Overcoming Health Literacy Barriers by Developing Standardized Surgical Discharge Instructions

Shruti R. Hegde, Madhuri B. Nagaraj, Gerardo J. Gonzalez-Guardiola, Fatemeh Malekpour, Michael Shih

Research output: Contribution to journalArticlepeer-review


Introduction: Approximately one-third of surgical patients exhibit low health literacy, and 39% of our patients are primary Spanish speakers. We first evaluated the current content of our arteriovenous fistula/graft discharge instruction (DCI) templates. Using the Plan-Do-Study-Act cycle quality improvement methodology, we then aimed to optimize the readability and formally translate new DCI and evaluate usage and inappropriate bouncebacks following implementation. Methods: Current arteriovenous fistula/graft template content was reviewed by the literacy department for readability and vascular faculty for completeness and accuracy. The literacy department edits were categorized by word choice, added/removed content, format change, and grammatical errors. Two vascular surgeons rated completeness and accuracy on a Likert scale (1-5). Retrospective chart review was performed for telephone calls and emergency department bouncebacks for 3 mo flanking new DCI implementation. Results: Of the 10 templates, all were in English and word count ranged from 192 to 990 words. Despite each template including all necessary subcategories, the median number of edits per 100 words was 9.2 [7.0-9.5]. Approximately half of the edits (5.4 [5.1-5.5]) were word choice edits. Overall, experts rated completeness at 3.9 [3.2-4.2] and accuracy at 4.0 [3.7-4.1]. Highest template utilization occurred during post-implementation months 1 (90%) and 3 (100%) with orientation sessions. There was a significant increase in concordant Spanish DCI use (P < 0.01) and no inappropriate bouncebacks after implementation. Conclusions: Our study demonstrated notable variability in the content and readability of our vascular access instruction templates. New DCI had strong usage and language concordance; continued use may decrease bouncebacks.

Original languageEnglish (US)
Pages (from-to)386-394
Number of pages9
JournalJournal of Surgical Research
StatePublished - Oct 2022


  • Bounceback
  • Discharge instructions
  • Health literacy
  • PDSA
  • Quality improvement
  • Spanish

ASJC Scopus subject areas

  • Surgery


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