Your patient may understand very little about ED instructions

Misunderstandings are common

ED patients often don't understand important information in their discharge instructions, according to a new study, which can result in bad outcomes and needless repeat visits.1

Even though the hospital's ED nurses gave both verbal and written instructions, says Carol Shaffer, RN, PhD, CIP, the study's co-author and research coordinator at Reston (VA) Hospital Center, patients clearly didn't understand the verbal explanations and didn't seem to read the written instructions.

"We were a bit surprised at some of the obvious misunderstandings," adds Shaffer. In some cases, patients didn't realize that analgesics were intended to ease discomfort, or didn't know why taking antibiotics was important.

"When you add in the medications the patient may have received and the distractions of the ED, it doesn't seem likely that patients will retain very much information," she says.

A worried, stressed ED patient will hear very little of what you say, says Leah M. Gehri, RN, MN, CCRN, director of emergency and trauma services at MultiCare Good Samaritan Hospital in Puyallup, WA.

"The process of discharging a patient is one of the most important dialogues that an ED nurse has with the patient," says Chris Modic, RN, BSN, an ED nurse at Legacy Mount Hood Medical Center in Gresham, OR. It is the last opportunity you have to educate the patient about new medications, treatments, and follow-up care, he adds.

Shaffer recommends giving instructions to family members as well as the patient, and giving the patient ample time to ask questions. Here are other strategies to improve comprehension of discharge instructions:

• Use a highlighter pen.

"If the patient is not going to read all four pages of instructions, use the highlighter pen for the things you want to draw his or her attention to," says Gehri. Gehri highlights anything that would require a 911 call or a trip back to the ED, and instructions for following up with a primary care physician or specialist.

• Have the patient verbalize the follow-up instructions back to you.

"This allows for any misunderstandings to be corrected," says Modic.

• Be persistent when teaching your patient.

Each time ED nurses at Legacy Mount Hood cared for a woman who presented several times a week for chronic pain, they recommended obtaining follow-up care. After months of trying, they were finally successful.

"We now see this patient about twice a year," says Modic. "When the patient comes in now, we normally get a call from her doctor explaining that the patient made an attempt to be seen at the office first, but could not get an appointment."

• Have a charge nurse or case manager briefly make contact with the patient.

"The purpose is to make sure that the patient was satisfied with their visit, and that the discharge instructions were understood clearly," says Modic.

• Make an attempt to reach the patient the next day.

"Find out how their visit was, how they are feeling now, and answer any questions about their follow-up care," says Modic. (See related stories on questions to ask and changes to medications, below.)

Reference

  1. Zavala S, Shaffer C. Do patients understand discharge instructions? J Emerg Nurs. 2011:37;138-140.

Sources

For more information on discharge instructions given to ED patients, contact:

  • Leah M. Gehri, RN, MN, CCRN, Director, Emergency/Trauma/Cardiac Services, MultiCare Good Samaritan Hospital, Puyallup, WA. Phone: (253) 697-1051. E-mail: leah.gehri@multicare.org.
  • Chris Modic, RN, BSN, Legacy Mount Hood Medical Center, Gresham, OR. E-mail: CModic@LHS.org.
  • Carol Shaffer, RN, PhD, CIP, Research Coordinator, Reston Hospital Center, Reston, VA. Phone: (703) 639-9437. Fax: (703) 639-9476. E-mail: carol.shaffer@hcahealthcare.com.

Clinical Tip

When discharging patient, always ask these questions

When an ED patient is asked "Do you have any questions?" at discharge, he or she almost always says no, according to Leah M. Gehri, RN, MN, CCRN, director of emergency and trauma services at MultiCare Good Samaritan Hospital in Puyallup, WA.

For this reason, Gehri says this instead: "There are a few things I want to make sure you understand. I'm going to ask you a couple questions, and you tell me what you heard." Next, Gehri asks the patient, "When are you going to follow up with your doctor?" "What would mean you should return to the ED or call 911?"

"If they don't recall it, you can find it where it is on the paper, underline it and teach it again," says Gehri.

Simply asking patients if they have any questions doesn't ensure they understand how often they should take their medications or what to do if vomiting occurs, says Kristen Wojtun, an ED nurse at Delnor Hospital, Geneva, IL. For this reason, Wotjun asks specific questions such as "What do you need to bring with you when you go to see the orthopedist?" or "Tell me how you will strain your urine at home."

This helps to prevent needless ED visits for the same complaint, says Wotjun. "For example, the patient will know how often to take their pain medications, or when to give acetaminophen or ibuprofen when a fever spikes again in a pediatric patient," she says.


Changes to meds? Review with patient

Did the ED physician tell your patient to take two diuretic pills instead of one, or to stop taking blood thinners for two days? If so, pay extra attention to these instructions at discharge, says Leah M. Gehri, RN, MN, CCRN, director of emergency and trauma services at MultiCare Good Samaritan Hospital in Puyallup, WA.

"If there are any changes to the patient's regular medication regimen, this is likely to get missed. It's really easy for patients to fall back into their regular schedule," she explains.