PICO(T) Evidence Review

PICO(T) Evidence Review


In adult intensive care patients, does nursing hand-off that involves the patient and family member compared to hand-off that only involves nurses improve nursing or clinician satisfaction with communication?

The lack of standardization of information shared during end of shift report or “handoff” in the intensive care unit often leads to inaccurate exchange of information. Without some standardization of what are pertinent issues and significant negatives, patient care is inconsistent and the results can be dissatisfaction among patient care staff, patient family members, and at times catastrophic for the patient. This is identified by the Joint Commissions as a need for improvement nationwide on hospital inpatient. National Patient Safety Goals (NPSB) includes improving the effectiveness of communication among caregivers in 2018 (Joint Commission, 2018). Handoff is defined as the transfer and acceptance of responsibility for patient care that is achieved through effective communication (Halm, 2013)PICO(T) Evidence Review.


Population (P): Adult patients in intensive care unit

Intervention ( I ): nursing handoff in patient room and involve patient and family member at the end of shift

Comparison ( C ): Standard practice – nurse hand off report at the nursing station

Outcomes ( O ): better care collaboration and comprehension of patient, patient safety and satisfaction

Time ( T ): within the length of ICU stay


The Joint Commission. (2018). The National Patient Safety Goals. Retrieved February 06, 2018 from


Halms, M. A. (2013). Nursing handoffs: Ensuring safe passage for patients. American Journal of Critical Care, 22(2), 158-161


Do Follow-up Phone Calls Post Discharge Impact ED Patients

Brett Kiser

University of Maryland, Baltimore


Do Follow-up Phone Calls Post Discharge Impact ED Patients

Adult patients’ understanding of discharge instructions is crucial in all hospital settings and departments, but particularly in emergency department (ED) visits. Misunderstanding of these instructions can lead to adverse patient outcomes, including readmittances to the ED for the same underlying condition. Research has estimated that 22% of patients discharged from the ED return to the ED within 30-days (Rising et al., 2014). While readmissions are a major concern, other patient outcomes, such as patient satisfaction, patient compliance with post visit treatments, health literacy, and healthcare costs may also be impacted (JHU, 2014). Recent studies have demonstrated the need for greater comprehension of ED discharge instructions, reporting that 66% of patients had a “major deficit” in comprehension of their discharge instructions (Engel et al., 2012). Additionally, and potentially even more devastating, the majority of ED patients are unable to perceive that they do not understand these instructions (Engel et al., 2009) and are therefore less likely to seek additional support as needed. It should be noted that while patients often report that ED physicians spent adequate time with them prior to discharge, most patients did not fully understand all of these instructions including information about medications, signs of improvement, signs of worsening, and if and when to return to the ED (Engel et al., 2012; Gignon, Ammirati, Mercier, & Detave, 2014). Clearly research should be conducted to understand ways to positively impact comprehensive of discharge instructions, reduce ED readmissions, and ultimately improve patient care and reduce costs PICO(T) Evidence Review.

PICO(T) Question

The following PICO(T) question was developed to perform an evidence review on best practices surrounding adult patient discharge instructions and follow-up post discharge from an emergency department. PICO(T): Do follow-up phone calls by nursing staff or a case manager in addition to standard written discharge instructions, compared to standard practice (i.e., written discharge instructions with no follow-up phone calls), lead to better comprehension of discharge instructions, patient satisfaction, and ultimately fewer return visits within 30-days post discharge for adult emergency department patients?

· Population (P): adult patients discharged from the emergency room

· Intervention (I): follow-up phone calls from nursing staff, in addition to standard written discharge instructions

· Comparison (C): standard practice – written discharge instructions with no follow-up phone calls

· Outcome(s) (O): better comprehension of discharge instructions, patient satisfaction, and ultimately fewer return visits

· Time (T): within 30-days post discharge.

Description of Search

For this evidence review, both the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed databases were used to find literature surrounding the PICO(T) question. Specifically, the following search terms were used within both databases: “emergency” AND (“follow up” or “discharge”) AND (“telephone” or “phone call”). Results of both searches were limited to the last five years (2012-2017) and for adult human populations only (to exclude pediatric studies); the CINAHL search was further restricted to peer reviewed articles only. Based on this search criteria, CINAHL yielded a total of 94 articles and PubMed yielded a total of 306 articles. In addition to the database searches, two additional articles were identified through background research on this topic and included in this review, as they were relevant to the PICO(T) question.

After 61 duplicates were removed, 341 article titles were reviewed and screened to determine if the article should be included within the full text article review for eligibility for this evidence review. Refer to Appendix A for a PRISMA flow diagram and additional details about the inclusion/exclusion criteria. Most of the articles were excluded as either the study population was not in the emergency department, or the intervention was non-telephone follow-up (e.g., telephone surveys may have been administered as part of study methods). Of the 21 articles identified for full text review, seven articles were excluded as the patient population was too specific, three were excluded as they were exploratory in nature, two were excluded due to non-telephone interventions, and three were excluded as they were either a repeat study, did not involve emergency department population, or involved a pharmacist only follow-up. After the full text review, six articles were eligible and all six are included in the evidence review process. Refer to Appendix B for the evidence review table of these six articles PICO(T) Evidence Review.


Engel, K. G., Heisler, M., Smith, D. M., Robinson, C. H., Forman, J. H., & Ubel, P. A. (2009). Patient comprehension of emergency department care and instructions: Are patients aware of when they do not understand? Annals of Emergency Medicine, 53(4), 454-e15. doi:10.1016/j.annemergmed.2008.05.016

Engel, K. G., Buckley, B. A., Forth, V. E., McCarthy, D. M., Ellison, E. P., Schmidt, M. J., & Adams, J.G. (2012). Patient understanding of emergency department discharge instructions: Where are knowledge deficits greatest? Academic Emergency Medicine, 19(9), E1035-44. doi:10.1111/j.1553-2712.2012.01425.x

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

Johns Hopkins University, Armstrong Institute for Patient Safety and Quality. (2014). Improving the emergency department discharge process: Environmental scan report. Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication No. 14(15)-0067-EF.

Rising, K. L., Victor, T. W., Hollander, J. E., & Carr, B. G. (2014). Patient returns to the emergency department: The time-to-return curve. Academic Emergency Medicine, 21(8), 864-871. doi:10.1111/acem.12442

Appendix A

PRISMA Search Flow Diagram

Records identified through manual searching


Records identified through PubMed database


Records identified through CINAHL database



Records excluded (n=320)

· Non-emergency department population (208)

· Emergency department-related, but non-related intervention (e.g., telephone was used during research methods) (95)

· Emergency department-related, but very specific patient population (12)

· Qualitative or exploratory in nature (5)

Full-text articles excluded, with reasons (n=15)

· Study was for narrow and specific population (7)

· Study was exploratory in nature, without control and intervention (3)

· Study included a non-telephone intervention (e.g., text, e-mail) (2)

· Study was not in an emergency department (1)

· Intervention was pharmacist only (1)

· Study was a repeat of another (included) study (1)

Records included in title screening (n=341)

Records after duplicates removed (n=341)

Full-text articles assessed for eligibility (n=21)

Studies included in synthesis (n=6) PICO(T) Evidence Review