Transition of Care from the Emergency Department to the Outpatient Setting: A Mixed-Methods Analysis

Abstract

IntroductionThe goal of this study was to characterize current practices in the transition of care between the emergency department and primary care setting, with an emphasis on the use of the electronic medical record (EMR).MethodsUsing literature review and modified Delphi technique, we created and tested a pilot survey to evaluate for face and content validity. The final survey was then administered face-to-face at eight different clinical sites across the country. A total of 52 emergency physicians (EP) and 49 primary care physicians (PCP) were surveyed and analyzed. We performed quantitative analysis using chi-square test. Two independent coders performed a qualitative analysis, classifying answers by pre-defined themes (inter-rater reliability > 80%). Participants’ answers could cross several pre-defined themes within a given question.ResultsEPs were more likely to prefer telephone communication compared with PCPs (30/52 [57.7%] vs. 3/49 [6.1%] P < 0.0001), whereas PCPs were more likely to prefer using the EMR for discharge communication compared with EPs (33/49 [67.4%] vs. 13/52 [25%] p < 0.0001). EPs were more likely to report not needing to communicate with a PCP when a patient had a benign condition (23/52 [44.2%] vs. 2/49 [4.1%] p < 0.0001), but were more likely to communicate if the patient required urgent follow-up prior to discharge from the ED (33/52 [63.5%] vs. 20/49 [40.8%] p = 0.029). When discussing barriers to effective communication, 51/98 (52%) stated communication logistics, followed by 49/98 (50%) who reported setting/environmental constraints and 32/98 (32%) who stated EMR access was a significant barrier.ConclusionSignificant differences exist between EPs and PCPs in the transition of care process. EPs preferred telephone contact synchronous to the encounter whereas PCPs preferred using the EMR asynchronous to the encounter. Providers believe EP-to-PCP contact is important for improving patient care, but report varied expectations and multiple barriers to effective communication. This study highlights the need to optimize technology for an effective transition of care from the ED to the outpatient setting.

Lessons learned from an evaluation of referrals to the emergency department

“…Communication between EDs and PCPs is essential [30]. One method of fostering this education and communication would be to send general information on reducing unnecessary referrals to all physicians in the relevant districts.…”

Assessment of the health care system functioning in Poland in light of the analysis of the indicators of the hospital emergency department (ED) and primary health care (PHC) – proposals for systemic solutions

“…This solution was adopted in some regions of the Netherlands [58]. On the other hand, Rider et al pointed out the need to coordinate activities between the ED and PHC, which, in practice, involves the need for communication between the ED physician and the primary care doctor during the discharge of the ED patient in order to optimise further patient care at the PHC level [59]. Communication and coordination can help emergency physicians as they formulate plans of care, particularly for patients with chronic illnesses who may have complex medical histories [40].…”

“…In addition, emergency physicians preferred telephone contact synchronous to the encounter, whereas primary care physicians were in favour of using the electronic medical record asynchronous to the encounter. The researchers indicated a need to optimise technology for an effective transition of the information from the ED to the outpatient setting [59]. Primary care doctors and home health care providers play a crucial role in the coordination of care.…”

Reasons for repeated emergency department visits among community‐dwelling older adults with dementia in Ontario, Canada

“…3 Older adults are at increased risk of adverse outcomes in the ED, including the development of delirium, 4 and ED visits may lead to loss of continuity of care due to difficulties in communication between the ED and primary care. 5 EDs are often time-stressed environments, and incomplete communication can lead to challenges in comprehensively assessing individuals whose needs involve multiple etiologies, complex histories, and/or geriatric syndromes. 6 Although ED-based geriatric multi-disciplinary assessment teams can improve patients outcomes, 7 they are not routinely available in all EDs.…”

“…Although EDs provide essential care for urgent health concerns, they are generally not ideal locations for older adults to receive care that could be delivered elsewhere in the community, particularly for those with complex health and social care needs 3 . Older adults are at increased risk of adverse outcomes in the ED, including the development of delirium, 4 and ED visits may lead to loss of continuity of care due to difficulties in communication between the ED and primary care 5 . EDs are often time‐stressed environments, and incomplete communication can lead to challenges in comprehensively assessing individuals whose needs involve multiple etiologies, complex histories, and/or geriatric syndromes 6 .…”