Patient Education in the Emergency Department - Wiley Online Library

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Wei, Camargo • PATIENT EDUCATION IN THE ED

Patient Education in the Emergency Department HENRY G. WEI, MA, CARLOS A. CAMARGO JR., MD, DRPH

Abstract. The emergency department (ED) visit provides an opportunity for patient education. Many ED patients have poor access to regular health care, including patient education. Accreditation standards, legal considerations, and cost-efficiency concerns encourage the clinician to implement formal patient education in the ED. More importantly, published clinical studies evaluating patient education in both the ED and comparable settings support the hypothesis

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ATIENT education is instruction directed at increasing a patient’s ability to manage personal health.1 The motivation to provide formal patient education is multifaceted. Inadequate health literacy negatively influences patient health.2 Accreditation criteria mandate that health care organizations provide patient and family education.3 From a legal standpoint, patient education helps to ensure informed consent, and can protect from malpractice claims.4 Also, patient education has been shown to be cost-beneficial and cost-effective both in general5 and for several specific conditions such as asthma and heart failure.6–10 The emergency department (ED) environment presents unique obstacles to patient education. Emergency clinicians work in an unpredictable environment where staff is limited and census unpredictable. Emergency department patients may be anxious, disoriented, or even hostile. Moreover, standardized patient education may be altogether absent from routine care in the ED. However, despite the challenges, the ED may be the sole point of contact with the health care system for many patients. Emergency department patients presenting with acute illness from chronic conditions such as asthma or diabetes may fail to From the Weill Medical College of Cornell University, New York, NY (HGW); the Department of Emergency Medicine, Massachusetts General Hospital (HGW, CAC) and Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital (CAC), Harvard Medical School, Boston, MA. Received August 20, 1999; revision received December 20, 1999; accepted January 11, 2000. Mr. Wei is supported by a student research grant from the Weill Medical College of Cornell University (New York, NY). Dr. Camargo is supported by grant HL-03533 from the National Institutes of Health (Bethesda, MD). Address for correspondence and reprints: Carlos A. Camargo Jr., MD, DrPH, Department of Emergency Medicine, Clinics 397, Massachusetts General Hospital, Boston, MA 02114. Fax: 617-724-4050; e-mail: [email protected]

that ED-based patient education improves outcomes. The article discusses considerations for instructional material, highlights challenges to ED-based patient education, and suggests possibilities for future research. Key words: emergency medicine; patient education; health education; disease management. ACADEMIC EMERGENCY MEDICINE 2000; 7: 710–717

seek regular nonemergency treatment, and thus miss an opportunity for patient education from their primary care providers. Further, the heightened attention of patients and their caregivers during ED visits may provide an important opportunity for patient education.11 The treatment of the ED patient may offer a ‘‘teachable moment,’’ when the patient is ready to accept new information.12 The object of the present review is to summarize current literature related to patient education in the ED and other comparable settings, to discuss considerations for instructional material, to highlight challenges to ED-based patient education, and to discuss possible avenues for future research.

STUDIES OF PATIENT EDUCATION IN ACUTE CARE The literature on ED-based patient education research is, unfortunately, quite limited. However, several studies of patient education have been conducted in other comparable acute care settings. Although many of these non-ED-based inpatient interventions are lengthy and often scheduled around the convenience of the inpatient staff educators, they are not entirely irrelevant. Collectively, the studies of patient education in the ED and other acute care settings can provide a useful background to assess the possible efficacy of patient education in the ED. Asthma. Because asthma is a chronic disease with acute episodes often presenting to the ED, asthma education is a prototype for ED-based patient education and prevention efforts. Emergency department patients with asthma often lack asthma knowledge and asthma management skills, such as proper inhaler technique.13,14 Fre-

ACADEMIC EMERGENCY MEDICINE • June 2000, Volume 7, Number 6

quent ED use by pediatric patients is associated with the lack of a predetermined crisis plan and lower levels of parental confidence in the efficacy of medicines.15 Several controlled studies have examined the results of educational interventions for asthma. Gibson et al. provide a comprehensive meta-analysis of published studies of patient education for asthma in several settings, both for limited ‘‘information-only’’ programs and for self-management instruction and regular review.16,17 Asthma education was found to significantly reduce hospitalizations, ED visits, unscheduled visits to the doctor, and days missed from work and school. The collective data support the role of patient education for asthma in both inpatient and outpatient settings. At the same time, the content and format of asthma education programs vary widely and are poorly described in the literature; this can impede attempts at replicating the program, as well as identifying effective components.18 For asthma education based specifically in the ED, data are sparse. In 1979, Maiman et al. found that verbal instruction given by nurses in the ED reduced revisits; however, no significant effect was observed with the use of supplementary written materials.19 More recently, when one hour of education was given to adult ED patients with asthma, hospitalizations decreased significantly in comparison with those for patients not receiving the educational intervention.20 Another study compared acute asthma patients at EDs with and without a ‘‘formal’’ asthma education program. Although there was marked heterogeneity in programs, and only an assumption that patients did (or did not) receive education, patients at sites with an asthma education program were less likely to have an ongoing exacerbation at two weeks in comparison with patients at sites without such a program.21 Myocardial Infarction and Chronic Heart Failure. While there are few published studies of EDbased patient education for cardiac conditions, there are a number of cardiac studies conducted in similar settings. For instance, much can be learned from attempts at patient education in the cardiac care unit (CCU), comparable to the ED in the patients’ degree of illness and, to a lesser extent, the patient care environment. Structured methods such as ‘‘programmed instruction’’ and teaching pathways for CCU patients have recently been described.22,23 Rather than being too stressful for the post-myocardial infarction (MI) patient, the CCU environment can serve as a motivation to learn.24 Male patients admitted to a CCU for a first-time acute MI reported higher satisfaction and significantly less anxiety and depression when they re-

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ceived in-hospital counseling.25 A study of an inpatient smoking-cessation intervention, initiated in the hospital and continued through telephone contact and a take-home manual, found that the 12-month smoking cessation rate was double that of the control group receiving routine care.26 In another program, post-MI inpatients who received two individual counseling sessions and two group sessions in the hospital reported a significantly greater decrease in unhealthful eating habits and better smoking-cessation results compared with those for the control group.27 Duryee comprehensively reviewed earlier studies of the efficacy of post-MI patient education, and highlighted various effective teaching methods, including audiovisual methods, such as videotapes or slides and audio, found to be as effective as a live educator.28 Within the ED itself, a program was designed to reduce out-of-hospital delays in ED patients presenting with chest pain. Emergency department patients were shown a discharge video and given a written action plan on the symptoms of a heart attack and appropriate actions to take. Three days after discharge, the patients were interviewed over the telephone. More than 90% of the patients were able to describe the symptoms of a heart attack, and more than 80% remembered the appropriate actions to take.29 Patients with chronic heart failure also may be targeted for education on the disease, medications, and continuing care. An intervention including comprehensive patient and family education and intensive follow-up was studied in high-risk patients with congestive heart failure. Those receiving the intervention had significantly fewer readmissions for heart failure and better improvements in quality-of-life scores at 90 days. The net cost-ofcare savings was $460 per patient, mainly due to the reduction in hospital admissions.30 Psychiatric Conditions. Patients with acute psychiatric conditions and requiring emergency care or hospitalization may not have an adequate understanding of their disease or its treatment. There are few controlled studies of brief patient education interventions in the psychiatric setting; much less for psychiatric care in urgent or acute settings. In a study of short-stay psychiatric hospitalization, patients received both group and individual medication instruction. At discharge, more than half did not correctly recall the name, dosage, or reasons for their prescribed medications, suggesting the need for a more active educational approach.31 Other programs have been more successful. In a group of outpatients with psychiatric disorders, a controlled study of brief health educational interventions found significantly improved medication compliance.32 In four

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acute-care receiving wards at a psychiatric hospital, postdischarge compliance was higher for those who had been given both written information and verbal reinforcement.33 Within the ED itself, an intervention for adolescent suicide attempters and their families was developed, using training workshops for ED staff, a supplemental videotape for families, and an on-call family therapist. The specialized intervention resulted in better attendance at subsequent treatment sessions and reduced selfreported psychiatric symptoms.34 Trauma and Injuries. The ED has the potential to play a very important role in patient education on injury prevention and management. Todd emphasizes that emergency physicians not only see a disproportionate number of patients who lack other access to health care, but also care for nearly all patients with serious injuries.11 He argues that emergency physicians should seize the opportunity to educate their patients about injury prevention. A retrospective chart review study of pediatric patients presenting with injuries a rural ED looked at injury prevention instruction by ED personnel. While injury prevention instruction was indicated in more than 25% of cases, it was documented in only 3%.35 Combined teaching methods for ED discharge instruction after head injury may help improve recall and comprehension.36 In a pediatric ED, a prospective study examined verbal and written explanation for parents of patients with mild head injury. Written instructions did not add significantly to recall, although 84% of the parents intended to keep them for further reference. The study did not compare the verbal explanation with giving no instruction.37 Still, the benefit of patient education for injury


management, rather than injury prevention, has not yet been quantitatively validated. While patient education has been urged in the ED management of injuries such as minor burns,38 no data exist from controlled studies. This may be due to a more widespread utilization of patient education for postinjury patients. Withholding patient education for ED-based injury management could be considered below the standard of care and therefore unethical, e.g., not providing instructions on burn, fracture, or wound management. Consequently, certain controlled clinical trials of patient education may not be possible.

IDENTIFICATION OF HIGH-RISK PATIENTS AND TARGETED EDUCATIONAL INTERVENTIONS The ED allows for identification of high-risk patients for focused patient educational efforts. For instance, a focused educational intervention for patients intubated for asthma resulted in better outcomes and cost savings when combined with other therapies and preventive measures.39 Substance abuse is a common condition that may be targeted in the ED for patient education and referral to outreach programs. Recently, a prevention project identifying at-risk patients in the ED was found to double the referral rate to alcohol and drug placement unit from the ED, with integrated community outreach and case staff working in conjunction with ED staff.40 Computer-based identification of high-risk patients and appropriate patient education content is promising. For example, adolescents may avoid bringing issues such as sexual activity or substance abuse to the attention of pediatricians. A

TABLE 1. Criteria for Evaluating Emergency Department (ED)-based Patient Education Programs* Fit for ED use

• Appropriate for time, staffing, and other logistic constraints of the ED

Validation

• Content and format validated by established or pilot program studies

Awareness of patient needs

• Appropriate to patients’ learning needs, abilities, and social/cultural backgrounds

Treatment information

• Teaches safe, effective use of medication and equipment, interactions and adverse effects

Patient interaction

• Continuously elicits feedback to ensure that the information is understood

Collaboration

• Coordinated among ED staff and consistent with other outside patient education

Patient responsibility

• Clearly delineates patient and family responsibility for patient’s ongoing health care needs

Preparation for ongoing care

• Educates on and rehabilitation techniques, additional community resources • Teaches when and where to obtain further treatment • Forwarding of any discharge instructions to patient’s continuing care providers

*Based on data obtained from: Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Hospitals, 1996. Oakbrook Terrace, IL: JCAHO, 1996.


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TABLE 2. Selected Internet Resources for Patient Education Material* Database of telephone hotlines for patients (National Institutes of Health) Patient handouts (with low-literacy versions) (UCSF Homeless Clinic) Online patient education Resource List (Oregon Health Sciences University) Patient information handouts (American Academy of Family Physicians) Health Info Handouts (Department of Health and Human Services) NOAH: Catalogued Patient Education Links (New York Online Access to Health)

http://newsis.nlm.nih.gov/hotlines http://itsa.ucsf.edu/⬃hclinic/handouts.dir/handouts.html http://www.ohsu.edu/bicc-Library/patiented/links.html http://familydoctor.org http://www.healthfinder.org/default.htm http://www.noah.cuny.edu

*Note: The reading level of many patient educational materials on the Internet is above that of many patients.71 Materials from these noncommercial sites may be used as written patient education materials in the emergency department, but must be reviewed for readability.

trial of a computerized questionnaire system found that teenagers reported significantly more often about high-risk issues and preferred the automated system, while still willing to share the results with a pediatrician.41 A similar system has been developed for the ED, with automated patient education output for a variety of issues ranging from sexual transmitted disease prevention to smoking cessation. Although a controlled trial of the ED-based system has been performed, results are still pending (Rhodes K, personal communication, Aug 1999).

CONSIDERATIONS FOR INSTRUCTIONAL MATERIAL Published studies of patient education programs often lack sufficiently detailed descriptions of the content and materials themselves. It has been suggested that a consensus be developed to standardize published descriptions and evaluations of educational interventions.18 Nevertheless, patient educational materials are readily available. Several detailed guides and examples already exist for implementing patient education in the ED.42–46 Additional patient educational materials can be obtained from numerous commercial and industrial sources, often free of charge. A suggested list of criteria to evaluate ED-based patient education programs is provided (Table 1). Though the ultimate factor in determining whether a specific educational intervention should be used must be its scientific validation in clinical trials, other factors are important as well. The theoretical framework, specific and general goals, content, and format of patient education program must be carefully reviewed. The efficacy of written educational material may be variable. Hospitalized stroke patients given an information packet were found to know more about stroke and report higher satisfaction;

also, their caretakers were found to have better mental health.47 Further, in an ED-based study, patients with nosebleeds who received information sheets in a previous visit, as a supplement to verbal instruction, demonstrated better recall of relevant first-aid knowledge.48 In addition, videotapes and other educational materials capitalize on otherwise unused and arguably wasted time when furnished to waiting patients and their families.49 Many handouts also can be accessed online and printed for patients (Table 2). However, clinicians should avoid relying exclusively on noninteractive written material. For instance, in a study of preventive health pamphlets distributed to ED patients, fewer than 65% of those contacted for follow-up had actually read the pamphlet.50 In a family practice clinic, noninteractive ‘‘environmental’’ education in the form of posters, pamphlets, and waiting room videos emphasizing preventive services did not significantly increase the actual use of preventive services.51 Ideally, written material should supplement rather than substitute direct one-on-one teaching by ED staff. Patient literacy is a significant factor in the use of written educational materials. A prospective study of comprehension of written discharge instructions by urban ED patients found that while the mean reading ability of the patients was at the sixth-grade level, printed discharge instructions were written at an 11th-grade reading level.52 A similar study found that only 72% of ED patients interviewed said they could read their discharge instructions.53 In a pediatric ED, it was found that several of the written instruction forms were above many parents’ reading levels.54 Physicians also significantly overestimate their patients’ understanding of discharge treatment instructions.55 It is worth noting that the various validated scales used in the studies of patient literacy may be useful in regular assessment of patient literacy in practice, outside of research studies. The potential consequences of this gap between

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patient literacy and the readability of educational materials are alarming. Poor and variable discharge instructions after ED visits can lead to noncompliance and unnecessary morbidity.56,57 Thus, patient educational materials already in place (and in development) need to be reviewed for readability.58,59 In a trial of a new set of simplified discharge instructions for wound care in sprains, patients who received the simplified instructions showed a significantly better understanding of the material when compared with historical control subjects receiving a previous version. In this instance, understanding was assessed by a five-question test, and patients were allowed to refer to the instruction sheet itself.60 Along these lines, illustrations and pictures may help.61 Emergency department patients with lacerations were randomly assigned to receive discharge instructions with or without illustrations; patients receiving text with illustrations rather than pure text instructions were significantly more likely to comprehend discharge instructions.62 Age-specific customization of discharge instructions also can be helpful. Elder patients in the ED were randomly assigned to receive either usual preprinted discharge instructions with handwritten medication information or computer-generated discharge instruction with enlarged-type information ordered within an elder memory schema (purpose, administration, emergency information). Medication knowledge was significantly higher for the subjects receiving the customized instructions, assessed by follow-up telephone interview 48–72 hours after discharge.63 A final consideration is the consistency in the manner in which patient education is delivered in the acute care setting. Although one study in a pediatric ED showed that parents given standardized rather than nonstandardized verbal instructions demonstrated significantly greater knowledge of information of their child’s illness,64 patient education should still be flexible to accommodate the patient’s learning needs. In all, patient education programs can be standardized and still allow intelligent customization to the requirements of each individual patient, and furthermore to the needs of each ED.

BEYOND THE ED Optimally, patient education should be a series of concerted efforts. Emergency department-based patient education should be integrated into disease management guidelines and pathways.65 Primary care providers, other health care professionals, and community-based programs all play a significant role in patient education outside the hospital. Furthermore, for certain illnesses and conditions, it


may be much simpler if the patient is admitted, for example, to a CCU, for a dedicated staff to perform patient education on a condition that is germane to their practice. The ED lends itself to only singular or episodic patient education sessions. Yet, it also offers an important opportunity to refer patients to programs that will continue the process of educating for better management and prevention of illness. This is particularly important for many patients who have poor access to health care outside of the ED, as well as for those who use the ED as their primary source of health care. Specific written and verbal instructions for follow-up with the primary care provider have been shown to significantly improve actual patient follow-up.66 Emergency department referral of patients to asthma education programs—a common strategy when no ED-based patient education is available—has been demonstrated to be effective in improving the management of asthma and patient outcomes.16,17 Recently, in an effort to decrease adolescent morbidity and mortality, youth violence interventions that begin in the hospital itself and focus on victims of violent assault have been evaluated.67 Also, telephone follow-up, used as part of several effective interventions mentioned above, can be a valuable component of patient education in an acute care setting. A trial of one telephone callback system for elder patients in the ED noted that several common concerns of patients were addressed by the telephone follow-up system, including clarification of home care instructions, advice to return to ED for re-evaluation, and referral to a medical social worker.68

CONCLUSIONS AND DIRECTIONS FOR FUTURE RESEARCH We should not dismiss formal patient education in the ED. Several controlled clinical studies have demonstrated the efficacy of standardized patient education in the ED for various conditions. Patient education also has been shown to improve patient outcomes in comparable acute care settings. The challenge that remains is to determine who are best targets for ED-based patient education, and how ED-based efforts can fit in with education offered by specialty-driven inpatient units that can concentrate on one specific condition or illness. It would be nearly impossible to offer patient education for every problem seen in the ED. The best approach will be to concentrate future research efforts on specific areas in patient education in which the ED is uniquely and strategically positioned. Emergency physicians should identify, for their specific setting, the most common conditions and


illnesses associated with ED revisits, particularly for those patients who use the ED as their sole source of health care. Randomized, controlled trials of educational interventions developed specifically for these conditions and patient populations are necessary. Patient education targeted for chronic diseases with acute episodes, such as asthma and diabetes, is particularly relevant for the ED setting. Prioritization and ensuing research at the national level may also be appropriate, particularly for those conditions that incur the heaviest ED utilization; these data are regularly updated and available in the National Hospital Ambulatory Medical Care Survey.69 Patient education in the ED can also be critical to address surveillance and prevention issues. The Society for Academic Emergency Medicine (SAEM) Public Health Task Force has identified several ‘‘candidate’’ activities for prevention, screening, and counseling in EDs, such as surveillance for domestic abuse and undiscovered alcohol abusers, as well as injury prevention and immunization.70 The heterogeneous ED patient population presents further challenges to future research. A great deal of research remains to be done on patient education designed for non-English speakers and/or multilingual populations. Useful studies could include simple quantitative assessments of the health knowledge of non-English-speaking and/or multilingual ED patients compared with control groups of English-speaking patients, as well as the effect of patient education in English vs nonEnglish native languages. Also, efforts aimed at developing intuitive interactive technologies could yield solutions capable of delivering patient education in multiple languages, as well as to illiterate patients, with minimal additional staffing requirements. In addition to studying the efficacy of ED-based educational interventions with respect to relevant health outcomes and ED utilization, it will also be useful to estimate the cost of these interventions, both direct and indirect. For example, while indepth ED education of the asthma patient may result in cost savings in terms of reduced hospitalizations and reduced mortality and morbidity, it is still unclear whether those savings can support hiring a full-time ED asthma educator. Relatively less expensive noninteractive education such as written or audiovisual presentations, as well as interactive educational technologies with little or no staffing requirements, will require rigorous validation studies to optimize their efficacy and justify their implementation. An overarching issue that needs further investigation, however, is the need to address logistic concerns of ED staff, such as the optimal amount of time to devote to patient education, and the most appropriate ED personnel to

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administer patient education, be they nurses (who have traditionally played the most prominent role in patient education), doctors, students, and/or trained nurse-educators. While ED-based patient education is a critical component of a broader set of interventions that continue beyond the ED, many patients who use the ED as their primary source of health care may not have access to formal patient education anywhere else. This becomes particularly relevant when patient education can improve outcomes in chronic illnesses with preventable acute episodes necessitating ED visits. Accreditation standards, legal considerations, and cost-efficiency concerns also compel the clinician to implement patient education in the ED. Finally, patient education has few, if any, adverse effects, and thus provides ideal interventions for research studies. Altogether, the literature suggests that patient education in the ED is feasible, while still indicating that additional research is needed to provide a more substantial evidence base from which to glean effective approaches designed specifically for EDs. The authors thank Drs. Stephen Emond and Sharon Smith for their thoughtful comments on the manuscript.

References 1. O’Leary MR. Lexikon: dictionary of health care terms, organizations, and acronyms for the era of reform. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 1994:xvi, 828. 2. Health literacy: report of the Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. JAMA. 1999; 281:552–7. 3. Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Hospitals, 1996. Oakbrook Terrace, IL: JCAHO, 1996:2v. 4. Blaes SM. Patient education protects from malpractice claims. Patient Educ Newslett. 1984; 7:8–9. 5. Bartlett EE. Cost–benefit analysis of patient education. Patient Educ Couns. 1995; 26:87–91. 6. Assal JP. Cost–effectiveness of diabetes education. Pharmacoeconomics. 1995; 8:68–71. 7. Sullivan S, Elixhauser A, Buist AS, Luce BR, Eisenberg J, Weiss KB. National Asthma Education and Prevention Program working group report on the cost effectiveness of asthma care. Am J Respir Crit Care Med. 1996; 154:S84–S95. 8. Hayslip DM, Suttle CD. Pre-ESRD patient education: a review of the literature. Adv Ren Replace Ther. 1995; 2:217–26. 9. Rich MW. Heart failure disease management: a critical review. J Card Fail. 1999; 5:64–75. 10. Lorish CD, Boutaugh ML. Patient education in rheumatology. Curr Opin Rheumatol. 1997; 9:106–11. 11. Todd KH. Air bags and the teachable moment. Ann Emerg Med. 1996; 28:242. 12. Bowling JR. Clinical teaching in the ambulatory care setting: how to capture the teachable moment. J Am Osteopath Assoc. 1993; 93:235–9. 13. McNamara RM, Worrilow CC. Asthma in the emergency department: an opportunity for education and intervention [abstract]. Acad Emerg Med. 1995; 2:158. 14. Shrestha M, Parupia H, Andrews B, et al. Metered-dose inhaler technique of patients in an urban ED: prevalence of incorrect technique and attempt at education. Am J Emerg Med. 1996; 14:380–4.

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15. Wasilewski Y, Clark NM, Evans D, Levison MJ, Levin B, Mellins RB. Factors associated with emergency department visits by children with asthma: implications for health education. Am J Public Health. 1996; 86:1410–5. 16. Gibson PG, Coughlan J, Wilson AJ, et al. Limited (information only) patient education programs for adults with asthma (Cochrane Review). The Cochrane Library. 1999. Oxford Update Software. 17. Gibson PG, Coughlan J, Wilson AJ, et al. Self-management education and regular practitioner review for adults with asthma (Cochrane Review). The Cochrane Library, 1999. Oxford Update Software. 18. Sudre P, Jacquemet S, Uldry C, Perneger TV. Objectives, methods and content of patient education programmes for adults with asthma: systematic review of studies published between 1979 and 1998. Thorax. 1999; 54:681–7. 19. Maiman LA, Green LW, Gibson G, MacKenzie EJ. Education for self-treatment by adult asthmatics. JAMA. 1979; 241:1919–22. 20. Kelso TM, Self TH, Rumbak MJ, Stephens MA, Garrett W, Arheart KL. Educational and long-term therapeutic intervention in the ED: effect on outcomes in adult indigent minority asthmatics. Am J Emerg Med. 1995; 13:632–7. 21. Emond SD, Reed CR, Graff LG IV, Camargo CA Jr. Asthma education in the emergency department [abstract]. Ann Emerg Med. 1999; 34(4 pt 2):S13. 22. Lindsay C, Jennrich JA, Biemolt M. Programmed instruction booklet for cardiac rehabilitation teaching. Heart Lung. 1991; 20:648–53. 23. Mayne JE. Teaching path balances LOS, education needs for MI. Hosp Case Manage. 1995; 3:171–4. 24. Perkins RJ, Oldenburg B, Andrews G. The role of psychological intervention in the management of patients after myocardial infarction. Med J Aust. 1986; 144:358–60. 25. Thompson DR, Meddis R. A prospective evaluation of inhospital counselling for first time myocardial infarction men. J Psychosom Res. 1990; 34:237–48. 26. Taylor CB, Houston-Miller N, Killen JD, DeBusk RF. Smoking cessation after acute myocardial infarction: effects of a nurse-managed intervention. Ann Intern Med. 1990; 113: 118–23. 27. van Elderen-van Kemenade T, Maes S, van den Broek Y. Effects of a health education programme with telephone followup during cardiac rehabilitation. Br J Clin Psychol. 1994; 33: 367–78. 28. Duryee R. The efficacy of inpatient education after myocardial infarction. Heart Lung. 1992; 21:217–25. 29. Blank FS, Doe S, Keyes M, Labrie L, Sabourin D, Patel S. Development of an ED teaching program aimed at reducing prehospital delays for patients with chest pain. J Emerg Nurs. 1998; 24:316–9. 30. Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med. 1995; 333:1190–5. 31. Clary C, Dever A, Schweizer E. Psychiatric inpatients’ knowledge of medication at hospital discharge. Hosp Community Psychiatry. 1992; 43:140–4. 32. Kelly GR, Scott JE, Mamon J. Medication compliance and health education among outpatients with chronic mental disorders. Med Care. 1990; 28:1181–97. 33. Robinson GL, Gilbertson AD, Litwack L. The effects of a psychiatric patient education to medication program on postdischarge compliance. Psychiatr Q. 1986; 58:113–8. 34. Rotheram-Borus MJ, Piacentini J, Van Rossem R, et al. Enhancing treatment adherence with a specialized emergency room program for adolescent suicide attempters. J Am Acad Child Adolesc Psychiatry. 1996; 35:654–63. 35. Dunn KA, Cline DM, Grant T, et al. Injury prevention instruction in the emergency department. Ann Emerg Med. 1993; 22:1280–5. 36. Kozak GS, Yura H. A comparison of teaching methods for ED discharge instruction after head injury. J Emerg Nurs. 1989; 15:18–22. 37. Warren D, Kissoon N. Usefulness of head injury instruction forms in home observation of mild head injuries. Pediatr Emerg Care. 1989; 5:83–5. 38. Smith S, Duncan M, Mobley J, Kagan R. Emergency room management of minor burn injuries: a quality management


evaluation. J Burn Care Rehabil. 1997; 18:76–80. 39. Doan T, Grammer LC, Yarnold PR, Greenberger PA, Patterson R. An intervention program to reduce the hospitalization cost of asthmatic patients requiring intubation. Ann Allergy Asthma Immunol. 1996; 76:513–8. 40. Bernstein E, Payne S, Levenson S, et al. Project ASSERT: a model for emergency department preventive intervention [abstract]. Acad Emerg Med. 1995; 6:298. 41. Paperny DM, Aono JY, Lehman RM, Hammar SL, Risser J. Computer-assisted detection and intervention in adolescent high-risk health behaviors. J Pediatr. 1990; 116:456–62. 42. Discenza DJ. A systematic approach to selecting and evaluating instructional materials. J Nurs Staff Dev. 1993; 9:196– 8. 43. Rush C. Patient education. In: Newberry L, Sheehy SB (eds). Sheehy’s Emergency Nursing: Principles and Practice. 4th/ed. St. Louis: Mosby, 1998:xv, 828. 44. Palmerini J, Jasovsky DA. Patient education: a guide for success. Nurs Manage. 1998; 29:45–6. 45. Guzzetta CE. Can critically ill patients be taught? In: Bille DA (ed). Practical Approaches to Patient Teaching. 1st ed. Boston: Little Brown, 1981:255–70. 46. Springhouse Corporation. Patient teaching. In: Nurse’s Reference Library. Springhouse, PA: Springhouse Corp., 1987: xvii, 683. 47. Mant J, Carter J, Wade DT, Winner S. The impact of an information pack on patients with stroke and their careers: a randomized controlled trial. Clin Rehabil. 1998; 12:465–76. 48. Lavy JA, Koay CB. First aid treatment of epistaxis—are the patients well informed? J Accid Emerg Med. 1996; 13:193– 5. 49. Kleemeier CP, Hazzard AP. Videotaped parent education in pediatric waiting rooms. Patient Educ Couns. 1984; 6:122– 4. 50. Berger P, Luskin M, Krishel S. Preventive health pamphlets in the emergency department. J Emerg Med. 1998; 16: 691–4. 51. Mead VP, Rhyne RL, Wiese WH, Lambert L, Skipper B. Impact of environmental patient education on preventive medicine practices. J Fam Pract. 1995; 40:363–9. 52. Spandorfer JM, Karras DJ, Hughes LA, Caputo C. Comprehension of discharge instructions by patients in an urban emergency department. Ann Emerg Med. 1995; 25:71–4. 53. Logan PD, Schwab RA, Salomone JA 3rd, Watson WA. Patient understanding of emergency department discharge instructions. South Med J. 1996; 89:770–4. 54. Chacon D, Kissoon N, Rich S. Education attainment level of caregivers versus readability level of written instructions in a pediatric emergency department. Pediatr Emerg Care. 1994; 10:144–9. 55. Calkins DR, Davis RB, Reiley P, et al. Patient–physician communication at hospital discharge and patients’ understanding of the postdischarge treatment plan. Arch Intern Med. 1997; 157:1026–30. 56. Thomas EJ, Burstin HR, O’Neil AC, Orav EJ, Brennan TA. Patient noncompliance with medical advice after the emergency department visit. Ann Emerg Med. 1996; 27:49–55. 57. de Oliveira M, Hassan TB, Sebewufu R, Finlay D, Quinton DN. Long-term morbidity in patients suffering a sternal fracture following discharge from the A and E department. Injury. 1998; 29:609–12. 58. Brooks DA. Techniques for teaching ED patients with low literacy skills. J Emerg Nurs. 1998; 24:601–3. 59. Lynch ME. When the patient is illiterate: how nurses can help. J Pract Nurs. 1992; 42:41–2. 60. Jolly BT, Scott JL, Sanford SM. Simplification of emergency department discharge instructions improves patient comprehension. Ann Emerg Med. 1995; 26:443–6. 61. Houts PS, Bachrach R, Witmer JT, Tringali CA, Bucher JA, Localio RA. Using pictographs to enhance recall of spoken medical instructions. Patient Educ Couns. 1998; 35:83–8. 62. Austin PE, Matlack R 2nd, Dunn KA, Kesler C, Brown CK. Discharge instructions: do illustrations help our patients understand them? Ann Emerg Med. 1995; 25:317–20. 63. Hayes KS. Randomized trial of geragogy-based medication instruction in the emergency department. Nurs Res. 1998; 47: 211–8.

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64. Isaacman DJ, Purvis K, Gyuro J, Anderson Y, Smith D. Standardized instructions: do they improve communication of discharge information from the emergency department? Pediatrics. 1992; 89:1204–8. 65. Ellrodt G, Cook DJ, Lee J, Cho M, Hunt D, Weingarten S. Evidence-based disease management. JAMA. 1997; 278:1687– 92. 66. Ogbevoen JO, Jaffe DM, Fisher EB, et al. Emergency department (ED)-based asthma educational intervention to increase the frequency of primary provider (PP) follow-up visits (FU) [abstract]. Acad Emerg Med. 1995; 2:430. 67. De Vos E, Stone DA, Goetz MA, Dahlberg LL. Evaluation of a hospital-based youth violence intervention. Am J Prev Med. 1996; 12:101–8.

68. Jones JS, Young MS, LaFleur RA, Brown MD. Effectiveness of an organized follow-up system for elder patients released from the emergency department. Acad Emerg Med. 1997; 4:1147–52. 69. Nourjah P. National Hospital Ambulatory Medical Care Survey: 1997 emergency department summary. Advance data from Vital and Health Statistics; No. 304. Hyattsville, MD: National Center for Health Statistics, 1997. 70. Rhodes K, Gordon J, Becker B, Lowe RA. Putting prevention into emergency medical practice. SAEM Newslett. 1998; 10(6):10–1. 71. Graber MA, Roller CM, Kaeble B. Readability levels of patient education material on the World Wide Web. J Fam Pract. 1999; 48:58–61.

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REFLECTIONS What do you think is the most important clinical advance our specialty has made? ‘‘The most important clinical advance that has been made in our specialty is the aggressive management of coronary artery disease and major trauma. The integration and management of emergency medical services outside of the medical establishment along with the emergency department care within the structure of the hospital are not necessarily clinical but have had a tremendous impact.’’ GEORGE PODGORNY, MD First President of ABEM, 1976–1981 ABEM Director, 1976–1988