Posted: Jan 24, 2012 2:36 PM ET

Emergency department communication study

People who are discharged from emergency departments are often unable to tell what symptoms should raise alarms and make them return to the hospital, a review suggests.

Dr. Stephen Porter, head of emergency medicine at Toronto’s Hospital for Sick Children, led a review of more than 50 studies on the subject. The papers examined the content, delivery and comprehension of discharge instructions for both adults and children.

In the hectic and distracting environment of an emergency department, key instructions to patients can be lost. (Paul Chiasson/Canadian Press)

It’s important for doctors and nurses to communicate effectively with patients to deliver the best care. But in the hectic and distracting environment of an emergency department, those key instructions can be lost.

“Discharge communication is an opportunity to recap the visit, teach patients and families how to safely care for themselves or their loved ones at home, and address any remaining questions,” Porter said in a release.

“Failure to understand important elements of care can result in medical error at home and safety risks including incorrect medication use, inappropriate home care and failure to follow-up on concerning symptoms.”

Porter and his co-authors found multiple reports in the medical literature showing poor comprehension at discharge, with patients or parents frequently unable to describe the diagnosis, treatment plan or why they should return, the study’s authors said in the January issue of the Annals of Emergency Medicine.

For example, one study found while 72 per cent of patients could read the discharge instructions aloud, only 49 per cent could report the treatment plan back.

Another study asked parents to understand the type of treatment, frequency and duration but not the name or dose of the medication for their child. Even then, only about 20 per cent of parents were able to show they understood the instructions.

Comprehension tips

To enhance recall, the authors suggested providing patients with structured content that is presented verbally with written and visual cues.

Clear written instructions should be in the patient’s own language at an appropriate reading level, they added.

Demonstrating medication use and dosing is vital, especially in pediatrics, where instructions for over-the-counter medications are often unclear, the authors said.

Preliminary studies of technologies such as using computer kiosks and discharge videos suggest these may also help.

The review was supported by Program for Patient Safety and Quality at Children’s Hospital Boston, the Emergency Medicine Foundation, the Institute for International Emergency Medicine and Health, Brigham and Women’s Hospital Department of Emergency Medicine and SickKids Foundation.

http://www.cbc.ca/news/health/story/2012/01/24/emergency-room-discharge-communication.html

By Emily Berry, amednews staff. Posted Jan. 16, 2012.

As the recession hit the U.S. in 2008 and 2009, more Americans, both uninsured and those with private health coverage, sought care in hospital emergency departments.

The most recent available estimates from the Centers for Disease Control and Prevention show a steep increase in visits to emergency departments and a rise in the percentage of emergency patients who were uninsured.

• In 2009, emergency department visits went up to 136 million from less than 124 million in 2008. That was nearly a 10% increase, the steepest single-year upsurge on record.
• Those 136 million visits worked out to 45.1 visits per 100 people, up from 41.4 per 100 in 2008 and 39.4 in 2007.
• Of the 136 million visits in 2009, 19% were uninsured patients and 39% were privately insured patients, compared with 15.4% and 41.9%, respectively, in 2008.
• In a poll by the American College of Emergency Physicians in March 2011, 80% of respondents said patient volume had increased “somewhat” or “significantly” during the previous year.

At the same time emergency volumes spiked, physician office visits have been in decline, as documented by the Kaiser Family Foundation and other sources.

The CDC doesn’t offer any opinions as to what is behind the increase, but ACEP attributes the rise in part to lack of access to, and use of, primary care.

David Seaberg, MD, is president of ACEP and dean of the University of Tennessee College of Medicine, Chattanooga. At Erlanger Health System in Chattanooga, where he is an attending emergency physician, he said he often sees patients with chronic conditions who can’t afford to fill their prescriptions or see a primary care physician and end up with acute problems.

“That’s extremely common,” he said.

Rather than acting as a replacement for primary care, ACEP maintains, emergency physicians treat mostly real emergencies, not routine problems that should be seen by a primary care physician. Often, patients are referred to the emergency department by their primary care physician, either out of caution or because the primary care physician can’t see them on short notice or after hours, according to ACEP polling.

Dr. Seaberg said other factors pushed patients to emergency care, including a rise in the number of uninsured in the period covered by the CDC survey and ACEP polling, and patient preference for the “immediate answers” that emergency care provides.

After the enactment of the Patient Protection and Affordable Care Act, uninsured rates actually are declining, from 48.6 million people in 2010 to 46.6 million in the first six months of 2011, according to the CDC. The percentage of people who said they had a usual source of care increased from 85.1% in 2010 to 86.9% in the first six months of 2011, it said.

Analysts attributed the changes in those rates mostly to the health reform law’s requirements that most group insurance plans allow dependent coverage up to age 26.

Those trends, and further expansion of insurance coverage under health reform, should drive down emergency department use, analysts said.

“The general wisdom is that in better economic times, people are more willing to spend more money on primary care and preventive medicine, so there is less volume in the [ED],” said Dennis Dunn, PhD, a Chicago-based senior scientist for Thomson Reuters, which has presented data showing consumer spending at physician offices is ticking up. “People are taking care of themselves, and ailments don’t become acute as much. Emergency room volume tends to be inversely related to the state of the economy.”

However, Dr. Seaberg said he expects emergency department visits to grow further in 2014, when the individual insurance mandate of the health reform law kicks in. The wave of newly insured patients will further strain already-busy primary care practices, leaving emergency physicians to see patients who can’t find a doctor to see them, he said. Nearly 90% of respondents to the ACEP poll conducted in March 2011 said they expect health system reform to drive up emergency department volumes.

Several surveys show that physician office visit rates are continuing to decline, in part because insured patients are shelling out more for coverage — and paying higher deductibles — so many are still putting off care because of cost.

If economic factors and difficulty accessing primary care continues to drive patients to emergency departments, emergency physicians need to think about how they can coordinate better with primary care physicians and help patients with preventive care and wellness, Dr. Seaberg said.

“The emergency room has to be part of the medical neighborhood,” he said.

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ADDITIONAL INFORMATION:

How emergency physicians view their workload

Most doctors who work in emergency departments have noticed an uptick in patient volume, according to a recent survey by the American College of Emergency Physicians. More than 80% said they saw an increase in the number of patients.

40.2%: Significantly increased
40.2%: Somewhat increased
5.9%: Somewhat decreased
0.7%: Significantly decreased
10.8%: No change
2.3%: Not sure

Source: American College of Emergency Physicians, ACEP 2011 National Emergency Physicians Survey Results, April 2011 (www.acep.org/WorkArea/DownloadAsset.aspx?id=78645)

The trend of voluminous, exhaustive discharge instructions puts the pressure on patients to understand and identify complex risk factors, like infection. According to the research, this is probably a bad idea.

I think that good discharge instructions are a great idea. In fact, I often wonder why they are only given out after an ED visit. Wouldn’t discharge instructions be useful after a visit to a primary care physician or after a hospitalization? But you don’t seem to see them being used in these other settings. Regardless, discharge instructions are an integral part of an ED visit, which begs the question: Are they working?

A few thoughts before we dive into the literature to answer this question. First is the issue of quantity over quality. Some people seem to think that if discharge instructions are a good thing, then the more the better. Now everyone is using computerized instructions that create little medical textbooks for parents and patients to take home. For the visit of a febrile child with gastroenteritis, your computer can spit out multiple instruction sheets (of course, written at a 6th grade level and in large type) on how to treat fever, vomiting, diarrhea and how to take the medications you’ve prescribed.

These computer-generated instructions can be needlessly voluminous.

Then there is the simple problem of poor communication. Take head injury instructions, which ask people to, “check the pupils.” Do parents know what the pupils are? And by the time the pupils are of different sizes is not the patient already comatose with a brain herniation? And watch for vomiting after a head injury. “Bring the child back if he/she vomits more than twice.”

Like vomiting once is OK after returning home from an ED visit. And “arouse the child to see if they are irritable.” Who wouldn’t be irritable after being awakened from a sound sleep?

I believe discharge instructions can reasonably instruct people about the diagnosis they have (what is a bladder infection? What is otitis media?) but I think we need to be very, very careful in expecting laypersons to differentiate the early signs indicating that things are going wrong.

For example, can laymen tell when a wound is getting infected? A study in our Emergency Medical Abstracts database specifically demonstrated that they could not. We even have a study that found that the agreement among EM residents was only moderate when it came to diagnosing a wound infection. Bottom line, routine, scheduled checks of selected wounds sounds reasonable rather than depending on a patient coming in if they thought they had an infection. (Citation: IS SINGLE OBSERVER IDENTIFICATION OF WOUND INFECTION A RELIABLE ENDPOINT? Greenwald, P.W., et al, J Emerg Med 23(4):333, November 2002.)

The following papers all challenge our basic assumption that discharge instructions create a substantial safety net that limits the risks of problems developing after discharge. The first in this series compared written discharge instructions with computer-generated ones. Were the outcomes better with the computerized instructions? No way.

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THE EFFECT OF DIAGNOSIS-SPECIFIC COMPUTERIZED DISCHARGE INSTRUCTIONS ON 72-HOUR RETURN VISITS TO THE PEDIATRIC EMERGENCY DEPARTMENT.

Lawrence, L.M., et al, Ped Emerg Care 25(11):733, November 2009

BACKGROUND: The percentage of children returning to the ED within 72 hours after an initial visit is sometimes used as a marker of quality of care. Studies have suggested that many return visits are due to inadequate patient education, and that a substantial proportion might be medically unnecessary.

METHODS: The authors, coordinated at Vanderbilt University in Nashville, reviewed the records of 18,647 children discharged after an ED visit during a six- month period in 2004-2005 and 21,771 children discharged from the ED during the same months in 2005-2006 to evaluate the characteristics of return visits occurring within 72 hours. Discharge instructions were hand-written by managing physicians during the former period, with no uniformity regarding content.

During the latter period, computer-generated diagnosis-specific discharge instructions were provided (via the “Discharge 1-2-3” system by Callibra) that were written at a 6th to 8th grade reading level and included information on the diagnosis, the expected course, guidance for home care, a list of signs and symptoms that should prompt return to the ED, designated periods for follow-up, and relevant clinic information.

RESULTS: The 72-hour return visit rate was 2.3% in the group receiving handwritten discharge instructions and 3.0% in the group receiving computer-generated discharge instructions. The percentage of return visits judged to be medically unnecessary was 13% in the former group and 15% in the latter.

CONCLUSIONS: Provision of diagnosis- specific, computer-generated discharge instructions after a pediatric ED visit did not reduce the rate of 72-hour return visits or of medically unnecessary return visits. 12 references ( laurie.lawrence@vanderbilt.edu for reprints)

Copyright 2010 by Emergency Medical Abstracts – All Rights Reserved 5/10 – #12
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The next two papers try to determine the level of comprehension that patients have for their discharge instructions. The first study looked at computer-generated discharge instructions provided to patients from an affluent, largely college-educated community. The bottom line – confusion regarding the instructions was common. The second paper also indicated that a series of predominantly college-educated patients often got elements of their discharge instructions wrong.

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DO PATIENTS UNDERSTAND DISCHARGE INSTRUCTIONS?

Zavala, S., et al, J Emerg Nurs 37(2):138, March 2011

BACKGROUND: It has been reported that as many as 78% of patients discharged from the ED do not understand their aftercare instructions but that only 20% are aware of their lack of understanding.

METHODS: This study, from the Reston Hospital Center in Virginia, reports on next day follow-up phone calls to 49 adults aged 22-91 (mean, 48) discharged from the ED to identify areas of confusion about discharge instructions. This 187-bed community hospital serves an affluent and largely college-educated adult population. Substantial efforts are made to personally explain computer-generated individualized discharge instructions, which are also provided in writing.

RESULTS: Reaching these patients for a telephone interview required placement of 155 phone calls (made between 9AM and 7PM). Nearly one-third of the patients (15/49) requested clarification of some elements of the discharge instructions and an additional 15 had a diagnosis-related concern that demonstrated poor comprehension of their aftercare instructions.

Nearly one-fifth of the patients (9/49) had questions about their prescribed medications, and an additional nine reported persistent or worsening symptoms and were reminded of the need for follow-up. Three patients reported significant discomfort but did not fill their analgesic prescriptions. Two patients stated that they had not received discharge instructions, despite chart documentation of the provision of this information.

CONCLUSIONS: Despite substantial efforts to review aftercare instructions prior to ED discharge, confusion appears to be common even among well-educated patients. This study also illustrates problems with attempts to contact patients by telephone after discharge and the importance of stressing the need for accurate contact information. 5 references ( carol.shaffer@hcahealthcare.com – no reprints) Copyright 2011 by Emergency Medical Abstracts – All Rights Reserved 9/11 – #16

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PATIENT COMPREHENSION OF EMERGENCY DEPARTMENT CARE AND INSTRUCTIONS: ARE PATIENTS AWARE OF WHEN THEY DO NOT UNDERSTAND?

Engel, K.G., et al, Ann Emerg Med 53(4):454, April 2009

METHODS: In this study, from the University of Michigan, 140 adults aged 19-83 (mean, 39 years) were interviewed at the time of ED discharge and their audiotaped statements about four aspects of the ED visit were compared with what was written on the ED chart. All of the patients had been given discharge instruction sheets that specifically listed the diagnosis, medications and instructions. The four domains addressed included diagnosis and cause, ED tests and treatments, prescribed post-ED care, and return instructions.

RESULTS: About two-thirds of the subjects (65%) reported a college or graduate school education. The mean satisfaction score for the ED visit was 4.1 on a scale of 1-5. Most patients (78%) were felt to be deficient in comprehending at least one of the study domains, and 51% to have deficiencies for two or more domains. These deficiencies involved understanding of post-ED care (34% of deficiencies) and care provided in the ED (29%) more than return instructions (22%) or diagnosis/cause (15%). Fewer than 30% of patients with a deficiency in comprehension acknowledged that one was present, while 12 of 31 patients who were felt by the rater to have perfect comprehension nevertheless reported difficulty with comprehension in at least one domain.

CONCLUSIONS: Most patients in this study appeared not to understand at least one element of their ED care, but most often were not aware of this. The authors recommend asking patients to repeat pertinent information in their own words, and making efforts to improve the content and organization of ED discharge instructions. 25 references ( kirsten.g.engel@gmail.com – no reprints)

Copyright 2009 by Emergency Medical Abstracts – All Rights Reserved 9/09 – #13

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My fundamental view is that asking laypersons to make certain medical judgments is hazardous. For 30 years we used a two-sided discharge instruction (a signed copy was kept in the patient’s medical record) and our discharge instructions were never an element in an alleged cases of malpractice during that time.

The front contained the most important information – what was the diagnosis (in plain English – middle ear infection, not otitis media), what imaging studies were done and the readings (and whether by the emergency physician or the radiologist), what ED treatment had been given (they also included a copy of any prescriptions). The concept was that the instructions were for the patient but also to advise the follow-up physician of the key information they would need as well.

The patient also received a sealed envelope containing their lab results and a copy of their EKG to be given to the follow-up physician along with the discharge instructions.

On the back of the page were general instructions regarding four common medical conditions (fever, vomiting, diarrhea and respiratory infections) and four common trauma diagnoses (head trauma, wounds, sprains and strains and back pain).

As can be ascertained, the instructions regarding these eight conditions were very brief and to the point.

By far, the most important instructions were on the front and in huge print. It said, “If you develop ANY new or worsening symptoms, or your symptoms persist longer than advised by the physician, return to the emergency department immediately.”

These instruction put the burden and obligation on the patient. We didn’t need a laundry list of symptoms for them to watch for. We didn’t need patients to make judgments whether new symptoms were significant or not. We just wanted them to come back if ANY new or worsening symptoms developed. And, we specifically told them to come back to the ED (not try to get an appointment with their PMD – who knows if they would be able to get a timely appointment?) and they were to return immediately (not the next day or two days later or who knows when they would return).

And there was one other feature. We were of the view that everyone did not need to go to a follow-up physician. I’ve seen many discharge instructions that mandate that all ED visits be seen by a follow-up physician. This is unethical. It requires patients to miss work, see a doctor and pay fees that are unnecessary just so the EP can think he/she has covered their butt.

Many conditions do not need routine follow-up. Most ankle sprains take about three weeks to resolve. To tell a patient to see a physician in a week is medically unindicated unless the problem is not gradually resolving. The same is true for a large variety of ED diagnoses, from sore throats to bronchitis to sprains. These conditions usually get better over a specific amount of time. So we wrote down on the discharge instruction when we thought patients ought seek care if symptoms associated with certain specific diagnoses persisted. And the option to come back to the ED was always extended.

So, be careful with your discharge instructions. Relying too heavily on laypersons to make important medical decisions can be risky. Don’t put yourself in a position where a patient can say, “I’m not a doctor. How was I to know that this new or worsening symptom was important?”

W. Richard Bukata, MD is the Editor of Emergency Medical Abstracts

http://www.epmonthly.com/columns/in-my-opinion/with-discharge-instructions-less-is-more/

Scheck, Anne

© 2012 Lippincott Williams & Wilkins, Inc.