Discharge Instructions: Do Illustrations Help Our Patients Understand Them?,☆☆,

Presented as a poster at the annual meeting of the Society for Academic Emergency Medicine, Washington, DC, May 1994.
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Abstract

Study objective: To determine whether the addition of illustrations to discharge instructions improves patient comprehension.

Design: Randomized, blinded, prospective study. A blinded investigator asked a series of questions designed to test the participant's comprehension of the discharge instructions. There were 10 possible correct responses. Setting: Emergency department of a rural Level I trauma center. Participants: Convenience sample of 101 patients discharged with the diagnosis of laceration. Interventions: Patients were randomly assigned to receive discharge instructions with (n=54) or without (n=47) illustrations. Results: The median number of correct responses was five. Patients with illustrations were 1.5 times more likely to choose five or more correct responses than those without illustrations (65% versus 43%; P =.033). The effect of illustrations varied by demographic group. Among nonwhites (n=51), patients with illustrations were more than twice as likely to choose five or more correct responses (P =.032). Among patients with no more than a high school education (n=71), patients with illustrations were 1.8 times more likely to choose five or more correct responses (P =.038). Among women (n=48), patients with illustrations were 1.7 times more likely to chose five or more correct responses (P =.006). Conclusion: The addition of illustrations to discharge instructions for patients who have sustained lacerations improves patient comprehension. There is a larger effect among patients who are nonwhite, female, or have no more than a high school education. [Austin PE, Matlack R, Dunn KA, Kesler C, Brown CK: Discharge instructions: Do illustrations help our patients understand them? Ann Emerg Med March 1995;25:317-320.]

Section snippets

INTRODUCTION

Nearly half of the adults in the United States have been found to lack the literacy skills necessary to cope with modern life.1, 2 This lack has been found to adversely affect the ability of emergency department patients to understand written discharge instructions.3 Our study was designed to test the hypothesis that the addition of illustrations would increase patient understanding of discharge instructions.

MATERIALS AND METHODS

This study was approved by the institutional review boards of Pitt County Memorial Hospital and the East Carolina University School of Medicine. During the study period, two sets of discharge instructions were used for patients with lacerations—one with illustrations (Figure 1) and one without illustrations. The written text was identical on both sets of discharge instructions. To facilitate comparison of results, these instructions are similar to those previously published by Jolly et al.3

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RESULTS

Of 271 patients with lacerations during the study period, 101 were enrolled. Seventy-six patients were interviewed by telephone, and 25 were interviewed in the ED. Fifty-four patients received discharge instructions with illustrations, and 47 patients received discharge instructions without illustrations. There were no statistically significant differences in the distributions of age, race, sex, or education between patients with and without illustrations.

There were 10 correct responses among

DISCUSSION

Jolly et al3 tested the ability of ED patients to comprehend preprinted discharge instructions by giving the instructions to patients and then asking a series of five questions designed to test comprehension. They found that patients with an educational level beyond the twelfth grade scored significantly better than those with a twelfth-grade education or less. In the same study, they applied readability formulas to 47 sets of preprinted discharge instructions from six different EDs; grade

CONCLUSION

The addition of illustrations to discharge instructions for care of lacerations improves patient comprehension.

References (6)

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    All 4 studies were conducted in emergency departments in the United States. One trial, conducted in a rural level 1 trauma center, recruited 101 participants (54 in the intervention group and 47 in the control group) who presented to the emergency department with lacerations between June 1993 and July 1993.38 The second study, involving 205 adults and children presenting to the emergency department with wounds of which 103 received wound care instructions with cartoons and 102 received instructions without cartoons, was conducted in a community hospital and tertiary care facility between April 1994 and July 1994.14

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    Pictures have also improved comprehension when closely linked with text or spoken words compared to text alone [45]. This relationship is likely increased for individuals with lower health literacy [5,45–48]. Previous reviews found that pictures facilitated patients’ learning and understanding of health information [45,49,53,54].

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From the Department of Emergency Medicine, East Carolina University School of Medicine*; East Carolina University School of Medicine (student); and Center for Health Sciences Communication, East Carolina University School of Medicine§, Greenville, North Carolina.

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Address for reprints: Kathleen A Dunn, MD, MSPH, Department of Emergency Medicine, Brody 4W-54, East Carolina University, Greenville, North Carolina 27858, 919-816-2954, Fax 919-816-3589,

Reprint no. 47/1/62317

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