125 Teach-back of discharge instructions in the ED CHAPTER 6 Study Setting and Population The study was performed in the ED of the Radboud University Medical Center (Radboudumc), an urban academic hospital with an annual ED census of 22,000 visits. We deliberately performed this study in a period when no major policy changes were scheduled that could have influenced healthcare delivery in the ED. Throughout the study period, we were alert to unexpected changes. We also chose this period to minimize the impact of seasonal effects on study group differences (e.g., size and characteristics). Two medical residents (N.K. and C.T.) scanned for potential eligible patients in consecutive order of appearance from Monday to Friday from 10 am to 7 pm. Eligible patients were identified in consultation with the ED triage nurse and the ED physician on duty after scanning the hospital information system (HIS). Patients were included if they were discharged from the ED to home, including outpatient assisted living facilities such as a senior home or a rehabilitation centre. Patients unable to speak the Dutch language, discharged to another medical facility or ward, or with a severe mental/cognitive impairment (e.g. advanced dementia) without being accompanied by a caregiver at the ED were excluded from the study. In the postintervention phase, patients were only included if the use of teach-back was reported by a health professional through ticking off a check box in the HIS. Eligible patients were informed about the study and asked to participate before discharge instructions were given. Written informed consent was obtained from all patients or informal carers before enrolment. Protocol After completion of the preintervention phase, a one-week period was used for teach-back training and practice behaviour adoption for nurses, physicians and residents working in the ED. These professionals were informed about the study and the teach-back method via an online newsletter and the display of posters and information cards in the ED. N.K., C.T., and one ED physician (O.S.), all familiar with the principles of teach-back, initially trained the professionals on using the teach-back method at discharge by demonstrations and role play. A pocket-size booklet with teach-back instructions was used for training purposes and functioned as a reminder on how to perform teach-back in clinical practice. For example, professionals were instructed to create a shame-free environment for teach-back (i.e., to highlight that teach-back is not intended to test patient knowledge but is instead a method to enhance patient comprehension and recall of instructions) and to use plain language to facilitate understanding. Multiple individual and group training sessions were held to cover all nurses, physicians and residents working in the ED at that time. Supplement 1 illustrates
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