Reducing Pediatric ED Wait Times Through Discharge Education

Background to the Problem

Every year, over 35 million discharges occur across the United States' hospital network (Alper et al., 2022). The process of discharging a patient from a hospital is complicated, as it makes families and patients responsible for coordinating their own care. In an ideal transition of care, the healthcare provider prepares the patient by adequately communicating crucial discharge information on medication, side effects, and when to schedule follow-ups, guided by the patient's health status and health literacy levels (Bajorek & McElroy, 2020). Studies have associated effective discharge education with greater medication compliance and lower readmission and mortality risks (Boden-Albala et al., 2018; deJong et al., 2020). For instance, deJong et al. (2020) found that a quality improvement bundle that included enhanced discharge information and follow-up reduced readmission rates in a pediatric hospital from 10 percent to 7.4 percent over a four-month period.

Unfortunately, healthcare providers may not always be in a position to predict a patient's discharge day, so in most cases discharges are conducted in an unstandardized and rushed manner on the day of discharge (Bajorek & McElroy, 2020). Patients mostly receive a large volume of new information explained hurriedly, with little consideration for their health status or health literacy levels (Boden-Albala et al., 2018). In most cases, healthcare providers use health-related jargon to explain medication side effects and indications, which patients may not understand or may find difficult to remember (Boden-Albala et al., 2018). Emergency Department (ED) patients and caregivers typically receive discharge information across four domains: ED-based care, diagnosis and cause, instructions on when to return, and post-ED care (Boden-Albala et al., 2018). In one study, researchers interviewed 140 English-speaking caretakers and patients upon release from the ED to assess how well they understood the discharge instructions they had received (Boden-Albala et al., 2018). The study found that fewer than 15 percent of respondents had understood all four domains of ED discharge instructions (Boden-Albala et al., 2018).

Poor understanding of discharge instructions is associated with unintended hospital revisits, a greater risk of readmission, and decreased patient satisfaction (Boden-Albala et al., 2018). Statistics indicate that 1 in 5 Medicaid patients in the US returns to hospital within 30 days of discharge. Cumulatively, readmissions alone account for approximately $42 billion in health spending annually.

Problem Statement and Resolution Strategy

The main problem at the selected Pediatric Emergency Department (PED) is extended wait times resulting from increases in the number of patients returning within two weeks of discharge. According to the nurse manager at the PED, over 65 percent of patients return within 14 days of discharge for complications listed in their discharge instructions, or for concerns expected in their diagnosis within the natural time frame of the illness — such as fever. The primary reason is that providers and nurses are not taking the time to effectively use discharge tools and educate patients at discharge. The result has been declining patient satisfaction, as shown by quarterly patient surveys. Patients have had to wait as long as four hours, and management is concerned that if the problem is not addressed, it could result in patients leaving without receiving care.

Bajorek and McElroy (2020) identify several risk factors that drive poor transitions and ineffective delivery of discharge education in healthcare settings. First, healthcare providers often rush the discharge process, overestimating the patient's health literacy, social determinants of health, and readiness to learn (Bajorek & McElroy, 2020). Additionally, caregivers or family members may not be adequately involved in discharge planning and education efforts (Bajorek & McElroy, 2020), meaning they may not understand medication names, side effects, indications, diagnosis, or the reasons for scheduling a follow-up appointment. A third risk factor is that discharge instructions and education are often provided by different healthcare providers who may use different terminology, causing confusion among patients (Bajorek & McElroy, 2020).

Strategies that address these factors can be categorized as post-discharge, pre-discharge, or bridging interventions (Alper et al., 2022). Pre-discharge interventions include medication reconciliation, discharge planning, patient education, and scheduling of follow-up appointments (Alper et al., 2022). Common post-discharge interventions include home visits and regular follow-up phone calls, while bridging interventions include clinician continuity between outpatient and inpatient settings and the use of transition coaches (Alper et al., 2022).

The purpose of the proposed project is to reduce the number of reoccurring visits resulting from ineffective discharge instructions by 50% over the next six months by implementing a program that incorporates enhanced pre-discharge education and post-discharge follow-up phone calls. The projected goal is to reduce patient wait times to less than one hour, thereby reducing the number of patients who leave without care and ultimately increasing patient satisfaction.

The project uses the IOWA Model of Evidence-Based Practice to guide the proposed intervention. The IOWA model was selected for two reasons. First, it effectively guides healthcare professionals at the PED to identify lack of proper patient education at discharge as a source of reoccurring visits, to select adequate pre- and post-discharge evidence-based interventions, to implement and evaluate those interventions, and finally to integrate them into daily practice (Cullen et al., 2022). Second, the IOWA model includes a stage of evidence appraisal, which ensures that healthcare providers use the best available evidence for clinical decision-making (Cullen et al., 2022).

Using the IOWA model, the project will implement an enhanced discharge education program that gives patients a workbook and instructional videos emphasizing the four domains of ED discharge instructions: ED-based care, diagnosis and cause, instructions on when to return, and post-ED care. The videos will educate patients on three crucial skills: physician-patient communication, medication adherence, and risk reduction. Additionally, providers will make follow-up calls to patients at 72 hours, 2 weeks, 1 month, and 3 months after discharge to assess their progress. Both interventions are adapted from Boden-Albala et al. (2018) and were found to be effective in reducing vascular risk among patients discharged from the ED.

Literature Review

Researchers have conducted several studies to assess the effectiveness of pre-discharge, post-discharge, and bridging discharge interventions in reducing the risk of reoccurring patient visits resulting from poor discharge education. In one such study, Boden-Albala et al. (2018) conducted a randomized controlled trial to test the efficacy of a discharge program that combined enhanced discharge education facilitated by a community health nurse with post-discharge follow-up phone calls in reducing vascular risk among patients with stroke and transient ischemic attacks. The 1,089 sampled patients visiting four New York-based facilities were randomized into control or treatment groups. The control group received usual discharge care, while the treatment group received a video and workbook emphasizing three skills — physician-patient communication, medication adherence, and risk reduction — in addition to post-discharge follow-up phone calls. The results showed clinically significant differences in blood pressure reduction between the two groups, supporting the conclusion that enhanced discharge education and follow-up phone calls significantly reduce vascular risk upon discharge.

In a similar study, deJong et al. (2020) conducted a quality improvement longitudinal study to assess the efficacy of enhanced discharge education and post-discharge follow-up in reducing 30-day readmission rates among pediatric patients. A comparison of pre- and post-intervention readmission rates found a reduction of 2.6%, from 10.3% prior to implementation to 7.4% after implementation. The study concluded that pre-discharge planning and education, combined with post-discharge follow-up and access to a transition clinic, significantly reduced readmission rates among pediatric patients.

Other studies have focused on specific discharge education strategies. Hodges et al. (2021) conducted a prospective non-randomized controlled trial to test the effectiveness of the teach-back method of delivering discharge education — a technique in which patients are asked to explain in their own words the key information about their health. Adopting a longitudinal design, the study found that 61% of patients were satisfied when the provider used the teach-back method, compared to 59% when standard education techniques were used (Hodges et al., 2021). The researchers concluded that the teach-back method may improve patient satisfaction when used in delivery of discharge education.

Other studies have focused exclusively on post-discharge strategies. Fruhan and Bills (2022) implemented a call-back program involving follow-up calls to patients after discharge from the ED. Among 8,810 participants randomized into control and treatment groups, odds ratio analysis showed that the odds of revisits and readmission were significantly lower for the intervention group, as those patients were more likely to understand their discharge plan, obtain their medications, and successfully schedule follow-up appointments with healthcare providers.

Taken together, this evidence supports the combined use of pre- and post-discharge interventions. The proposed project therefore incorporates both enhanced discharge education and a follow-up call-back program to reduce reoccurring visits attributable to inadequate information at discharge.

Conclusion

The proposed project seeks to address the problem of extended wait times resulting from increased reoccurring visits due to inadequate patient education at discharge. According to the nurse manager, discharges are mostly carried out in a rushed manner and patients often receive large amounts of new information that they are unable to memorize. The result is a high number of reoccurring visits for concerns that fall within the expected course of a patient's diagnosis — such as fever — which drives extended wait times and patient dissatisfaction. The project seeks to streamline the discharge process by implementing an enhanced discharge education program and a post-discharge call-back program at the PED.

The purpose of the proposed project is to reduce the number of reoccurring visits resulting from ineffective discharge instructions by 50% over the next six months. Ultimately, this will reduce patient wait times to less than one hour, thereby reducing the number of patients who leave without care and, consequently, increasing patient satisfaction.

Alper, E., O'Malley, T., & Greenwald, J. (2022). Hospital discharge and readmission. UpToDate. https://www.uptodate.com/contents/hospital-discharge-and-readmission

Bajorek, S. A., & McElroy, V. (2020). Discharge planning and transitions of care. Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-care

Boden-Albala, B., Goldmann, E., Parikh, N. S., Carman, H., Roberts, E. T., Lord, A. S., Torrico, V., Appleton, N., Birkemeir, J., Parides, M., & Quarles, M. (2018). Efficacy of a discharge educational strategy versus standard discharge care on reduction of vascular risk in patients with stroke and transient ischemic attacks: The DESERVE randomized controlled trial. JAMA Neurology, 76(1), 20–27.

Cullen, L., Hanrahan, K., Farrington, M., Tucker, S., & Edmonds, S. (2022). Evidence-based practice in action: Comprehensive strategies, tools, and tips from University of Iowa Hospitals & Clinics. Sigma Theta Tau.

deJong, N. A., Kimple, K., Morreale, M., Han, S., Davis, D., & Steiner, M. J. (2020). A quality improvement intervention bundle to reduce 30-day pediatric readmissions. Pediatric Quality & Safety, 5(2), e264.

Fruhan, S., & Bills, C. B. (2022). Association of a call-back program with emergency department (ED) revisit rates among patients seeking emergency care. JAMA Network Open, 5(5), e2213154.

Hodges, R., Stepien, S., & Kim, L. Y. (2021). Quality improvement: Using the teach-back to improve patient satisfaction during discharge in the emergency department. Journal of Emergency Nursing, 1(1), 1–9.

Powell, B. J., Fernandez, M. E., Williams, N. J., Aarons, G. A., Beidas, R. S., Lewis, C. C., McHugh, S. M., & Weiner, B. J. (2019). Enhancing the impact of implementation strategies in healthcare: A research agenda. Frontiers in Public Health, 7(3), 19–26. https://doi.org/10.3389

Rortveit, K., Hansen, B. S., Joa, I., Lode, K., & Severinsson, E. (2020). Qualitative evaluation in nursing interventions — A review of the literature. Nursing Open, 7(5), 1285–1298.