Perceptions and experience of emergency discharge as reported by nurses and medical officers

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Australasian Emergency Care journal homepage: www.elsevier.com/locate/auec

Research paper

Perceptions and experience of emergency discharge as reported by nurses and medical officers Leahanna Stevens a,∗ , Margaret Fry b , Michael Jacques c , Arthit Barnes a a

Mersey Community Hospital Tasmanian Health Service North West, Australia Northern Sydney Local Health District, Faculty of Health, University of Technology Sydney, Royal North Shore Hospital, Level 7 Kolling Building, St. Leonards, NSW 2065, Australia c Royal Hobart Hospital, Tasmanian Health Service South, Clinical Facilitator, Flinders University, Australia b

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Article history: Received 11 July 2019 Received in revised form 27 November 2019 Accepted 12 December 2019 Keywords: Emergency medicine Discharge instructions Compliance Satisfaction Patient communication Discharge planning, patient safety, care transition, follow up

a b s t r a c t Background: Emergency Department (ED) discharge involves the communication of healthcare information to optimise patient safety, selfmanagement, and understanding and compliance with ongoing treatment. However, little is known about the discharge practices or processesn undertaken by emergency clinicians. Therefore, the aim of this study was to explore the experience and perceptions of managing ED patient discharge by clinicians. Methods: A qualitative descriptive study was conducted in one district Tasmanian hospital. Data collection involved face to face interviews with emergency clinicians. Results: Twenty-one (36%) (12 medical officers, 6 registered nurses and 3 nurse practitioners) emergency clinicians agreed to participate in the study. From the data, five key themes emerged; (1) managing emergency department discharge; (2) Managing the workload of discharge; (3) Working as a team to support discharge; and (4) Building a safety net for the transition of care and (5) Improving emergency discharge. Conclusions: Emergency discharge can be improved with the availability of a broader range of written patient discharge flyers, family and carer involvement, greater discharge role clarification, integration of electronic medical record and investigation ordering systems, defined nurse led discharge roles particularly after hours (after 4 pm) to improve the safety of patient discharged. Crown Copyright © 2019 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia. All rights reserved.

Introduction Timely patient discharge is important to ensure emergency department (EDs) patient flow is optimised, resources are appropriately allocated and capacity for treating new patients is available. Equally important is the quality of discharge communication to ensure the safe transition and/or transfer of care, thereby preventing patient harm, avoidable re-presentations, and poor selfmanagement and compliance [1–4]. Many studies [3,5–7] have identified that poor discharge outcomes have been associated with information deficits. Across Australia, during 2016–17, over 65% of people who presented to the ED were discharged to their usual place of residence

∗ Corresponding author. E-mail addresses: [email protected] (L. Stevens), [email protected] (M. Fry), [email protected] (M. Jacques), [email protected] (A. Barnes).

[8]. There is no evidence of how Australian ED clinicians communicate discharge instructions; allocate team discharge role activities; or perceive discharge planning activities [9,10]. Further, a number of studies [3–5,11,12] have identified that discharge information is often inconsistently, incompletely or sub optimally delivered by health professionals. Safe and timely discharge can assist to minimise patient adverse events, re-presentations and maximise self-management [13,14]. Failure to appropriately prepare a patient for discharge could have a significant impact on ED resource utilisation and hospital readmission [9,15]. There is little evidence across Australia if patients receive verbal or written discharge instructions or a combination of both [3,16,17]. Unclear or inadequate discharge communication, between the clinician, the patient and/ or their carer; can result in sub-optimal adherence and could potentially contribute to avoidable adverse events [13,14,18]. To date we know very little about how clinicians individually and as a team provide instruction and or arrange follow up care for

https://doi.org/10.1016/j.auec.2019.12.002 2588-994X/Crown Copyright © 2019 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia. All rights reserved.

Please cite this article in press as: Stevens L, et al. Perceptions and experience of emergency discharge as reported by nurses and medical officers. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.002

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patients being discharged from ED [3,7,13,16,19]. Therefore, the aim of the study was to explore perceptions and experiences of ED discharge, as reported by clinicians. Aim The aim of this study was to explore Registered Nurses (RNs), Nurse Practitioners (NPs) and Medical Officers (MOs) experience and perceptions of ED discharge practices and processes. Study method A qualitative descriptive study was undertaken over a two-year period (December 2016–December 2018). Data collection involved face to face interviews with emergency clinicians.

for accuracy and allowed researchers to be immersed in the data. Transcripts were imported into an electronic program (NVIVO 11TM ) where refinement of coding and thematic analysis emerged [21]. To enhance rigor and reduce subjective biases, coding was performed independently by two researchers (LS and MF) with consensus on analysis and interpretation achieved. Ethics approval Human Research Ethics Committee granted approval (H0015928) for the study. The conduct of the researchers was in accordance with the National Statement on Ethical Conduct in Research involving Humans [22]. Results

Setting This single-site Tasmanian study was conducted in one district hospital. In 2016–2017, there was approximately 25,522 presentations with an estimated 80% discharge rate [20]. The ED has two resuscitation, six acute and three sub-acute beds, and a fast track (two beds and one consultation room) area. The staffing profile consisted of 33 full time equivalent RNs, one nurse unit manager, one full time clinical nurse educator, three Nurse Practitioners (NPs), one director of emergency (split over two district hospitals), five emergency physicians, 10 registrars, and eight intern MOs. Sample A purposive sample of MOs, NPs and RNs were recruited for the study. Face to face interview technique was selected to enable the researchers to develop a deeper understanding of discharge processes within the ED context. The one inclusion criteria required that a participant have a scope of practice that enabled them to discharge patients or support safe discharge. ED staff were informed of the study through posters and flyers. The study was also disseminated and discussed in staff meetings, during handover and at in-service education times where clinicians were verbally invited to participate in a face to face interview. Interview tools A structured interview tool (22 items) was developed based on ED discharge literature. The interview questions directed clinicians’ thoughts towards discharge planning, management, communication and transition of care. The interview questions were open ended and were conducted over a four-week period and lasted on average 25 min. Data collection Interview data included demographics (age, gender), professional and clinical experience and discharge information (referral patterns, investigations, discharge communication, working as a team, follow up processes, safety process, patient self-management and discharge resources utilised). Analysis Demographic data were analysed using IBM SPSS v.21 and descriptive statistics were calculated depending on the variable level and distribution i.e. median and interquartile range (e.g. age) for continuous data and frequencies and percentages for counts (e.g. gender). Given the small sample size non-parametric testing (Mann-Whitney Test) was used for baseline comparisons between the two study groups (MOs and RNs). Qualitative data were analysed and interpreted through an iterative process using Gibb’s (2018) framework. Each interview was transcribed verbatim with each participant assigned a code. Then each interview was checked

Of the 58 emergency clinicians rostered during the time of interviews, 21 (36%) agreed to participate. The sample included 12 MOs, 6 RNs and 3 NPs. The median clinical experience was 8 years (IQR 3.2–21.0 years) and emergency experience 7.0 years (IQR 1.5–15 years). There was no statistical difference between MO and RN groups for health professional experience (Mann–Whitney U = 45.5, p = .554), ED experience (Mann–Whitney U = 49.5, p = .754), or age (Mann–Whitney U = 51.5, p = .862). Data saturation was reached after 18 interviews; a further three interviews were conducted to confirm data saturation. Five themes emerged: (1) Communicating discharge information; (2) Managing the ED workload and discharge processes; (3) Working as a team to support discharge; (4) Building a safety net for the transition of care; and (5) Improving emergency discharge. Theme 1: communicating discharge information Participants reported that appropriate communication could reduce a persons’ risk of re-presenting, improve self-management, clarify expectations of treatment and minimise disruption to family life once home. For many participants, ED discharge required the sharing of complex information with patients and/or carers. Both NPs and MOs spoke of providing discharge information that included diagnosis, investigation results, medication information and or self-management treatment directions. If I am happy for them to go home, then I would let the patient know what I think the diagnosis is if I know, or why I am happy for them [to] go home I suppose if there isn’t a definite diagnosis. . .and I would let them know any, what I want them to do at home. So if they need to take any analgesia, any antibiotics, anything like that, so describe their discharge medications, describe any particular ‘red flags’ that I would want them to trigger a representation to the emergency department. (Interview 5 MO) The majority of participants perceived that discharge information delivery varied and was dependent on patient condition, clinician knowledge, expertise and memory as the following typifies. I will also give them general advice. So if it’s like an illness you know if it gets worse, or develops any ‘red flags’, which I will explain it to them. If they have general concerns especially if it’s like a mum with kids so don’t be afraid to come on back. (Interview 6 MO) And Well usually before they go I might just speak some recommendations. (Interview 4 MO)

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Patient understanding of discharge information was important to all participants. While patient informedness was an important discharge goal for most participants this was not always achieved. In part, participants reported that discharge conversations were inconsistently delivered for many patients. I feel like I say things too quickly and sometimes I feel like I don’t ask them enough, for what questions and give them time to think of questions they might have. Well, I’m not sure what they mean by ‘how’, usually I just go and say who to followup with and what over the counter medications to take, what prescription medications to take, when to come back, for red flags and I do try to cover those things, like what they can do for themselves at home, but I guess sometimes I feel for red flags it would be better to give them something written, instead of just saying come back if this happens, or this happens, or this happens, but I try to cover those areas. (Interview 4 MO) Participants reported the use of different communication strategies to support patient understanding of discharge information. The communication strategies often used, by participants, to enhance patient understanding was repetition and requiring the patient to repeat back discharge instructions. For example: I try and ensure that they seem to be comprehending and understanding what I am saying and able to repeat back to me and often might give the discharge information. I might give them it twice like, I say so just to recap that this is what I think is going on and this is what I want you to do. (Interview 8 MO) And I always, at every point of care, when I am caring for a patient, I’m always talking to, you know, interacting with the doctors and actually discussing with the doctors what’s going to happen, what’s the next plan, you know, if they are having an ultrasound. So, I am actually informing the patient also and then I can actually get a better understanding into what’s really going on with the patient. (Interview 1 RN) All participants relied on verbal communication reinforcement, but many also used written information flyers. The majority of participants favoured providing patients with written information yet reported that the information flyers available were from different hospitals or states making the content less relevant. The following quotes illustrate. Sometimes I feel that for red flags it would be better to give them something written instead of just saying come back if this happens. But I try to cover those areas. (Interview 4 MO) However, given the limited number of written information flyers available many participants resorted to providing their own written instructions. Consequently, many of the participants wrote instructions on available paper. Sometimes I use a Post-it note and I write down the regular dosing of paracetamol and ibuprofen and the anti-nausea medication – which are just some of over the counter things [medicines] that you can take regularly for their pain. Just to remind them to take regular pain medications. (Interview 5 MO) However, a few participants perceived that the use of written information was unhelpful for patients or a waste of paper as the following typifies:

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cation of discharge information. Yet the ED workload and patient volume often impacted on a participant’s ability to ensure not only timely discharge but patient safety. The following theme explores this aspect of care practices. Theme 2: managing the ED workload and discharge processes While all participants spoke of the importance of safe discharge the majority reported that their ED workload limited the time available to spend with individual patients being discharged. Increased episodes of ‘busyness’ were perceived by all participants to influence the time they had to dedicate to discharge activities and processes. ‘Busyness’ was reported to escalate with a sudden rush of patient presentations, increased length of stay, and or general overcrowding. The following illustrates. Patients don’t always get a good deal with the senior doc[tor] cause you can pick a patient up, start, get pulled away, go back then you organise their test and then you get pulled away again, then there is delay going back with the result of the test. But certainly the time pressures. (Interview 5 MO) And You know, where it gets difficult. . . because you know we are under pressure, we are under time pressure so much of the time so yes it’s often not as good as it could be. (Interview 11 MO) The workload of the ED often created a time poor environment that reduced the opportunity to optimise discharge planning and patient preparation. Most participants reported that when ED workload increased they were often too busy to pursue the outcome of their discharged patient and were unsure of the appropriateness of the patient’s discharge process. There is nothing worse than when you are working up a new patient, and then the patient who was in [bed] three has just completely gone and you’ve got no idea. And you sort of think, Oh. . .OK was everything done? (Interview18 RN) However, when time permitted many participants reported that they were keen to explore patient education opportunities that focused on prevention and wellbeing. The following illustrates. Management of their acute condition is an opportunity for education to improve their overall health and literacy. You know, it’s an opportunity to immunise if they’ve not been immunised, it’s an opportunity to discuss with them their risky behaviour, it’s an opportunity and that includes alcohol, drugs, cigarettes and weight management by and large. It’s an opportunity to get people that are vulnerable to make a difference to their lives. (Interview 2 MO) However, the discharge of patients and opportunity for education was often secondary to other ED work activities such as caring for newly arrived or acutely unwell patients. For some participants when the ED became busy discharge planning was perceived at times to be less important. Theme 3: working as a team to support discharge

I think it’s a real problem, which is why we have discharge handouts but what’s the point of giving it to someone who is just going to throw it in the bin or can’t read it. (Interview 8 MO)

In contrast to the RN, MOs and NPs reported that they were responsible for the decision to discharge a patient. However, how MOs and NPs communicated these decisions to and interacted with the team and specifically the RN was less clear. For the majority of participants discharge communication between team members relied on passing conversations during clinical encounters.

For many participants the role of emergency discharge was to maximise patient safety and reduce risk through the communi-

‘. . . maybe we could work on our communication a little bit better. Between medical staff and primary care nurse just to

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say, “Hey look we are going to send this patient home. This is what we are doing. Do you have any concerns? That would be really great. (Interview 18 RN) The role of the RN in discharge conversations was unclear. The RN reported to confirm verbally with the relevant MO/NP about whether a patient could or would be discharged. However, at times a patient would advise the RN that they could be discharged, but this did not always correlate with the MO/NPs decision. To confirm disposition the RN needed to locate the appropriate MO/NPs and have a verbal conversation about discharge. First thing is I confirm with the Dr that they are actually able to be discharged, just been caught there a couple of times when the patient thinks they can go home and Dr’s been like ‘No they need to stay- I’ve got to do this or that. (Interview 16 RN) The reported role of the RN in the discharge process was to assist in confirming with the patient their understanding of discharge information. However, the structure, content, quality or effectiveness of these conversations was unclear. Registered Nurses’ reported that their primary discharge role was focused on ensuring patient’s understanding of discharge services, self-management needs, support services and referral(s) as the following quote illustrates. By ensuring a) that they understand b) that they don’t forget and know when to take their tablets, when to come back, when to be worried or not. (I16 RN) And I think the other thing to do is make sure the patient knows where to go to get further advice if they need it, and if they don’t understand or they are not sure generally that will be their GP, or if they have got supportive services in place, palliative care, community nurses, that sort of thing, that may be appropriate, diabetic educator, you know, those questions should go to that particular place. (Interview 18 RN) Working as a team was important for participants when determining if a patient was safe for discharge. However, participant knowledge, level of expertise and skills varied across disciplines and this influenced their approach to discharge, with less experienced MOs seeking advice before the discharge of a patient. Junior Doctors don’t pick up on those cues anywhere near as much particularly if this culture is not the culture you grew up in. I think that sometimes verbal cues of rabbit in the headlights and I haven’t a clue what you’re saying to me I’ll just say yes because I’ve got no understanding I’ll just find someone else. That look I don’t think they’ve picked that up at all. (Interview 8 MO) And as the following junior medical officer details First, I would get approval from the senior doctor that they’re safe to go home and ask if what/if they should follow up with their GP or what recommendations. Check with them about what prescriptions or follow up they should have. Then I would go talk to the patient and tell them that they’re safe to go home, and [give] their follow up instructions, I would give them their prescriptions and sometimes I would give them written by me or printed out material and I would ask them if they had any questions. But sometimes I would forget to do that task, ask them if they had any questions. (Interview 4 MO) Discharge responsibilities and actions were largely reliant on established knowledge and verbal team communication. However, the discharge process was reliant, for both RNs and MOs, on adequate time for preparation, explanation of risks, treatments, health

goals and self-management. RNs reported the need to avoid missing a vital piece of information before a patient was discharged that might adversely impact on patient outcomes, self-management, or treatment once home. So at the end of our patient care with the patient I ensure sure they are absolutely safe before they go home, if not, and they understand everything that we are saying and I make sure they can walk and they can take themselves to the toilet, there’s no issues around the fact that they feel a bit dizzy or anything they need physio input. I make sure that’s been implemented, you know, all the issues. If they have outpatient services that have to go, I sit down and I explain, and sometimes I can explain about ten times before that patient, you know, because sometimes if that patient is sick they don’t hear what you are trying to tell them. So I try and actually talk to them and say is there somebody I can talk to who lives with you at home who can come in and then I explain the whole process to them. (Interview 1 RN) Some participants spoke of the need to increase opportunities to get together as a team and reflect on what would best assist a patient being discharged to improve quality, consistency and safety. For example; In an ideal world, maybe a pit stop, just before they actually leave the department, to say OK, do you have your medical certificate? Do you have your script? Do you understand the plan? I don’t know if its liaison person or if it has to be a nurse. Because a lot of the time they are out of the bed and there is a new person. (Interview 18 RN) While the decision for patient discharge was clear to NPs and MOs, how this was communicated between team members was not well elucidated by participants. Nonetheless, all participants working in their team viewed that the ED provided a safety net for patients and that the environment supported the transition of care.

Theme 4: building a safety net for the transition of care All clinicians expressed that for a safe transition of care discharge processes needed to: involve family and carers; community referral(s); support patient understanding; and convey the reasons for returning to ED. For all participants, families and carers played an important role for safe discharge planning. In fact, the absence of family or a carer support at home could alter a discharge decision and instead require a patient to remain in hospital. I do think carers and family play a big part cause it’s not just one person that comes in its their whole surrounds. (Interview 18 RN) And In terms of discharging the patient so for [sic] there are other people in a better place for that but if somebody was going home I would need to know that they can ambulate sufficiently to do their activities of daily living. And hopefully have some back up. If there was no doubt that there was no relatives or anything I would probably admit them if I was worried. (Interview 20 MO) Yet, there did not appear any criteria or systematic approach to predict whether a patient was safe for discharge. Across the ED the process was more dependent on why the individual presented; and discharge was more diagnostically driven. Indeed, for people arriving to an ED with additional co-morbidities, such as hypertension or diabetes, the prevailing view was that these chronic of conditions were better managed by general practitioners.

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I suppose it would give me pause for thought but. You know, for example, if it was moderate hypertension and we had a plan for follow up with the GP. I wouldn’t necessarily keep them in the ED. (Interview 5 MO) For many MOs community health service referrals provided an important safeguard for patient discharge. However, participants relied on patients to adhere to discharge advice and make referral follow up appointments to general practitioners or medical specialists. However, there was always a concern as to whether patients followed discharge advice. Sometimes you tell them to go a see the GP, but there is no way of really knowing or easy way of knowing if they have done that, unless you phone up. (Interview 4 MO) Despite often providing ED discharge referrals participants were unsure if patients were able to obtain a timely referral appointment. A few participants supported the notion of the ED making discharge referral appointments for patients before leaving the ED. The following illustrates. If there was any easy way to book patients for a GP follow up appointment from the ED. (Interview 5 MO) Participants reported that unless a patient returned to the ED, compliance with follow up referrals and/or patient outcomes was largely unknown. Many participants reported that they had minimal time to follow up patients, laboratory or radiology results given their workload and rotating shifts. As a result, the major safety net cast by participants involved a spoken discharge caveat, which was viewed by all to maximise safety and that was to encourage patients to return to the ED. For example I do always say to them that if you cannot get into a GP then to come back to us any time of the day. (Interview 2 NP) The caveat was delivered by all participants and sought to overcome symptoms of deterioration, a lack of patient self-management or discharge instruction adherence. It still doesn’t guarantee that they’re going to go back but at least I’ve taken steps to know that I’ve done everything in my power to make sure that they have some adequate follow up. (Interview 3 NP) Building a safety net for the transition of care was viewed as challenging for participants given their workload, roster and time constraints. Yet, all voiced the importance of maintaining patient safety and integration of care with community services. For a few participants they reported potential areas for improvement that might better standardise ED discharge and create a more consistent approach. Theme 5: improving emergency discharge Participants voiced a variety of strategies to improve ED discharge. A common suggestion provided by some participants was to provide patients with a discharge letter. In this department patients were not provided with a discharge summary, instead a discharge summary was electronically sent to general practitioners. A few participants perceived that providing a patient with a discharge letter may better assist to improve understanding and enhance compliance with discharge instructions. I’ve been thinking it would be helpful to give the patient a copy of this [discharge summary] as well, just in case they’ve changed their GP or somehow it gets lost. . . So I would always write the written discharge instructions for the GP or the patient’s records or the track ED computer system. Then I would usually write

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for the GP to discuss with patient ongoing follow up with these issues. But I wouldn’t give the patient the printed out copy, but maybe I should. (Interview 4 MO) Communication was reported as important for an efficient discharge process, both between patients and clinicians, and RNs and MOs. However, discharge communication relied on verbal conversation that was often perceived as suboptimal. For many participants the ad hoc discharge communication process would benefit from a more structure approach and/or framework. I think some more awareness of having a really structured discharge plan just different information techniques. How do we relay information to these patients effectively based on clinical presentations, based on family dynamics, based on individual circumstances. (Interview 3 NP) The majority of participants spoke of resource constraints, which would often limit the capacity to support a safe and timely transition of care. Participants reported it was necessary to wait for investigation reports and then treatment to be completed before they could determine the appropriateness of discharge and only then participants would identify resources needed to support the transition of care. Not all services needed to support safe discharge were available after business hours, which meant at times a discharge decision could be altered. We have to ring somebody up and then they might be busy and usually by the time we decide if they’re fit for discharge it’s when these guys are going home. . . It’s resource-constrained. (Interview 20 MO) Improving discharge for one participant was based on a need to increase funding. Primarily the view reported was that safe discharge was dependent on increased funding. The barriers to [discharge] are number 1 is money, number 2 is money number 1 and 2 and 3 are money, number 4 is imagination of our greater bosses to think about how we can do this better, fear, fear of privacy and confidentiality, but most importantly we fear of being criticised by the patient. Fear of things getting out into the sphere. (Interview 8 MO) For some participants, a nurse led discharge or referral role provided another solution for timely and consistent discharge. Nurse led discharge roles were suggested as an appropriate solution for a range of non-complex conditions. Participants reported that RNs, and specifically triage nurses, could refer or discharge patients to general practitioners. For example Unfortunately, the triage [nurses] doesn’t have the power to send the people to their GP. I think the triage should have the power to send the patient to the GP. (Interview 6 MO) Similarly, RNs and MOs considered the development of a discharge nurse role would facilitate timely and safe ED discharge. However, how a nurse led discharge role would be operationalised was unclear from participants. It would be really nice to have a discharge nurse. (Interview 4 MO) Having a formalised discharge system could better ensure the safety of vulnerable groups. Participants identified vulnerable groups that would improve with more formalised discharge processes. Increasing discharge planning services would be very useful actually especially for the elderly there isn’t a great deal of support for them. (Interview 2 NP)

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For many participants, improving ED discharge was considered achievable with a broader range of available written discharge documentation. It would be nice to have a standardised group of patient handouts that we could easily access that were relevant to the area. Like when you give someone a X handout the content is perfect, but sometimes the referral processes, who to look out for or where to go next obviously says X hospital. (Interview 1 TNP) Many participants reported ED discharge could be improved through stronger family and carer involvement; improved electronic medical record integration with investigation reporting systems; and nurse discharge roles. Further, ED discharge would improve through better defined discharge team roles, nurse led discharge criteria, and after hour discharge resources.

Discussion Participants in this study reported on the importance of safe discharge and their strategies to ensure patient understanding. Patient informedness was a priority for all participants, but time and resource constraints often limited a participant’s ability to ensure optimal information delivery and patient comprehension. Similar findings were evident within the literature [4,23–25]. Nonetheless, an Australian single site ED study [26], demonstrated that the majority of people discharged home were satisfied, safe and felt confident to be discharged. At the study site, verbal conversations were mainly relied upon to share discharge information. At times this was perceived by participants as suboptimal and that a more structured approach to discharge would benefit both patients and staff. A more structured approach for discharge has been well supported in the literature [3,17,27,28]. Further, screening tools has been shown to increase safety, reduce re-presentations and provide for a more structured approach to discharge communication [4,29,30]. In this study, team members interacted together to share discharge information, but these opportunities were dependent on opportunistic interactions rather than a structured collaborative discharge team approach. Furthermore, some participants reported that they were unaware that a patient they were caring for had left the ED and were unclear about the discharge information delivered. These findings suggested a lack of team coordination and communication. Improving team discharge role clarity, behaviours and activities could assist to standardise ED discharge practice [4,25,31–33]. To date there is a paucity of literature that has examined interdisciplinary team collaboration and ED discharge [3,4,28,34]. From the interview data, participants would inform patients being discharged about ‘red flags’ with the aim of improving safety, reducing anxiety and empowering patients to return to seek appropriate medical assistance. While the ‘red flags’ were conveyed verbally, they provided the patient with a plan to return to the ED or GP if symptoms or conditions persisted or emerged. However, conveying appropriate ‘red flags’ was dependent on participant’s knowledge, experience and expertise and so in absence of providing a patient with the appropriate ‘red flags’ discharge may be suboptimal. This could be especially so for junior MOs who were responsible for the delivery of discharge information despite senior MO oversight. Further research is needed to explore the structure of discharge content and the communication of ‘red flags’ to improve patient understanding and ensure appropriate re-presentation [25,31,35,36]. A nurse led discharge model of care was reported as a solution to assist with timely ED patient discharge, which has also been reported by other researchers [13,31]. Clearly, for a nurse

led discharge model of care, structured guidelines would need to be developed to enable early referral and/or discharge of patients with non-complex conditions. Potentially, the model of care could be enhanced with the inclusion of predictive algorithms to support early referral or discharge [37–39]. Internationally nurse led discharge models have been shown to maintain patient safety and improve outcomes 31,40,41]. The range of prepared written information was limited to a few conditions at the study site. Most participants valued having these available to give to patients. But all reported that the information flyers came from different hospitals and organisations and that the lack of standardisation and context specificity made their usefulness limited. Instead, embedding within emergency electronic medical record systems context specific information flyer templates could better support discharge planning [38]. Furthermore, sending discharge information electronically to discharged patients may also prevent loss of information and be a record for future reference. Research is needed to explore the value and utility of verbal reinforcement and/or written information received by patients on satisfaction, adherence, compliance and self-management [3–5,25]. Many participants spoke of referring patients to community based practitioners for follow up care. However, participants were unsure whether a patient attended their follow up appointment. A few participants suggested that ED-made appointments for a person’s follow up appointment(s) may improve compliance. However, two studies, which examined the impact of ED-made appointments on re-presentation rate and compliance found no difference [42,43]. Limitations There are a number of limitations that could be considered in relation to these findings. Given that purposive sampling was used and staff self-selected the data may not be representative of everyday ED discharge practice. Data collection relied on clinician recall, which may not be reflective of everyday practice or behaviour. Therefore, response bias may have influenced the interpretation of findings. Interviews were conducted over a four-week period, which may have limited the opportunity for staff to participate and provide a different viewpoint. Consequently, the findings may not be applicable to ED clinicians. The interview schedule was not tested for validity or reliability and so the findings may not be representative of discharge activities. Transcripts were not returned to participants and so confirming the transcript and support of the subsequent findings may be low. Conclusion This study has provided insight and understanding into how emergency clinicians undertake discharge activities. EDs could consider strategies that promote team communication and role clarification of RNs, NPs and MOs when managing discharge planning, assessment and referral. The findings highlighted that ED discharge could be improved with a broader range of prepared written information flyers and patient discharge documentation. These findings could be used to better inform discharge policy and guidelines for emergency clinicians to enhance the discharge process and patient outcomes. Author contributions MF, LS, MJ and AB conceived the study, design the trial and obtained the research funding. MF, LS, MJ and AB supervised the

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Please cite this article in press as: Stevens L, et al. Perceptions and experience of emergency discharge as reported by nurses and medical officers. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.12.002