The practice of emergency medicine/review article
Effective Discharge Communication in the Emergency Department

https://doi.org/10.1016/j.annemergmed.2011.10.023Get rights and content

Communication at discharge is an important part of high-quality emergency department (ED) care. This review describes the existing literature on patient understanding and implementation of discharge instructions, discusses previous interventions aimed at improving the discharge process, and recommends best practices and future research. MEDLINE and Cochrane databases were searched, using combinations of key terms. Literature from both the adult and pediatric ED populations was reviewed. Multiple reports have shown deficient comprehension at discharge, with patients or parents frequently unable to report their diagnosis, management plan, or reasons to return. Interventions to improve discharge communication have been, at best, moderately successful. Patients need structured content, presented verbally, with written and visual cues to enhance recall. Written instructions need to be provided in the patient's language and at an appropriate reading level. Understanding should be confirmed before the patient leaves the ED. Further research is needed to describe the optimal content, channel, and timing for the ED discharge process and the relationship between discharge process and outcomes.

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

References (96)

  • S. Zavala et al.

    Do patients understand discharge instructions?

    J Emerg Nurs

    (2011)
  • E.J. Thomas et al.

    Patient noncompliance with medical advice after the emergency department visit

    Ann Emerg Med

    (1996)
  • C.E. Saunders

    Patient compliance in filling prescriptions after discharge from the emergency department

    Am J Emerg Med

    (1987)
  • A.M. Rogers et al.

    The association between guideline-based treatment instructions at the point of discharge and lower 1-year mortality in Medicare patients after acute myocardial infarction: the American College of Cardiology's Guidelines Applied in Practice (GAP) initiative in Michigan

    Am Heart J

    (2007)
  • B.T. Jolly et al.

    Simplification of emergency department discharge instructions improves patient comprehension

    Ann Emerg Med

    (1995)
  • P.S. Houts et al.

    Using pictographs to enhance recall of spoken medical instructions

    Patient Educ Couns

    (1998)
  • P.S. Houts et al.

    Using pictographs to enhance recall of spoken medical instructions II

    Patient Educ Couns

    (2001)
  • T.C. Chan et al.

    Impact of an Internet-based emergency department appointment system to access primary care at safety net community clinics

    Ann Emerg Med

    (2009)
  • J.M. Baren et al.

    A randomized, controlled trial of a simple emergency department intervention to improve the rate of primary care follow-up for patients with acute asthma exacerbations

    Ann Emerg Med

    (2001)
  • S.R. Smith et al.

    Improving follow-up for children with asthma after an acute emergency department visit

    J Pediatr

    (2004)
  • S. Kripalani et al.

    Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists

    J Hosp Med

    (2007)
  • W.C. Cooley et al.

    Improved outcomes associated with medical home implementation in pediatric primary care

    Pediatrics

    (2009)
  • A. Vashi et al.

    “Sign right here and you're good to go”: a content analysis of audiotaped emergency department discharge instructions

    Ann Emerg Med

    (2011)
  • A.A. Ginde et al.

    Hospitalization and discharge education of emergency department patients with hypoglycemia

    Diabetes Educ

    (2008)
  • C. Clarke et al.

    Emergency department discharge instructions comprehension and compliance study

    CJEM

    (2005)
  • D. Chacon et al.

    Education attainment level of caregivers versus readability level of written instructions in a pediatric emergency department

    Pediatr Emerg Care

    (1994)
  • Y. Waisman et al.

    Do parents understand emergency department discharge instructions?a survey analysis

    Isr Med Assoc J

    (2003)
  • M.K. Paasche-Orlow et al.

    How health care systems can begin to address the challenge of limited literacy

    J Gen Intern Med

    (2006)
  • M.K. Paasche-Orlow et al.

    The prevalence of limited health literacy

    J Gen Intern Med

    (2005)
  • K. Eichler et al.

    The costs of limited health literacy: a systematic review

    Int J Public Health

    (2009)
  • D.W. Baker et al.

    Health literacy and the risk of hospital admission

    J Gen Intern Med

    (1998)
  • D.W. Baker et al.

    The relationship of patient reading ability to self-reported health and use of health services

    Am J Public Health

    (1997)
  • D.W. Baker et al.

    Functional health literacy and the risk of hospital admission among Medicare managed care enrollees

    Am J Public Health

    (2002)
  • C.A. Mancuso et al.

    Impact of health literacy on longitudinal asthma outcomes

    J Gen Intern Med

    (2006)
  • M.K. Paasche-Orlow et al.

    Tailored education may reduce health literacy disparities in asthma self-management

    Am J Respir Crit Care Med

    (2005)
  • A. Manson

    Language concordance as a determinant of patient compliance and emergency room use in patients with asthma

    Med Care

    (1988)
  • A.D. Bagchi et al.

    Examining effectiveness of medical interpreters in emergency departments for Spanish-speaking patients with limited English proficiency: results of a randomized controlled trial

    Ann Emerg Med

    (2010)
  • S.N. Hastings et al.

    Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes

    J Patient Saf

    (2011)
  • D.J. Isaacman et al.

    Standardized instructions: do they improve communication of discharge information from the emergency department?

    Pediatrics

    (1992)
  • G. Grover et al.

    Parental recall after a visit to the emergency department

    Clin Pediatr (Phila)

    (1994)
  • P.D. Logan et al.

    Patient understanding of emergency department discharge instructions

    South Med J

    (1996)
  • K.G. Engel et al.

    Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand?

    Ann Emerg Med

    (2009)
  • H.S. Yin et al.

    Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications

    JAMA

    (2010)
  • H.K. Simon et al.

    Over-the-counter medicationsDo parents give what they intend to give?

    Arch Pediatr Adolesc Med

    (1997)
  • H.S. Yin et al.

    Parents' medication administration errors: role of dosing instruments and health literacy

    Arch Pediatr Adolesc Med

    (2010)
  • J.F. Graumlich et al.

    Patient and physician perceptions after software-assisted hospital discharge: cluster randomized trial

    J Hosp Med

    (2009)
  • D.C. Sims et al.

    Evaluation and development of potentially better practices to improve the discharge process in the neonatal intensive care unit

    Pediatrics

    (2006)
  • L.O. Hansen et al.

    Hospital discharge documentation and risk of rehospitalisation

    BMJ Qual Saf

    (2011)
  • Cited by (159)

    • Optimizing Discharge Knowledge and Behaviors

      2021, Journal of Emergency Nursing
    View all citing articles on Scopus

    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.

    View full text