Is it safe to discharge the patient from the emergency room?

Safe Discharge from the Emergency Room: Assessment and Criteria

Before discharging a patient from the emergency room, a thorough safety assessment must be performed to ensure the patient does not require continued monitoring or intervention. This assessment should focus on identifying risk factors that could lead to deterioration after discharge.

Key Discharge Safety Assessment Components

For Patients with Suspected Cardiac Issues:

• Risk Stratification:

  • Young patients (<40 years) with non-classical presentations, no history of ischemic heart disease, normal serial biomarkers, and non-diagnostic ECGs have very low short-term adverse event rates 1
  • Patients with a HEART score of 0 (indicating <1% risk of major adverse cardiac events) can be safely discharged 2
  • Inpatient-derived risk scoring systems (e.g., TIMI Risk Score) should NOT be used to identify ED patients safe for discharge 1

• Diagnostic Testing:

  • Serial biomarkers and ECGs should be used in combination for selected low-risk patients 1
  • For patients with suspected ACS but negative initial workup, consider advanced testing such as CT angiography, cardiac MRI, or stress testing before discharge 1

For Patients with Mild Traumatic Brain Injury:

• Patients with isolated mild TBI who have a negative head CT scan result are at minimal risk for developing an intracranial lesion and may be safely discharged 1
• Patients with MTBI who present >6 hours after injury, have a normal clinical examination, and a head CT scan without acute injury can be safely discharged 1

For Patients with Suicidal Ideation/Attempts:

• Never discharge a patient with suicidal ideation without verifying the patient's account with their caretaker 1
• Before discharge, ensure:
  • Firearms and lethal medications will be secured or removed from the home
  • The patient has adequate support at home
  • Follow-up appointments have been scheduled
  • A safety plan has been created 1

Pre-Discharge Checklist

1. Clinical Stability:

   • Vital signs stable for at least 2-4 hours
   • Pain adequately controlled
   • No concerning symptoms requiring further monitoring

2. Risk Assessment:

   • Low risk for deterioration based on diagnosis-specific criteria
   • No signs of clinical deterioration in the hours before planned discharge 3

3. Home Support:

   • Verify that a supportive person will be available at home 1
   • Ensure the patient has transportation to return home

4. Follow-up Plan:

   • Scheduled follow-up appointment
   • Clear instructions on when to return to the ED

5. Patient Education:

   • Provide written discharge instructions (improves recall to 58% vs. 47% with verbal only) 4
   • Consider video instructions for even better comprehension (67% recall) 4
   • Ensure patient understands warning signs requiring return to ED

Special Considerations

Observation Units

• Consider observation unit management for low to intermediate-risk patients with conditions like heart failure instead of immediate discharge or admission 5
• This approach allows for continued treatment and more precise risk stratification

High-Risk Populations

• Patients recently discharged from ICU have higher cardiac arrest rates (14.7/1,000 vs. 6.8/1,000) and require extra caution before ED discharge 3
• Older patients require more thorough evaluation as they are more difficult to risk-stratify 1

Common Pitfalls to Avoid

1. Inadequate Risk Assessment:

   • Failing to identify subtle signs of deterioration
   • Not performing serial evaluations before discharge decision

2. Poor Communication:

   • Discharge instructions are often poorly remembered - only using verbal instructions results in only 47% recall 4
   • Failing to verify understanding of discharge instructions

3. Insufficient Follow-up Planning:

   • Not scheduling appropriate follow-up
   • Failing to ensure the patient has means to obtain prescribed medications

4. Overlooking Home Safety:

   • Not addressing access to lethal means for suicidal patients
   • Failing to assess home support system

Conclusion

The decision to discharge a patient from the emergency room should be based on a structured assessment of clinical stability, risk factors for deterioration, home support, and follow-up planning. Using condition-specific guidelines and ensuring comprehensive discharge instructions will help ensure patient safety after leaving the emergency department.