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EREM: Pitfalls and Perils of Emergency Department Discharge Instructions

2016-11-11T19:37:15+00:00

DischargePaperworksmIn the emergency department (ED), failure to comply with discharge instructions has been associated with an increased rate of adverse outcomes for patients. 1,2  There is tremendous variability in the information that is provided to patients in discharge paperwork. In some EDs, a simple handwritten discharge note is given to the patient, while in others, extensive, diagnosis specific pre-created instructions are provided to patients at time of discharge. To improve patient outcomes and reduce their medicolegal risk, providers must recognize pitfalls associated with discharge instructions and include two key elements as a part of all discharge paperwork.

Written instructions can be problematic

Written discharge instructions are often poorly understood and in some instances may increase a provider’s medicolegal risk. Multiple studies have demonstrated that patients have difficulty understanding their discharge instructions from the ED. In a study population where 65% of patients reported a college or post-graduate level of education, Engel et al. found that 22% of patients had difficulty understanding their discharge instructions. Despite high rates of poor understanding, only 30% of patients recognized their deficiency in comprehension. 3

There is little evidence to suggest that computerized, disease-specific instructions are superior to a more generalized set of instructions. Lawrence et al. compared custom hand-written discharge instructions to computerized, disease-specific instructions and found no association between the type of discharge instructions provided and the rate of return visits over a 72-hour period. 4

Written discharge instructions may expose providers to additional medicolegal risk. In an ED where busy providers often rely on pre-formatted disease specific discharge instructions, a simple error in printing instructions may have serious downstream consequences. For instance if a provider or a scribe printed instructions for gastroenteritis rather than for unspecified abdominal pain, these instructions could be used to support a claim of misdiagnosis in the event that the patient has an adverse outcome.

Provide and document verbal discharge instructions

To mitigate some of the limitations of written discharge instructions providers should provide and document verbal discharge instructions in addition to any paperwork that is provided. The importance of verbal instructions was emphasized in Celelland V. Haas. Despite clear limitations in the written discharge instructions the court stated: “once these documented instructions were supplemented with the additional verbal instructions…the discharge instructions as a whole did not fall below the applicable standard of care.” 5

A statement such as: “Additional verbal discharge instructions were given and discussed with the patient.” Should be included in the chart of all patients who are discharged.

All discharge instructions should include address two key elements

  1. Information regarding follow-up.
  2. Signs and symptoms that should indicate the need to return to the ED.

Most discharge instructions include specific medication instructions; however, this will be covered in a separate post.

Follow-up should be time and action specific

Providers should provide a clear time frame for patient follow-up. Repeatedly, courts have maintained that providers should not fully rely on the patient to determine the appropriate timing of their follow-up care. In Hill v. Wilson, a patient was discharged with a lumbar wound and was instructed to “Make an appointment with a plastic surgeon when available for treatment.” The patient scheduled a follow-up appointment in two weeks but unfortunately decompensated and returned to the ED one week after discharge. The appeals court ruled that the provider should have emphasized the need for expedient follow-up rather than relying on the patient to determine the appropriate interval for follow up care. 6 Statements such as “follow-up as needed” offer little in the way of guidance for the patient and protection for the provider.

Conversely, in a separate case, a patient was diagnosed with gastroenteritis and was instructed to follow up with their doctor within 2 days. The patient failed to follow these instructions and eventually returned to the ED 7 days later with perforated appendicitis. The patient required extensive surgical intervention and sued the ED provider. Fortunately, the jury ruled in favor of the doctor and the hospital. 7

Follow-up should also be action specific. For instance, in a patient with persistent pain overlying the scaphoid, it may be more appropriate to instruct the patient to follow up with an orthopedic surgeon rather than instruct them to follow up with their primary care physician. Not all patients need to follow up with specialists; however, the ED provider needs to make an effort to ensure that he or she is instructing the patient to follow-up with an appropriate provider when appropriate.

Return instructions should be open-ended

Previous court cases have found that patients should not be expected to accurately diagnose their own illness or recognize that they were getting worse. In one instance, a patient discharged with a finger sprain was instructed to follow up as needed with his doctor but was not given clear information in terms of the need for follow-up. Several weeks later when they continued to have issues with range of motion, they were seen by a hand surgeon and were diagnosed with a tendon injury. The patient sued the ED provider alleging that the instructions they received were not adequate and that they were not responsible for recognizing specific symptoms that signified that they were getting worse. The jury returned a verdict for the plaintiff and awarded $110,000. 8 Ultimately the patient has some responsibility to recognize if they are getting worse; however effective return instructions should utilize plain, easily understood language that encourages patients to have a low threshold to return seek care or return to the ED.

A phrase such as, “patient asked to return to the emergency department immediately for any new or concerning symptoms or if they get worse” can cover a broad range of pathology and gives parameters for returning that should be understood by a broad range of patients without relying too heavily on their ability to diagnose themselves or recognize specific symptoms.

Bottom Line

Adverse events after discharge from the ED are associated with bad outcomes for patients and increased medicolegal risk for providers. 9 Discharge instructions exist in an effort to improve patient outcomes. When providing discharge instructions, providers should give written and verbal directions that emphasize time- and action-specific follow-up instructions and provide nonspecific, easily understood return precautions.

 

1.
Taylor D, Cameron P. Discharge instructions for emergency department patients: what should we provide? J Accid Emerg Med. 2000;17(2):86-90. [PubMed]
2.
McCarthy D, Engel K, Buckley B, et al. Emergency Department Discharge Instructions: Lessons Learned through Developing New Patient Education Materials. Emerg Med Int. 2012;2012:306859. [PubMed]
3.
Engel K, Heisler M, Smith D, Robinson C, Forman J, Ubel P. Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand? Ann Emerg Med. 2009;53(4):454-461.e15. [PubMed]
4.
Lawrence L, Jenkins C, Zhou C, Givens T. The effect of diagnosis-specific computerized discharge instructions on 72-hour return visits to the pediatric emergency department. Pediatr Emerg Care. 2009;25(11):733-738. [PubMed]
5.
Carter C. Clelland v. Haas.(Louisiana Court of Appeal 2000).
6.
Fitzgerald PJ. Hill v. Wilson.(Michigan Court of Appeals 1995).
7.
Laska L. Man diagnosed with perforated appendix after discharge from ED. Medical Malpractice Verdicts, Settlements, and Experts. 1998;14:14.
8.
Laska L. Injury to ring finger. Medical Malpractice Verdicts, Settlements, and Experts. 1998;14:16.
9.
Karcz A, Holbrook J, Burke M, et al. Massachusetts emergency medicine closed malpractice claims: 1988-1990. Ann Emerg Med. 1993;22(3):553-559. [PubMed]

ALiEM Copyedit

Dr. DeLaney,

I applaud your tackling this important topic that has relevance for providers and patients. I have specific comments, but additionally I’m very concerned that the wordiness of the post allows the main points to be lost and discourages readers from actually finishing it. For example, if this post were a set of discharge instructions, I’m not sure it would be clear which parts are most important.

I recommend extensive editing. For example, offsetting discharge instruction examples in text boxes or showing side by side graphics of examples of good and bad instructions would strengthen the post. It’s both visually appealing (breaking up the paragraphs of text) as well as gives readers a quick reference point if they’re scanning. It also encourages visual learners.

I hope you don\'t mind, I have made a few changes in terms of wording.

More specific suggestions include:

  1. Paragraph 2: “Despite the wide variability of discharge instructions provided” doesn’t really contrast with the drawback in computerized instructions. It seems you’re really contrasting with our assumption that technology and long printouts with pictures are always better. Possibly, “Despite our assumptions about technology and the use of customized instructions” or something similar.
  2. Orthopedic surgeon for scapular pain seems like a poor example. Is there a better one, such as a gastroenterologist for presumed peptic ulcer disease?
  3. The second section is a little confusing as you seem to say that “nonspecific” return instructions are best and give an example of “return for new or concerning symptoms”, but also say that instructions should be clear and give the hand injury as an example. Wouldn’t the hand injury need specific instructions such as loss of movement or function? I’m not sure the reader is going to get a clear message. Perhaps giving good and bad examples of what to say to someone with a finger sprain would be more helpful.
  4. The paragraph on the difficulty providers have identifying wound infections might cause readers to throw their hands in the air. If we can’t expect MD’s agree then what’s the point of discharge instructions at all. I’d de-emphasize this and move on such as, “In one study, two physicians disagreed about whether a wound was infected almost half the time” and then move to a reassuring point about how to address this.
Matthew Zuckerman, MD
Assistant Professor, University of Colorado School of Medicine, Department of Emergency Medicine, Medical Toxicology Section; Creator and host of ToxNow.org

Expert Peer Review

Dr. DeLaney provides an insightful and succinct overview of a very important patient safety and medico-legal topic. Discharging patients from the ED is a significant area of vulnerability in EM practice, as most malpractice claims in EM involve patients who were discharged home and suffered a bad outcome. Plaintiffs often cite failure to provide adequate discharge instructions as part of their negligence claims. From a legal standpoint, the adequacy of discharge instructions is determined by expert witness testimony on a case-by-case basis and ultimately decided by a jury. From a practical and patient safety standpoint, adequate discharge instructions would include several key components as Dr. DeLaney has pointed out. I agree that discharge instructions should include who to follow up with, when to follow up, and signs and symptoms that should prompt return to the ED. I would also emphasize the importance of memorializing verbal discharge instructions. Dr. DeLaney notes “In some cases, verbal instructions that are clearly charted and understood by the patient may be more efficacious than a lengthy computer printout.” This statement warrants emphasis and more discussion.

In the era of ED overcrowding and of increased pressure for patient throughput and satisfaction, detailed hand-written discharge instructions are time- and cost-prohibitive. With a scribe’s mouse click, canned disease-specific discharge instructions are ready to be given to the patient. The canned discharge instructions could potentially expose the provider to additional liability. What happens if a scribe accidentally clicks the adult discharge instructions for otitis media for a peds patient or gives gastroenteritis instructions when you meant to give abdominal pain, unspecified? It may bolster a claim of misdiagnosis, etc. This is where documentation of additional verbal discharge instructions may help. Clelland v. Haas illustrates the importance of memorializing verbal discharge instructions. The court stated that “even if the documented discharge instructions alone were insufficient, once these documented instructions were supplemented with the additional verbal instructions given by the [defendant EDP], the jury could have reasonably concluded that the discharge instructions as a whole did not fall below the applicable standard of care.”

Ideally, discharge instructions would be discussed with the patient and specifically detailed in the chart; however, this is impossible to do for every discharged patient in the current ED environment, and a brief statement should suffice. I try to to include a statement in my charts for discharged patients that “Additional verbal discharge instructions were given and discussed with the patient, who understood and was agreeable with the plan. Strict return precautions were given, including for any new or worsening symptoms.”

I would modify the last sentence of the post to include something of the sort: When providing discharge instructions, providers should give written time- and action- specific follow-up instructions and IN ADDITION to any disease-specific instructions, should provide written nonspecific, easily understood return precautions. Providers should also attempt to discuss discharge instructions with the patient and reference these discussions in the chart.

Additional notes:

  • I would include citations for the three cases where specific case facts were discussed. (Hill v. Wilson, the appendicitis case, and the tendon injury case).
  • I would revise: “All discharge instructions should include [AND] address two key elements”

Thank you, Dr. DeLaney for an excellent post, as usual.

References:
Clelland v. Haas, 774 So.2d 1243, 99-2971 (La.App. 1 Cir. 2000).

Christina Cooley, MD JD
Emergency Physician, DCH Regional Medical Center, Tuscaloosa, AL; Law School Graduate, University of Alabama

Drs. Zuckerman and Cooley,

Thanks for your comments and critiques.

  • I cut several sections to decrease the overall length, I\'m happy to add graphic depictions of discharge instructions, but I worry that this may be somewhat redundant with the written examples. I could offset the examples of documentation in boxes if that was more aesthetically pleasing.
  • I wanted to clarify your comment on the need to improve the example of Ortho referral for scaphoid pain. You had mentioned scapular pain, which I agree would be a bad referral; however I think continued scaphoid pain is a decent reason to refer someone to a specialist. Not sure if an earlier draft may have read scapular instead of scaphoid.
  • I reworked the end of the post to clarify the need to have non-specific return instructions, I cut a few sources that had initially been included but did not specifically support this point.

Thanks again for your help.
MCD

Matthew DeLaney, MD, FACEP, FAAEM
Assistant Professor of Emergency Medicine, University of Alabama at Birmingham, Assistant Residency Director
Matthew DeLaney, MD

Matthew DeLaney, MD

Assistant Professor of Emergency Medicine
Assistant Medical Director
University of Alabama at Birmingham