Emergency physicians face unique challenges in providing 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 the patients they see. According to Margaret E. Samuels-Kalow, MD, MPhil, effective communication is paramount when patients are discharged from the ED, but this element is often overlooked. “Discharge communication is often an afterthought in the ED,” she says. “We’re limited to brief exchanges of forms and prescriptions, leaving patients with uncertainty about their care plan and increasing their risks for more health issues down the line.”
Further complicating matters is that many patients and families who arrive at EDs have limited health literacy, do not speak English, or have had difficult experiences with the healthcare system. “These types of patients are at risk for being discharged from the ED without comprehending instructions from emergency personnel,” says Dr. Samuels-Kalow.
Seizing Communication Opportunities
Effective discharge communication provides an opportunity for emergency personnel to summarize patient visits and teach them how to safely care for themselves at home, Dr. Samuels-Kalow says. “It also gives ED physicians a chance to address any remaining questions or concerns. We can help connect patients to providers who can best manage their needs after discharge. Focused interactions with nurses and physicians are opportunities for education during the entire ED stay.”
In the August 2012 Annals of Emergency Medicine, Dr. Samuels-Kalow and colleagues published a review that discussed the roles of content, delivery, comprehension, and implementation in identifying patient understanding of ED discharge instructions (Table 1). “It’s imperative that instructions are complete and understandable to the learner,” says Dr. Samuels- Kalow. “Unfortunately, ED discharge instructions are often written at an inappropriately high reading level. Additionally, many patients who leave the ED are unable to recall important elements of their visit and their discharge plan. This can reduce the likelihood of patients adhering to their post-discharge plans.”
Improving Communication at Discharge
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. “Ideally, emergency providers will communicate crucial information, verify that this information is comprehended, and tailor educational messages to ensure patient safety at home,” Dr. Samuels-Kalow says. “It’s a delicate balance for EDs to provide standardized care reliably and efficiently while also considering time constraints and the wide range of literacy levels and cultural backgrounds.”
To improve patient understanding of discharge instructions, Dr. Samuels-Kalow recommends that EDs standardize their organization of discharge instructions and simplify written and verbal instructions for patients and their caregivers at home. “This can be especially helpful for those with low health literacy or for those who speak languages other than English,” she says. Other approaches that may benefit patient outcomes include providing supplemental written information, using visual and multimedia adjuncts, allowing time for longer discussions with providers, and instituting “read-back–teachback” methods. Demonstrating how medications should be used and dosed is also vital, especially in cases for which instructions on using certain drugs may be unclear.
Following Up After Discharge
Appropriate follow-up with primary care physicians is a key element of post-ED care and is frequently recommended as part of the discharge communication. “Several interventions have been effective in studies, including counseling, written materials, and follow-up telephone calls,” Dr. Samuels-Kalow says. “However, the decision about how and when to follow up is most likely multifactorial. It may relate more to clinical status, insurance considerations, and convenience or access issues than discharge communication.”
Dr. Samuels-Kalow recommends several areas of future research to enhance ED discharge communication (Table 2). “We need to evaluate how best to structure ongoing dialogue so patients can process new information, ask questions, and have their understanding confirmed before they’re discharged. Other interventions continue to be investigated, and it’ll be helpful to determine their efficacy in studies. Ultimately, researchers need to continue striving toward better discharge communications so that we can further ensure patient safety.”
Readings & Resources (click to view)
Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med. 2012;60:152-159. Available at: http://www.annemergmed.com/article/S0196-0644(11)01762-8/fulltext and at: http://download.journals.elsevierhealth.com/pdfs/journals/0196-0644/PIIS0196064411017628.pdf.
Makaryus AN, Friedman EA. Patients’ understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005;80:991-994.
Engel KG, Heisler M, Smith DM, et al. Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand? Ann Emerg Med. 2009;53:454-461, e415.
Kripalani S, Jackson AT, Schnipper JL, et al. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists . J Hosp Med. 2007;2:314-323.
Rhodes KV, Vieth T, He T, et al. Resuscitating the physician-patient relationship: emergency department communication in an academic medical center. Ann Emerg Med. 2004;44:262-267.
Waisman Y, Siegal N, Chemo M, et al. Do parents understand emergency department discharge instructions? (A survey analysis). Isr Med Assoc J. 2003;5:567-570.
Hansen LO, Strater A, Smith L, et al. Hospital discharge documentation and risk of rehospitalisation . BMJ Qual Saf. 2011;20:773-778.