Curbing Return Visits to Emergency Dept. Depends on Docs

The main reason patients return to the emergency department is fear and uncertainty about their conditions. The remedy? Teaching future physicians how to talk to patients, says one medical educator.

This article first appeared in the October 2014 issue of HealthLeaders magazine.

Better physician communication and more coordinated patient care in the emergency department could have an impact on hospital readmission rates, a new study suggests.

The results of a five-month study at two Philadelphia area hospitals was published this week in the Annals of Emergency Medicine. It offers insight into why patients return to the emergency department based on information learned directly from patients and gleaned from medical records.

ED use frequently focuses on the socioeconomic, demographic, and clinical data to determine who the frequent fliers are. While these studies are useful, little has been done to assess the patient's perspective, an important component in designing processes that improve care, cost, and satisfaction.

To find out why patients were returning to the ED, the authors interviewed 60 adults who were at least 18 years old and had returned to the ED within nine days of their initial discharge. The study was done over a period of five months, and excluded patients who were supposed to return to the ED for a wound check, or who left against medical advice.

Though the study was open to anyone over the age of 18, the average age of patients who returned was 43 years old, and 65% were women. Slightly more than half the patients (31) had been to the ED once or twice in the previous year, while slightly more than one-third (21) were considered frequent ED users, having been to the ED more than four times the previous year.

Most of the patients who returned to the ED did so within six days of being initially discharged. The discharge process has been closely studied and monitored to streamline issues that can come up and contribute to a readmission.

But most patients (41) said they didn't have a problems with their discharge instructions or process. Instead, patients reported they returned because they were afraid the medical condition that prompted them to visit the ED in the first place was getting worse.

"Well, I came because symptoms have gotten worse, and it was kind of a decision I had to make on my own," one patient told researchers. In addition to the anxiety, the patient's belief that no one else was available to help determine whether returning to the ED was the right decision underscores the problem of fragmented care that exists throughout healthcare.

Increasing Emotional Intelligence
Hospitals and health systems are increasingly focusing on smoothing out the continuum of care for patients, but it's difficult. Christopher Zipp, DO, FACOFP, FAAFP, osteopathic director of medical education for Atlantic Health System, a nonprofit, five-hospital system based in New Jersey told me that patients and physicians stereotype who takes care of what.

"You go to your family physician for hugs, and you go to a surgeon for steady hands," says Zipp, who runs a residency program that attempts to incorporate treating the patient as a whole and treat them as more than their medical condition.

Training Physicians for Empathy

Zipp's work of teaching future physicians how to talk to patients is the core recommendation of the study. Kristin Rising, MD, director of acute care transitions and attending physician at Philadelphia-based Thomas Jefferson University Hospital, writes, "emergency providers should be more proactive in ensuring that patient concerns have been addressed before discharge…."

How do you tell a doctor that they need to do a better job communicating?

"With proper coaching," says Zipp.

Many times, data is used as the catalyst to force physicians to change. But when you're trying to change interpersonal behavior, data doesn't always work, says Zipp. Instead, what he tries to do is relate to the physician's sense of wanting to provide good, even better care.

"It depends on how the learner needs to receive information," he says. "If I said, 'Your emotional intelligence needs to be higher,' the doctor is not going to receive that well. What he or she needs to hear is, "I'm going to give you feedback now."

That's kind of what the patient is asking for—feedback, next steps, and what to expect. Rising says in an emergency department, communication with patients is limiting. The patients are not always discharged with a clear diagnosis, but she says physicians could better manage the consequent anxiety.

Upping the emotional intelligence of ED doctors and discharge staff is not, however, enough to prevent highly concerned patients from returning. "We suggest the medical system must adapt to be able to encourage ongoing dialogues with patients in contrast to the episodic nature of current healthcare delivery," says Rising.