Emergency visit often ends in disconnect
The vast majority of patients don't fully understand the instructions they receive from doctors when they leave the emergency department, according to a new report.
Further, the vast majority of those patients weren't aware that they didn't understand.
The study, published online this month in the Annals of Emergency Medicine, followed 140 patients or their primary caregivers at two hospitals in southeastern Michigan. Researchers asked patients to recall what their doctors told them about their diagnosis and cause, emergency department care, post-emergency department care, and return instructions. Researchers then compared their responses with their actual charts, and asked whether the patients thought they had fully understood the instructions.
The biggest source of confusion: what they were supposed to do when they left the hospital.
That is "at minimal, distressing," said Dr. Kirsten G. Engel, the study's lead author and a clinical instructor of emergency medicine at Northwestern University's Feinberg School of Medicine. "If there's one aspect of a patient's care and instructions that I would hope they'd leave the emergency department with, it's . . . what they should be doing when they get home.
"This means that those people are likely to have difficulty following the directions," Engel said.
It's a problem Dr. Richard Wolfe, chief of emergency medicine at Beth Israel Deaconess Medical Center, is familiar with - but he said the article gave doctors their first hard data.
"This confirms what we've been suspecting for a while," he said. In response to those concerns, the hospital is now rewriting discharge instructions and uses nurses - instead of doctors - to slowly and carefully walk patients through what they should do when they get home.
Another important aspect of the paper was the degree to which patients either weren't aware - or weren't willing to admit - that they didn't understand instructions from doctors, Engel said.
"If they have a deficit, the vast majority - four out of five - of these people are not going to tell us they have a problem," she said. "They won't even say [their comprehension is] only very good - they'll say it's excellent."
While the study's design is sound, its small size and limited area - two hospitals within 15 minutes of each other - makes it hard to generalize to patients throughout the country, said Dr. Richard Bachur, chief of emergency services at Children's Hospital Boston.
"The design was very nice, and the journal that it's in is, to me, the premiere journal in emergency medicine," he said. But because of its size, "it's almost like a pilot study."
The fact that patients were given handwritten discharge notes, instead of the printed, bullet-point style fact sheets that have become standard, he said, was also problematic.
Still, the study exposes a vulnerability in a field that is constantly stretched because of pressure to see patients rapidly, he said.
"Whatever strategy people develop for a discharge procedure should be sure it includes real-time communication and an opportunity to ask questions," Bachur said, particularly in emergency departments. "That could make some of the concerns in this article obsolete."
