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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This article brings up a critical issue that often goes unnoticed in emergency departments. It’s concerning to see that discharge instructions are frequently inadequate, leaving patients with incomplete understanding and potentially putting their health at risk.
As a patient, I can’t stress enough how crucial it is to receive clear and comprehensive instructions before leaving the ED. It’s quite unsettling to think that the expected course of my condition was only explained in 24% of cases. When you’re in pain or distress, you rely on healthcare professionals to guide you through your recovery journey.
I wholeheartedly agree with the proposed solutions to improve the discharge process. Having a dedicated nurse to provide instructions and making follow-up appointments would make a significant difference. A follow-up phone call the next day is such a thoughtful gesture that shows genuine care for the patient’s well-being.
I hope this article reaches every emergency department out there, and they take the message seriously: talking to patients before sending them home is crucial. “Sign right here and you’re good to go” is simply not enough. Let’s strive for better patient care and communication, so we can all feel more confident and supported in our recovery process.