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Objectives Emergency department (ED) discharge requires conveying critical information in a time-limited and distracting setting. Limited health literacy may put patients at risk of incomplete comprehension, but the relationship between discharge communication needs and health literacy has not been well defined. The goal of this study was to characterize the variation in needs and preferences regarding the ED discharge process by health literacy, and identify novel ideas for process improvement from parents and patients. Methods This was an in-depth qualitative interview study in two EDs using asthma as a model system for health communication. Adult patients and parents of pediatric patients with an asthma exacerbation and planned discharge were enrolled using purposive sampling to balance across literacy groups at each site. Interviews were audiotaped, transcribed, coded independently by two team members, and analyzed using a modified grounded theory approach. Interviews were conducted until thematic saturation was reached in both literacy groups at each site. Results In-depth interviews were completed with 51 participants: 20 adult patients and 31 pediatric parents. The majority of participants identified barriers related to ED providers, such as use of medical terminology; and systems of care, such as absence of protected time for discharge communication. Patients with limited health literacy, but not those with adequate literacy, identified conflicting information between health care sources as a barrier to successful ED discharge. Conclusions Participants across literacy groups and settings identified multiple actionable areas for improvement in the ED discharge process. These included the use of simplified/lay language, increased visual learning and demonstration, and the desire for complete information. Individuals with limited literacy may particularly benefit from increased attention to consistency.

Objective Teach-back may improve communication, but has not been well studied in the emergency setting. The goal of this study was to characterize perceptions of teach-back in the emergency department (ED) by health literacy. Methods We conducted an in-depth interview study the ED discharge process teach-back techniques in two tertiary care centers (adult and pediatric), using asthma as a model system for health communication. Participants were screened for health literacy, and purposive sampling was used to balance the sample between literacy groups. Interviews were conducted until thematic saturation was reached for each literacy group at each site; audiotaped, transcribed, coded, and analyzed using a modified grounded theory approach. Results Fifty-one interviews were completed (31 parents; 20 patients). Across all groups, participants felt that teach-back would help them confirm learning, avoid forgetting key information, and improve doctor-patient communication. Participants with limited health literacy raised concerns about teach-back being condescending, but suggested techniques for introducing the technique to avoid this perception. Conclusion Most participants were supportive of teach-back techniques, but many were concerned about perceived judgment from providers. Practice Implications Future investigations should focus on feasibility and efficacy of teach-back in the ED and using participant generated wording to introduce teach-back

Background Measuring outcomes of emergency care is of key importance, but current metrics, such as 72-hour return visit rates, are subject to ascertainment bias, incentivize over-testing and over-treatment at initial visit, and do not reflect the full burden of disease and morbidity experienced at home following ED care. There is increasing emphasis on including patient-reported outcomes, but the existing patient-reported measures have limited applicability to emergency care. Objective To identify concepts for inclusion in a patient-reported outcome measure for ED care, and assess differences in potential concepts by health literacy. Design/Methods A three-phase qualitative study was completed using freelisting and semi-structured interviewing for concept identification, member checking for concept ranking and cognitive interviewing for question development. Participants were drawn from three tertiary care EDs. Parents of patients (pediatric) or patients (adult) with asthma completed a demographic survey and an assessment of health literacy. Phase 1 participants also completed a freelisting exercise and qualitative interview regarding the definition of success following ED discharge. Phase 2 participants completed a member checking survey based on concepts identified in Phase 1. Phase 3 was a pilot of trial questions based on the highest-ranked concepts from Phase 2. Results Phase 1 enrolled 22 adult patients and 37 parents of pediatric patients. Phase 2 enrolled 41 adult patients and 200 parents. Phase 3 involved 15 parents. Across all demographic / literacy groups, Phase 1 participants reported return to usual activity and lack of asthma symptoms as the most important markers of success. In Phase 2, symptom improvement, medication use and access and asthma knowledge were identified as the most important components of the definition of post-ED discharge success. Phase 3 resulted in 5 questions for the proposed measure. Conclusions A step-wise qualitative process can identify, rank, and formulate questions based on patient-identified concepts for inclusion in a patient-reported outcome measure for ED discharge. The 4 key concepts identified for inclusion: symptom improvement, medication access, correct medication use and asthma knowledge are not measured by existing quality metrics.

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Background The COVID-19 pandemic has necessitated rapid development of preparedness and response plans to quell transmission and prevent illness across the world. Increasingly, there is an appreciation of the need to consider equity issues in the development and implementation of these plans, not least with respect to gender, given the demonstrated differences in the impacts both of the disease and of control measures on men, women, and non-binary individuals. Humanitarian crises, and particularly those resulting from conflict or violence, exacerbate pre-existing gender inequality and discrimination. To this end, there is a particularly urgent need to assess the extent to which COVID-19 response plans, as developed for conflict-affected states and forcibly displaced populations, are gender responsive. Methods Using a multi-step selection process, we identified and analyzed 30 plans from states affected by conflict and those hosting forcibly displaced refugees and utilized an adapted version of the World Health Organization’s Gender Responsive Assessment Scale (WHO-GRAS) to determine whether existing COVID-19 response plans were gender-negative, gender-blind, gender-sensitive, or gender-transformative. Results We find that although few plans were gender-blind and none were gender-negative, no plans were gender-transformative. Most gender-sensitive plans only discuss issues specifically related to women (such as gender-based violence and reproductive health) rather than mainstream gender considerations throughout all sectors of policy planning. Conclusions Despite overwhelming evidence about the importance of intentionally embedding gender considerations into the COVID-19 planning and response, none of the plans reviewed in this study were classified as ‘gender transformative.’ We use these results to make specific recommendations for how infectious disease control efforts, for COVID-19 and beyond, can better integrate gender considerations in humanitarian settings, and particularly those affected by violence or conflict.

Science and Engineering (S&E) fairs are a valuable educational activity and are believed to increase students’ engagement and learning in science and engineering. However, due to differences in resources, many schools do not implement fairs to achieve these benefits for their students. This study reports the findings of a program intended to increase the participation of students from low-achieving and under-resourced schools in a regional fair program that feeds into the international fair competition. We found that the number of schools and projects participating in our regional fair increased dramatically since the start of the program. Teachers had mostly positive expectations for the project and expressed buy-in for the effort the project would take. They recruited a diverse pool of students to participate in the school fairs. Quasi-experimental methods allowed us to explore the impact of completing S&E fairs on student gains on science self-efficacy, interest and value perceptions. Controlling for pre-existing differences in these attitudes, we found that students not completing projects showed declines in their science attitudes during the year. Students who completed projects maintained similar attitudes, while those whose projects advanced to the regional fair had substantial gains on all three variables. It is unknown whether this gain can be attributed to the experience of engaging with a quality project, from being the kind of student who completes a quality project, or some other factor. Future research with greater experimental control could address these questions.

Background: In the emergency department (ED), residents and attendings may have a short-term relationship, such as a single shift. This poses challenges to learner assessment, instructional strategy selection, and provision of substantive feedback. We implemented a process for residents to identify goals for ED shifts; characterized residents' goals; and determined how goal identification affected learning, teaching, and feedback. Methods:This was an observational study in a large, tertiary pediatric ED using mixed methods. Residents were asked to identify learning goals for each shift and were asked postshift if they had identified, accomplished, and/ or received feedback on these goals. Goals were categorized by Accreditation Council for Graduate Medical Education Core Competencies. Predictors of goal identification, accomplishment, and receipt of feedback were determined. Residents and attendings were interviewed about their experiences.Results: We collected 306 end-of-shift surveys (74% response rate) and 358 goals and conducted 29 interviews. We found that: 1) Goal setting facilitated perceived learning. Residents identified goals 54% of the time. They accomplished 89% of and received feedback on 76% of goals. 2) Residents' perceived weaknesses, future practice settings, and available patients informed their goals. Most goals mapped to patient care (59%) or medical knowledge (37%) competencies. 3) Goal identification helped attendings determine residents' needs. 4) Ideal goals were specific and achievable. 5) Common barriers were busyness of the ED and difficulty creating goals. Residents were less likely to identify goals (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.41 to 0.94) and receive feedback on busy evening shifts (OR = 0.19, 95% CI = 0.10 to 0.37) and were most likely to receive feedback overnight (OR = 3.66, 95% CI = 1.87 to 7.14). Conclusions:Asking residents to identify goals for ED shifts as an instructional strategy facilitated perceived learning, goal accomplishment, and receipt of feedback. Resident-driven goal identification is a simple and effective instructional strategy that physicians can incorporate into their precepting in the ED.