Patients’ Comprehension of Their Emergency Department Encounter: A Pilot Study Using Physician Observers

doi:10.1016/j.annemergmed.2014.08.012

Annals of Emergency Medicine

Volume 65, Issue 2, February 2015, Pages 151-155.e4

https://doi.org/10.1016/j.annemergmed.2014.08.012 Get rights and content

Study objective

The current study examines patients’ comprehension of their emergency department (ED) encounter, using physician observers to document both physician communication and details of the encounter.

Methods

Eighty-nine patients were recruited from a convenience sample in an urban ED. To be included in this study, patients had to have low triage levels (4 and 5) and be discharged from the ED. Physician observers were present throughout the encounter, documenting physician communication and procedures performed. Patients were then interviewed by physician observers about their communication with physicians, accuracy in recalling facts about the encounter, and understanding of information provided during the encounter.

Results

The majority of patients were black and had a high school education. Physicians typically engaged in behaviors related to building rapport and diagnosing patients. However, physicians informed patients about test results and diagnoses less frequently. In terms of patients’ accuracy and understanding of the visit, patients were generally aware of basic facts in regard to their ED encounter (ie, whether they had blood drawn), but 65.9% of patients demonstrated less than “good” understanding in at least 1 area assessed.

Conclusion

The findings of the current study indicate physicians could improve communication with patients, particularly in regard to care received in the ED. This study also indicates that a large percentage of patients fail to understand information about their ED encounter even when physicians provide it. A primary limitation of the current study is the relatively homogenous physician sample.

Introduction

Communication between emergency physicians and patients is one of the most important aspects of patient care, affecting attainment of an adequate medical history,¹ as well as patients’ abilities to understand health-related information, make informed decisions about their health care,2, 3 and pursue follow-up after the emergency department (ED) visit.⁴ Numerous barriers to effective communication in the ED have been identified, including a loud chaotic environment, patients’ symptoms and anxiety, large amounts of information provided to patients and caregivers within a limited period, and time constraints.⁵ Emergency physicians must also build rapport while performing assessments and procedures. Demographic differences (ie, social discordance) such as race, sex, and education may produce cultural barriers between physicians and patients that inhibit communication in medical settings.6, 7 Social discordance leads to lower patient satisfaction and lower positive patient affect,⁷ and can cause patients to believe that their physicians are less participatory during interactions.⁶

Editor’s Capsule Summary

What is already known on this topic

Patients have difficulty understanding the details of their emergency department (ED) visits and desire more information.

What question this study addressed

This study compared patient reports of care processes and test results shortly after their ED visit, with direct observations during the visit.

What this study adds to our knowledge

Patients' recall of basic facts was good, but almost two thirds showed decreased understanding in at least 1 area; 30% showed poor understanding of their diagnosis. Physicians did not speak with patients before discharge in about 30% of cases or tell them their diagnoses in almost 25%, but often understanding was limited even if these details were conveyed.

How this is relevant to clinical practice

These results suggest that physicians could provide more detailed information about the results of ED care, but that providing additional information is only part of the solution.

Communication failure can result in patients being discharged from the ED with an inadequate understanding of their diagnosis, test results, and plan for follow-up. A large proportion of patients do not understand their written ED discharge instructions,2, 8, 9 limiting their ability to reference these documents once they leave the ED. Only 1 study has examined patients’ understanding of the care they received in the ED, including understanding of laboratory results and procedures.³ Engel et al³ had patients rate their understanding of multiple domains (eg, diagnoses, ED care, post-ED care, return instructions) immediately after discharge. Patient recall during the interview was compared with a review of their medical record to determine patients’ understanding. Overall, 78% of patients demonstrated deficiencies in understanding information in at least 1 domain.

One critique of the study by Engel et al³ is the use of retrospective chart review as the objective standard in measuring patient understanding. Previous studies have demonstrated that physicians do not always convey information adequately to patients.¹⁰ Therefore, this study had physician observers present throughout the ED encounter to record information discussed with patients by the treating physician. Physician observers interviewed patients about their understanding of the information immediately after discharge. This in situ documentation of the encounter is believed to provide a more accurate estimation of patients’ understanding. Also, physician observers rated their impressions of patient comprehension before and after the interview to determine whether asking questions might improve physician estimation of patient understanding. It was hypothesized that a large percentage of patients would demonstrate poor understanding of their ED encounter.

Section snippets

Selection of Participants

Participants were recruited from a state-run, urban ED that treats approximately 30,000 patients per year, regardless of ability to pay for care. This was a cross-sectional, convenience sample of patients assigned low acuity triage levels (4 and 5) and discharged from the ED. Patients were approached between 8 am and 6 pm. Exclusion criteria were aged younger than 18 years, non-English speaking, discharged to another facility, inmates, and a chief complaint of mental illness. Patients signed

Results

The majority of patients were black (71%) and women (56%). Age ranged from 18 to 65 years. Of the total sample, 38% of patients did not finish high school and 13% of patients graduated from college. Less than a quarter of the patients had insurance (ie, private, Medicaid, Medicare). Approximately half were unemployed. Patients reported between 0 and 8 (median 2) previous ED visits in the past 12 months.

Of the 89 ED encounters, 54 patients were treated by male physicians, 10 by female

Limitations

Limitations of the current study include a relatively homogenous physician sample that inhibited our ability to examine social concordance and its effect on communication more closely. Also, this study focused on whether patients were able to understand information that was provided to them by physicians. Future studies should further examine communication as shared understanding between patients and the medical staff by examining whether patient engagement during the visit (eg, asking

Discussion

The purpose of the present study was to examine, in a minority population, ED patients’ understanding of their encounter. Documentation of the ED encounter by another physician is a strength of the current study. Studies that rely on retrospective chart review may misinterpret lack of information provided for lack of patient understanding, overestimating percentages of patients who do not comprehend their ED encounters. Findings of the current study suggest that patients are largely aware of

References (11)

J.A. Crane
Patient comprehension of doctor-patient communication on discharge from the emergency department
J Emerg Med
(1997)
K.A. Cameron et al.
Examining emergency department communication through a staff-based participatory research method: identifying barriers and solutions to meaningful change
Ann Emerg Med
(2010)
R.L.J. Thornton et al.
Patient-physician communication and patients’ perceptions of health care quality
Patient Educ Couns
(2011)
M.E. Samuels-Kalow et al.
Effective discharge communication in the emergency department
Ann Emerg Med
(2012)
K.V. Rhodes et al.
Resuscitating the physician-patient relationship: emergency department communication in an academic medical center
Ann Emerg Med
(2004)

There are more references available in the full text version of this article.

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Emergency Department-to-Community Transitions of Care: Best Practices for the Older Adult Population
2023, Clinics in Geriatric Medicine
Quality Improvement: Using Teach-Back to Improve Patient Satisfaction during Discharge in the Emergency Department
2021, Journal of Emergency Nursing
Patients discharged in the emergency department often have poor understanding of their discharge instructions. Teach-back is a communication method that involves asking patients to explain in their own words what a health care provider just told them. The purpose of this project was to determine whether nurse-led teach-back at discharge could improve patient satisfaction with discharge information.
A teach-back method was used to educate patients on what to do if they do not feel better after leaving, using a single site quality improvement design. Patient satisfaction was measured using a standardized benchmark question on whether providers explained what to do if they did not feel better after leaving. The department goal for this question was established as achieving a response of “Yes, definitely” for 64.4% or more of the satisfaction surveys. Patient satisfaction data were collected before and after intervention through a survey given to patients within 24 hours after their visit. A statistical process chart was used to analyze whether the observed improvements coincided with implementation of the teach-back intervention.
Although there was an overall increase in post-intervention scores (61%) from baseline scores (59%), there were no special cause variations signaling that the intervention had a significant impact.
Teach-back may improve patient satisfaction with discharge information. Future implementation with measures of intervention adoption, fidelity, accountability, and sustainability are needed.
Feeling Informed Versus Being Informed: Mixed-Methods Analysis of Family Perceptions and Behavior Following a Pediatric Emergency Department Visit
2021, Journal of Pediatric Nursing
To examine perceptions of family-centered care, satisfaction, and quality of communication with health professionals during a pediatric emergency department visit, and to evaluate the perceived usefulness of the information received and whether provider treatment recommendations were followed after discharge.
Embedded mixed methods design with two concurrent phases. Participants in phase 1 were 385 adult relatives of children (age 6 days-17 years, mean 5.0 years, SD 4.5) seen in a pediatric emergency department. On the day of the visit, relatives completed questionnaires exploring perceptions of family-centered care, satisfaction (CSQ-8), and quality of communication with professionals (ad hoc instrument). For phase 2, we conducted daily structured telephone interviews with 37 of these parents over the six consecutive days following the emergency visit.
Satisfaction with the visit was significantly related to the perception of family-centered care (B = 0.25; 95% CI [0.20, 0.29]; p < .001). Follow-up interviews revealed that 45.9% (n = 17) of families did not follow the prescribed treatment and 32.4% (n = 12) made a further appointment with their primary care pediatrician. Qualitative analysis suggested that families lacked certain information from care providers.
Elements of a family-centered approach were rated positively and families believed that the information they received was useful. Importantly, more than half of the families who were followed up by telephone had doubts about provider treatment recommendations.
Family-centered care in the pediatric emergency department could enhance communication and help to ensure that treatment recommendations are followed at home.
How is test-related information communicated in Australian Emergency Departments? – ED clinicians’ and patients’ perspectives
2021, Patient Education and Counseling
Citation Excerpt :
Previous studies on patient-clinician communication in ED have shown that information giving by clinicians often occurs dispersed throughout the visit [35,36] and summarised as part of discharge instructions [35,37–40]. Studies focused on discharge communication highlighted that information giving at discharge is often limited [25,36,37], and that even if informed, many patients cannot retain relevant information especially as it relates to home care, reason to return to ED, and tests-results [25,38,38,39,40] creating significant patient safety risks. Fewer studies have focused on the communication of test-related information to ED patients.
To investigate the communication processes involving test-related information in Australian Emergency Departments (EDs); specifically what and how ED clinicians communicate test-related information to patients, what patients know and understand about the provided information, and how patients view the potential to access their test-results electronically.
We conducted face-to-face semi-structured interviews with clinicians (n = 26) and patients (n = 32) across three Australian EDs. Interviews were transcribed and analysed iteratively, following principles of qualitative content analysis and grounded theory.
Depending on various contextual (e.g. time pressures) and patient factors (e.g. perceived health literacy), ED clinicians provided, and patients recalled receiving, test-related information along a continuum, ranging from “no or limited” information to “specific” information. Many patients were confused about how to access their test-results. Patients welcomed the potential for future electronic access to results but viewed their individual health and/or computer literacy skills and knowledge as potential barriers.
EDs are highly dynamic environments where contextual forces impinge on the amount and quality of test-related information that clinicians communicate to ED patients.
Systemic and patient factors need to be addressed to optimise the provision of test-related information in ED settings, improve patient understanding and foster patient empowerment.
Deficiencies in Provider-Reported Interpreter Use in a Clinical Trial Comparing Telephonic and Video Interpretation in a Pediatric Emergency Department
2020, Joint Commission Journal on Quality and Patient Safety
Professional interpretation improves health care quality and outcomes for limited English proficient (LEP) patients, yet interpreter use remains low even when interpretation is available remotely. The researchers analyzed the effect of remote interpretation (telephone or video) on pediatric emergency provider attitudes and behaviors around professional interpretation.
A cross-sectional questionnaire of pediatric emergency providers was conducted as part of a randomized trial of telephone vs. video interpretation with Spanish speaking LEP families. Providers recalled lapses of professional interpretation for medical communication (use of an ad hoc or no interpreter), if they had delayed or deferred communication due to the need for professional interpretation, and were asked about their satisfaction with the interpretation modality. Bivariate and multivariate analysis of professional interpreter use and communication behaviors were analyzed by self-report of study group assignment.
One third of providers reported lapses of professional interpretation and many reported less frequent (45.6%) and deferred (34.6%) communication due to the need for interpretation. There was no significant difference in these outcomes between telephone and video assignment. Interpreter skill and technical difficulties were similar between groups. Providers assigned to telephone, compared to video, were more likely to be dissatisfied (p < 0.001) and to report that interpretation was ineffective (p = 0.002).
Despite access to interpretation, providers caring for patients enrolled in a study of professional interpreter modalities reported frequent lapses in professional interpretation and deferring or delaying communication because an interpreter was needed. Addressing barriers to remote interpreter use will improve quality of care and health equity for LEP patients.
Patient Discharge Instructions in the Emergency Department and Their Effects on Comprehension and Recall of Discharge Instructions: A Systematic Review and Meta-analysis
2020, Annals of Emergency Medicine
Citation Excerpt :
In various studies, one or more of the different domains of patient education were investigated. For example, a single-center cross-sectional study demonstrated that 66% of patients had a fair or poor understanding of discharge instructions in at least one domain of discharge instructions.16 Another cross-sectional study found that the most accurate recall was on domain of diagnosis; this was correct for 82% of patients, whereas only 43% of patients could correctly recall discharge instructions in all 4 domains.15
We conduct a systematic review with meta-analysis to provide an overview of the different manners of providing discharge instructions in the emergency department (ED) and to assess their effects on comprehension and recall of the 4 domains of discharge instructions: diagnosis, treatment, follow-up, and return instructions.
We performed a systematic search in the PubMed, EMBASE, Web of Science Google Scholar, and Cochrane databases for studies published before March 15, 2018. A quality assessment of included articles was performed. Pooled proportions of correct recall by manner of providing discharge instructions were calculated.
A total of 1,842 articles were screened, and after selection, 51 articles were included. Of the 51 included studies, 12 used verbal discharge instructions only, 30 used written discharge instructions, and 7 used video. Correct recall of verbal, written, and video discharge instructions ranged from 8% to 94%, 23% to 92%, and 54% to 89%, respectively. Meta-analysis was performed on data of 1,460 patients who received verbal information only, 3,395 patients who received written information, and 459 patients who received video information. Pooled data showed differences in correct recall, with, on average, 47% for patients who received verbal information (95% confidence interval 32.2% to 61.7%), 58% for patients who received written information (95% confidence interval 44.2% to 71.2%), and 67% for patients who received video information (95% confidence interval 57.9% to 75.7%).
Communicating discharge instructions verbally to patients in the ED may not be sufficient. Although overall correct recall was not significantly higher, adding video or written information to discharge instructions showed promising results for ED patients.

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: Please see page 152 for the Editor’s Capsule Summary of this article.

: Supervising editor: Robert L. Wears, MD, PhD

: Author contributions: All authors were responsible for conception and design of the study. JNP supervised the conduct of the trial, and RD, KA, ML, and DL participated in data collection. GNJ provided statistical advice on study design and analyzed the data. MWM and GNJ drafted the article, and all authors contributed substantially to its revision. MWM takes responsibility for the paper as a whole.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

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The practice of emergency medicine/brief research reportPatients’ Comprehension of Their Emergency Department Encounter: A Pilot Study Using Physician Observers

Study objective

Methods

Results

Conclusion

Introduction

Editor’s Capsule Summary

Section snippets

Selection of Participants

Results

Limitations

Discussion

J Emerg Med

Ann Emerg Med

Patient Educ Couns

Ann Emerg Med

Ann Emerg Med

The practice of emergency medicine/brief research report
Patients’ Comprehension of Their Emergency Department Encounter: A Pilot Study Using Physician Observers