, 32
Table 3. Awareness of Comprehension Difficulties
Awareness of comprehension deficiencies Domains with complete concordance Domains with less than complete concordance N/A (unable to assess) Total scored domains (119 pts. x 4 domains)
375
Total number
Number with perceived deficit/ difficulty (%); 95% CI
305
92 (30); 25, 35
164
59 (36); 29, 43
7 476
4 (57); 8, 100 155 (33); 28, 37
Tertiary Care Transfer Experience: One Month of Emergency Department Transfers
Black KP, Ko PY, Grant WD/SUNY Upstate Medical University, Evans Mills, NY
Study Objectives: Transfers to tertiary care emergency department (ED) centers provide beneficial effects to patient care due to the increased availability of medical specialists and services. Are there characteristics which help determine the appropriateness of these transfers? The objective of this study was to describe the nature of outside facility transfers to a tertiary care center ED. Methods: The charts of all hospital transfers to a tertiary care ED during August 2013 were examined. The orders and diagnosis of the transferring emergency physician were extracted from the electronic medical record. The orders and diagnosis of the emergency physician at the tertiary care center were also extracted. Results: There were 296 patients transferred from 30 different facilities (60.5% male, mean age 36.5 years, SD 27.2 years, 95% CI 33.4 to 39.6 years, range 3 months to 99 years). The primary diagnosis was related to injury or trauma for 167 patients (58.4%). The primary diagnosis was in a specialty surgical field 65.6% of the time (orthopedics 25.7%, Otolaryngology 17.6, trauma surgery 11.8% and neurosurgery 10.5%), with general surgery 7.4%, neurology 5.7%, general medicine 4.1%, and gastroenterology 3.4%. At the outside EDs, each patient had an average of 7.1 orders, 3.8 of which were labs and 2.2 radiographs. The tertiary care emergency physician had an average of 4.7
Volume 64, no. 4s : October 2014