General points

Safe and robust discharge plans are vital to the care of our patients.

Consider this checklist whenever you are discharging patients from the ED:

• Is it safe?
  • Have a low threshold for SSOU admission overnight if it is late and they are elderly or from out-of-town (see Special Patient Groups).
• Have you given the patient:
  • printed discharge summary
  • written instructions and advice, including an analgesic plan if relevant
  • printed information sheets or handouts
  • discharge script
  • medical/workcover/TAC certificates
• Have you communicated with the NOK?
• Have you communicated with the nursing home or care facility?

Ensure the patient is discharged from EPR with the time recorded they actually left the department, not the time you discharge them from EPR. This ensures the data collected on EPR accurately reflects the patient’s length of stay in ED.

Communication and documentation

Prior to going home, ensure you have a discussion with the patient and their family covering the following:

• Diagnosis
• Anticipated clinical course
• Self-care at home
• Reasons to return
• Follow-up advice

Give them an opportunity to ask questions and ensure understanding. It is good practice to give written information, in plain language, which may be as simple as a handwritten note or, as an example, a quickly typed management plan.

When you are prescribing a pain management plan, particularly if it is involving multi-modal analgesia, it is vital that you give patients a written plan and information.

Where appropriate, provide written hand-outs. Useful resources for these include:

• The Royal Children’s Hospital for anything paediatric
• Safer Care Victoria patient fact sheets, including for chest pain and abdominal pain
• Better Health Channel for general factsheets, both adult and paediatric
• The Royal Woman’s Hospital for pregnancy related factsheets
• Emergency Care Institute (New South Wales). While not from this state, this resource has some excellent handouts, including some translated into other languages:

Make sure you are aware of the contents prior to giving it to the patient so that you are able to answer any questions. It is often easier to get the patient to look up the resource on their phone than printing it out for them.

Document your discussion and any handouts provided in the notes.

Dealing with diagnostic uncertainty

In general, clinicians and the general public are becoming less tolerant of diagnostic uncertainty. This can lead to a heavy reliance on tests, which can lead to increased morbidity and utilisation of limited resources.

Share with patients that not test is ever definitive and that some diagnoses are purely clinical.

Take care in giving patients a misdiagnosis or wrong label, as this can initiate diagnostic momentum.

It can be helpful to explain that today we know what their symptoms are not (certain serious conditions) and sometimes time is needed to make a diagnosis. Reassure them that they don't need further treatment in hospital today and that it is safe for them to go home. Do not say to them 'there is nothing wrong with you'. 

Nursing Home Patients

If discharging a patient back to a nursing home, ensure you take the following steps:

• Phone the nursing home to provide a verbal handover and explain that the patient will be returning
• Notify the family
• Print out a discharge summary to go back with the patient to the nursing home. The electronic version only gets sent to the GP. If it is not sent with the patient, the nursing home will not get a copy of this.
• If starting a new medication, provide a drug chart and prescription (if out-of-hours, provide the medication from ED)

See the section Special Patient Groups for further information

Discharge summaries

A discharge summary should be completed for every patient sent home from ED or SSOU (done on EPR). Ideally do this at the time you discharge the patient, at least do it by the end of that shift. For patients who gave GP details at registration, the summary is sent directly to the GP practice. If a patient does not have a regular GP, is from inter-state, you have asked them to follow-up with someone other than their regular GP (including a specialist) or there are specific instructions for the patient to follow, give them a copy of the discharge summary prior to them leaving.

Here are few tips:

• If you want the patient to see their GP within a few days of leaving the ED, give them a hard copy of their discharge summary and tell them to bring it with them to the appointment. While the electronic summary should have got to them, sometimes it hasn’t, can’t be located or has gone to a different GP.

• The GPs are busy, they want to know the bottom line, not necessarily get every single piece of the patient’s medical record copied in. This is fine for a quick AC patient. If a patient has been in the department for many hours, multiple notes written or a SSOU patient, either be selective what you include or write a brief summary. Consider a brief summary with the key information and then include the notes for reference.

• Likewise, taking a minute to fill out a few more of the available fields (reason for presentation, clinical summary, complications) give some of that bottom line information GPs want. To add a diagnosis to the GP letter, go to 'Notes', from the left hand menu select 'add ED diagnosis' and complete the diagnosis here.

• If there are specific things you would like the GP to do, make this very obvious. Write this in the clinical summary box. They may miss something if it is buried in body of the notes.

• If you would like the GP to follow-up some blood tests or other investigation, ensure you include them on the request as a recipient of the results so that they actually receive the result.

• Language matters, GPs are experienced doctors, experts in primary care. Rather than giving instructions, ‘please do x/y/z’, ask them to ‘consider x/y/z if they feel appropriate’ or ‘work-up patient as they see fit’. They know the patient’s history, what has been done previously, what is the most appropriate follow-up in a GP setting. Think how challenging it is to manage a patient with fixed expectations after they have been told by the GP that ED will do x/y/z for them (organise an MRI for their six months of back pain), it is the same for the GP.

• Language matters, the phrase ‘GP to chase’ is a phrase that rubs GPs up the wrong way as much as them asking us to ‘do the needful’ has the same effect on us (me at least). Something like ‘please follow up patient’s blood/xray result’ is better. Also make sure they are copied in other receive the results to make it easier for them.

Medical certificates

Ask patients and carers if they need a medical certificate. It is much easier to do this when they are here than for them to have to return.

WorkSafe/TAC certificates

If someone presents after a work-placed incident or incident on a public road, you will need to complete a specific work-Safe/Transport Accident Commission (TAC) form rather than a standard medical certificate. The clerks at triage will note which patient presentations are eligible for these.

Your role as the treating doctor is to complete a Certificate of Capacity, which is not the same as a standard sick leave certificate. The purpose is to document the specific limitations caused by the injury and its treatment and to recommend modifications of movement. This allows the employer to plan suitable return to work arrangements.

Whilst their injury may prevent them from performing their usual role and tasks (their “pre-injury employment”), the benefits of returning to the workplace, even in a limited capacity (“suitable employment”) are recognised for both employees and employers.  It is the responsibility of the employers to provide suitable alternate duties, allowing for the restrictions that the employee’s injury has placed on their movement. These duties may include office and online tasks, training and education.

It should be the aim to ensure that an injured worker returns to the workplace as soon as possible, either the day of the injury, where possible, or the day after. This short amount of time should be noted as “No capacity for employment” and refers to absolute sick leave. Injured workers may have different expectations, including that they will be granted automatic time off work following injury; however, this is not the intention of the WorkSafe provisions.

Some important notes:

• Inability to drive does not preclude from suitable employment (alternatives include other travel to work arrangements or working from home)
• Use of crutches or slings does not preclude workers from being capable of suitable employment
• Use of simple analgesia should be encouraged; if opiates are required, caution is recommended, both from a prescribing perspective as an ED doctor, and also from a WorkSafe perspective. The minimum dosage and number of tablets should be dispensed or prescribed, and provisions made for close follow-up.

Important to note whether it is a WorkSafe or TAC Claim (it can be uncertain, e.g. patient has an accident whilst driving for a work-related task ==> WorkSafe, not TAC).

“Estimated timeframe to return to work” should indicate that patient will be able to return to workplace within 1-2 days ideally. These timeframes are independent of rostering. It is not the certifying doctor’s role to determine the correct shift.

Please make an effort to tick all three boxes. If a patient requires a separate medical clearance before return to usual active duties, leave this box blank. Otherwise, you should be able to specify their immediate Return to Work (within a day or so, with this certificate), and a period of modified duties required before resuming their usual active role.

If you are unsure, please ask for assistance!

Patient Follow-up

As a general rule, patients should be directed back to their GP for ongoing follow-up.

With a few exceptions (fracture clinic, EPAS etc.) we do not refer patients from ED to outpatients clinics.

See the Referral Options tab for further details.

If in doubt, discuss with your supervising consultant.