In an evaluation of written discharge instructions, only 76% included a diagnosis or an explanation of the patient’s symptoms, and only 34% provided instructions on when and how to return.22 Another study of the discharge process showed that the average verbal discharge exchange lasted only 76 seconds and that 65% of instructions were not complete. Patients were often not given a diagnosis, an explanation of their prescriptions, or proper return precautions.23 Deficits in the discharge process places patients at risk for medical and medication errors.
The discharge exchange must provide information on the diagnosis, what was done in the ED, and what needs to happen next. This must be done both verbally and in writing, in the patient’s native language, and at his or her health-literacy level. There should be time for the patients and those accompanying them and who are also responsible for their health to ask questions to ensure that everyone understands what has taken place and what must be done after leaving the ED. Patients should be given information on all prescription and over-the-counter medications they are instructed to take, as well as any changes to their previously prescribed medications.
Patients should be told specifically with whom to follow up and within what time frame. If possible, the exact time and location of a follow-up appointment should be provided. For patients with lower health literacy and less understanding of the health-care system, a process should be in place to help them navigate and ensure they get to necessary appointments.21
Handoffs and Transitions of Care
Case Scenario 3
A 70-year-old man with hypertension and hyperlipidemia had an episode of chest pain and was evaluated in the ED for possible myocardial ischemia. His initial electrocardiogram was interpreted as nonischemic and his troponin level was below detection 30 minutes after the episode. As the initial provider was leaving the ED, he endorsed the patient to the oncoming EP, with instructions to follow up on the chest X-ray interpretation. The initial provider, however, did not tell the oncoming EP to check the results of a repeat troponin determination. The patient was discharged home after the second troponin test had been sent to the laboratory, but before the results had been checked.
Discussion
Emergency department patients still under evaluation or in the process of being admitted to the inpatient hospital are “handed off” to the next shift of providers. Handoffs, or transitions of care, place patients at high risk for adverse events or bad outcomes. Important information can be lost whenever care is transferred to another provider. For example, there can be a lack of communication about pending tests that require follow-up, the need for further testing, or contingency planning for any problems that may arise. Loss of information and lack of follow-up can lead to diagnostic error and improper disposition.
According to the Joint Commission and a 2006 National Patient Safety Goal, handoffs should be standardized.24 The four stages for safe ED-provider-to-ED-provider handoffs are pre-turnover, arrival of new provider, meeting of providers, and post-turnover.25 During pre-turnover, the initial provider should review what has happened in the patient’s care and the next steps needed to finalize patient disposition. The arrival of the new provider signals the start of a new shift. During the meeting with the new provider, important information should be verbally transmitted to the oncoming provider.25 This meeting needs to be standardized to include a patient summary, tasks and tests to follow up, and contingency planning. Many tools can aid in transitions of care, including verbal mnemonics, tools to integrate with the medical record, and tools to develop a complete process for transition of care. Post-turnover is completed by the oncoming provider as he or she finishes any tasks related to the patient’s care to ensure the treatment plan is completed.25
There are many ways to improve the safety of handoffs. First, the number of handoffs should be limited. Having more patients dispositioned by the provider who initiated their care reduces the risk of an adverse event. This can be accomplished by having overlapping shifts to allow out-going providers time to complete care for their patients. During handoffs, interruptions and distractions should be limited to give the off-going provider appropriate time to present a succinct but complete overview of the patient’s care and communicate all outstanding tasks as “to-do” or “action lists,” with contingency planning for any changes in the patient’s status, test results, etc. There should be time for the oncoming provider to ask questions to ensure he or she is clear about the next steps.25 At the end of the transition, there should be some signal that the patient’s care is passed on to the oncoming provider and the outgoing physician should leave the patient-care area to finish documentation.