The effect of training and education at the emergency department 121 6 A study from Schluep et al. in some other hospitals in the Netherlands showed a discrepancy between the documented code status, and patients memory of what was discussed and registered.19 Besides, an interview study with internal medicine outpatient clinic patients we performed, showed several misconceptions regarding the topic of care decisions, and necessities in the patients view for a proper care decision discussion.20 We used the lessons we learned from these previous studies to develop two interventions, one for physicians and one for patients, to improve care decision discussions at the emergency department. Because research shows educating both physicians’ and patients simultaneously is more effective in improving shared decision making than either of them alone 21, we decided to implement both interventions at the same moment in time, and evaluate the effect of this combined intervention. 2. Methods 2.1 Setting and context This study was set at the internal medicine emergency department (ED) of the University Medical Centre Utrecht, a tertiary teaching hospital in the Netherlands. Patients were included between October-December 2020 (beforegroup) and January-April 2021 (after-group). This study was performed in accordance with Dutch and European guidelines for medical research and ethical review was waived by the Medical Research Ethics Committee Utrecht (MREC 20-539). The study was reported using the SQUIRE-2.0-checklist for reporting quality improvement studies.22 2.2 Participants and procedures Patients aged > 18 years that were hospitalized following an ED visit for internal medicine (and related specialisms: endocrinology, hematology, gastroenterology, geriatrics, immunology, infectious disease, nephrology, oncology, rheumatology and vascular diseases) were eligible for inclusion. Exclusion criteria were refusal to participate or a condition that limited their ability to answer the survey (e.g. language barrier, decreased cognitive function, too critically ill, dementia or delirium). A patient was eligible to participate with every distinctive admission to the ED and could therefore be included multiple times.
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