eHealth Intervention for Patients in Transitional Care Who Have Suffered Traumatic Injury
Emergency departments (ED) have become the default first line of healthcare. 81.8% of unscheduled hospital admissions come through the ED and 17.9% of America’s GDP is going toward healthcare (Most Unscheduled Hospital Admissions Now Come Through ER, 2013). Healthcare and pensions jointly hold first place, 17.9% being the highest percentage of all GDP segments (Health expenditure, total (% of GDP) World Bank, 2015). In order for our economy to improve we are going to need to reduce both those numbers, even while the percentage of our elderly (and their greater associated healthcare cost) increases from 12.4% to 19% (Administration on Aging (AoA) Aging Statistics, 1600). It is estimated that the healthcare expenditure will increase to US$4.6 trillion by the year 2020 (Moreno, 2013). Improving the efficiency of the ED would help more rapidly discharge that 81.8% of unscheduled visits, hopefully leading to better outcomes and reducing the drain on medical resources.
Every year approximately 22% of ED admissions are due to injuries (National Hospital Ambulatory Medical Care Survey, 2010). Unintentional injuries are coded to include falls, motor vehicle traffic, struck against or struck accidentally by objects or persons, overexertion or strenuous movement, cutting or piercing instruments or objects, natural and environmental factors, foreign bodies, fire and flames, hot substances or objects, caustic or corrosive and steam, motor vehicle nontraffic, pedal cycle, caught accidentally in or between two objects, suffocation, and machinery. Intentional injury includes assault, unarmed fight or brawl, striking by blunt or thrown object, cutting or piercing instruments, and self-inflicted injury. Finally, there are injuries of undetermined intent, which include medical and surgical complications, adverse drug effects, and alcohol and drug use.
Many of these patients require specialty care, but encounter roadblocks along the way that encourage them to postpone follow-up care until their condition has become acute (Messina et al., 2013). They then return to the ED in an advanced state of distress, which makes them both more difficult and more expensive to treat. If patients can be encouraged to transition from the ED into follow-on care successfully, there will be better outcomes for the patient and a reduction in preventable healthcare costs for the system at large.
The target population of the proposed eHealth intervention will be patients who have suffered traumatic injury and are being discharged from the ED to transition into specialist care and/or physical therapy. Traumatic will be defined as any patient with an Injury Severity Score (ISS) of 15 or higher.
Primary Information Needs of the Target Population
Information to encourage medication adherence is a significant need. 66% of medication errors happen during transition periods, when patients are not under medical supervision and are likely to be juggling too much information to consolidate it into a seamless whole (Moreno, 2013). Research shows that self-paced learning and the ability to review video instruction may result in patients following medication instruction (Saidinejad and Zorc, 2014). However the information is provided, managing (often multiple) medications requires keeping track of dosage, timing, and adverse reaction due from combining medications or simply experiencing side effects.
Whether or not patients have a primary care provider (PCP), that individual may or may not provide care coordination. More and more, patients and their caregivers are required to provide the bulk of the labor with scheduling appointments, maintaining records, administering medication, tracking vital signs, and the list goes on. They need help managing this change.
Patients leaving the ED are being given their information in a time-crunched environment filled with distractions and a high level of stress. In some cases, the length of time provided for discharge instructions averaged 76 seconds (Samuels-Kalow, Stack, & Porter, 2011). Even the most benign conditions can have a poor prognosis with such cursory communication.
Patients often do not follow up with the specialty care they require after a visit to the ED (Messina et al., 2013). The urgency that brought them to the ED in the first place may subside, contact information may be hard to acquire, appointments can be hard to secure, and the payment burden associated with specialty care is likely to be unclear. This results in a cluster of information needs to address these gaps, including readily available specialty contact numbers, transparent financial arrangements, and accessible scheduling procedures with reasonable appointment backlogs.
Verbal communication is the most frequently used form of communication in the ED (Ayatollahi, Bath, & Goodacre, 2013). While this makes sense in an urgent care environment, it does not bode well for patient retention of discharge instructions and their ability to accurately recall those instructions in transition. Additionally, patients are not good judges of how much time is required for them to retain information. In one study, most patients said they were satisfied with both the quality of the discharge instructions and the amount of time provided to pass that knowledge along. However, half of that study group did not sufficiently understand those instructions (Gignon, Ammirati, Mercier & Detave, 2014).
Patients asked to provide input on their discharge information needs highlighted several issues. The most basic was that medical terms often needed to be simplified. They thought that significant points in the treatment plan should be spotlighted visually, and graphics should be used for clarification. Medical practices that had perhaps been updated recently should also be emphasized. One example provided was that the treatment for concussions had changed (from keeping the patient awake to letting them sleep) and that old practices would be continued if the change was not stressed (Buckley et al., 2013). Common sense suggests that often people will fall back on the practices they were raised with even after presented with evidence that a change is in order. Overall, further clarification seems to be the overall information need.
Another study of what patients looked for themselves in discharge instructions included information about free and/or community services available to them, and information about where and how to fill their medication requests (Kington and Short, 2010). This is a good example of how seemingly simple details can short-circuit what should be a straightforward process. A healthcare provider might assume that all patients already have a pharmacy that they use, but this may not be the case. Almost nothing can be assumed when assessing the information needs of ED patients. Particularly because most patients being discharged have either experienced or are continuing to experience a high level of stress, even assumptions about mainstream human behavior may have to be reassessed.
Patients need to know a seemingly endless array of details. When and where their next appointments for specialist and PCP follow-up will occur. How to take their medication and a plan for withdrawing from pain medication dependency. What symptoms they should be on the lookout for that would indicate an immediate return to the ER. What symptoms they should be on the lookout for that would indicate contacting their PCP. A complete outline of their prognosis, including the range of likely outcomes and the range of dates when those outcomes can be expected or have been seen in other patients with similar injuries. What steps they can take to aid in their healing. What steps they can take to develop resilience to cope with the traumatic injury. It is hard to say what their primary needs are, because in some respects they need to know everything.
This eHealth intervention proposes to support several health challenges. First, it should impact the lack of understanding commonly experienced by patients upon receiving discharge instructions. Second, it should address the lack of understanding experienced by caregivers. Through these two avenues it should reduce complications that result in ED readmission. Finally, it should help to alleviate the stress that results from experiencing traumatic injury by building resilience.
Factors that could prevent users from engaging in the promoted behaviors
There are many factors that could prevent users from engaging in the promoted behavior. Pain, depression, frustration from limitations created by their injury, the side effects of medication, or dependency on pain medication could all limit their desire and ability to engage in behaviors that would improve their situation. In addition, some patients may lack caregiver and/or social support.
Factors that could prevent users from participating in a technology-based intervention
Several of the factors that could prevent users from engaging in the promoted behaviors could also prevent those users from participating in a technology-based intervention, such as pain, depression, frustration, and the effects of medication. This group tends to be younger so there should be little resistance to the use of technology per se (Powers, et al., 2013). However, in the case of poverty, users could lack access to a platform from which to access the information at home. Additionally, younger patients may still rely on caregiving from an older relative, who may be resistant or uncomfortable to an eHealth intervention.
User factors to consider when designing the proposed eHealth intervention
Other user factors that could be considered when designing the eHealth intervention include the effect of location, the effect of language barriers, and the effect of the user’s health literacy. Does the user’s location in an urban, rural, or suburban location affect their access or attitudes toward technology or their ability to access health services? Does their fluency in English compromise their ability to utilize the intervention? Are they so unfamiliar with the healthcare system that it impacts the level of care that they are able to advocate for?
Needs Analysis Bibliography
Administration on Aging (AoA) Aging Statistics. (1600, December 31). Retrieved February 5, 2015, from http://www.aoa.acl.gov/Aging_Statistics/index.aspx
Ayatollahi, H., Bath, P. a., & Goodacre, S. (2013). Information needs of clinicians and non-clinicians in the Emergency Department: A qualitative study. Health Information and Libraries Journal, 30, 191–200. doi:10.1111/hir.12019
Buckley, B. a., McCarthy, D. M., Forth, V. E., Tanabe, P., Schmidt, M. J., Adams, J. G., & Engel, K. G. (2013). Patient input into the development and enhancement of ED discharge instructions: A focus group study. Journal of Emergency Nursing, 39(6), 553–561. doi:10.1016/j.jen.2011.12.018
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
Health expenditure, total (% of GDP) World Bank. (2015). Retrieved February 5, 2015, from http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS
Kington, M., & Short, A. E. (2010). What do consumers want to know in the emergency department? International Journal of Nursing Practice, 16, 406–411. doi:10.1111/j.1440-172X.2010.01858.x
Messina, F. C., Weaver, C., Trammel, a., McDaniel, M., Ervin, D., & Perkins, a. (2012). 33 Improving Specialty Follow-up Care after an Emergency Department Visit Using a Unique Referral System. Annals of Emergency Medicine, 60(4), S14. doi:10.1016/j.annemergmed.2012.06.060
Most Unscheduled Hospital Admissions Now Come Through ER. (2013, June 20). Retrieved February 5, 2015, from http://newsroom.acep.org/2013-06-20-Most-Unscheduled-Hospital-Admissions-Now-Come-Through-ER
Moreno, P. K. (2013). Rethinking healthcare transitions and policies: Changing and expanding roles in transitional care. Health Education Journal. doi:10.1177/0017896912471046
National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables. (2010). Retrieved February 15, 2015, from http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf
Powers, M. B., Warren, A. M., Rosenfield, D., Roden-Foreman, K., Bennett, M., Reynolds, M. C., … Smits, J. a J. (2014). Predictors of PTSD symptoms in adults admitted to a Level I trauma center: A prospective analysis. Journal of Anxiety Disorders, 28(3), 301–309. doi:10.1016/j.janxdis.2014.01.003
Saidinejad, M. & Zorc, J. (2014). Mobile and Web-Based Education: Delivering Emergency Department Discharge and Aftercare Instructions. Pediatric Emergency Care, 30(3), 211-216. doi:10.1016/j.jemermed.2008.01.020
Samuels-Kalow, M. E., Stack, A. M., & Porter, S. C. (2012). Effective discharge communication in the emergency department. Annals of Emergency Medicine, 60(2), 152–159. doi:10.1016/j.annemergmed.2011.10.023