PICO(T):
In adult intensive care patients, does nursing hand-off that involves the patient and family member compared to hand-off that only involves nurses improve nursing or clinician satisfaction with communication?

The lack of standardization of information shared during end of shift report or “handoff” in the intensive care unit often leads to inaccurate exchange of information. Without some standardization of what are pertinent issues and significant negatives, patient care is inconsistent and the results can be dissatisfaction among patient care staff, patient family members, and at times catastrophic for the patient. This is identified by the Joint Commissions as a need for improvement nationwide on hospital inpatient. National Patient Safety Goals (NPSB) includes improving the effectiveness of communication among caregivers in 2018 (Joint Commission, 2018). Handoff is defined as the transfer and acceptance of responsibility for patient care that is achieved through effective communication (Halm, 2013).
Population (P): Adult patients in intensive care unit
Intervention ( I ): nursing handoff in patient room and involve patient and family member at the end of shift
Comparison ( C ): Standard practice – nurse hand off report at the nursing station
Outcomes ( O ): better care collaboration and comprehension of patient, patient safety and satisfaction
Time ( T ): within the length of ICU stay
Reference:
The Joint Commission. (2018). The National Patient Safety Goals. Retrieved February 06, 2018 from
http://www.jointcommission.org/standards_information/npsgs.aspx
Halms, M. A. (2013). Nursing handoffs: Ensuring safe passage for patients. American Journal of Critical Care, 22(2), 158-161

PICOT Evidence Review 1 Evidence Search
Name
Institution

Date
PICOT Evidence Review 1 Evidence Search

The Joint Commission has predicted an estimate of 80% of serious level medical errors as being associated with the miscommunication between the caregivers during hand-off among the patients. The implication of the handoff is the transfer as well as the acceptance of the responsibility for the care of the patient attainable by means of enhancing communication effectiveness (Halms, 2013). In most cases, crucial information about the care of the patient is lost during changes in shifts. There is thus a need for enhancement of the safety and quality of handoff that requires the implementation of strategies that can support that initiative (Gordon & Findley, 2011). This assignments posits to shed light on the issue of hand-off and identify potential solution through the PICO(T) question formulation. It is also prudent to make use of information technology in searching the databases that offer evidence and select the suitable evidence that support the PICO(T) question as well as a critical appraisal of the evidence.
Most facilities lack information standardization that is essential during handoff in intensive care units that translates to high degree of inaccuracy in information exchange. The situation leads to inconsistent patient care with a high degree of dissatisfaction among the patients as well as the staff responsible for the patient care. The family members of the patients can also be affected and it can be catastrophic to the patients. The Joint Commissions and the National Patient Safety Goals suggests the need for improvements in communication effectiveness among the caregivers (The Joint Commission, 2018).
The evidence search shall be guided by a PICO(T) question that is developed for the purpose of executing evidence review on the best practices that entails the adult patients who are discharged with instructions as well as follow-up post disacharge in the emergency department.
Among the adults in the intensive care unit (P), does the handoff among the nurses that incorporate the patients with the family members (I), relative to the handoff that involves the nurses only (C), leads to improved nursing and the clinician satisfaction in communication (O) during the length of stay in the ICU (T).
In the above PICO(T) question, the population, P includes the adult patients in the ICU. The intervention, I is the nursing handoff at the end of the shift that involves the patient and the family members. The standard practice –comparison is the nurse handoff report. The outcomes, O entail the enhanced collaboration of care as well as the comprehension of the patient, the patient safety as well as satisfaction. Time, T is the length of stay in the ICU.
Description of Search
The search of evidence entails the utilization of the HS/HSL instructional librarian, the faculty, the feedback from the discussion board and module 3 as the guide to the search as well as the choice of evidence. It is appropriate to account for five studies that shall contribute in responding to the PICO(T) question and four out of the total are primary sources while the rest can be secondary or even primary sources. The prospective intervention studies coupled with the randomized controlled trials can form the best and ideal primary sources and thus, they deserve to be accorded priority. The evidence review also required the use of the CINAHL and the PubMed databases in the identification of the literature that addresses the PICO(T) question.
Specifically, the following were the search terms that formed the basis of evidence search: hand-off, change of shift, patient information, care safety, nurse staff satisfaction. The access to updated data was a crucial consideration that prompted limiting of the search to recent publications, not older than 5 years (2013 – 2018) that addressed issues relating to adult populations only. There was a further restriction to the peer reviewed articles when using CINAHL and PubMed. Apart from the searches in the databases, some articles were also resourceful that were located through the background research on the topic of handoff and due to the relevance to the PICO(T) question.
It is prudent to consider placing a greater echelon of emphasis on the high-quality of the outcomes in the handoff studies that focuses on the system factors in addition to the human performance relative to the effectiveness of the structured protocols, evaluation as well as education. The current research focuses on particular departments and institutions with much of their emphasis on the convenience use of designs, samples as well as outcome measures. The starting point in the future research in handoff must be the development of the conceptual framework that places the PICOT questions within the theoretical framework on the basis of the previous evidence search. It is also suitable to isolate the articles identified through evidence search that are not particular to the items of the PICOT questions. Only the articles that address all issues as suggested in the PICOT questions can be considered for use in the research.

 
Reference
Benham-Hutchins, M. M., & Effken, J. A. (2010). Multi-professional patterns and methods of communication during patient handoffs. International journal of medical informatics, 79(4), 252-267.
Butcher, L. (2015). The high-stakes handoff. Trustee, 68(3), 8-10,12. Retrieved from https://search.proquest.com/docview/1667959809?accountid=45049
Gordon, M & Findley, R., (2011). Educational interventions to improve handover in health care: a systematic review. Med Educ. 45(11):1081–1089.
Halms, M. A. (2013). Nursing handoffs: Ensuring safe passage for patients. American Journal of Critical Care, 22(2), 158-161
Halms, M. A. (2013). Nursing handoffs: Ensuring safe passage for patients. American Journal of Critical Care, 22(2), 158-161
The Joint Commission. (2018). The National Patient Safety Goals. Retrieved February 06, 2018 from http://www.jointcommission.org/standards_information/npsgs.aspx
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University of Maryland School of Nursing
NRSG 790 Methods for Research and Evidence-Based Practice

PICO(T) Evidence Review 1: Evidence Search Guidelines/Rubric
The purpose of this assignment is to identify a practice issue/problem, and approach the problem through the formulation of a PICO(T) question. Students will employ information technology to search databases for evidence, select evidence that supports the PICO(T) question, and critically appraise the evidence.
 Section 1 Practice Problem: utilize faculty, peers, Module 1 to guide problem identification.
 Section 2 Formulation of PICO(T): utilize faculty, peers, Modules 1 & 2, and faculty feedback on Discussion Board 2 to formulate a searchable PICO(T) question.
 Section 3 Evidence Search/Selection: utilize HS/HSL instructional librarian, faculty, Module 3 and Discussion Board feedback to guide a search for and selection of evidence:
o Include five studies to answer the PICO(T) question – four of which must be primary sources. The remainder may be either a primary or secondary source. Prospective intervention studies and randomized controlled trials are considered ideal primary sources and should be prioritized.
o Include a PRISMA flow diagram as an appendix
 Section 4 Evidence Review: utilize faculty feedback on the critique assignment and Modules 4 – 8 to guide the appraisal of the evidence, and complete an Evidence Review Table
 Utilize the Writing Center as needed. See sample paper and table templates in the Evidence Review Assignment folder under the Assignments/Assessment menu link on Blackboard

PICO(T) Evidence Review 1 Grading Rubric
Submission Requirements (submissions that fail to meet requirements will be returned)
 Submitted on Blackboard, through SafeAssign, under Assignment/Assessment menu link
 Completed in Word format, 3-4 pages in length excluding title page, references, and Appendices
 Students MAY NOT use papers from other courses as the basis of this assignment
Return submissions will be subject to the course policy for late assignments beginning the day the assignment is returned to the student for correction.

Section Content Potential Points Points
Practice Problem Practice problem is described and includes population, setting, practice area, and data to support the origin, magnitude & scope of the problem (incidence, prevalence, morbidity, mortality). Appropriate references are cited. 4
PICO(T)
Question
Components A PICO(T) question is framed to guide a foreground evidence review and includes: population, intervention, comparison group, outcome, and timeframe as applicable. 2
Evidence Search/Selection Search is described to include search strategy, databases, keywords & MESH terms, inclusion and exclusion criteria, and in sufficient detail so that others can reproduce the search. Includes PRISMA flow diagram detailing the search.
Identifies a total of 5 studies (4 relevant primary sources and 1 additional primary or secondary source) to answer the PICO(T) question (presented in Evidence Review Table). 3
Evidence Review Table

Evidence Review Table (submitted as appendices) is comprehensive/complete, and evaluated appropriate number of studies. Studies were high-quality, included an intervention, reflected each component of the PICO(T), and were rated appropriately. 5
Format Appropriate use of APA format, included a title page, references, and Appendices. Correct grammar, syntax, punctuation. 3-4 page limit, excluding title page, references, and Appendices 1
TOTAL POTENTIAL POINTS/GRADE 15

Appendix A

PRISMA Diagram

Appendix B

Evidence Appraisal Table Template

Study citation:
Study objective/intervention or exposures compared Design Sample (N) Intervention Outcomes studied (how measured) Results Level

Do Follow-up Phone Calls Post Discharge Impact ED Patients
Do Follow-up Phone Calls Post Discharge Impact ED Patients?

Introduction

Emergency department (ED) patients are often discharged home with instructions for follow-up care, such as medication use, wound care, or appointments with primary care providers or specialists. However, many patients do not adhere to these instructions, which may lead to adverse outcomes, such as ED return visits, hospitalization, or death. Older patients are especially vulnerable to these outcomes, as they may have multiple comorbidities, functional and cognitive impairments, and lack of social support. Therefore, it is important to ensure that ED patients receive adequate transitional care after discharge.

One possible strategy to improve transitional care is to provide telephone follow-up (TFU) calls to ED patients after discharge. TFU calls are intended to assess the patient’s condition, reinforce the discharge instructions, address any barriers or concerns, and facilitate the coordination of care. TFU calls may also enhance the patient’s satisfaction and trust in the health care system. However, the evidence on the effectiveness of TFU calls for ED patients is mixed and limited. Therefore, this research essay aims to answer the following question: Do follow-up phone calls post discharge impact ED patients?

Methods

This essay will conduct a systematic review of the literature on TFU calls for ED patients discharged home. The review will follow the PRISMA guidelines and will include the following steps:

– Define the eligibility criteria for selecting studies: The review will include controlled studies (randomized or non-randomized) that compare TFU calls by health care professionals (nurses, physicians, pharmacists, etc.) with usual care or other interventions for ED patients aged 18 years or older who are discharged home. The studies should report at least one of the following outcomes: ED return visits, hospitalization, mortality, medication adherence, discharge plan adherence, patient satisfaction, or quality of life. The studies should be published in English from 2016 to 2024.
– Search the relevant databases and sources: The review will search the following databases: PubMed, Cochrane Library, CINAHL, Web of Science, and Scopus. The search strategy will use a combination of keywords and MeSH terms related to TFU calls, ED patients, and discharge. The review will also search the reference lists of the included studies and relevant systematic reviews for additional studies.
– Screen the titles and abstracts of the retrieved records: Two reviewers will independently screen the titles and abstracts of the records using a predefined form based on the eligibility criteria. Any disagreements will be resolved by discussion or consultation with a third reviewer.
– Assess the full-text articles of the potentially eligible records: Two reviewers will independently assess the full-text articles of the records that passed the screening stage using a predefined form based on the eligibility criteria. Any disagreements will be resolved by discussion or consultation with a third reviewer.
– Extract the data from the included studies: Two reviewers will independently extract the data from the included studies using a predefined form that covers the following information: study characteristics (authors, year, country, design, setting, sample size), intervention characteristics (timing, frequency, duration, content, provider), control characteristics (usual care or other intervention), outcome measures (definition, assessment method, time point), and results (effect size, confidence interval, p-value).
– Assess the risk of bias of the included studies: Two reviewers will independently assess the risk of bias of the included studies using the Cochrane risk of bias tool for randomized trials or the ROBINS-I tool for non-randomized trials. The tool covers domains such as randomization, allocation concealment,

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

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?

Assignment
Institution Affiliation
Name of Student
Instructor’s Name

Making a significant focus on the PICO (T) question review, a single aspect would be considered and discussed. This is; in patients with dementia, is using medications more effective than alternative therapies (i.e. art, music, tasks) for a reduction in agitation within one to three hours? This PICOT question is an interventional question. It addresses agitation in dementia patients, and which interventions are most effective.
The clinical issue of agitation in dementia patients is important. Much of the time, medications are used for a reduction in agitation. This method has pros and cons. By using a medication, it is considered a chemical restraint, and proper documentation needs to be implemented to ensure that the facility is in compliance with state regulations. Another issue, too, with the use of these medications in the elderly is the way the body processes them. The elderly have physiological changes that affect the way their body processes medications. There is a lowering of hepatic blood flow – which slows down the rate of which the body uses and metabolizes the drug (Wooten, 2012). Another factor to consider is that many of these medications can increase the risk of falls in the elderly. Not only are the elderly more susceptible to the sedative effect, hypotension can be induced – both of which can elicit more falls in said population (Lindsey, 2009). That being said, there is a use, as well as evidence based practice, that alternative therapies can be effective to reduce agitation in the elderly.
There is evidence that alternative therapies can be used to reduce agitation. Some examples of alternative therapies include: art therapy, aromatherapy, music therapy, and activity therapy. There is even something called bright-light therapy that is used for those with sundowning, and this has shown some effect in studies. (Douglas, James, Ballard, 2004). In Hong Kong, a study was performed using aromatherapy in Chinese dementia patients. Lavender inhalation was used, and found to be effective in reducing anxiety in these patients (Lin, Chan, Ng, Lam, 2007).
Of course, this does not in any way disregard the effectiveness and necessity of using medications to address agitation. Unfortunately, alternative therapies do not always work and then the use of an anti-anxiety medication is warranted. It is important, though, to ensure that alternative interventions are attempted in order to reach the best possible outcome with the least side effects.
Nurses are quite busy throughout their day, and do not always have the time to intervene using alternative modalities. Therefore, it is important that auxiliary staff – such as recreational staff and nursing assistants are taught how to utilize these alternative modalities, as it is proven in evidence-based practice that there are better outcomes for the patient by using alternative therapies in dementia patients. Agitation in dementia patients can be decreased in a reasonable amount of time by utilizing strategies of alternative therapies and are just as, if not more, effective than the use of psychotropic medication.

References:
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
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
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
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
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
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
Douglas, S., James, I., Ballard, C. (2004): Non-pharmacological interventions in dementia. Advances in Psychiatric Treatment. Retrieved July 9, 2014 from http://apt.rcpsych.org/content/10/3/171.full
Lin, P., Chan, W., Ng, B., Lam, L. (2007). Efficacy of aromatherapy (Lavender angustifolia) as an intervention for agitated behaviours in Chinese older persons with dementia: A cross-over randomized trial. University of Hong Kong. Retrieved July 10, 2014, from http://hub.hku.hk/handle/10722/174236
Lindsey, P.L. (2009). Psychotropic Medication Use among Older Adults: What All Nurses Need to Know. Journal of Gerontological Nursing. Retrieved July 9, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3128509/
Wooten, J. M. (2012). Pharmacotherapy Considerations in Elderly Adults. National Center for Biotechnology Information. Retrieved July 9, 2014, from http://www.ncbi.nlm.nih.gov/pubmed/22864103

APPENDCES
Appendix 1
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?

Appendix 2:
PRISMA Search Flow DIagram

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