Form 1 Emergency Department Discharge Tool (EDT)

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment A:

Emergency Department Discharge Tool (EDT)

Background

The Emergency Department (ED) is an important and frequently utilized place of care for a large portion of the U.S. population. Because of the episodic nature of ED care, high quality transitions from the ED to other settings are critical to patient wellbeing. Notably, the ED discharge process (transition to home) is critically important, because patients are moving from an intensive medical care setting to home, where there are far less expertise and resources. Given these challenges, it is not surprising that a significant percentage of patients (up to 7%) end up back in the ED within 72-hours. Moreover, frequent ED users (those with 4 or more visits per year) can account for up to 21% to 28% of all visits.

The Emergency Department Discharge Tool (EDT) is designed as a screening tool to identify patients at high risk for discharge failure. Moreover, it serves as a guide to direct interventions aimed at reducing discharge failure.

Components of the ED Discharge Tool

The Emergency Department Discharge Tool (EDT) contains two elements: 1) a screening component to identify patients at high risk of Emergency Department (ED) return visits (the “ED Discharge High Risk Screening Checklist”) and 2) a set of recommended interventions that are targeted towards individual patient risk factors for ED discharge problems.

A designated ED provider will screen the medical record of all adult patients for the presence of frequent ED use, the key risk factor for ED discharge failure. Frequent ED is use is defined as: 1) 1 or more (>1) previous ED visit within the last 72-hours, OR2 or more ( >2) previous ED visits within the last 3 months, OR3 or more ( >3) ED visits within the last 12 months. This definition can be modified to align with the resources of the individual ED.

For those patients that meet the frequent ED use criteria, the provider will complete the ED High Risk Screening Tool. This will enable the provider to identify those underlying risk factors that may be leading to frequent ED use. The provider will implement the targeted interventions based upon the patient’s specific risk factors.

The EDT is appropriate for patients that are to be discharged from the ED, including those placed under observation status. The provider will interact with the treating physician to determine whether or not the patient will be discharged home. If the patient is admitted to the hospital, no further interventions will apply. It is assumed that these interventions will be implemented on the in-patient side.

Prior to implementation of the EDT, the algorithm/procedures for implementing the interventions should already be put in place. This critical step will, by definition, be adaptive. Each ED and its medical community will have to work together to develop a specific plan towards improving the health of these high-risk patients. Contacts and relationships with community resources will be need to be already developed. An ED-specific “manual of resources” should be developed and kept up-to-date for each site. Toward this end, a User’s Guide is included as an Appendix to the Tool with suggestions on creating these procedures and resources that may be useful in doing so.

Resources for implementation of the EDT can come from a variety of locations. Some of the resources might come from the ED's internal budget. Other resources might come from hospital resources. Given the recent focus on preventing hospital readmissions, hospitals might be motivated to work closely with the ED to improve outpatient care coordination. Finally, resources may come from a variety of community health services (see User's Guide for more details).

ED Discharge High Risk Screening Checklist Tool

 Frequent ED User

• 4 prior visits in the last 12 months

OR

• 3 prior visits in the last 3 months

OR

• 1 prior visit in the last 72 hours

(not including scheduled revisits [e.g. for wound check, suture removal])

Check all that apply if the patient meets the Frequent ED User criteria above.

• Uninsured (obtain from medical record)

• Self-pay or uninsured identified in the medical record

AND

• Confirmed with patient

• Lack of Primary Care Physician

• Lack of named primary care physician or clinic in the medical record

AND

• Confirmed with patient

• Psychiatric Disease (obtain from medical record)

• Past medical history of: schizophrenia, bipolar, psychosis

OR

• Current chief complaint involving: homicidal ideation, suicidal ideation

• Substance Dependence (obtain from medical record)

• Past medical history of: alcohol dependence, narcotic dependence

OR

• Current chief complaint involving: acute alcohol intoxication, alcohol withdrawal, cocaine overdose, narcotic overdose

• Difficulties for Self-Care [Physical impairment, cognitive impairment, complexity of medical condition]

• Refer to physical/cognitive impairment tool

• Poor Discharge Instruction Comprehension (interview at end of visit)

• Refer to discharge comprehension too

• Possible challenges facing interventions

• Refer to possible challenges facing interventions tool

Physical/Cognitive Impairment Tool ***
In general, do you have trouble seeing well?	Yes	No
In general, do you have serious problems with your memory?	Yes	No
Do you use walking aids or need assistance when walking or transferring (getting up and down from a chair or bed)?	Yes	No
Do you take four or more (>4) prescription medications? (see medication list)	Yes	No

*** Patient screens positive if they have two or more (>2) of any of these conditions.

Comprehension of Emergency Department Discharge Tool
	Is the patient’s response adequate?
What did the provider say was the cause of your illness?	Yes	No
Did the provider tell you to take any medications?	Yes	No
How did he or she tell you to use each of them?	Yes	No
What are some of the worrisome symptoms the provider told you to pay attention to?	Yes	No
What did the provider tell you about to follow up (with whom and when)?	Yes	No

Possible Challenges Facing Intervention
Accessibility (no need to wait for an appointment)
Family obligations
Monetary (in case of co-pays)
Paperwork complexity (in case of applying for insurance)
Prefer the ED care over PCP care (if checked, asked why)
Transportation
Work obligations
Other (specify)

Interventions

Uninsured/Underinsured

1. PCP Appointments

2. Medication Voucher

(H) Post-Discharge Phone Call

(J) Care Coordination

Lack of Primary Care

1. PCP Appointment

(H) Post-Discharge Phone Call

Psychiatric Disease

(C) Outpatient Psychiatry Appointment

(D) Referral to Outpatient Psychiatry

(H) Post-Discharge Phone Call

Substance Abuse

(E) Detox Center Appointment

(F) Transportation to Detox Center

(G) Referral to Substance Abuse Rehabilitation Center

Inability to Care for Self

(H) Post-Discharge Phone Call

(J) Care Coordination

Poor Discharge Comprehension

(I) Teach Back

(H) Post-Discharge Phone Call

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