Discharge Strategies

Author: Adaira Landry MD (@AllaroundDoc – Ultrasound Fellow, Dept of EM, Brigham & Women’s Hospital) // Edited by: Alex Koyfman MD (@EMHighAK) and Stephen Alerhand MD (@SAlerhand)

As a newly minted attending, I recognize my slight level of anxiety when discharging patients (I don’t suspect being alone here). During the end of my residency, I mustered up a basic approach to discharging patients. This was a protective strategy for my patients and, admittedly, a mechanism to help decrease any risk of post-shift insomnia. I felt inspired by Bouncebacks! Emergency Department cases: ED Returns by Michael Weinstock and Ryan Longstreth. This was truly the book that opened my eyes to how I approach patient care, especially at the time of discharge. It is a good resource for both new and seasoned physicians.

Surely, no algorithm is unerring, but this basic technique supplies skills and experiences that may help me as an attending. As of now (and granted this is a wavering target), these are my top 5 things I do prior to discharging a patient:

1. Shake my patient’s hand: There’s no better feeling than stopping over to say goodbye to a patient who is dressed, energized, and fully ready to leave with a clear understanding of medical decision making, return precautions, and follow-up plans. These patients appreciate your company and you, as the provider, get the sense of relief that you have a satisfied patient leaving your team. However, I’ve often noticed that even after the resident and nurse have given a clear discharge summary, the patient (or family members) will still miss a crucial portion of information that was just force-fed to them. They’ll want to clarify, “So I can take 4 Percocet if the pain isn’t improved with 1 tab?” Or one might ask, “I should come back to the Emergency Department tomorrow to see my primary care doctor?” It’s so easy for instructions to get jumbled after they digest lab and imaging results, instructions for prescriptions, and action plans after discharge. Our baseline should be to assume that the patient has questions at discharge, and our role is to mitigate confusion. To help, I just start the conversation with “do you have any questions about what happened here today or what you need to do when you get home?” There are always some remaining questions.

2. Trust your instincts: I won’t claim to be very creative. This is something that you’ve heard before…but it’s worth mentioning again: If I walk past a patient and my gut tells me “this person is going to bounce-back” or “maybe that patient does have a PE”, I re-address my plan (usually with the resident/PA, nurse, or patient). Instincts are like the shadow of clinical competence. They show up unannounced, don’t necessarily make sense, and make you doubt yourself to an uncomfortable degree. That being said, our instincts are there for a reason, to prevent us from being cavalier and to remind us that we are obligated to protect our patient in the emergency room as well as AFTER they are discharged. Our responsibility doesn’t end when the patient leaves those department doors.

3. Read over the chart: So often I see notes in triage that read “Patient has chest pain x 2 days” but the resident’s presentation doesn’t mention this or the patient doesn’t bring it up. You can find your own strategy to chisel out the time to do this, but I’ve taken the approach of skimming the triage summary, vitals, and last 2-3 notes (or discharge summaries) prior to speaking to the patient. It makes the conversation easier, and the patient appreciates someone knowing his or her history. I also double-check reads on imaging/labs and repeat vitals, since the worst feeling is to discharge a patient with a documented HR of 120 or a incidental nodule on chest-xray that you never told the patient about. (FYI all my patients with incidental findings on imaging or labs get a handout of the report, clear instructions written on their discharge papers to follow up with their PMD to prevent disease, disability or death, and I document the conversation in the chart).

4. Examine your patient (twice is better than once): At this stage, I do my own physical exam based on the complaint. It’s not that I don’t trust a resident, medical student, or physician assistant’s exam. I do a detailed exam because I was a resident 2 months ago and know I often forgot to walk the patient, check visual acuity, and make sure the patient’s back had no decubitus ulcers. I also am a big fan of a repeat physical exam, vitals, and further probing of history (with appropriate associated documentation as well). It’s amazing how the picture of our patients can be clarified with each reassessment.

5. Check to see that my patient can eat, talk, walk, poop, and pee. This is an abbreviated list that sums up the idea that I’d like my patients to do the things necessary for life that they were previously able to do. To be honest, not all of the patients who can’t eat, talk, walk, poop, or pee need to be admitted. For instance, the BPH patient can sometimes go home with a leg bag and outpatient urology follow-up. Or, the patient with constipation can sometimes leave if he or she prefers to take an enema at home. However, all of these patients, with perhaps even a clear diagnosis, still make me think twice before immediate discharge.