Article, Emergency Medicine

Closing the loop: best practices for cross-setting communication at ED discharge

a b s t r a c t

Purpose: This study aimed to develop emergency department best practice guidelines for improved com- munication during patient care transitions.

Basic Procedures: To our knowledge, there are no specific guidelines for communication at the point of transition from the emergency department to the community. In Rhode Island, we used a multistage collaborative quality improvement process to define best practices for emergency department care tran- sitions. We reviewed the medical literature, consensus statements, and materials from national campaigns; gathered preferences from emergency medicine and Primary care clinicians; and created guidelines that we vetted with emergency medicine clinicians and other key stakeholders.

Main Findings: Because we did not find any guidelines that globally addressed care transitions from the emergency department, we drew from studies on patient discharge instructions and extrapolated from the evidence base available for other, related settings. Our key outcome is a set of care transition best practices for emergency departments, which can be implemented to establish measurable, communitywide ex- pectations for cross-setting clinician-to-clinician communication. They include obtaining information about patients’ outpatient clinicians, sending summary clinical information to downstream clinicians, performing modified medication reconciliation, and providing patients with effective education and written discharge instructions.

Principal Conclusions: The best practices provide feasible standards for evaluating and improving how patients transition out of the emergency department and can provide a framework for emergency department leaders expanding their collaboration with community partners, particularly in the context of emerging payment models. They also catalyze introspection and debate about how to improve communication and accountability across the care continuum.

(C) 2013

  1. Introduction

Guidelines to improve communication during patient care transi- tions between health care settings have the potential to improve health outcomes and patient satisfaction, as well as to decrease overall health care costs [1-3]. During care transitions, patients’ clinicians, including those in the emergency department, are responsible for ensuring that clinical information is shared across settings and that,

? Disclaimer: This study was funded by Contract No. HHSM-500-2008-RI, titled “Uti- lization and Quality Control Peer Review for the State of Rhode Island,” sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government.

* Corresponding author. Healthcentric Advisors, 235 Promenade St, Suite 500, Box 18, Providence, RI 02908, USA. Tel.: +1 401 528 3230; fax: +1 401 528 3210.

E-mail address: [email protected] (R.L. Gardner).

when necessary, direct clinician-to-clinician communication occurs to address time-sensitive questions and to transfer accountability for patients’ care [4-6].

Communication is particularly critical after emergency depart- ment visits, given the acuity of care in this setting. There is frequently a need for prompt patient follow-up with community-based physicians and for emergency department clinicians to provide recommendations to the outpatient clinicians assuming responsibil- ity for patient care (see Fig.) [7]. Effective Information transfer allows outpatient physicians to immediately assume care of discharged patients without spending time on requests for records or repeat testing and without defaulting (in the absence of information) to referring patients back to the emergency department. In addition, notifications about emergency department visits may generate primary care physician awareness of emergency department use, prompting outreach to patients for follow-up or education about appropriate use.

0735-6757/$ – see front matter (C) 2013 http://dx.doi.org/10.1016/j.ajem.2013.04.017

clinicians, including emergency department physicians, with the in- formation they need to assume responsibility for patient care.

Self-Referral, Emergency Medical

Self-Referral, Services Ambulatory

Urgent Care or Walk-In Clinic

Study setting and population

Rhode Island emergency department nurses and physicians, primary care physicians and other stakeholders.

Study protocol

Fig. Patient flow to and from the emergency department.

Despite the importance of emergency department communica- tion with downstream clinicians, the complex, fragmented nature of the US health care system leads to significant variability in the fre- quency, quality, and effectiveness of cross-setting communication [8-10]. In an international survey, only 23% of US primary care phy- sicians reported that they were always notified when their patients had visited the emergency department [11]. Although patients can be instrumental in transferring information between clinicians and settings, inconsistent comprehension of emergency department events and variation in adherence to discharge instructions further prevents patients from completely filling the communication gap [12]. In 2008, Healthcentric Advisors, the Medicare quality Improve- ment Organization for Rhode Island, was awarded a Medicare contract to collaborate with local health care providers to improve the safety of patient care transitions and to reduce avoidable hospital read- missions. Our approach included piloting patient and provider in- terventions and then translating Effective interventions into sustainable systems change by developing setting-specific standards, or best practices, for care transitions from the emergency department to other settings. To our knowledge, there are no specific national guidelines for communication regarding care transitions between the emergency department and other settings of care. This contrasts with the robust literature available for patient hand-offs among emergency department staff at change of shift. Our objective was to develop best

practices for cross-setting care transitions.

  1. Methods
    1. Study design

In this study, we expanded on previously developed best practices for care transitions, creating a set specific to the emergency de- partment setting. Before our development of the emergency depart- ment best practices in 2012, we developed best practices for primary care physicians [13], home health agencies, hospitals, and nursing homes; subsequently, we developed best practices for urgent care centers. Each set of best practices focuses on actions within the con- trol of a specific setting. They are intended to provide receiving

Following the same systematic, collaborative quality improve- ment process that we used to develop previous sets of setting-specific best practices, we undertook a multistaged approach to define emer- gency department care transition best practices.

First, we reviewed the evidence base (the medical literature, consensus statements, and materials from national quality improve- ment campaigns) to identify processes linked to Improved care transition outcomes. Two of the authors independently searched Medline and Google Scholar using the following terms, alone and in combination: “emergency department,” “care transitions,” “continu- ity of care,” “communication,” “discharge,” “bounce-backs,” “Hospital readmissions,” “patient safety,” “instructions,” and “patient transi- tions.” They then searched the Web sites of the following professional associations: the American College of Emergency Physicians [14], the Society for Academic Emergency Medicine [15], the American Medical Association [16], the Joint Commission [17] and its Ambulatory Care Accreditation Program [18], and the American Academy of Ambula- tory Care Nursing [19]. Finally, we reviewed several established care transition interventions and guidelines: Project Better Outcomes for Older Adults through Safer Transitions [20], the Care Transitions Intervention [1], the Transitions of Care Consensus Policy Statement [6], the Joint Commission’s National Patient Safety Goal on Reconciling Medication Information [21], Project Re-Engineered Discharge [12], and the National Quality Forum’s Safe Practices [22]. They also re- viewed the reference lists of materials identified in this search, as well as during our previous development of best practices for primary care physicians, home health agencies, hospitals, and nursing homes. Using a qualitative process, 3 of the authors then together re- viewed the search results to identify and record interventions and concepts applicable to cross-setting communication at the time of a patient’s discharge from the emergency department. We did not systematically grade the quality of the evidence, although we gave greater weight to interventions tested in clinical trials over those identified solely from other sources (eg, consensus statements). After achieving agreement among the authors, we then worked internally to create a preliminary draft of the best practices based on

these findings.

Simultaneously, we gathered verbal feedback about community preferences from a convenience sample of emergency department and primary care clinicians, using existing committees and ongoing meetings. This included individual conversations and group discus- sions with clinicians who refer patients to emergency departments and those who receive patients after emergency department dis- charge, including a series of discussions with the Rhode Island Department of Health’s Primary Care Physician Advisory Council. We gathered information from these clinicians informally, based on verbal conversations. Based on these initial discussions with physi- cians, as described above, we further refined the preliminary set of emergency department best practices.

Third, we conducted 2 community meetings to elicit feedback on the draft concepts, feasibility, definitions, and metrics. Our goal was to refine and ensure usability of each best practice within the emergency department’s workflow. We strove to include opinion leaders, representation from Primary care settings, and nurses and physicians with various clinical expertise and viewpoints. We also targeted leadership from every hospital in the state with an

Table

Emergency department best practices for safe care transitionsa

Best practice Comments

Table (continued)

Best practice Comments

  • Education may be provided to the patient,

    Record the name of patients’ primary care provider (PCP)

  • The first 2 best practices lay the foundation for consistent communication with patients’ community-based providers.
  • A PCP is defined as the clinician or care setting identified by the patient as their regular source of care and may include a primary care physician, specialist, midlevel provider, or a location such as an office,

8. Provide patient with written discharge instructions

before discharge

family, or caregiver.

  • The instructions should include the information provided

verbally as part of effective education (see no. 7), as well

as the name of the emergency department clinician and a telephone number the patient can call with questions, if needed.

Record the name of patients’ home care provider
  • Send summary clinical information to PCP upon discharge
  • Send summary clinical information to home care provider upon discharge
  • Send summary clinical information to downstream/receiving physicians (in another facility) upon discharge or transfer
  • Perform modified medication
  • clinic, skilled nursing, or long-term care facility.

    • If the patient does not have a PCP, this should be noted in the medical record instead.
    • A home care provider is defined as any organization that provides home or community-based medical, nursing, social, or Therapeutic treatment, including home health agencies and hospice programs.
    • A home care provider’s name should only be recorded if the patient is currently receiving services.
    • This information should be sent within 1 hour by fax, e-mail, or other secure electronic means.
    • It should include the medical diagnosis, any medication changes and the reason for

    the modification, results of relevant diagnostic tests, the presence of pending tests, contact information for follow-up questions, discharge instructions, and recommended follow-up.

    • “Relevant” tests are defined as those that, in the emergency department clinician’s judgment, are relevant to follow-up care.
    • Same information as above (no. 3).
    • In addition to the summary clinical information described above in no. 3, this includes information regarding the clinical services provided: medications dispensed, procedures performed, relevant vitals and physical examination findings, nursing notes, and other information that, in the emergency department clinician’s judgment, is relevant to the patient’s care in the receiving facility.
    • If patients are discharged to a skilled nursing facility, it is recommended to also send the summary clinical information to the patient’s PCP.
    • Medication reconciliation in emergency

    a Full best practice measure details, including specifications, included and excluded populations, and additional comments and definitions are available from the authors upon request.

    b This more robust definition of medication reconciliation includes identifying the name, dosage, route, frequency, and indication for every medication a patient is taking. Although this approach is not currently required by the Joint Commission in the emergency department, some may wish to adopt this more comprehensive definition.

    emergency department. We provided all participants with the draft best practices, including definitions and metrics, and facilitated a group discussion about each best practice. Our facilitation focused on the desirability and feasibility of each concept; we asked for group consensus on any changes proposed to the concepts, language, or definitions. After the meeting, we shared an updated draft, incorpo- rating the participants’ feedback, and asked all invitees (present and absent) to share additional comments.

    Finally, we vetted the best practices with the Safe Transitions community advisory board. The advisory board included diverse stakeholders: inpatient and outpatient physicians, pharmacists, nurses, and representatives from commercial health plans, Medicaid and the home health, hospice, and hospital and nursing home settings. Incorporating successive, step-by-step feedback allowed us to obtain consensus while revising the best practices to their final form.

    The Rhode Island Department of Health’s institutional review board reviewed this Quality improvement project and determined that it was exempt.

    Key outcome measure

    Our key outcome was stakeholder consensus on a set of care transition best practices for emergency departments, including related definitions and metrics, which can be implemented to es- tablish measurable, communitywide expectations for emergency de- partment communication.

    1. Results

    reconciliation before emergency department is defined as identifying which

    In our review of the medical literature, we found references that

    department discharge

    7. Provide patient with effective education before discharge

    medications the patient should stop, start, or adjust after the visit. A more robust definition is used in most other health care settings but may not be feasible in the emergency department.b

    • A written list of these medications should be provided to both the patient and their downstream providers, along with the reason for any changes.
    • Education should include the diagnosis, any medication

    changes and the reason for the change, condition-specific “Red flags” that should prompt the patient to seek medical attention and whom the patient should call, activity and other limitations, and recommended follow-up.

    • Effective education includes assessment of the patient’s understanding of the

    information provided, incorporates concepts of health literacy and cultural competence, and should adhere to statutory linguistic requirements.

    outlined specific content for emergency department discharge paperwork [23] and that recommended approaches to improving verbal communication with emergency department patients at the time of discharge [12]. We did not find any emergency department- specific guidelines that globally addressed the transition of care from the emergency department, including the transmission of discharge information to downstream clinicians. As a result, we drew from studies that tested interventions to improve comprehension of and adherence to discharge instructions, and we also extrapolated from the evidence base available for other, related settings (See Appendix). We combined our research with feedback about community pre- ferences to draft our best practices and then refined those measures after conducting stakeholder meetings with broad representation from across the state. Although some of these processes may already be implemented in some emergency departments, our conversations with emergency department clinicians, primary care physicians, and other stakeholders demonstrate that there is significant variability among institutions and individual practitioners. For our community meetings, we invited approximately 70 individuals, including

    emergency department nurses and physicians, hospital quality directors, primary care physicians, and other stakeholders from across the state, such as payors and state agencies. Altogether, we held 2 community meetings with a total of 35 individuals. All but one the hospitals with an emergency department sent participants, and we achievED representation from all of the targeted groups.

    The Table presents the 8 resulting emergency department care transition best practices. The related measure specifications (available upon request) provide additional detail about measurement criteria and would enable consistent implementation across providers and payors. The 8 best practices primarily detail expectations for cross- setting clinician-to-clinician communication and also incorporate elements of patient activation. They include best practices that stipulate obtaining contact information for patients’ outpatient clini- cians, sending summary clinical information to downstream clini- cians, performing modified medication reconciliation, and providing patients with effective education and written discharge instructions. We did not set or recommend benchmarks for these metrics, recognizing that baseline rates remain unknown and that adherence will not be 100% achievable for each best practice. We also believe that local preferences should drive goals.

    1. Discussion

    Nearly 130 million visits were made to US emergency departments in 2010, and although 82% of these resulted in discharge, 63% (of the total visits) included a discharge plan specifying follow-up with an outside physician or clinic [7]. These best practices are, to our knowledge, the first emergency department-specific guidelines for the care transition of discharged patients. Although some of the best practice concepts may seem intuitive and may, in fact, be supported by Joint Commission or other requirements, we developed these based on community feedback that they are not happening consis- tently with every clinician, in every emergency department. With the best practices, we establish communitywide expectations for emer- gency departments seeking to improve patient safety, prevent unschedulED return visits, and build relationships with community partners. To develop and refine the best practices, we drew upon the medical literature, national campaigns, consensus statements, and input from all but one emergency department in the state, as well as primary care physicians and other stakeholders. A reciprocal set of care transition best practices for community physicians [13] sets forth similar standards for primary care practices’ responsibilities when referring patients to the emergency department and receiving patients recently seen in the emergency department, thus helping to ensure that emergency department clinicians receive the information they need and that their discharged patients experience seamless care. The best practices help to further patient safety goals set forth by the Institute of Medicine, which defines health care quality as the extent to which health care services are consistent with professional knowledge and help to make care safe, equitable, effective, efficient, timely, and patient centered [24].

    Emergency department clinicians face unique challenges in

    providing high-Quality patient care, particularly at discharge: they provide episodic care to increasingly high volumes of patients of varying acuity in a fast-paced environment, often with limited knowl- edge of patients’ medical histories [9,25]. The emergency department also includes numerous distractions and a shift model for staffing, both of which may make it difficult for emergency department clinicians to initiate communication with outpatient downstream providers clinicians and for primary care physicians receiving clini- cians to follow-up directly with the treating emergency clinician for information. At the same time, these factors make discharge communication critically important, particularly for frail, institution- alized patients, although the data supporting specific sequelae are sparse [26].

    Unfortunately, studies have demonstrated that patients cannot always bridge the communication gap between the emergency department and their primary care physician office. Although patients are often the only communication link with outpatient providers, emergency department discharge instructions may be delivered in as little as 2 minutes [27] and often without assessing patient com- prehension [12]. In an analysis of audiotaped discharge instructions, most patients were instructed to follow up with their primary care physician, but only 39% were provided with a specific time rec- ommendation for that visit; only half of patients received an ex- planation of their expected course of illness, and even fewer were told what symptoms should prompt a return to the emergency depart- ment [28]. Even if discharge instructions are adequate, patients may not comprehend or recall the instructions [29,30] and often do not adhere to recommended follow-up appointments or prescribed medication [31-34]. Standard communication processes, as defined in these best practices, will allow primary care physicians to close the loop when their patients are not able to follow through with recommended follow-up care.

    The emergency department best practices are intended for implementation by the clinicians (physicians, nurses, and others) directly responsible for patients’ care and discharge. The best practices necessitate common, defined expectations–which is particularly important in the fast-paced emergency department, where tasks viewed as “nonessential” may not be prioritized within the con- straints and workflow of the emergency department. For example, the sixth best practice (medication reconciliation before patient dis- charge) uses a modified definition of medication reconciliation that can be accomplished quickly and without detailed knowledge of patients’ medication histories.

    In addition to filling a communication void, the emergency department best practices complement existing, care transition best practices that (organization name) has developed for other care settings, including urgent care centers, hospitals, and primary care physicians. Each set of best practices focuses on actions within the control of a specific setting, whereas the best practice sets, taken as a whole, aim to provide all clinicians with the information they need from both their upstream (referring) and downstream (receiving) partners. This includes ensuring that urgent care centers and primary care physicians send clinical information to the emergency department when referring patients for evaluation. Only a third of US primary care physicians have any arrangements for patients to be seen after-hours without going to an emergency department, and fewer than half of these physicians report that their sick patients can get a same or next-day appointment in the office [11]. With emergency departments increasingly filling this need, bidirectional and reciprocal information sharing in both directions is critical. In Rhode Island, some payors have begun to adopt elements of the hospital and primary care physician best practices in their contracts with local providers, providing resources and recognition for providers who implement and report data on these practices.

    1. Limitations

    Although there are professional consensus statements that refer to patient care transitions from the emergency department, we did not find any emergency department-specific guidelines during our review of the medical literature. Therefore, many of the emergency department best practice processes are drawn from interventions performed in other health care settings and in controlled research environments. Some are proven to improve care transitions when implemented in combination, rather than as individual processes; others reflect clinician preferences about information flow after emergency department clinical encounters. Although research in the hospital and other care settings has established the impact of such communication on patient experiences and outcomes [1,5], we have not implemented or evaluated the impact of these best practices. Further research is needed to link

    increased adoption of these consensus-based emergency department standards, either alone or in combination, with improved provider relationships and patient outcomes. Although we were able to obtain broad stakeholder input into the best practices, we did not include patients or caregivers; future work would benefit from ensuring that these concepts are patient directed. Lastly, the consensus process occurred in a single state, which may limit the generalizability of these best practices to other regions of the country.

    1. Conclusion

    These care transition best practices provide feasible standards for evaluating and improving how discharged patients transition out of the emergency department. Based on the medical literature, com- munity consensus, and national guidelines, these measures establish core expectations for communication with downstream providers and also address recognized gaps in transmission of clinical information from the emergency department to outpatient clinicians caring for recently discharged patients. The best practices also present several opportunities. They provide a framework for emergency department leaders to expand their collaboration with community partners in the context of emerging payment models such as Accountable Care Organizations and bundled payments. Most importantly, the best practices propose a standard that can catalyze introspection and debate about our culture of care, as well as how to improve commu- nication and accountability across the care continuum.

    Acknowledgments

    The authors thank the members of the Safe Transitions team who supported the development of the emergency department care transition best practices and this manuscript, particularly Lynne Chase (Health- centric Advisors) and Hannah Shamji (then at Healthcentric Advisors).

    In addition, the authors thank the stakeholders who collaborated with the Safe Transitions Project to develop the emergency depart- ment care transition best practices. These stakeholders include the emergency department and primary care clinicians who spoke with our team and attended in-person meetings. They also include the Safe Transitions Project’s community advisory board, which encompasses inpatient and outpatient physicians and representatives from com- mercial health plans, Medicaid, and the home health, hospice, hospital, nursing home, and physician office settings.

    Through community collaboration, Healthcentric Advisors’ Medi- care-funded Safe Transitions Project aims to transform the Rhode Island health care system into one in which discharged patients and their caregivers understand their conditions and medications, know who to contact with questions, and are supported by health care professionals who have access to the right information, at the right time. This is our vision statement.

    Appendix A. Supplementary data

    Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2013.04.017.

    References

    1. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 2006;166(17):1822-8.
    2. Jack BW, Cherry VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009;150(3):178-87.
    3. Naylor MD, Brooten DA, Campbell RI, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc 2004;52(5):675-84.
    4. Coleman EA, Boult C. The American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc 2003;51(4):556-7.
    5. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009;360(14):1418-28.
    6. Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, et al. Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society- American College of Emergency Physicians-Society of Academic Emergency Medicine. J Gen Intern Med 2009;24(8):971-6.
    7. National Center for Health Statistics, Centers for Disease Control, Prevention. National Hospital Ambulatory Medical Care Survey: 2010 emergency department summary tables. http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/ 2010_ed_web_tables.pdf . Accessed Feb 21, 2013.
    8. Gillespie SM, Gleason LJ, Karuza J, Shah M. Healthcare providers’ opinions on communication between nursing homes and emergency departments. J Am Med Dir Assoc 2010;11(3):204-10.
    9. Carrier E, Yee T, Holzwart RA. Coordination between emergency and primary care physicians. National Institute for Health Care Reform. 2011; Research Brief No. 3. http://www.nihcr.org/ED-Coordination.html. Accessed January 17, 2013.
    10. Terrell KM, Miller DK. Challenges in transitional care between nursing homes and emergency departments. J Am Med Dir Assoc 2006;7:499-505.
    11. Schoen C, Osborn R, Squires D, Doty M, Rasmussen P, Pierson R, et al. A survey of primary care doctors in ten countries shows progress in use of health information technology, less in other areas. Health Aff 2012;31(12):2805-16.
    12. Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med 2012;60(2):152-9.
    13. Baier RR, Gardner R, Gravenstein S, Besdine R. Partnering to improve hospital- physician office communication through by implementing care transitions best practices. Health/Medicine RI 2011;94(6):178-82.
    14. American College of Emergency Physicians (ACEP). Appropriate interhospital patient transfer. http://www.acep.org/Content.aspx?id=29114. Accessed January 10, 2013.
    15. Society for Academic Emergency Medicine (SAEM). http://www.saem.org/. Accessed January 10, 2013.
    16. American Medical Association (AMA). http://www.ama-assn.org/. Accessed January 10, 2013.
    17. Joint Commission. http://www.jointcommission.org/. January 10, 2013.
    18. Joint Accreditation for Ambulatory Care. Facts About Ambulatory Care Accred- itation. http://www.jointcommission.org/assets/1/18/Ambulatorycare_1_112. PDF . Accessed January 10, 2013.
    19. American Academy of Ambulatory Care Nursing (AAACN). https://my.aaacn.org/ eweb/StartPage.aspx. Accessed January 10, 2013.
    20. Society of Hospital Medicine. Better Outcomes for Older adults through Safer Transitions (Project BOOST). http://www.hospitalmedicine.org/BOOST/. Accessed January 10, 2013.
    21. Joint Commission. National patient safety goal on reconciling medication information (Jt. Comm). Available at: http://www.jointcommission.org/ standards_information/npsgs.aspx . Accessed January 17, 2013.
    22. National Quality Forum. Safe practices for better healthcare–2010 update. Available at: http://www.qualityforum.org/Publications/2010/04/ Safe_Practices_for_Better_Healthcare_%e2%80%93_2010_Update.aspx. Accessed January 17, 2013.
    23. ABIM Foundation, American College of Physicians, Society of Hospital Medicine. The Physician Consortium for Performance Improvement (PCPI). Care transitions performance measurement set (phase i: inpatient discharges & emergency department discharges). http://www.abimfoundation.org/News/ABIM- Foundation-News/2009/~/media/Files/PCPI%20Care%20Transition%20 measures- public-comment-021209.ashx . Accessed January 17, 2013.
    24. Committee on the Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
    25. Knopp R, Rosenzweig S, Bernstein E, Totten V. Physician-patient communication in the emergency department, part 1. Acad Emerg Med 1996;3(11):1065-9.
    26. Terrell KM, Miller DK. Critical review of transitional care between nursing homes and emergency departments. Ann Long Term Care 2007;15:33-8.
    27. Rhodes KV, Vieth T, He T, Miller A, Howes DS, Bailey O, et al. Resuscitating the physician-patient relationship: emergency department communication in an academic medical center. Ann Emerg Med 2004;44(3):262-7.
    28. Vashi A, Rhodes KV. “Sign right here and you’re good to go”: a content analysis of audiotaped emergency department discharge instructions. Ann Emerg Med 2011; 57(4):315-22.
    29. Clarke C, Friedman SM, Shi K, Arenovich T, Monzon J, Culligan C. Emergency department discharge instructions comprehension and compliance study. CJEM 2005;7(1):5-11.
    30. Zavala S, Shaffer C. Do patients understand discharge instructions? J Emerg Nurs 2011;37(2):138-40.
    31. Barlas D, Homan CS, Rakowski J, Houck M, Thode Jr HC. How well do patients obtain short-term follow-up after discharge from the emergency department? Ann Emerg Med 1999;34:610-4.
    32. Zorc JJ, Scarfone RJ, Li Y, Hong T, Harmelin M, Grunstein L, et al. Scheduled follow- up after a pediatric emergency department visit for asthma: a randomized trial. Pediatrics 2003;111(3):495-502.
    33. Baren JM, Boudreaux ED, Brenner BE, Bydulka RK, Rowe BH, Clark S, et al. Randomized, controlled trial of emergency department interventions to improve primary care follow-up for patients with acute asthma. Chest 2006;129(2): 257-65.
    34. Kyriacou DN, Handel D, Stein AC, Nelson RR. Brief report: factors affecting outpatient follow-up compliance of emergency department patients. J Gen Intern Med 2005;20(10):938-42.

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