Confusion Over ED Instructions Remains Unaddressed Even After Discharge
By Stacey Kusterbeck
As an undergraduate research assistant in the pediatric clinical research program at Primary Children’s Hospital, Bridget Dorsey noticed many communication gaps between ED providers and families. Dorsey started keeping a list of terms that caused misunderstandings, including “positive” and “negative” test results, “sexually active,” and “fracture.” Dorsey and colleagues set out to explore this further. They asked 220 caregivers at a pediatric ED, “What words or phrases have been used during this visit that are unclear or don’t make sense to you?”1 Sixty-two reported there were some unclear words or phrases used during the ED visit that confused them.
Some of what they were told about signs and symptoms were not understood, such as “mottled,” “tachycardia,” and “post-ictal.” There also was confusion over terminology used to describe lab tests, such as “liver enzymes,” or “PCR lab.”
Using overly simple terms also caused misunderstandings, such as the use of “pictures” instead of “X-ray.” In terms of the treatment plan, words such as “NPO” and “hemolysis” were unclear.
Medication instructions also were problematic, such as an instruction to “titrate the MiraLAX.” One participant stated, “They taught her how to use the inhaler, but didn’t tell her what was in it. What is a steroid?”
One patient experienced a 30-minute delay in discharge because the patient did not understand the phrase “PO challenge,” which meant the patient had to be able to drink or eat without vomiting before discharge clearance.
Even general terms, such as “follow up” and “admitted” were misunderstood. One patient did not understand why vital signs were gathered if no one ever explained if anything was abnormal.
Overall, participants were not focused on a single word they did not understand; patients expressed broader communication concerns. Some found providers’ questions hard to answer, asking their caregivers to repeat themselves several times. Others objected to providers talking to them “like we were little kids,” suggesting oversimplification is not effective communication.
Responses that were recorded after the patient was discharged from the ED carried the highest proportion of communication problems. “Families reported unresolved gaps in communication, even after they received discharge teaching,” Dorsey says.
This means no one caught those misunderstandings during the ED visit. Thus, patients and families left still confused about what to do. “This tells me that we aren’t always verifying that folks understand what we are saying, or they don’t always feel comfortable asking all of their questions,” says Dorsey, a student at the University of Utah School of Medicine.
Effective communication is necessary for this to happen. Dorsey and colleagues offered some recommendations to improve communication. Try using a combination of simplified and more technical language. Administer assessment tools for health literacy testing during waiting periods to identify patients with higher risk of confusion. These patients at higher risk could receive a brief informational handout or watch a video to learn more about what to expect during their visit. Also, ask open-ended question, such as “What words or phrases have been used that are confusing?”
Dorsey says emergency providers “have the opportunity to make the ED a place where people feel heard and feel like they received what they needed, which is especially important because the ED is a crucial point of contact for some historically underserved populations.”
Discharge instructions become the focus of some malpractice lawsuits. Patients claim they were never told something that becomes a central issue during litigation. EPs should provide verbal and written discharge instructions to all patients discharged from the ED, advises Jay Brenner, MD, FACEP, medical director of the Community ED at SUNY Upstate Medical University. Brenner says verbal instructions should include sitting with the patient, explaining the instructions, soliciting questions, checking for understanding, using an interpreter when a patient’s primary language is not English, and documenting the discussion.
Brenner recommends asking “What questions do you have?” rather than “Do you have any questions?” On multiple occasions, patients admitted they did not understand instructions for prescribed medications, especially antibiotics, anticoagulants, anticonvulsants, and antihypertensives. In Brenner’s experience, that is especially common if ED providers initiated new prescriptions or changed dosing, along with patients who lack the ability to comprehend and rely on caregivers. “Asking what questions they have and the teach-back method have definitely saved me from errors in comprehension from reaching the patient and causing harm,” Brenner reports.
Brenner says written instructions should give a diagnosis in layperson’s terms, prescriptions (if any) with information about possible side effects, post-discharge care instructions, follow-up instructions, return-to-ED instructions, incidental findings (if any), and the patient’s signature. “Of course, even when we do all of this, patients still may not comprehend,” Brenner laments.
To ensure patients understand their discharge instructions, some EDs provide video instructions.2,3 Overly technical terminology can block the way. “Rather than saying ‘pulmonary embolism,’ an emergency physician might want to use a more vernacular term, such as ‘blood clot,’” Brenner offers.
EPs also can use “teach-back” methods to ensure patients comprehend.4 Many ED charts simply state, “Patient understood.” Brenner would rather see specifics on what the patient reports. “It’s not necessary to quote a patient or family’s response verbatim. However, it may be helpful to paraphrase their response,” Brenner suggests.
He offers this example of good documentation: “Patient/caregiver reflected understanding of discharge instructions, stating they would return to the ED if they spiked a fever or cannot control their pain with their prescribed medication at home.”
Confirming comprehension with discharge instructions is especially important if the emergency provider is wearing a mask. One accommodation that can be made is to wear a translucent mask when requested. “Many patients simply cannot understand you through your mask,” Brenner explains. “This is common among geriatric patients who may be hard of hearing and are relying more on lip reading than they realize.”
1. Dorsey BF, Kamimura A, Cook LJ, et al. Communication gaps between providers and caregivers of patients in a pediatric emergency department. J Patient Exp 2022 Jul 6;9:23743735221112223. doi: 10.1177/23743735221112223. eCollection 2022.
2. Bloch SA, Bloch AJ. Using video discharge instructions as an adjunct to standard written instructions improved caregivers’ understanding of their child’s emergency department visit, plan, and follow-up: A randomized controlled trial. Pediatr Emerg Care 2013;29:699-704.
3. Hoek AE, Anker SCP, van Beeck EF, et al. Patient discharge instructions in the emergency department and their effects on comprehension and recall of discharge instructions: A systematic review and meta-analysis. Ann Emerg Med 2020;75:435-444.
4. Slater BA, Huang Y, Dalawari P. The impact of teach-back method on retention of key domains of emergency department discharge instructions. J Emerg Med 2017;53:e59-e65.
There is an opportunity to make the ED a place where people feel heard and like they received what they needed, which is especially important because the ED is a crucial point of contact for some historically underserved populations.
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