The effect of training and education at the emergency department 123 6 Patient leaflet From December 2020 onwards, all patients at the internal medicine ED received a patient leaflet on care decisions at the ED. We chose to distribute the leaflet to all patients, because the information might be useful for all patients, not just those who will be admitted. Besides, it is not always clear right away whether a patient is admitted or not. This was a quality improvement intervention, the leaflet was distributed to aid care decision discussions at the ED, thereby improving shared-decision-making, patient-centered-care, and complying with the Wise Choice of the Dutch association for Internal Medicine. Patients may use the information to feel better informed, feel more clear about what is of importance to them and gain accurate expectations of the choices to be made.21,24 The leaflet was developed by the research team using an earlier developed patient information webpage on this subject (developed with the aid of the UMC Utrecht patient panel) and data from the previously mentioned interview-study.20 The research team consisted of an (acute) internal medicine resident/ PhD student (SB), a language and communication scientist (TvC) and a professor of acute internal medicine and program director of the internal medicine residency (HHK), thereby leading to an interdisciplinary approach with a focus on education. The written language was adjusted to Dutch B1 level. The residents at the ED distributed the leaflet, and received weekly reminders by mail to do so. 2.4 Study of the interventions We chose to conduct a before-after intervention study to evaluate the effect of both interventions combined. Because research shows educating both physicians’ and patients simultaneously is more effective in improving shared decision making than either of them alone,21 and for practical reasons, we decided to implement the training and leaflet at the same moment in time, and evaluate the effect of this combined intervention. Measures Our primary outcome is the patient satisfaction with the care decision discussion at the emergency department. We used the validated Quality of Communication (QOC) questionnaire,25 which we translated to Dutch using the validated forward-backward method.26 We handled the questionnaires in accordance
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