Discharge communication practices in pediatric emergency care: a systematic review and narrative synthesis

Background The majority of children receiving care in the emergency department (ED) are discharged home, making discharge communication a key component of quality emergency care. Parents must have the knowledge and skills to effectively manage their child’s ongoing care at home. Parental fatigue and stress, health literacy, and the fragmented nature of communication in the ED setting may contribute to suboptimal parent comprehension of discharge instructions and inappropriate ED return visits. The aim of this study was to examine how and why discharge communication works in a pediatric ED context and develop recommendations for practice, policy, and research. Methods We systematically reviewed the published and gray literature. We searched electronic databases CINAHL, Medline, and Embase up to July 2017. Policies guiding discharge communication were also sought from pediatric emergency networks in Canada, USA, Australia, and the UK. Eligible studies included children less than 19 years of age with a focus on discharge communication in the ED as the primary objective. Included studies were appraised using relevant Joanna Briggs Institute (JBI) checklists. Textual summaries, content analysis, and conceptual mapping assisted with exploring relationships within and between data. We implemented an integrated knowledge translation approach to strengthen the relevancy of our research questions and assist with summarizing our findings. Results A total of 5095 studies were identified in the initial search, with 75 articles included in the final review. Included studies focused on a range of illness presentations and employed a variety of strategies to deliver discharge instructions. Education was the most common intervention and the majority of studies targeted parent knowledge or behavior. Few interventions attempted to change healthcare provider knowledge or behavior. Assessing barriers to implementation, identifying relevant ED contextual factors, and understanding provider and patient attitudes and beliefs about discharge communication were identified as important factors for improving discharge communication practice. Conclusion Existing literature examining discharge communication in pediatric emergency care varies widely. A theory-based approach to intervention design is needed to improve our understanding regarding discharge communication practice. Strengthening discharge communication in a pediatric emergency context presents a significant opportunity for improving parent comprehension and health outcomes for children. Systematic review registration PROSPERO registration number: CRD42014007106. Electronic supplementary material The online version of this article (10.1186/s13643-019-0995-7) contains supplementary material, which is available to authorized users.


Background
The discharge process in a pediatric emergency department (ED) can introduce vulnerability for parents and caregivers. Attention to this phenomenon is critical given that following a visit to the ED the majority of children are discharged home under the care of their parents [1,2]. Ideally, parents should depart the ED with the necessary knowledge and skills to effectively manage their children's care at home. However, following ED discharge, many caregivers and patients are unable to specify their diagnosis, list medications they received, outline post-ED care, or identify when to seek further medical attention [3][4][5]. The discharge process should include communication of important information about the child's illness, verification of comprehension, and tailoring of the discharge instructions to address areas of misunderstanding [6]. Yet, this is not always the parents' experience, and evidence supports that poor quality ED discharge communication can impact subsequent health care utilization, including unscheduled return visits to the ED [7,8]. Comprehension of discharge communication has been shown to be an important factor in promoting adherence to discharge instructions and preventing unnecessary return visits; however, comprehension is rarely assessed in practice [9]. A number of factors are known to impact comprehension including quality of the communication provided [10], health literacy, numeracy, and reading ability [11][12][13].
A number of recent reviews have explored discharge communication, including a recent systematic review to establish the cost-effectiveness of implementing electronic discharge communication to support the transition between acute and community care [14]. Another review focused on the parent management of inpatient and ED discharge instructions [15]. We conducted a systematic review and narrative synthesis of the discharge communication literature to gain a better understanding of how and why discharge communication functions in a pediatric ED context and to inform the development of recommendations for future research, policy, and practice change. Our review addressed the following questions: (1) What types of interventions, processes, and policies have been examined regarding discharge communication in a pediatric ED context and (2) How does the discharge process impact parent, patient, and provider outcomes?

Study design
We conducted a systematic review with narrative synthesis following methods outlined by Popay et al. [16]. This type of review explores relationships within and between studies [17]. Techniques are employed to expose the context and characteristics of the included studies to facilitate comparison of similarities and differences across studies [18]. Further details of the review protocol have been published elsewhere [19]. The protocol was registered with PROSPERO (CRD42014007106).
We embedded an integrated knowledge translation (iKT) approach in our review, whereby we met with key knowledge users (e.g., ED clinicians, administrators, parents, and researchers) during each stage of the review to strengthen the relevancy of our research questions and tailor our recommendations. We employed a number of communication strategies to maximize engagement including email and face-to-face and teleconference meetings. Critical reflection of engagement was conducted through detailed documentation of team discussions at all meetings, outlining input from the different stakeholder groups, and underlying rationale for decisions made at each stage of the synthesis process. We also integrated a knowledge user check-in strategy, where at regular intervals during each meeting, we paused to summarize the discussion and solicit questions. Three key meetings included (1) a teleconference to refine the research question, (2) a face-to-face meeting to discuss the results of the preliminary analysis, and (3) a teleconference meeting to discuss findings and draft recommendations. Finally, authors from three of the included studies (all ED physicians from academic teaching hospitals) were contacted by email and invited to provide feedback on the preliminary findings. Expert feedback was provided through a brief telephone interview lasting 15-30 min.
We used the Behaviour Change Wheel (BCW) [20], a theory-based method for characterizing and designing behavior change interventions, as a guiding framework to examine the discharge communication interventions in the included studies. Pairs of two reviewers (KM, MB, AG, or JAC) independently coded the narrative descriptions of all interventions. A directed content analysis approach was used to classify intervention description according to the nine intervention function types (i.e., the mechanism by which the intervention is proposed to function) of the BCW [20]. Reviewers met to compare consistency after coding the first and third study and then after every five studies. Differences in coding were discussed to achieve consensus.
We also coded the 75 included studies to identify barriers and enablers to intervention implementation and effectiveness as reported by the study author. Full text articles were loaded into NVivo (QSR International) and were coded by two reviewers (JAC and AG) [21]. Reviewers met throughout the process to ensure consistent coding of barriers and enablers and to discuss sections that were challenging to code.

Search strategy
The search strategy was developed in consultation with a library scientist and peer reviewed by a second library scientist from the Alberta Research Centre for Child Health Evidence (ARCHE; University of Alberta) prior to being implemented in three databases from their date of inception to July 7th, 2017: CINAHL, Medline, and Embase. Please see Additional file 1 for the list of all search strategy terms. We also hand-searched relevant emergency pediatric journals for articles published between January 1st, 2009

Study selection
Studies were included if they described or evaluated changes in the structure or process of care in the ED to enhance discharge communication as their primary objective. Quantitative, qualitative, and mixed methods study designs were eligible for inclusion. Studies were excluded if interventions took place outside of the ED or primary outcomes were not relevant to discharge communication. The published protocol paper for this review provides further details on the process of selecting studies [19]. Detailed inclusion and exclusion criteria for studies and abstracts can be found in Additional file 2.

Data extraction
Data were extracted by teams of two independent reviewers using a customized data abstraction form and discrepancies were assessed by JAC. Full data extraction included study design details (i.e., year of publication, country, type of ED), detailed description of the intervention (i.e., description of individual components, reported use of theory or assumptions about causal mechanisms supporting the different components, duration, and timing of the intervention), implementation strategies (i.e., training or instructions provided to participants, timing), participant details (i.e., age of the child, illness presentation, parent characteristics, health care provider characteristics), and author reported factors and/or processes identified as impacting implementation. Our primary outcome of interest was any change in process, parent, healthcare provider, or patient outcome related to the discharge communication intervention. We extracted details about authored reported primary outcomes (i.e., timing, measures, target of the intervention). Data was managed using excel and intervention descriptions were exported to NVivo 10 (QSR International) for analysis [19].

Quality assessment
Study quality was assessed at the study level by two independent reviewers using critical appraisal checklists from Joanna Briggs Institute (JBI) [22]. Each study was appraised using the appropriate checklist for the study design. JBI checklists are designed to assess the quality of a study's methodologies and outcomes, and to identify potential sources of bias or confounding variables within the study [22]. Options for checklist responses included "yes," "no," "unclear," or "not applicable." Each reviewer used the JBI definitions and checklists and provided evidence from the article to support the reasoning for their scoring. At two points in the appraisal process, the reviewers met to meet consensus and resolve discrepancies. A third reviewer was consulted when discrepancies could not be resolved.

Data synthesis
The primary aim of this review was to understand how and why discharge communication interventions and processes work in a pediatric ED context. To address this aim, we employed a number of data synthesis strategies proposed by Popay et al. [16] to examine the individual study findings. We developed summary tables, which outlined study design, clinical context, intervention components, intervention target, quality appraisal, outcome measures, and direction of effect. Findings of included studies did not lend themselves to quantitative analysis due to the wide range of intervention descriptions and outcome measures. We also developed structured textual summaries of all included studies that outlined primary objectives, details regarding context and setting, descriptions of any interventions and implementation strategies, relevant outcomes, and barriers reported by study authors. Content analysis was carried out on all extracted data to assist with identifying importing themes and gaps in the existing evidence.

Quality of the evidence
Study quality was assessed using critical appraisal checklists from the Joanna Briggs Institute (JBI) [22]. The majority of the cross-sectional studies were of moderate quality (6/8 appraisal criteria present). The two appraisal questions that had mixed results were related to identifying and addressing potential confounding. Only a third of the studies (n = 9; 32%) identified possible confounders and even fewer studies noted how these confounders were adjusted for during data analysis (n = 8; 29%).
The 24 RCT were appraised using the Checklist for Randomized Controlled Trials and 46% of the studies (n = 11) did not clearly identify if a true randomization method was used. Additionally, only four RCT clearly stated how allocation concealment was used during the study [60][61][62][63].
The Checklist for Quasi-Experimental Studies was used for 11 studies in the review. These quasiexperimental studies (n = 11) scored consistently well across all of the appraisal checklist criteria, with the exception of concerns about composition of the comparison groups. We found that just over half of studies (n = 6; 55%) had at least one or more key variables with  Physicians working in pediatric ED were significantly more likely to know about hospital resources to assist with child safety compared to physicians in non-pediatric centres (p < 0.001).
More than half of physicians identified that they likely would not provide written discharge communication about car seats following a motor vehicle collision. Most patients were not told to restrict activities following their concussion, although activity restriction was more likely to be discussed with patients with sports-based injuries.

Melzer
Gaucher et al. 2011 [32] To examine the effect of nurse counseling on common childhood illnesses on the return rates of patients who leave the ED without being seen by a physician.
Retrospective cohort study Cohort Canada 10,323 children (< 19 years) who were triaged by a nurse but left the ED before being seen by a physician.
Nurse counseling for patients leaving the ED prior to seeing a physician significantly reduced likelihood of return to the ED within 48 h than those who were not counseled by a nurse (8.1% vs. 6.1%; OR 0.78, 95% CI 0.65-0.94).
There was a significant increase in proportion of children told to return for follow-up (54% to 81%, p = < 0.0001), but there was no difference in follow-up rates (7% to 6%) following implementation of the tool.
Porter et al.
2006 [80] To determine the effectiveness of an asthma information kiosk on parent satisfaction, and clinician use of the kiosk information.    Education + Environmental Restructuring Parents watched a video and were mailed a letter to schedule follow-up care for their child's asthma. Parents of children with persistent asthma also received an additional letter to encourage follow-up with a PCP.

Parent
Research team Parent compliance with scheduling and attending follow-up appointment.

No change
Komoroski et al. 1996 [93] Incentivization + Environmental Restructuring Parents received one of two interventions. The first intervention group had their follow-up appointment booked for them and received a written reminder. The second intervention group received the same intervention as the first group with the addition of a mailed reminder one week prior to the appointment, a reminder phone call the day before the appointment, a work excuse, assistance with transportation to and from the appointment, and receiving child care.

Parent
Research team Parent compliance with attending follow-up appointment. Education + Enablement + Environmental Restructuring Parents received a structured written action plan with information about asthma management, treatment, in addition to an asthma assessment tool and a prescription. A valved spacer and MDIS were also provided for children. Surveys and/or telephone calls were completed to determine parents' completion of educational classes, follow-up visits with PCP and number of return visits to the ED.

Parent
ED physicians and pharmacists Adherence to prescribed asthma medications four weeks following ED discharge. + Gorelick et al.
2006 [62] Education + Enablement + Environmental Restructuring Parents received one of two interventions. Group one received standardized information in addition to having information faxed to their PCP, and phone calls to offer assistance scheduling the followup care with PCP. The second group received the same care as intervention group one, in addition to being assigned a nurse or social worker to provide home visits, and additional education and links to community services.

Parent
Research team and home health care staff Rates of return ED visits six months following initial ED asthma visit.  Enablement + Environmental Restructuring customized written asthma action plan that was provided to parents and sent to their PCP. Asthma coaches conducted follow-up calls with parents to ensure follow-up with their PCP and to reinforce messages from the asthma plan. A phone line was also provided so parents could call with asthma management questions.
provider and parent respiratory care practitioners, and a layperson and reducing ED visits.

Intervention functions
Asarnow et al. 2011 [92] Education + Environmental Restructuring + Restriction + Training Family members received education and training about the importance of mental health, outpatient treatment, how to provide support and ways to remove access to potential lethal means in the house. Patients and family members also received therapy sessions, including how to identify potential triggers and how to develop safe and healthier coping mechanisms for potential future suicidal thoughts.

Patient and parent Clinicians
Rates of follow up outpatient treatment after ED discharge. + ED emergency department, MDIS metered-dose inhaler spacers, PCP primary care provider a 10% difference or more between the study groups. These differences raise some concerns about potential selection bias. Finally, the three included qualitative studies were assessed using the Checklist for Qualitative Research. Deficits were identified in all studies regarding reporting of the philosophical perspective guiding the study methods and clearly describing the role of the researchers within the studies.

Types of interventions
We identified 44 discharge communication interventions among the 75 included studies in the review ( Table 2). Interventions were comprised of one to four intervention function types, according to the BCW (Table 3) [20]. The heterogeneity of intervention descriptions and outcome measures limited our ability to carry out meta-analysis.
The remaining education type intervention studies (13/23) examined printed discharge communication alone [73,77,94] or with other supports such as cartoons [33,60], verbal reinforcement of written instructions [51,54,59,[74][75][76], confirming appropriate understanding through observation of parent technique [27], or verbal instructions alone [32]. These studies targeted a range of illness presentations and examined a variety of outcomes including feasibility in the ED, improvement of parent's knowledge, comprehension and/ or recall about specific diagnosis, important signs and symptoms or treatment instructions, and adherence to instructions (including follow-up). Overall direction of effect was positive in most studies examining parent recall of discharge information [33,51,76] and knowledge and comprehension [54,59,60] (Table 2).
The four single intervention studies that did not involve education as an intervention function contained environmental restructuring (changing the physical and social context) [79,80], modeling (providing an example for people to aspire to or imitate) [81], or enablement (increasing the means/reducing barriers to increase capability or opportunity) [82]. Both environmental restructuring interventions targeted healthcare providers, focused on asthma, and included paper-based reminders. There was no significant change in provider behavior in either study (Table 2).

Two intervention function types
Eleven of the included studies combined two intervention functions in their discharge communication strategy (see Table 2). Again, education was a common intervention function across ten of these studies, with a second intervention function added to either overcome existing barriers (environmental restructuring) [42,49,83,85,87] or provide additional support to encourage a specific behavior (enablement [43,63,84,86] or modeling [88]). Only one intervention did not include an education component, instead favoring incentivization and environmental restructuring [93]. All two intervention function studies targeted parents or parents/children and were generally focused on either improving care at home or improving adherence with follow-up instructions.

Three intervention function types
Five studies reported using a combination of three different intervention function types, including education, enablement, environmental restructuring, training, and incentivization [61,62,[89][90][91] (Table 2). Four of the studies were focused on improving asthma management following an ED visit and one was focused on improving care provided to adolescent females who attempted suicide and presented to an ED. Three of the four asthma-focused studies used education in combination with enablement and environmental restructuring [61,62,89].

Four intervention function types
We identified one study that included four intervention functions (Table 3). Asarnow et al. (2011) developed an intervention which included a brief crisis therapy session in the ED and a structured telephone contact for motivating and supporting outpatient treatment within the first 48 h after the ED visit. We noted this intervention involved education, environmental restructuring, restriction, and training to improve follow-up rates of youth experiencing suicidality treated in an ED [92].
Most studies provided few details about the timing of intervention implementation, typically referencing that it was provided during the ED stay [60, 61, 63, 64, 66-68, 73, 74, 76, 80-92]. Thus, it was difficult to determine the exact point during the care process the intervention was delivered and the duration of the intervention. When specific timing of the interventions was indicated, it was either described as at the time of discharge [63], upon ED admission [77], directly following triage [65], or after the child was evaluated by an ED physician [69].

Conceptual mapping
Conceptual mapping is a useful technique for exploring relationships in the data of narrative synthesis [98]. Using a consensus approach, three members of the research team reviewed the narrative summaries of all included studies during two half-day meetings and identified several key concepts and relevant terms to describe how discharge communication worked or did not work for children and their parents in ED settings (Fig. 2). The final schematic depicts the key barriers and enablers for discharge communication across all included studies. Key concepts include ED context, knowledge, attitudes and beliefs, ED healthcare providers, child and parents, intervention, education, and outcomes. Important linking terms include health literacy, timing, illness severity, readiness to learn, rapport, and training.
Barriers and enablers to successful discharge communication were identified at a number of levels, including the intervention, healthcare providers, child/parent, and the context in which care is delivered. The majority of interventions targeted parents and included education as a core strategy. Although not explicitly stated, the educational interventions in the studies appear to operate on the assumption that imparting information will improve health care provider or parent knowledge and subsequently change behaviors. Few studies used theory to guide design of the intervention [71,80,81,83,84,89,90,95], and there was no formal assessment of potential barriers to changing parent, child, or health care provider behaviors. This made it difficult to understand how the interventions were expected to improve outcomes. Barriers related to intervention design (language, literacy level, content, readability) and delivery (timing during the visit, duration, fidelity, mode, extent of interactivity) were identified as important factors across a number of studies [26, 55, 57, 60, 65-67, 74, 78, 84, 86, 89, 99]. While there was variation in who delivered the interventions, it is important to highlight that in a number of the experimental trials, the interventions were delivered by individuals who were not regular members of the ED team [33,51,59,63,64,66,69,70,72,73,79,82,85,88]. A collaborative approach to co-designing interventions was proposed by some authors as a possible strategy to enhance implementation [33,40,49,70]. A number of barriers and enablers related to the patient and parent were reported including complexity of the patient presentation [53,57,69,75,84], first language and health literacy [35,42,46,52], expectations of care [25], and past experience [66,71]. Parents' health literacy was considered an important factor in both the design [54,63,67] and the mode of delivery [46,50,57,65] of the intervention. Parental stress was also considered an important influence on parents' readiness to engage in discharge communication [26,53,69]. Actively engaging parents in the discharge process throughout their ED visit [27,78,81] and presenting information using multiple delivery modes [33,51,68,75,80,83,96] were thought to be important enablers. Parent decision making about the nuances of follow-up care post discharge can be complex [94]. It was also recognized that parents leverage a number of external knowledge sources including family and non-healthcare workers when making decisions about care for their child at home following an ED visit [52,64,65,97].
Several studies suggested that ED healthcare providers recognize discharge communication as an important aspect of their everyday professional practice for both clinical and medicolegal reasons [23,32], but there appears to be a fuzzy boundary between patient education and the provision of discharge information [70]. Discharge communication practice variation was common across a number of studies [30,31,100]. Healthcare provider training [23,27,28,55,74,77,86], beliefs and attitudes about discharge communication [40,41,57], and limited use of medical jargon [53,96] were identified as important factors influencing success. Rapport between healthcare providers and parents was also considered an important factor contributing to successful discharge communication [69,81,95]. Although we did not identify any interventions that focused specifically on building rapport between providers and parents, the quality of the interaction between providers and patients/parents was highly valued as contributing to successful discharge communication [34,46,60,69,76,81,84,88,97].
The context of the ED including factors related to managing multiple patients in a compressed period of time and emphasis on patient flow can pose unique barriers to discharge communication [30,55,92]. Approaches to address some of these contextual barriers include a dedicated space for teaching, easily accessible resources, and the inclusion of strategies that reduce the time burden on ED providers and can easily be incorporated into the busy workflow of the ED [55,79,80,86,96]. However, Macy et al. (2011) noted that even the use of video education can be hindered during times of high patient volumes [65]. Ideal structures support discharge communication that is consistent and comprehensive yet succinct and relevant [23,44,97]. ED team practice norms regarding discharge communication [42,78] and roles in the ED specifically dedicated to discharge communication may assist with consistent and reliable delivery [27,39,76]. Although there was wide variation in primary outcomes across studies, parent knowledge, comprehension, and recall were deemed important outcomes in a number of studies [33,51,59,63,65,67,68,[70][71][72]. Unfortunately, there was little consistency in how knowledge, comprehension, and recall were measured across these studies.

Policies guiding pediatric discharge communication
We received a total of 36 responses to our email surveys (Canada = 17; Australia = 13, USA = 6) with no relevant pediatric ED discharge communication policies or guidelines identified. Following our search of the gray literature, three documents were discovered that included either policies or guidelines regarding the provision of discharge communication [101]. A joint policy developed by the American Academy of Pediatrics and the Committee on Pediatric Emergency Medicine recommended the provision of discharge communication within a familycentered care approach, [101]. Generally, this guideline contained very little direction in the way of discharge content and processes, and it is unclear if it translates into active policy development [101]. The Scottish Intercollegiate Guidelines Network (SIGN) has produced a generic discharge document tool that can be implemented to guide the discharge process [102]. The discharge document provides guidance on important content that should be communicated at discharge, including primary discharge diagnosis, presenting complaint, significant procedures, new medications, and follow-up instructions [102]. However, no specific recommendations are made about how the SIGN discharge document should be generated, updated, and used in ED clinical practice [102]. Finally, the National Guidelines Clearinghouse contained one active policy that is currently utilized by affiliated children's hospitals in the USA. This policy outlines standards for discharge communication as the primary responsibility of the ED nurse and that all patients are to be discharged home with explicit plans for follow-up care, a summary of the visit, appropriate instructions for care, and prescription medications [103]. Prior to discharge, it is the responsibility of the nurse to verify that all health care concerns have been addressed, parents are aware of when to return to the ED, documentation is complete, and medications have been reviewed with the patient [103].

Discussion
The body of literature exploring discharge communication in a pediatric ED context is highly heterogeneous, reporting a range of interventions, delivery methods, and outcome measures across a variety of illness presentations. These findings are consistent with systematic reviews of discharge communication practices in hospital settings [15,104]. In general, our findings demonstrate that discharge communication in pediatric emergency practice environments has been largely oversimplified with a corresponding atheoretical approach to intervention design, involving strategies that ignore the context of where the communication takes place (ED) and where the information is primarily used by the parents (home). Education was the most common type of intervention evaluated. The underlying assumption appears to be that a parent's lack of knowledge is the most important contributor to poor child outcomes and educational interventions are the most viable solution. We noted a lack of focus on child and youth comprehension and limited attention on healthcare provider knowledge and skills to deliver discharge communication. However, through a concept mapping exercise, we were able to identify factors at the individual, intervention, and system level that may affect successful discharge communication in a pediatric emergency care context.
Many of the educational interventions included in our review relied on passive dissemination strategies to deliver information. Yet, we know that behavior change requires more than simply the acquisition of knowledge [105]. Passive dissemination of educational material is rarely effective in changing the behavior of providers or improving patient outcomes [106,107]. Adults learn best when there is a perceived need, active participation, reinforcement of new behaviors, and immediate feedback and correction of misconceptions [108,109]. Active engagement in learning such as the use of teach-back strategies have been associated with improved comprehension, more patient-centered communication, and increased engagement of parents [110][111][112]. Teach-back is a way of checking comprehension by asking patients to repeat back in their own words what they have been told by their health care provider [113]. However, further research is needed regarding the efficacy, feasibility, fidelity and acceptability of teach-back in an ED setting [112]. The use of behavior change theories to specify behavioral targets and guide intervention design in future discharge communication studies are needed to strengthen this body of literature and assist with identifying and evaluating the "active ingredients" that affect intervention outcomes [114].
While standardizing discharge communication may be viewed as one way of achieving good quality discharge communication, our synthesis demonstrated conflicting results pertaining to the effectiveness of standardized discharge communication. Standardized instructions are often recommended to increase familiarity with ED discharge documentation for patients, staff, and general practitioners [115]. One study in this synthesis showed improved communication of important discharge information through the use of standardized discharge communication in children with otitis media [84]. However, other authors reported that standardized instructions were insufficient to enhance adherence and comprehension [50]. In light of this, ensuring that discharge instructions contain common elements, while still allowing for adaptation and tailoring to accommodate provider and parent needs, might be a more appropriate approach.
Finally, our findings reveal a dearth of existing policies guiding discharge communication practice in a Canadian pediatric ED context. Further, there appears to be a lack of clarity regarding professional accountability for discharge communication in the literature. Tavender et al. (2014) examined factors that influence management of mild traumatic brain injury in the ED. They noted that physicians felt primarily responsible for discharge communication as they were the health care provider responsible for discharging a patient; however, nurses felt discharge communication should be a shared responsibility to ensure patients were adequately educated prior to being sent home [116]. Many of the studies included in our review, particularly those related to asthma [79], recognized the importance of an interdisciplinary approach to discharge communication. Clear guidelines and polices regarding discharge communication practice are critical to ensure more sustainable and reliable discharge communication strategies in the future.

Strengths and limitations
This review followed established review methodologies including a comprehensive search of the published and gray literature, assessment of risk of bias, and established narrative synthesis strategies to explore relationships across a range of study designs. We incorporated an iKT approach to ensure our findings were relevant to stakeholder needs.
Due to the heterogeneity of the interventions and outcomes, we were unable to perform a meta-analysis. While we used an established behavioral framework to guide our examination of discharge communication interventions, our classification of the included interventions was limited to the details provided in the study reports. It is possible that the interventions contained additional functions that were not captured in our analysis because they were not reported by the study author.