Overlooking Barriers to Safe and Effective Emergency Department Discharge

Physician awareness of a patient's social and functional barriers to effective and safe care after discharge from the emergency department (ED) is crucial. Yet, limited data exist evaluating the ability of resident physicians to identify these barriers.

We performed a prospective cohort study of patients age ≥ 18 at a single urban ED with an emergency medicine (EM) residency program from 10/2024 to 5/2025. A research team member assessed barriers with each patient, including transportation access, difficulty affording medications, need for assistance with activities of daily living (ADL), and lack of a primary care provider. We measured health literacy and cognitive function with the Rapid Estimate of Adult Literacy in Medicine-Revised and Mini-Cog, respectively. Patient report or measurement of barriers (criterion standard) was matched to written survey data completed by the EM resident caring for the patient. We calculated sensitivity of resident identification of barriers and measured agreement using Cohen's kappa.

The sample included 234 patients with complete barrier data cared for by 40 EM residents. Patients consistently reported barriers at higher rates than physicians. Physicians had poor sensitivity for accurate identification of patient barriers. For example, 20.4% of patients reported they had no primary care physician (PCP) and 9.8% of residents reported their patient had no PCP [sensitivity 26.1% (95% CI 14.3-41.1), κ = 0.25]. Limited health literacy was identified in 59.0% of patients and reported by 37.6% of residents [sensitivity 44.7% (95% CI 35.7-53.9), 57.7% agreement]. Abnormal cognition was present in 53.6% of adults age ≥ 65 and reported by 16.7% of residents [sensitivity 27.3% (95% CI 13.3-45.5), 58.6% agreement].

Patients report barriers to effective care transitions after ED discharge at higher rates than resident physicians identify these barriers. Poor agreement between patient-reported and physician-identified challenges suggests a need for enhanced training, systematic screening, and interdisciplinary collaboration.