Effective communication between caregivers and patients is a critical element of providing high-quality patient care in the ED. In recent years, a greater emphasis has been placed on information delivery at ED discharge and its downstream implications for adherence and outcomes. “Despite recognizing the importance of communication, the complex ED environment can make it challenging to communicate effectively,” says Kirsten G. Engel, MD. “Many patients leave the ED with an incomplete understanding of their care and instructions.” (see also, Communicating More Effectively at ED Discharge)
The causes of poor communication at ED discharge are multifactorial and likely reflect problems with both written and verbal communication. Written discharge instructions often exceed patients’ health literacy or reading levels, and verbal communication is frequently brief and incomplete. Previous research has suggested that the majority of patients have a comprehension deficit for at least one area of their ED care and instructions, with the most frequent deficits found in the domain of post-ED care. “The effect of poor discharge communication is profound because many patients are leaving the ED without the knowledge they need to properly care for themselves at home,” Dr. Engel says. “This increases their risk for adverse events, as well as repeat ED visits and hospitalization.”
Deficits in Patient Understanding at Discharge
To address problems with information delivery at ED discharge, Dr. Engel says it is essential to better define deficits in patients’ understanding of discharge instructions. “We need to characterize knowledge gaps that may put patients at risk for complications or poor outcomes following their ED visits,” she adds. “Identifying these areas serves as a critical next step in understanding patients’ unmet needs and how we can enhance discharge processes in the future to ensure that patients leaving the ED are well prepared to care for themselves at home.”
In the Academic Emergency Medicine, Dr. Engel and colleagues had a study published that assessed patient knowledge at ED discharge. The analysis looked at five common diagnoses (ankle sprain, back pain, head injury, kidney stone, and laceration) across the domains of diagnosis, medications, home care, follow-up, and return instructions. After interviewing 159 adult English-speaking patients within 24 to 36 hours of ED discharge, the authors determined knowledge based on the concordance between direct patient recall and both patient- and diagnosis-specific discharge instructions.
A key finding that emerged in the study was that knowledge deficits were present in the majority of patients, with the most frequent and severe deficits in the domains of home care instructions and return to ED instructions (Figure). Less frequent deficits were observed for the domains of follow-up, medications, and diagnosis.“Minimal or no understanding in at least one domain was demonstrated by more than two-thirds of patients in our study,” adds Dr. Engel (Table). “Minimal or no understanding was found in 40% of cases for home care and 51% of cases for return to ED instructions. Interestingly, many patients failed to read written instructions, which appeared to contribute to knowledge deficits. These findings suggest that more emphasis is needed to improve discharge communication processes, with particular attention to those areas demonstrating the greatest deficits.”
Consistency & Thoroughness at Discharge
Following ED visits, ensuring patient safety requires that discharged patients are aware of the reasons why they should return to the ED. “This information will help patients recognize complications and minimize adverse outcomes,” says Dr. Engel. “Unfortunately, this information is not reaching patients on a consistent and thorough basis. Multiple elements are at play, including both patient and provider factors and the nature of our verbal and written communication. In some cases, the downstream implications of poor discharge communication can be catastrophic.”
Ultimately, understanding the deficiencies in the information delivery process should drive efforts to develop comprehensive and rigorous strategies that will enhance discharge communication in ways that are realistic and feasible in the ED. Innovative approaches to ED discharge communication processes should be designed with input from providers and patients and address all important elements of interactions with patients, according to Dr. Engel. “Such efforts include giving patients written documents that are visually appealing and literacy appropriate so that they’ll want to read them. Verbal communication needs to be high quality and thorough, but it should also complement and support written documentation. Particular attention is needed on home care and return to ED instructions so that we can reduce knowledge deficits and decrease risks for dangerous misunderstandings. In the future, new and innovative technologies may be helpful in supporting ED discharge communication.”
Engel KG, Buckley BA, Forth VE, et al. Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest? Acad Emerg Med. 2012;19:1035-1044. Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2012.01425.x/abstract.
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.
Engel KG, Buckley BA, McCarthy DM, et al. Communication amidst chaos: challenges to patient communication in the emergency department. J Clin Outcomes Manag. 2010;17:4.
Chugh A, Williams MV, Gigsby J, Coleman EA. Better transitions: improving comprehension of discharge instructions. Front Health Serv Manage. 2009;25:11-32.
Forster AJ, Rose NG, Van Walraven C, Stiell I. Adverse events following an emergency department visit. Qual Safe Health Care. 2007;16:17-22.
Han CY, Barnard A, Chapman H. Discharge planning in the emergency department: a comprehensive approach. J Emerg Nurs. 2009;35:525-527.