Evaluation of the R2D2 protocol: A Novel Method for Assessing Emergency Department Disposition for Residents

The emergency department (ED) disposition and discharge process is a critical period in a patient's transition from an acute care setting to self-care or a bridge to other healthcare providers. The emergency physician plays a pivotal role in this process and is ultimately responsible for ensuring that patients are safely released from their care. We developed a protocol to guide residents through the ED discharge process using the mnemonic "R2D2": reassess the patient, recheck the workup, discuss the disposition plan with the attending, and finally discuss the discharge plan with the patient.

The objective was to assess the effectiveness of the R2D2 discharge protocol, executed by resident physicians, in improving patients' understanding of their diagnosis and treatment plans.

This is a before-and-after study in the ED of a county hospital and included all patients discharged by a resident physician from the ED 1 week before and 1 week after implementation of the R2D2 protocol. All participating resident physicians received a brief 10-minute orientation to the R2D2 protocol at the end of the first week of the study period. Consecutive patients were identified, consented, and given a brief questionnaire about their discharge by research assistants. Certain exclusion criteria applied such as inability to speak English or Spanish or no phone for follow-up. One to 2 weeks after ED discharge, patients from both groups were contacted by phone to assess their recall of their discharge instructions. Data analyses were performed using Fisher's exact, chi-square tests, or two independent-sample proportions tests as appropriate.

We recruited 164 patients in the control group and 148 patients in the intervention group, totaling 312 patients. A total of 73.8% of the control group patients and 77.0% of the intervention group patients completed the follow-up. On telephone follow-up, 88% of the intervention patients knew their discharge diagnosis versus only 74% of control patients (p = 0.0062). Eighty percent of intervention patients knew their discharge treatment plan versus only 67% of control patients (p = 0.0259).

The R2D2 protocol resulted in significant improvement in patients' understanding of their discharge diagnosis and treatment plan.