PEDIATRICS/BRIEF REPORT
Do Parents Value Drowning Prevention
From the Department of Pediatrics,
University of Washington School of
Medicine,* Children’s Hospital and
Regional Medical Center,‡ Harbor-
view Injury Prevention and Research
Center and the Department of
Epidemiology, School of Public Health
and Community Medicine,§ University
of Washington, Seattle, WA.
Received for publication
August 14, 2000. Revision received
December 22, 2000. Accepted for
publication January 8, 2001.
Supported in part by grant No. MCH-
534003-01-0 from the Department of
Health and Human Services, Health
Resources and Services Administration,
Maternal and Child Health Bureau,
Emergency Medical Services for
Children, and by a gift from the
Norcliffe Fund.
Reprints not available from the
authors.
Address for correspondence: Linda
Quan, MD, Emergency Services
CH04, Children’s Hospital and
Regional Medical Center, 4800 Sand
Point Way NE, Seattle, WA 98105;
206-526-2599, fax 206-729-3070;
E-mail lquan@chmc.org
Copyright © 2001 by the American
College of Emergency Physicians.
0196-0644/2001/$35.00 + 0
47/1/114091
doi:10.1067/mem.2001.114091
3 8 2
Information at Discharge From the Emergency
Department?
Linda Quan, MD*‡
Elizabeth Bennett, MPH, CHES‡
Peter Cummings, MD, MPH‡§
Peter Henderson
Mark A. Del Beccaro, MD*‡
Study objective: We determined parent recall and perceived
usefulness of drowning prevention messages included in routine
computer-generated discharge instructions.
Methods: All pediatric emergency department patients’ com-
puterized discharge instructions included 3 prevention messages:
wear a life vest, swim in safe areas, and do not drink alcohol
while swimming or boating. Parents were telephoned 1 to 2
weeks after the visit and asked to recall the prevention messages
and rate the usefulness of the instructions. Responses were
linked with patient characteristics and ED visit variables (day
and time of visit, duration of ED visit, severity of condition, diag-
nostic category, number of tests, and treatments).
Results: Of 914 parents who were contacted, 795 were eligi-
ble. Of those, 619 (78%) completed the interview. Fifty percent
of parents recalled receiving drowning prevention information;
of these, 41% recalled unaided the life vest messages and
35% of 155 parents who did not own a life vest stated they
would subsequently consider buying their child a life vest. Most
(88%) rated the prevention information useful or very useful.
No patient or visit variables were associated with usefulness
ratings.
Conclusion: Written injury prevention messages with dis-
charge instructions were well received by parents of children in
a pediatric ED. The ED may be a setting where families could
receive injury prevention education.
[Quan L, Bennett E, Cummings P, Henderson P, Del Beccaro MA.
Do parents value drowning prevention information at discharge
from the emergency department? Ann Emerg Med. April
2001;37:382-385.]
ANNALS OF EMERGENCY MEDICINE 37:4 APRIL 2001
DROWNING PREVENTION AND CHILDREN
Quan et al
INTRODUCTION
Emergency departments could be fertile sites for dissemi-
nation of injury prevention education and materials. In
1998, a total of 100,350,000 patients visited EDs; 25%
were children younger than 15 years. Potentially, the
majority of the 25 million children/families seen in EDs
represented an educational opportunity. Moreover, ED
patients and their families may be in need of injury pre-
vention education; only 45% of ED parents believed that
most injuries could be prevented.1
Many ED care plans are based on the belief that patients
in crisis recognize their vulnerability and are more open
to interventions. Limited data support this concept; the
caretakers of pediatric patients with mental health crises
had increased likelihood of limiting access to potentially
lethal weapons if they received injury prevention educa-
tion in the ED.2 Yet, most ED patients with ingestions did
not receive poisoning prevention instructions.3
The process of providing patient information in the ED
is plagued with logistical problems. Procuring, storing,
updating, and distributing handouts of written instruc-
tions are cumbersome tasks in a busy ED. Their use is left
to the memory, time, and motivation of individual ED
staff. If provided, injury prevention education is probably
most often given as verbal advice, which is not standard-
ized for correctness of content or delivery of the message.
Many EDs now have discharge instruction software pro-
grams that generate patient visit information and discharge
instructions. These systems allow the development of a
model whereby standardized injury prevention educational
messages can be included in ED discharge instructions.
An important first step in developing a strategy for
educational interventions would be to determine whether
parents value this education. We elected to use drowning
prevention as a model for injury prevention education in
the ED setting. The goal of this study was to distribute
standardized injury prevention information to ED parents
and to determine whether they recalled the information
and perceived the advice as useful in the context of an ED
visit for another problem.
M AT E R I A L S A N D M E T H O D S
The setting was the ED at a large, pediatric tertiary referral
and teaching hospital with 23,978 ED visits in 1999; the
admission rate was 24%. Sponsor mix for the patient pop-
ulation was 36% Medicaid, less than 1% Medicare, 5%
self-pay, and 13% health maintenance organization/pre-
ferred provider organization (HMO/PPO). All discharged
APRIL 2001 37:4 ANNALS OF EMERGENCY MEDICINE
patients received computer-generated, printed discharge
instructions (Echart version 4.10; Spacelabs Medical,
Inc., Redmond, WA). A nurse or physician reviewed the
discharge instructions with the patient’s family.
Between May 14 and July 6, 1999, all discharge in-
structions included 3 brief messages: wear a life vest
around water, swim in safe areas, and do not drink alco-
hol while swimming or boating (Figure). These messages
were at a sixth-grade reading level in English and Spanish
and without illustrations. ED staff were aware of the water
safety messages but were not asked to review them with
patients.
The interviews were conducted through Market Trends
(Seattle, WA), a market research firm that conducts quali-
tative and quantitative research. Telephone interviewers
used by the company were specially trained for this pro-
ject and had their calls monitored.
An interviewer made up to 4 attempts to telephone eli-
gible parents between 1 and 2 weeks after their children’s
ED visit. Parents or caregivers were eligible if they had
accompanied the patient to the ED. They were not eligible
if the discharge diagnosis was suspected abuse or the visit
was a repeat ED visit during the study period. Interview
information was not collected if the call was not made
within the 2-week interval, if the eligible parent was not
Figure.
Discharge instructions included 3 brief messages.
SUMMER SAFETY ALERT
Drowning happens quickly and quietly. The risk of drowning is greater during
the summer months. Take time now to be prepared. Here are three things you
can do that will help keep you, your family, and friends safe when you are out
on the water.
1. Wear a life vest.
Check that everyone in your family has a life vest. Make sure it fits. There
are many styles of life vests to buy at marine supply or sporting goods
stores. Many life vests are low-cost and look good. Or you can ask someone
to give your child a life vest as a gift.
Tips on when to wear a life vest:
• Young children need to wear life vests when they play in or near the
water, on docks, and in inner tubes, rafts, or boats.
• Teens and adults need to wear life vests in inner tubes, rafts, or boats,
especially small boats.
2. Swim in lifeguarded areas.
No matter how well you can swim, cold, deep, or moving water is
dangerous. It is easy to be fooled by the water. So swim in a lifeguarded
area or wear a life vest when swimming in a lake, river, or salt water.
3. Don’t drink alcohol when you are out on the water.
Never allow or use alcohol while swimming or when out in a boat. It’s just
like drinking and driving, but the effects of alcohol are even worse when you
are on or in the water.
To get your free water safety packet and children’s “tattoos,” call Children’s
Resource Line at 206-526-2500, extension 4.
3 8 3
DROWNING PREVENTION AND CHILDREN
Quan et al
home or could not come to the telephone, if the number
given in the ED did not reach the correct family, or if the
parents could not speak sufficient English. There was no
inducement for participation.
The telephone survey had 27 structured questions; 9
of these evaluated the injury prevention messages. The
survey took approximately 5 minutes to complete. The
protocol for this study was approved by the state’s and
hospital’s institutional review boards.
We determined the patient and visit characteristics for
patients discharged from the ED during the study period.
For each patient we determined the following: sex, age,
visit date, day of the week, duration of ED visit, severity of
ED visit, diagnosis category, and whether or not the
patient received any laboratory tests, radiologic tests, intra-
venous medications, intramuscular medications, or oral
medications.
We compared the patient and visit characteristics of (1)
parents who were surveyed with those not surveyed, and
(2) parents who rated the prevention materials useful with
those who did not. Comparisons were made using t tests
for continuous variables and χ2 tests for categorical vari-
ables. We used Stata Statistical software (release 6.0, 1999;
Stata Corporation, College Station, TX).
R E S U LT S
During the study period, 2,291 eligible patients younger
than 20 years were discharged from the ED. Of these
patients, 1,785 families were telephoned, and 506 could
not be telephoned within the 2-week time constraint and
thus were never called. Of those called, 871 were not con-
tacted because of wrong numbers or no answer. Of the
914 eligible parents/caregivers who were contacted, 115
refused to participate, 119 had communication barriers,
24 did not recall receiving instructions, 37 terminated the
call partway through the conversation, and 619 completed
the interview (response rate 35% [619/1,785] and com-
pletion rate 67.7% [619/914]).4
The children of the 619 interviewed parents were com-
pared with those of the 1,672 parents who were eligible
but not interviewed. Median date of ED visit was 4 days
later for those interviewed (P<.001), the interviewed
parents were less likely to have visited on a weekend
(30% versus 37%, P=.001), and the interviewed parents
were more likely to have had a radiologic procedure (26%
versus 21%, P=.02). The interviewed and not interviewed
parents did not differ significantly (P>.05) in regard to
median hour of arrival (5 PM versus 6 PM), median duration
of visit (103 versus 103 minutes), low visit severity (80%
3 8 4
versus 84%), median child age (3.6 versus 4.0 years), diag-
nostic category (15% infection, 31% other medical, 32%
trauma, 22% other versus 16% infection, 32% other medi-
cal, 28% trauma, 24% other), proportion male (57% versus
56%), proportion that had a laboratory test (24% versus
24%), proportion that had no intramuscular medications
(98% versus 98%), no intravenous medications (90% ver-
sus 92%), or no oral medications (85% versus 87%).
Nearly all parents (599/619, [97%]) recalled receiving
written discharge instructions, and another 20 recalled
the instructions when they were reminded what they
looked like. Of the 619 parents who recalled receiving
written discharge instructions, 309 (50%) recalled re-
ceiving a water safety alert with the discharge instructions.
When asked without prompting what the message was
about, 41% recalled a message about life vests, 25% re-
called a message about drowning risks, and 13% recalled
a message about swimming. Many parents (253/619 [41%])
reported that they already owned a life vest for a child. Of
155 parents who did not own a life vest and recalled in-
structions about life vests, 35% said they were considering
buying a life vest as a result of the information they re-
ceived. Most parents reported that receiving drowning
prevention information in the ED was very useful (373/619
[60%]) or somewhat useful (171/619 [28%]).
The 544 (88%) parents who rated the drowning pre-
vention messages as very or somewhat useful were com-
pared with the 75 (12%) who rated them as little or no
use. Using 13 variables (age, sex, date of visit, time of
visit, duration of visit, weekend visit, condition severity,
diagnosis category, and whether or not the patient received
a radiologic test, laboratory test, or oral, intramuscular, or
intravenous medication), forward stepwise logistic regres-
sion identified no statistically significant associations
between any variable and parent rating of usefulness.
When asked for suggestions on how to best distribute
water safety information to families, the ideas mentioned
most often by 391 parents were mailings (24%), television/
radio/newspapers (23%), physician’s office (19%), ED
waiting room (13%), school presentations (12%), and
swimming lessons (8%).
DISCUSSION
This study showed that parents perceived injury preven-
tion education in the ED as useful. Parent rating of useful-
ness was unrelated to any visit factors, including the time of
day, day of week, diagnostic category, number of laboratory
or radiologic tests, number of therapeutic interventions, or
length or patient severity for the ED visit. Moreover, nearly
ANNALS OF EMERGENCY MEDICINE 37:4 APRIL 2001
DROWNING PREVENTION AND CHILDREN
Quan et al
half of the parents who recalled receiving the water safety
information were able to state 1 to 2 weeks later that the
primary prevention message was about life vests.
Parent recall and valuing of the drowning prevention
information does not necessarily ensure that change will
occur. A limitation of this study is that it measured ex-
pressed opinions about advice but did not measure any
action. However, parents who recalled the water safety
information contemplated changing their behaviors based
on the prevention message; 35% of those who did not own a
life vest reported that they would consider buying a life vest.
Further studies should determine whether ED-based pre-
vention advice can change behavior and prevent injuries.
A large proportion of ED adult patients are functionally
illiterate, and therefore our written instructions may have
been useless to some parents.5 The illiteracy rate in our
population is unknown but may explain some refusals
and reported lack of recall and usefulness. Our prevention
materials were written at the recommended sixth-grade
reading level. Austin et al6 demonstrated that illustrations
increased patient understanding of discharge instructions.
When questioned about how to improve the instructions,
many surveyed parents in our study suggested including
illustrations.
We specifically did not ask ED staff to review the water
safety messages with the families because we sought to
deliver them in a realistic ED setting where staff members
would inconsistently review them with parents depending
on time constraints and other demands. Isaacman et al7
found that giving both verbal and computerized instruc-
tions led to better patient recall than giving only comput-
erized instructions. Further studies should identify ways
to increase patient/parent recall and follow-through on
injury prevention messages given in the ED.
The recall of our study population may be high because
parents were surveyed within 2 weeks of their ED visit.
However, the interval between visit and survey was longer
than other studies of ED discharge instruction recall.5-7
Parent recall of the water safety messages was elicited
without prompting. It is possible, however, that parents
remembered these water safety messages from ongoing
drowning prevention activities in the region.
The failure to interview the majority of eligible parents
is a limitation of this study. However, exclusion of Spanish-
speaking families excluded only a small percentage of our
patients; in 1998, the ED used Spanish interpreters for
688 families. Although not all families of discharged
patients were surveyed, the analyses of patient age, gen-
der, visit, diagnostic, and therapeutic variables showed
the surveyed and unsurveyed groups were similar; thus,
APRIL 2001 37:4 ANNALS OF EMERGENCY MEDICINE
there was no reason to believe that their responses would
differ. We did not assess receptivity to the prevention in-
formation among non–English-speaking families, and
thus these results may not apply to non–English-speaking
families.
Injury prevention should be provided to families from
multiple sources.8 Reliance on primary care providers for
injury prevention education is problematic; many patients
and families do not regularly visit their primary care pro-
viders, especially once children reach school age. In addi-
tion, many primary care providers have not been trained
in injury prevention, and increasing numbers of injury
prevention issues compete for practioners’ limited patient
time. Even in the high-risk drowning region of Los Angeles,
CA, only a third of pediatricians provide drowning pre-
vention counseling.9 The ED represents an important
additional setting for health care providers to provide
prevention information to families.
The role of the ED in injury prevention has been
envisioned as a surveillance tool but this role can be
expanded.8,10 This study showed that families find injury
prevention information useful and can recall the informa-
tion even when provided in the context of an unrelated
ED visit. New technologies coupled with patient interest
in health information allow us to develop, without adding
burden to ED staff, the ED as an injury prevention resource
and educational setting for large numbers of patients.
We thank Kathy Williams, Washington State Department of Health, Jacque Jacobs, Jill
Baullinger, the physicians, nurses, and registrars of Children’s Emergency Services for
their help with this study.
REFERENCES
1. Coffman S, Martin V, Prill N, et al. Perceptions, safety behaviors, and learning needs of par-
ents of children brought to an emergency department. J Emerg Nurs. 1998;24:133-139.
2. Kruesi MJ, Grossman J, Pennington JM, et al. Suicide and violence prevention: parent edu-
cation in the emergency department. J Am Acad Child Adolesc Psychiatry. 1999;38:250-255.
3. Dunn KA, Cline DM, Grant T, et al. Injury prevention instruction in the emergency depart-
ment [see comments]. Ann Emerg Med. 1993;22:1280-1285.
4. Lehman DR. Market Research and Analysis. Homewood, IL: Irwin; 1989.
5. Jolly BT, Scott JL, Sanford SM. Simplification of emergency department discharge instruc-
tions improves patient comprehension. Ann Emerg Med. 1995;26:443-446.
6. Austin PE, Matlack R II, Dunn KA, et al. Discharge instructions: do illustrations help our
pateints understand them? Ann Emerg Med. 1995;25:317-320.
7. Isaacman DJ, Purvis K, Gyuro J, et al. Standardized instructions: do they improve communi-
cation of discharge information from the emergency department? Pediatrics. 1992;89(6 Pt
2):1204-1208.
8. Bonnie R, Fulco C, Liverman C. Reducing the Burden of Injury. Washington, DC: National
Academy Press; 1999.
9. Barkin S, Gelberg L. Sink or swim—clinicians don’t often counsel on drowning prevention.
Pediatrics. 1999;104(5 Pt 2):1217-1219.
10. Hargarten SW, Karlson T. Injury control. A crucial aspect of emergency medicine. Emerg
Med Clin North Am. 1993;11:255-262.
3 8 5