Running head: SYNTHESIS PAPER

Synthesis Paper
Eduardo Alegria
University of South Florida

SYNTHESIS PAPER

2
Abstract

The quality of the education that is delivered to patients in any hospital, especially during
discharge, is one of the most imperative parts of the patient-centered care process. Therefore,
healthcare providers must contribute to this critical component by making themselves easily
understood. When patients are being discharged from the hospital they receive paperwork and
explanations summarizing treatments and procedures received during their stay as well as
instructions for at-home care. These written materials may also include follow-up care
appointments as well as medication management and/or symptoms to monitor. How can we
improve a patients understanding and compliance of hospital discharge instructions? How can
we assist the healthcare provider better administer these hospital discharge instructions? For
adult hospitalized patients (P) how does recording discharge instructions (I) compared to verbal
instructions with supplemental take-home written materials (C) affect patient compliance and
understanding rates (O) as measured by telephonic follow-up calls three to five days post
hospital discharge (T)? This Evidence Based Practice (EBP) synthesis paper contains the
following search engines: Google Scholar, PubMed, and Cochrane, with key words such as
Randomized controlled trials (RCT) for hospital discharge materials, standardized discharge
materials, emergency room RCT discharge materials, follow up, and telephonic survey. Several
RCTs using standardized or video discharge instructions, with follow-up phone calls
approximately three to five days afterwards, resulted in higher understanding, patient
compliance, and overall satisfaction. These results formulate a strong argument for converting
traditional discharge practices into use of more standardized written materials or video
recordings with follow-up calls to validate patient compliance and understanding as best EBP
guidelines.

SYNTHESIS PAPER

Synthesis Paper
Quality patient education is critical to a successful treatment outcome. Therefore, there is
always room for improvement in this area. For example, when patients are being discharged
from the hospital, the information they receive may not be presented in a standardized manner.
Often lacking is a method for verifying a patient has good understanding of instructional
materials received. The magnitude alone of instructional materials received may be
overwhelming during a stressful time while the patient is typically not mentally engaged or
physically feeling well (Bloch, S., & Bloch, A., June 2013). Furthermore, a caregiver or loved
one who may be present to assist might not fully grasp the materials provided. Additionally, the
healthcare provider him/herself may be pushed for time and/or overworked with several patients
on an existing caseload, yet must adequately prepare a patient for hospital discharge. With these
factors in mind, a challenge exists all the way around to provide adequate instructional materials
while verifying the patient or caregiver has full comprehension of all discharge expectations.
How can we improve a patients understanding and compliance of hospital discharge
instructions? How can we assist the healthcare provider to better administer these hospital
discharge instructions? Therefore, for adult hospitalized patients (P) how does recording
discharge instructions (I) compared to verbal instructions with supplemental take-home written
materials (C) affect patient compliance and understanding rates (O) as measured by telephonic
follow-up calls three to five days post hospital discharge (T)?
Literature Search
Several search engines were used in the conduct of this Evidence Based Practice (EBP)
synthesis paper: Google Scholar, PubMed, and Cochrane. The key words/terms that were used
included: Randomized controlled trials (RCT) for hospital discharge materials, standardized
discharge materials, emergency room RCT discharge materials, follow up, telephonic survey, and

SYNTHESIS PAPER

telephonic follow up questionnaires. These search term and phrase examples yielded the
following sites/reference materials: ncbi.nlm.nih.gov (PLOSONE.org), onlinelibrary.wiley
(Pediatric Emergency Care), journals.lww (Academic Emergency Medicine).
Literature Review
Healthcare providers commonly discuss that their patients do not always fully understand
hospital discharge materials and expectations, and may not be fully compliant, for a variety of
reasons addressed previously. Depending on the department and/or hospital, patients may
receive instructions in various ways, including but not limited to the following: verbal
instructions presented by a nurse, written instructions presented with a brief verbal explanation,
written paperwork inclusive of some pictures, verbal and/or written explanations summarizing
treatments and procedures received during the patients stay, instructions for at-home care, verbal
or written instructions for appropriate cause for concern and immediate follow-up, expected
follow-up care appointments with a primary care provider, verbal or written materials regarding
routine follow-up care information such as medication management and/or symptoms to monitor.
Furthermore, caregivers or loved ones present to help the patient might not fully grasp the
materials provided for a variety of reasons (life stressors, language barriers, lack of full
understanding of the patients medical situation, discharge logistics, etc.). Lastly, perhaps the
healthcare provider is unable to clearly and concisely present discharge materials due to patient
workload and/or a lack of standardized discharge materials.
Therefore, to improve the healthcare providers abilities to present appropriate discharge
materials as well as improve a patients understanding and compliance with discharge
instructions, several organizations have begun use of video recordings and/or standardized
diagnoses-specific discharge instructions, in conjunction with subsequent phone follow-up
questionnaires.

SYNTHESIS PAPER

Bloch, S. & Bloch, A., (2013) reported that previous studies have demonstrated patients
do not always understand discharge information. They designed a study to assess if video
recordings would help caregivers (N=436) of a pediatric emergency room population (aged 29
days -18 years diagnosed with fever, vomiting, diarrhea, and wheezing or asthma) better
understand the treatment plan and follow-up care rather than just receiving the standard of care
with limited physician interaction and written instructions. The patients caregivers that watched
a recorded three-minute video (n=216) felt that it was a lot more helpful than those that had to
read the written orders (n=220). In fact, questionnaire results about the interactive methodologies
found the following: of the 341 caregivers completing a follow-up questionnaire, the video
discharge instruction group had significantly higher scores both in the emergency department
(12.2 vs 8.9) (p=0.0001) as well as when questioned two to five days after discharge (11.1 vs
7.8). 29% (8.4-9.4) (p<0.005) of the written instruction group rated the instructions as
extremely helpful whereas 42% of the video instruction group rated discharge materials as
extremely helpful. A strength of this study was that the caregivers and the two groups were
randomly selected. The weakness of this study was that it was only restricted to English
speakers and that the researchers assistant may have introduced bias to the caregivers prior to
the research.
Yet another study conducted in a different emergency department evaluated video
instructions to determine if this would be a better mode for information administration due to the
crowded environment and often short interaction time with physicians. Atzema, C. et. al. (2013)
chose a group of thirty-eight diagnoses and enrolled 133 patients, mean age of 46.1 with 55%
being female, for random grouping into either an online video viewing or usual standard of care
written discharge materials. Patients were then contacted by phone and asked three questions

SYNTHESIS PAPER

about the instructions received. A secondary satisfaction measure was also utilized by using a
ten-point scale. Patients in the online video viewing group had a 19% higher mean score than
patients in the standard of care control group. Additionally, the video viewing group rated the
videos as ten on a ten-point scale for helpfulness. The strengths of this research were that
thirty-eight different discharge diagnoses videos were pre-made before the study, the scripts were
pilot-tested & corrected, and reasons for patients not completing this RCT were explained and
analyzed into this research data. The weaknesses of this research study were that the study
occurred only at one site, the diagnoses were not dictated by the study, and this study was only
conducted in English.
In a third study conducted by Biese, K., et. al. (2014), the authors believe elderly patients
may have a more difficult time understanding discharge materials after visiting an emergency
department. Therefore, they conducted a randomized controlled clinical trial of 120 patients ages
65 and older, 60% female, 72% white, with a mean age of 75 years. The authors created groups
of either intervention (n=39), placebo (n=35), or the control (n=46). The intervention group
received a nurses call approximately three days post discharge, asking about the patients
understanding of all discharge materials, the discharge/treatment plan, and current symptoms.
The placebo group received a nurses follow-up for a patient satisfaction survey call of their
hospital stay and discharge experience. The control group did not receive a phone call of any
type. Chi-square and Fishers exact tests were utilized on the data. The intervention group
remembered to follow-up, as instructed, with their Primary Care Physician within five days of
discharge (p=0.04). The strengths were that patients were randomly selected and reasons for
patients not completing the trial were analyzed. However, the study was only performed at one

SYNTHESIS PAPER

site and patients were randomized after leaving the emergency department, which could have
introduced bias.
Synthesis
The study designed by Bloch, S. & Bloch, A. (2013), which used video recordings for
better understanding of treatment plans and instructions post discharge, followed up with phone
calls, was similar to findings by Atzema, C. et. al. (2013). These authors evaluated either online
video viewing or usual standard of care written discharge materials, followed up by a phone call.
Lastly, telephone call follow up care after hospital video viewing was also used in the conduct of
a study by Biese, K., et. al. (2014). The authors of these studies found results encouraging
because they feel medical management continues beyond the emergency room visit with
instructions received for self-care, with follow up requirements being critical to prevent repeat
visits due to complications. While it is important to provide good discharge instructions, it is
often time prohibitive in an emergency room environment. If healthcare providers know a video
is being recorded and a follow-up survey will be administered regarding quality of care, they
may be more likely to provide clear, concise directions, and solicit better feedback from patients
regarding their understanding of all discharge instructions. All three studies discussed above had
positive findings with regards to the use of video discharge and pre-written materials as
documented by follow-up phone calls.
Clinical Recommendations
All three studies attempted to standardize discharge instructions to enable a more
understandable presentation of informational materials. Additionally, all three studies used
telephonic follow-up to measure the actual caregivers or patient populations understanding,
compliance, and or overall experience. While the three studies were not performed in the same
facility or with the same patient population, they all found that standardized materials presented

SYNTHESIS PAPER

by video, on-line recordings, and or talking points, followed up by a phone call in approximately
three to five days resulted in measurably higher understanding, patient compliance, and overall
satisfaction with the hospital discharge experience.
These studies represent a growing body of literature and common consensus in the
healthcare arena that hospital discharge materials, when supported by video recordings and
follow-up phone calls, improve both the healthcare providers abilities to distribute important
information as well as the patients abilities to better comprehend and comply with instructions
as warranted. The RCTs provided evidence that these techniques promote strong arguments to
formulate evidence based practice guidelines for providing and presenting hospital discharge
informational materials.

SYNTHESIS PAPER

9
Annotated Bibliography

Atzema, C., Austin, P., Wu, L., Brzozowski, M., Feldman, M., McDonnell, M., & Mazurik, L.
(November 2013). Speak fast, use jargon, and dont repeat yourself: A randomized trial
assessing the effectiveness of online videos to supplement emergency department
discharge instructions. PLOSONE.org.8(8). e77057
Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3823877/
The authors conducted a randomized trial assessing the effectiveness of online videos to
supplement educational discharge instructions for patients understanding and ability to
remember information received. Patients randomly selected fell into thirty-eight specific
diagnoses and were again randomly placed in a video viewing group or to the usual
standard of care group. The video group was given access to online videos specific to
their diagnosis for viewing after leaving the emergency department. Trial analysis
revealed the video group had a 19% higher score than the control group (p=0.002). The
authors believe that appropriate medical management continues after a patient leaves the
emergency department in order to continue self-care, proper follow-up, and mitigate the
need for return visits due to complications or misunderstandings. The authors further
emphasized that comprehension is the major predictor of compliance with discharge
instructions.
Biese, K., M., Lamantia, F., Shofer, B., Mccall, E., Roberts, S., C. Stearns, S., Principe,
J., S. Kizer, C., B. Cairns, and J., Busby-Whitehead. (2014) "A randomized trial
exploring the effect of a telephone call follow-up on care plan compliance among older
adults discharged home from the emergency department." Academic Emergency
Medicine 21(2) 188-95. Web. Retrieved from

SYNTHESIS PAPER

10

http://onlinelibrary.wiley.com.ezproxy.hsc.usf.edu/doi/10.1111/acem.12308/abstract;jsessi
onid=5526DC685AA6BD29802438B24678C3F4.f01t03>.
The authors believe elderly patients may have a more difficult time understanding
discharge materials after visiting an emergency department. Therefore, they conducted a
randomized controlled clinical trial of 120 patients ages 65 and older, 60% female, 72%
white, with a mean age of 75 years. The authors created groups of either intervention,
placebo, or the control. The intervention group received a nurses call approximately
three days post discharge, asking about the patients understanding of all discharge
materials, the discharge/treatment plan, and current symptoms. The placebo group
received a nurses follow-up for a patient satisfaction survey call of their hospital stay
and discharge experience. The control group did not receive a phone call of any type.
Chi-square and Fishers exact tests were utilized on the data. The intervention group
remembered to follow-up, as instructed, with their Primary Care Physician within five
days of discharge (p=.04).
Bloch, S., & Bloch, A. (June 2013). Using video discharge instructions as an adjunct to standard
written instructions improved caregivers understanding of Their childs emergency
department visit, plan and follow-up: A randomized controlled trial. Pediatric
Emergency Care. 29(6), 699-704. Doi: 10. 1097/PEC.0b013e182955480 Retrieved from
http://journals.lww.com/pec-online/pages/articleviewer.aspx?year=2013
The authors of this randomized controlled trial, report that many studies have indicated
patients and or their caregivers often experienced difficulty comprehending information
received at discharge. They elected to trial video discharge instructions specific to the
emergency department visit diagnoses. The videos were approximately three minutes in

SYNTHESIS PAPER

11

length. The patient population was caregivers of pediatrics. A questionnaire was

administrated after watching the video prior to leaving the emergency department and a
telephone follow-up questionnaire was given between two to five days post-discharge. Of
the 436 caregivers enrolled, 220 received standard written discharge instructions while
216 randomly received the three-minute video. Surveys analyzed revealed statistical
significance by Mann-Whitney U testing (P < 0.05), yielding higher findings of better
understanding with the video both prior to leaving the emergency department and after
receiving the follow-up phone call.