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