The practice of emergency medicine/review articleEffective Discharge Communication in the Emergency Department
Introduction
Discharge from the hospital is a period of significant potential vulnerability for patients. Patients leaving the hospital after inpatient admission often fail to understand important elements of their discharge and home care plan,1 leaving them at potential risk of a medical error or adverse drug event.2 Compared with the inpatient provider, the emergency department (ED) physician faces unique challenges in the provision of high-quality, patient-centered care in a distraction-filled and time-limited environment without previous knowledge of the patients. Precise bidirectional communication at discharge from the ED is a key and often overlooked element in this process. Discharge communication in the ED provides an opportunity to summarize the visit, teach patients how to safely care for themselves at home, address any remaining questions or concerns, and help patients connect to the medical home or primary care providers where their chronic needs may be best managed.3
At patient discharge, the emergency provider must effectively complete 3 tasks: communicate the crucial information, verify comprehension, and tailor teaching to areas of confusion or misunderstanding to ensure patient safety in the home environment. This process must balance reliability and efficiency gains provided by standardization with the flexibility required to be effective across a wide range of parental literacy levels and cultural backgrounds. Too often, however, discharge communication becomes an afterthought, limited only to a brief exchange of forms and prescriptions, leaving patients with uncertainty about the care plan and at risk of errors in medication use. Patients and families with limited health literacy or language fluency are likely to be at particular risk of departing from the ED with insufficient comprehension.
Patients arrive in the ED with various amounts of information, experience with the health care system, language fluency, and health literacy. They are presented with information from the environment (posters, handouts) throughout their ED stay. Focused interactions with nursing and physician providers are opportunities for education during the whole ED stay. In many cases, the discharge education will begin with the initial assessment and conversation with the family. Patient, provider, and environmental factors influence the success or failure of information transmission at discharge.
This review will focus on communication during the formal discharge process, the conversation with a provider before the patient departs from the ED. It will describe the deficiencies of current discharge processes through an examination of their content and method of delivery, discuss the data on patient understanding and implementation of those instructions, and then review the reported interventions that have attempted to improve the discharge process.
Section snippets
Materials and Methods
MEDLINE (1980 to date) and Cochrane databases were searched, using combinations of the following terms: “pediatric,” “discharge,” “communication,” “ED,” “patient-centered,” “adherence,” “compliance,” and “instructions.” A single reviewer (MES-K) examined titles and abstracts and reviewed the full text of relevant articles. References were reviewed from review articles and cited articles. Literature from both the adult and pediatric ED populations was reviewed.
Recommendations for Practice and Directions for Future Research
At discharge from the pediatric inpatient service, parents reported that they wanted understandable verbal and written information, opportunities to ask questions, self-management plans, and clear instructions on follow-up,91 and patients likely require similar information on discharge from the ED (Table). The safe and effective ED discharge must address all of these issues in an efficient manner that can be tailored to the particular learning needs of individual patients. Patients need
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Supervising editor: Steven M. Green, MD
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This work was supported by Program for Patient Safety and Quality at Children's Hospital Boston, the Emergency Medicine Foundation and the Institute for International Emergency Medicine and Health, Brigham and Women's Hospital Department of Emergency Medicine.
Earn CME Credit: Continuing Medical Education is available at www.ACEP-EMedHome.com.
Publication date: Available online January 4, 2012.