Patients leave ED thinking they know what happened
Study suggests EDs do more
Every year, more than 115 million patients enter hospital emergency rooms (ER) in the United States. And many of them – as many as 75% leave the ER not really clear about what happened and what they should do next, a University of Michigan study reveals.1
The researchers involved say their results suggest that ER teams need to do a better job of making sure patients go home with clear information and instructions, and that patients and family shouldn't leave until they fully comprehend their situation.
The researchers interviewed 140 English-speaking patients who visited one of two ERs and were discharged home. They compared those interviews with the patients' medical records, and found a serious mismatch between what doctors and nurses found or advised, and what patients comprehended.
And 80% of the time, patients were fairly confident about what they "knew" even if what they "knew" was incorrect. In other words, patients leave clinical encounters confident that they know what happened and why, but with little reason on which to base that confidence.
"It is critical that emergency patients understand their diagnosis, their care, and perhaps most important, their discharge instructions," says lead author Kirsten Engel, MD, a former University of Michigan emergency medicine fellow and Robert Wood Johnson Clinical Scholar who is now at Northwestern University.
Engel says she finds it disturbing that not only did patients not understand their post-ER care instructions, but that they didn't recognize where the gaps in understanding were.
"Patients who fail to follow discharge instructions may have a greater likelihood of complications after leaving the emergency department," she comments.
Patients', doctors' idea of care doesn't mesh
The researchers measured the extent to which patients' reports agreed with their doctors' records in four areas: diagnosis, emergency care that was given, post-ED care needs, and what kinds of symptoms or signs would require a return visit to the ED for immediate care.
Only 22% of patients' reports aligned with what their care teams reported on all four counts. Fifty-eight percent of patients understood at least two of the four areas, but 20% were off on three or four areas of their care and follow-up needs.
After asking patients about their diagnosis, care, and post-ER instructions, the team also asked them if they were not sure about any of the four areas. Interestingly, patients whose understanding perfectly matched their doctors' records were just as likely to report being unsure as patients whose understanding was lacking.
The researchers suggest doctors or nurses need to not only ask patients if they have questions, but ask them to explain, in their own words, what they think is wrong with their health and what they can do about it.
Not surprisingly, the biggest area of misunderstanding or lack of comprehension was post-emergency care that is, what steps the patient needs to take to be seen by their regular doctor or a specialist; how soon to seek follow-up; and what medicines or self-care steps they need to take, how to take them, and when. (Patients were given a brief cognition test before being interviewed, to make sure their thinking and understanding abilities were normal. In some cases, caretakers were also interviewed.)
Engel and her colleagues found that 34% of the deficiencies in patient comprehension reflected a less-than-complete understanding of what their ED team recommended they do after they left the hospital. Meanwhile, 22% of the deficiencies in the study had to do with patients' understanding of what symptoms or changes in their condition should spur them to return to the ED.
Health system reacts to boost understanding
In response to the frequency with which patients left the ED with a misunderstanding of what happened and what comes next, the University of Michigan Health System has launched the Emergency Medicine Consult/Referral Service.
The service is staffed by referral coordinators who follow up with ED patients by phone within 24 hours of their ED visit, to help schedule appointments with physicians for specialty care at the medical center if the patients' insurance allows it or make sure they know that they need to schedule an appointment elsewhere.
More than 12,000 follow-up appointments have been scheduled for recent medical center ED patients since the program began in February 2007, and 81% of those patients have arrived for their scheduled follow-ups, up from 59% before the program began, and fewer appointments are being cancelled.
Reference
1. Engel KG, Heisler M, Smith DS, et al. Patient comprehension of emergency department care and instructions: Are patients aware of when they do not understand? Ann Emerg Med 2008; online ahead of print. Available online at www.annemergmed.com.
Every year, more than 115 million patients enter hospital emergency rooms (ER) in the United States. And many of them – as many as 75% leave the ER not really clear about what happened and what they should do next, a University of Michigan study reveals.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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