Hospital Discharge Instructions using Mind Mapping

HOSPITAL DISCHARGE INSTRUCTIONS USING MIND MAPPING

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Vulnerability of Patients after Hospital Discharge

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Vulnerability of Patients after Hospital Discharge [1]

• About half of the adult patients, experience at least one medical error after a hospital discharge. [2]

• Between a 19 and a 23% suffer an adverse effect after discharge, most of the times related to medication. [3-5]

• When there are adverse effects, 66% are related to medication, 17% to procedures. [4]

Adherence of Patients to Discharge Instructions

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Factors that influence conformity and satisfaction of the patient with the post-discharge plan [6,7]

• Amount of information

• Quality of the information

• Capacity of the patient to understand the information

Study investigating patient perceptions of the quality of discharge instruction 1997-2001 [8]

• Patient satisfaction decreased significantly every year.

• Patients gave lower ratings to the quality of discharge

instruction than to the overall quality of their hospital stay.

• Patient assessments of discharge instruction quality varied

systematically among conditions

Main areas of non-compliance with discharge instructions

• Medication

• Cures

• Medical appointments

• Diet

• Exercise

• Habitual behaviors

Quantification of Patient’s Adherence to Medical Recommendations [9]

• Average: 75%

• Minimum: less than 50%

Consequences of non-adherence to medical recommendations

• Unnecessary phone calls

• Unnecessary visits

• Delay in rehabilitation

• Unnecessary readmissions

• Unnecessary relapses

• Superfluous medical costs Image courtesy of ddpavumba at FreeDigitalPhotos.net

Problems when discharge instructions are too simple or incomplete

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If discharge instructions are too simple or incomplete, patients look for complementary information through

• Relatives

• Friends

• Newspapers and

magazines

• Internet

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The Toronto Consensus [10]

• “Effective communication between doctor and patient is a central clinical function that cannot be delegated.”

If the patient has to look for the information she needs through relatives, friends, internet or any other non reliable source, effective commnication is interrupted.

Shortcomings of Health Information on the Internet [11]

• Uneven quality of medical information available.

• Difficulties in finding, understanding and using this information.

• Lack of access for the unconnected population.

• The potential for harm and risks of overconsumption.

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Problems when discharge instructions are complex

Main problems when discharge instructions are complex [12]

• Inadequate health literacy of patients and relatives.

• Unrecognized cognitive impairment of patients.

• Linear text is very difficult to understand when it is extensive, even for people not affected by any of the two previous problems.

• Difficulty in memorizing the combination of verbal and written instructions. [13]

IMPROVEMENT OF THE DISCHARGE INSTRUCTIONS

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Use of images. Study 1. [14]

• The patients given cartoon instructions were more likely to have read the instructions (98% versus 79%)

• More likely to answer all wound care questions correctly (46% versus 6%)

• More compliant with daily wound care (77% versus 54%)

Use of images. Study 2 [15]

50% improvement in the comprehension of instructions.

Standardized Electronic Discharge Instructions [16]

• Implementation of standardized electronic discharge instructions was not associated with reduction in post-discharge hospital utilization.

• More studies are needed but simply using electronic discharge instructions does not solve the fundamental problems.

The main problem

• If the discharge instructions are short and simple, they cannot include all needed information.

• If the discharge instructions are complex and extensive, patients cannot assimilate all the information due to the limitations of linear text.

• The consequence is that patients cannot be empowered.

The biopsychosocial model and the discharge instructions [17]

• Discharge instructions have to be adapted to the new biopsychosocial model.

• This is needed in order to empower the patient.

Mind mapping in the biopsychosocial model as a tool to empower the patient

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The Mind Mapping technique [18]

It is a graphical technique for the vualization of hierarchical connections beween several elements of information. Each element of information is linked with other elements through lines, creating a network of relations. They are always organized around a single central idea or information.

A mind map is a diagram created using this technique.

Most important characteristics of mind maps

Fast processing of images in the brain + Hierarchical organization + Chunking of information + Whole picture and detail views at the same time + Visible relationship between the parts + Collapse / Expansion of the branches + Use of color (facilitating grouping) + Multimedia (text, images, documents, videos, sound) + 1 single compressed file, easy to send by email or FTP + Collaboration (online and presential) + Autoformatting + No need to change from one screen to another (no context loss) + Less mental fatigue + Easy to create, visualize and edit + The most important information is at the center (better vision)

Prototype of discharge instructions mind map

A mind map is a single compressed file

that can include the following elements:

• Shoft texts • Free text Notes • Icons • Images • Spreadsheets • Charts • Internet hyperlinks • Hyperlinks to other mind maps • Attached files of any type:

• Images • PDF • Word • Excel • Videos

Mind maps only need a free viewer (MindManager)

or a browser (HTML5)

Environments

Windows iPad, iPod, iPhone Android

Attached PDF containing the detail of the instructions as linear text

Introduction to Discharge Instructions

Ho to get to the hospital

Wound care

Medication (With a free text Note)

Precautions

Exercise

Feeding (with attached video)

Follow up

Advantages of mind maps as discharge instructions

• Visual. • Easy to use by the patient. • No limit to the amount of information. • All information on a single screen. No screen changes. • All types of multimedia elements. • Reduce / eliminate communication errors. • Reduce / eliminate the problems of linear text o web

pages. • Easy to send and visualize. • Small size. • Free viewer.

How are mind maps created?

• By automation from information contained in data bases.

• Can be personalized for each patient from her Personal Health Record.

• Software developed in C#.NET for Windows.

• After being created, the mind map can be sent as an attached file by email or FTP’s to a web page to be downloaded by the patient.

References [1] Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2:314–323. [2] Moore C, et al., Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18:646-651. [3] Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170:345-349. [4] Forster AJ et al., The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-167. [5] Forster AJ, et al., Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2005;20:317-323 [6] Vukmir RB. Kremen R. Ellis GL, et al. Compliance with emergency department referral: the effect of computerized discharge instructions. Ann Emerg Med. 1993; 22:819-23. [7] Jolly BT, Scott JL, Feied CF, et al. Functional illiteracy among emergency department patients: a preliminary study. Ann Emerg Med. 1993; 22:573-8 [8] Clark PA et al., Patient perceptions of quality in discharge instruction, Patient Education and Counseling 59 (2005) 56–68 [9] DiMatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care 2004;42:200–209. [10] Simpson M et al., Doctor-patient communication: the Toronto consensus statement, BMJ7 1991;303:1385-7 [11] Benigeri M, Pluye P., Shortcomings of health information on the Internet, Health Promotion International Vol. 18. No. 4, 2003 [12] Chugh A et al., Better Transitions: Improving Comprehension of Discharge Instructions, Frontiers of Health Services Management, 2009 Spring;25(3):11-32. [13] Krohn DA, Discharge Instructions in the Outpatient Setting: Nursing Considerations, J Radiol Nurs 2008;27:29-33. [14] Delp C, Jones J, Communicating Information to Patients: The Use of Cartoon Illustrations to Improve Comprehension of Instructions, Academic Emergency Medicine Mar 1996 Vol 3/No 3 [15] Austin PE, Discharge Instructions: Do Illustrations Help Our Patients Understand Them?, Annals of Emergency Medicine , March 1995, 25:3. [16] Showalter JW, Effect of Standardized Electronic Discharge Instructions on Post-Discharge Hospital Utilization. J Gen Intern Med 26(7):718–23 (2011) [17] Engel GJ, The Biopsychosocial Model and the Education of Health Professionals, Ann N Y Acad Sci. 1978 Jun 21;310:169-87.

[18] Guerrero JM, Ramos P, Introduction to the Applications of Mind Mapping in Medicine, International Medical Publishing, 2015.

Introduction to the Applications of Mind Mapping in Medicine

Introducción a la Técnica de Mapas Mentales Gestión Visual de Información Compleja con MindManager 16 http://www.editorialuoc.cat/introduccion-a-la-tecnica-de-mapas-mentales

José M. Guerrero jm@infoseg.com http://www.infoseg.com/imi.shtml https://es.linkedin.com/in/josemguerrero2012 http://www.slideshare.net/jmgf2009/presentations https://twitter.com/InfosegS http://paper.li/InfosegS/1356259200

Hospital Discharge Instructions using Mind Mapping

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