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Barriers to compliance with emergency department discharge instructions: lessons learned from patients’ perspectives

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Abstract

The objective of this study is to understand patients’ perspectives about system-based barriers that may influence decision-making regarding following discharge instructions. In this qualitative study, subjects were interviewed by phone 1–4 weeks following being discharged to home from the emergency department (ED). We used a semi-structured interview guide to ask a series of open-ended questions about subjects’ recent ED visit and subsequent course, including discharge instructions, whether or not they complied with those instructions, and reasoning behind their decisions to follow-up or not. All interviews were recorded and transcribed to identify themes among the transcripts, which were analyzed to identify barriers to compliance. While the majority of those interviewed expressed no specific concerns or challenges, four system-based themes did emerge regarding patient attitudes toward and experiences with discharge instructions. They were: (1) failure to ensure clarity about diagnosis at the time of discharge from the ED, (2) failure to identify patients’ feelings of hopelessness regarding the utility of follow-up, (3) difficulty in scheduling follow-up appointments, and (4) the importance of a clear discharge process. This study finds several system-based barriers might influence compliance. The four identified themes suggest a recurring cycle of visiting the ED, being discharged to primary care or specialists, and ultimately returning to the ED. We propose that systems-based interventions may help to break this cycle.

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Acknowledgements

The authors would like to thank Nancy Campbell, RN, and her research project team for the assistance in the planning and conduction of this study.

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Authors and Affiliations

  1. Department of Emergency Medicine, The Pennsylvania State University College of Medicine, Hershey, PA, USA

    Erica Schenhals & Lawrence Edward Kass

  2. Department of Medicine, The Pennsylvania State University College of Medicine, Hershey, PA, USA

    Paul Haidet & Lawrence Edward Kass

  3. Department of Humanities, The Pennsylvania State University College of Medicine, Hershey, PA, USA

    Paul Haidet

  4. Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA

    Paul Haidet

  5. The Woodward Center for Excellence in Health Sciences Education, The Pennsylvania State University College of Medicine, Hershey, PA, USA

    Paul Haidet

Authors
  1. Erica Schenhals
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  2. Paul Haidet
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  3. Lawrence Edward Kass
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Corresponding author

Correspondence to Lawrence Edward Kass.

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Conflict of interest

The authors have no potential conflicts of interest.

Human and animal rights statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Appendix 1. Semi-structured interview guide

Appendix 1. Semi-structured interview guide

  1. 1.

    I would now like to begin asking you a few questions about your recent visit to the Emergency Department at Penn State Hershey Medical Center on ___(date)___.

  2. 2.

    When you left the emergency department, what was your diagnosis?

    1. a.

      Could you tell me more about your understanding of that diagnosis?

  3. 3.

    Tell me about the physician’s or healthcare staff’s recommendations for when you were discharged.

    1. a.

      Probing questions:

      1. i.

        What (if anything) was difficult to understand and why?

      2. ii.

        What (if anything) was easy to understand and why?

      3. iii.

        What people or things (that you or others did) helped you understand the recommendations?

      4. iv.

        Regardless of whether you agreed or not with the recommendations (we will get to that in a moment), describe how well you felt that you understood the recommendations when you left the ED?

  4. 4.

    Could you tell me about your experience in following those recommendations?

  5. 5.

    Talk about any medications that you were given prescriptions for.

    1. a.

      Probing questions (ask for each prescription).

      1. i.

        What were your thoughts about the prescription?

      2. ii.

        How well did you think it would work? Please explain.

      3. iii.

        What influenced your decision to fill or not fill the prescription?

      4. iv.

        What did you expect that the prescription would do? How well did it meet your expectations?

      5. v.

        What (if any) financial issues were there in getting the prescription?

      6. vi.

        What (if any) financial hardship did paying for the prescription cause?

  6. 6.

    Describe the plan, as you understood it, for following up with a doctor or other health provider after your ED visit.

    1. a.

      Probing Questions.

      1. i.

        What were your thoughts about this follow-up plan? (Probe whether they intended to follow it or not and why).

      2. ii.

        How well were you feeling at the time your follow-up was to occur? How if at all, did this influence your decision to attend the follow-up visit?

      3. iii.

        What (if any) financial issues influenced your decision to follow-up or not follow-up?

      4. iv.

        What (if any) barriers did you encounter to attending your follow-up appointment? (probe transportation, scheduling, etc).

  7. 7.

    We have talked about what the emergency physician thought was going on and what plan they recommended when you were discharged. What did you think was going on?

    1. a.

      How, if at all, was that different from what the doctors were thinking?

    2. b.

      What (if any) effect did that have on your decisions to follow the plan they suggested or not follow it?

    3. c.

      How much input did you feel that you had in making the plan?

    4. d.

      If you could have made up your OWN plan, what would it have been?

    5. e.

      What were you hoping the doctors would do when you decided to go to the ED? Did that happen? (Why or why not?)

  8. 8.

    This concludes the interview. Do you have any questions for me?

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Schenhals, E., Haidet, P. & Kass, L.E. Barriers to compliance with emergency department discharge instructions: lessons learned from patients’ perspectives. Intern Emerg Med 14, 133–138 (2019). https://doi.org/10.1007/s11739-018-1943-6

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  • DOI: https://doi.org/10.1007/s11739-018-1943-6

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