Introduction
The process of emergency department (ED) discharge provides critical information for patients regarding the next steps of their care. Discharge instructions are often required by hospital accreditation and governmental organizations for quality or monitoring metrics. However, studies show that many patients do not fully understand or recall the instructions they receive [1,2]. In addition to patient-specific factors contributing to lack of comprehension and care compliance, the myriad situational challenges inherent to every emergency department as well as individual clinician skills and knowledge of best discharge practices further impact patient experience, understanding, and subsequent outcomes.
In many instances, the discharge process is often limited to a brief exchange of documents, prescriptions, and verbal description of the diagnosis, frequently leaving patients with uncertainty about their care plan. Understanding discharge instructions can be very challenging for a variety of reasons. Physical or emotional discomfort can impact receptiveness to and comprehension of imparted information, for example. Patients or family members eager to leave may be less interested in the instructions; conversely those presented with a devastating diagnosis may be less able to process specific details.
Moreover, a significant number of patients have low literacy and/or health literacy levels. In addition, the busy ED setting may distract the patient’s attention from such instructions. Understanding the challenges surrounding discharge communications in the ED from the patient’s perspective and having a clear approach and purpose is essential. Much more critical than an afterthought, discharge is the first step of a patient’s care transition and greatly impacts quality outcomes, litigation, experience, and team morale [3,4].
Understanding the Challenges
Emergency physicians face unique challenges while ensuring high-quality care due to distractions and time limitations that are common throughout ED settings. In most cases, emergency physicians have little or no previous knowledge of their patients and are unlikely to partake in the follow-up process, making effective communication paramount when patients are discharged from the ED. Providing clear and consistent communication throughout the entire patient care encounter, including the discharge process, is an important aspect of quality and patient-centered emergency medical care.
Unfortunately, many patients are discharged from the ED with an incomplete understanding of the information needed to safely care for themselves at home or when to promptly return to the ED [1, 5-6]. Patients have particular difficulty comprehending post-ED care instructions regarding medications, home care, and follow-up expectations. And while all patients discharged from the emergency department should be provided instructions for ongoing management of their medical condition, studies demonstrate that patient recall and understanding of diagnosis, treatment, and follow-up plan are generally quite poor [1,2,5-9]. This raises significant concerns for care plan adherence and medical outcomes, which studies show are poorer in cases of low health literacy. Given current trends toward value-based care and the fact that nearly half of the lawsuits in emergency medicine revolve around discharge instructions and plans, ongoing improvements in the discharge communication process is essential [3,4].
While some of this relates heavily to the ability of the provider to establish a trusting and positive patient-provider relationship within the ED constraints, several additional strategies can be used to enhance the recall of instructions, improve compliance, and minimize litigation.
Discharge Essentials
Effective discharge communication provides an opportunity for the emergency department team to summarize a patient’s visit, teach them how to safely care for themselves at home, and provide specifics regarding the next steps in their care process. It also gives ED physicians a chance to address any remaining questions or concerns, often augmenting patient and family understanding while improving care plan retention. Although patient education at discharge typically begins with initial assessments and conversations with patients and family, other factors can also influence the success or failure of how information is transmitted at discharge.
Common interventions promoting an effective ED discharge process include using a standardized approach to relaying content, providing various modes of information delivery and tailoring them to the individual patient, confirmation of comprehension, post-discharge care follow-up planning, review of vital signs, and a patient-centered closure (Table 1) [8,9].
Table 1: Interventions in the ED Discharge Process
Domain | Intervention |
Content | Standardize approach |
Delivery | Verbal instructions (language and culture appropriate) |
| Written instructions (mindful of lower literacy levels) |
| Basic Instructions (including return precautions) |
| Media, visual cues, or adjuncts |
Comprehension | Confirm comprehension (teach-back method) |
Implementation | Resource connections (Rx, appointment, durable medical supplies, follow-up) |
| Medication review |
Content refers to the education provided to our patients related to their ED testing, procedures, and treatment, as well as further education on diagnosis, expected course of illness, post-ED treatment and follow-up plan, and medication reconciliation. Instructions should specifically highlight time-sensitive next steps in care plans, including when and how to schedule follow-up appointments with whom and why. Further, emergency physicians should assist in arranging critical follow up prior to discharge as able. Precautions regarding when to return to the ED versus waiting for any follow-up appointments should additionally be provided, as well as instructions for how to care for oneself until follow-up. These basic tenants of discharge, often described as the ‘rules of the road’ (Table 2), may serve as a basic framework for the discharge process.
Table 2: Rules of the Road for Successful Discharge
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In addition to the content itself, the importance of the quality and approach of its delivery cannot be overstated. The ED provider and care team members must consider the wide range in literacy, health literacy, cultural backgrounds, and access to outpatient resources when delivering the ongoing care instructions [6,7]. In many instances, EDs attempt to improve patient and family understanding of discharge instructions through standardization and simplification of written and verbal instructions. Due to literacy variability, current literature recommends instructions are written at a late elementary educational level [10]. Verbal discussions in conjunction with written instructions have been shown to be superior to written instructions alone [11]. For patients with a primary language differing from that of the clinician, use of interpreter services, when available, has been shown to improve quality of discharge communication and clinical understanding [12]. Other approaches that may benefit patient outcomes include providing supplemental written information and using visual and multimedia adjuncts to support understanding [8,9].
Essential to any successful approach is the comprehension of the patient regarding all of the information provided. After all, if the content and delivery are exceptional but the comprehension is poor, this should be seen as a discharge failure as it decreases care compliance and outcome quality. To address this specific aspect of the discharge process, instituting a read-back or teach-back method is recommended. This method involves asking the patient to repeat back their understanding of the information imparted, which allows the physician to identify any remaining gaps in understanding and provide additional instruction as needed.
The implementation of discharge care processes frequently falls short due to unidentified social and medical factors that prevent the plan from being carried out. Social factors could include homelessness, low income, uninsured/underinsured status, lack of transportation, or lack of primary care. Medical factors could include concurrent psychiatric illness, substance abuse, cognitive impairment, inability to care for self, or young/advancing age. Understanding these circumstances will help identify patients at high risk for discharge complications and trigger additional resource considerations for these patients.
The discharge process provides an opportunity to ensure the patient’s condition is well understood, that no additional medical red flags need to be addressed, and that the care plan and follow-up are well understood. In an online video, Dr. Oller provides another process to engage the ‘moment of safety‘ related to discharge and outlines 5 essential steps (Table 3) for any ED discharge [13].
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Barriers to Successful Discharge
The barriers to successful discharge are myriad. Some are intrinsic to the ED work environment and nature of emergency department patient arrival and flow. Others relate to the challenging or often unidentified social and medical factors that prevent the plan from being completely carried out. In a recent American College of Emergency Physician Quality Improvement and Patient Safety section meeting, Dr. Pham shared a conceptual framework for understanding the barriers to success and improving the discharge process (Figure 1) [14].
While this framework may not be uniformly representative of all EDs, it addresses many of the operational failures that occur outside of the ED and outlines opportunities for hospitals and health systems to align for improved patient care outcomes. And while screenings for high-risk discharges in EDs occur, the additional resources needed to ensure appropriate social work or case management care coordination are often limited.
Post-discharge follow-up processes for patients at risk for failing discharge instructions exist in some systems. This may include flagging a patient’s chart for a social work follow-up to assess and assist with the patient’s ability to obtain necessary medications, make and attend follow-up appointments, or address other concerns identified by the provider. Some physician groups routinely call patients the next day to see how the patient is doing and ensure understanding of their discharge instructions and care plan [7,8].
Types of Discharge Information Packets
Discharge instructions vary widely by practice location and resources available. However, there remain 3 primary means of providing discharge information and instruction: a basic care instruction note, a preformatted illness specific instruction sheet, and a templated software-based discharge product [8].
Commonly used, an instruction note is simply a set of instructions handwritten or typed on plain paper, without the assistance of computer programs. In settings with limited resources, this may be the only means of providing essential care information for the patient, their family, and the provider with whom they may follow-up. While uniquely tailored, they may lack substantial content for care, take time to prepare, and be limited by literacy and handwriting.
Information sheets are pre-printed education and instruction documents that describe care information related to one specific illness. They can be developed for the most common medical illnesses for each institution and have essential information regarding plans of care. Information sheets are immediately available, inexpensive, reproducible, and can be designed to include simple language and or pictorial education. They are not patient specific, may not provide adequate instruction in difficult or complicated cases, and require computer, printer, and copying capacity.
For settings with an integrated EHR, software products that create discharge packets (including discharge diagnoses, medications, medical care instructions and information regarding the illness, outlined care course after leaving the ED, and essential contact information for those next steps) are available. These are highly resource dependent and therefore may not be routinely available.
Each form of written discharge materials offers its own unique benefits and drawbacks. Regardless of type utilized, physicians should exercise the basic principles outlined above in ensuring appropriate readability and quality of information provided. While specific details are helpful and important, distilling instructions into a short, high-yield sheet has been shown to be more effective than providing a large stack of superfluous [information] that patients may not entirely review [15].
Leave Against Medical Advice and Elopement
In certain circumstances, patients may request to leave prior to completion of their medical evaluation and treatment. In this situation, it is essential for the last health care professional caring for the patient to clearly document why the patient left and attest that the patient had the mental capacity to make such a decision at that time. While some electronic documentation systems have templates in place to assist with this documentation, Table 4 provides basic information for against medical advice (AMA) discharge documentation that can be used to create a uniform template [3,4,16,17].
Table 4: Documentation for Patients Leaving Against Medical Advice
Component | Description |
Capacity | Establish a patient’s decision-making capacity, and clarify aspects of care which may affect capacity (i.e. patient is now clinically sober, etc.) |
Risks | Specific condition-associated risks that were discussed (missed diagnosis, potential harms from untreated disease process, etc.) |
Verify comprehension | Patient’s understanding of the risks |
Patient’s decision | Include the patient’s decision, and any alternative plans (i.e. patient refused admission, but agreed to follow up with the primary physician tomorrow) |
Signatures | Patient’s and provider’s signatures |
An attempt should be made to provide the patient with appropriate discharge instructions, even in the event that a complete diagnosis may not yet be determined. Include advice for the patient to follow up with their own physician, strict return precautions, and concerning symptoms that should prompt the patient to seek further care. In addition, it should be made clear that leaving against medical advice does not prevent the patient from returning to the emergency department for further evaluation if their symptoms worsen or if they change their mind about receiving care. Despite a common notion to the contrary, AMA discharge does not automatically provide the emergency physician with immunity from potential medical liability [16,17]. In the event that a patient lacks decision-making capacity to adequately understand the rationale and consequences of leaving AMA and their condition places them at risk for imminent harm, involuntary hospitalization is warranted and often legally required depending on the location of practice. In unclear circumstances and if available, a psychiatrist can assist in determining capacity, especially in the case of patients with mental health conditions.
Elopement is a similar process in which patients disappear during the care process. While it is difficult to provide discharge paperwork for these patients, documenting the actions taken to find the patient is essential (e.g. searching the ED, having security check the surrounding areas). In addition, clinicians should attempt to reach the patient by phone to discuss their elopement and any additional care issues or concerns. Documentation of these attempts or any additional conversation is critical in mitigating legal risks [3,4].
Conclusion
Discharge instructions are a very important part of the emergency department care process and record. It is essential to ensure each patient has a complete understanding of their instructions in order to promote care compliance and improve transitions in care. Verbal instructions remain more effective than written instructions, but both are needed and a multimodal approach to relaying information is preferable to a single modality. Be explicit, keep it simple, and have the patients repeat back instructions to ensure understanding. These simple steps will improve patient outcomes and compliance, and help clinicians avoid medical and legal pitfalls.
Authors
Dominique GELMANN
Dominique Gelmann is an Emergency Medicine resident at Wake Forest University. Her interests include patient-physician communication and health literacy. During medical school she completed a one-year research and leadership fellowship investigating health literacy as a social determinant of health, and helped author an institutional white paper with actionable strategies for improving health literacy education. She has given several lectures on the topic to various audiences, and developed a curriculum on health literacy and best-practice patient-provider communication principles for a free student-run health clinic. She looks forward to continuing strengthening her passion for this work throughout her career.
Bret NICKS
Bret Nicks, MD, MHA is an emergency physician that embraces the breadth of our specialty. He is a Professor and Executive Vice Chair of Emergency Medicine at Wake Forest University School of Medicine. He is the past president of the North Carolina College of Emergency Medicine. He served as the Chief Medical Officer of the award-winning Wake Forest Baptist Davie Medical Center. Dr. Nicks served as the founding Associate Dean for the Wake Forest Office of Global Health. He has lived, practiced, and led in many resource austere locations globally, although calls the academic tertiary care emergency department his home. He is passionate about, consults and lectures on the interface of clinical quality, leadership and team culture – and is dedicated to developing EM leaders for the future of our specialty and the transformation of healthcare. He loves anything outdoors, enjoys blogging on various life and leadership topics; http://www.bretnicksmd.com/blog, and recently published his first book.
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2018 version of this topic – https://iem-student.org/discharge-communications/
References
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Reviewed By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
