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Use of a daily discharge goals checklist for timely discharge and patient satisfaction.

Introduction

Despite the importance of discharge preparations, qualitative research has found discharge teaching is addressed inadequately by nursing staff and not begun until well into the patient's hospitalization.

Purpose

To determine if use of a daily discharge goals checklist during inter-professional rounds decreases the time from medically ready for discharge and actual discharge and/or improves patient satisfaction with discharge education/information

Methods

Participants were assigned randomly to a group with use of a daily discharge goals checklist during interprofessional rounds or usual care. The checklist was begun within a day of admission and continued each day of hospitalization for the intervention group. Study outcomes included the difference in time between medically ready for discharge and actual discharge, and patient satisfaction with discharge teaching.

Findings

A sample of 65 medical inpatients was included in the study (use of a daily discharge goals checklist during interprofessional rounds, n=36; no checklist, n=29), with most patients admitted for treatment of a sickle cell crisis. Time difference between medically ready for discharge and actual discharge averaged 3.9 [+ or -] 2.2 and 5.4 [+ or -] 6.9 hours between the intervention and usual care groups, respectively, with no statistical differences found (p>0.05). Overall patient satisfaction with discharge teaching was high and statistically similar for the two groups (p>0.05).

Conclusion

Use of a daily discharge goals checklist during interprofessional rounds did not decrease significantly the time from when medical discharge occurred and when hospital discharge actually occurred. Overall patient satisfaction with discharge teaching was high for both groups, with no difference between groups.

Frequently discharged with prescriptions for new medications and/or treatments, hospitalized patients may have new physical limitations that must be accommodated in the home environment before discharge. Patient and family education also is needed to address these changes and preparation made for a safe transition from hospital to self-care. The primary responsibility for coordinating and implementing discharge education and planning belongs to nurses caring for the patient (Kalisch, 2006).

Significance

Prior studies confirmed the significant effect of early discharge preparation process on decreased hospital length of stay (LOS) as well as post-discharge readmission and mortality (Fox et al., 2013; Sheppard et al., 2013). Despite the recognized importance of discharge preparation, qualitative research has found discharge teaching/preparation is one of several nursing care activities that either is not done at all or addressed inadequately by nursing staff (Kalisch, 2006; Kalisch & Xie, 2014). Kalisch (2006) noted discharge preparations tended to occur close to the time of discharge.

Waiting to begin discharge preparations until just before the patient is scheduled to leave the hospital may delay discharge for hours or days. This is especially true for patients and family members who must learn complex information and/or skills (e.g., administration of injectable medications, dietary restrictions, complex medication regimen), obtain home healthcare equipment before discharge, or arrange transportation home. An estimated 30% of all hospital discharges are delayed for non-medical reasons due to inadequate patient assessment by health professionals of post-discharge health and social care needs; late notification of impending discharge, making transport arrangements difficult and delaying a timely discharge; and poor communication between hospital staff regarding follow-up community services care (Sheppard et al., 2013).

One key to decreasing the number of non-medical discharge delays could be use of a simple screening process early in the hospital admission to help interprofessional clinicians identify and eliminate non-medical factors that could delay timely discharge. A recent descriptive study found nurses reported less instances of missed care (care which should have been provided but was not) when they used a reminder function on the electronic medical record (Piscotty, Kalisch, Gracey-Thomas, & Yarandi, 2015). By using an easy-to-implement reminder system, busy clinicians may address earlier discharge preparations and avoid unnecessary delays when patients are medically ready for discharge.

Purpose

The primary purpose of this study was to determine if implementation of an easy-to-use daily discharge goals checklist during interprofessional rounds on an inpatient medical unit would decrease discharge delays when a patient is deemed medically ready for discharge. A secondary purpose was to evaluate patient satisfaction with discharge planning.

Review of the Literature

The initial review of the literature included searches of PubMed and CINAHL databases for 2010-2015. Due to the lack of recent studies, search years were extended to 2005-2015. Search terms included discharge screening, discharge checklist, daily goal setting, daily goals form, discharge goal setting, early discharge preparation, early discharge education, and patient satisfaction with discharge planning. Randomized controlled trials (RCTs) identified in systematic reviews of the literature on these topics also were included.

No RCTs or meta-analyses were found that evaluated use of daily goal setting for discharge preparation with medical or surgical inpatients. Since 2003, only performance improvement (PI) projects, descriptive studies, or quasi-experimental studies reported using a simple checklist of items to help clinicians focus on patient care factors thought to be key activities for transfer from the intensive care unit (ICU) to a general patient care area (Lane, Ferri, Lemaire, McLaughlin, & Stelfox, 2013; Provonost et al., 2003). The checklists were designed for daily use by rounding members of the interprofessional team to provide consistent patient evaluation culminating with establishment of goals for transfer from the ICU. The checklist was identified commonly as a daily goals form based on literature review and/or investigator experience.

The first publication of a daily goals form for use during inter-professional rounds involved evaluation by checklist originators (Provonost et al., 2003). The checklist included daily assessment of impediments to timely discharge from the ICU (e.g., safety risks, pain management, immobility, ventilator support), followed by identification of goals to improve time to discharge from the ICU (e.g., nutritional advancement, mobility, weaning from mechanical ventilation). Using a PI approach, project managers found ICU LOS was decreased for 10 months after implementation of the daily goals process (mean 1.5 days, compared to 2.2 days before implementation over an 8-week period). In addition to LOS improvements, nurses and physicians reported better understanding of the daily plans for each patient after implementation of the daily goals form.

Several other groups evaluated the use of an ICU daily goals form for adult (Centofanti et al., 2014; Narasimhan, Eisen, Mahoney, Acerra, & Rosen, 2006) and pediatric patients (Agarwal, Frankel, Tourner, McMillan, & Sharek, 2008; Phipps & Thomas, 2007; Seigel et al., 2014). A quality improvement project in a 16-bed medical ICU evaluated effects of use of a daily goals worksheet on nurse-physician communication and ICU LOS (Narasimhan et al., 2006). The goals worksheet was completed once a day during inter-professional rounds, setting goals for patient management over the next day. Nurses (n=21) and physicians (n=12) noted improvement in communications after implementation of the daily goals worksheet, finding significant reductions in LOS (average of 4.3 days vs. 6.4 days for the same period 1 year before implementation, p=0.02).

In an uncontrolled longitudinal study using a pre-post design, Phipps and Thomas (2007) surveyed pediatric ICU nurses about their perception of communication between nurses and physicians before (n=42) and 12 months after (n=40) implementation of the daily goals form during inter-professional rounds. Survey items were a combination of Likert and multiple choice responses. Surveys were returned by over half the nursing staff (n=22 of 42 before, n=4 of 40 after), with mean scores on all communication statements improved after use of the daily goals form compared to pre-survey responses. Over 90% of nurses recommended continued use of the daily goals form during inter-professional rounds.

In an uncontrolled longitudinal study with a pre-post design, Agarwal and colleagues (2008) replicated procedures used by Provonost and co-authors (2003) in a PI evaluation of the use of the daily goals form during interprofessional rounds in a pediatric ICU. While mean LOS decreased from 4.1 days pre-intervention (n=299, 2-week period) to 3.7 days post-intervention (n=342, 2-week period) following a 4-month implementation period, the decrease was not significant. Over three-quarters of team members surveyed after implementation of the daily goals form found the format beneficial for understanding patient goals and/or increasing their comfort in explaining goals to parents.

In a descriptive study of adult ICU clinicians' perspectives and attitudes about use of a daily goals form on interprofessional rounds, Seigel and co-authors (2014) found the majority of clinicians surveyed (n=52 of 56) indicated a belief patient management, clinician-to-clinician communication, and momentum in the patient's recovery from critical illness improved after implementation of the daily goals form. In another descriptive study of adult ICU clinicians in a 15-bed medical-surgical ICU, investigators surveyed 56 clinicians and observed another six clinicians during interprofessional rounds to determine their perspectives and attitudes about use of a daily goals form (Centofanti et al., 2014). The daily goals form was completed 93% of the time (n=73 of 80 observations). Its use was perceived by nurses and physicians to improve patient care management by creating a systematic, comprehensive approach to setting daily goals for the patient.

Given the positive outcomes observed with use of a daily goals form to improve patient care processes related to discharge from the ICU, researchers hypothesized this type of approach could have benefits in a medical unit to help clinicians focus each day on identification and resolution of non-medical barriers to hospital discharge. By revising the ICU daily goals form to focus on assessment of situations or conditions that can delay timely discharge from a medical care unit, clinicians would be more likely to focus on discharge preparations earlier in the admission. Because much of the delay in hospital discharge is related to performance of discharge teaching and/or planning at the last minute (Sheppard et al., 2013), getting clinicians to focus on post-discharge needs and potential barriers to discharge each day after unit admission should help to decrease non-medical discharge delays.

Although none of the cited literature included patient satisfaction as an outcome, investigators of the current study suggested beginning discharge preparations earlier in hospitalization may improve patient satisfaction with discharge education/preparation.

Methodology

This study was conducted in a 511-bed academic medical center in the southeastern United States on a 26-bed medical oncology and hematology inpatient unit. Study approval was obtained from the institution's investigational review board before data collection, with consent obtained from all participants by study investigators. Anonymity was maintained by use of assigned numbers rather than personal identifiers on all data collection items. Participants were informed of their right to withdraw from the study at any time. Data collection continued over 8 months.

Study Design

A posttest randomized, controlled design was used to evaluate use of a daily discharge goals checklist during interprofessional rounds on the study unit. Group assignment was made using a computer randomization program. Dependent variables included the difference between time of actual unit discharge and time when the patient was deemed medically ready for hospital discharge, and level of patient satisfaction with discharge planning and education.

Intervention

The daily discharge goals checklist used in this study was developed by the study investigators (see Table 1). The checklist was an adaptation of the daily ICU goals form concept used in prior projects (Narasimhan et al., 2006; Provonost et al., 2003), with checklist items refocused to address previously identified non-medical reasons for discharge delays (Sheppard et al., 2013). Study interventions included the following: once-daily use of the discharge goals checklist during inter-professional rounds initiated within 24 hours of unit admission, communication of discharge goals and identified tasks for resolution on the wall whiteboard near the patient's bed, and maintenance of the discharge goals checklist at patient's bedside.

Timely discharge was defined as the difference between time the discharge order was written and time patient left the study unit, both verified by notation in medical record. Patient satisfaction with discharge planning was defined as the score on the Quality of Discharge Teaching Scale (QDTS). The QDTS is an 18- or 24-item survey used to evaluate all teaching received by patients during their hospitalization before discharge (Maloney, & Weiss, 2008; Weiss & Piacentine, 2006; Weiss et al., 2007). The QDTS version used in this study was 24 questions (see Table 2). Survey items are rated on a 0-10 scale (0=item was not addressed, 10=item was addressed a great deal). Patients also rate the educational content and how well the content was delivered. The QDTS was tested initially in postpartum mothers (Weiss & Lokken, 2009; Weiss, Ryan, & Lokken, 2006) and expanded later for use with medical-surgical patients (Maloney & Weiss, 2008; Weiss & Piacente, 2006; Weiss et al., 2007). Cronbach's alpha reliability coefficient in non-maternal adults for the total score was 0.92, and 0.85 and 0.93 respectively for content received and delivery subscales (Weiss & Piacente, 2006).

Sample Selection and Setting

Subjects for this study were consenting adult patients admitted to an inpatient medical unit. Inclusion criteria included age 19 or older, no cognitive impairment, and anticipated length of stay of at least 72 hours. Sample size was calculated a priori and based on power analysis for statistical testing with t-tests on the primary outcome variable (time difference between actual discharge and when the medical order for discharge was implemented). A minimum sample size of 64 patients was determined based on an effect size of 0.71, power of 0.8, and a of 0.05 (Faul, Erdfelder, Lang, & Buchner, 2007). An effect size of 0.7 would detect at least a 25% reduction in the primary outcome variable.

Study Procedure

All patients who met eligibility criteria and consented to study inclusion were assigned randomly to one of two groups:

* Use of a daily discharge goals checklist during interprofessional rounds

* No use of a discharge goals checklist during interprofessional rounds

Within 24 hours of patient admission, use of the daily discharge goals checklist during interprofessional rounds (see Table 1) was begun for members of the intervention group. Study investigators, registered nurses with experience in inpatient care, completed the checklist and used that document during discussions of discharge preparations with interprofessional team members (social worker, clinical nurse specialist, shift nurse manager, clinical nurse) at daily care coordination meetings; no effort was made to determine interrater reliability. Discharge goals and activities needed to resolve non-medical barriers then were written on the wall whiteboard near the patient's bed. No discharge goals checklist was used for assessment of patients assigned to the control group or during interprofessional care coordination meetings. Participants in both groups completed a survey on patient satisfaction with discharge education on the day of discharge from the unit. The times of medical readiness for discharge and actual physical discharge from the unit were identified from the medical record.

Data Analysis

Data were summarized using descriptive statistics. Chi-square analysis was used to determine differences between groups for nominal data. Kaplan-Meier log-rank test was used to test for differences between groups for time to discharge. Independent Student's t-test was used to determine if average patient satisfaction scores by group were significantly different. Level of significance for all tests was p<0.05.

Findings/Results

Of 65 inpatients enrolled in the study, 36 (55%) were in the intervention group and 29 (45%) in the control group. See Table 2 for a summary of patient characteristics. No significant differences were found in patient characteristics between the two groups.

The difference between time a discharge order was written and time the patient left the unit ranged from 0.6 to 33.4 hours (mean 3.9 [+ or -] 2.2 and 5.4 [+ or -] 6.9 hours respectively for intervention and control groups). Discharge time differences were not distributed normally, requiring time-to-event data to be evaluated with a Kaplan-Meier analysis. The time difference between the daily discharge goals checklist and no checklist groups was not statistically significant. The average patient satisfaction survey score with discharge preparation was 5.7 [+ or -] 2.4 for the intervention group and 6.6 [+ or -] 2.4 for the control group; this difference was not significant.

Discussion

This is the first RCT of use of a daily discharge goals checklist in a non-ICU setting. While the time difference between medical readiness for discharge and actual discharge was shorter in the checklist group, the difference was not statistically significant. This lack of statistical difference is similar to findings from two of the three previous non-controlled projects or studies of a discharge goals form evaluating ICU LOS (Agarwal et al., 2008; Provonost et al., 2003). The lack of statistical difference could be related to the decision to power the study to detect at least a 25% difference between the groups. Using a larger sample size may allow detection of a significant difference. Authors believed detecting at least a 25% difference between groups was a reasonable expectation to justify the additional cost of increased effort by clinicians using a checklist.

Long delays in actual discharge times were not experienced once patients were deemed medically ready for discharge. The use of a daily discharge goals checklist during interprofessional rounds might be more effective for units experiencing larger delays in actual discharge compared to times of medical readiness for discharge. In addition, the intervention was applied by the study investigators, who thus could not evaluate if the checklist would assist clinicians to perform discharge planning earlier.

No prior ICU studies evaluated patient satisfaction. The finding of no difference in satisfaction between the two groups was somewhat unexpected because authors believed patients would have an improved discharge experience if planning was begun earlier and did not seem rushed. The timing of satisfaction measurement (just before discharge) may not have been ideal; at the time of discharge, patients may not have been able to focus clearly on survey completion.

Limitations

The lack of difference between the intervention and control groups also may be a result of the very few patients who had more than a few hours delay in discharge once they were medically ready for discharge; the average differences in the control group was only 5.4 hours. Other efforts to decrease discharge delays at the institution (e.g., a PI initiative emphasizing 10:00 a.m. discharge time for patients) also may have eliminated some discharge delays before or during the current study.

Nursing Implications

Even though the study did not find any statistical difference in discharge times between the two groups, a similar easy-to-use tool could help clinicians focus on common non-medical barriers to a timely discharge and be beneficial for some units. Clinicians may find it easier to begin preparations well before patient discharge. In particular, patients with complex discharge preparation needs (e.g., learning to give self-injections, needing home medical equipment) may benefit from nurses' use of a checklist.

Recommendations for Future Research

Because the difference between medical readiness for discharge and actual discharge time was small for the control group in this study, research should be replicated in situations where greater discharge delays are expected. In addition, the study should be restricted to patients with a high likelihood of having complex, non-medical discharge needs, such as financial difficulties in obtaining medication or complex transportation needs. Measurement of patient satisfaction as an outcome might be accomplished better by a day or more before or after discharge.

Conclusion

This study represented the first RCT of use of a daily discharge goals checklist for patients on a medical unit. Use of the checklist during interprofessional rounds did not decrease significantly the time from order entry for medical discharge to the patient's actual discharge from the hospital. Overall patient satisfaction with discharge teaching was high with no difference between groups.

REFERENCES

Agarwal, S., Frankel, L., Tourner, S., McMillan, A., & Sharek, P. (2008). Improving communication in a pediatric intensive care unit using daily patient goal sheets. Journal of Critical Care, 23(2), 227-235. Centofanti, J., Duan, E., Hood, N., Swinton,

M., Perri, D., Waugh, L ... Cook, D. (2014). Use of daily goals checklist for morning ICU rounds: A mixed methods study. Critical Care Medicine, 42(8), 1797-1803.

Faul, F., Erdfelder, E., Lang, A., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavioral Research Methods, 39(2), 175-191.

Fox, M., Persaud, M., Maimets, I., Brooks, D., O'Brien, K., & Tregunno, D. (2013). Effectiveness of early discharge planning in acutely ill or injured hospitalized older adults: A systematic review and metaanalysis. British Medical Corporation Geriatrics, 13, 70-79.

Kalisch, B. (2006). Missed nursing care: A qualitative study. Journal of Nursing Care Quality, 21(4), 306-313.

Kalisch, B., & Xie, B. (2014). Errors of omission: Missed nursing care. Western Journal of Nursing Research, 36(7), 875-890.

Lane, D., Ferri, M., Lemaire, J., McLaughlin, K., & Stelfox, H. (2013). A systematic review of evidence-informed practices for patient care rounds in the ICU. Critical Care Medicine, 41(8), 2015-2029.

Maloney, L., & Weiss, M. (2008). Patients' perceptions of hospital discharge informational content. Clinical Nursing Research, 17(3), 200-219.

Narasimhan, M., Eisen, L., Mahoney, C., Acerra, L., & Rosen, M. (2006). Improving nurse-physician communication and satisfaction in the intensive care unit with a daily goals worksheet. American Journal of Critical Care, 15(2), 217-222.

Phipps, L., & Thomas, N. (2007). The use of daily goals sheet to improve communication in the paediatric intensive care unit. Intensive and Critical Care Nursing, 23(5), 264-271.

Piscotty, R., Kalisch, B., Gracey-Thomas, A., & Yarandi, H. (2015). Electronic nursing care reminders: Implications for nursing leaders. Journal of Nursing Administration, 45(5), 239-242.

Pronovost, P., Berenholtz, S., Dorman, T., Lipsett, P., Simmonds, T., & Haraden, C. (2003). Improving communication in the ICU using daily goals. Journal of Critical Care, 18(2), 71-75.

Sheppard, S., Lannin, N., Clemson, L., McCluskey, A., Cameraon, I., & Barras, S. (2013). Discharge planning from hospital to home. Cochrane Database of Systematic Review, (1), CD000313. doi:10.1002/14651858.CD000313.pub4

Seigel, J., Whalen, L., Burgess, E., Joyner, B., Purdy, A., Saunders, R.....Willis, T (2014). Successful implementation of standardized multidisciplinary bedside rounds, including daily goals, in a pediatric ICU. Joint Commission Journal of Quality and Patient Safety, 40(2), 83-90.

Weiss, M., & Piacentine, L. (2006). Psychometric properties of the Readiness for Hospital Discharge Scale. Journal of Nursing Measurement, 14(3), 163-180.

Weiss, M., Piacentine, L., Lokken, L., Ancona, J., Archer, J., Gresser, S..... Vega Stromberg, T. (2007). Perceived readiness for hospital discharge in adult medical-surgical patients. Clinical Nursing Specialist, 21(1), 31-42.

Weiss, M., & Lokken, L. (2009). Predictors and outcomes of postpartum mothers' perceptions of readiness for discharge after birth. Journal of Obstetric, Gynecologic and Neonatal Nursing, 38(4), 406-417.

Weiss, M., Ryan, P., & Lokken, L. (2006). Validity and reliability of the perceived readiness for discharge after birth scale. Journal of Obstetric, Gynecologic and Neonatal Nursing, 35(1), 34-35.

Shakir Gabriel, Janese Gaddis, Netsai Nancy Manga, Femi Obanor, Onyaka Theo Okafor, Ayana Thornton, and Whitney Molasky

Shakir Gabriel, MSN, RN, OCN, FNP-C, is Unit Charge Nurse, Medical and Hematology Oncology Unit, Emory University Hospital Midtown, Atlanta, GA.

Janese Gaddis, MSN, RN, OCN, is Infusion Staff Nurse, Georgia Cancer Center for Excellence, Grady Health System, Atlanta, GA. She was Nurse Educator, Medical and Hematology Oncology Unit, Emory University Hospital Midtown, Atlanta, GA, at the time of the study.

Netsai Nancy Mariga, MPH, BSN, RN, OCN, is Cancer Support Case Manager, United-Health Group, Atlanta, GA. She was Staff Nurse, Medical and Hematology Oncology Unit, Emory University Hospital Midtown, Atlanta, GA, at the time of the study.

Femi Obanor, BSN, RN, is Staff Nurse, Medical and Hematology Oncology Unit, Emory University Hospital Midtown, Atlanta, GA.

Onyaka Theo Okafor, RN, is Staff Nurse, Medical and Hematology Oncology Unit, Emory University Hospital Midtown, Atlanta, GA.

Ayana Thornton, MSN, RN, is Clinical Nurse Educator, Grady Health System, Atlanta, GA. She was Staff Nurse, Medical and Hematology Oncology Unit, Emory University Hospital Midtown, Atlanta, GA, at the time of the study.

Whitney Molasky, MSN, APRN, ACNS-BC, OCN, is Pain Clinical Nurse Specialist, Duke University Health System, Durham, NC. She was Clinical Nurse Specialist, Medical and Hematology Oncology Unit, Emory University Hospital Midtown, Atlanta, GA, at the time of the study.

Acknowledgment: Special thanks to Marianne Chulay, PhD, RN, FAAN, for assistance with study design, data analysis, and manuscript preparation.
TABLE 1.
Discharge Goals Checklist Used in Interprofessional Rounds

* Home health: Not needed; needed and date home health contacted

* Placement: Going home; date when facility contacted if
  not going home

* Equipment/supplies: Needed for home after discharge
  (e.g., walker, bed, oxygen, dressings)

* Home medication pre-certifications required
  (e.g., enoxaparin, filgrastim, pegfilgrastim, insulin):
  List precertification required and data completed

* Transportation home: Personal ride
  (note when responsible party notified of
  discharge date/time); taxi (note when social
  worker notified of discharge date/time)

* Outpatient appointments: None required;
  appointments made; patient instructed to
  call office for appointment

* Discharge medication prescriptions written:
  None required; on medical record

TABLE 2. Patient Characteristics (N=65)

                                             Early Discharge
                                             Planning (n=36)

Age *                                       42.6 [+ or -] 16.0

Gender Identity        Male                     16 (44.4%)
                       Female                   20 (55.6%)

Reason for Admission   Sickle cell crisis        18 (50%)
                       Chemotherapy             4 (11.1%)
                       Symptom management       6 (16.7%)
                       Other                    8 (22.2%)

Primary Diagnosis      Sickle cell anemia      20 (55.6 %)
                       Cancer                  12 (33.3 %)
                       Other                    4 (11.2 %)

                        Usual Discharge
                        Planning (n=29)

Age *                  41.5 [+ or -] 17.7

Gender Identity            6 (20.7%)
                           23 (79.3%)

Reason for Admission       15 (51.7%)
                           4 (13.8 %)
                           8 (27.6 %)
                           2 (6.9 %)

Primary Diagnosis         16 (55.2 %)
                          12 (41.4 %)
                           1 (3.4 %)

* Mean [+ or -] SD
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Title Annotation:Research for Practice
Author:Gabriel, Shakir; Gaddis, Janese; Mariga, Netsai Nancy; Obanor, Femi; Okafor, Onyaka Theo; Thornton,
Publication:MedSurg Nursing
Date:Jul 1, 2017
Words:4225
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