understanding in home care (40%) and return instructions (51%) occurring most often A study examining children with a return visit within 72 hours of discharge from the ED found that 41% of caregivers were not instructed on all key components of discharge, and almost half (47%) were not educated on the likely duration of illness Other studies have shown that less than half of important discharge concepts (medication details, signs of improvement vs worsening condition) were recalled at exit interviews from the ED In addition, Engel found that although 78% of patients demonstrated problems with comprehension, only 20% of patients recognized their comprehension deficits This suggests that multiple factors, such as inadequate provision of instructions, and poor comprehension of instructions create obstacles to effective discharge teaching LITERACY AND LANGUAGE COMPREHENSION Compliance with discharge instructions and follow-up is closely tied to comprehension of the instructions Two of the greatest variables that influence patient comprehension are reading ability and English language comprehension In 1992, the National Adult Literacy Survey evaluated the condition of literacy in the United States Almost one-fourth of U.S adults displayed skills in the lowest category of proficiency, with the average adult in the United States reading between the 8th and 9th grade levels This study was repeated in 2003 with minimal change in average reading level Several studies examined average reading level of patients compared to the average reading level required to comprehend discharge instructions The majority of these studies focused on the adult population, but as many young children rely on their parent’s literacy level, these studies remain pertinent to the pediatric population Clarke found that 60% of patients read below grade level Studies conducted in pediatric EDs show that although most discharge instructions are written at a college reading level, almost half of parents had a high school education or less Considering the above, discharge instructions should be written at or below 6th grade reading level in order to optimize chances that the majority of patients/guardians will be able to comprehend them The use of medical jargon is particularly difficult to comprehend and should be avoided It is important to note that reading literacy does not always translate to functional health literacy Health literacy is defined by the Institute of Medicine as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” An estimated 36% of adults have limited health literacy, which may not be related to years of education or general literacy Low health literacy has been related to medication error, repeat emergency department visits, and morbidity/mortality after discharge When reviewing discharge instructions, the practitioner must be aware of possible health literacy deficits and pay particular attention to cultural considerations affecting understanding of discharge instructions and medication instructions, including dosing The addition of careful verbal instruction review may help to overcome health literacy disparity NONNATIVE ENGLISH-SPEAKING PATIENTS Nonnative English speakers may be at higher risk of failing to understand discharge instructions, especially if adequate interpretation services are not available Use of a professional interpreter has been associated with greater odds of caregiver comprehension and complete discharge education content, including critical aspects such as medication dosing Instructions, when possible, should be provided in the native language of the parent/guardian in written form, or at least reviewed using an interpreter to verbally translate the most critical aspects of the discharge instructions Interpretation services are crucial to allow the family a final opportunity to clarify any questions they may have prior to discharge MEDICATIONS AND MEDICATION RECONCILIATION Between 12% and 22% of patients not fill medications prescribed from an ED visit Novel approaches such as dispensing medications from the ED pharmacy, especially during late hours when outpatient pharmacy care is limited, may help improve medication adherence Inappropriate dosing and use of medications are related to health literacy deficits, and are also related to morbidity and mortality To help improve medication compliance, names and instructions for use of new medications should be included in discharge instructions Physicians should write in lay terms (e.g., “three times a day” instead of “TID”) For pediatric dosing, consider marking a syringe to show the correct liquid dosing or asking a caregiver to demonstrate the correct way to measure and administer the medication Any changes to a patient’s normal medication regimen should also be noted The Joint Commission requires a complete, reconciled list of the patient’s medications provided directly to the patient/guardian All newly prescribed medications should be listed on the hospital discharge instruction form in addition to including directions to continue, modify, or discontinue previously prescribed medications FOLLOW-UP Compliance with outpatient physician follow-up is improved if an appointment is made prior to discharge from the ED It is helpful to provide phone numbers for primary care physicians (especially for patients who not have a primary physician) and for subspecialists Discharge instructions can reinforce the importance of follow-up with the patient’s medical home, and encourage families to coordinate their follow-up care with their primary provider SUMMARY Discharge instructions are an integral part of the ED experience and are crucial for optimal continued care of the acute medical condition Many patients/guardians not fully comprehend discharge instructions, especially those with low literacy skills or low health literacy Discharge instructions should be reviewed orally by the primary practitioner or nurse who cared for the patient The person providing instructions should provide an opportunity for the patient/guardian to clarify any remaining questions concerning care prior to discharge Well-designed discharge instructions should be concise, with organized structure, including visual cues to enhance recall, and should be presented verbally with a summary written component Both verbal and written instructions should be provided in the patient/guardian’s native language when possible, and should be written at or below a 6th grade level using lay medical terms They should review the key components to discharge, including patient diagnosis, anticipated length of illness, home care, and return precautions, and should include information about newly prescribed medications and changes to prior medication regimens The understanding of and receipt of the instructions should be confirmed by one of the main care providers The use of technology will continue to expand the options for delivery of discharge content In an ideal system, follow-up phone calls from an ED clinician may provide an opportunity to answer ongoing questions, reinforce discharge instructions, or identify patients in need of further care Suggested Readings and Key References Atzema CL, Maclagan LC The transition of care between emergency department and primary care: a scoping study Acad Emerg Med 2017;24(2):201–215 Bloch SA, Bloch AJ Using video discharge instructions as an adjunct to standard written instructions improved caregivers’ understanding of their child’s emergency department visit, plan, and follow-up: a randomized controlled trial Pediatr Emerg Care 2013;29(6):699–704 Centers for Medicare & Medicaid Services Transition record with specified elements received by discharged patients Available online at https://cmit.cms.gov/CMIT_public/ReportMeasure?measureId=2584 Accessed April 5, 2019 Chernick LS, Stockwell MS, Wu M, et al Texting to increase contraceptive initiation among adolescents in the emergency department J Adolesc Health 2017;61(6):786–790 Clarke C, Friedman SM, Shi K, et al Emergency department discharge instructions comprehension and compliance study Can J Emerg Med 2005;7(1):5–11 Engel KG, Heisler M, Smith DM, et al Patient comprehension of emergency department care and instructions: are patients aware of when they not understand? Ann Emerg Med 2009;53(4):454–461.e15 Gutman CK, Cousins L, Gritton J, et al Professional interpreter use and discharge communication in the pediatric emergency department Acad Pediatr 2018;18(8):935–943 Health Literacy Available online at http://nnlm.gov/outreach/consumer/hlthlit.html Accessed April 9, 2019 Hill B, Perri-Moore S, Kuang J, et al Automated pictographic illustration of discharge instructions with Glyph: impact on patient recall and satisfaction J Am Med Inform Assoc 2016;23(6):1136–1142 Institute for Healthcare Improvement Ask Me 3: Good Questions for your Good Health Available online at ... contraceptive initiation among adolescents in the emergency department J Adolesc Health 2017;61(6):786–790 Clarke C, Friedman SM, Shi K, et al Emergency department discharge instructions comprehension... Cousins L, Gritton J, et al Professional interpreter use and discharge communication in the pediatric emergency department Acad Pediatr 2018;18(8):935–943 Health Literacy Available online at http://nnlm.gov/outreach/consumer/hlthlit.html... instructions Physicians should write in lay terms (e.g., “three times a day” instead of “TID”) For pediatric dosing, consider marking a syringe to show the correct liquid dosing or asking a caregiver