Author: Amy E. Betz, MD (Clinical Assistant Professor, Harborview Medical Center, University of Washington Division of Emergency Medicine, Seattle, WA) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Jennifer Robertson, MD

Background:

In a busy emergency department (ED), the discharge process can seem like an afterthought. However, evidence suggests it is one of the most important processes in patient care (1).

Considering that discharge to home occurs for four out of every five ED patients, this process is performed numerous times during a single shift (2). The transition of care from ED to home represents a shift in responsibility from healthcare providers to the patient, and, in some cases, family or caregivers. This is a vulnerable time for patients. Gaps in communication and poor understanding of instructions are not uncommon at the time of discharge, and they represent significant threats to patient safety (3-6).

When patients do not understand their diagnosis or their recommended post-discharge care, they are at risk for adverse events including (7-8):

Medication non-compliance, avoidable side effects, or overdose

or Dissatisfaction with care which contributes to poor self-efficacy

which contributes to Follow-up non-compliance

Avoidable return visits to the ED

to the ED Worsening of medical condition

Return visits requiring hospital admission

Unexpected death

Accordingly, ED discharge is a high frequency, high-stakes event. Education of the discharge process should focus on system-level interventions aimed at minimizing the risks described above.

The discharge process as a procedure:

One way to improve the discharge process is to consider it as a “high-stakes procedure”, similar to processes involving invasive procedures such as central venous catheterization. The method that governs line placement, including consent, preparation, time out, procedure, confirmation, and documentation, provides a helpful analogy for steps that facilitate safe ED discharge processes (see Table 1).

Step Central venous catheterization Discharge process Consent · Discuss risks, benefits, alternatives· Ask for permission · Is the patient comfortable with anticipated disposition plan?· Assess for barriers (physical, mental, emotional, social, financial) Preparation · Prepare line kit· Identify puncture site by US Position patient · Prepare the patient· Are there any red flags that prohibit discharge?· Prepare the paperwork Time out · Correct patient, procedure, site · Are the appropriate people present (e.g. family member, ideally RN)? Procedure · Identify and access vessel· Place and secure catheter · Dialogue about essential information· Engage and empower the patient to ask questions· Discharge paperwork to reinforce discussion and for family not present Confirmation · Order and review chest xray · Closing the loop, assessing for patient understanding (e.g. Teachback) Documentation · Procedure note · Summarize in ED note

Table 1. Analogy for steps that facilitate safe ED discharge processes

Consent

As with invasive procedures such as central venous catheterization, the first step of the discharge process is to obtain consent, which includes discussing its risks and benefits. This step is often best initiated as soon as discharge appears to be a reasonable disposition. This approach, as well as assessing for barriers (physical, mental, emotional, social, financial) early in the patient encounter, can save time in the end. This can also minimize gaps in communication by uncovering vulnerabilities and addressing them along the way. Review each patient’s visit information and, when available, the anticipated disposition plan.

Is the patient comfortable going home? Engage the patient and empower them to participate in this decision and begin to assume responsibility for their own care Assess for barriers (physical, mental, emotional, social, financial)



Preparation

The next step is preparation of the patient and any materials needed for safe discharge.

Ask nursing or staff to evaluate the following when relevant: Is the patient ambulating safely? Is the patient tolerating oral liquids and/or solids? What is the patient’s ambulatory oxygen saturation? Are there any abnormal vital signs?

when relevant: Are there any red flags ? Is there any abnormal vital sign, cognitive impairment, or language barrier? If the patient is non-English speaking, an interpreter should be used by phone or in-person.

? Does the patient require any additional resources such as social work assistance?

assistance? Do they have a primary care provider already established or do they need assistance with access?

already established or do they need assistance with access? Consider the pieces of information you will need to convey to the patient; what is most important ?

? Prepare the paperwork Include information about their diagnosis, post-discharge education, prescriptions or information about relevant medications, follow-up care, and return precautions



Time out

As with any procedure, before beginning the discharge conversation, perform a time out.

Are the appropriate people present ? If a patient is cognitively impaired, a family member or caregiver needs to be present or contacted by phone. Ideally, a registered nurse (RN) should be present to enhance the conversation. He or she may facilitate efficient final departure by ensuring any intravenous line (IV) has been discontinued, the patient has his or her personal items, and the paperwork has been signed.

?

Procedure

Sit down and speak slowly, giving the patient time to digest and consider the information you are presenting. Engage and empower the patient to ask questions and have a dialogue about the essential information.

Briefly summarize each of the following for the patient Diagnosis Post-discharge education Prescriptions or information about relevant medications Follow-up care Return precautions

This can be done effectively in a few sentences with emphasis on the most important pieces of information the patient needs to understand to care for them self or when to seek medical attention.

Provide paperwork that includes the same information you wish to reinforce to the patient, and so that family or caregivers who are not present can review it at a later time.

Confirmation

As with invasive procedures such as central venous catheterization, an important closing step of the discharge process is confirmation. This is the time to confirm patient understanding and close the loop. Schillinger introduced the concept of “closing the loop” and demonstrated that patients whose physicians assessed recall or comprehension were more likely to have hemoglobin A1c levels below the mean. (9) “Closing the loop” involves explaining a new concept to the patient and then immediately assessing the patient’s recall and understanding, clarifying the explanation if needed, and then reassessing comprehension and continuing to clarify until the patient expresses appropriate understanding (see Figure 1).

Figure 1. Closing the Loop communication cycle (9)

“Closing the loop” or “Teach-back” technique has consistently been listed in the top patient safety practices for reducing medical errors in the National Quality Forum Safe Practices for Better Healthcare since 2003. Teach-back has been demonstrated to have a positive impact on patient experience and self-efficacy. (10)

Did the patient and family understand what was done, what they need to do upon discharge, and what symptoms should prompt return? Ask the patient to say in their own words what they need to know or do. This is a much more effective way to gauge comprehension than simply asking, “Do you understand?”

By having the patient explain back in their words, they improve their self-confidence and ability to address their needs outside of the ED or it becomes clear that further clarification is needed. (10)

Documentation

Finally, document the highlights of your discharge procedure in the ED encounter note. Similar to documentation of other procedures, document what you routinely do or say as part of your discharge process and include specific relevant information to an individual patient.

What prescriptions were provided?

What follow up location and time frame were recommended?

Was a family member or caregiver present?

Was an interpreter used?

Summary:

ED discharge is a high frequency, high-stakes event and is a procedure that should be performed with as much care, and with supporting process and structure, as invasive procedures such as central venous catheterization. The steps that govern line placement are applicable to the discharge procedure: consent, preparation, time out, procedure, confirmation, and documentation. The discharge process can seem like an afterthought in a busy ED, but considering the volume of patients we send home and the implications of poor understanding on patient outcomes, it is useful to consider it as a “high-stakes procedure”.

References/Further Reading

Improving the Emergency Department Discharge Process. December 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.arhq.gov/professionals/systems/hospital/edenvironmentalscan/index.html CDC/NCHS, National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary Tables, Table 24. Engel KG, Heisler M, Smith DM, Robinson CH, Forman JH, Ubel PA. Patient Comprehension of Emergency Department Care and Instructions: Are Patients Aware of When They Do Not Understand? Ann Emerg Med. 2009 Apr;53(4):454-461. Hastings S, Stechuchak K, Oddone E, Weinberger M, Tucker D, Knaack W, Schmader K. Older veterans and emergency department discharge information. BMJ Qual Saf. 2012 Oct;21(10):835-42. Epub 2012 May 3. Logan PD, Schwab RA, Salomone JA 3rd, Watson WA. Patient Understanding of Emergency Department Discharge Instructions. South Med J. 1996 Aug;89(8):770-4. PMID: 8701374. Vashi A, Rhodes KV. Sign Right Here and You’re Good to Go”: A Content Analysis of Audiotaped Emergency Department Discharge Instructions. Ann Emerg Med. 2011 Apr;57(4):315-322. Clarke C, Friedman SM, Shi K, Arenovich T, Monzon J, Culligan C. Emergency department discharge instructions comprehension and compliance study. CJEM. 2005 Jan;7(1):5-11. Hastings SN, Barrett A, Weinberger M, Oddone EQ, Ragsdale L, Hocker M, Schmader KE. Older Patients’ Understanding of Emergency Discharge Information and Its Relationship With Adverse Outcomes. J Patient Saf. 2011 Mar;7(1):19-25. Schillinger D, Piette J, Grumbach K, Wang F, Daher C, Leong-Grotz K, Castro C, Bindman A. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90. Ahrens SL and Wirges AM. Using evidence to improve satisfaction with medication side-effects education on a neuro-medical surgical unit. J Neurosci Nurs. 2013;45:281-7.