Majority of emergency patients don't understand discharge instructions
Majority of emergency patients don't understand discharge instructions
Poor communication often results in more frequent readmissions
A woman who initially had come into the ED at Northwestern Memorial Hospital in Chicago with a miscarriage returned three days later. She was extremely upset because she had continued to bleed.
"My resident came to me to discuss the case, and it gradually became clear there was nothing atypical, except that the patient did not understand what the expectations were when she left," recalls Kirsten Engel, MD, a clinical instructor in the Department of Emergency Medicine at Northwestern University's Feinberg School of Medicine and an ED physician at Northwestern Memorial. "She was so upset about her continued bleeding, when she should have expected it at those levels." The only reason that patient returned to the ED, insists Engel, was lack of communication.
This lack of communication was not an isolated incident, as underscored in a new study that should serve as a wake-up call for ED managers. Researchers at Northwestern, led by Engel, report that more than 75% of ED patients interviewed after discharge showed "deficient comprehension," or "less-than-complete concordance," in at least one of the following four areas: diagnosis and cause, ED care, post-ED care, and return instructions.1 In addition, the study published in the Annals of Emergency Medicine reports that more than half showed the same lack of understanding in at least two of these four domains.
What's more, the researchers noted, only 20% of those patients with poor comprehension actually perceived that they were having difficulty understanding what the doctor told them. The study involved 140 English-speaking adult patients in two EDs in Michigan.
"These are distressing findings for us, because these are the specific recommendations we hope people are going to follow when they leave our department," says Engel. "We have every expectation that if they were followed, they would have [a positive] impact on the patients' health."
While no studies have been conducted to demonstrate worse outcomes among ED patients who don't follow discharge instructions, "we do know from studies in the field of internal medicine that patients who leave visits from the office who don't understand their problem and what they need to do about it have [a negative] impact on things like blood pressure control and glucose control," says Engel. She adds that she is "clearly concerned" about the impact of poor comprehension on outcomes. "If a patient does not understand their instructions we have every reason to expect it would have an impact on health and outcomes, as well as on recidivism," Engel says.
This lack of communication is no surprise to Bruce Janiak, MD, FACEP, FAAP, professor of emergency medicine, Medical College of Georgia, and vice chair of the ED at MCG Health Medical Center, both in Augusta. "One of the biggest problems with lack of communication is that we [give the patients] way too much in terms of home-going instructions," Janiak says. "It's like the contract you get for buying a house. So many patients may not read it."
Engel has a different viewpoint, saying that the chaotic environment of the ED is at the heart of the problem. "The environment is, at best, loud and confusing, the medical problems are challenging, and providers see many patients with conflicting demands," she says. "They don't know these patients and have no basis for understanding them. All this leads to us probably not spending as much time with them and communicating what we should."
Reference
- Engel KG, Heisler M, Smith DM, et al. Patient comprehension of emergency department care and instructions: Are patients aware of when they do not understand? Ann Emerg Med 2008; Doi:10.1016/j.annemergmed.2008.05.016.
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