After the ER: Ensuring a Safe Transition of Care



By Laurie Ross

A trip to the emergency department or the hospital for asthma or anaphylaxis leaves most people drained of energy and fearful of another emergency.

How do you regroup and go about keeping yourself or your loved one healthy?

The key, say healthcare professionals, is communication – among patients, caregivers, physicians and hospital staff. And each play a central role.

Andrea Jensen of Salt Lake City, Utah, has three children with asthma and allergies – and has asthma herself. After multiple ER visits and hospital stays for asthma-related emergencies, she’s seen it all – and knows the challenges of coping afterward.

Her advice: “Listen closely to what the doctor and nurse say, especially on the discharge information, and don’t get distracted by the flurry of activity around you. If you feel pressured, ask to see a patient advocate. Ask questions.

“Find out what you need to do if symptoms return or get worse. Carefully read and follow every detail of the treatment plan the hospital gives you.”

When discharged from the ER, it’s critical to follow up with your doctor – a primary care physician or pediatrician, or if you or your child see a specialist, a board-certified allergist or pulmonologist.

“Coordination with your primary care physician or specialist is of the utmost importance to prevent another flare,” says W. Scott Russell, MD, medical director of pediatric emergency medicine at Children’s Hospital, Medical University of South Carolina.

Patients should not view emergency departments as a no-appointment-necessary doctor visit, Dr. Russell adds.

“What we are is a crisis unit,” Dr. Russell says. “We can acutely manage severe or moderate exacerbations, but we don’t routinely take responsibility for primary care or a long-term treatment plan. If you see one particular healthcare provider who understands you, understands the challenges you face, then you have a better chance of managing your condition long term with that provider than if you see five ER physicians over the course of two weeks of an exacerbation.”

Discharge Instructions

When you leave the ER or hospital, you’ll be given discharge instructions about how to care for yourself or your child at home. Some facilities will give you a written Asthma Action Plan or Allergy and Anaphylaxis Emergency Plan that spells out the details.

“Make sure information is given in a manner you understand,” Dr. Russell says. “Repeat back to the doctor or nurse what you understand and make sure it’s what they meant for you to understand.”

If possible, he suggests having someone with you to help – it’s hard to focus on details when you are worried, physically exhausted or in pain.

The discharge instructions may include a prescription for medication – a quick-relief bronchodilator inhaler for asthma or epinephrine auto-injectors for anaphylaxis. Get it filled right away.

Questions to ask at discharge include:

  • How long should I take my medicine?
  • What are the possible side effects?
  • Will it interfere with other drugs?
  • What activities should I avoid?
  • Are there danger signs I should watch out for that might indicate a relapse?
  • Is there someone at the ER clinic I can contact if I start to feel worse?
  • When and with whom do I follow up?

Follow Up With Your Physician

Think of the ER visit as a wake-up call: a chance to improve your understanding of your asthma or allergies and develop an effective prevention and treatment plan. The ER focuses on intense medical management; your physician’s job is preventing another acute episode.

“If you’re sick enough to go to the emergency room, you’re sick enough to see a doctor within the next few days,” Dr. Russell says.

The first thing you should tell your doctor is what you think triggered the asthma or anaphylaxis flare.

“I want to know what happened before you went to the ER and what happened there,” says J. Wesley Sublett, MD, a board-certified allergist with Family Allergy & Asthma in Louisville, Kentucky. “In the case of anaphylaxis, did you use your epinephrine auto-injector before going? Were you given more there? Did they discharge you with a prescription? Have you filled it? Keep all your discharge papers and notes with you when you leave.”

Dr. Sublett even urges patients to call him on the way to the ER, in order to begin the communication process right away.

Talk openly about your symptoms with your doctor so that you both arrive at the best treatment plan to keep you healthy. Be your own best patient advocate – insist on quality care.

Home Care: It’s Up To You Now

Remember, you are likely to be exhausted from the stress of the ER and possible lack of sleep. Andrea Jensen recommends:

  • Put a chart on the fridge that lists medication times and other reminders. Set alerts on your phone.
  • Make the follow-up appointment.
  • Accept offers of help from others – meals, groceries, child or animal care can help enormously.
  • If children are involved, contact teachers and the school nurse to explain what’s happened and how long the child is expected to be out of school; ask what to do to keep the child from falling behind. Contact siblings’ teachers as well, as this is a stressful time for the whole family.
  • Write down your version of what happened – when, what and how the episode developed – then take it to your follow-up appointment. This will help you remember questions to ask.
  • Realize that recovery will take time. The emergency is not over; it’s moved into a different phase. “I think people don’t understand that,” says Jensen. “They think the kids are fine and they’re just going to go back to school the next day, but no, they’re not. It takes time to get their strength back; it takes time for the swelling in their lungs to go down or the infection to clear out; it takes time for the child and parents to let go of the worry and anxiety.”

Reviewed by William Berger, MD, Eileen Censullo, RRT and Andrea Holka, executive director of AIRE Nebraska