Original Contribution

The implementation of a gastroenteritis education program?,??,?,??

Stephen B. Freedman MDCM, MSc ^a,?, Maggie Couto RN ^b,

Laurie Spooner RN ^b, J. Kimberly Haladyn MSc ^a

^aDivision of Paediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children,

The University of Toronto, Toronto, ON, Canada M5G 1X8

^bDepartment of Nursing, The Hospital for Sick Children, The University of Toronto, Toronto, ON, Canada M5G 1X8

Received 14 September 2009; revised 25 September 2009; accepted 26 September 2009

Abstract

Purpose: The objective of this study is to determine if intensive gastroenteritis education results in greater caregiver knowledge and a reduction in future emergency department (ED) visits.

Methods: This was a concurrent control, prospective, single-blind trial. One hundred five children aged 3 to 48 months were assigned to receive an ED-based educational intervention and a home nursing education visit or neither. In the ED and 1 and 6 months postvisit, caregivers completed a 38-item Caregiver Gastroenteritis Knowledge Questionnaire.

Results: One month postintervention, the scores in the intervention group had risen compared with controls (3.3 vs 0.9, P = .11). At 6 months, the difference was negligible. At 1-year follow-up, 37% of children in both groups had an ED any-cause visit; gastroenteritis visits occurred in 27% and 13%. Conclusion: An intensive ED and home gastroenteritis education program did not result in a long-term increase in disease-specific caregiver knowledge or a reduction in future ED visits.

(C) 2011

Introduction

^? Presented at the Canadian Pediatric Society 86th Annual Conference, Ottawa, ON, June 24, 2009. Platform presentation.

^?? 2009 Pediatric Academic Society Annual Meeting, Baltimore, Md,

May 3, 2009. Poster presentation.

^? Funding for this research project was provided to Dr Stephen Freedman by a Pediatric Consultants Educational Research Grant. The study

sponsor played no role in the study design; in the collection, analysis, and interpretation of the data; in the writing of the report; and in the decision to submit the report for publication.

^?? Registered at www.clinicaltrials.gov; identifier NCT00311831 avail-

able at http://clinicaltrials.gov/ct2/show/NCT00311831?term=freedman+

gastroenteritis&rank=4.

* Corresponding author. Tel.: +1 416 813 7654×2382; fax: +1 416 813 5043.

E-mail address: [email protected] (S.B. Freedman).

Worldwide, diarrhea remains a leading cause of child- hood mortality, with 2.5 million deaths estimated to occur annually among children younger than 5 years [1]. In the United States alone, acute gastroenteritis accounts for more than 1.5 million outpatient visits, 200 000 hospitalizations, and approximately 300 deaths/year [2]. Thus, an enormous burden is placed on the health care system and emergency departments (EDs), where overcrowding has become epidemic [3,4]. Therefore, minimizing the rate of return visits, which are felt to be strongly connected to the care giving process [5], should be a priority.

Previous research conducted in Jamaica has reported that the children of caregivers who are less knowledgeable

0735-6757/$ – see front matter (C) 2011 doi:10.1016/j.ajem.2009.09.032

about diarrhea, dehydration, and oral rehydration are at increased risk for presenting to a hospital secondary to dehydration [6]. In addition, education on injury prevention has been shown to improve caregiver knowledge, beliefs, and practices [7]. However, translating these findings into improved outcomes has been difficult. Pamphlet and videotape presentations on common childhood illnesses did not result in a significant reduction in ED revisits [8], and a Cochrane Database Review of ED asthma educa- tional interventions found that such interventions resulted in an insignificantly lower revisit rate [9]. This may be due to the fact that many interventions are provided while caregivers are awaiting discharge and they are tired, distracted, and anxious to leave.

Phone calls after an ED visit can improve parental compliance with follow-up [10], and a printed information sheet provided 2 months after the initial intervention can reduce physician contacts and Medication errors [11]. Minor illness education during a home visit reduces health clinic use [12], and behavior management training conducted by trained counselors appears to be successful for specific diseases [13]. A postpartum/infant home visit program has demonstrated that the visits are standardized and have a positive impact on the health of the clients [14]. To date, there is no literature describing experiences with illness- specific home visitation after an ED encounter.

This study describes the evaluation of an intensive ED- based education program combined with a postvisit home- based gastroenteritis education intervention for children presenting to an ED with gastroenteritis. The primary objective was to determine if a significantly greater increase in caregiver knowledge as measured on a Caregiver Gastroenteritis Knowledge Questionnaire (CGKQ) [15] would occur among those who receive intensive education compared with those who receive standard discharge teaching. The secondary objective was to determine if ED visits for gastroenteritis, diarrhea, vomiting, or dehydration would be reduced among those who received intensive education.

Methods

Study design and recruitment

This study was a nonrandomized concurrent control, prospective, single-blind (individual scoring the question- naires and assessing follow-up visits), single-center trial that was nested within an ongoing intraVenous rehydration randomized clinical trial. Children diagnosed with acute gastroenteritis in the ED of The Hospital for Sick Children in Toronto, ON, Canada, were eligible for recruitment between December 2006 and May 2007. Staff screened and recruited subjects 6 days/wk, 12 hours/d. A variety of shifts were worked to allow for the sampling of children presenting during night, weekends, and weekdays. The

primary hypotheses were that subjects in the intervention group would have a significantly greater increase in their gastroenteritis knowledge as measured on a CGKQ 1 year later [15]. We also hypothesized that subjects in the intervention group would have a greater mean score on the CGKQ, and they would have fewer ED visits for gastroenteritis symptoms over the subsequent year than Control subjects.

Study population

Inclusion criteria were as follows: a diagnosis of gastroenteritis as determined by the attending physician, aged 3 to 48 months, caregiver older than 16 years, a working telephone contact number, and the ability of the caregiver to speak and read English. Children were excluded if they lived outside the Greater Toronto Area and if they had previously been enrolled in this trial. Written informed consent was obtained from the caregiver of each subject. The study was approved by the hospital’s Research Ethics Board.

Study protocol

There were 2 intervention components, an ED-based intensive nursing intervention and a home-based education visit. Children were assigned to receive neither or both based on the need for intravenous rehydration as determined by the supervising ED physician. The control group received standard discharge instructions, which include the provision of our hospital’s “vomiting and diarrhea” discharge pam- phlet, which includes information on the following topics: signs of dehydration, indications to see a physician, oral rehydration therapy, solid intake and refeeding, medication use, and disease transmission.

Emergency department education was provided by pediatric nurses (MC and LS) who were trained by the principal investigator (SF) and had a minimum of 5 years of ED nursing experience and 1 year of previous experience working on gastroenteritis research projects. The nurses provided 1:1 care during a 4-hour intravenous rehydration period. Throughout this period, the nurse worked with the family to enhance the caregiver’s ability to administer oral rehydration therapy. The nurses focused on the topics to be reviewed during the home education visit, namely, the assessment of dehydration, choice of oral rehydration solutions, the administration of oral rehydra- tion therapy, when to see a physician, and what to expect after discharge.

The home nursing education visits were provided by pediatric nurses who are contracted by Central Toronto’s Community Care Access Center. These are local organiza- tions that help people access government-funded home care services. Children who received intravenous rehydration received a home nursing assessment and educational visit

after ED or inpatient discharge. Before initiating the study, the principal investigator (SF) met with the directors of the 3 agencies who were contracted by the Community Care Access Center to conduct home nursing visits. The directors were oriented to the study, and they were provided with copies of The Hospital for Sick Children’s “vomiting and diarrhea” discharge pamphlet, which was reviewed in detail. They also received a structured presentation on the principles of gastroenteritis education including all topics that were to be covered during the home nursing visit. They were provided with a copy of the presentation to educate all of their staff members. A standardizED referral template was created, which requested that the following be performed during each home visit:

• • 1. Assess child for ongoing gastroenteritis symptoms.
    2. Assess child’s clinical status.
    3. Educate the caregiver regarding gastroenteritis:
       1. Signs of dehydration
       2. Indications to see a physician
       3. Oral rehydration therapy
       4. Solid intake and refeeding
       5. Medication use
       6. Disease transmission.

Outcome measures

Basic demographic information was gathered for each subject. Before intravenous fluid administration or discharge teaching by the ED physician, caregivers completed a CGKQ. This questionnaire is a 38-item true/false questionnaire (maximum score of 38) whose properties have recently been reported [15]. It covers the following domains: signs of dehydration, indications to see a physician, oral rehydration therapy, solid intake and refeeding, medication use, and disease transmission. It has been demonstrated to possess construct validity as evidenced by an incremental increase in mean total scores from caregivers to nurses to physicians and to have good internal consistency [15]. The primary outcome was the change in score (delta) on the CGKQ between enrollment and the 12-month follow-up questionnaire. However, because a poor response rate at both the 1- and 6-month follow-ups, the study was terminated, and the data available from the 6-month follow-up were used for the calculation of the primary outcome. Methods to enhance the success of follow-up included the inclusion of gift certificates and a preaddressed and stamped envelope with the mailings, which were sent up to 3 times per response period to nonresponders. After the third mailing, we conducted telephone follow-up and left messages up to a maximum of 3 times, offering caregivers an opportunity to complete the CGKQ on the telephone. Each time the questionnaire is administered, it contains the identical set of questions and response options.

Secondary outcomes included comparing the mean scores on the CGKQ and the proportion of children experiencing a repeat ED visit for gastroenteritis symptoms (diarrhea,

vomiting, dehydration) in the subsequent 12-month period. ED visits during the subsequent year were captured using our electronic patient chart.

Data analysis

Analyses were run by using SAS 9.1 (SAS Institute Inc, Cary, NC). All analyses were undertaken by the intention to treat principle using 2-sided statistical tests with significance set at the .05 level. Baseline characteristics were compared between the intervention and the control groups using the appropriate descriptive statistics. Frequency counts and percentages are provided for discrete variables and means, medians, and SDs for continuous variables. Baseline char- acteristics were analyzed to determine if there is a need to adjust for any significant differences between the study groups. Outcome analyses were performed comparing the inter- vention and control groups. The primary outcome, the change in CGKQ score between the baseline and 6-month scores, was anticipated to be a normally distributed, continuous variable and, thus, was analyzed by comparing the mean difference between groups using the t test. ?2 test and Fisher exact test were used to compare frequencies as appropriate. The continuous secondary outcome of mean score was analyzed using a 2-sample t test. To minimize the possibility of a type II error, we repeated the analysis with the CGKQ, including only the 25 questions with item discrimination index scores greater than 0.20 [15]. In addition, an analysis of covariance (ANCOVA) was conducted to test whether certain covariates may have influenced any of the outcome variables. The inclusion of potential covariates increases the statistical power

of our study by accounting for some of the variability.

Future ED visits was analyzed both as a dichotomous variable as well as a continuous variable. The former was analyzed by using logistic regression, with the baseline value of the outcome included in the model to adjust for any preintervention differences.

Sample size

An a priori sample size estimate was made on the basis of data from the development phase of this questionnaire [15], which reported a mean difference in knowledge scores between caregivers and nurses to be 5.2. On this basis, we felt that a meaningful difference in the change in knowledge scores between the intervention and the control groups would be half of this difference, 2.6 points. The SD used (3.0) was based on previously published data [15]. Because the intervention was fairly labor intensive, we planned to recruit

2.5 controls for each intervention subject to minimize the number of intervention subjects required. To have 80% power, 15 subjects in the intervention arm would be required along with 38 controls. Based on previous experience with the completion of questionnaires at home [15], we anticipated a 50% loss to follow-up for the 12-month questionnaire; thus we planned to enroll 30 experimental and 75 control subjects.

Health care use“>Results

Demographics

A total of 105 subjects were enrolled in this study. The caregiver who completed the questionnaire in the interven- tion group was more frequently the mother, and the children tended to be older. Follow-up questionnaire data are available at 1 month for 60 (57%) of 105 subjects and 59 (56%) at 6 months (Fig. 1). Follow-up ED visit data were available for all children at 1 year. The follow-up questionnaire completion rate was similar in both groups (P = .35 at 1 month; P = .13 at 6 months) (Table 1).

Caregiver Gastroenteritis Knowledge Questionnaire

At baseline, the 2 groups showed no difference in knowledge with similar CGKQ scores of 29.5 +- 4.0 and

29.3 +- 4.8 (P = .87) for the control and intervention groups, respectively (Table 2). At the 1-month follow-up questionnaire, the improvement in scores was slightly

greater in the intervention group (3.3 +- 6.9 vs 0.9 +- 4.3, P = .11). Neither group was significantly better than their baseline scores (P = .23, intervention; P = .29, control). By 6 months, the difference was negligible with increases from baseline of 2.7 +- 9.2 and 2.1 +- 6.6 in the intervention and control groups, respectively (P = .78). Similarly, there was no difference between 6 months, and baseline scores were no different within each group (P = .70, intervention; P = .49, control). Mean scores on the questionnaire were also compared at time 0, 1 month, and 6 months; no significant differences were detected at any of these time points. When the abridged, 25-question version of the CGKQ data was analyzed, the results remained unchanged (Table 2). All analyses were repeated using ANCOVA, and there were no significant changes in the tests of statistical significance.

Health care use

At baseline, the 2 groups showed no differences in the number of Previous ED visits for gastroenteritis symptoms and the number of visits requiring intravenous rehydration.

Fig. 1 CONSORT flow diagram.

Table 1 Baseline intervention and control group characteristics (n = 105)

Table 3 Health care use Intervention Control P

Intervention

Control

P

group

group

group

group

(n = 30)

(n = 75)

(n = 30)

(n = 75)

Baseline

Child characteristics

No. of prior ED visits for

0.37 +- 0.70

0.38 +- 0.74

.96

Age, mean +- SD (y)

2.5 +- 1.3

1.9 +- 1.2

.02

gastroenteritis, mean +- SD

Has a primary care physician, yes (%) a

30 (100)

67 (94)

.32

Proportion with prior ED visits for gastroenteritis, n (%)

8 (27)

22 (26)

.88

Total no. of siblings,

1.5 +- 0.7

1.7 +- 1.1

.40

mean +- SD

One-year follow-up

Vomiting episodes in the past

9.3 +- 8.6

6.5 +- 5.1

.04

No. of Subsequent ED visits for

0.43 +- 1.0

0.20 +- 0.62

.15

24 h, mean +- SD

gastroenteritis, mean +- SD

Diarrhea episodes in the past

5.0 +- 5.8

4.2 +- 5.2

.51

Proportion with subsequent ED

8 (27)

10 (13)

.10

24 h, mean +- SD

visits for gastroenteritis, n (%)

No. of prior ED visits for

0.37 +- 0.70

0.38 +- 0.74

.96

No. of subsequent ED visits for

0.93 +- 2.3

0.64 +- 2.3

.39

gastroenteritis, mean +- SD

any reason, mean +- SD

Prior ED visits for

2 (7)

4 (5)

.79

Proportion with subsequent ED

11 (37)

28 (37)

.95

gastroenteritis requiring intravenous fluids, n (%) Has chronic medical problem, 2 (7) 8 (11) .72 n (%)

visits for any reason, n (%) 4. Discussion

Neither the proportions of children nor the mean number of future ED visits per child was significantly different between groups because it relates to gastroenteritis specific visits or total visits for any reason (Table 3).

Table 2 Caregiver Gastroenteritis Knowledge Questionnaire Scores

Caregiver characteristics Age, mean +- SD (y)		32.1 +- 4.6	31.9 +- 6.2	.89
Relationship to child Mother, n (%)		27 (90)	50 (67)	.02
Father, n (%) Highest level of education, n		3 (10) (%) a	25 (33)
	Elementary	0	0
	High school	1 (6)	15 (27)	.17
	College/trade school	14 (82)	36 (66)
	Postgraduate	2 (12)	4 (7)
	a Responses not reported/available for entire study population.

Intervention group		Control group	P
Full CGKQ
Time 0–enrollment	29.3 +- 4.8	29.5 +- 4.0	.87
Time 1-mo follow-up	32.9 +- 5.4	30.7 +- 4.3	.11
Time 6-mo follow-up	32.0 +- 7.7	32.0 +- 6.3	.99
Improvement at 1 mo	3.3 +- 6.9	0.85 +- 4.3	.11
Improvement at 6 mo	2.7 +- 9.2	2.1 +- 6.6	.78
Modified CGKQ
Time 0–enrollment	19.5 +- 3.4	19.4 +- 3.4	.97
Time 1-mo follow-up	21.1 +- 2.8	20.1 +- 3.1	.29
Time 6-mo follow-up	19.4 +- 3.2	20.0 +- 2.3	.39
Improvement at 1 mo	1.1 +- 3.3	0.47 +- 2.9	.51
Improvement at 6 mo	-0.37 +- 4.0	0.30 +- 2.7	.46

To our knowledge, this is the first description of a post- ED visit, disease-specific, home education program. We evaluated a caregiver gastroenteritis educational program, which included both ED and home-based components. The intervention addressed common knowledge deficits among caregivers with the hope of increasing their knowledge and reducing the need for future ED visits. Unfortunately, we found that the intervention resulted in an insignificant increase in caregiver knowledge at 1 month, which was not sustained at the 6-month assessment. In addition, no reduction in ED visits was detected overall or specifically for gastroenteritis symptoms.

A considerable number of parents fail to fully compre- hend the diagnosis and treatment directives provided to them at the time of discharge [16]. Parents have suggested that more extensive explanations provided by a dedicated nurse would improve their understanding [16]. In addition, disease-specific sheets containing detailed information on the diagnosis, treatment, and follow-up has been shown to result in improved parental understanding of the discharge treatment instructions [17]. However, a lack of improvement in overall parental understanding of the discharge diagnosis was noted, which may be explained by the limited time caregivers have to read the sheets that are handed to them when they are departing. This suggests that parents focus more on the process of helping their child get better than on the disease itself. Another limitation of discharge instructions is that the language used is not comprehended, with discharge instructions being written at mean reading levels of 10th to 11th grade [18,19], which is well above that of the general ED population [18-20]. Others have shown that written instructions in addition to standardized verbal instructions did not improve parental recall [21], and the

reinforcement of discharge advice by telephone consultation has limited effect [22]. However, a home education visit regarding minor illness resulted in a reduction in health clinic visits [12]. The additional benefits of postdischarge, personalized, and individualized education have been documented by Chande and Exum et al [10] who demonstrated that follow-up telephone calls improve com- pliance with discharge instructions. Thus, our ED educa- tional initiative was followed by an in-person home visit at a less stressful time to hopefully enhance caregiver under- standing of the overall disease process.

Our intervention neither increased knowledge nor re- duced future ED visits. Although one study that used pamphlets and a videotaped presentation found a 17% reduction in future ED visits [8], more recent reports have found no reduction in future ED visits [23,24]. Previous educational interventions have occurred while caregivers are awaiting discharge and when they are anxious to leave, tired, and distracted. We managed to avoid such issues by having the second portion of the educational intervention occur at home 12 to 36 hours later. We hoped our strategy would allow us to capture the “teachable moment,” when the patient’s need for knowledge is acutely greater, making it the optimal time for knowledge gain to occur [25]. However, despite taking these factors into account, our intervention did not result in improved outcomes. These findings should serve as a reminder that even programs that intuitively “make sense” need to be proven to have benefit before the additional work of implementing them is undertaken.

Limitations

This study has several inherent limitations. Most notably, the intervention was not randomly assigned or blinded, which may have resulted in bias. Our inability to randomize was due to cost constraints, which required that the education visit be tied to enrollment in a concomitant study. Although it is possible that the children and the caregivers of those who received intravenous rehydration were fundamentally differ- ent than those who did not, it is unlikely that this fully explains our findings. Because the children in the interven- tion group were probably sicker at the time of presentation, as evidenced by the need for intravenous rehydration, it is possible that, in general, their caregivers are less likely to seek medical care. However, this may have changed after the ED visit because the caregivers of children in the intervention group may be more likely to seek medical care for subsequent illnesses because of the medical intervention provided during the index visit (ie, intravenous rehydration). The control group on the other hand received care that could have been administered at home, thereby making them less likely to seek ED care with subsequent illnesses. However, there is evidence that subsequent ED use is higher among children with mild illness severity at the

index visit [26]. Previous research has also found that excessive ED use is associated with the lack of a medical home [27,28]. In our cohort, primary care provider access was similar between groups. Thus, because it was difficult to determine the direction of bias because of the lack of randomization, we conducted a robust analysis with adjustment for covariates using ANCOVA. This did not significantly change the results.

The study’s sample size was calculated around the primary outcome measure and, thus, was underpowered to detect a difference in future ED gastroenteritis visits. However, the trend from our sample was in fact toward reduced visits among the control group; thus, it is unlikely that we would have detected a reduction, even if the study had adequate power for that outcome measure. We additionally could only verify ED visits if they occurred at our institution. However, previous research has shown that despite our efforts to have caregivers bring their children to alternative EDs, caregivers almost always return to our institution for future ED care [29].

Conclusions

In conclusion, although a small and transient increase in disease-specific caregiver knowledge can occur after a home nursing visit, this does not appear to be sustained over time, nor does it appear to reduce future ED visits. The literature to date seems to indicate that an alternative approach, aside from education, needs to be attempted to reduce ED visits for minor childhood ailments.

Acknowledgments

We would like to thank Margot Jeffrey, the Client Services Manager for Toronto’s Central Community Care Access Centre, for supporting this research and education initiative. We additionally are indebted to the managers of the 3 agencies who provided and trained the nurses who conducted the home visits–Michelle Vahamaki (Saint Elizabeth Health Care), Glynis Stringer (VHA Home Healthcare), and Enza Mendez (Comcare Health).

References

1. Kosek M, Bern C, Guerrant RL. The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. Bull World Health Organ 2003;81(3):197-204.
2. King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 2003;52(RR-16):1-16.
3. Overcrowding crisis in our nation’s emergency departments: is our safety net unraveling? Pediatrics 2004;114(3):878-88.
4. Hostetler MA, Mace S, Brown K, Finkler J, Hernandez D, Krug SE, et al. Emergency department overcrowding and children. Pediatr Emerg Care 2007;23(7):507-15.
5. Guttmann A, Razzaq A, Lindsay P, Zagorski B, Anderson GM. Development of measures of the quality of emergency department care for children using a structured panel process. Pediatrics 2006;118(1): 114-23.
6. Bachrach LR, Gardner JM. Caregiver knowledge, attitudes, and practices regarding childhood diarrhea and dehydration in Kingston, Jamaica. Rev Panam Salud Publica 2002;12(1):37-44.
7. King WJ, LeBlanc JC, Barrowman NJ, Klassen TP, Bernard-Bonnin AC, Robitaille Y, et al. Long term effects of a home visit to prevent childhood injury: three year follow up of a randomized trial. Inj Prev 2005;11(2):106-9.
8. Rosenberg EE, Pless IB. Can effective parent education occur during emergency room visits? Fam Med 1993;25(9):598-601.
9. Haby MM, Waters E, Robertson CF, Gibson PG, Ducharme FM. Interventions for educating children who have attended the emergency room for asthma. Cochrane Database Syst Rev 2001(1):CD001290.
10. Chande VT, Exum V. Follow-up phone calls after an emergency department visit. Pediatrics 1994;93(3):513-4.
11. Casey R, McMahon F, McCormick MC, Pasquariello Jr PS, Zavod W, King Jr FH. Fever therapy: an educational intervention for parents. Pediatrics 1984;73(5):600-5.
12. Robbins H, Hundley V, Osman LM. Minor illness education for parents of young children. J Adv Nurs 2003;44(3):238-47.
13. Wolke D, Gray P, Meyer R. Excessive infant crying: a controlled study of mothers helping mothers. Pediatrics 1994;94(3):322-32.
14. Wager KA, Lee FW, Bradford WD, Jones W, Kilpatrick AO. Qualitative evaluation of South Carolina’s Postpartum/Infant Home Visit program. Public Health Nurs 2004;21(6):541-6.
15. Freedman SB, Deiratany S, Goldman RD, Benseler S. Development of a Caregiver Gastroenteritis Knowledge Questionnaire. Ambul Pediatr 2008;8(4):261-5.
16. Waisman Y, Siegal N, Chemo M, Siegal G, Amir L, Blachar Y, et al. Do parents understand emergency department discharge instructions? A survey analysis. Isr Med Assoc J 2003;5(8):567-70.
17. Waisman Y, Siegal N, Siegal G, Amir L, Cohen H, Mimouni M. Role of diagnosis-specific information sheets in parents’ understanding of emergency department discharge instructions. Eur J Emerg Med 2005;12(4):159-62.
18. Spandorfer JM, Karras DJ, Hughes LA, Caputo C. Comprehension of discharge instructions by patients in an urban emergency department. Ann Emerg Med 1995;25(1):71-4.
19. Williams DM, Counselman FL, Caggiano CD. Emergency department discharge instructions and patient literacy: a problem of disparity. Am J Emerg Med 1996;14(1):19-22.
20. Jolly BT, Scott JL, Feied CF, Sanford SM. Functional illiteracy among emergency department patients: a preliminary study. Ann Emerg Med 1993;22(3):573-8.
21. Isaacman DJ, Purvis K, Gyuro J, Anderson Y, Smith D. Standardized instructions: do they improve communication of discharge informa- tion from the emergency department? Pediatrics 1992;89(6 Pt 2): 1204-8.
22. Khan MS, O’Meara M, Stevermuer TL, Henry RL. Randomized controlled trial of asthma education after discharge from an emergency department. J Paediatr Child Health 2004;40(12):674-7.
23. Chande VT, Wyss N, Exum V. Educational interventions to alter pediatric emergency department utilization patterns. Arch Pediatr Adolesc Med 1996;150(5):525-8.
24. Baker MD, Monroe KW, King WD, Sorrentino A, Glaeser PW. Effectiveness of fever education in a pediatric emergency department. Pediatr Emerg Care 2009;25(9):565-8.
25. Johnson SB, Bradshaw CP, Wright JL, Haynie DL, Simons-Morton BG, Cheng TL. Characterizing the teachable moment: is an emergency department visit a teachable moment for intervention among assault-injured youth and their parents? Pediatr Emerg Care 2007;23(8):553-9.
26. Gregor MA, Wheeler JR, Stanley RM, Mahajan PV, Maio RF, Piette JD. Caregiver adherence to follow-up after an emergency department visit for common pediatric illnesses: impact on future ED use. Med Care 2009;47(3):326-33.
27. Christakis DA, Mell L, Koepsell TD, Zimmerman FJ, Connell FA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics 2001;107(3): 524-9.
28. Vivier PM, Lewander WJ, Block SH, Simon PR, Alario AJ, Linakis JG. Is continuity of care preserved in children who utilize the pediatric emergency department? Pediatrics 1995;95(1):37-41.
29. Freedman SB, Thakkar VA. Easing the strain on a pediatric tertiary care center: use of a redistribution system. Arch Pediatr Adolesc Med 2007;161(9):870-6.