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Wednesday, November 25, 2009

After a Visit to the Emergency Room Most Patients are Clueless.....


Every year, more than 115 million patients enter emergency rooms at hospitals around the nation. More than three-quarters of them leave without a clear impression of what should happen next....

Bob DeMarco
Alzheimer's Reading Room
Editor




Five years ago I had to take my 88 year old mother to an emergency room after she fell and broke her little finger. When we signed in I told the triage nurse that my mother's finger was clearly broken and that she was in pain. In addition, her ring finger was very swollen and turning purple. I was worried that the circulation to her finger might get cut off.

What happened next? We sat in the waiting room area for 8 hours.

After two hours, I asked for and received some KY jelly and slowly but surely worked the ring off my mother's finger.

When they finally took my mother into the treatment area it took another 30 minutes before someone finally looked at her. After a less than one minute evaluation it was decided that she needed to have her hand X-rayed.

Sure enough her little finger was broken in two places. The doctor wrapped some tape on it and told me she would need to see a specialist. I asked them if they could set-it right there and he said, "NO".

After ten hours and thirty minutes they sent us home. Three days later we finally had a referral to a hand specialist. The first thing he did after re-X-raying her hand was to re-break my mothers finger so they could set it and put a cast on it. The needle he used to numb my mother's hand before re-breaking it was longer than a Dixon Ticonderoga number two lead pencil. Fortunately, it was a lot thinner than a pencil.

Over the years I learned a sad lesson. Many of my mother's friends visit the emergency room and they have little or no understanding of what they should do next when they come home.

Often this confusion leads to inaction that leads to a second trip to the emergency room for the same problem.

I am not making this up. On one occasion our neighbor and close friend fell and his knee swelled up. His wife dialed 911 and off he went to the emergency room. After five hours he came home in an ambulance. When I asked him and his wife what they needed to do they couldn't tell me.

I looked at the documents and told them they needed to call their personal care physician the next morning and get a referral to a specialist. When I checked in the next day, they told me they had an appointment in ten days. I just shook my head.

The next day his knee was very very swollen and he was in pain. I said to his wife he needs to go back to the hospital and this time we are all going with him. You'll keep an eye on my mothers.

He was in so much pain he couldn't walk, so we had to dial 911 for a second time.

He gets there and they do the same exact tests including an x-ray all over again. Finally, I demand to talk to the emergency room doctor. I say to him, why don't you just drain that knee and see what happens. He says good idea.

They drain the knee. Our friend experiences immediate relief. The pain is gone. I then ask the doctor, why didn't they drain his knee two days ago. He shrugs. I say, you aren't going to answer that question are you? He smiles and says, no.

I think fair enough for now, I am learning the drill.

A new study indicates that three-quarters of those making an Emergency room visit don’t understand either what’s wrong, what was done, or what they should do after leaving emergency room.

Here are two things I learned about the emergency room over the years.

First, when my mother broke her finger I drove her to the emergency room. Mistake. I should have dialed 911. This would have insured that she was placed into the emergency room treatment area immediately. This solution does cost you money.

Second, when in doubt ask for the charge nurse, the nurse in charge. When we had to get our friend back home from the emergency room we could not call 911. They can take you to the hospital, but they are not allowed to bring you back home.

When it was time to get our friend with the bad knee home we were informed that it would $450 for the ambulance service. By the way, we live 1.9 miles from the hospital. This is when I asked for the charge nurse. I smiled and whispered in her ear. She smiled and said have a seat I'll be back. My neighbor paid $88.50 to get back home in an ambulance.

Third, when in doubt in the emergency room ask to speak with the most loving, caring person that is on duty at the time. Watch closely at the look you get when you ask this question. Why watch closely? Because I want you to come here and write about it. Trust me, you will need to repeat your question.

I would bet some bucks on this. The most loving, caring person on duty in the emergency room won't be a doctor. When you find that person ask them your questions or for help. I learned that loving, caring people are not lazy, and they actually take pride in what they do.

By the way, with what I now know, when the doctor in the emergency room refused to set my mother's broken finger I would have gently asked him -- do you think you are taking on any potential liability by sending my mother home in this condition? Liability, good word to use in when dealing with the medical system. Say it with a smile. ;>)

One last piece of advice. You always get better results when you use sugar then you do if you use vinegar.
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After ER visit, many patients in a fog, U-M study finds

That’s the finding of study led by University of Michigan Health System researchers, and published early online in the Annals of Emergency Medicine. The results suggest that emergency room teams need to do a better job of making sure patients go home with clear information and instructions – and that patients and their loved ones shouldn’t leave until they fully comprehend their situation.

The researchers carried out detailed interviews with 140 English-speaking patients who visited one of two emergency departments, and were released to go home. They compared those interviews with the patients’ medical records, and found a serious mismatch between what doctors and nurses found or advised, and what patients comprehended.

What’s worse, patients were pretty sure of what they “knew” 80 percent of the time – even if what they knew wasn’t quite right.

“It is critical that emergency patients understand their diagnosis, their care, and perhaps most important, their discharge instructions," says lead author Kirsten Engel, M.D., a former U-M emergency medicine fellow and Robert Wood Johnson Clinical Scholar who is now at Northwestern University. "It is disturbing that so many patients do not understand their post-emergency department care, and that they do not even recognize where the gaps in understanding are. Patients who fail to follow discharge instructions may have a greater likelihood of complications after leaving the emergency department.”

The study’s senior author agrees. “As a physician, I would like to think I could look someone in the eye and ask: ‘Do you have any questions?,’ and those who were confused or overwhelmed would ask for more help,” says Peter Ubel, M.D., a professor of internal medicine at the U-M Medical School. “This study shows that many patients walk away from important clinical encounters confident that they know what happened and why, but with little reason to be so confident.”

The researchers measured the extent to which patients’ reports agreed with their doctors’ records in four areas: diagnosis, emergency care that was given, post-ER care needs and what kinds of symptoms or signs would require the patient to return to the ER or seek immediate care.

Only 22 percent of patients’ reports were in complete harmony with what their care teams reported on all four counts.

Fifty-eight percent of patients understood at least two of the four areas, but 20 percent were off on three or four areas of their care and follow-up needs.

After asking patients about their diagnosis, care and post-ER instructions, the team also asked them if they were not sure about any of the four areas. Interestingly, patients whose understanding perfectly matched their doctors’ records were just as likely to report being unsure as patients whose understanding was lacking.

“Doctors need to not only ask patients if they have questions, but ask them to explain, in their own words, what they think is wrong with their health and what they can do about it,” says Ubel. “And patients need to ask their doctors more questions, and even need to explain, to their doctors, what they think is going on.”
The biggest area of misunderstanding or lack of comprehension was post-emergency care – that is, what steps the patient needs to take to be seen by their regular doctor or a specialist, how soon to see a doctor, or what medicines or self-care steps they need to take, how to take them, and when.

Ubel, Engel and their colleagues found that 34 percent of the deficiencies in patient comprehension reflected a less-than-complete understanding of what their ER team recommended they do after they left the ER. Meanwhile, 22 percent of the deficiencies in the study had to do with patients’ understanding of what symptoms or changes in their condition should spur them to return to the ER.

Recently, the U-M Health System introduced a program that aims directly at this problem: the Emergency Medicine Consult/Referral Service, run by the Department of Emergency Medicine and the Physician and Consumer Communications division of Public Relations & Marketing Communications.

It is staffed by referral coordinators who follow up with ER patients by phone within 24 hours of their ER visit, to help schedule appointments with U-M physicians for primary or specialty care if the patients’ insurance allows it, or make sure they know that they need to schedule an appointment elsewhere.

More than 12,000 follow-up appointments have been scheduled for recent U-M ER patients since the program began in February 2007, and 81 percent of those patients have arrived for their scheduled appointments, up from 59 percent before the program began. Appointment cancellations are also down.

Before the program began, 24 percent of U-M ER patients who needed a follow-up appointment never scheduled one. And many patients and clinicians who did try to arrange follow-up care went through a frustrating and confusing process that is repeated every day in hospitals around the country. The new call center offers a standardized, centralized way to make sure patients get scheduled to see the provider they need soon after their ER visit.

The new study involved patients from ages 18 to 83 years, 59 percent of whom were women. Nineteen percent of patients were African-American, and 68 percent were white, with the remaining percentage being other races or without a race recorded on their record. Thirty-five percent had a high school education or less. Patients were given a brief cognition test before being interviewed, to make sure their thinking and understanding abilities were normal. In some cases, caretakers were also interviewed.

In addition to Engel and Ubel, who directs the Center for Behavioral and Decision Sciences in Medicine, the new study’s authors include Michele Heisler, M.D., MPA, Dylan Smith, Ph.D., Claire Robinson, MPH, and Jane Forman, M.D. The study was funded by the Robert Wood Johnson Foundation and the U-M Clinical Scholars Program.

Reference: Annals of Emergency Medicine, doi:10.1016/j.annemergmed.2008.05.016
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Bob DeMarco is the editor of the Alzheimer's Reading Room and an Alzheimer's caregiver. The Alzheimer's Reading Room is the number one website on the Internet for news, advice, and insight into Alzheimer's disease. Bob has written more than 950 articles with more than 8,000 links on the Internet. Bob resides in Delray Beach, FL.

Original content Bob DeMarco, Alzheimer's Reading Room