#CommunicatED 1: Discharge & Safety Netting in ED

SAFETY NETTING-2

#CommunicatED is a series on core communication topics in the ED.

What do we mean by safety netting?

Safety netting is a term used to describe the advice we give to patients or their relatives or carers as we discharge them from the Emergency Department. Since we send the majority of our patients home at the end of their clinical encounter this is something we can anticipate doing quite a lot! The term refers to the specific guidance we give to patients about their condition and particularly how and when to seek further medical help.

How should we approach patients we are sending home?

As knowledgeable healthcare professionals it can be difficult to remember that there was a time when physical symptoms didn’t automatically trigger a differential diagnosis and an interpretation leading to a clinical impression. But I can promise you that time existed! You haven’t always known that the twinge in your right arm isn’t a heart attack. It’s easy to get frustrated with patients when we forget that they don’t have our medical knowledge.

The majority of patients we see in the Emergency Department really don’t want to be there – they would prefer not to have the symptoms that have brought them to the emergency department and they would usually rather not have to come to a crowded, noisy ED to find out exactly what their pain or suffering represents. It can be difficult for us to appreciate this when the waiting room has morphed into a den of wall-to-wall hostility (you know what I mean – that point in the shift when you dread entering the waiting room in full knowledge that every face that doesn’t belong to the person whose name you did call will glare at you in momentary solidarity). I think it’s important that when we find ourselves sliding into that mindset we take a moment to reframe our perspective.  This talk by Iain Beardsell at SMACC Gold is really helpful in that regard.

When we decide that it’s time for these patients to go home we often subconsciously dismiss their symptoms. We have decided that the patient doesn’t have a PE and now we need them to leave. It might be subconscious but you can bet patients pick up on it. Rick and his research team did some fantastic primary research on patients reasons for attending the ED and found that they had four main priorities which can help us to deliver the best possible care. We can look after all our patients better and improve their healthcare experience if we understand their priorities. EPICC is a nice acronym to help us remember the things we should be addressing in ED, from the patient perspective:

EPICC-3

The conversation we have at the time of discharge is vital in addressing all of these points. It is probably the most important part of the consultation and I think it’s something we don’t immediately appreciate when we first start in EM.

How does safety netting come into this?

The other thing we fail to appreciate when we first start in Emergency Medicine is how often we get things wrong. It’s great to watch our new junior doctors developing during their time in ED but we as senior doctors are acutely aware that there is a point, usually around three to four months into the job, where they will reach a peak confidence level. “I get it now!” they say, “this EM thing is easy!”

MAKE NO MISTAKE – THIS IS A FALLACY.

Emergency medicine is NOT EASY.

THIS WILL HAPPEN TO YOU (IT HAPPENED TO ME).

Enjoy it while it lasts because sooner or later something will shatter that illusion and from there on the uncertainty of EM is here to stay (which is really part of the fun of it all).

What should we say?

It’s easy, particularly when you are new to the department, to see the closure of your consultation as the time when you tell the patient there is nothing wrong with them and tell them to go home. Sometimes we ask nursing staff to discharge patients on our behalf – particularly if the patient was waiting for results of investigations which we have reviewed and found to be within normal limits.

Remembering that we know that we make mistakes, I would suggest we should invest a little more time and thought in the closing conversation.

Here’s my structure for a closing conversation, developed over the last 9 years.

Discharge & Safety Netting-2

 

  • Sit down with the patient – this has been shown to increase perception of empathy. No matter how busy the Emergency Department is, it is not okay to hold a consultation in the waiting room.
  • Validate concerns: verbalise your understanding of why the patient came to the ED in the first place.
  • Explain findings and important conditions excluded; this might include reviewing x-rays together or showing the patient their blood results. It helps them to see your processes. Be extremely cautious about saying their condition definitely isn’t something; remember there are confidence intervals and inherent false negatives in all diagnostic processes. It’s useful to have the phrase “for now” in your repertoire – for example, “there’s no signs in your blood tests to suggest this pain represents appendicitis, so I don’t think we need to do anything else for now.”
  • Explain your impression/diagnosis if possible/applicable. Sometimes we can’t explain patients’ symptoms – you must be honest about this. Some patients attend expecting a diagnosis but many simply want reassurance. New docs regularly fall into the trap of wanting to give every patient a diagnosis. It’s OK not to do this. Medicine is complicated!

  • Explain the expected clinical course, what the patient needs to do and why. This is key to preventing unnecessary reattendance. For example, if you see a patient immediately after a simple rear-end shunt with mild neck pain, you can explain that it’s very likely their neck will be more stiff and painful the following morning and that they don’t need to return to the ED if this happens. Explain that the muscle spasms will ease more quickly with regular movement but that movement will be painful, so painkillers (while not directly treating the underlying condition) are important in helping them to get back to normal as soon as possible. Reassure the patient that symptoms will gradually improve over the next 7 days and in a week they should be back to normal. This structure is similar to advice I give for ankle sprains, gastroenteritis… If the patient needs to follow up with their GP, tell them so and tell them how soon (and what you would like the GP to do). This will prevent the patient from feeling they need to return if they can’t see their GP the next day.
  • Highlight red flags which would necessitate ED reattendance. This is what most people would consider to be safety netting but I would argue this is only a small part of it. 
  • Close with reassurance that it’s ok to return if concerned. I have a standard script I use for this part, especially for parents bringing their children to the ED. We know that it’s difficult when she’s ill and we know that things can change, quickly, so if you are concerned at any point – even if you just get to the car park and think “she’s not right”, just come back – we won’t tell you off! We would rather see you and reassure you that everything is ok than have you at home worrying.”

What should we do?

Reinforce verbal information with written information. We know that patients do not understand everything we say in the ED, let alone remember it all. Written advice can reduce confusion about when to return and provides additional reassurance.

unnamed-20Document in the notes that you have provided advice. I do this in a standard way.  Even though it doesn’t seem to mean much, I know that if I document as in the pic on the left then I have provided condition-specific advice on what to expect in both written (w) and verbal (v) format and advised the patient on when to return.

Include a note to the GP on discharge paperwork. We use a computerised patient management system in our ED and it’s easy to let the nursing staff “take patients off the screen”; however the programme also automatically generates GP notifications of attendance and these are a great opportunity to improve communication with our colleagues in the community as well as explaining any advice you have given the patient. This is particularly important if you’ve asked the patient to follow up with their GP; ED discharge paperwork can be frustratingly sparse in detail and if the patient can’t accurately articulate the reasons behind the need for review the GP is as lost as we are when patients come to the ED “because the GP said my bloods were abnormal.” Use the space provided to communicate directly with the GP. There will be a space to do this. Honestly.

Stop thinking of reattendance as failure. Patients do get worse and need to return. This is an important lesson to learn in the ED and it’s the reason we can sleep at night. When I first worked in an ED I had a week of terrible dreams about patients I’d discharged coming back horribly ill. Then a patient came back because something I’d warned them about had happened – and I stopped worrying. They didn’t blame me or shout at me for getting things wrong because I’d said it might happen and asked them to come back if it did. Good quality safety netting means you can sleep better 🙂

 

Are there any special things we need to think about?

Many of our patients come to the ED from community care settings. If patients are usually cared for by someone, it’s helpful to have a conversation with that person too, whether that’s a nursing home or a relative (with the patient’s consent of course). A phonecall will be appreciated as well as allowing you to assess the safety of the discharge itself. Document that conversation too.

Consider community support – we are fortunate enough to have children’s community nurses who can provide follow up and review in the community. Knowing that someone is coming to offer a review can alleviate concerns.

When you are sending home a patient with a head injury to the care of a responsible adult, you need to give the safety netting explanations to that adult as well as to the patient. Do not rely on your head injured patient being able to recall information accurately enough to pass it on.

References & Further Reading

Breaking Bad News – how sitting versus standing affects perceptions of empathy http://pmj.sagepub.com/content/21/6/501.short

Safety netting in the GP setting (lots of transferable advice and guidance here) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2765844/

Cochrane on verbal versus written advice at hospital discharge http://www.ub.edu/farmaciaclinica/projectes/webquest/WQ1/docs/johnson.pdf

 

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10 Comments

  1. Simon Carley

    Excellent Work Nat. These tips are really helpful and essential reading for everyone in EM (young and old).

    Question for you – how do we teach, monitor and feedback on colleagues who do this well (and not so well).

    vb

    S

    Reply
  2. Zaf Qasim

    Great tips Nat! Appropriate and adequate communication is key in ensuring our patients get the best care. A couple of additional thoughts:

    Important to remember our patients for whom English is not their primary language (or the country-appropriate equivalent for our colleagues abroad of course) – the use of professional interpreters can be invaluable if available not only in the initial consultation but also to ensure adequate comprehension of the information we give them and improve the safety of discharge – in particular when explaining the reasons to seek medical attention again. In contrast to your example of the patient with a head injury, in this case relying on “helpful” relatives to translate can backfire. This also goes for the written advice we provide – tricky if it is only available in one language, though individual departments may have the ability to provide discharge instructions in more than one language.

    Also, just another paper which shows how patients love it when their doctor sits down with them (even if the actual time spent with the patient is no different than when standing): http://1.usa.gov/1zll71Q

    Thanks again for a great post!

    Zaf

    Reply
    1. Natalie May (Post author)

      Thanks Zaf – I have a separate post later in the #CommunicatED series all about using translators!

      Reply
  3. Dave Laithwaite

    A nice structured approach for an inportant topic – thanks.

    I just wanted to check that you’d include an assessment of understanding with regard to the advice you’ve given in your closing conversation. I find chunking the advice (which would fit very nicely in the structure you’ve provided) then checking understanding helpful when I want to be certain that my patient or their relative/carers have grasped what I’m trying to communicate.

    Reply
  4. Lakshay

    Great Post..I used to have similar nightmares like “leaving a Pulmonary Embolism unattended!!”

    Regarding “how to teach this”, I think simulation sessions with the residents is a good way to start, where residents act as patients and FEEL what difference this kind of communication makes OR for the first few times, the residents can just be around and observe how we communicate.

    Reply
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