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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, January 2, 2017

Safe discharge advice: What’s safe for your patient, is safe for you.

A lot of patients come to the emergency department with various issues ranging from a simple fever to other life-threatening conditions like arrhythmias etc. It’s the responsibility of the emergency physician to decide who needs to be admitted and which patients are safe to be discharged home. About 4 out of 5 patients who come to the ED are discharged home.  Failure to provide safe discharge advice can have significant clinical as well as medico-legal consequences. A lack of understanding or providing discharge advice can cause avoidable return to the ED within 72 hours or more, medication non-compliance, dissatisfaction with the care, progression of the illness and even unexpected death.


Why do we fail to provide safe discharge advice?
The most common reasons why we fail to provide safe discharge instructions to the patients are time constraints due to overcrowding in the ED, miscommunication, lack of understanding of the importance of a safe discharge advice, fear of difficult questions from the patient or the attenders, assuming it to be common sense what needs to be done after discharge, hesitance of the patient and attenders to ask questions.






Written vs verbal discharge instructions.
There is little evidence that suggests superiority of written advice over verbal advice. The problem with written instructions is that they can be difficult to comprehend by some and can carry a medico-legal risk to the provider. Some of the problems that can hinder understanding of written advice are uneducated patients, difficult to decipher handwriting of the provider, unclear instructions etc. So, the best method is to provide and document verbal instructions. For eg. “Patient explained about the warning signs of a mild head injury and advised to return to ED if any of them occur”. 




What should the discharge instructions comprise of?
There are 3 key elements to discharge instructions.
1.   Signs and symptoms that warrant return to the ED.
2.   Follow up information.
3.   Clear medication instructions.


Summary:
Safe discharge advice is a process of minimizing the adverse outcomes to a discharged patient to an acceptable minimum. It is an important although often neglected aspect of continued healthcare. ED discharge is a frequent, high-stakes procedure that should be performed with a lot of care. Discharge instructions should be provided keeping the patients’ best interest in mind as well as avoiding medico-legal implications.


Take home points:
1.   Communication is the key.
2.   Provide safe discharge advice to all patients getting discharged from the ED.
3.   Clear verbal advice that is documented is better that written advice.



Author: 
Dr. Mohammed Noor Shoeb,
Junior Consultant - Emergency Medicine at Care Hospitals, Hitech City, Hyderabad.
MRCEM(UK), MBBS.
Email: drshoeb1909@gmail.com


References:
1.   Improving the Emergency Medicine Discharge Process: Environment Scan Report.
2.   EREM: Pitfalls and Perils of Emergency Medicine Discharge Process – Dr. Matthew Delaney, MD.
3.   Safe Discharge: AN Irrational, Unhelpful and Unachievable Process – Dr. S. Goodacre.
4.   The Worrisome Discharged Patient: What do we miss and how do we do better? – Dr. Britlong, MD
5.   Maximizing The Safe Discharge – Amy E Betz, MD.




4 comments:

  1. Read this wonderful article published in Annals: https://www.ncbi.nlm.nih.gov/pubmed/27156123 Fear and uncertainty are drivers of emergency department. We need to address these fears for improving patient satisfaction and safe discharge. I especially liked the point where they highlighted the importance of rule out tests, we as em docs feel safe in discharging based on ruling out tests, but the patient's fears are not addressed. They come for answers and we may discharge by saying what you have isn't life threatening so you can go home!

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  2. Emad Mohammed (EM Resident)January 8, 2017 at 11:44 AM

    Very good EM pearl, will from now on follow all the components of discharge intstructions.

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