ORIGINAL RESEARCH CONTRIBUTION

Patient Understanding of Emergency

Department Discharge Instructions:
Where Are Knowledge Deficits Greatest?
Kirsten G. Engel, MD, Barbara A. Buckley, RN, Victoria E. Forth, MA, Danielle M. McCarthy, MD,
Emily P. Ellison, MS, Michael J. Schmidt, MD, and James G. Adams, MD

Abstract
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 demon-
strated 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.
ACADEMIC EMERGENCY MEDICINE 2012; 19:1035–1044 ª 2012 by the Society for Academic
Emergency Medicine

From the Department of Emergency Medicine (KGE, VEF, DMM, MJS, JGA) and the Department of General Internal Medicine
(EPE), Northwestern University, Chicago IL; and Northwestern Memorial Hospital (BAR, JGA), Chicago IL.
Received December 7, 2011; revisions received March 7 and April 23, 2012; accepted April 30, 2012.
Presented at the Society for Academic Emergency Medicine, Boston, MA, June 2011.
The Davee Foundation provided funding to support this study.
Supervising Editor: Richard Byyny, MD, MSc.
The authors have no relevant financial information or potential conflicts of interest to disclose.
Address for correspondence and reprints: Kirsten G. Engel, MD; e-mail: kirsten.g.engel@gmail.com.

ª 2012 by the Society for Academic Emergency Medicine ISSN 1069-6563

doi: 10.1111/j.1553-2712.2012.01425.x PII ISSN 1069-6563583 1035
 15532712, 2012, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2012.01425.x by Cochrane Philippines, Wiley Online Library on [26/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1036 Engel et al. • PATIENT UNDERSTANDING OF ED DISCHARGE INSTRUCTIONS

La Comprensión del Paciente de las

Recomendaciones al Alta del Servicio
de Urgencias: ¿Cuáles son los Mayores
Déficits de Conocimiento?
Resumen
Objetivos: Un gran número de pacientes son dados de alta desde el servicio de urgencias (SU) con una
comprensión deficitaria de la información necesaria para un cuidado seguro de sí mismos en el domici-
lio. Los pacientes tienen una dificultad especial en comprender las instrucciones a seguir tras su atención
en el SU (incluyendo fármacos, cuidados en domicilio y seguimiento). El objetivo de este estudio fue
caracterizar estos déficits e identificar las lagunas de conocimiento que pueden situar al paciente en ries-
go de padecer complicaciones u obtener malos resultados.
Método: Se trata de un estudio de cohorte prospectivo basado en una entrevista telefónica a 159 pacien-
tes de habla inglesa entre las 24–36 horas tras el alta del SU. El conocimiento del paciente se valoró en
cinco diagnósticos (esguince de tobillo, dolor de espalda, traumatismo craneal, litiasis renal y heridas) a
través de los siguientes cinco dominios: diagnóstico, fármacos, cuidados en domicilio, seguimiento, e in-
strucciones de alerta para reconsultar a urgencias. El conocimiento se determinó mediante la concor-
dancia entre los recuerdos directos del paciente y las instrucciones al alta en función del diagnóstico
junto con la revisión de la historia clínica. Dos investigadores puntuaron cada caso de forma independi-
ente y discutieron las discrepancias antes de dar una puntuación final para cada dominio (comprensión
nula, mínima, parcial o total). Se realizó un análisis descriptivo de los datos.
Resultados: La población del estudio tenía una mediana de edad de 41 años (rango intercuartílico de 29
a 53 años), y el 50% eran mujeres. La mayoría de los pacientes tenían déficit de comprensión en el domi-
nio de las instrucciones de los cuidados en casa (80%) y en la necesidad de reconsulta a urgencias (79%).
Los déficits menos frecuentes fueron en los dominios de seguimiento (39%), de medicaciones (22%) y de
diagnóstico (14%). La comprensión mínima o nula en al menos un dominio estuvo presente en más de
dos tercios de los pacientes y se encontró en un 40% de los casos para los cuidados en el domicilio y en
un 51% para las instrucciones de reconsulta a urgencias. Estos déficits ocurrieron con menor frecuencia
en los dominios de seguimiento (18%), diagnóstico (3%) y medicaciones (3%).
Conclusiones: Se muestra que los déficits de conocimiento más frecuentes de los pacientes son el cui-
dado en casa y las instrucciones de reconsultar a urgencias, y generan una preocupación cada vez
mayor en cuanto a la adherencia y los resultados.

T
he process of communication between caregivers
and patients is widely recognized as a critical ele-
ment of high-quality patient care in the emer-
gency department (ED).1–10 In particular, there is
increasing emphasis on the importance of information
delivery at ED discharge and its downstream implica-
tions for adherence and outcomes.11–14
Despite the recognition of the importance of commu-
nication, the complex ED environment poses significant
challenges to this process.13,15–17 Previous research
indicates that patients often leave the ED with an
incomplete understanding of their care and instruc-
tions.18–21 The etiology of these deficits is clearly multi-
factorial and reflects problems with both written and
verbal communication. Numerous studies have demon-
strated that written ED discharge instructions often
exceed patients’ health literacy or reading levels.22–24
Two previous studies of audiotaped ED discharge
encounters found that verbal exchange between
patients and providers was very brief (76 seconds on
average for providers and 14 seconds on average for
patients) and often incomplete. Moreover, the authors
found significant variability in content, frequent defi-
ciencies in the information provided, and rare opportu-
nities for patients to ask questions.25,26
Given these significant problems with both written
and verbal communication at ED discharge, it is not
surprising that, in a previous study, members of our
research team found that 78% of patients demonstrated
a comprehension deficit for at least one area of their
ED care and instructions.27 In this previous study, com-
prehension was assessed across four domains (diagnosis
and cause; ED care, including tests and treatments;
post-ED care, including medication, home care, and fol-
low-up instructions; and return to ED instructions) for
patients discharged with any diagnosis. Comprehension
deficits were most common for the domain of post-ED
care and were present in over one-third of patients.27
These findings have significant implications for patient
outcomes, with growing evidence linking discharge
communication with undesirable outcomes.11,13,14,28,29
As a result of ineffective communication, patients often
leave the ED without the knowledge necessary to
properly care for themselves at home.18–20,27,30,31 In

ACADEMIC EMERGENCY MEDICINE • September 2012, Vol. 19, No. 9
turn, patients frequently fail to adhere to their dis-
charge instructions and are at risk for adverse events
and increased resource utilization, including repeat ED
visits and hospitalization.11,12,14,27–29,32–36
To address problems with information delivery at ED
discharge, it is essential to build on previous work by
defining deficits in patients’ understanding of discharge
instructions with greater detail and specificity. In par-
ticular, it is critical to characterize knowledge gaps that
may place patients at risk for complications or poor
outcomes following their ED visits. This detailed insight
will guide effective redesign of ED discharge processes.
For this study, we hypothesized that a majority of
patients would fail to completely understand their dis-
charge instructions and that knowledge deficits would
be most frequent for information falling within the
domain of post-ED care (medication, home care, and
follow-up instructions). Specifically, this study was
designed to build on our previous work27 by assessing
patient understanding of each of the subset compo-
nents of post-ED care separately and determining in
which of these areas (medication, home care, and
follow-up instructions) deficits are most common.
Moreover, this study targeted five common ED diagno-
ses to allow more specific assessments of knowledge
gaps in all areas. This research provides a critical next
step in understanding patients’ unmet needs and how
the discharge process can be improved in the future to
address these needs. By identifying specific areas
where patient knowledge is deficient, this work serves
as a foundation for future efforts to develop and imple-
ment intervention strategies that will effectively
enhance discharge communication and ensure that
patients leaving the ED are well prepared to care for
themselves at home.
METHODS
Study Design
We conducted a prospective cohort study involving
phone interviews of adult English-speaking patients
within 24 to 36 hours after ED discharge. Approval for
this study was obtained from the institutional review
board. All participants verbally consented to study
enrollment.
Study Setting and Population
This study was conducted at an academic urban teach-
ing hospital in Chicago with a census of approximately
85,000 patients per year. Patients discharged from the
ED in the 1-year period beginning April 2010 with one
of five common diagnoses were eligible for enrollment:
ankle sprain, back pain (muscle strain), head injury,
kidney stone, or laceration (closed with staples or
stitches). Exclusion criteria were: non–English-speaking
patients, patients age < 18 years, patients with signifi-
cant psychiatric history, patients with a history of sig-
nificant dementia or cognitive impairment, patients
who were not responsible for their care at home, and
any patient without a phone number listed in the chart.
Patients with a history of significant psychiatric disease,
dementia, or cognitive impairment were identified by
review of the electronic medical record and were
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• www.aemj.org 1037
excluded. Patients who were not responsible for their
care at home were identified during the phone inter-
view with specific questions and subsequently excluded.
Patients with more than one diagnosis were initially
enrolled in the study, as long as at least one diagnosis
was among the five chosen for this study. However,
during the early phase of phone interviews, it was
noted that patients had significant difficulty distinguish-
ing the discharge information for each of the two diag-
noses, and this made it very difficult to accurately
assess knowledge. For this reason, all patients with more
than one diagnosis were excluded from our sample.
Study Protocol
At discharge, patients receive two types of computer-
generated discharge instruction sheets. The first is a
patient-specific document that is completed by the pro-
vider and includes the diagnosis, medications, follow-
up recommendations, and open comments. The second
is a diagnosis-specific sheet that provides additional
information specific to the patient’s discharge diagnosis.
This latter document is a commercially available prod-
uct from a private company that is contracted by our
ED to provide this resource. These commercially avail-
able documents generally contain information regard-
ing diagnosis, home care instructions, and reasons to
return to the ED.
The five diagnoses were chosen by our study team
because they incorporate a diversity of medical condi-
tions with well-established discharge information and
are among the highest frequency discharge diagnoses
in our ED. Five ED nurses received extensive training
in conducting phone interviews with patients during a
pilot phase. Audiotapes from these initial sessions were
reviewed with the nurses to emphasize important skills.
Appropriate patients were identified from an elec-
tronic data warehouse query of chief complaints and
ICD-9 codes for the five diagnoses being studied. Chart
review was performed for each patient on the list to
ensure that they were diagnosed with one of the five
conditions being studied and were eligible for enroll-
ment. Eligible patients were called and verbally
consented to participate. All phone interviews were
audiotaped and then transcribed for review. At the
completion of each interview, nurses reinforced care
recommendations, corrected any errors in the patient’s
responses, and offered to answer additional questions.
The recruitment goal for this study was 170 patients
with approximately 35 per diagnosis. This study is part
of a larger project that will involve an additional assess-
ment of patient knowledge following changes and
improvements to our discharge process. A power
calculation based on findings from our previous study27
indicated that we needed approximately 170 patients
(before and after the intervention) to demonstrate a
meaningful change (15% to 20%) in knowledge among
discharged patients. Ultimately, the recruitment goal of
35 was reached for some diagnoses but not others.
Recruitment was stopped after 159 patients had
been enrolled due to decreased availability of nurse
interviewers.
The audiotaped interviews assessed satisfaction
and understanding of discharge instructions. Nurse
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1038 Engel et al. • PATIENT UNDERSTANDING OF ED DISCHARGE INSTRUCTIONS

interviewers asked scripted questions that were part of
a structured interview guide. The interview guide was
modeled closely after the methodology of our previous
study.27 The patient was first asked three questions
about his or her satisfaction with the visit and the infor-
mation received. The patient was then asked about the
information and instructions he or she received during
the visit. Questions targeted five domains: 1) diagnosis
(‘‘what were you told was wrong with you’’); 2) medica-
tions (‘‘what medications, if any, were you told to
take’’); 3) home care (‘‘were you told to do other things
to take care of this problem besides taking medica-
tion’’); 4) follow-up (‘‘are you supposed to follow-up
with any doctors about this problem’’); and 5) return to
ED instructions (‘‘which symptoms or changes should
cause you to come back to the ED’’). All questions were
open-ended with follow-up prompts to ensure that
patients had the opportunity to provide as much infor-
mation as possible. An additional question was asked
about whether or not the patient had read the dis-
charge instructions. The interview guide was tested
during a pilot phase. Minor changes were incorporated
after the initial pilot phase of data collection, according
to a review of preliminary results, as well as feedback
from the nurse interviewers.
All interviews were transcribed in full by a profes-
sional transcription service. The accuracy of transcrip-
tion was assessed by review of each transcript by an
author (BAB) immediately after transcription. If there
were missing words or any areas of concern, then the
complete audiotape was reviewed and appropriate
changes were made to the document.
For each domain of the ED visit, level of understand-
ing was determined according to the concordance
between direct patient recall and ED chart review, com-
bined with key teaching points obtained from diagnosis-
specific discharge instructions. The key teaching points
for each of the five diagnoses were established as part
of a larger study evaluating the discharge process and
discharge documents. The process to establish these
teaching points included review of the existing diagno-
sis-specific discharge documents combined with input
from ED providers (nurses, residents, and attending
physicians) and subspecialists (e.g., urologist for kidney
stone, sports medicine for ankle sprain), as well as
practice guidelines. These key teaching points were
items that the multidisciplinary group concurred were
essential for patients to know to ensure safe outcomes
upon discharge. While it was not possible to know
what information was shared with the patient verbally,

Table 1
Concordance Coding Examples

Key Teaching Omitted ⁄ Discordant

Examples Patient Interview Chart Review Points Information Score Given
Laceration: ‘‘No, not really, no.’’ Return if worsening Return to ED for Not aware of return to No
return to ED ‘‘No, not that pain, fever, increased redness, ED instructions. understanding
instructions I remember.’’ bleeding, purulent warmth, or
discharge. swelling around
the wound;
cloudy, pus-like
drainage from the
wound; increased
pain; reopening of
the wound; fever.
Back pain: ‘‘When it’s feeling Apply heat to your Be active (as long Omits avoid lifting, Minimal
home care better to do some low back for as not painful); heat, and ice. understanding
exercises or you just 20 minutes at a avoid heavy lifting;
have therapy.’’ time, several apply heat (before
times a day. activity); apply ice
(after activity).
Kidney ‘‘I have hydrocodone, Cipro, Flomax, NA Omits Flagyl (for Partial
stone: ciprofloxacin, Norco, and Flagyl. bacterial vaginosis). understanding
medications ondansetron, and Discordant information
tamsulosin. The with statement that
hydrocodone is for Flomax is an
pain. The Cipro is an antibiotic.
antibiotic, I believe.
The ondansetron
…it’s for nausea.
Tamsulosin is
another antibiotic,
I believe.’’
Ankle sprain: ‘‘Dr M … in Call referral number Follow-up with NA Complete
follow-up orthopedics.’’ to arrange for ortho or PMD in understanding
‘‘Within a week. follow up with 7–10 days.
… he can check it out Dr M ... of
and see how well it’s orthopedics
healing.’’ in 1 week.

NA = not applicable.
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ACADEMIC EMERGENCY MEDICINE • September 2012, Vol. 19, No. 9 • www.aemj.org 1039

the diagnosis-specific documents did provide the 854 eligible patients identified
patients with information in the areas included in the with electronic data
key teaching points. The inclusion of key teaching warehouse and called
points in our assessments of knowledge ensured con- 547 unable to
sistent rating across all patients for a given diagnosis, contact
despite differences in the quantity and quality of infor-
307 successfully reached by
mation provided in the patient-specific discharge
phone
instructions.
88 (29%)
A four-category concordance coding scale (no con-
refused
cordance, minimal concordance, partial concordance,
complete concordance) and specific guidelines were 219 interviews conducted
established by the consensus of all the authors after (71% participation rate) 17 excluded
reviewing a subset of cases. These guidelines were 34 incomplete interviews
based on those created for our previous study.27 These
9 poor quality recordings
guidelines ensure that concordance coding will identify Final sample:
only clinically significant knowledge deficits. For example, 159 participants
according to these guidelines, patients who refer to
their medication bottles for proper dosing or indicate Figure 1. Enrollment strategy.
follow-up plans that are consistent (although not identical)
with those in the discharge instructions are scored as
concordant. The coding guidelines are available from Table 2
the authors upon request. Two authors (KEE, BAB) Characteristics of the Sample and Refusal Populations
coded each case independently. The two coders dis-
cussed any coding discrepancies before deciding on a Total Sample Refusals
final score. Table 1 provides examples of concordance Characteristic (N = 246) (n = 159) (n = 87)
coding for each category on the scale across the different Female 49.7 43.7
domains of the discharge information. A designation of Age* (yr), 41 (29–53) 39 (29–46)
median (IQR)
‘‘dangerous misunderstanding’’ was included to indi-
Head injury 17.1 18.2 14.9
cate that an event of discordance reflected inaccurate Kidney stone 15.5 19.5 8.1
information or information that directly conflicted with Laceration 24.4 22.0 28.7
the discharge instructions in such a way that the patient Back pain 27.2 22.6 35.6
was felt to be at risk for an adverse event. Ankle sprain 15.9 17.6 12.6

Values are % unless otherwise noted

Data Analysis IQR = interquartile range.
All data were double entered with Microsoft Excel *Full range was 18 to 88 years.
(Microsoft Corp., Redmond, WA) and inconsistent data
were identified and reconciled. Statistical analysis was
conducted with SAS 9.2 (SAS Institute, Cary, NC). No Minimal Partial Complete

Simple descriptive statistics (medians, frequencies) 100.00%

were used to describe demographic information,
80.00%
patient understanding, and the presence of dangerous
misunderstandings. Post hoc analysis was done to 60.00%
determine if patient understanding was associated with
reported reading of discharge instructions. For bivariate 40.00%

analyses, chi-square tests were used for categorical 20.00%

variables and Wilcoxon Mann-Whitney tests for contin-
uous variables (the only continuous variable examined 0.00%
Diagnosis Medication Home Care Follow-Up Return to ED At least one
in bivariate analyses was age, which was skewed). Deficit

RESULTS Figure 2. Knowledge deficits.

During the study period, a total of 307 patients were
reached by phone and a final sample of 159 participants
was enrolled and completed participation in the study.
Figure 1 summarizes the recruitment and enrollment
process. Patients with back pain refused participation
with greater frequency than those with other diagnoses
(see Table 2, p = 0.03).
Of the 159 patients in the final sample, the median
age was 41.0 years and 49.7% were female (Table 2).
Seventy percent of patients indicated that they read
their discharge paperwork. The weighted kappa for
concordance coding between the two raters’ initial
responses was 0.84 (95% confidence interval = 0.82 to
0.86). All of the initial disagreements were due to coder
error, indicating that one coder had missed information
or failed to follow a scoring guideline. None of the dis-
agreements were due to differences in interpretation of
the coding guidelines, and agreement was easily
achieved in all areas of initial disagreement.
Figure 2 summarizes the results for the frequency of
knowledge deficits by domain. Across all five domains
of the ED discharge instructions, 92% of patients
demonstrated a deficit (partial, minimal, or no under-
standing) in at least one domain. Sixty-six percent of
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1040 Engel et al. • PATIENT UNDERSTANDING OF ED DISCHARGE INSTRUCTIONS

Table 3
Severe Knowledge Deficits (No or Minimal Understanding) by Domain and Diagnosis

Total Head Injury Kidney Stone Laceration Back Pain Ankle Sprain
Category (N = 159) (n = 29) (n = 31) (n = 35) (n = 36) (n = 28)
Diagnosis 3.2 3.5 0.0 0.0 11.4 0.0
Medication 3.2 3.6 0.0 2.9 8.3 0.0
Home care 40.1 58.6 20.0 38.2 58.3 21.4
Follow-up 18.4 41.4 6.5 0.0 25.7 21.4
Return to ED 50.7 44.4 42.9 39.4 94.3 22.2
At least one category 66.0 82.8 48.4 54.3 94.4 46.4
At least one categories 56.0 65.5 45.2 51.4 69.4 46.4

All values are percentages, and represent row percentages or the percent of those in each diagnosis category who scored
minimal or no understanding in a domain.

patients demonstrated a severe deficit (no or minimal Table 4

understanding) in at least one domain, and 33% of Reported Reading of Discharge Instructions and Severe
patients had more than one domain with a severe defi- Knowledge Deficits (No or Minimal Understanding) by Domain
cit. Knowledge deficits were most frequent for home
care and return to ED instructions and less frequent for Read Did Not Read
diagnosis, medication, and follow-up instructions. The Minimal or No Instructions Instructions
frequency of more severe deficits (no or minimal under- Understanding (%) (n = 105) (n = 43) p-value
standing) was also higher for the domains of home care Diagnosis 3.9 2.2 0.61
and return to ED instructions, compared to the other Medication 1.9 7.0 0.15
Home care 32.4 60.5 0.002
three domains. Follow-up 13.3 27.3 0.04
Table 3 provides results for scores of understanding Return to 48.5 54.6 0.50
by diagnosis. All percentages represent the percent of ED instructions
participants with each diagnosis who scored minimal
or no understanding in a domain. Knowledge deficits
were most common for head injury and back pain. and knowledge deficits in diagnosis, medication, or
These two diagnoses demonstrated the highest fre- returning to the ED (p > 0.05).
quencies of deficits for home care and return to ED
instructions, but the overall trend for finding the great- DISCUSSION
est deficits in these domains was consistent across all
diagnoses. Notably, for head injury and ankle sprain, In this sample of patients from an academic urban
knowledge deficits were found as frequently for follow- teaching hospital, our findings confirm that many
up as for home care and return to ED instructions. patients leave the ED with considerable deficits in their
Eleven patients exhibited a dangerous misunder- understanding of ED discharge instructions. This study
standing in at least one of the five domains of patient took a critical next step by identifying with greater
comprehension. Dangerous misunderstandings were detail which areas of ED discharge instructions are
most common for medications, but also found for home associated with the most significant knowledge deficits.
care. Three patients misunderstood medication dosing Both home care and return to ED instructions were
(e.g., 600 mg of ibuprofen every 4 hours), three patients more difficult for patients to understand than informa-
had difficulty understanding the medication itself (e.g., tion about diagnosis, medications, or follow-up. Our
stated that Flomax was an antibiotic or that Motrin and study suggests that patients are not only more likely to
Tylenol were the same medication), three patients have deficits in these two areas, but also these deficits
described inappropriate wound care (e.g., keeping the are more severe.
wound moist or putting alcohol on the wound), and Our previous work found that patients have the
one patient indicated that he or she should stay in bed greatest difficulty with post-ED care instructions includ-
for 3 days due to back pain (raising concern for compli- ing medications, home care recommendations, and
cations of immobility following this injury). follow-up; however, this previous study did not distin-
Patients who reported reading their discharge guish between the individual elements of ‘‘post-ED
instructions were found to be less likely to demonstrate care’’ in the analysis.27 Our current findings add to this
knowledge deficits. Our results are summarized in body of literature by demonstrating that home care and
Table 4. Patients who did not read the instructions were follow-up instructions appear to be more challenging
more likely to demonstrate a severe knowledge deficit for patients to recall than medications. In addition, the
(no or minimal understanding) for follow-up care (13% results demonstrate an interesting and new finding,
severe deficit if read instructions vs. 27% severe deficit with profound knowledge deficits shown for return to
if not read, p = 0.04) and home care (32% severe deficit ED instructions. The frequency of knowledge deficits
vs. not-read 60% severe deficit, p = 0.002). There was for this area was somewhat higher in this current study
no relationship between reading discharge instructions because our study design compared patient recall to

ACADEMIC EMERGENCY MEDICINE • September 2012, Vol. 19, No. 9
key teaching points, rather than simply to chart review.
This approach allowed for consistent rating of under-
standing across all patients for a given diagnosis,
despite differences in the quantity and quality of infor-
mation written by providers in the patient-specific dis-
charge instructions. In our previous study, it was found
that many providers included very simple return
instructions (‘‘return if worse’’) or no return instruc-
tions at all.27 For this reason, many participants in our
previous study were rated as having complete under-
standing for this category, irrespective of their
responses. In this study, we focused on only a small
subset of common ED diagnoses and were able to iden-
tify significant deficits in patients’ understanding of
return to ED instructions based on well-established
teaching points. Following an ED visit, it is critical for
patient safety that discharged patients are aware of the
reasons why they should return to the ED, because this
information will help them to recognize complications
and minimize adverse outcomes. Despite the recognized
importance of this area of the ED discharge instruc-
tions, it is clear that this information is not reaching
our patients on a consistent and thorough basis.
The first and most obvious reaction to our study find-
ings is ‘‘why’’ are these identified areas of the ED dis-
charge instructions so problematic. The answer to this
question undoubtedly reflects multiple elements, includ-
ing both patient and provider factors, as well as the
nature of our verbal and written communication. At the
time of discharge from the ED, patients tend to be very
oriented toward their diagnoses and medications
because these categories of information are often
viewed as the tangible outcomes of the visit, i.e.,
answers to the questions: what is wrong? and what can
I take to cure or improve my symptoms? In addition,
providers likely place greater emphasis on these topics.
A large study of verbal communication at discharge
found that instructions about medications are given
much more often (80%) than information about reasons
to return to the ED (34%).26 Moreover, patient-specific
written instructions prepared by providers most often
emphasize diagnosis, medications, and follow-up
recommendations. The diagnosis is typically written at
the top of the discharge instructions, and patients are
given prescriptions and phone numbers that highlight
key information for medications and follow-up. By con-
trast, home care and return instructions are often lim-
ited to diagnosis-specific instruction documents that
may not be reviewed at discharge or may be difficult
for patients to understand due to readability and liter-
acy levels.22–24 In this study, we found that knowledge
deficits were more frequent for patients who reported
that they did not read their discharge instructions. This
emphasizes the importance of providing patients with
written documents that are both visually appealing and
literacy appropriate, so that patients want to read them.
In addition, it highlights the need for high-quality and
consistent verbal communication that complements and
supports written documentation. Further work is
needed to better understand the origins and contribut-
ing factors for the identified trends in patients’ knowl-
edge deficits. This insight will facilitate interventions to
improve patient understanding.
15532712, 2012, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2012.01425.x by Cochrane Philippines, Wiley Online Library on [26/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
• www.aemj.org 1041
In addition to exploring why these knowledge deficits
occur, it is appropriate and important to consider
downstream implications of poor patient understanding.
Knowledge difficulties in any area are concerning, but
those in the areas of home care and return to ED
instructions raise particular concerns about adherence,
safety, and outcomes. In recent years, a patient’s transi-
tion from hospital to home has been recognized as a
high-risk time for communication failures and, in turn,
adverse patient events.13,37 To date, most of the research
in this area has been done in the inpatient setting; how-
ever, the implications for the ED are readily apparent.
In one study of hospitalized patients, nearly 20% were
found to have an adverse event within 3 weeks of dis-
charge from a general internal medicine service. More
than half of these events were related to medications,
and nearly three-quarters of them could have been pre-
vented or ameliorated.38 In a later study, discharge sum-
maries were provided to primary care providers after
an inpatient visit without any subsequent change in the
frequency of incomplete follow-up care and testing.39
These findings emphasize the importance of direct
patient–provider communication and indicate that defi-
ciencies in this process cannot be simply offset by
enhancing information delivery to providers.
Although the specific downstream effect of the deficits
identified in our study are unclear, the potential implica-
tions are readily apparent. Approximately 7% of our
study population demonstrated a dangerous misunder-
standing (or a discordance in their recall of discharge
instructions) that was felt to place them at risk for a com-
plication. These difficulties were most frequent for medi-
cations with obvious parallels to the internal medicine
study of discharged inpatients discussed above.38
Although adverse events following ED discharge have
only been studied on a very limited basis,40 there is good
reason to be concerned that such episodes of misunder-
standing are responsible for unfavorable outcomes.41
The majority of the other deficits identified in this
study were errors of omission (i.e., patient failed to
report key information in a domain despite repeated
questioning by the nurse interviewer). Although the clin-
ical significance of these errors is unknown, they have
important implications. Failure to recall medication and
home care instructions raise concerns that patients may
take longer to recover because they are not following
desired care recommendations. Delayed recovery may
lead to increased resource utilization with additional vis-
its to the ED or outpatient services. Patients’ lack of
awareness of follow-up and return to ED instructions are
concerning due to the potential for poor outcomes.
Without an understanding of these instructions, there is
missed opportunity to prevent or ameliorate future com-
plications or to recognize symptoms and changes that
require acute medical management. It is clear that com-
munication failures play a significant role in patient reci-
dividism.28,29 Approximately 3% of all ED patients return
to the ED within 48 to 72 hours of their initial visit, and of
these returns, it is estimated that 20% to 50% of these
events may have been prevented with enhanced commu-
nication.28,29,42,43 More work is needed in this area, and
our group looks forward to future efforts to characterize
the downstream implications and outcomes of these

1042 Engel et al.
knowledge deficits. In the future, efforts to improve
information delivery in the ED must involve a compre-
hensive and rigorous approach with strategies that are
realistic and feasible in our setting.
The provision of safe, high-quality patient care
requires effective communication, and there is evidence
from the inpatient setting that patients who are better
prepared for transitions in their care experience
improvements in morbidity and resource utilization.44–47
Unfortunately, the complexity of the ED environment
serves as a great challenge to the effective delivery of
discharge instructions. Innovative approaches to this
process must be designed with input from both provid-
ers and patients and address all important elements of
our interactions, including both written and verbal
communication. Given our current findings, providers
should give particular attention to the consistent and
enhanced delivery of home care and return to ED
instructions, as well as to the recognition and reduction
of dangerous misunderstandings. Previous study find-
ings48,49 linking satisfaction and communication indi-
cate that efforts to improve understanding will not only
have important implications for better outcomes and
decreased resource utilization, but also will enhance the
patient experience and raise satisfaction scores.
Research in this area must be approached with sound
methodology such that new interventions or strategies
can be assessed for their effect on knowledge of key
teaching points and clinically meaningful outcomes fol-
lowing ED discharge.
LIMITATIONS
Our study has several important limitations. First, it
was conducted at a single teaching hospital, limiting its
generalizability. Second, phone interviews were con-
ducted by nurses who were not blinded to the patient’s
diagnosis and instructions, raising the possibility that
they would facilitate patient responses and anticipate
information that was not explicitly given. Nurse inter-
viewers were extensively trained to minimize this bias,
and there is little evidence from the interview
transcripts that it occurred. In addition, it is likely that
this type of bias would skew scores of understanding
higher rather than lower. A third limitation involves the
concordance coding process. In some cases this was
limited by the number and detail of follow-up questions
asked by the nurse interviewer. To minimize subjective
judgment, we established clear guidelines on how to
handle these situations. In extreme situations in which
significant information was missing because of inade-
quate follow-up questions, a score of NA (not able to
code) was given. In those cases in which the patient
provided incomplete answers, a score was provided
according to what was available from the transcript, and
patients were not scored lower for information that was
lacking because of inadequate follow-up questioning by
the nurse interviewer. This approach was intended to
ensure that scores of understanding were not underesti-
mated. A fourth limitation is that our study did not assess
factors that may have influenced patients’ ability to
understand discharge information, such as their literacy
levels and the quality and quantity of verbal communication
15532712, 2012, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2012.01425.x by Cochrane Philippines, Wiley Online Library on [26/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
• PATIENT UNDERSTANDING OF ED DISCHARGE INSTRUCTIONS
that was provided by the provider team. Since patients
were enrolled at the time of phone contact following the
ED visit, we were limited in our ability to obtain this
information. However, this limitation does not under-
mine study findings that identify those domains for
which patients are most often leaving the ED without the
information that is recognized as essential to ensure safe
outcomes upon discharge. Related research by our
group is exploring the components of the verbal interac-
tion that are most effective in enhancing patient under-
standing, as well as intervention strategies that will
improve discharge communication across different
patient literacy levels. The final limitation relates to the
difficulty of obtaining high-quality recordings during
phone interviews. Although our rates of refusal to partic-
ipate were relatively low, we had numerous recordings
that were not able to be used due to poor quality. Techni-
cal modifications were made to address these issues over
the course of the study, but often this difficulty was
unavoidable because patients were talking on cell
phones in areas with variable reception and significant
background noise.
CONCLUSIONS
Patients frequently leave the ED with incomplete under-
standing of their discharge instructions. Knowledge
deficits are most frequent in the domains of home care
(i.e., self-care other than medications) and return to ED
instructions (which symptoms or changes should cause
patients to come back to the ED). These findings may
reflect that greater emphasis is placed on other aspects
of the discharge instructions (diagnosis, medications,
and follow-up instructions) in both written and verbal
communication at discharge. Moreover, patients’ failure
to read written instructions appears to contribute to the
identified deficits. Knowledge deficits have significant
implications for patients’ adherence and outcomes fol-
lowing an ED visit. Future work must explore and
define factors (environmental, patient, and provider)
that contribute to these deficits and, in turn, identify
corresponding strategies and approaches that can serve
to improve discharge communication within our
challenging clinical setting.
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