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Improving the ED Discharge Process

                                                                                                      

 Mayowa Ijagbemi                        Julius Cuong Pham

Mayowa Ijagbemi, MPH
Sr. Research Program Coordinator
Johns Hopkins University School of Medicine
Armstrong Institute for Patient Safety
and Quality

 

Julius Cuong Pham, MD PhD
Department of Emergency Medicine
Department of Anesthesia and Critical Care Medicine
Armstrong Institute for Patient Safety and Quality
Johns Hopkins University School of Medicine

 

Implementing exceptional discharge processes in the emergency department (ED) is integral in ensuring patient safety and quality in the ED.  It is also important in the continuing efforts to reduce unnecessary return visits by patients in the ED.

On January 15, 2013 during the QIPS All-Section call, Dr. Julius Cuong Pham, an emergency physician and associate professor at the Johns Hopkins University School of Medicine, shared a conceptual framework for improving the ED discharge process.  The three core components of this framework (based on an environmental scan and ongoing research by Dr. Pham and a multidisciplinary team at Johns Hopkins University) include: educating and communicating with patients; supporting post-ED discharge care; and coordinating care with other providers and services (see Figure 1).

During the call, about 40 emergency physicians across the country shared current thinking, methods, and best practices that emergency departments are using to ensure that patients – especially those most at risk of returning to the ED – receive everything that they need upon and after an ED discharge.  With the variety of ED settings, patient populations, and resources that exist, best practices surrounding the ED discharge process are seemingly infinite. 

The environmental scan outlines interventions that have been evaluated to improve the ED discharge process (see Table 3).  These can be divided into some broad categories: 1) discharge education/simplification, 2) telephone follow-up, 3) ED-made appointments, 4) Prescription assistance, 5) Transportation assistance, 6) Care coordination, 7) Discharge planning, 8) Risk screening & care coordination, 9) Housing assistance, and 10) Behavioral/Psychiatric interventions.  In general, efforts at aimed discharge instruction education/simplification, telephone follow-up, and ED-made appointments were successful.  Efforts at care coordination had mixed results; some bundle of interventions resulted in decreased ED utilization, while others resulted in a decrease in utilization.  Specifically, care coordination that was coupled with a risk screening process tended to be more successful than efforts aimed at a more general population.

Based on feedback during the QIPs call, follow-up contact (via either phone calls or text messages) and case management appear to be the most effective ED discharge processes or interventions.  These interventions appear to be most beneficial to patients experiencing certain medical factors (e.g. substance dependence, psychiatric illness, physical and cognitive impairment, specific medical presentations) and psychosocial factors (e.g. homelessness, being uninsured/underinsured, having low income, no primary care, poor health literacy or comprehension) (see Table 2).

Responding through an informal poll during the call, most physicians said that they screen for high-risk discharges in their EDs (89.5%).  For the most part (84.2%), patients in these EDs do not receive follow-up phone calls after being discharged.  Additionally, most on the call (80.0%) do not belong to EDs that have 24-hour social work or case management coverage.  Case managers in these EDs do not have a nursing or nurse practitioner background (88.9%).

Through investigations and the application of ED clinicians’ experiences, Dr. Pham and colleagues plan to develop a universal ---tool aimed to improve the ED discharge process.

 Figure 1. Map of barriers that hinder ED discharge

 MAp of Barriers

 

 

 

 

Table 1.  Broad Functions of ED Discharge Process

Communicate with/Educate Patients Support Post-ED Discharge Care Coordinate Care with other Providers and Services
Communicate with patients what occurred during the ED visit (treatments, tests, procedures) Ensure patients appropriately take new medications Share records with Primary Care Physician(PCP)/Specialists 
Educate patient on diagnosis Ensure patients stop/avoid taking certainmedications (depending on condition)  Communicate further plans with PCP/Specialists
Educate patient on treatment plan

Ensure patients are capable and able to care for wounds  Make appointment with PCP/Specialists
Communicate with patients about reconciled medication listed Ensure patients understand and comply with dietary restrictions  Facilitate admission to substance abuse recovery facilities
Educate patient on expected course of illness Ensure patients are able to receive the appropriate physical therapy (depending on condition) Facilitate public housing services 
Educate patient signs/symptoms to look out for Employment of medical devices (crutches, walker, neck brace, inhalers, glucometers)  
  Facilitate activity restrictions   
  Facilitate further diagnostic testing  
  Facilitate further healthcare provider evaluation and tx  

 

 



 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 2: Risk factors for ED “discharge failure”

Social Factors Medical Factors
Homelessness Substance dependence
Uninsured/underinsured Psychiatric illness
Low income Inability for self-care
Lack of primary care Cognitive impairment
Poor comprehension/health literacy Advancing/young age
Race/ethnicity Specific medical presentations

  

Table 3: Interventions to improve ED discharge

Interventions
ED discharge instructions/education
Appointment assistance
Medication assistance
Transportation assistance
Case management/care coordination
Telephone follow-up

 

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