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

Background: 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. Objectives: 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. Methods: 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. Results: 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). Conclusions: The R2D2 protocol resulted in significant improvement in patients' understanding of their discharge diagnosis and treatment plan.