A Mixed-Methods Evaluation of Clinician Education Modules on Reducing Surgical Opioid Prescribing.

BACKGROUND: In this study, we developed online interactive clinician education modules highlighting best practices to minimize opioid prescribing at discharge after surgery. The modules were implemented as part of a multicomponent quality improvement initiative across a six-hospital health system. This article describes the development and evaluation of this educational intervention. MATERIALS AND METHODS: Clinician education modules targeting surgical prescribers, nurses, and pharmacists were developed and implemented by an interdisciplinary team. Clinicians were invited to participate in an evaluation survey after completing the modules. Survey items assessed clinicians' rating of the module and intention to change clinical practice because of the module. Quantitative and qualitative survey responses were analyzed by the study team. RESULTS: A total of 2119 clinicians completed the module and 1831 of these clinicians (86.4%) completed the survey. Of clinicians completing the survey, 65.6% reported that they intend to change clinical practice after completing the module. Intended changes were related to increased knowledge and awareness, provider empowerment, opioid prescribing practices, nonopioid prescribing practices, and patient education. Many clinicians who indicated they do not intend to change practice reported that their clinical practices were already in line with module recommendations. Some clinicians did not perceive the module to be relevant to their role. CONCLUSIONS: Module completion was associated with the intention to improve clinical practice in areas related to provider empowerment, opioid prescribing, nonopioid prescribing, and patient education. Evaluation data will inform future module improvements. There is an opportunity to ensure that all clinicians, including those who are not prescribers, recognize their role in opioid stewardship.

Recognition: key to the entrepreneurial strategies of rural coalitions in advancing access to health care.

OBJECTIVES: Considerable evidence has advanced the role of citizen-led coalitions (CLC) in supporting the health and social needs of rural citizens. There has been little research focusing on the experiences and strategies of coalitions, with their limited resources and status, in targeting health inequities in their rural communities. The aim of this study was to understand the entrepreneurial strategies and experiences of rural coalitions to effect change in the delivery of health services for their older adult populations. METHOD: A qualitative descriptive study method was used to generate understanding of the entrepreneurial experiences and strategies of CLCs in advancing health services to meet the health and social needs of their citizens. Seven diverse CLCs (n = 40) from different rural communities participated in focus groups and in individual and coalition-level surveys. Thematic analysis was used to construct themes from the data. RESULTS: Two over-riding themes emerged: entrepreneurial strategies and societal recognition. CLCs engaged in numerous entrepreneurial strategies that enabled actions and outcomes in meeting their health care needs. These strategies included: securing quick wins, leveraging existing resources, and joining forces with stakeholder groups/individuals. However, despite these strategies and successes, coalitions expressed frustration with not being seen and not being heard by decision-makers. This pointed to a key structural barrier to coalition successes -- a broader societal and institutional problem of failing to recognize not only the health needs of rural citizens, but also the legitimacy of the community coalitions to represent and act on those needs. CONCLUSIONS: Despite the potential for coalitions to mobilize and effect change in addressing the inequities of rural health service access for older adults, broader barriers to their recognition, may undermine their entrepreneurial strategies and success.

Minimizing Opioid Prescribing in Surgery (MOPiS) Initiative: An Analysis of Implementation Barriers.

BACKGROUND: The United States is in the midst of an opioid epidemic. In response, our institution developed the Minimizing Opioid Prescribing in Surgery (MOPiS) initiative. MOPiS is a multicomponent intervention including: (1) patient education on opioid safety and pain management expectations; (2) clinician education on safe opioid prescribing; (3) prescribing data feedback; (4) patient risk screening to assess for addictive behavior; and (5) optimizations to the electronic health record (EHR). We conducted a preintervention formative evaluation to identify barriers and facilitators to implementation. MATERIALS AND METHODS: We conducted 22 semistructured interviews with key stakeholders (surgeons, nurses, pharmacists, and administrators) at six hospitals within a single health care system. Interviewees were asked about perceived barriers and facilitators to the components of the intervention. Responses were analyzed to identify common themes using the Consolidated Framework for Implementation Research. RESULTS: We identified common themes of potential implementation barriers and classified them under 12 Consolidated Framework for Implementation Research domains and three intervention domains. Time and resource constraints (needs and resources), the modality of educational material (design quality and packaging), and prescribers' concern for patient satisfaction scores (external policy and incentives) were identified as the most significant structural barriers. Resident physicians, pharmacists, and pain specialists were identified as potential key facilitating actors to the intervention. CONCLUSIONS: We identified specific barriers to successful implementation of an opioid reduction initiative in a surgical setting. In our MOPiS initiative, a preintervention formative evaluation enabled the design of strategies that will overcome implementation barriers specific to the components of our initiative.

Alternative approaches for acute inhalation toxicity testing to address global regulatory and non-regulatory data requirements: An international workshop report.

Inhalation toxicity testing, which provides the basis for hazard labeling and risk management of chemicals with potential exposure to the respiratory tract, has traditionally been conducted using animals. Significant research efforts have been directed at the development of mechanistically based, non-animal testing approaches that hold promise to provide human-relevant data and an enhanced understanding of toxicity mechanisms. A September 2016 workshop, "Alternative Approaches for Acute Inhalation Toxicity Testing to Address Global Regulatory and Non-Regulatory Data Requirements", explored current testing requirements and ongoing efforts to achieve global regulatory acceptance for non-animal testing approaches. The importance of using integrated approaches that combine existing data with in vitro and/or computational approaches to generate new data was discussed. Approaches were also proposed to develop a strategy for identifying and overcoming obstacles to replacing animal tests. Attendees noted the importance of dosimetry considerations and of understanding mechanisms of acute toxicity, which could be facilitated by the development of adverse outcome pathways. Recommendations were made to (1) develop a database of existing acute inhalation toxicity data; (2) prepare a state-of-the-science review of dosimetry determinants, mechanisms of toxicity, and existing approaches to assess acute inhalation toxicity; (3) identify and optimize in silico models; and (4) develop a decision tree/testing strategy, considering physicochemical properties and dosimetry, and conduct proof-of-concept testing. Working groups have been established to implement these recommendations.

A cross-disciplinary evaluation of evidence for multipollutant effects on cardiovascular disease.

BACKGROUND: The current single-pollutant approach to regulating ambient air pollutants is effective at protecting public health, but efficiencies may be gained by addressing issues in a multipollutant context since multiple pollutants often have common sources and individuals are exposed to more than one pollutant at a time. OBJECTIVE: We performed a cross-disciplinary review of the effects of multipollutant exposures on cardiovascular effects. METHODS: A broad literature search for references including at least two criteria air pollutants (particulate matter [PM], ozone [O3], oxides of nitrogen, sulfur oxides, carbon monoxide) was conducted. References were culled based on scientific discipline then searched for terms related to cardiovascular disease. Most multipollutant epidemiologic and experimental (i.e., controlled human exposure, animal toxicology) studies examined PM and O3 together. DISCUSSION: Epidemiologic and experimental studies provide some evidence for O3 concentration modifying the effect of PM, although PM did not modify O3 risk estimates. Experimental studies of combined exposure to PM and O3 provided evidence for additivity, synergism, and/or antagonism depending on the specific health endpoint. Evidence for other pollutant pairs was more limited. CONCLUSIONS: Overall, the evidence for multipollutant effects was often heterogeneous, and the limited number of studies inhibited making a conclusion about the nature of the relationship between pollutant combinations and cardiovascular disease.

The heart as an extravascular target of endothelin-1 in particulate matter-induced cardiac dysfunction.

Exposure to particulate matter air pollution has been causally linked to cardiovascular disease in humans. Several broad and overlapping hypotheses describing the biological mechanisms by which particulate matter exposure leads to cardiovascular disease have been explored, although linkage with specific factors or genes remains limited. These hypotheses may or may not also lead to particulate matter-induced cardiac dysfunction. Evidence pointing to autocrine/paracrine signaling systems as modulators of cardiac dysfunction has increased interest in the emerging role of endothelins as mediators of cardiac function following particulate matter exposure. Endothelin-1, a well-described small peptide expressed in the pulmonary and cardiovascular systems, is best known for its ability to constrict blood vessels, although it can also induce extravascular effects. Research on the role of endothelins in the context of air pollution has largely focused on vascular effects, with limited investigation of responses resulting from the direct effects of endothelins on cardiac tissue. This represents a significant knowledge gap in air pollution health effects research, given the abundance of endothelin receptors found on cardiac tissue and the ability of endothelin-1 to modulate cardiac contractility, heart rate, and rhythm. The plausibility of endothelin-1 as a mediator of particulate matter-induced cardiac dysfunction is further supported by the therapeutic utility of certain endothelin receptor antagonists. The present review examines the possibility that endothelin-1 release caused by exposure to PM directly modulates extravascular effects on the heart, deleteriously altering cardiac function.

Conceptual model for assessing criteria air pollutants in a multipollutant context: A modified adverse outcome pathway approach.

Air pollution consists of a complex mixture of particulate and gaseous components. Individual criteria and other hazardous air pollutants have been linked to adverse respiratory and cardiovascular health outcomes. However, assessing risk of air pollutant mixtures is difficult since components are present in different combinations and concentrations in ambient air. Recent mechanistic studies have limited utility because of the inability to link measured changes to adverse outcomes that are relevant to risk assessment. New approaches are needed to address this challenge. The purpose of this manuscript is to describe a conceptual model, based on the adverse outcome pathway approach, which connects initiating events at the cellular and molecular level to population-wide impacts. This may facilitate hazard assessment of air pollution mixtures. In the case reports presented here, airway hyperresponsiveness and endothelial dysfunction are measurable endpoints that serve to integrate the effects of individual criteria air pollutants found in inhaled mixtures. This approach incorporates information from experimental and observational studies into a sequential series of higher order effects. The proposed model has the potential to facilitate multipollutant risk assessment by providing a framework that can be used to converge the effects of air pollutants in light of common underlying mechanisms. This approach may provide a ready-to-use tool to facilitate evaluation of health effects resulting from exposure to air pollution mixtures.

ToF-SIMS imaging of molecular-level alteration mechanisms in Le Bonheur de vivre by Henri Matisse.

Time-of-flight secondary ion mass spectrometry (ToF-SIMS) has recently been shown to be a valuable tool for cultural heritage studies, especially when used in conjunction with established analytical techniques in the field. The ability of ToF-SIMS to simultaneously image inorganic and organic species within a paint cross section at micrometer-level spatial resolution makes it a uniquely qualified analytical technique to aid in further understanding the processes of pigment and binder alteration, as well as pigment-binder interactions. In this study, ToF-SIMS was used to detect and image both molecular and elemental species related to CdS pigment and binding medium alteration on the painting Le Bonheur de vivre (1905-1906, The Barnes Foundation) by Henri Matisse. Three categories of inorganic and organic components were found throughout Le Bonheur de vivre and co-localized in cross-sectional samples using high spatial resolution ToF-SIMS analysis: (1) species relating to the preparation and photo-induced oxidation of CdS yellow pigments (2) varying amounts of long-chain fatty acids present in both the paint and primary ground layer and (3) specific amino acid fragments, possibly relating to the painting's complex restoration history. ToF-SIMS's ability to discern both organic and inorganic species via cross-sectional imaging was used to compare samples collected from Le Bonheur de vivre to artificially aged reference paints in an effort to gather mechanistic information relating to alteration processes that have been previously explored using µXANES, SR-µXRF, SEM-EDX, and SR-FTIR. The relatively high sensitivity offered by ToF-SIMS imaging coupled to the high spatial resolution allowed for the positive identification of degradation products (such as cadmium oxalate) in specific paint regions that have before been unobserved. The imaging of organic materials has provided an insight into the extent of destruction of the original binding medium, as well as identifying unexpected organic materials in specific paint layers.

Safety of an ED High-Dose Opioid Protocol for Sickle Cell Disease Pain.

INTRODUCTION: A nurse-initiated high dose, opioid protocol for vaso-occlusive crisis (VOC) was implemented. Total intravenous morphine sulfate equivalents (IVMSE) in mgs] and safety was evaluated. METHODS: A medical record review was conducted for all ED visits in adult patients with VOC post protocol implementation. Opioids doses and routes administered during the ED stay, and six hours into the hospital admission were abstracted and total IVMSE administered calculated. Oxygen saturation (SPO2), respiratory rate (RR), administration of naloxone or vasoactive medications, evidence of respiratory arrest, or any other types of resuscitation effort were abstracted. A RR of <10 or SPO2 <92% were coded as abnormal. Descriptive statistics report the total dose. Logistic regression was used to predict abnormal events. Predictors were age, gender, ED dose (10 mg increments) administered, and time from 1st dose to discharge from ED. RESULTS: 72 patients, 603 visits, 276 admitted. The total (ED & hospital dose) mean (95% CI) mg IVMSE administered for all visits was 93 mg (CI 86, 100), ED visit 63 mg (CI 59, 67) and hospital 66 mg (CI 59, 72). The mean (SD) time from administration of 1st analgesic dose to discharge from the ED was 203 (143) minutes, (range = 30-1396 minutes). During two visits, patients experienced a RR <10; while 61 visits were associated with a SPO2 <92%. No medications were administered, or resuscitative measures required. Controlling for demographics and evaluated at the average total ED dose, the longer patients were in the ED, patients were 1.359 times more likely to experience an abnormal vital sign. Controlling for demographics and evaluated at the average total time in the ED, for every 10 mg increase in IVMSE, patients were 1.057 times more likely to experience an abnormal vital sign. The effect of ED dose on the odds of experiencing an abnormal vital sign decreased by a multiplicative factor of 0.0970 for every 1 hour increase in time until discharge. The larger the dose administered in less time, the more likely patients experienced an abnormal vital sign. DISCUSSION: High opioid doses were safely administered to patients with sickle cell disease.

Healing efficacy and participant outcomes of chemical matrixectomies using a hydrogel containing oakin.

BACKGROUND: We sought to demonstrate the healing efficacy of an antimicrobial hydrogel containing Oakin, an oak extract, to heal postoperative partial and total chemical matrixectomies. METHODS: Sixty participants were eligible for this open-label prospective study by having an ingrown toenail and a willingness to have the ingrown portion of the nail or the entire toenail permanently removed. All of the participants underwent a similar nail surgery, were provided a postoperative kit that included the study hydrogel, and received the same sheet of instructions for aftercare. RESULTS: Fifty-four participants could be contacted for follow-up and final evaluation; 54% (n = 29) were men and 46% (n = 25) were women. Eighty-nine partial hallux nail avulsions with phenol matrixectomy were performed. The median ± SD time to healing was 7.00 ± 0.00 days for 80% of participants (n = 43) and 8.85 ± 4.15 days for 98% (n = 53). An analysis of variance showed that the proportion healed time trend is significant (F1,53 = 79.265; P < .001). CONCLUSIONS: The study hydrogel's ability to stop phenol's caustic activity is clinically beneficial in phenol matrixectomy aftercare. Providing each participant with a kit that included the same dressing supplies yielded consistent aftercare outcomes and 98% patient satisfaction (n = 53). The findings show that the Oakin-containing hydrogel was efficacious in healing phenol matrixectomies without the need for soaking. Furthermore, we suggest that the study hydrogel could also reduce healing times.

Talk-time in the emergency department: duration of patient-provider conversations during an emergency department visit.

BACKGROUND: Analyses of patient flow through the emergency department (ED) typically focus on metrics such as wait time, total length of stay (LOS), or boarding time. Less is known about how much interaction a patient has with clinicians after being placed in a room, or what proportion of their in-room visit is also spent waiting. OBJECTIVE: Our aim was to assess the proportion of time that a patient spent in conversation with providers during an ED visit. METHODS: Seventy-four audio-taped encounters of patients with low-acuity diagnoses were analyzed. Recorded ED visits were edited to remove downtime. The proportion of time the patient spent in conversation with providers (talk-time) was calculated as follows: (talk-time = [edited audio time/{LOS - door-to-doctor time}]). RESULTS: Participants were 46% male; mean age was 41 years (standard deviation 15.7 years). Median LOS was 126 min (interquartile range [IQR] 96 to 163 min), median time in a patient care area was 76 min (IQR 55 to 122 min). Median time in conversation with providers was 19 min (IQR 14 to 27 min), corresponding to a talk-time percentage of 24.9% (IQR 17.8%-35%). Multivariable regression analysis revealed that patients with older age, longer visits, and those requiring a procedure had more talk-time: total talk-time = 13 s + 9 s × (total time in room in minutes) + 8 s × (years in age of patient) + 482 s × (procedural diagnosis). CONCLUSIONS: Approximately 75% of a patient's time in a care area is spent not interacting with providers. Although some of the time waiting is out of the providers' control (eg, awaiting imaging studies), this significant downtime represents an opportunity for both process improvement efforts and innovative patient-education efforts to make use of remaining downtime.

Development of a screening and brief intervention and referral for treatment for ED patients at risk for undiagnosed hypertension: a qualitative study.

INTRODUCTION: Providing a screening, brief intervention, and referral for treatment (SBIRT) may encourage patients to obtain provider follow-up for definitive evaluation and treatment of undiagnosed hypertension (HTN). The aims of this study were to determine characteristics of an intervention that would persuade patients to follow-up with a primary care physician for further blood pressure (BP) evaluation, and encourage ED clinicians to provide an SBIRT for patients with elevated BP with no known history of HTN. METHODS: Qualitative methods were used to analyze individual interviews with ED clinicians and patients. Questions focused on participants' opinions of the meaning of elevated BP, and facilitators and barriers to recommending referral for follow-up (clinicians) or facilitators and barriers to making and keeping a follow-up appointment (patients). Three reviewers coded the interviews using grounded theory. RESULTS: Clinicians identified time constraints and patient-specific factors such as difficulty securing follow-up as major barriers. Some clinicians considered an electronic reminder as a potential facilitator to providing counseling. Patients reported family support and information about complications of uncontrolled HTN such as stroke would increase the likelihood of follow-up. Patient-specific barriers to follow-up included inability to obtain time off from work, forgetfulness, and wait time for an appointment. CONCLUSIONS: An SBIRT-HTN could be developed to target patients with elevated BP during an ED visit. The intervention must be simple, easy to implement, and include automated processes to remind clinicians to deliver the intervention. The intervention should include a description of the complications of untreated HTN and an outpatient physician referral.

SR-FTIR imaging of the altered cadmium sulfide yellow paints in Henri Matisse's Le Bonheur de vivre (1905-6)--examination of visually distinct degradation regions.

SR-FTIR imaging has been used to map the mid-IR active photo-degradation phases in two thin sections of cadmium yellow paint removed from Henri Matisse's Le Bonheur de vivre (1905-1906, The Barnes Foundation). These samples represent both the darkened cadmium yellow foliage in the upper left of the work and the lightened cadmium yellow field beneath the central reclining figures. The altered cadmium yellow paints from both regions were found to contain cadmium carbonate (CdCO3), cadmium sulphate (CdSO4), and cadmium oxalate (CdC2O4). Each of these phases was imaged to determine their positions as a function of depth, with the aim of better understanding the role of each phase in the degradation mechanism. This speciation mapping is critical because cadmium oxalate was used in this period as an additive in cadmium yellow light. In addition, cadmium carbonate and cadmium sulphate were synthesis starting materials for cadmium yellow, and so their distribution throughout the paint layer can provide an indication of their roles. It was established that cadmium oxalate is localized at the surface of the paint layer, cadmium carbonate is found deeper in the layer but still enriched at the surface, and cadmium sulphate is distributed throughout the layer. This distribution, along with the chloride content of the paint suggesting a cadmium chloride starting material, is consistent with an alteration mechanism in which the cadmium sulphide is oxidized to sulphate and this is then converted to carbonate and oxalate. The relative solubilities of the three photo-degradation products are also relevant to their locations in the paint film.

Understanding patient-provider conversations: what are we talking about?

OBJECTIVES: Effective patient-provider communication is a critical aspect of the delivery of high-quality patient care; however, research regarding the conversational dynamics of an overall emergency department (ED) visit remains unexplored. Identifying both patterns and relative frequency of utterances within these interactions will help guide future efforts to improve the communication between patients and providers within the ED setting. The objective of this study was to analyze complete audio recordings of ED visits to characterize these conversations and to determine the proportion of the conversation spent on different functional categories of communication. METHODS: Patients at an urban academic ED with four diagnoses (ankle sprain, back pain, head injury, and laceration) were recruited to have their ED visits audio recorded from the time of room placement until discharge. Patients were excluded if they were age < 18 years, were non-English-speaking, had significant history of psychiatric disease or cognitive impairment, or were medically unstable. Audio editing was performed to remove all silent downtime and non-patient-provider conversations. Audiotapes were analyzed using the Roter Interaction Analysis System (RIAS). RIAS is the most widely used medical interaction analysis system; coders assign each "utterance" (or complete thought) spoken by the patient or provider to one of 41 mutually exclusive and exhaustive categories. Descriptive statistics were calculated for all 41 categories and then grouped according to RIAS standards for "functional groupings." The percentage of total utterances in each functional grouping is reported. RESULTS: Twenty-six audio recordings were analyzed. Patient participants had a mean (±SD) age of 38.8 (±16.0) years, and 30.8% were male. Intercoder reliability was good, with mean intercoder correlations of 0.76 and 0.67 for all categories of provider and patient talk, respectively. Providers accounted for the majority of the conversation in the tapes (median = 239 utterances, interquartile range [IQR] = 168 to 308) compared to patients (median = 145 utterances, IQR = 80 to 198). Providers' utterances focused most on patient education and counseling (34%), followed by patient facilitation and activation (e.g., orienting the patient to the next steps in the ED or asking if the patient understood; 30%). Approximately 15% of the provider talk was spent on data gathering, with the majority (86%) focusing on biomedical topics rather than psychosocial topics (14%). Building a relationship with the patient (e.g., social talk, jokes/laughter, showing approval, or empathetic statements) constituted 22% of providers' talk. Patients' conversation was mainly focused in two areas: information giving (47% of patient utterances: 83% biomedical, 17% psychosocial) and building a relationship (45% of patient utterances). Only 5% of patients' utterances were devoted to question asking. Patient-centeredness scores were low. CONCLUSIONS: In this sample, both providers and patients spent a significant portion of their talk time providing information to one another, as might be expected in the fast-paced ED setting. Less expected was the result that a large percentage of both provider and patient utterances focused on relationship building, despite the lack of traditional, longitudinal provider-patient relationships.

Cardiovascular outcomes and the physical and chemical properties of metal ions found in particulate matter air pollution: a QICAR study.

BACKGROUND: This paper presents an application of quantitative ion character-activity relationships (QICAR) to estimate associations of human cardiovascular (CV) diseases (CVDs) with a set of metal ion properties commonly observed in ambient air pollutants. QICAR has previously been used to predict ecotoxicity of inorganic metal ions based on ion properties. OBJECTIVES: The objective of this work was to examine potential associations of biological end points with a set of physical and chemical properties describing inorganic metal ions present in exposures using QICAR. METHODS: Chemical and physical properties of 17 metal ions were obtained from peer-reviewed publications. Associations of cardiac arrhythmia, myocardial ischemia, myocardial infarction, stroke, and thrombosis with exposures to metal ions (measured as inference scores) were obtained from the Comparative Toxicogenomics Database (CTD). Robust regressions were applied to estimate the associations of CVDs with ion properties. RESULTS: CVD was statistically significantly associated (Bonferroni-adjusted significance level of 0.003) with many ion properties reflecting ion size, solubility, oxidation potential, and abilities to form covalent and ionic bonds. The properties are relevant for reactive oxygen species (ROS) generation, which has been identified as a possible mechanism leading to CVDs. CONCLUSION: QICAR has the potential to complement existing epidemiologic methods for estimating associations between CVDs and air pollutant exposures by providing clues about the underlying mechanisms that may explain these associations.

Patient input into the development and enhancement of ED discharge instructions: a focus group study.

OBJECTIVES: Previous research indicates that patients have difficulty understanding ED discharge instructions; these findings have important implications for adherence and outcomes. The objective of this study was to obtain direct patient input to inform specific revisions to discharge documents created through a literacy-guided approach and to identify common themes within patient feedback that can serve as a framework for the creation of discharge documents in the future. METHODS: Based on extensive literature review and input from ED providers, subspecialists, and health literacy and communication experts, discharge instructions were created for 5 common ED diagnoses. Participants were recruited from a federally qualified health center to participate in a series of 5 focus group sessions. Demographic information was obtained and a Rapid Estimate of Adult Literacy in Medicine (REALM) assessment was performed. During each of the 1-hour focus group sessions, participants reviewed discharge instructions for 1 of 5 diagnoses. Participants were asked to provide input into the content, organization, and presentation of the documents. Using qualitative techniques, latent and manifest content analysis was performed to code for emergent themes across all 5 diagnoses. RESULTS: Fifty-seven percent of participants were female and the average age was 32 years. The average REALM score was 57.3. Through qualitative analysis, 8 emergent themes were identified from the focus groups. CONCLUSIONS: Patient input provides meaningful guidance in the development of diagnosis-specific discharge instructions. Several themes and patterns were identified, with broad significance for the design of ED discharge instructions.

Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest?

OBJECTIVES: Many patients are discharged from the emergency department (ED) with an incomplete understanding of the information needed to safely care for themselves at home. Patients have demonstrated particular difficulty in understanding post-ED care instructions (including medications, home care, and follow-up). The objective of this study was to further characterize these deficits and identify gaps in knowledge that may place the patient at risk for complications or poor outcomes. METHODS: This was a prospective cohort, phone interview-based study of 159 adult English-speaking patients within 24 to 36 hours of ED discharge. Patient knowledge was assessed for five diagnoses (ankle sprain, back pain, head injury, kidney stone, and laceration) across the following five domains: diagnosis, medications, home care, follow-up, and return instructions. Knowledge was determined based on the concordance between direct patient recall and diagnosis-specific discharge instructions combined with chart review. Two authors scored each case independently and discussed discrepancies before providing a final score for each domain (no, minimal, partial, or complete comprehension). Descriptive statistics were used for the analyses. RESULTS: The study population was 50% female with a median age of 41 years (interquartile range [IQR] = 29 to 53 years). Knowledge deficits were demonstrated by the majority of patients in the domain of home care instructions (80%) and return instructions (79%). Less frequent deficits were found for the domains of follow-up (39%), medications (22%), and diagnosis (14%). Minimal or no understanding in at least one domain was demonstrated by greater than two-thirds of patients and was found in 40% of cases for home care and 51% for return instructions. These deficits occurred less frequently for domains of follow-up (18%), diagnosis (3%), and medications (3%). CONCLUSIONS: Patients demonstrate the most frequent knowledge deficits for home care and return instructions, raising significant concerns for adherence and outcomes.

Emergency Department Discharge Instructions: Lessons Learned through Developing New Patient Education Materials.

Our multidisciplinary team developed a new set of discharge instructions for five common emergency department diagnoses using recommended tools for creating literacy-appropriate and patient-centered education materials. We found that the recommended tools for document creation were essential in constructing the new instructions. However, while the tools were necessary, they were not sufficient. This paper describes the insights gained and lessons learned in this document creation process.