by Justin Brooten and Bret Nicks
The process of patient discharge from the emergency department (ED) provides critical information for patients to manage the next steps of their care. Hospital accreditation and governmental organizations often require these instructions for quality or monitoring metrics. However, studies show that many patients do not fully understand or recall the instructions they receive (Clarke, 2005; Clark, 2005). Add to this the myriad challenges inherent in every emergency department that only perhaps compound this lack of comprehension and subsequently impact care compliance, outcomes, and patient experience.
In many situations, 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. Certainly, understanding discharge instructions can be very challenging. At the time of discharge, patients or family members may be experiencing physical and emotional discomfort. They may be eager to leave, and thus, less interested in the instructions. Moreover, a significant number of patients have low literacy or health literacy levels (Zeng-Treitler & Hunder, 2008). Also, the busy ED setting may distract the patient’s attention from such instructions. Therefore, understanding the challenges around discharge communications in the ED from the patient’s perspective and having a clear approach and purpose is essential. Discharge is not an afterthought; it is the first step of a patient’s care transition and greatly impacts quality outcomes, litigation, experience and team morale (Henry, 2013; Siff, 2011).
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, making effective communication paramount when patients are discharged from the ED (Jon, 2013). Recognizing the value of early quality communication continued throughout the patient care encounter may carry over to the discharge care processes and, in turn, improve an important aspect of quality and patient-centered emergency medical care.
It has been demonstrated that many patients are discharged from the ED with an incomplete understanding of the information needed to care safely for themselves at home (Clarke, 2005; Crane, 1997; Engel, 2012; Sameuls-Kalow, 2015; Taylor & Cameron, 2000). Patients have demonstrated particular difficulty in comprehending post-ED care instructions regarding medications, home care, and follow-up expectations. And while all patients discharged from the ED should be provided instructions for ongoing management of their medical condition, studies have demonstrated that the patient recall and understanding of diagnosis, treatment, and follow-up plan are quite poor (Clarke, 2005; Clark, 2005; Crane, 1997; Engel, 2012; Sameuls-Kalow, 2015; Taylor, 2000; Zeng-Treitler & Hunder, 2008). This raises significant concerns for care plan adherence and medical outcomes. Given current trends toward value-based care and the fact that nearly half of the lawsuits in emergency medicine revolve around discharge instructions and the discharge program given to patients, ongoing improvements in the discharge communication process is essential (Henry, 2013; Siff, 2011). 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 strategies can be used to enhance the recall of instructions, improve compliance, and minimize litigation.
Effective discharge communication provides an opportunity for the ED team to summarize a patient’s visit, teach them how to care safely 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 (Jon, 2013), often augmenting patient and family understanding while improving care plan retention. Although patient education at discharge typically begins with initial assessments and conversations with the patient and his family, other factors can also influence the success or failure of how information is transmitted at discharge (Jon, 2013).
Common interventions included in an effective ED discharge process consist of a standardized approach (content), information delivery, confirmation of comprehension, post-discharge care follow-up planning, review of vital signs and a patient-centered closure (Table1) (Taylor, 2000; Zeng-Treitler & Hunder, 2008).
Interventions in the ED Discharge Process
|Delivery||Verbal instructions (language and culture appropriate)
Written instructions (literary 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)
Content refers to the education provided to our patients related to the treatments, tests, and procedures performed during the ED visit, as well as further education on diagnosis, treatment plan, the expected course of illness and medication reconciliation. It should also include time-sensitive and specific information associated with their diagnosis and care plan regarding what to do and when to do it. This should include precautions about when to return to the ED versus waiting for any follow-up appointments, and what steps have already been taken to assist with this process. Utmost clarity regarding what type of follow-up is needed and why, as well as how to care for oneself until that time, improves outcomes and compliance. Some have phrased these basic tenants of discharge as the ‘rules of the road’; however, this may serve as the basis from which to develop your process.
Rules for the Road
- Have the right diagnosis
- Time & Action Specific Instructions
- What to do
- When to do it
- Provider Specific
- Who to contact
- Why and When
- Printed Information, Verbally Explained
- Verbally confirmed
The quality and approach of a physician’s delivery of content cannot be overstated. The ED provider and care team members must consider the wide range of literacy (and health literacy), cultural backgrounds and access to outpatient resources when delivering the ongoing care instructions (Engel, 2012; Sameuls-Kalow, 2015). In many instances, to improve patient understanding of discharge instructions, EDs attempt to improve patient and family understanding of discharge instructions through standardization and simplification of written and verbal instructions for patients and those with them. This verbal discussion can be especially helpful for those with low health literacy. Also, utilizing interpreter services for those who speak other languages may be vital. Other approaches that may benefit patient outcomes include providing supplemental written information and using visual and multimedia adjuncts to support understanding (Taylor & Cameron, 2000; Zeng-Treitler & Kim, 2008). Essential to any successful approach is the patient’s comprehension 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.
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 of discharge failure and trigger additional resource considerations for these patients.
The discharge process provides an opportunity to ensure the patient’s condition is well understood that there aren’t any additional medical red flags that need to be addressed, and that the care plan and follow-up are fully comprehended. In an online video, Dr. Oller (2016) provides another process to engage the ‘moment of safety’ related to discharge and outlines five essential steps for any ED discharge.
ED Discharge: Moment of Safety
- Has the medical provider discussed the findings, diagnosis, and plan of care (including medications and follow-up plan)?
- Confirm the discharge instructions and prescriptions match the patient identifiers
- Review all prescriptions and clarify any changes
- Review of current vital signs
Barriers to Successful Discharge
The barriers to successful discharge are myriad. Some are intrinsic to the ED work environment and the nature of ED 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 (2016) shared a conceptual framework for understanding the barriers to success and improving the discharge process (Figure 1).
Figure 1: Barriers to Successful ED Discharge
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 with improved patient care outcomes. Moreover, while screening 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, obtain follow-up appointments, or address other concerns identified by the provider. Some physician groups routinely call the patient the next day to see how the patient is doing and ensure understanding of his/her discharge instructions and care plan (Sameuls-Kalow, 2015; Taylor 2000).
Types of Discharge Information Packets
Discharge instructions vary widely by practice location and resources available. However, there remain three primary means of providing discharge information and instruction: basic care instruction note, a pre-formatted illness specific instruction sheet, and templated software-based discharge product (Taylor, 2000).
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 families and the provider with whom they may follow-up. While uniquely tailored, they may lack substantial content for care, take time to prepare, and are 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.
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 document clearly why the patient left and attested that the patient had the mental capacity to make such a decision at that time (Henry, 2013). While some electronic documentation systems have templates in place to assist with this documentation, Table 2 provides basic information for against medical advice (AMA) discharge documentation that can be used to create a uniform template (Henry, 2013; Siff, 2011; Levy, 2012; Devitt, 2000).
Documentation for Patients Leaving Against Medical Advice
|Capacity||Establish 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 patient’s decision, and any alternative plans (i.e. patient refused admission, but agreed to follow up with primary physician tomorrow.)|
|Signatures||Patient's and provider's signatures|
An attempt should be made to provide the patient with appropriate discharge instructions, even if a complete diagnosis may not yet be determined. Include advice for the patient to follow up with his physician, strict return precautions, and concerning symptoms that should prompt the patient to seek further care. It should also be made clear that leaving against medical advice does not prevent the patient from returning to the emergency department for further evaluation if his symptoms worsen, or if he changes his mind. Despite a common notion to the contrary, simply leaving against medical advice does not automatically imply that physicians are immune to potential medical liability (Levy, 2012; Devitt, 2000). If a patient lacks decision-making capacity to be able to adequately understand the rationale and consequences of leaving AMA and his condition places him at risk for imminent harm, involuntary hospitalization is warranted. In unclear circumstances and if available, psychiatry can assist in determining capacity, especially in the case of patients with mental health conditions.
Elopement is a similar process where 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, attempt to reach the patient by phone to discuss his elopement and any additional care issues or concerns. Documentation of these attempts or any additional conversation is very important (Henry, 2013; Siff, 2011).
Discharge instructions are a very important part of the ED care process and record. It is essential to ensure each patient has a complete understanding of her instructions and to recognize that verbal instructions remain more effective than written instructions, but both are needed. Be explicit, keep it simple and have the patients repeat back instructions to ensure understanding. These simple steps will improve patient outcomes, compliance and avoid legal pitfalls.
References and Further Reading
- Clarke C, Friedman SM, Shi K, et al. Emergency department discharge instructions comprehension and compliance study. CJEM 2005 Jan;7(1):5-11.
- Clark PA, Drain M, Gesell SB, et al. Patient perceptions of quality in discharge instruction. Patient Educ Couns. 2005 Oct;59(1):56-68.
- Henry GL, Gupta G. (2013). Medical-Legal Issues in Emergency Medicine. In Adams (Ed.), Emergency Medicine Clinical Essentials, 2nd Ed; 1759-65. Philadelphia, PA: Elsevier.
- Siff JE. (2011). Legal Issues in Emergency Medicine. In Tintinalli’s (Ed.), Emergency Medicine, 7th Ed; 2021-31. McGraw-Hill.
- Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med1997;15:1–7
- Engel KG, Buckley BA, Forth VE, et al. Patient Understanding of Emergency Department Discharge Instructions: Where Are Knowledge Deficits Greatest? Acad Emerg Med 2012; 19(9):1035-1044.
- Sameuls-Kalow ME, et al. Unmet Needs at the Time of Emergency Department Discharge. Acad Emerg Med. 2015 Dec 18.
- Taylor DM, Cameron PA. Discharge instructions for emergency department patients: what should we provide? J Acad Emerg Med. 2000; 17:86-90.
- Zeng-Treitler Q, Kim H, Hunder M. Improving Patient Comprehension and Recall of Discharge Instructions by Supplementing Free Texts with Pictographs. AMIA Annu Sympo Proc 2008:849-853.
- Oller C. Discharge Moment of Safety. Available at: https://www.youtube.com/watch?v=xuLjBWkfomE Accessed January 30, 2016.
- Pham JC, Ijagbemi M. Improving the ED Discharge Process. ACEP. Available at: http://www.acep.org/content.aspx?id=90940 Accessed January 15, 2016.
- Levy F, Mareiniss DP, Lacovelli C. The Importance of a Proper Against-Medical-Advice (AMA) Discharge. How Signing Out AMA May Create Significant Liability Protection for Providers. J Emerg Med. 2012;43(3):516-520.
- Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51:899-902.
- Jon N. 2013 Communicating More Effectively at ED Discharge. Accessed May 1, 2017. https://www.physiciansweekly.com/tag/discharge-communication/