RESEARCH ARTICLE

Parents Support Teach-back, Demonstration, and aPostdischarge Phone Call to Augment DischargeEducationSarah H. Vepraskas, MD,a Peter O’Day, BS,a Liyun Zhang, MS,a Pippa Simpson, PhD,a Sandra Gage, MD, PhDb

A B S T R A C TOBJECTIVES: To identify caregiver preferences for discharge education components, content, andtechniques.

METHODS: Before discharge education, a 9-question structured interview was performed withcaregivers of children from 2 populations admitted to the hospital medicine service: patients withasthma (age 2–17 years) or children who were not dependent on technology (age ,2 years). McNemar’stests were used to evaluate for significant differences between response options. Open coding was usedfor theme development to interpret qualitative responses about information caregivers wished to receivebefore leaving the hospital.

RESULTS: The interview was administered to 100 caregivers. More than 90% of caregivers believedthat instruction regarding follow-up appointments, medications, and reasons to call the pediatrician orreturn to the emergency department were important aspects of discharge education. Caregivers alsoidentified a desire for education on their child’s condition, care at home, and illness prevention. Mostcaregivers reported that teach-back, early discharge education, and a postdischarge phone call would bebeneficial. Caregivers varied in their preferences for written, verbal, and video instruction, whereas livedemonstration was rated almost universally as an effective method by 97% of caregivers (P , .0001).

CONCLUSIONS: In our study, we provide insight into caregivers’ perspectives on the content, timing,and style of education needed to promote a safe transition of care from the hospital to the home.These findings add caregiver support to the expert consensus in Project Improving Pediatric Patient-Centered Care Transitions and elucidate additional themes to aid in further study and optimization ofdischarge education.

aDepartment ofPediatrics, Medical

College of Wisconsin,Milwaukee, Wisconsin;

and bPhoenix Children’sHospital, Phoenix, Arizona

www.hospitalpediatrics.orgDOI:https://doi.org/10.1542/hpeds.2018-0119Copyright © 2018 by the American Academy of Pediatrics

Address correspondence to Sarah H. Vepraskas, MD, Section of Hospital Medicine, Department of Pediatrics, Medical College ofWisconsin, Children’s Corporate Center, C560, 999 N. 92nd St, Milwaukee, WI 53226. E-mail: svepraskas@mcw.edu

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Mr O’Day was funded by the Medical College of Wisconsin Summer Research Program with a summer research internship thatallowed for him to perform caregiver interviews.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Dr Vepraskas contributed to the conceptualization of the study design, participated in the qualitative data analysis, and drafted theinitial manuscript; Mr O’Day contributed to the conceptualization of the study design, performed data collection, participated in thequalitative data analysis, and reviewed and revised the manuscript; Ms Zhang and Dr Simpson performed the quantitative statisticalanalysis and reviewed and revised the manuscript; Dr Gage contributed to the conceptualization of the study design, reviewed thequalitative data analysis, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted andagree to be accountable for all aspects of the work.

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Hospital discharge presents a safetyrisk for pediatric patients. Inadequatedischarge preparedness can lead tomissed follow-up appointments, medicationerrors, and failure to recognizecomplications.1–5 Several dischargeinitiatives are used to promote the useof evidence-based strategies to improvethe discharge transition, such ascomprehensive education of thecontingency plan, the use of teach-back forconfirming discharge instructions, and apostdischarge phone call.6–8 In preparationfor the American Academy of Pediatrics,Section on Hospital Medicine Transitionsof Care Collaborative’s Project ImprovingPediatric Patient Centered Care Transitions(IMPACT), primary care providers andhospitalists were surveyed to gainconsensus regarding which informationis essential for discharge education.9–11

Providers concurred that follow-upappointments, medications, and reasonsto call medical providers or go to theemergency department are essentialelements of discharge education.

Caregivers of pediatric patients (parents,guardians, or the primary person presentwith the child during the hospital stay)likewise acknowledge the need forthorough and complete dischargeeducation and report dissatisfactionwhen this is not provided. However,caregivers also report that comprehensivedischarge education can be overwhelmingbecause of the volume of material,mental exhaustion, and competingconcerns during the hospitalization andat the time of discharge.12 As a resultof these barriers, caregiver assimilationof discharge material may be limited.Hence, information provided at dischargeneeds to be patient centric andindividualized to the needs of therecipient.13,14 Discharging providers arechallenged to provide comprehensiveinformation in a manner that is readilyunderstood, remembered, and able to beexecuted postdischarge.

There is a developing body of literature inwhich the efficacy of different teachingstyles for patient and family education isexamined. Instructional methods that are

investigated include written and verbaleducation, visual aids, demonstration, andteach-back.15–30 Although little is knownabout caregiver educational preferences,we inferred that aligning learnerpreferences with proven teaching methodscould facilitate improved communication ofimportant discharge content.

With increasing importance placed onimproving discharge instruction,investigation of caregivers’ attitudesregarding recommended strategies andlearning styles is the next logical step inimproving the discharge transition. Ourobjective for this study was to investigatecaregiver preferences and attitudesregarding discharge education learningstyles, content, techniques, and strategies tooptimize the educational approach.

METHODSStudy Design

In this descriptive mixed-method study, weused a structured interview to assesscaregiver preferences regarding dischargeeducation. A 9-question interview wasdeveloped via consensus of the study groupon the basis of a review of the literature anddiscussion with local discharge transitionexperts. Questions were focused onassessment of caregiver perceptions of theimportance of various components ofdischarge educational content, preferredteaching styles and timing, and attitudesregarding teach-back. Interview questionswere reviewed by a member of thehospital’s family advisory council andworded at a fifth-grade reading level.A single study group member read thequestions aloud to caregivers of children atany point during their hospitalization beforethe onset of discharge education. Theresponses were summarized in writingduring the interview and reviewedimmediately after the interview to ensureaccuracy. Responses were then transcribedinto REDCap. In this article, we discuss thefindings of the 6 questions that werefocused on caregiver perspectives ondischarge education.

Setting

The study took place at an urban, free-standing, tertiary-care pediatric hospital

with 306 beds, 16 436 admissions peryear, and an average daily census of215 patients. The average daily hospitalmedicine census was 27 patients with anaverage length of stay of 3.11 days.Previous local work revealed that 55%(276 of 495) of caregivers presenting to theemergency department had low healthliteracy, as determined by the Newest VitalSign, a 6-question test used to assesshealth literacy.31,32

Caregiver Selection

Potential participants were selected to alignwith patients enrolled in our local ProjectIMPACT study group and included caregiversof children ,2 years of age who were notdependent on technology and childrenbetween the ages of 2 and 17 years withasthma admitted to the hospital medicineservice on an acute care unit. Selection wasbased on mutual caregiver and intervieweravailability. Interviews were performedduring an 8-week period 7 days per weekduring daytime hours. Interpreter serviceswere available for the interview in manynon-English languages. Project IMPACT issupported by the American Academy ofPediatrics and is a multisite qualityimprovement initiative and researchcollaborative formed to promotepartnership between patients, caregivers,and medical teams to improve dischargetransition outcomes.

Variables and Outcomes

The structured interview contained Likertscale and yes or no questions, with anopen-ended response option available onthe basis of the initial answer (see Fig 1).Questions were formulated to investigatecaregiver attitudes and preferencesregarding the following: (A) goals ofhospitalization, (B) concerns aboutdischarge, (C) learning styles, (D) teach-back, (E) discharge education content,and (F) timing of discharge education.For the sake of this mixed-methods study,responses to questions related to items Cto F above are presented and analyzed inthis report and correspond to questions1 to 6 (Fig 1).

Categorical data, including insurance type,study population (ie, children ,2 years of

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age who were not dependent on technologyor children between the ages of 2 and17 years with asthma), previoushospitalization at our institution within3 years, and length of stay, were collectedvia a chart review.

Data Analysis

Frequency counts were used to showdistributions of the responses to the Likertscale–based questions. The McNemar’sexact test was used for paired comparisonsof learning style preferences to determinesuperiority. Fisher’s exact test was used toanalyze the association between preferencefor teach-back and other variables. A 2-sided P value of ,.05 was consideredstatistically significant. All analyses wereconducted by using SAS 9.4 (SAS Institute,Inc, Cary, NC).

To analyze the open-ended responses toquestion 2 (“Are there any other things thatyou would like to learn about before youleave the hospital? If so, what are thosethings?”), 1 researcher with qualitativeexperience formulated coding principlesand provided instruction to 2 additionalmembers. Two of the members of the coding

team reviewed the responses andperformed open coding to identifycategories and then grouped the categoriesinto 3 themes. The study team leaderindependently reviewed the results toprovide feedback and arbitratediscrepancies.

Ethical Issues

The study was approved by the Children’sHospital of Wisconsin Institutional ReviewBoard.

RESULTSPatient and Caregiver Characteristicsof Interview Participants

Of 101 caregivers who were approached tocomplete the structured interview,100 caregivers agreed. Eighty-seveninterviews were completed with just1 caregiver (70 with just the mother and17 with just the father), and 9 interviewswere completed with both caregivers. Twointerviews were completed with thepatient’s grandmother, and 2 interviewswere completed with a foster mother. Eachinterviewee completed the entire interview.All caregivers who were intervieweddesignated English as their primary

language. For patient demographics andother information, see Table 1.

Discharge Education ContentPreferences

In response to the Likert scale questionsused to determine caregiver attitudesregarding discharge education content, themajority of caregivers rated each of theelements as extremely important, as shownin Fig 2.

Additional Desired InformationCaregivers Would Like to LearnBefore Leaving the Hospital

Caregiver responses regarding additionalinformation they would like to learnbefore leaving the hospital were analyzedby using open coding. Forty-four distinctresponses from 28 different respondentswere categorized into 3 themes (Table 2).Themes included understanding care athome (50% of responses), understandingclinical condition (31.8% responses), andillness prevention (18.2% of responses).

Learning Style Preferences

In response to the question about learningstyle preferences, most caregivers (90%)rated live demonstration (someone showsyou) as a very good way to learn how togive a medication. Between 34% and 37% ofthe time, the other 3 methods (videoinstruction, verbal instruction, or writtendirections) were rated as a very good wayto learn (Fig 3). When live demonstrationwas compared with the other learningstyles individually by using McNemar’sexact test, preference for livedemonstration over each was statisticallysignificant with a P value of ,.0001 for all3 comparisons.

Preferences for Teach-back, Timing ofDischarge Education, andPostdischarge Communication

Most caregivers (90%) agreed thatrepeating what they had learned (teach-back) would be beneficial. The majority(92%) also believed it would be helpful toreceive a follow-up phone call. Lastly, 97%of caregivers believed that it would behelpful to begin discharge instructionbefore the day of discharge. There was nodifference between the rate of teach-back

FIGURE 1 Selected structured interview questions.

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preferences between study groups(children ,2 years of age versus children2–17 years of age with asthma; Fisher’sexact test P value 5 .644).

DISCUSSION

With the results of our study, we provideinsight into caregivers’ educationalpreferences regarding dischargeeducation. With our findings, we confirmthat caregivers agree with medicalproviders regarding the content ofinformation deemed essential to be

communicated before discharge. Inaccordance with the survey of primarycare physicians and hospitalists thatwas used to inform the content of theProject IMPACT bundle, most caregiversagree that information about follow-upappointments, medications, and reasons tocall medical providers or go to theemergency department are essentialelements of discharge education. Whengiven an opportunity to express whatother information may be helpful at thetime of discharge, desired content

generally fit into the following 3 themes:care at home, information about the child’scondition, and illness prevention. Theseadditional themes reinforce the need toallow families time and opportunity to askquestions specific to their child’s situation.

In addition to tailoring content, teachingstyle preferences should also be consideredto maximize learning. In response to thequestion about learning methodpreferences, caregiver responses variedwidely. Although 1 caregiver may feel thatvideo instruction is a good way to learn,another may prefer written directions. Wefound that most caregivers desired livedemonstration as a technique for learningabout medication administration. Involvingcaregivers in deciding on their dischargeeducation methods and supplementalcontent could help families better assimilatethis information before they leave thehospital.

Regardless of the teaching style used,confirmation of understanding is essentialto ensure caregiver readiness fortransition of the care plan to home. Teach-back as a method of confirmingunderstanding has gained attention as animportant educational tool among healthcare providers. Previous studies haverevealed teach-back to be an effectivemethod for discharge education in both theemergency department and inpatientsettings.23,24,29,30 As part of our local ProjectIMPACT efforts, a hospital-wide initiative topromote the use of teach-back wasundertaken. However, a chart review ofdischarge education documentationrevealed that compliance by nursingpersonnel was poor.33 Nursing personnelidentified 1 cause of poor compliance astheir perception that home caregiversfound the practice insulting or tedious.Contrarily, the findings from this workreveal that most caregivers of children inthe hospital reported that teach-backwould increase their comfort with thecontent of discharge education. We haveused this information locally to promotethe use of teach-back with significantsuccess, as revealed by increased rates ofteach-back use on the follow-up chartreview.33

TABLE 1 Patient Characteristics

Patient Characteristics Overall, N 5 100

Age, y, median (IQR) 0.57 (0.11–4.12)

Sex, n

Boys 62

Girls 38

Length of stay, d, median (IQR) 2.00 (1.00–2.75)

Diagnosis, n

Asthma or reactive airway disease 35

Infant with fever 10

Bronchiolitis 7

Brief resolved unexplained events 7

Febrile urinary tract infection or pyelonephritis 6

Bacteremia 6

Failure to thrive 4

Cellulitis 4

Croup 3

Hyperbilirubinemia 2

Other (including dehydration, viral illness,Escherichia coli, and meningitis)

16

Population, n

Children age 2–17 y with asthma 28

Infant or toddler ,2 y of age 72

Race, n

White 38

Black or African American 43

Asian American 7

American Indian or Alaskan native 1

Other 11

Ethnicity, n

Not Hispanic or Latino 85

Hispanic or Latino 8

Other 7

Payer, n

Private insurance 32

Medicaid 68

IQR, interquartile range.

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Almost all caregivers reported thatbeginning discharge education before thedate of discharge would be helpful for theirhospital-to-home transition. Evidence fromthe educational literature suggests that theinstructional strategy of spaced repetitionpromotes effective learning.34 Multipledischarge initiatives, including ProjectIMPACT, have been used to promote theinitiation of discharge education before thedate of discharge. With our study, weconfirm that caregivers are open to thisstrategy. By starting discharge educationearlier and spreading it throughout the

hospitalization, caregivers may haveimproved retention of the dischargeinformation.

Previous work has revealed thatpostdischarge phone calls can be beneficialin reinforcing both the discharge plan anduse of home medications in pediatricpatients.35,36 The fact that most caregiversthought a postdischarge phone call wouldbe helpful reinforces the importance ofthese calls as a component of completehospital-to-home care. However, routinepractice of placing postdischarge phonecalls is labor intensive, representing

significant organizational commitment andcost. More research is needed to determineif certain populations would benefit morethan others in receiving postdischarge calls.

As a descriptive mixed-methods study, ourapproach has limitations related to validityand sample population. The interviewquestions were developed by study groupconsensus to address questions related tolocal practice and are not validated.Additional open-ended questions may haveallowed for interviewees to elaborate morefully on specific learning style preferences;however, this would have limited the abilityto perform comparative statistical analyses.Although language spoken other thanEnglish did not exclude participation,because of caregiver and intervieweravailability, only English-speakingindividuals were included in the study. Inaddition, caregivers were chosen on thebasis of whether their child met the criteriafor the previously defined Project IMPACTstudy populations; thus, the results may notbe generalizable to all caregivers. Althoughthese results serve to reveal that variationsin teaching style preferences by individualsand populations may exist, a survey ofcaregivers of a broader population ofpatients would be necessary to make moreglobal conclusions.

With our findings, we provide insight intocaregivers’ preferences for dischargeeducation content and methods. Caregiversendorsed the Project IMPACT dischargeelements and additionally identified a desirefor education on the child’s condition, careat home, and illness prevention. Caregiverssupported starting education early duringhospitalization and following-up with apostdischarge phone call, suggesting apreference for a comprehensive program ofeducation. In line with adult learning theory,caregivers’ preferences for methods ofinstruction varied across verbal, written,and video instruction. Caregivers almostuniversally endorsed a preference for livedemonstration and teach-back duringdischarge education. Overall, we providewith our study important insight intocaregivers’ perspectives on the timing,content, and style of education needed topromote a safe transition of care from the

FIGURE 2 Caregiver ratings of Project IMPACT discharge education elements. ED, emergencydepartment.

TABLE 2 Selected Examples of Caregiver Responses About What Else They Would Like to LearnBefore Leaving the Hospital

Theme and Code Example Response

Understanding care at home

What to expect at home “Timeline of what will happen when she goes home”

Caring for child after condition improves “When she can go back to day care”

Medication discharge education “Tips on how to get him to use the inhaler better”

Condition-specific discharge education “How to tell if wheezing and other noises are bad ornormal”

Contingency plan “What to look for”

Understanding clinical condition

Condition-specific information “They talked about mucous in his lungs; I would like to knowmore about what is going on.”

Pending results follow-up “If something is discovered after we leave, how will weknow?”

Understanding current condition “Know what is really going on because I don’t want to comeback”

Illness prevention

How to prevent illness “How to prevent it from happening again”

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hospital to the home. In future studies,comparing these approaches to determinewhich patients benefit most could helpguide resource allocation.

Acknowledgments

We thank the Project IMPACT NationalCollaborative for allowing us to perform thisstudy within the larger study, in particular,Drs David Cooperberg, Leah Mallory, andSnezana Osorio (national Project IMPACTproject leaders); our local Project IMPACTworking group for their contributions tointerview development and data analysis;Kelsey Porada for assistance with tablesand figures after the creation of the article;the pediatric hospital medicine faculty forallowing the caregivers of their patients tobe interviewed; and the parents andcaregivers for their participation in ourstudy.

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DOI: 10.1542/hpeds.2018-0119 originally published online November 21, 2018; 2018;8;778Hospital Pediatrics 

Sarah H. Vepraskas, Peter O'Day, Liyun Zhang, Pippa Simpson and Sandra GageAugment Discharge Education

Parents Support Teach-back, Demonstration, and a Postdischarge Phone Call to

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Sarah H. Vepraskas, Peter O'Day, Liyun Zhang, Pippa Simpson and Sandra GageAugment Discharge Education

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