The percentage of written discharge instructions that included eight recommended elements
increased significantly after a quality improvement initiative was launched in a pediatric
emergency department (ED).
Giving patients a written visit summary and guidelines for self-care has been shown
to improve communication and patient management. Thorough discharge instructions provided
by EDs are considered particularly important since the stress of the visit may diminish
parents’ and patients’ ability to remember advice given verbally.
In 2012, the Centers for Medicare & Medicaid Services (CMS) outlined what should be
included in written instructions given to patients when they are discharged from the
An academic tertiary pediatric ED conducted a quality improvement initiative to increase
the number of patients who received written discharge instructions that included the
following eight elements based on the CMS measures and group consensus: a customized
note, explanation of presenting complaint/diagnosis, tests performed, test results,
new medications, reason for medications, reasons to follow up and name of follow-up
physician/specialty. Staff members were educated on the elements through email and
A random sample of 329 patient charts before and 1,434 charts after the intervention
were reviewed to see if the discharge instructions included each element.
Results showed significant increases in the inclusion of each element after the intervention.
The greatest improvements were seen in documentation of tests performed (26% of instructions
before vs. 92% after the intervention) and test results (24% vs. 91%).
Discharge notes that included all eight elements increased from 23% to 79%.
The authors noted that the rate of patients returning to the ED within 48 hours did
not improve significantly after the intervention.
“Our study was not designed to be able sort out (the) various reasons for return to
the ED and was therefore not able to evaluate the impact of improved DCI (discharge
instructions) on return rates to the ED,” they said.