Talk to your patients before sending them home from the ED

So you’re not having a heart attack like your wife thought. That’s the good news. But what is wrong, what did cause that pain, and what should you do from here on out?

That’s the purpose of discharge instructions, and it’s not enough for the ED staff to just print out some forms, say “sign here,” and send you on your way.

What constitutes good discharge instructions, and why are they critical in the decision to pursue or defend a malpractice case?

Annals of Emergency Medicine in April published a thorough study by Drs. Anita Vashi and Karin Rhodes on the quality of ED D/C instructions. They audio-taped 477 discharge encounters and evaluated them for content in 9 areas:

• Explanation of illness
• Expected course
• Self-care
• Medication instructions
• Symptoms prompting return to the ED
• Specific time for a follow-up visit
• Instructions to seek follow-up care
• Opportunity for questions
• Confirmation of patient understanding

According to the authors’ assessment, discharge instructions on key elements of an emergency department visit were – at best – excellent 73% of the time and then in only one of nine areas. Instructions were less than excellent in as many as 98% of the charts in the area of “confirmation of patient understanding.” The “expected course of the disease” was adequately explained only 24% of the time.

Total time spent on the discharge process amounted to just under 4 minutes, meaning that (no surprise here) doctors spend more time charting than they do actually talking to patients.

On average, discharge instructions were present but less than excellent nearly 2/3 of the time. This means that these patients leave the Emergency Department with an incomplete understanding of the nature of their problem, what could happen, what to expect and what to do if the unexpected happens. Clearly there is room for improvement.

The authors suggest several solutions, such as the ED actually making a follow-up appointment for patients, dedicating a nurse to the discharge process, confirming the patient’s contact information at discharge, and making a follow-up phone call the following day to review the course of the illness and the instructions.

In the meantime, the message to Emergency Department physicians and nurses is “Talk to your patients before sending them home.”

“Sign right here and you’re good to go,” while a common approach, is not enough.

Charles A. Pilcher is an emergency physician who has helped both plaintiff and defense attorneys with malpractice litigation for over 25 years. He can be reached at his self-titled site, Charles A. Pilcher, MD.

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