الفهرس 
ACKNOWLEDGMENT
Effective Discharge Communication in the Emergency DepartmentOnly 14 pages are availabe for public view
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Abstract
Poor communication and thus poor handover can lead to significant incidents and potential for patient harm. Discharge summaries are integral to bridging the gap between secondary to primary care and ensuring safe transfer of information. General Practitioners in the East and North Hertfordshire area have highlighted gaps in the handover of information.
(British Medical Association, London: BMA, 2004) (Till A, Sall H, Wilkinson J, 2014)
The purpose of this study is to outline the Trust policy for the Discharge and Transfer of children and contains the responsibilities, procedures and the documentation required to carry out the process. The policy becomes effective from the date of ratification. To ensure that consideration is given to appropriate and timely discharge or transfer arrangements. Children carers are entitled to expect to be fully involved in the planning of these arrangements including an explanation of the process. The decision to transfer a child or young person is a clinical one but planning should involve children and their families. (Royal cornwall hospitals NHS- DH: Working Together to SafeguardChildren 2013)
Problems with Understanding of ED Discharge Instructions Content: There are limited data examining the content of verbal discharge instructions in the ED. A recent study by Vashi and Rhodes examined recorded tapes of clinical encounters, which were assessed by independent coders and compared with a predefined standard. They found that although 76% of patients received an explanation of their symptoms, only 34%of patients
received instructions about symptoms that should cause them to return to the ED (1)
Delivery: Even the most complete instructions will result in deficient comprehension unless they are presented in a way that is understandable to the learner. However, written ED discharge instructions are often at an inappropriately high reading level, and marked differences in comprehension have been reported, depending on level of educational attainment (Makaryus AN,Friedman EA, 2009)
Comprehension: Patients leaving the ED are frequently unable to recall important elements of the ED visit and discharge plan. One small study examining elderly patients ’comprehension of discharge instructions found that 21% did not understand their diagnosis and 56% did not understand their return instructions, although these were not significantly associated with adverse events. (Clarke C, Friedman SM,Shi K, et al, 2005) Implementation: Studies have shown that between 12% and 22% of patients have failed to fill their prescription when called after discharge from the ED. Dissatisfaction with discharge instructions was associated with not filling theprescription. In pediatrics, dosing directions and medication devices are often confusing and highly variable.(Thomas Ej,Burstin HR, ONeil AC et al, 2009)
Interventions to Improve Understanding of Discharge Instructions:
Successful communication of discharge information is critical because comprehension deficits can result in safety risks for patients after discharge. Theoretic risks include inappropriate home care, including incorrect medication use, and failure to return for concerning symptoms or follow-up as directed. Ideally, the provider conducting the discharge communication would
have a variety of approaches available to tailor the conversation to different parental and environmental circumstances . (wasstenpw,mckinstry b, 2009)
Content: A successful discharge instruction process should contain all of the relevant information in a format that is understandable to patients. To ensure communication of key content, standardized organization of discharge instructions has been attempted in the inpatient setting, using computerized prompts39 or checklists. One cardiology study of hospitalized patients demonstrated a significant mortality decrease inpatients given guideline-based instructions on discharge successfully improve comprehension in this group. (Johnson A, SandfordJ, Tyndall J, 2003)
Delivery: Written materials provided at discharge have been associated with improved recall of information in most but not all reports. Differences are potentially explicable by the various rates of literacy and use of the written information, as well as the contents of the written instructions. Diagnosis specific instructions improve understanding, recall, and compliance with treatment recommendations but may not decrease the number of unnecessary repeated visits to the pediatric ED (Johnson A, SandfordJ, Tyndall J, 2003) Comprehension: No trials of ED-based processes to formally check for comprehension have been reported in the literature, tour knowledge. A small study of the informed consent process found that having patients repeat the key points to the provider until able to do so correctly was associated with increased recall of the information. A ―read-back, teach-back‖ communication strategy in which the provider assesses patient recall and comprehension and need for clarification after each concept has been associated with improved outcomes in the primary care and surgical literature (Jolly BT, Scott JL, Sandford SM, 2OO4)
Implementation
In the ED, parental assistance with medication delivery and pictograms have also been associated with decreased medication dosing errors and improved medication adherence.. Appropriate primary care follow-up is a key element of post-ED care and is frequently recommended as part of the discharge communication. Both the pediatric and adult literature contains reports of very low rates of follow-up. A variety of interventions to improve follow-up have been attempted, with limited results..(Zeng-Treitter Q, Kim H, Hunter M ,2008)
(MPhil, Anne M.Stack, MD, 2oo9).
Guidelines for the patient requiring intermediate care
I. Respiratory Diseases
- Patients with moderate pulmonary or airway disease requiring multidisciplinary intervention and frequent monitoring, including but not limited to the following, may be admitted:
- Patients with the potential need for endotracheal intubation
II. Cardiovascular Diseases
- Patients with moderate cardiovascular disease requiring multidisciplinary intervention and frequent monitoring, including but not limited to the following, may be admitted:
- Patients with non–life-threatening dysrhythmias with or without the need for cardio version.
- Patients with non–life-threatening cardiac disease requiring low-dose intravenous inotropic or vasodilator therapy.
III. Neurologic Diseases
- Patients with non–life-threatening neurologic disease requiring multidisciplinary intervention, frequent monitoring, and neurologic assessment not more than every 2 hours, including but not limited to the following, may be admitted:
- Patients with seizures who are responsive to therapy but require continuous cardiorespiratory monitoring and who do not have hemodynamic compromise but have the potential for respiratory compromise.
IV. Hematologic/Oncologic Diseases
- Patients with potentially unstable hematologic or oncologic disease or non– life-threatening bleeding requiring multidisciplinary intervention and frequent monitoring, including but not limited to the following, may be admitted:
- Patients with severe anemia without hemodynamic or respiratory compromise.
- Patients with moderate complications of sickle cell crisis, such as respiratory distress, without acute chest syndrome.
VI. Gastrointestinal Diseases
- Patients with potentially unstable gastrointestinal disease requiring multidisciplinary intervention and frequent monitoring, including but not limited to the following, may be admitted:
- Patients with acute gastrointestinal bleeding but who do not have hemodynamic or respiratory instability.
- Patients with a gastrointestinal foreign body or other gastrointestinal problem
- Requiring emergency endoscopy but who do not have cardiorespiratory compromise.
(David G. Jamovich, MD American academy of pediatric, 2004)
Effective communication between the physician and patient is required for optimum post-emergency department management. Written emergency department discharge instructions, when used to complement verbal instructions, have been shown to improve communication and patient management. This review examines the purpose, advantages, and disadvantages of three commonly used types of discharge instruction. The desirable features of discharge instructions are described. (Powers RD, 2000)
Essential elements of written discharge
Instructions
• x Patient name
• x Physician name
• x Purpose of discharge instruction
• x Diagnosis/expected course
• x Potential complications
• x Patient instruction
• General
• Medication
• x Follow up
• Specific time lines
• Documentation of receipt
Guidelines to a Good Discharge Summary
from the perspective of GP, parents and families and the RCH Discharge summaries are invaluable for continuity of care, safe transition between the hospital and community, and improved patient communication and education.
1- Plan for discharge at the time of admission and write as much of the discharge summary as possible at that time. Keep the parents involved in the discharge planning process.
2- Remember the ABC Rule: Accurate / Brief / Complete.
3- Include:
– Weight
– Relevant pathology/ radiology results (include pending results/ who to follow up)
– Medication list (remember pharmacy can provide a list)
– ACTION PLAN: OPD appointments, discharge destination, allied health input
– Appropriate contact name/ number/ pager (consultant/ care manager)
4- Avoid:
– Abbreviations (or define meaning on first use)
5- State EXACTLY what you would like the GP or community Pediatrician to do (follow-up care, further investigations etc). Consider phoning the GP or Pediatrician if the patient’s care has been complex or requires significant follow-up. Always call the GP or Pediatrician for significant events including death and major diagnosis. Calling the GP or Pediatrician of rural patients is especially important as they will often take over a large proportion of patient care.
6- Remember that your summary may be read by the parents / family. Always ensure any potentially sensitive content has been discussed with them first.
7- Send a copy of the discharge summary to the GP, the child’s usual Pediatrician, and other specialists/ allied health who have consulted during the admission. Also consider sending a copy to the doctor who treated the patient in the Emergency Department.
8- REMEMBER: a discharge summary is only as good as it’s TIMELINESS!
Aim to have it ready for discharge, especially for rural/ inter-state patients.
9- REMEMBER: discharge summaries are also used for hospital funding; certain details for coding are important. (Melbourne Children’s Hospital, 2014)