People seek care in emergency departments for lots of different reasons, including treatment of injuries, evaluation of pain, complications related to chronic illnesses, and fear that a symptom is or could become serious or even deadly. Almost always, people want to know what the problem is and what they should do about it.
The treating physician spends the bulk of his/her time gathering and analyzing data and information that will point them to a diagnosis. Once that is done, if the condition does not require hospitalization, they turn their attention to treatment (usually some sort of medication) and disposition (usually home with follow-up in an outpatient setting of some sort). Ok, that’s done, time to move on to the next patient – they are, after all, piling up at alarming rates in many EDs.
At the end of the visit, does the patient understand what they are supposed to do?
There is a critical element in the ED visit that may mean the difference between a good outcome and one that is not so good. That element is being sure the patient understands their condition and, equally important, understands what to expect and do over the next number of hours or days. They need good discharge instructions, but are they getting them?
Emergency Physicians Anita Vashi, MD, MPH (Mt. Sinai School of Medicine Dept. of Emergency Medicine) and Karin Rhodes, MD, MS (University of Pennsylvania School of Medicine Dept. of Emergency Medicine) have published a study in the April 2011 Annals of Emergency Medicine that sheds some light on the adequacy of ED discharge instructions.
As a part of a larger study related to disclosure of domestic violence in ED settings, they arranged to audio tape discharge instructions in two different Emergency Departments – an urban academic medical center ED and a suburban community hospital ED. Because the study was related to domestic violence, the patients selected for the study were all women. Of the 871 discharges audiotapes, only 477 (55%) captured audible instructions.
The audiotaped discharge instructions were analyzed for a variety of types of communication, including the following:
• Was the illness explained to the patient?
• Was the expected course of the illness explained?
• Was the patient given self-care instructions?
• Was the patient told specific signs that should prompt a return to the ED?
• Was the patient given the opportunity to ask questions?
• Did the discharge professional confirm the patient understood the instructions?
The study found that most patients (73%) were given instructions to follow up in a clinic or with their primary care physician. They also received explanations of their illness and instructions about medication use (76% and 80% respectively). Only half of patients were provided with information about the expected course of illness. Even fewer (39%) were given specific recommendations on when to seek a follow-up visit or (34%) what should prompt return to the ED. Very few providers (22%) confirmed whether the patient understood the discharge instructions even though there is evidence that this simple act improves compliance with prescribed treatments.
The study also looked at the adequacy of the communication in each of the different subject areas examined. Let’s look at one: the opportunity to ask questions. Overall, most of the interviews documented that patients were “given the opportunity” to ask questions. However, in only 57% of the cases were the verbal instructions rated by the researchers as “adequate” or “excellent.” In the rest of the cases, the rating was “minimal” defined as “there was a dialogue between the provider and the patient.”
What actually happened
When it came to confirming the patients’ understanding of the discharge instructions only 10% of the 22% given the opportunity to confirm understanding were rated as “adequate/excellent.” Most were rated as “minimal” defined as “…the provider said a variation of the following: ‘Take this medication, okay’” Is it any wonder that patients often leave the ED without a clue about what they are supposed to do when they get home?
Health reform, in particular, the development of Accountable Care Organizations, has an explicit focus on “patient-centeredness.” There are a lot of components of patient-centeredness, but certainly, taking the time to adequately explain to patients what they have, what they should expect, what they can do about it, when and with whom they should follow-up with, and specifically what should prompt them to return to the ED seem critical to any patient-centered health care encounter.
We have a lot of work to do to transform our current provider-centric delivery system to one that consistently delivers great service as well as great quality (and, by the way, at an affordable cost). Studies like this one are important because they attempt to quantify aspects of service delivery that were previously ignored or taken for granted. I look forward to seeing emergency medicine’s response. As with all “failures” or “less than optimal” outcomes, it is not the individual that needs to be fixed, rather it is the system. Standardized pre-discharge interview check lists, discharge plan coordinators, and electronic health records are all interventions that could improve the discharge process. It’s time to get to work.