In My Opinion
The trend of voluminous, exhaustive discharge instructions puts the pressure on patients to understand and identify complex risk factors, like infection. According to the research, this is probably a bad idea.
I think that good discharge instructions are a great idea. In fact, I often wonder why they are only given out after an ED visit. Wouldn’t discharge instructions be useful after a visit to a primary care physician or after a hospitalization? But you don’t seem to see them being used in these other settings. Regardless, discharge instructions are an integral part of an ED visit, which begs the question: Are they working?
A few thoughts before we dive into the literature to answer this question. First is the issue of quantity over quality. Some people seem to think that if discharge instructions are a good thing, then the more the better. Now everyone is using computerized instructions that create little medical textbooks for parents and patients to take home. For the visit of a febrile child with gastroenteritis, your computer can spit out multiple instruction sheets (of course, written at a 6th grade level and in large type) on how to treat fever, vomiting, diarrhea and how to take the medications you’ve prescribed.
These computer-generated instructions can be needlessly voluminous.
Then there is the simple problem of poor communication. Take head injury instructions, which ask people to, “check the pupils.” Do parents know what the pupils are? And by the time the pupils are of different sizes is not the patient already comatose with a brain herniation? And watch for vomiting after a head injury. “Bring the child back if he/she vomits more than twice.”
Like vomiting once is OK after returning home from an ED visit. And “arouse the child to see if they are irritable.” Who wouldn’t be irritable after being awakened from a sound sleep?
I believe discharge instructions can reasonably instruct people about the diagnosis they have (what is a bladder infection? What is otitis media?) but I think we need to be very, very careful in expecting laypersons to differentiate the early signs indicating that things are going wrong.
For example, can laymen tell when a wound is getting infected? A study in our Emergency Medical Abstracts database specifically demonstrated that they could not. We even have a study that found that the agreement among EM residents was only moderate when it came to diagnosing a wound infection. Bottom line, routine, scheduled checks of selected wounds sounds reasonable rather than depending on a patient coming in if they thought they had an infection. (Citation: IS SINGLE OBSERVER IDENTIFICATION OF WOUND INFECTION A RELIABLE ENDPOINT? Greenwald, P.W., et al, J Emerg Med 23(4):333, November 2002.)
The following papers all challenge our basic assumption that discharge instructions create a substantial safety net that limits the risks of problems developing after discharge. The first in this series compared written discharge instructions with computer-generated ones. Were the outcomes better with the computerized instructions? No way.
THE EFFECT OF DIAGNOSIS-SPECIFIC COMPUTERIZED DISCHARGE INSTRUCTIONS ON 72-HOUR RETURN VISITS TO THE PEDIATRIC EMERGENCY DEPARTMENT.
Lawrence, L.M., et al, Ped Emerg Care 25(11):733, November 2009
BACKGROUND: The percentage of children returning to the ED within 72 hours after an initial visit is sometimes used as a marker of quality of care. Studies have suggested that many return visits are due to inadequate patient education, and that a substantial proportion might be medically unnecessary.
METHODS: The authors, coordinated at Vanderbilt University in Nashville, reviewed the records of 18,647 children discharged after an ED visit during a six- month period in 2004-2005 and 21,771 children discharged from the ED during the same months in 2005-2006 to evaluate the characteristics of return visits occurring within 72 hours. Discharge instructions were hand-written by managing physicians during the former period, with no uniformity regarding content.
During the latter period, computer-generated diagnosis-specific discharge instructions were provided (via the “Discharge 1-2-3” system by Callibra) that were written at a 6th to 8th grade reading level and included information on the diagnosis, the expected course, guidance for home care, a list of signs and symptoms that should prompt return to the ED, designated periods for follow-up, and relevant clinic information.
RESULTS: The 72-hour return visit rate was 2.3% in the group receiving handwritten discharge instructions and 3.0% in the group receiving computer-generated discharge instructions. The percentage of return visits judged to be medically unnecessary was 13% in the former group and 15% in the latter.
Copyright 2010 by Emergency Medical Abstracts - All Rights Reserved 5/10 - #12
The next two papers try to determine the level of comprehension that patients have for their discharge instructions. The first study looked at computer-generated discharge instructions provided to patients from an affluent, largely college-educated community. The bottom line – confusion regarding the instructions was common. The second paper also indicated that a series of predominantly college-educated patients often got elements of their discharge instructions wrong.
DO PATIENTS UNDERSTAND DISCHARGE INSTRUCTIONS?
Zavala, S., et al, J Emerg Nurs 37(2):138, March 2011
BACKGROUND: It has been reported that as many as 78% of patients discharged from the ED do not understand their aftercare instructions but that only 20% are aware of their lack of understanding.
METHODS: This study, from the Reston Hospital Center in Virginia, reports on next day follow-up phone calls to 49 adults aged 22-91 (mean, 48) discharged from the ED to identify areas of confusion about discharge instructions. This 187-bed community hospital serves an affluent and largely college-educated adult population. Substantial efforts are made to personally explain computer-generated individualized discharge instructions, which are also provided in writing.
RESULTS: Reaching these patients for a telephone interview required placement of 155 phone calls (made between 9AM and 7PM). Nearly one-third of the patients (15/49) requested clarification of some elements of the discharge instructions and an additional 15 had a diagnosis-related concern that demonstrated poor comprehension of their aftercare instructions.
Nearly one-fifth of the patients (9/49) had questions about their prescribed medications, and an additional nine reported persistent or worsening symptoms and were reminded of the need for follow-up. Three patients reported significant discomfort but did not fill their analgesic prescriptions. Two patients stated that they had not received discharge instructions, despite chart documentation of the provision of this information.
- no reprints) Copyright 2011 by Emergency Medical Abstracts - All Rights Reserved 9/11 - #16
PATIENT COMPREHENSION OF EMERGENCY DEPARTMENT CARE AND INSTRUCTIONS: ARE PATIENTS AWARE OF WHEN THEY DO NOT UNDERSTAND?
Engel, K.G., et al, Ann Emerg Med 53(4):454, April 2009
METHODS: In this study, from the University of Michigan, 140 adults aged 19-83 (mean, 39 years) were interviewed at the time of ED discharge and their audiotaped statements about four aspects of the ED visit were compared with what was written on the ED chart. All of the patients had been given discharge instruction sheets that specifically listed the diagnosis, medications and instructions. The four domains addressed included diagnosis and cause, ED tests and treatments, prescribed post-ED care, and return instructions.
RESULTS: About two-thirds of the subjects (65%) reported a college or graduate school education. The mean satisfaction score for the ED visit was 4.1 on a scale of 1-5. Most patients (78%) were felt to be deficient in comprehending at least one of the study domains, and 51% to have deficiencies for two or more domains. These deficiencies involved understanding of post-ED care (34% of deficiencies) and care provided in the ED (29%) more than return instructions (22%) or diagnosis/cause (15%). Fewer than 30% of patients with a deficiency in comprehension acknowledged that one was present, while 12 of 31 patients who were felt by the rater to have perfect comprehension nevertheless reported difficulty with comprehension in at least one domain.
- no reprints)
Copyright 2009 by Emergency Medical Abstracts - All Rights Reserved 9/09 - #13
My fundamental view is that asking laypersons to make certain medical judgments is hazardous. For 30 years we used a two-sided discharge instruction (a signed copy was kept in the patient’s medical record) and our discharge instructions were never an element in an alleged cases of malpractice during that time.
The front contained the most important information – what was the diagnosis (in plain English – middle ear infection, not otitis media), what imaging studies were done and the readings (and whether by the emergency physician or the radiologist), what ED treatment had been given (they also included a copy of any prescriptions). The concept was that the instructions were for the patient but also to advise the follow-up physician of the key information they would need as well.
The patient also received a sealed envelope containing their lab results and a copy of their EKG to be given to the follow-up physician along with the discharge instructions.
On the back of the page were general instructions regarding four common medical conditions (fever, vomiting, diarrhea and respiratory infections) and four common trauma diagnoses (head trauma, wounds, sprains and strains and back pain).
As can be ascertained, the instructions regarding these eight conditions were very brief and to the point.
By far, the most important instructions were on the front and in huge print. It said, “If you develop ANY new or worsening symptoms, or your symptoms persist longer than advised by the physician, return to the emergency department immediately.”
These instruction put the burden and obligation on the patient. We didn’t need a laundry list of symptoms for them to watch for. We didn’t need patients to make judgments whether new symptoms were significant or not. We just wanted them to come back if ANY new or worsening symptoms developed. And, we specifically told them to come back to the ED (not try to get an appointment with their PMD – who knows if they would be able to get a timely appointment?) and they were to return immediately (not the next day or two days later or who knows when they would return).
And there was one other feature. We were of the view that everyone did not need to go to a follow-up physician. I’ve seen many discharge instructions that mandate that all ED visits be seen by a follow-up physician. This is unethical. It requires patients to miss work, see a doctor and pay fees that are unnecessary just so the EP can think he/she has covered their butt.
Many conditions do not need routine follow-up. Most ankle sprains take about three weeks to resolve. To tell a patient to see a physician in a week is medically unindicated unless the problem is not gradually resolving. The same is true for a large variety of ED diagnoses, from sore throats to bronchitis to sprains. These conditions usually get better over a specific amount of time. So we wrote down on the discharge instruction when we thought patients ought seek care if symptoms associated with certain specific diagnoses persisted. And the option to come back to the ED was always extended.
So, be careful with your discharge instructions. Relying too heavily on laypersons to make important medical decisions can be risky. Don’t put yourself in a position where a patient can say, “I’m not a doctor. How was I to know that this new or worsening symptom was important?”
W. Richard Bukata, MD is the Editor of Emergency Medical Abstracts