Information structuring improves recall of emergency discharge information: a randomized clinical trial.

This article examines the extent to which structuring Emergency Department discharge information improves the ability to recall that information, and whether such benefits interact with relevant prior knowledge. Using three samples of students with different levels of prior medical knowledge, we investigated the amount of information recalled after structured vs. non-structured presentation of information. Across all student samples, the structured discharge information led to a relative increase in recalled items of 17% compared to non-structured discharge information (M = 9.70, SD = 4.96 vs. M = 8.31, SD = 4.93). In the sample with least medical knowledge, however, the structured discharge information resulted in a relative increase in recall by 42% (M = 8.12 vs. M = 5.71). These results suggest that structuring discharge information can be a useful tool to improve recall of information and is likely to be most beneficial for patient populations with lower levels of medical knowledge.

Discharge Communication in Patients Presenting to the Emergency Department With Chest Pain: Defining the Ideal Content.

In an emergency department (ED), discharge communication represents a crucial step in medical care. In theory, it fosters patient satisfaction and adherence to medication, reduces anxiety, and ultimately promotes better outcomes. In practice, little is known about the extent to which patients receiving discharge information understand their medical condition and are able to memorize and retrieve instructions. Even less is known about the ideal content of these instructions. Focusing on patients with chest pain, we systematically assessed physicians' and patients' informational preferences and created a memory aid to support both the provision of information (physicians) and its retrieval (patients). In an iterative process, physicians of different specialties (N = 47) first chose which of 81 items to include in an ED discharge communication for patients with acute chest pain. A condensed list of 34 items was then presented to 51 such patients to gauge patients' preferences. Patients' and physicians' ratings of importance converged in 32 of the 34 items. Finally, three experts grouped the 34 items into five categories: (1) information on diagnosis; (2) follow-up suggestions; (3) advice on self-care; (4) red flags; and (5) complete treatment, from which we generated the mnemonic acronym "InFARcT." Defining and structuring the content of discharge information seems especially important for ED physicians and patients, as stress and time constraints jeopardize effective communication in this context. Chest pain accounts for up to 10% of all patient presentations in emergency departments (EDs) (Konkelberg & Esterman, 2003). The majority of these patients will usually be discharged within hours, after exclusion of serious conditions such as myocardial infarction (Goodacre et al., 2011). A comprehensive workup of low- to intermediate-risk patients is not feasible in the ED (Reichlin et al., 2009). Yet many of these patients go on to suffer from repeated episodes of chest pain, associated with anxiety and uncertainty about diagnosis and outcome (Jones & Mountain, 2009). Effective discharge communication, empowering patients to understand and memorize medical information, should therefore be an integral part of patient care. It is a likely contributor to better outcomes (Bishop, Barlow, Hartley, & William, 1997; Kessels, 2003), higher patient satisfaction (Kessels, 2003), better adherence to medication (Cameron, 1996; Kessels, 2003), more adequate disease management, and reduced anxiety (Galloway et al., 1997; Mossman, Boudioni, & Slevin, 1999).

Are Mortality and Acute Morbidity in Patients Presenting With Nonspecific Complaints Predictable Using Routine Variables?

OBJECTIVES: Patients presenting to the emergency department (ED) with nonspecific complaints are difficult to accurately triage, risk stratify, and diagnose. This can delay appropriate treatment. The extent to which key medical outcomes are at all predictable in these patients, and which (if any) predictors are useful, has previously been unclear. To investigate these questions, we tested an array of statistical and machine learning models in a large group of patients and estimated the predictability of mortality (which occurred in 6.6% of our sample of patients), acute morbidity (58%), and presence of acute infectious disease (28.2%). METHODS: To investigate whether the best available tools can predict the three key outcomes, we fed data from a sample of 1,278 ED patients with nonspecific complaints into 17 state-of-the-art statistical and machine learning models. The patient sample stems from a diagnostic multicenter study with prospective 30-day follow-up conducted in Switzerland. Predictability of the three key medical outcomes was quantified by computing the area under the receiver operating characteristic curve (AUC) for each model. RESULTS: The models performed at different levels but, on average, the predictability of the target outcomes ranged between 0.71 and 0.82. The better models clearly outperformed physicians' intuitive judgments of how ill patients looked (AUC = 0.67 for mortality, 0.65 for morbidity, and 0.60 for infectious disease). CONCLUSIONS: Modeling techniques can be used to derive formalized models that, on average, predict the outcomes of mortality, acute morbidity, and acute infectious disease in patients with nonspecific complaints with a level of accuracy far beyond chance. The models also predicted these outcomes more accurately than did physicians' intuitive judgments of how ill the patients look; however, the latter was among the small set of best predictors for mortality and acute morbidity. These results lay the groundwork for further refining triage and risk stratification tools for patients with nonspecific complaints. More research, informed by whether the goal of a model is high sensitivity or high specificity, is needed to develop readily applicable clinical decision support tools (e.g., decision trees) that could be supported by electronic health records.

Emergency Presentations With Nonspecific Complaints-the Burden of Morbidity and the Spectrum of Underlying Disease: Nonspecific Complaints and Underlying Disease.

The prevalence of diagnoses, morbidity, and mortality of patients with nonspecific complaints (NSC) presenting to the emergency department (ED) is unknown.To determine the prevalence of diagnoses, acute morbidity, and mortality of patients with NSC.Prospective observational study with a 30-day follow-up. Patients presenting to 2 EDs were enrolled by a study team and diagnosed according to the World Health Organization ICD-10 System.Of 217,699 presentations to the ED from May 2007 through to February 2011, a total of 1300 patients were enrolled. After exclusion of 90 patients who fulfilled exclusion criteria, 1210 patients were analyzed. No patient was lost to follow-up. In patients with NSC, the underlying diseases were spread throughout 18 chapters of the ICD-10. A total of 58.7% of the patients were diagnosed with acute morbidity. Thirty-day mortality was 6.4% overall. Patients with acute morbidity and suffering from heart failure and pneumonia had mortalities >15%; patients lacking acute morbidity, but suffering from functional impairment or depression/anxiety had mortalities of 0%. Although the history did not allow any prediction, age and sex were predictive of morbidity and mortality.The differential diagnoses in patients presenting with NSC is broad. Acute morbidity and mortality were high in the presented cohort, the predictors of morbidity and mortality being age and sex rather than the nature of the complaints. Urgently needed management strategies could be based on these results.ClinicalTrials.gov (#NCT00920491).

Improving patient recall of information: Harnessing the power of structure.

OBJECTIVE: Assess the amount of medical information laypeople recall, investigate the impact of structured presentation on recall. METHODS: 105 first-year psychology students (mean age 21.5±3.8 years; 85% female) were randomised to two information-presentation conditions: structured (S group) and nonstructured (NS group). Students watched a video of a physician discharging a patient from the emergency department. In the S Group, content (28 items of information) was divided into explicit "chapters" with "chapter headings" preceding new information. Afterwards, participants wrote down all information they recalled on an empty sheet of paper. RESULTS: The S group (N=57) recalled significantly more items than NS group (N=41) (8.12±4.31 vs. 5.71±3.73; p=0.005), rated information as easier to understand (8.0±1.9 vs. 6.1±2.2; p<0.001) and better structured (8.5±1.5 vs. 5.5±2.7; p<0.001); they rather recommended the physician to friends (7.1±2.7 vs. 5.8±2.6; p<0.01). CONCLUSION: University students recalled around 7/28 items of information presented. Explicit structure improved recall. PRACTICE IMPLICATIONS: Practitioners must reduce the amount of information conveyed and structure information to improve recall.

The proportion of correct diagnoses is low in emergency patients with nonspecific complaints presenting to the emergency department.

OBJECTIVE: To determine the proportion of correct emergency department (ED) diagnoses and of hospital discharge diagnoses, in comparison with final diagnoses at the end of a 30-day follow-up, in patients presenting with nonspecific complaints (NSCs) to the ED; to determine differences between male and female patients in the proportion of missed diagnoses. METHODS: Prospective observational study. Diagnoses made at the ED, hospital discharge diagnoses, and final diagnoses were compared. RESULTS: Of 22,782 nontrauma patients presenting to the ED from May 2007 until May 2009, 9,926 were triaged as emergency severity index level 2 or 3, of whom 789 presented with NSCs. After exclusion of 217 patients, 572 were included for final analysis. The final diagnosis at the end of follow-up was taken to be the correct "gold standard" diagnosis. In 263 (46.0%) patients, this corresponded to the primary ED diagnosis, and in 292 (51%) patients to the hospital discharge diagnosis. The most frequent final diagnoses were urinary tract infections (n=49), electrolyte disorders (n=40) and pneumonia (n=37), and were correctly diagnosed at the ED in 23, 21 and 27 patients, respectively. Of the twelve most common diagnoses (corresponding to 354 patients), functional impairment was most frequently missed. Among these 354 patients, diagnoses were significantly more often missed in women than in men (142 of 231 [62%] women vs 57 of 123 [46%] men, p=0.004). CONCLUSION: Patients presenting to the ED with NSCs present a diagnostic challenge. New diagnostic tools are needed to help in the diagnosis of these patients.

Physician's first clinical impression of emergency department patients with nonspecific complaints is associated with morbidity and mortality.

The association between the physician's first clinical impression of a patient with nonspecific complaints and morbidity and mortality is unknown. The aim was to evaluate the association of the physician's first clinical impression with acute morbidity and mortality. We conducted a prospective observational study with a 30-day follow-up. This study was performed at the emergency departments (EDs) of 1 secondary and 1 tertiary care hospital, from May 2007 to February 2011. The first clinical impression ("looking ill"), expressed on a numerical rating scale from 0 to 100, age, sex, and the Charlson Comorbidity Index (CCI) were evaluated. The association was determined between these variables and acute morbidity and mortality, together with receiver operating characteristics, and validity. Of 217,699 presentations to the ED, a total of 1278 adult nontrauma patients with nonspecific complaints were enrolled by a study team. No patient was lost to follow-up. A total of 84 (6.6%) patients died during follow-up, and 742 (58.0%) patients were classified as suffering from acute morbidity. The variable "looking ill" was significantly associated with mortality and morbidity (per 10 point increase, odds ratio 1.23, 95% confidence interval [CI] 1.12-1.34, P < 0.001, and odds ratio 1.19, 95% CI 1.14-1.24, P < 0.001, respectively). The combination of the variables "looking ill," "age," "male sex," and "CCI" resulted in the best prediction of these outcomes (mortality: area under the curve [AUC] 0.77, 95% CI 0.72-0.82; morbidity: AUC 0.68, 95% CI 0.65-0.71). The physician's first impression, with or without additional variables such as age, male sex, and CCI, was associated with morbidity and mortality. This might help in the decision to perform further diagnostic tests and to hospitalize ED patients.

Correlates of diagnostic accuracy in patients with nonspecific complaints.

OBJECTIVE: To investigate diagnostic accuracy in patient histories involving nonspecific complaints and the extent to which characteristics of physicians and structural properties of patient histories are associated with accuracy. METHODS: Six histories of patients presenting to the emergency department (ED) with nonspecific complaints were provided to 112 physicians: 36 ED physicians, 50 internists, and 26 family practitioners. Physicians listed the 3 most likely diagnoses for each history and indicated which cue(s) they considered crucial. Four weeks later, a subset of 20 physicians diagnosed the same 6 histories again. For each history, experts had previously determined the correct diagnoses and the diagnostic cues. RESULTS: Accuracy ranged from 14% to 64% correct diagnoses (correct diagnosis listed as the most likely) and from 29% to 87% correct differential diagnoses (correct diagnosis listed in the differential). Acute care physicians (ED physicians and internists) included the correct diagnosis in the differential in, on average, 3.4 histories, relative to 2.6 for the family practitioners (P = 0.001, d = .75). Diagnostic performance was fairly reliable (r = .61, P < 0.001). Clinical experience was negatively correlated with diagnostic accuracy (r = -.25, P = 0.008). Two structural properties of patient histories-cue consensus and cue substitutability-were significantly associated with diagnostic accuracy, whereas case difficulty was not. Finally, prevalence of diagnosis also proved significantly correlated with accuracy. CONCLUSIONS: Average diagnostic accuracy in cases with nonspecific complaints far exceeds chance performance, and accuracy varies with medical specialty. Analyzing cue properties in patient histories can help shed light on determinants of diagnostic performance and thus suggest ways to enhance physicians' ability to accurately diagnose cases with nonspecific complaints.

Discharge communication in the emergency department: physicians underestimate the time needed.

OBJECTIVE: In an emergency department, discharge communication represents a key step in medical care. The efficiency of this doctor-patient interaction could be hampered by two bounds: The limited time in emergency care and patients' mind's limited capacity to encode, store and maintain information. Such limitations are the focus of this study. Specifically, we examine the number of items physicians deem crucial in a discharge communication and the necessary time estimated to present them. METHODS: A vignette of a patient with chest pain was presented to 47 physicians (38 internists, 9 emergency physicians). Physicians were offered a list of 81 items possibly conveyed to patients and asked to select the important ones assuming a discharge interaction of 15 minutes. Additionally, 7 experts estimated the time required to communicate each item. RESULTS: Physicians' mean clinical experience was 10.1 years. From the list of 81 items, physicians selected, on average, 36 items (Range: 20-57). Experts rated the time necessary to communicate this subset to be 44.5 minutes - almost three times the preset 15 minutes. While emergency physicians, relative to internists, selected an insignificantly lower number of items (31.6 ± 6.2 vs. 37.4 ± 10.2), the time estimated for communicating the information was significantly shorter (36.9 ± 6.3 vs. 46.4 ± 13.5). CONCLUSIONS: Physicians in our study proved to be miscalibrated with regard to the number of items they could realistically discuss in a discharge communication. We conclude that there is an obvious need to train physicians in skills of implementing efficient discharge communication.