February 8, 2018 | Susan Pasley, MS, BSN, RN
Discharge: How to Prepare Your Patients
This article is the first in a series to be released over the next few months. The table below will be updated as subsequent articles are released. Follow us on Twitter or LinkedIn to get the updates.
All too common
This situation is played out in emergency rooms every day with patients across the lifespan and diagnoses ranging from mild to severe. There are a wide variety of reasons why patients leave the ED without proper comprehension. Unfortunately, this frequently leads to lack of adherence to the treatment plan, worsened health, and recidivism. In Charity’s case, her concentration was impaired by worry about how she would get to work; perform her job duties; care for two toddlers while in a cast; pay for her car repairs and medical bills; and the nagging pain in her arm. Anxiety, often mixed with minimal education and a seventh-grade reading level, sets the stage for a patient unprepared to care for herself post discharge.
A few factors facing EDs across the country create the conditions that lead to an inadequate patient discharge process: significant emphasis on turnaround times, growing patient volumes and increasing acuity levels. While you cannot address every factor that may decrease compliance, such as complex social determinants of health, there are steps that every ED and clinician can take to ensure patients are well equipped to care for themselves once they leave your department.
What is a high-quality discharge?
Roughly 80 percent of patients treated in the ED are discharged to home. This equates to over 113 million patients annually who rely on discharge education for the information and instruction required to care for themselves when out of the direct purview of healthcare professionals. Despite the importance of quality education, research shows that patients’ knowledge of their ED treatment plan is woefully inadequate. One study of 159 patients found that 24-36 hours after discharge, 92 percent had some level of knowledge deficit regarding home care instructions, return instructions, follow-up, medications and/or diagnosis. The most significant deficiencies, 80 percent and 79 percent, were found in home care instructions and return instructions respectively. A 2009 study found similar results with inadequate comprehension in 78 percent of patients in at least one of four domains. Further, Lin, Tirosh and Landry (2015) analyzed the discharge process for 75 ED patients and found that 80 percent of the time key aspects of the ED care and return care in 70 percent of cases were omitted from the discharge education.
With significant time constraints in the department, the discharge process can sometimes seem like a formality to opening the next available bed. However, as patients rely on this information to be adequately prepared to execute on the plan of care, a high-quality discharge is as important as an accurate diagnosis.
Every patient treated and released from the ED deserves a high-quality discharge. According to an environmental scan on how to improve the ED discharge process commissioned by the Agency for Healthcare Quality, a high-quality ED discharge can be defined by the following three characteristics:
- It informs and educates patients on their diagnosis, prognosis, treatment plan, and expected course of illness. This includes informing patients of the details of their visit (treatments, tests, procedures).
- It supports patients in receiving post-ED discharge care. This might include medications, home care of injuries, use of medical devices/equipment, further diagnostic testing, and further health care provider evaluation.
- It coordinates ED care within the context of the health care system (other health care providers, social services, etc.).
When a failure in any one of these crucial aspects is present it can be classified as a discharge failure. The risks of a discharge failure can be significant and include the following consequences.
- ED recidivism
- High utilization of the ED
- High utilization of emergency medical services
- Post-ED visit hospital admission
- Poor patient comprehension of discharge instructions
- Poor patient adherence to primary care or specialty follow-up
- Poor patient adherence to prescribed medications
- Poor patient adherence to care plan
- Poor management of specific condition (i.e. asthma, diabetes)
- Death post-ED visit
Each element of a high-quality discharge will be explored in this series. Over the course of the following months, we will take an in-depth look at each component and the best practices that can be implemented in your ED to improve this process for patients.
It is important to note that the discharge process is dynamic and impacted by a variety of patient risk factors that include both social and medical conditions. While it is not always possible to overcome significant risks—such as homelessness, low socio-economic status, alcohol or drug dependence and cognitive impairment—with a concerted effort and quality processes, many of these risks can be successfully mitigated.
Centers for Disease Control and Prevention (2014). National Center for Health Statistics, FastStats Homepage, Emergency Department Visits. Source: National Hospital Ambulatory Medical Care Survey: 2014 Emergency Department Summary Tables, https://www.cdc.gov/nchs/fastats/emergency-department.htm.
Engel, K. G., Buckley, B. A., Forth, V. E., McCarthy, D. M., Ellison, E. P., Schmidt, M. J. & Adams, J. G. (2012). Patient understanding of emergency department discharge instructions: Where are knowledge deficits greatest? Academic Emergency Medicine, 19(9), 1035-1044.
Engel, K. G., Heisler, M., Smith, D. M., Robinson, C. H., Forman, J. H. & Ubel, P. A. (2009). Patient comprehension of emergency department care and instructions: Are patients aware of when they do not understand? Annals of Emergency Medicine, 53(4), 454-461.
Lin, M. J., Tirosh, A. G. & Landry, A. (2015). Examining patient comprehension of emergency department discharge instructions: Who says they understand when they do not? Internal and Emergency Medicine, 10, 993-1002.
AHRQ Improving the Emergency Department Discharge Process: Environmental Scan Report.