Christy Bowen; Bridget Carey; Jessica Palozie; Maren Reinholdt

Learning Objectives

By the end of this section, you will be able to:

Describe the framework for optimal discharge planning from the emergency department
Discuss components for effective patient education and hand-off communication for discharge planning
Identify care coordination of the services needed by the patient being discharged from the emergency department

According to the Centers for Disease Control and Prevention, a survey across the United States revealed that more than 35 million people are discharged yearly from emergency departments. Emergency department nurses can discharge or transfer several patients a day. With nurses delivering the majority of discharge instructions and educating patients and families, it is imperative that they communicate effectively and provide comprehensive teaching. To avoid long wait times and diversions, health-care organizations must implement strategies to improve patient transfer and develop effective handoff communication (Institute for Health Improvement, 2023). Nurses should abide by a framework, understand the components for effective patient education, and identify any areas of need with respect to care coordination.

Framework for Discharge from the Emergency Department

One of the measures implemented by the Centers for Medicare & Medicaid Services is to track 30-day hospital readmission rates. Some patients return to the ED due to a lack of adherence or a lack of available resources after discharge. Following an optimal framework for discharge planning can potentially help reduce hospital readmission rates. Discharge planning should begin upon initial assessment, where the nurse utilizes screening tools that apply to the patient. For example, some patients may need to be screened for fall risk before discharge. Regardless of the patient’s time in the hospital, coordination of care should begin after initial assessment and should be an ongoing process. Nurses and health-care providers must continuously assess patient discharge readiness, available resources, and follow-up appointments. Post-discharge follow-up calls by the nurse are an integral part of the discharge framework as well (Yam et al., 2012).

Reducing Transfer Time

By implementing effective strategies, nurses and health-care team members can also work to reduce the transfer times to other departments within the same health-care system. Strategies should be implemented on a daily basis and across the facility to maximize patient flow. A few suggestions for reducing transfer time include the following:

Evaluation of patient flow processes, from the moment of entry at the front desk, through registration, and into discharge.
Properly triage patients according to the acuity assigned to them upon arrival to ED. The term acuity represents how the health-care team determines the severity of a patient’s status (Managed Healthcare Executive, 2020).
Admission decisions should be identified in a timely manner to allow for quicker placement into the appropriate unit.

Nursing Responsibilities for Transfer from ED

Under the Emergency Medical Treatment and Labor Act (EMTLA), patients must be stable prior to being transferred to any other unit or health-care facility. In an emergency, the health-care team must work diligently to stabilize the patient prior to any transfer. When initializing and stabilizing the patient, nurses should follow the ABCDE triage assessment method. Prior to transfer, the nurse should confirm that all vital signs are stable, and all provider orders have been implemented. This includes administering any medication, starting continuous IV infusions, and emergent diagnostic testing. When completing patient transfers, the nurse must communicate any outstanding orders or patient care concerns to the nurse taking over the patient’s care.

Effective Communication between Departments

The gold standard for reporting hand-off is using the SBAR method (Dalky et.al., 2020). SBAR stands for Situation, Background, Assessment, and Recommendations. When the SBAR communication handoff tool is implemented, nurses communicate using a standard set of objectives related to the patient’s condition. When reconsidering information about the situation, the nurse first details the patient’s current medical condition or identified problem. Next, the nurse discusses background information relevant to the situation. This includes information about any comorbidities, past surgeries, or treatments for the same condition. The nurse then reports any related or significant assessment findings about the patient. For example, the nurse may recognize cues, such as bilateral coarse breath sounds, for the patient who is being admitted to the intensive care unit for pneumonia. Lastly, the nurse provides any recommendations for care, such as future interventions, testing, or care coordination needed (Shahid and Thomas, 2018). SBAR communication will look different at each point in the patient’s transfer process. For instance, if the nurse is communicating with the MRI technician, the SBAR report will include more information about the provider’s orders and the problem that was identified. If the nurse is transferring the patient to another inpatient unit within the same facility, however, the SBAR report will be more comprehensive, including items, such as past medical history, drains, lines, and other information.

Link to Learning

Johns Hopkins Medicine provides a great SBAR tool with examples nurses can use when communicating amongst health-care team members.

Patient Education and Communication

When discharging a patient, nurses should provide education to patients and their families. Health-care education can be difficult to comprehend at times. Nurses need to ensure discharge information is conveyed in a clear, concise, easily understood format, keeping in mind the patient’s preferred language and educational level. The nurse should use an interpreter for patients who do not speak the same native language. Nurses should review information, such as diagnoses, completed and pending diagnostics tests, referrals, medications with timing of future dosages, and the dates and times for follow-up appointments. If the patient has a new diagnosis, the nurse should print out and review any information relevant to the new condition. Additionally, the nurse should review any new medications, along with potential side effects, dosages, timing, and compliance. Signs and symptoms of a worsening condition and when to return to the emergency department should be reviewed as well. If possible, ensure that follow-up appointments or additional diagnostic tests are scheduled prior to discharge. Moreover, if a patient has received sedation, aftercare activities are reviewed with a companion to safely discharge the patient.

Care Coordination with Providers and Services

Care coordination is a vital component of patient care in any setting but can be especially important (and challenging) in fast-paced acute care settings. Effective coordination starts as soon as the patient arrives and continues with the end goal of ensuring the patient experiences a seamless transition through different phases of care and is, ultimately, able to leave the facility safely.

Care coordination should begin as soon as possible to ensure a seamless discharge, whether the patient is going home or to another facility. Assessment of readiness is a team effort by all providers involved in a patient’s care, making communication of the utmost importance. This exchange of information should be efficient and accurate and may take the form of shared notes in an electronic record, phone consultations, or other means of communication. Nurses and providers will verify patient readiness and decide whether additional care at another facility, such as long-term care or rehabilitation, is needed or if the patient can be discharged home.

Coordinating with providers who will be receiving the patient at another facility or those in the community who will be supporting the patient when they are recovering at home is critical to ensuring the best possible outcomes and preventing any important information for follow-up from “falling through the cracks.”

Before a patient leaves, education about what will happen next needs to be provided and the nurse must confirm that the patient understands and feels ready for the next step. It is also key to assess the patient’s support system and ensure that they will have the resources they need upon discharge. The nurse will document these steps in the patient’s discharge plan and ensure that they have a clear path forward once they leave the facility.