Perspective: Emergency Department discharge instructions: “Sign right here and your good to go.”

By Charles A. Pilcher MD FACEP
August, 2011

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 shown below. The percentage of encounters including instructions in each area is shown in the category list below, and when “Present,” the percentage of those encounters in which the instructions were “Excellent” is also shown. Multiplying the the two percentages together gives one a “Summary” percentage of charts in which the discharge instructions were both present and excellent:
Present %  Excellent %    Summary %
Explanation of illness                                         76               60                      46
Expected course                                                   51               47                       24
Self-care                                                                69               74                       51
Medication instructions                                    80               71                        57
Symptoms prompting return to the ED         34               89                       30
Specific time for a follow-up visit                    39               NA                        3
Instructions to seek follow-up care                 73               NA                      73
Opportunity for questions                                 91               57                        52
Confirmation of patient understanding         22               10                          2

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.

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