Examples of pico questions for emergency nursing

PICOT EVIDENCE REVIEW 7

Do Follow-up Phone Calls Post Discharge Impact ED Patients

Brett Kiser

University of Maryland, Baltimore

Running Head: PICOT EVIDENCE REVIEW 1

Do Follow-up Phone Calls Post Discharge Impact ED Patients

Adult patients’ understanding of discharge instructions is crucial in all hospital settings and departments, but particularly in emergency department (ED) visits. Misunderstanding of these instructions can lead to adverse patient outcomes, including readmittances to the ED for the same underlying condition. Research has estimated that 22% of patients discharged from the ED return to the ED within 30-days (Rising et al., 2014). While readmissions are a major concern, other patient outcomes, such as patient satisfaction, patient compliance with post visit treatments, health literacy, and healthcare costs may also be impacted (JHU, 2014). Recent studies have demonstrated the need for greater comprehension of ED discharge instructions, reporting that 66% of patients had a “major deficit” in comprehension of their discharge instructions (Engel et al., 2012). Additionally, and potentially even more devastating, the majority of ED patients are unable to perceive that they do not understand these instructions (Engel et al., 2009) and are therefore less likely to seek additional support as needed. It should be noted that while patients often report that ED physicians spent adequate time with them prior to discharge, most patients did not fully understand all of these instructions including information about medications, signs of improvement, signs of worsening, and if and when to return to the ED (Engel et al., 2012; Gignon, Ammirati, Mercier, & Detave, 2014). Clearly research should be conducted to understand ways to positively impact comprehensive of discharge instructions, reduce ED readmissions, and ultimately improve patient care and reduce costs.

PICO(T) Question

The following PICO(T) question was developed to perform an evidence review on best practices surrounding adult patient discharge instructions and follow-up post discharge from an emergency department. PICO(T): Do follow-up phone calls by nursing staff or a case manager in addition to standard written discharge instructions, compared to standard practice (i.e., written discharge instructions with no follow-up phone calls), lead to better comprehension of discharge instructions, patient satisfaction, and ultimately fewer return visits within 30-days post discharge for adult emergency department patients?

· Population (P): adult patients discharged from the emergency room

· Intervention (I): follow-up phone calls from nursing staff, in addition to standard written discharge instructions

· Comparison (C): standard practice – written discharge instructions with no follow-up phone calls

· Outcome(s) (O): better comprehension of discharge instructions, patient satisfaction, and ultimately fewer return visits

· Time (T): within 30-days post discharge.

Description of Search

For this evidence review, both the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed databases were used to find literature surrounding the PICO(T) question. Specifically, the following search terms were used within both databases: “emergency” AND (“follow up” or “discharge”) AND (“telephone” or “phone call”). Results of both searches were limited to the last five years (2012-2017) and for adult human populations only (to exclude pediatric studies); the CINAHL search was further restricted to peer reviewed articles only. Based on this search criteria, CINAHL yielded a total of 94 articles and PubMed yielded a total of 306 articles. In addition to the database searches, two additional articles were identified through background research on this topic and included in this review, as they were relevant to the PICO(T) question.

After 61 duplicates were removed, 341 article titles were reviewed and screened to determine if the article should be included within the full text article review for eligibility for this evidence review. Refer to Appendix A for a PRISMA flow diagram and additional details about the inclusion/exclusion criteria. Most of the articles were excluded as either the study population was not in the emergency department, or the intervention was non-telephone follow-up (e.g., telephone surveys may have been administered as part of study methods). Of the 21 articles identified for full text review, seven articles were excluded as the patient population was too specific, three were excluded as they were exploratory in nature, two were excluded due to non-telephone interventions, and three were excluded as they were either a repeat study, did not involve emergency department population, or involved a pharmacist only follow-up. After the full text review, six articles were eligible and all six are included in the evidence review process. Refer to Appendix B for the evidence review table of these six articles.

References

Engel, K. G., Heisler, M., Smith, D. M., Robinson, C. H., Forman, J. H., & Ubel, P. A. (2009). Patient comprehension of emergency department care and instructions: Are patients aware of when they do not understand? Annals of Emergency Medicine, 53(4), 454-e15. doi:10.1016/j.annemergmed.2008.05.016

Engel, K. G., Buckley, B. A., Forth, V. E., McCarthy, D. M., Ellison, E. P., Schmidt, M. J., & Adams, J.G. (2012). Patient understanding of emergency department discharge instructions: Where are knowledge deficits greatest? Academic Emergency Medicine, 19(9), E1035-44. doi:10.1111/j.1553-2712.2012.01425.x

Gignon, M., Ammirati, C., Mercier, R., & Detave, M. (2014). Compliance with emergency department discharge instructions. Journal of Emergency Nursing, 40(1), 51-55. doi:10.1016/j.jen.2012.10.004

Johns Hopkins University, Armstrong Institute for Patient Safety and Quality. (2014). Improving the emergency department discharge process: Environmental scan report. Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication No. 14(15)-0067-EF.

Rising, K. L., Victor, T. W., Hollander, J. E., & Carr, B. G. (2014). Patient returns to the emergency department: The time-to-return curve. Academic Emergency Medicine, 21(8), 864-871. doi:10.1111/acem.12442

Appendix A

PRISMA Search Flow Diagram

Records identified through manual searching

(n=2)

Records identified through PubMed database

(n=306)

Records identified through CINAHL database

(n=94)

Identification

Records excluded (n=320)

· Non-emergency department population (208)

· Emergency department-related, but non-related intervention (e.g., telephone was used during research methods) (95)

· Emergency department-related, but very specific patient population (12)

· Qualitative or exploratory in nature (5)

Full-text articles excluded, with reasons (n=15)

· Study was for narrow and specific population (7)

· Study was exploratory in nature, without control and intervention (3)

· Study included a non-telephone intervention (e.g., text, e-mail) (2)

· Study was not in an emergency department (1)

· Intervention was pharmacist only (1)

· Study was a repeat of another (included) study (1)

Records included in title screening (n=341)

Records after duplicates removed (n=341)

Full-text articles assessed for eligibility (n=21)

Studies included in synthesis (n=6)

Screening

Eligibility

Included

PICOT EVIDENCE REVIEW 6

Appendix B

Evidence Appraisal Review

Citation:

Biese, K., LaMantia, M., Shofer, M., McCall, B., Roberts, E., Stearns, S. C., Principe, S., Kizer, J. S., Cairns, C. B., & Busby-Whitehead, J. (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), 188-195. doi:10.1111/acem.12308

Study objective/ intervention or exposures compared

Design

Sample (N)

Intervention

Outcomes studied (how measured)

Results

Level

To assess the impact of a follow-up phone call by a nurse post discharge has on older patients' adherence to discharge instructions and likelihood to return to the ED.

Prospective randomized control trial (RCT) Patients 65 years old or older were selected from Sunday, Monday, or Tuesday across a 10-week period, to facilitate phone calls during the week (2-3 days post discharge). Each day, 9 randomly selected discharged patients were randomly assigned to one of the three treatment groups, using a block randomization (researches pulled a colored marble out of a bag).

Eligible: 180 patients

2 were excluded as on those days, they were the 10th patient intercepted. 18 declined, 19 could not be reached for follow-up, 21 excluded due to incomplete or disqualifying circumstances post acceptance Accepted: 120 patients Control: 46 patients Placebo: 35 patients Intervention: 39 patients

Control group: received standard discharge instructions and no follow-up phone call Placebo group: received standard discharge instructions and a scripted patient satisfaction survey 1-3 days post discharge Intervention group: received standard discharge instructions and a follow-up phone call by a trained nurse 1-3 days post discharge, to review and assess discharge instructions with the patient

Each patient in the study received a study-related phone interview 5-8 days post discharge and 30-35 days post discharge. Dependent Variables Respondents report of follow-up appointment already scheduled Date of follow-up appointment (if applicable) Whether new ED prescriptions had been filled Patient's comprehension of medication indications and dosing Whether or not the patient had an ED visit post discharge Secondary variable: economic analysis of impact of return ED visits

All study groups were not significantly different on gender, race, age, or whether the patient versus a caregiver was interviewed. While differences existed on all variables between groups, statistically significant differences were not observed in most dependent variables (p-values > 0.05). The intervention group was more likely to attend their follow-up appointment within 5-days post discharge than the other groups (54% vs. 37% control & 20% placebo; p=0.05).

2

Study PICO(T):

For ER patients 65 years old or older, does a follow-up phone call by a nurse 1-3 days post discharge along with standard discharge instruction, compared to standard discharge instructions and no follow-up phone call or standard discharge instructions and a follow-up satisfaction survey phone call, impact patients' adherence to discharge instructions 35-days post discharge?

Citation:

Cossette, S., Frasure-Smith, N., Vadeboncoeur, A., McCusker, & Guertin, M. C. (2015). The impact of an emergency department nursing intervention on continuity of care, self-care capacities and psychological symptoms: Secondary outcomes of a randomized controlled trial. International Journal of Nursing Studies, 52, 666-676. http://dx.doi.org/10.1016/j.ijnurstu.2014.12.007

Study objective/ intervention or exposures compared

Design

Sample (N)

Intervention

Outcomes studied (how measured)

Results

Level

To assess the impact additional discharge instructions (i.e., a nurse meeting prior to discharge) and two follow-up phone calls by the nurse post discharge have on patients' perceptions of care, illness, symptom management, medication adherence, and psychological symptoms, for higher returning risk adult patients.

Secondary analysis of a randomized control trial (RCT) Adult patients who were at higher risk of returning to the ER (based on risk criteria) being discharged from the ER during a 4-year period were randomly selected and assigned to either the control group or the intervention group. Patients were randomized to groups by a statistician and the nurse recruiting patients was blind to the assignment at time of recruitment.

Eligible: 1,436 patients 825 had logistical issues, 346 refused Accepted: 256 patients Control group: 133 patients originally, 95 for this analysis (38 dropped out or were unable to be contacted for final assessment) Intervention group: 132 patients originally, 108 for this analysis (131 received first encounter, 121 received first follow-up call, 126 received second follow-up call; 24 dropped out or were unable to be contacted for final assessment)

Control group: standard level of care (i.e., standard discharge instructions without additional follow-up) Intervention group: standard discharge instructions, plus an additional nurse meeting prior to discharge, a follow-up phone call by a nurse 2-4 days post discharge, and a second follow-up phone call by a nurse 7-10 days post discharge.

An interview of participants included validated measures of perceived health, self-care, and psychological variables. Dependent Variables: Variables included the following categories (with subvariables within each category) rated on a scale from 1 (strongly disagree) to 5 (strongly agree) and values were then scored: • Continuity of healthcare post discharge • Perception of their illness • Self-care goals and perceptions • Psychological factors related to illness and ER visit • Medication adherence

Both the control group and the intervention group were similar on all demographic variables, and the characteristics of the initial ER visit, except the intervention group was more likely to arrive to the ER via ambulance (23% vs 10%; p=0.038). Intervention patients had statistically significantly higher values on the following variables: • Perceptions of health care continuity (p=0.003) • Perceptions of treatment (p=0.037) • Perceptions of self-care management (p=0.021) • Psychological measures, e.g., anxiety (p=0.007) Tertiary outcomes: Additional qualitative information was gathered about the intervention group.

2

Study PICO(T):

For adult patients to the ER, does a series of additional nursing encounters (both in person and follow-up phone calls) in addition to standard discharge instructions, compared to standard discharge instructions alone, impact patients' perceptions of treatment, healthcare continuity, self-care management, and psychological state related to their visit within 30-days post discharge?

Citation:

Cossette, S., Vadeboncoeur, A., Frasure-Smith, N., McCusker, J., Perreault, D., & Guertin, M. C. (2015). Randomized controlled trial of a nursing intervention to reduce emergency department revisits. Canadian Journal of Emergency Medicine, 17(1), 13-20. doi:10.2310/8000.2013.131291

Study objective/ intervention or exposures compared

Design

Sample (N)

Intervention

Outcomes studied (how measured)

Results

Level

To assess the impact of additional discharge instruction (i.e., a nurse meeting prior to discharge) and two follow-up phone calls by the nurse post discharge have on return rates to the ED.

Randomized control trial (RCT) Adult patients who were at higher risk of returning to the ER (based on risk criteria) being discharged from the ER during a 4-year period were randomly selected and assigned to either the control group or the intervention group. Patients were randomized to groups by a statistician and the nurse recruiting patients was blind to the assignment at time of recruitment.

Eligible: 1,436 patients 825 had logistical issues, 346 refused Accepted: 256 patients Control group: 133 patients Intervention group: 132 patients (131 received first encounter, 121 received first follow-up call, 126 received second follow-up call)

Control group: standard level of care (i.e., standard discharge instructions without additional follow-up) Intervention group: standard discharge instructions, plus an additional nurse meeting prior to discharge, a follow-up phone call by a nurse 2-4 days post discharge, and a second follow-up phone call by a nurse 7-10 days post discharge.

Dependent Variables: Whether or not the patient returned to the ED ("Yes" or "No") Secondary variable: The amount of time between discharge and the patient's return to the ED (if applicable) measured in number of days.

Both the control group and the intervention groups were not significantly different on all demographic characteristics. The intervention group was not statistically more like to not return to the ED compared to the control group (p=0.81). Additionally, the control group and the intervention group were not statistically different in the amount of time that passed between discharge and return to the ED (if applicable; p-values >0.05).

2

Study PICO(T):

For adult patients who were at higher risk of returning to the ED, does a series of additional nursing encounters in addition to standard discharge instructions, compared to standard discharge instruction alone, impact ED return rates within 30-days post discharge?

Citation:

Franzen, C., Brulin, C., Stenlund, H., & Bjornstig, U. (2008). Injured road users’ health-related quality of life after telephone intervention: a randomized controlled trial. Journal of Clinical Nursing, 18, 108-116. doi:10.1111/j.1365-2702.2008.02436.x

Study objective/ intervention or exposures compared

Design

Sample (N)

Intervention

Outcomes studied (how measured)

Results

Level

To assess the impact of a follow-up phone call 3-weeks post discharge by a nurse for patients who have experienced a "road-based trauma" (i.e., car crash, bicycle accident, pedestrian injury) on health quality indicators.`

Randomized control trial (RCT) Patients were selected on a sample of days across two years. Patients were selected using a stratified consecutive sample to get a representative sample from the three patient populations. Patients from each of the stratified populations were randomly assigned to the control or intervention group.

Eligible participants: 920 = 321 car occupants, 305 cyclists (cycle), 294 pedestrians (ped) Accepted participation: 568 participants = 321 car, 305 cycle, 294 ped Control group: 81 car, 101 cycle, 98 ped 6-month follow-up completion: 71 car, 88 cycle, 91 ped Intervention group: 87 car, 99 cycle, 102 ped 3-month follow-up phone call: 84 car, 98 cycle, 97 ped 6-month follow-up completion: 76 car, 90 cycle, 94 ped

Control group: standard discharge instructions, with no follow-up phone call Intervention group: standard discharge instructions plus nurse follow-up phone call 3-weeks post discharge

A paper-based survey was administered to study "health-related quality of life" of the individual. Dependent Variables Questions of health-related quality of life included factors of:

• mobility

• ability for self-care

• ability to do their normal activities

• pain and discomfort

• anxiety or depression.

The questionnaire was administered 2-weeks post discharge, 3-months post discharge (for the intervention group) and 6-months post discharge (at study completion).

Both control groups and intervention groups were mostly similar, with only statistically significant differences on two variables in two of the groups (i.e., gender differences in the cycle group, p=0.029; gender differences in who received advice as part of the intervention in the cycle group, p=0.037) At two-weeks post discharge (prior to intervention) no differences were observed between groups (p>0.05). After 6-months post discharge, the intervention groups rated the health quality metrics better than the control groups (p<0.001). Significant differences between control and intervention groups varied by subgroup type.

2

Study PICO(T):

For ER patients of road-based traumas (i.e., car crashes, bicycle accidents, pedestrian accidents), does a follow-up phone call by a nurse 3-weeks post discharge in addition to standard discharge instructions, compared to standard discharge instructions with no follow-up phone call, impact health-related quality of life metrics within 6-months post discharge?

Citation:

Guss, D. A., Leland, H., & Castillo, E. M. (2013). The impact of post-discharge patient call back on patient satisfaction in two academic emergency departments. The Journal of Emergency Medicine, 44(1), 236-241. http://dx.doi.org/10.1016/j.jemermed.2012.07.074

Study objective/ intervention or exposures compared

Design

Sample (N)

Intervention

Outcomes studied (how measured)

Results

Level

To assess the impact of healthcare provider phone calls post discharge from the ER on patients' overall satisfaction with their ER visit.

Retrospective analysis The study design consisted of analyzing Press Ganey survey data of two emergency departments. Within the survey, a question asked "After discharge, did you receive a phone call from an ED staff member?" Survey data from a 12-month period were used for this study, with surveys mailed to a random sample of 50% of patients who visited the ED during the time period.

Eligible: 30,000 surveys were mailed; Returned survey: 2,250 (7%) were returned No follow-up call group: 1,903 (85% of those returned) Follow-up call group: 347 (15% of those returned)

Control group (n follow-up call group): This group reported not receiving a follow-up phone call from an ED staff member (checked “No” when asked). Treatment group (follow-up call group): This group reported receiving a follow-up phone call from an ED staff member at an unspecified time (checked “Yes” when asked).

As mentioned, survey data from the Press Ganey survey were used to collect information for this retrospective study. Dependent Variable Patient satisfaction was the primary outcome of this study. This was measured using the "likelihood of recommending this ED to others" survey question. Responses were scaled from 1-5, with 1 = very poor and 5 = very good. Responses were dichotomized into 1-4 and 5 categories.

No direct comparison of characteristics of the two treatment groups was discussed. Those participants who reported a follow-up phone call from an ED staff member were significantly more likely to recommend this ED to others compared to those that did not receive a follow-up phone call (71% vs. 51%, p<0.001).

3

Study PICO(T):

For ER patients of two different emergency rooms, does a follow-up phone call by an ED staff member in addition to standard discharge instructions, compared to standard discharge instructions with no follow-up phone call, impact patient satisfaction ratings of the ER?

Citation:

Wong, F. K., Chow, S., Chang, K., Lee, A., & Liu, J. (2004). Effects of nurse follow-up on emergency room revisits: a randomized controlled trial. Social Science & Medicine, 59(11), 2207-2218. doi:10.1016/j.socscimed.2004.03.028

Study objective/ intervention or exposures compared

Design

Sample (N)

Intervention

Outcomes studied (how measured)

Results

Level

To assess the impact of follow-up phone calls by a nurse on ER patients post discharge at an urban acute care hospital on health outcomes and utilization of healthcare providers (e.g., ER, general practitioner).

Randomized control trial (RCT) Patients were selected on a sample of days through an entire year, and across all hours of the day. Participants were randomly assigned to the control or intervention group using a computer generated algorithm.

Eligible participants: 900 20 were excluded due to language barrier or unwilling Accepted: 880 patients Control group: 440 enrolled, 40 were unable to be followed up with; 400 patients completed study Intervention group: 440 selected, 45 quit early or were unable to be followed up with; 395 patients completed study

Control group: standard discharge instructions prior to discharge, with no follow-up phone calls Intervention group: standard discharge instructions plus nurse follow-up phone calls: •1st call 1-2 days post discharge •2nd call 4-5 days post discharge

Both dependent variables were assessed via a follow-up phone-based interview 30-days post discharge, using validated questions - both quantitative and open-ended Dependent Variables Health outcome

• affecting daily life

• improvement of conditions

• self-reported health

•consumer satisfaction) Health care utilization

Number of times visiting

• general practitioner

• general outpatient clinic

• ER)

Control and intervention group were not statistically different on demographic characteristics (p>0.05). Intervention group was more likely to report a general "improvement of condition" compared to control group (97% vs. 93%; p=0.026) Intervention group was more likely to report a revisit to the ER within 30-days post discharge compared to control group (30% vs. 24%; p=0.036)

2

Study PICO(T):

For adult patients discharged from the emergency room, does the implementation of two nurse delivered follow-up phone calls post discharge along with standard discharge instructions, compared to standard instructions alone, impact health outcomes and utilization of health care services within 30-days post discharge?