Playing it safe with patient discharge

Being discharged from hospital is generally an experience that patients and their doctors look forward to, but it’s not without risk. This is particularly so for patients discharged from the emergency department (ED) where the interaction has frequently been brief; the investigations limited; and the certainty around the diagnosis may be unclear.

Research suggests that fewer than 50 per cent of patients discharged from the ED with non-specific complaints will have a correct diagnosis at discharge.

Patients generally have faith in the diagnosis made in a hospital setting, and in the care provided. And doctors, particularly junior doctors, often feel compelled to come to a definite diagnosis prior to sending a patient home. Wanting to be right and wanting to do something are inherent traits in most doctors. It fits in with our high-achieving personalities and the desire to help. That’s why many of us studied medicine.

Having the confidence and maturity to acknowledge uncertainty is an important component of practising good medicine. When a patient is determined to be well enough to be discharged home but uncertainty remains about the diagnosis, it’s much safer if both the patient and the ongoing healthcare providers are aware of it. This makes it much more likely that the patient will seek review if their condition changes or doesn’t improve as expected. It also gives the outpatient healthcare provider (usually the GP) an awareness that further investigation, treatment or referral might be necessary.

Reducing the risks

Some simple steps can reduce the risk of serious misadventure after a patient leaves hospital, either from the ED or following an in-patient stay.

• Step 1: Follow-up

Make sure the patient knows with whom they should follow up, when they should follow up, and the purpose of the follow-up.

• Step 2: Explain the condition and the treatment

Whether there is diagnostic certainty or not, make sure the patient understands what you think is wrong with them and how certain you are about this. In my practice, if I’m unsure about the diagnosis, I tell the patient that I’m not exactly sure about the cause of their symptoms, but I’m reasonably confident that all acute sinister causes have been excluded – but this means they do need to be alert for any change in their condition and seek review if necessary.

Make sure they understand any medications they have been prescribed including dosage, frequency, and possible side effects.

• Step 3: Explain what you expect will happen

Again, this somewhat depends on your diagnostic certainty, but you should be able to provide a reasonable estimate of how their condition will progress. For instance, if you’ve diagnosed a community-acquired pneumonia and you’re discharging them on oral antibiotics, they should understand that it will be a few days before their symptoms improve significantly, but they shouldn’t get any worse.

• Step 4: Tell them when to come back or get reviewed

This is probably the most important part of safe discharge planning. Give the patient both general and specific symptoms they should watch out for, and which of these should lead them back for further medical review. For instance, in the case of the pneumonia patient, general advice would include “come back if you feel too systemically unwell to manage at home due to poor oral intake, fatigue or pain”. But specifically, “come back immediately if your shortness of breath worsens, you have persistent vomiting, or you feel confused”.

• Step 5: Write it all down

Even with the best medical care and best discharge planning, things will sometimes go wrong. Your best defence is to document ALL of the above and to also provide the patient with written discharge advice. Make sure the GP (or appropriate ongoing provider) receives a copy of the discharge information.

Finally, keep the door open for the patient to come back. Regardless of how minimal their complaint may seem and how confident you are that there’s nothing serious going on, always encourage them to seek further review if they have any concerns.

A simple mnemonic to summarise safe discharge planning:

Health literacy – does the patient understand the diagnosis?

Organise follow-up

Medications – make sure the patient understands the timing and dose of new medications, and the important side effects

Expectations – what to do if symptoms get worse or are no better in the expected timeframe.

Reference.

Nemec M, Koller MT, Nickel CH et al. Patients presenting to the emergency department with non-specific complaints. Academic Emergency Medicine 2010;17:284-92.

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