Barriers to compliance with emergency department discharge instructions: lessons learned from patients' perspectives

The objective of this study is to understand patients' perspectives about system-based barriers that may influence decision-making regarding following discharge instructions. In this qualitative study, subjects were interviewed by phone 1-4 weeks following being discharged to home from the emergency department (ED). We used a semi-structured interview guide to ask a series of open-ended questions about subjects' recent ED visit and subsequent course, including discharge instructions, whether or not they complied with those instructions, and reasoning behind their decisions to follow-up or not. All interviews were recorded and transcribed to identify themes among the transcripts, which were analyzed to identify barriers to compliance. While the majority of those interviewed expressed no specific concerns or challenges, four system-based themes did emerge regarding patient attitudes toward and experiences with discharge instructions. They were: (1) failure to ensure clarity about diagnosis at the time of discharge from the ED, (2) failure to identify patients' feelings of hopelessness regarding the utility of follow-up, (3) difficulty in scheduling follow-up appointments, and (4) the importance of a clear discharge process. This study finds several system-based barriers might influence compliance. The four identified themes suggest a recurring cycle of visiting the ED, being discharged to primary care or specialists, and ultimately returning to the ED. We propose that systems-based interventions may help to break this cycle.