A recent review article co-authored by a team from the University of Toronto, The Hospital for Sick Children (SickKids), and Children’s Hospital in Boston has found that patients and their families often leave the ED with an incomplete understanding of the patient’s diagnosis, at-home care instructions (including medication use), and confusion about follow-up visits. The review, published in the January issue of Annals of Emergency Medicine, points to poor communication between ED staff and patient-families as the primary cause of many of these risks.
Dr. Stephen Porter, Division Head for Paediatric Emergency Medicine at SickKids and associate professor at U of T explained that the article, which looked at over 50 studies of ED care, broke down the issue of communication into four parts: “We looked at papers that discussed problems with content [of discharge information], issues with the delivery of content, comprehension that patients or family members showed as outcomes of the discharge process, and implementation.” Porter added that the review also evaluated existing interventions aimed at improving the discharge process.
According to Porter, most studies demonstrated that patients often left with gaps in information regarding their condition. When it came to the delivery of this information, challenges with regard to communication often had to do with the kind of language used by healthcare professionals.
“Medicine struggles with not putting our words in clear enough language. We found that standard written emergency instructions were almost at an advanced university reading level, even though in the general population, this is not the case,” said Porter. He also pointed out problems with the overuse of medical terminology. “We have to be aware of what words we use, what words we write down, and what people will understand,” he said. Often, even if a patient is able to read the written instructions, the medical vocabulary will be unfamiliar.
Porter explained that in the area of comprehension, one of the most interesting papers came out of Chicago, where researchers had conducted standardized interviews with adult patients immediately after discharge. Patients were asked to review what they had just been told by the ED staff with regard to their diagnosis, the emergency care they had received, post-discharge care, and indications for follow-up. “Over one-third of these patients had a deficit [of knowledge] in at least one area. And, most of them didn’t even realize that they didn’t know.”
This is not uncommon, particularly for patients and families facing other challenges to health-care access, such as language barriers or cultural differences. In an emergency health care setting that often involves first-time visits for patients, it can be difficult to plan ahead to ensure that translators or cultural brokers are always present when necessary.
Through a synthesis of the available literature, Porter and his team have offered a number of recommendations to improve ED discharge communication and clarify instructions to patients and families.
“One of the lessons learned in the review is that there are some relatively simple and easy to implement strategies. For example, standardizing the most common discharge instruction in simple language, and making them available in other languages that may be needed,” said Porter.
“If there is any concern with the patient’s understanding, it is important to use a read-back or feed-back approach, and check in to verify that what we said was understood. Instead of just telling patients what to do, we need to show them and have them show us,” he added.
Simple interventions such as these require little time and effort on the part of ED staff, but produce tangible improvements to patient health outcomes.
The review has opened up areas of further inquiry when it comes to ED care and long-term health status. “In Ontario, people tend to come to the emergency room first, because that’s the most available resource. Often times it’s not acuity that drives them to us, it’s simply a matter of seeking the best option,” said Porter. Efforts to minimize failures of communication and improve patient-family comprehension are certainly central to ensuring good quality emergency room care.
