51
|
Minen MT, Boubour A, Wahnich A, Grudzen C, Friedman BW. A Retrospective Nested Cohort Study of Emergency Department Revisits for Migraine in New York City. Headache 2017; 58:399-406. [DOI: 10.1111/head.13216] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 09/06/2017] [Accepted: 09/06/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Amanda Wahnich
- New York City Department of Health and Mental Hygiene; New York NY USA
| | - Corita Grudzen
- Department of Emergency Medicine; NYU Langone Medical Center; New York NY USA (C. Grudzen)
| | - Benjamin W. Friedman
- Department of Emergency Medicine; Albert Einstein College of Medicine; New York NY USA
| |
Collapse
|
52
|
Goldman MP, Monuteaux MC, Perron C, Bachur RG. Identifying discordance between senior physicians and trainees on the root cause of ED revisits. Emerg Med J 2017; 34:825-830. [PMID: 28801485 DOI: 10.1136/emermed-2016-206444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 06/26/2017] [Accepted: 07/15/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Analysis of 72-hour ED revisits is a common emergency medicine quality assurance (QA) practice. Our aim was to compare the perceived root cause for 72-hour ED revisits between senior physicians (attendings) and trainees. We proposed that discordance in perception of why the revisit occurred would guide improvements in 72-hour revisits QA and elucidate innovative educational opportunities. METHODS Questionnaire-based observational study conducted in an urban academic paediatric ED. Treating attendings and trainees independently completed questionnaires on revisit cases. The primary outcome was the revisit's perceived root cause, dichotomised into 'potential medical deficiency' or 'not potential medical deficiency'. Discordance between provider pairs was measured, stratified by revisit disposition. RESULTS During the study period, 31 630 patients were treated in the ED, 559 returned within 72 hours and 218 met inclusion criteria for paired analysis. The proportion of cases assigned 'potential medical deficiency' by the attending and trainee was 13% and 9%, respectively. Discordance in the dichotomised root cause between attendings and trainees was 17% (38/218, 95% CI 12% to 22%). Revisit cases requiring admission revealed attending-trainee discordance of 25% (23/92, 95% CI 16% to 34%). CONCLUSIONS Attendings and trainees frequently disagree on whether a potential medical deficiency was the root cause for an ED revisit, with more disagreement noted for cases requiring admission. These findings support the premise that there may be opportunities to improve 72-hour revisits QA systems through trainee integration. Finally, reuniting attending-trainee pairs around revisit cases may be a novel educational opportunity.
Collapse
Affiliation(s)
- Michael P Goldman
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine Perron
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
53
|
Lauque D, Fernandez S, Lecoules N, Charpentier S, Azéma O, Edlow J, Bellou A. Revue de la littérature sur les retours précoces aux urgences pour améliorer la qualité et la sécurité des soins. ANNALES FRANCAISES DE MEDECINE D URGENCE 2017. [DOI: 10.1007/s13341-017-0737-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
54
|
Samuels-Kalow ME, Rhodes KV, Henien M, Hardy E, Moore T, Wong F, Camargo CA, Rizzo CT, Mollen C. Development of a Patient-centered Outcome Measure for Emergency Department Asthma Patients. Acad Emerg Med 2017; 24:511-522. [PMID: 28146297 PMCID: PMC5426977 DOI: 10.1111/acem.13165] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 12/26/2016] [Accepted: 01/14/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Measuring outcomes of emergency care is of key importance, but current metrics, such as 72-hour return visit rates, are subject to ascertainment bias, incentivize overtesting and overtreatment at initial visit, and do not reflect the full burden of disease and morbidity experienced at home following ED care. There is increasing emphasis on including patient-reported outcomes, but the existing patient-reported measures have limited applicability to emergency care. OBJECTIVE The objective was to identify concepts for inclusion in a patient-reported outcome measure for ED care and assess differences in potential concepts by health literacy. METHODS A three-phase qualitative study was completed using freelisting and semistructured interviewing for concept identification, member checking for concept ranking, and cognitive interviewing for question development. Participants were drawn from three tertiary care EDs. Parents of patients (pediatric) or patients (adult) with asthma completed a demographic survey and an assessment of health literacy. Phase 1 participants also completed a freelisting exercise and qualitative interview regarding the definition of success following ED discharge. Phase 2 participants completed a member checking survey based on concepts identified in Phase 1. Phase 3 was a pilot of trial questions based on the highest-ranked concepts from Phase 2. RESULTS Phase 1 enrolled 22 adult patients and 37 parents of pediatric patients. Phase 2 enrolled 41 adult patients and 200 parents. Phase 3 involved 15 parents. Across all demographic/literacy groups, Phase 1 participants reported return to usual activity and lack of asthma symptoms as the most important markers of success. In Phase 2, symptom improvement, medication use and access, and asthma knowledge were identified as the most important components of the definition of post-ED discharge success. Phase 3 resulted in five questions for the proposed measure. CONCLUSIONS A stepwise qualitative process can identify, rank, and formulate questions based on patient-identified concepts for inclusion in a patient-reported outcome measure for ED discharge. The four key concepts identified for inclusion: symptom improvement, medication access, correct medication use, and asthma knowledge are not measured by existing quality metrics.
Collapse
Affiliation(s)
| | - Karin V Rhodes
- Office of Population Health, Hofstra Northwell School of Medicine, Great Neck, NY
| | - Mira Henien
- Drexel University College of Medicine, Philadelphia, PA
| | - Emily Hardy
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Thomas Moore
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Caroline T Rizzo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Cynthia Mollen
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| |
Collapse
|
55
|
Chan AHS, Ho SF, Fook-Chong SMC, Lian SWQ, Liu N, Ong MEH. Characteristics of patients who made a return visit within 72 hours to the emergency department of a Singapore tertiary hospital. Singapore Med J 2017; 57:301-6. [PMID: 27353286 DOI: 10.11622/smedj.2016104] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION 72-hour emergency department (ED) reattendance is a widely-used quality indicator for quality of care and patient safety. It is generally assumed that patients who return within 72 hours of ED discharge (72-hour re-attendees) received inadequate treatment or evaluation. The current literature also suggests considerable variation in probable causes of 72-hour ED reattendances internationally. This study aimed to understand the characteristics of these patients at the ED of a Singapore tertiary hospital. METHODS We conducted a retrospective cohort study on all ED visits between 1 January 2013 and 31 December 2013. 72-hour re-attendees were compared against non-re-attendees based on patient demographics, mode of arrival, patient acuity category status (i.e. P1/P2/P3/P4), seniority ranking of doctor-in-charge and medical diagnoses. Multivariate analysis using the generalised linear model was conducted on variables associated with 72-hour ED re-attendance. RESULTS Among 104,751 unique patients, 3,065 (2.93%) were in the 72-hour re-attendees group. Multivariate analysis showed that the following risk factors were associated with higher risk of returning within 72 hours: male gender, older age, arrival by ambulance, triaged as P2, diagnoses of heart problems, abdominal pain or viral infection (all p < 0.001), and Chinese ethnicity (p = 0.006). There was no significant difference in the seniority ranking of the doctor-in-charge between both groups (p = 0.419). CONCLUSION Several patient and event factors were associated with higher risk of being a 72-hour re-attendee. This study forms the basis for hypothesis generation and further studies to explore reasons behind reattendances so that interventions can be developed to target high-risk groups.
Collapse
Affiliation(s)
- Amy Hui Sian Chan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | | | | | - Nan Liu
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
| |
Collapse
|
56
|
Hutchinson A, Pickering A, Williams P, Bland JM, Johnson MJ. Breathlessness and presentation to the emergency department: a survey and clinical record review. BMC Pulm Med 2017; 17:53. [PMID: 28320369 PMCID: PMC5360046 DOI: 10.1186/s12890-017-0396-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 03/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Breathlessness is a frequently occurring symptom of cardiorespiratory conditions and is a common cause of emergency department presentation. The aim of this study was to estimate the prevalence of acute-on-chronic breathlessness as a cause for presentation to the major emergencies area of the emergency department. METHODS A prospective patient self-report survey and clinical record review of consecutive attendees to the major emergencies area of the emergency department in a single tertiary hospital between 12/5/14 and 29/5/14 was conducted. Eligible patients were clinically stable and had mental capacity to provide data. RESULTS There were 2,041 presentations during the study period, of whom 1,345 (66%) were eligible. There was a 90% survey response rate (1,212/1,345); 424/1,212 (35%) self-reported breathlessness most days over the past month of whom 245 gave breathlessness as a reason for this presentation. Therefore, the prevalence of acute-on-chronic breathlessness as a reason to present to the major emergencies area was 20.2% (245/1,212, 95% CI 17.9% to 22.5%). During this period there were 4,692 major and minor presentations; breathlessness was therefore a cause of at least 5.2% (245/4,692, 95% CI 4.6 to 5.9%) of all emergency department presentations. CONCLUSIONS This study found that one in five ambulance presentations to the ED were due to acute-on-chronic breathlessness. Most patients had non-malignant underlying conditions, had experienced considerable breathlessness for an extended period, had discussed breathlessness with their GP and presented out of daytime hours. Others were often involved in their decision to present. This represents clinically significant burden for patients, their family carers and the emergency health services.
Collapse
Affiliation(s)
- Ann Hutchinson
- Hull York Medical School, University of Hull, Hull, HU6 7RX, UK.
| | | | | | | | | |
Collapse
|
57
|
Burokienė S, Kairienė I, Strička M, Labanauskas L, Čerkauskienė R, Raistenskis J, Burokaitė E, Usonis V. Unscheduled return visits to a pediatric emergency department. MEDICINA-LITHUANIA 2017; 53:66-71. [PMID: 28233682 DOI: 10.1016/j.medici.2017.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 01/04/2017] [Accepted: 01/05/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Return visits (RVs) to a pediatric emergency department (ED) within a short period after discharge have an influence on overcrowding of the ED and reveal some weaknesses of the health care system. The aim of this study was to determine the rate of RVs and factors related to RVs to the pediatric ED in Lithuania. MATERIALS AND METHODS A retrospective study in an urban, tertiary-level teaching hospital was carried out. Electronic medical records of all patients (n=44097) visiting the ED of this hospital between 1 January and 31 December 2013 were analyzed. Demographic and clinical characteristics of patients who return to the ED within 72h and those who had not visited the ED were compared. Factors associated with RVs were determined by multivariable logistic regression. RESULTS Of the overall ED population, 33889 patients were discharged home after the initial assessment. A total of 1015 patients returned to the ED within 72h, giving a RV rate of 3.0%. Being a 0-7-year old, visiting the ED during weekdays, having a GP referral, receiving of laboratory tests and ultrasound on the initial visit were associated with greater likelihoods of returning to the ED. Patients who arrived to the ED from 8:01a.m. to 4:00p.m. and underwent radiological test were less likely to return to the ED within 72h. Diseases such as gastrointestinal disorders or respiratory tract/earth-nose-throat (ENT) diseases and symptoms such as fever or pain were significantly associated with returning to the ED. The initial diagnosis corresponded to the diagnosis made on the second visit for only 44.1% of the patients, and the highest rate of the congruity in diagnosis was for injuries/poisoning, surgical pathologies (77.2%) and respiratory tract diseases (76.9%). CONCLUSIONS RVs accounted for only a small proportion of visits to the ED. RVs were more prevalent among younger patients and patients with a GP referral as well as performed more often after discharging from the ED in the evening and at night.
Collapse
Affiliation(s)
- Sigita Burokienė
- Clinic of Children's Diseases, Faculty of Medicine, Vilnius University, Lithuania.
| | - Ignė Kairienė
- Clinic of Children's Diseases, Faculty of Medicine, Vilnius University, Lithuania
| | - Marius Strička
- Department of Preventive Medicine, Faculty of Public Health, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Liutauras Labanauskas
- Department of Children Diseases, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rimantė Čerkauskienė
- Clinic of Children's Diseases, Faculty of Medicine, Vilnius University, Lithuania
| | - Juozas Raistenskis
- Department of Rehabilitation, Physical and Sports Medicine, Faculty of Medicine, Vilnius University, Lithuania
| | - Emilija Burokaitė
- Clinic of Children's Diseases, Faculty of Medicine, Vilnius University, Lithuania
| | - Vytautas Usonis
- Clinic of Children's Diseases, Faculty of Medicine, Vilnius University, Lithuania
| |
Collapse
|
58
|
Turcato G, Cervellin G, Luca Salvagno G, Zaccaria E, Bartucci G, David M, Bonora A, Zannoni M, Ricci G, Lippi G. The Role of Red Blood Cell Distribution Width for Predicting 1-year Mortality in Patients Admitted to the Emergency Department with Severe Dyspnoea. J Med Biochem 2017; 36:32-38. [PMID: 28680347 PMCID: PMC5471657 DOI: 10.1515/jomb-2016-0026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 09/20/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Universally accepted and validated instruments for predicting the outcome of patients presenting to the emergency department (ED) with severe dyspnoea do not exist so far, nor are they regularly used by the emergency physicians. This study hence aimed to establish whether red blood cell distribution width (RDW) may be a predictive parameter of 1-year mortality in a population of patients admitted to the ED with severe dyspnoea attributable to different underlying disorders. METHODS We retrospectively evaluated all the patients undergoing arterial blood gas analysis for severe dyspnoea (irrespective of the cause) during admission to ED of University Hospital of Verona from September 1, 2014 to November 31, 2014. RESULTS The final study population consisted of 287 patients for whom complete clinical and laboratory information was available. Overall, 36 patients (12.5%) died after a 1-year follow-up. The RDW value was found to be considerably increased in patients who deceased during the follow-up compared to those who survived (17.2% versus 14.8%; p<0.001). In both univariate and multivariate analyses, the RDW value was found to be a significant predictor of 1-year mortality. In particular, patients with RDW ≥ 15.0% displayed a 72% increased risk of 1-year mortality after multiple adjustments. CONCLUSIONS The measurement of RDW, a very simple and inexpensive laboratory parameter, may represent an important factor for predicting medium-term mortality in patients presenting to the ED with severe dyspnoea.
Collapse
Affiliation(s)
- Gianni Turcato
- Emergency Department, University Hospital of Verona, Verona, Italy
| | | | - Gian Luca Salvagno
- Section of Clinical Biochemistry, University of Verona, Verona, Piazzale LA Scuro, 37100 - Verona, Italy
| | | | | | - Marco David
- Emergency Department, University Hospital of Verona, Verona, Italy
| | - Antonio Bonora
- Emergency Department, University Hospital of Verona, Verona, Italy
| | - Massimo Zannoni
- Emergency Department, University Hospital of Verona, Verona, Italy
| | - Giorgio Ricci
- Emergency Department, University Hospital of Verona, Verona, Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Piazzale LA Scuro, 37100 - Verona, Italy
| |
Collapse
|
59
|
Minen M, Shome A, Femia R, Balcer L, Grudzen C, Gavin NP. Emergency Department concussion revisits: Chart review of the evaluation and discharge plans of post-traumatic headache patients. Am J Emerg Med 2016; 35:365-367. [PMID: 27908509 DOI: 10.1016/j.ajem.2016.10.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 10/30/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022] Open
Affiliation(s)
- Mia Minen
- Department of Neurology, NYU Langone Medical Center, United States
| | - Ashna Shome
- Barnard College, Columbia University, United States
| | - Robert Femia
- Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, United States
| | - Laura Balcer
- Department of Neurology, NYU Langone Medical Center, United States
| | - Corita Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Department of Population Health, NYU School of Medicine, United States
| | - Nicholas P Gavin
- Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, United States.
| |
Collapse
|
60
|
Jiménez-Puente A, Del Río-Mata J, Arjona-Huertas JL, Mora-Ordóñez B, Martínez-Reina A, Martínez Del Campo M, Nieto-de Haro L, Lara-Blanquer A. Which unscheduled return visits indicate a quality-of-care issue? Emerg Med J 2016; 34:145-150. [PMID: 27671021 DOI: 10.1136/emermed-2015-205603] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 08/24/2016] [Accepted: 09/05/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND The rate of unscheduled return visits is often used as a quality-of-care indicator in EDs, although its validity is not yet fully established. Our aim was to identify the characteristics of return visits that may be attributed to problems in quality of care. METHODS Retrospective paired review of medical charts in a random sample of return visits during the 72 hours following discharge from the ED in three hospitals of Andalusia, Spain in 2013. Charts were reviewed by senior medical physicians to determine which return visits reflected quality-of-care problems. Time frame for return visit, index and return visit acuity, disposition and diagnosis were compared with determine which variables were associated with a quality problem. Sensitivity and specificity for each variable to indicate a quality problem were determined. RESULTS We studied the causes of 895 return visits, finding that 65 (7.3%) were due to inadequate quality of care in the index visit. Potentially avoidable return visits were more common in more severely ill patients, in those with greater severity in the return than in the index visit and in patients hospitalised after the return. The combination of this three variables presented sensitivity 66% and specificity 68% in identification of quality-related returns. CONCLUSIONS The overall level of return visits cannot be considered a valid indicator of quality of care. However, certain specific variables, including the level of severity of the patient's condition or the discharge destination following the return visits, could be considered valid in this respect.
Collapse
Affiliation(s)
- Alberto Jiménez-Puente
- Evaluation Unit, Costa del Sol Public Health Care Agency, Marbella, Málaga, Spain.,Health Services Research on Chronic Patients Network (REDISSEC), Marbella, Spain
| | - José Del Río-Mata
- Medical Documentation Department, Virgen de la Victoria University Hospital, Málaga, Spain
| | | | - Begoña Mora-Ordóñez
- Emergency Department, Virgen de la Victoria University Hospital, Málaga, Spain
| | - Alfonso Martínez-Reina
- Medical Documentation Department, Virgen de la Victoria University Hospital, Málaga, Spain
| | | | | | - Antonio Lara-Blanquer
- Medical Documentation Department, Costa del Sol Public Health Care Agency, Marbella, Málaga, Spain
| |
Collapse
|
61
|
Characteristics and outcomes of patients with emergency department revisits within 72 hours and subsequent admission to the intensive care unit. Tzu Chi Med J 2016; 28:151-156. [PMID: 28757746 PMCID: PMC5442903 DOI: 10.1016/j.tcmj.2016.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/13/2016] [Accepted: 07/19/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the characteristics and outcomes of patients with emergency department (ED) revisits within 72 hours and subsequent admission to the intensive care unit (ICU). MATERIALS AND METHODS The medical records of all adult patients revisiting the ED of a single tertiary referral medical center with ICU admissions between January 2012 and September 2014 were reviewed in terms of patient characteristics, clinical manifestations, diagnoses, triage according to the Taiwan Triage and Acuity Scale, causes of revisits, and mortality. RESULTS The majority of the 51 patients reviewed were male (64.7%). Their mean age was 62.9 ± 14.9 years. Most patients visited the ED during the evening shift (51%) and were categorized into triage Level III (76.5%) during their first ED visit. The causes of revisits were doctor-related (21/51, 41.1%), illness-related (18/51, 35.3%), and patient-related (12/51, 23.5%). Disease categories included the neurological (23.5%), digestive (23.5%), and cardiovascular systems (21.6%). Abdominal pain and vertigo/dizziness were the two most common initial manifestations. The mortality rate was 27.5%. Malignancy and hepatic diseases were the two most common underlying medical conditions for nonsurvivors. In addition, patients initially presenting to the ED with lower triage scores (III & IV) had a higher mortality rate than those with higher scores (I & II). CONCLUSION Most of the patients who revisited the ED within 72 hours and were subsequently admitted to the ICU visited the ED during the evening shift and were categorized into triage Level III on their first visit. The most common chief complaint at the first visit was abdominal pain. The most common cause of revisits with ICU admission was doctor-related, while the most common underlying disease was hypertension. Significantly higher mortality was observed after ED revisits in patients with lower triage scores with underlying malignancy and liver cirrhosis.
Collapse
|
62
|
Hart J, Woodruff M, Joy E, Dalto J, Snow G, Srivastava R, Isaacson B, Allen T. Association of Age, Systolic Blood Pressure, and Heart Rate with Adult Morbidity and Mortality after Urgent Care Visits. West J Emerg Med 2016; 17:591-9. [PMID: 27625724 PMCID: PMC5017844 DOI: 10.5811/westjem.2016.6.30353] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 03/16/2016] [Accepted: 06/30/2016] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Little data exists to help urgent care (UC) clinicians predict morbidity and mortality risk. Age, systolic blood pressure (SBP), and heart rate (HR) are easily obtainable and have been used in other settings to predict short-term risk of deterioration. We hypothesized that there is a relationship between advancing age, SBP, HR, and short-term health outcomes in the UC setting. METHODS We collected retrospective data from 28 UC clinics and 22 hospitals in the Intermountain Healthcare system between years 2008-2013. Adult patients (≥18 years) were included if they had a unique UC visit and HR or SBP data. Three endpoints following UC visit were assessed: emergency department (ED) visit within three days, hospitalization within three days, and death within seven days. We analyzed associations between age, SBP, HR and endpoints using local regression with a binomial likelihood. Five age groups were chosen from previously published national surveys. Vital sign (VS) distributions were determined for each age group, and the central tendency was compared against previously published norms (90-120mmHg for SBP and 60-100bpm for HR.). RESULTS A total of 1,720,207 encounters (714,339 unique patients) met the inclusion criteria; 51,446 encounters (2.99%) had ED visit within three days; 12,397 (0.72%) experienced hospitalization within three days; 302 (0.02%) died within seven days of UC visit. Heart rate and SBP combined with advanced age predicted the probability of ED visit (p<0.0001) and hospitalization (p<0.0001) following UC visit. Significant associations between advancing age and death (p<0.0001), and VS and death (p<0.0001) were observed. Odds ratios of risk were highest for elderly patients with lower SBP or higher HR. Observed distributions of SBP were higher than published normal ranges for all age groups. CONCLUSION Among adults seeking care in the UC, associations between HR and SBP and likelihood of ED visits and hospitalization were more pronounced with advancing age. Death following UC visit had a more limited association with advancing age or the VS evaluated. Rapidly increasing risk below SBP of 100-110 mmHg in older patients suggests that accepted normal ranges for SBP may need to be redefined for patients treated in the UC clinic.
Collapse
Affiliation(s)
- James Hart
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah
| | - Michael Woodruff
- Intermountain Healthcare, Intermountain Medical Center, Department of Emergency Medicine, Salt Lake City, Utah
- Intermountain Healthcare, Quality and Patient Safety, Salt Lake City, Utah
| | - Elizabeth Joy
- Intermountain Healthcare, Community Benefit, Salt Lake City, Utah
| | - Joseph Dalto
- Intermountain Healthcare, Quality and Patient Safety, Salt Lake City, Utah
| | - Gregory Snow
- Intermountain Healthcare, Office of Research, Salt Lake City, Utah
| | - Rajendu Srivastava
- Intermountain Healthcare, Office of Research, Salt Lake City, Utah
- Intermountain Healthcare, Institute for Healthcare Leadership, Salt Lake City, Utah
- Intermountain Healthcare, Intermountain Medical Center, Department of Medicine, Salt Lake City, Utah
- University of Utah School of Medicine, Department of Pediatrics, Salt Lake City, Utah
| | - Brad Isaacson
- Intermountain Healthcare, Office of Research, Salt Lake City, Utah
| | - Todd Allen
- Intermountain Healthcare, Intermountain Medical Center, Department of Emergency Medicine, Salt Lake City, Utah
- Intermountain Healthcare, Institute for Healthcare Leadership, Salt Lake City, Utah
| |
Collapse
|
63
|
Revisits within 48 Hours to a Thai Emergency Department. Emerg Med Int 2016; 2016:8983573. [PMID: 27478642 PMCID: PMC4961813 DOI: 10.1155/2016/8983573] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 06/02/2016] [Accepted: 06/19/2016] [Indexed: 11/23/2022] Open
Abstract
Objective. Emergency department (ED) revisits are a common ED quality measure. This study was undertaken to ascertain the contributing factors of revisits within 48 hours to a Thai ED and to explore physician-related, illness-related, and patient-related factors behind those revisits. Methods. This study was a chart review from one tertiary care, urban Thai hospital from October 1, 2009, to September 31, 2010. We identified patients who returned to the ED within 48 hours for the same or related complaints after their initial discharge. Three physicians classified revisit as physician-related, illness-related, and patient-related factors. Results. Our study included 172 ED patients' charts. 86/172 (50%) were male and the mean age was 38 ± 5.6 (SD) years. The ED revisits contributing factors were physician-related factors [86/172 (50.0%)], illness-related factors [61/172 (35.5%)], and patient-related factor [25/172 (14.5%)], respectively. Among revisits classified as physician-related factors, 40/86 (46.5%) revisits were due to misdiagnosis and 36/86 (41.9%) were due to suboptimal management. Abdominal pain [27/86 (31.4%)] was the majority of physician-related chief complaints, followed by fever [16/86 (18.6%)] and dyspnea [15/86 (17.4%)]. Conclusion. Misdiagnosis and suboptimal management contributed to half of the 48-hour repeat ED visits in this Thai hospital.
Collapse
|
64
|
Gabayan GZ, Gould MK, Weiss RE, Patel N, Donkor KA, Chiu VY, Yiu SC, Jones JP, Hoffman JR, Sarkisian CA. Poor Outcomes After Emergency Department Discharge of the Elderly: A Case-Control Study. Ann Emerg Med 2016; 68:43-51.e2. [PMID: 26947799 DOI: 10.1016/j.annemergmed.2016.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 12/22/2015] [Accepted: 01/04/2016] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE The emergency department (ED) is an inherently high-risk setting. Our objective is to identify the factors associated with the combined poor outcome of either death or an ICU admission shortly after ED discharge in older adults. METHODS We conducted chart review of 600 ED visit records among adults older than 65 years that resulted in discharge from any of 13 hospitals within an integrated health system in 2009 to 2010. We randomly chose 300 patients who experienced the combined outcome within 7 days of discharge and matched case patients to controls who did not experience the outcome. Two emergency physicians blinded to the outcome reviewed the records and identified whether a number of characteristics were present. Predictors of the outcome were identified with conditional logistic regression. RESULTS Of 1,442,594 ED visits to Kaiser Permanente Southern California in 2009 to 2010, 300 unique cases and 300 unique control records were randomly abstracted. Characteristics associated with the combined poor outcome included cognitive impairment (adjusted odds ratio [AOR] 2.10; 95% confidence interval [CI] 1.19 to 3.56), disposition plan change (AOR 2.71; 95% CI 1.50 to 4.89), systolic blood pressure less than 120 mm Hg (AOR 1.48; 95% CI 1.00 to 2.20), and pulse rate greater than 90 beats/min (AOR 1.66; 95% CI 1.02 to 2.71). CONCLUSION We found that older patients discharged from the ED with a change in disposition from "admit" to "discharge," cognitive impairment, systolic blood pressure less than 120 mm Hg, and pulse rate greater than 90 beats/min were at increased risk of death or ICU admission shortly after discharge. Increased awareness of these high-risk characteristics may improve ED disposition decisionmaking.
Collapse
Affiliation(s)
- Gelareh Z Gabayan
- Department of Medicine, University of California, Los Angeles, CA; Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA.
| | - Michael K Gould
- Department of Research and Evaluation, Kasier Permanente Southern California, Pasadena, CA
| | - Robert E Weiss
- Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Neil Patel
- Department of Medicine, University of California, Los Angeles, CA; Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
| | - Kwame A Donkor
- Department of Medicine, University of California, Los Angeles, CA; Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
| | - Vicki Y Chiu
- Department of Research and Evaluation, Kasier Permanente Southern California, Pasadena, CA
| | - Sau C Yiu
- Department of Research and Evaluation, Kasier Permanente Southern California, Pasadena, CA
| | - Jason P Jones
- Kaiser Foundation Hospital and Health Plan, Pasadena, CA
| | - Jerome R Hoffman
- Emergency Medicine Center, University of California, Los Angeles, CA
| | - Catherine A Sarkisian
- Department of Medicine, University of California, Los Angeles, CA; Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA
| |
Collapse
|
65
|
Sabbatini AK, Kocher KE, Basu A, Hsia RY. In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department. JAMA 2016; 315:663-71. [PMID: 26881369 PMCID: PMC8366576 DOI: 10.1001/jama.2016.0649] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Unscheduled short-term return visits to the emergency department (ED) are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care. OBJECTIVE To examine in-hospital clinical outcomes and resource use among patients who are hospitalized during an unscheduled return visit to the ED. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of adult ED visits to acute care hospitals in Florida and New York in 2013 using data from the Healthcare Cost and Utilization Project. Patients with index ED visits were identified and followed up for return visits to the ED within 7, 14, and 30 days. EXPOSURES Hospital admission occurring during an initial visit to the ED vs during a return visit to the ED. MAIN OUTCOMES AND MEASURES In-hospital mortality, intensive care unit (ICU) admission, length of stay, and inpatient costs. RESULTS Among the 9,036,483 index ED visits to 424 hospitals in the study sample, 1,758,359 patients were admitted to the hospital during the index ED visit. Of these patients, 149,214 (8.5%) had a return visit to the ED within 7 days of the index ED visit, 228,370 (13.0%) within 14 days, and 349,335 (19.9%) within 30 days, and 76,151 (51.0%), 122,040 (53.4%), and 190,768 (54.6%), respectively, were readmitted to the hospital. Among the 7,278,124 patients who were discharged during the index ED visit, 598,404 (8.2%) had a return visit to the ED within 7 days, 839,386 (11.5%) within 14 days, and 1,205,865 (16.6%) within 30 days. Of these patients, 86,012 (14.4%) were admitted to the hospital within 7 days, 121,587 (14.5%) within 14 days, and 173,279 (14.4%) within 30 days. The 86,012 patients discharged from the ED and admitted to the hospital during a return ED visit within 7 days had significantly lower rates of in-hospital mortality (1.85%) compared with the 1,609,145 patients who were admitted during the index ED visit without a return ED visit (2.48%) (odds ratio, 0.73 [95% CI, 0.69-0.78]), lower rates of ICU admission (23.3% vs 29.0%, respectively; odds ratio, 0.73 [95% CI, 0.71-0.76]), lower mean costs ($10,169 vs $10,799; difference, $629 [95% CI, $479-$781]), and longer lengths of stay (5.16 days vs 4.97 days; IRR, 1.04 [95% CI, 1.03-1.05]). Similar outcomes were observed for patients returning to the ED within 14 and 30 days of the index ED visit. In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit. CONCLUSIONS AND RELEVANCE Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay. These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.
Collapse
Affiliation(s)
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Anirban Basu
- Department of Health Services and Economics, University of Washington, Seattle
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco6Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| |
Collapse
|
66
|
Jin B, Zhao Y, Hao S, Shin AY, Wang Y, Zhu C, Hu Z, Fu C, Ji J, Wang Y, Zhao Y, Jiang Y, Dai D, Culver DS, Alfreds ST, Rogow T, Stearns F, Sylvester KG, Widen E, Ling XB. Prospective stratification of patients at risk for emergency department revisit: resource utilization and population management strategy implications. BMC Emerg Med 2016; 16:10. [PMID: 26842066 PMCID: PMC4739399 DOI: 10.1186/s12873-016-0074-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 02/01/2016] [Indexed: 11/18/2022] Open
Abstract
Background Estimating patient risk of future emergency department (ED) revisits can guide the allocation of resources, e.g. local primary care and/or specialty, to better manage ED high utilization patient populations and thereby improve patient life qualities. Methods We set to develop and validate a method to estimate patient ED revisit risk in the subsequent 6 months from an ED discharge date. An ensemble decision-tree-based model with Electronic Medical Record (EMR) encounter data from HealthInfoNet (HIN), Maine’s Health Information Exchange (HIE), was developed and validated, assessing patient risk for a subsequent 6 month return ED visit based on the ED encounter-associated demographic and EMR clinical history data. A retrospective cohort of 293,461 ED encounters that occurred between January 1, 2012 and December 31, 2012, was assembled with the associated patients’ 1-year clinical histories before the ED discharge date, for model training and calibration purposes. To validate, a prospective cohort of 193,886 ED encounters that occurred between January 1, 2013 and June 30, 2013 was constructed. Results Statistical learning that was utilized to construct the prediction model identified 152 variables that included the following data domains: demographics groups (12), different encounter history (104), care facilities (12), primary and secondary diagnoses (10), primary and secondary procedures (2), chronic disease condition (1), laboratory test results (2), and outpatient prescription medications (9). The c-statistics for the retrospective and prospective cohorts were 0.742 and 0.730 respectively. Total medical expense and ED utilization by risk score 6 months after the discharge were analyzed. Cluster analysis identified discrete subpopulations of high-risk patients with distinctive resource utilization patterns, suggesting the need for diversified care management strategies. Conclusions Integration of our method into the HIN secure statewide data system in real time prospectively validated its performance. It promises to provide increased opportunity for high ED utilization identification, and optimized resource and population management. Electronic supplementary material The online version of this article (doi:10.1186/s12873-016-0074-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Bo Jin
- HBISolutions Inc., Palo Alto, CA, 94301, USA
| | - Yifan Zhao
- HBISolutions Inc., Palo Alto, CA, 94301, USA
| | - Shiying Hao
- Department of Surgery, Stanford University, S370 Grant Building, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Andrew Young Shin
- Departments of Pediatrics, Stanford University, Stanford, CA, 94305, USA
| | - Yue Wang
- Department of Surgery, Stanford University, S370 Grant Building, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | | | - Zhongkai Hu
- HBISolutions Inc., Palo Alto, CA, 94301, USA
| | - Changlin Fu
- HBISolutions Inc., Palo Alto, CA, 94301, USA
| | - Jun Ji
- HBISolutions Inc., Palo Alto, CA, 94301, USA
| | - Yong Wang
- Statistics Stanford University, Stanford, CA, 94305, USA.,Academy of Mathematics and Systems Science, Chinese Academy of Sciences, Beijing, 10019, China
| | - Yingzhen Zhao
- Department of Surgery, Stanford University, S370 Grant Building, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Yunliang Jiang
- Department of Surgery, Stanford University, S370 Grant Building, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Dorothy Dai
- HBISolutions Inc., Palo Alto, CA, 94301, USA
| | | | | | | | | | - Karl G Sylvester
- Department of Surgery, Stanford University, S370 Grant Building, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Eric Widen
- HBISolutions Inc., Palo Alto, CA, 94301, USA
| | - Xuefeng B Ling
- Department of Surgery, Stanford University, S370 Grant Building, 300 Pasteur Drive, Stanford, CA, 94305, USA.
| |
Collapse
|
67
|
Hocagil AC, Bildik F, Kılıçaslan İ, Hocagil H, Karabulut H, Keleş A, Demircan A. Evaluating Unscheduled Readmission to Emergency Department in the Early Period. Balkan Med J 2016; 33:72-9. [PMID: 26966621 DOI: 10.5152/balkanmedj.2015.15917] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 07/03/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The readmission in the early period (RAEP) is defined as the admission of a patient to emergency department (ED) for the second time within 72 hours after discharge from the ED. AIMS The aim of this study was to determine the disease, patient, doctor, and system related causes of RAEP. STUDY DESIGN Descriptive study. METHODS This study is a two-stage study that was conducted at Department of Emergency, Gazi University Faculty of Medicine. The causes of RAEP were defined as disease, patient, doctor, and system related causes. RESULTS A total of 46,800 adult patients admitted to ED during the study period and 779 (1.66%) patients required RAEP. After the exclusion criteria, 429 of these patients were included the study. The most common reasons for RAEP were renal colic in 46 (10.7%) patients. It was detected that 60.4% of the causes of RAEP were related to disease, 20.0% were related to the doctor, 12.1% were related to the patient, and 7.5% were related to the hospital management system. CONCLUSION This study revealed that there are patient-, doctor-, and system-related preventable reasons for RAEP and the patients requiring RAEP constitute the high risk group.
Collapse
Affiliation(s)
- Abdullah Cüneyt Hocagil
- Department of Emergency Medicine, Bülent Ecevit University Faculty of Medicine, Zonguldak, Turkey
| | - Fikret Bildik
- Department of Emergency, Gazi University Faculty of Medicine, Ankara, Turkey
| | - İsa Kılıçaslan
- Department of Emergency, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Hilal Hocagil
- Department of Emergency Medicine, Bülent Ecevit University Faculty of Medicine, Zonguldak, Turkey
| | - Hasan Karabulut
- Department of Emergency, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ayfer Keleş
- Department of Emergency, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ahmet Demircan
- Department of Emergency, Gazi University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
68
|
Hudspeth J, El-Kareh R, Schiff G. Use of an Expedited Review Tool to Screen for Prior Diagnostic Error in Emergency Department Patients. Appl Clin Inform 2015; 6:619-28. [PMID: 26767059 DOI: 10.4338/aci-2015-04-ra-0042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 08/10/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Missed diagnoses are an important area of care quality resulting in significant morbidity and mortality. Determination of rates and causes has been limited by difficulties in screening, including the effort of manual chart review. We developed and tested a semi- automated review tool to expedite screening for diagnostic errors in an electronic health record (EHR). METHODS We retrospectively reviewed patients seen in the emergency department (ED) of a teaching hospital over 31 days, using an automated screen to identify those with a prior in-system visit during the 14 days preceding their ED visit. We collected prior and subsequent notes from the institution's EHR for these cases, then populated a specially designed relational database enabling rapid comparison of prior visit records to the sentinel ED visit. Each case was assessed for potential missed or delayed diagnosis, and rated by likelihood as "definite, probable, possible, unlikely or none." RESULTS A total of 5 066 patient encounters were screened by a clinician using the tool, of which 1 498 (30%) had a clinical encounter within the preceding 14 days. Of these, 37 encounters (2.6% of those reviewed) were "definite" or "probable" missed diagnoses. The rapid review tool took a mean of 1.9 minutes per case for primary review, compared with 11.2 minutes per case for reviews without the automated tool. CONCLUSIONS Diagnostic errors were present in a significant number of cases presenting to the ED after recent healthcare visits. An innovative review tool enabled a substantially increased efficiency in screening for diagnostic errors.
Collapse
Affiliation(s)
- J Hudspeth
- Department of Medicine, Boston University , Boston, MA, United States
| | - R El-Kareh
- Department of Medicine, University of California , San Diego, CA, United States
| | - G Schiff
- Department of Medicine, Brigham and Women's Hospital , Boston, MA, United States
| |
Collapse
|
69
|
Using data envelopment analysis for assessing the performance of pediatric emergency department physicians. Health Care Manag Sci 2015; 20:129-140. [DOI: 10.1007/s10729-015-9344-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 09/23/2015] [Indexed: 11/26/2022]
|
70
|
Carlström ED, Hansson Olofsson E, Olsson LE, Nyman J, Koinberg IL. The unannounced patient in the corridor: trust, friction and person-centered care. Int J Health Plann Manage 2015; 32:e1-e16. [PMID: 26369302 DOI: 10.1002/hpm.2313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/29/2015] [Accepted: 07/29/2015] [Indexed: 11/06/2022] Open
Abstract
In this study, a Swedish cancer clinic was studied where three to four unscheduled patients sought support from the hospital on a daily basis for pain and nutrition problems. The clinic was neither staffed nor had a budget to handle such return visits. In order to offer the patients a better service and decrease the workload of the staff in addition to their everyday activities, a multidisciplinary team was established to address the unscheduled return visits. The team was supposed to involve the patient, build trust, decrease the friction, and contribute to a successful rehabilitation process. Data were collected from the patients and the staff. Patients who encountered the team (intervention) and patients who encountered the regular ad hoc type of organization (control) answered a questionnaire measuring trust and friction. Nurses in the control group spent 35% of their full-time employment, and the intervention group staffed with nurses spent 30% of their full-time employment in addressing the needs of these return patients. The patients perceived that trust between them and the staff was high. In summary, it was measured as being 4.48 [standard deviation (SD) = 0.82] in the intervention group and 4.41 (SD = 0.79) in the control group using the 5-point Likert scale. The data indicate that using a multidisciplinary team is a promising way to handle the problems of unannounced visits from patients. Having a team made it cost effective for the clinic and provided a better service than the traditional ad hoc organization. Copyright © 2015 John Wiley & Sons, Ltd.
Collapse
Affiliation(s)
- Eric D Carlström
- The Sahlgrenska Academy - Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden.,Centre for Person-Centred Care (GPCC), Gothenburg University, Gothenburg, Sweden
| | - Elisabeth Hansson Olofsson
- The Sahlgrenska Academy - Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden.,Centre for Person-Centred Care (GPCC), Gothenburg University, Gothenburg, Sweden
| | - Lars-Eric Olsson
- The Sahlgrenska Academy - Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden.,Centre for Person-Centred Care (GPCC), Gothenburg University, Gothenburg, Sweden
| | - Jan Nyman
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Inga-Lill Koinberg
- The Sahlgrenska Academy - Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden.,Centre for Person-Centred Care (GPCC), Gothenburg University, Gothenburg, Sweden.,Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
71
|
Characteristics and Risk Factors of Out-of-Hospital Cardiac Arrest Within 72 Hours After Discharge. Am J Med Sci 2015; 350:272-8. [PMID: 26332728 DOI: 10.1097/maj.0000000000000551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the characteristics and risk factors for patients who developed out-of-hospital cardiac arrest (OHCA) within 72 hours after emergency department (ED) discharge. METHODS A nested case-control study (1:4 ratio) was conducted in 5 EDs from January 2002 to December 2011. The study group consisted of adults experiencing nontraumatic OHCA who revisited ED within 72 hours after discharge. Patients matched in sex, age group and chief complaints were selected for the control group. Demographic data, discharge diagnosis, discharge vital signs and laboratory result were collected. Etiologies of cardiac arrest and whether the events were expected or related to the 1st ED visit were reviewed. RESULTS In all, 1,657,870 patients were discharged during the study period; 109 developed OHCA within 72 hours of ED discharge (6.6/100,000 per year). The mean age was 64.7 years and 67.9% were men. After comparison with the control group, a higher heart rate (88.5 ± 18.23 versus 81.7 ± 15.93 beat per minutes, P = 0.003) and higher serum creatinine level (2.2 ± 2.30 versus 1.4 ± 1.38 mg/dL, P = 0.002) remain the statistical significant characteristics of study group by conditional logistic regression. Approximately 60% events were expected or unrelated to the 1st ED visit. Among patients whose OHCA were unexpected and related to the 1st ED visit, 71.4% had a cardiac cause. Of these, 20% had chest pain, but 40% had angina-equivalent symptoms during 1st presentation. CONCLUSIONS A higher discharge heart rate and higher creatinine level are risk factors in these patients.
Collapse
|
72
|
The role of airflow for the relief of chronic refractory breathlessness. Curr Opin Support Palliat Care 2015; 9:206-11. [DOI: 10.1097/spc.0000000000000160] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
73
|
Lee SH, Kim K, Kim H, Jeong JH, Kang C, Rhee JE, Byeon YI, Im YS, Park C, Kim J, Hwang SS. Effect of multifaceted interventions on reducing return visits within 72 h after non-traumatic emergency department visits. Emerg Med Australas 2015; 27:431-9. [DOI: 10.1111/1742-6723.12457] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Soo Hoon Lee
- Department of Emergency Medicine; Gyeongsang National University School of Medicine and Gyeongsang National University Hospital; Jinju Republic of Korea
| | - Kyuseok Kim
- Department of Emergency Medicine; Seoul National University Bundang Hospital; Gyeonggi-Do Republic of Korea
| | - Hooyoung Kim
- Department of Emergency Medicine; Seoul National University Bundang Hospital; Gyeonggi-Do Republic of Korea
| | - Jin Hee Jeong
- Department of Emergency Medicine; Gyeongsang National University School of Medicine and Gyeongsang National University Hospital; Jinju Republic of Korea
| | - Changwoo Kang
- Department of Emergency Medicine; Gyeongsang National University School of Medicine and Gyeongsang National University Hospital; Jinju Republic of Korea
| | - Joong Eui Rhee
- Department of Emergency Medicine; Seoul National University Bundang Hospital; Gyeonggi-Do Republic of Korea
| | - Young Im Byeon
- Department of Emergency Medicine; Seoul National University Bundang Hospital; Gyeonggi-Do Republic of Korea
| | - Yeon Sook Im
- Department of Emergency Medicine; Seoul National University Bundang Hospital; Gyeonggi-Do Republic of Korea
| | - Chanjong Park
- Department of Emergency Medicine; Seoul National University Bundang Hospital; Gyeonggi-Do Republic of Korea
| | - Joonghee Kim
- Department of Emergency Medicine; Seoul National University Bundang Hospital; Gyeonggi-Do Republic of Korea
| | - Seung Sik Hwang
- Department of Social and Preventive Medicine; Inha University School of Medicine; Incheon Republic of Korea
| |
Collapse
|
74
|
Early Revisit to the Emergency Department: An Integrative Review. J Emerg Nurs 2015; 41:285-95. [DOI: 10.1016/j.jen.2014.11.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 10/21/2014] [Accepted: 11/22/2014] [Indexed: 11/20/2022]
|
75
|
Lavecchia M, Abenhaim HA. Effect of Menstrual Age on Failure of Medical Management in Women With Early Pregnancy Loss. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 37:617-623. [DOI: 10.1016/s1701-2163(15)30199-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
76
|
Jenab Y, Haghani S, Jalali A, Darabi F. Unscheduled Return Visits and Leaving the Chest Pain Unit Against Medical Advice. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e18320. [PMID: 26082847 PMCID: PMC4464376 DOI: 10.5812/ircmj.17(5)2015.18320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 09/18/2014] [Accepted: 10/06/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Rate of Unscheduled Return Visits (URVs) to the Emergency Department has been considered as a key indicator for evaluating the quality of the Emergency Department care for decades. A higher rate of URVs can have a negative impact on the quality of health care. Investigations of the reasons for these returns have indicated that many of these visits can be preventable. OBJECTIVES Given that there are no clear findings about the frequency and reasons for 72 hours URVs to the Chest Pain Unit (CPU), in the present study, we investigated the causes of 72 hours URVs to our CPU in order to find out the inadequacies, and propose preventive strategies. PATIENTS AND METHODS This research was a single-center retrospective case control study in the setting of CPU of Tehran Heart Center (a 460-bed, tertiary-care teaching hospital), Tehran, Iran. The medical records of the patients who were presented to our CPU with the chief complaint of chest pain between December 28(th), 2010 and February 28(th), 2011 were reviewed. Of the 6247 eligible patients, forty-nine URVs that fulfilled our criteria were identified. The control group consisted of 196 patients who did not return to the Emergency Department during our study period. RESULTS Patient-related factors accounted for most 72 hours URVs (49%). Multivariable analysis revealed that in our CPU, leaving Against medical advice was the most important predictor for 72 hours URVs (P value < 0.001). Additionally, male sex, history of hypertension, first-visit disposition to observation unit and age were the other factors associated with URVs. CONCLUSIONS Considering that the most frequent reason for our URVs was patient-related factors, where all cases had left the CPU Against Medical Advice (AMA) during their first attendance, we recommend that further appropriate strategies be devised to prevent leaving against medical advice.
Collapse
Affiliation(s)
- Yaser Jenab
- General Cardiology Department, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Shima Haghani
- Clinical Research Department, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Arash Jalali
- Clinical Research Department, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Farzad Darabi
- Clinical Research Department, Tehran University of Medical Sciences, Tehran, IR Iran
| |
Collapse
|
77
|
Wen LS, Espinola JA, Mosowsky JM, Camargo CA. Do emergency department patients receive a pathological diagnosis? A nationally-representative sample. West J Emerg Med 2015; 16:50-4. [PMID: 25671008 PMCID: PMC4307726 DOI: 10.5811/westjem.2014.12.23474] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 11/17/2014] [Accepted: 12/13/2014] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Understanding the cause of patients' symptoms often requires identifying a pathological diagnosis. A single-center study found that many patients discharged from the emergency department (ED) do not receive a pathological diagnosis. We analyzed 17 years of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to identify the proportion of patients who received a pathological diagnosis at ED discharge. We hypothesized that many patients do not receive a pathological diagnosis, and that the proportion of pathological diagnoses increased between 1993 and 2009. METHODS Using the NHAMCS data from 1993-2009, we analyzed visits of patients age ≥18 years, discharged from the ED, who had presented with the three most common chief complaints: chest pain, abdominal pain, and headache. Discharge diagnoses were coded as symptomatic versus pathological based on a pre-defined coding system. We compared weighted annual proportions of pathological discharge diagnoses with 95% CIs and used logistic regression to test for trend. RESULTS Among 299,919 sampled visits, 44,742 met inclusion criteria, allowing us to estimate that there were 164 million adult ED visits presenting with the three chief complaints and then discharged home. Among these visits, the proportions with pathological discharge diagnosis were 55%, 71%, and 70% for chest pain, abdominal pain, and headache, respectively. The total proportion of those with a pathological discharge diagnosis decreased between 1993 and 2009, from 72% (95% CI, 69-75%) to 63% (95% CI, 59-66%). In the multivariable logistic regression model, those more likely to receive pathological diagnoses were females, African-American as compared to Caucasian, and self-pay patients. Those more likely to receive a symptomatic diagnosis were patients aged 30-79 years, with visits to EDs in the South or West regions, and seen by a physician in the ED. CONCLUSION In this analysis of a nationally-representative database of ED visits, many patients were discharged from the ED without a pathological diagnosis that explained the likely cause of their symptoms. Despite advances in diagnostic testing, the proportion of pathological discharge diagnoses decreased. Future studies should investigate reasons for not providing a pathological diagnosis and how this may affect clinical outcomes.
Collapse
Affiliation(s)
- Leana S. Wen
- George Washington University, Department of Emergency Medicine, Washington, District of Columbia
| | - Janice A. Espinola
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Joshua M. Mosowsky
- Brigham and Women’s Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Carlos A. Camargo
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| |
Collapse
|
78
|
Calder L, Pozgay A, Riff S, Rothwell D, Youngson E, Mojaverian N, Cwinn A, Forster A. Adverse events in patients with return emergency department visits. BMJ Qual Saf 2014; 24:142-8. [PMID: 25540424 PMCID: PMC4316869 DOI: 10.1136/bmjqs-2014-003194] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objectives This study describes the proportion of emergency department (ED) returns within 7 days due to adverse events, defined as adverse outcomes related to healthcare received. Design Prospective cohort study. Setting We used an electronically triggered adverse event surveillance system at a tertiary care ED from May to June 2010 to examine ED returns within 7 days of index visit. Participants One of three trained nurses determined whether the visit was related to index emergency care. For such records, one of three trained emergency physicians conducted adverse event determinations. Main outcome measure We determined adverse event type and severity and analysed the data with descriptive statistics, χ2 tests and logistic regression. Results Of 13 495 index ED visits, 923 (6.8%) were followed by ED returns within 7 days. The median age of all patients was 47 years and 52.8% were women. After nursing review, 211 cases required physician review. Of these, 53 visits were adverse events (positive predictive value (PPV)=5.7%, 95% CI 4.4% to 7.4%) and 30 (56.6%) were preventable. Common adverse event types involved management, diagnostic or medication issues. We observed one potentially preventable death and 58.5% of adverse events resulting in transient disability. The PPV of a modified trigger with a cut-off of return within 72 h, resulting in admission was 11.9% (95% CI 6.8% to 18.9%). Conclusions Our electronic trigger efficiently identified adverse events among 12% of patients with ED returns within 72 h, requiring hospital admission. Given the high degree of preventability of the identified adverse events, this trigger also holds promise as a performance measurement tool.
Collapse
Affiliation(s)
- Lisa Calder
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Anita Pozgay
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shena Riff
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - David Rothwell
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Erik Youngson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Naghmeh Mojaverian
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Adam Cwinn
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan Forster
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
79
|
Gabayan GZ, Sarkisian CA, Liang LJ, Sun BC. Predictors of admission after emergency department discharge in older adults. J Am Geriatr Soc 2014; 63:39-45. [PMID: 25537073 DOI: 10.1111/jgs.13185] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To identify predictors of hospital inpatient admission of older Medicare beneficiaries after discharge from the emergency department (ED). DESIGN Retrospective cohort study. SETTING Nonfederal California hospitals (n = 284). PARTICIPANTS Visits of Medicare beneficiaries aged 65 and older discharged from California EDs in 2007 (n = 505,315). MEASUREMENTS Using the California Office of Statewide Health Planning and Development files, predictors of hospital inpatient admission within 7 days of ED discharge in older adults (≥65) with Medicare were evaluated. RESULTS Hospital inpatient admissions within 7 days of ED discharge occurred in 23,340 (4.6%) visits and were associated with older age (70-74: adjusted odds ratio (AOR) = 1.12, 95% confidence interval (CI) = 1.07-1.17; 75-79: AOR = 1.18, 95% CI = 1.13-1.23; ≥80: AOR = 1.4, 95% CI = 1.35-1.46), skilled nursing facility use (AOR = 1.82, 95% CI = 1.72-1.94), leaving the ED against medical advice (AOR = 1.82, 95% CI = 1.67-1.98), and the following diagnoses with the highest odds of admission: end-stage renal disease (AOR = 3.83, 95% CI = 2.42-6.08), chronic renal disease (AOR = 3.19, 95% CI = 2.26-4.49), and congestive heart failure (AOR = 3.01, 95% CI = 2.59-3.50). CONCLUSION Five percent of older Medicare beneficiaries have a hospital inpatient admission after discharge from the ED. Chronic conditions such as renal disease and heart failure were associated with the greatest odds of admission.
Collapse
Affiliation(s)
- Gelareh Z Gabayan
- Department of Medicine, University of California at Los Angeles, Los Angeles, California; Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California; Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | | | | | | |
Collapse
|
80
|
Hao S, Jin B, Shin AY, Zhao Y, Zhu C, Li Z, Hu Z, Fu C, Ji J, Wang Y, Zhao Y, Dai D, Culver DS, Alfreds ST, Rogow T, Stearns F, Sylvester KG, Widen E, Ling XB. Risk prediction of emergency department revisit 30 days post discharge: a prospective study. PLoS One 2014; 9:e112944. [PMID: 25393305 PMCID: PMC4231082 DOI: 10.1371/journal.pone.0112944] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 10/16/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Among patients who are discharged from the Emergency Department (ED), about 3% return within 30 days. Revisits can be related to the nature of the disease, medical errors, and/or inadequate diagnoses and treatment during their initial ED visit. Identification of high-risk patient population can help device new strategies for improved ED care with reduced ED utilization. METHODS AND FINDINGS A decision tree based model with discriminant Electronic Medical Record (EMR) features was developed and validated, estimating patient ED 30 day revisit risk. A retrospective cohort of 293,461 ED encounters from HealthInfoNet (HIN), Maine's Health Information Exchange (HIE), between January 1, 2012 and December 31, 2012, was assembled with the associated patients' demographic information and one-year clinical histories before the discharge date as the inputs. To validate, a prospective cohort of 193,886 encounters between January 1, 2013 and June 30, 2013 was constructed. The c-statistics for the retrospective and prospective predictions were 0.710 and 0.704 respectively. Clinical resource utilization, including ED use, was analyzed as a function of the ED risk score. Cluster analysis of high-risk patients identified discrete sub-populations with distinctive demographic, clinical and resource utilization patterns. CONCLUSIONS Our ED 30-day revisit model was prospectively validated on the Maine State HIN secure statewide data system. Future integration of our ED predictive analytics into the ED care work flow may lead to increased opportunities for targeted care intervention to reduce ED resource burden and overall healthcare expense, and improve outcomes.
Collapse
Affiliation(s)
- Shiying Hao
- HBI Solutions Inc., Palo Alto, California, United States of America
- Department of Surgery, Stanford University, Stanford, California, United States of America
| | - Bo Jin
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Andrew Young Shin
- Department of Pediatrics, Stanford University, Stanford, California, United States of America
| | - Yifan Zhao
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Chunqing Zhu
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Zhen Li
- Department of Surgery, Stanford University, Stanford, California, United States of America
| | - Zhongkai Hu
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Changlin Fu
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Jun Ji
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Yong Wang
- Department of Statistics, Stanford University, Stanford, California, United States of America
- Academy of Mathematics and Systems Science, Chinese Academy of Sciences, Beijing, China
| | - Yingzhen Zhao
- Department of Surgery, Stanford University, Stanford, California, United States of America
| | - Dorothy Dai
- HBI Solutions Inc., Palo Alto, California, United States of America
| | | | | | - Todd Rogow
- HealthInfoNet, Portland, Maine, United States of America
| | - Frank Stearns
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Karl G. Sylvester
- Department of Surgery, Stanford University, Stanford, California, United States of America
| | - Eric Widen
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Xuefeng B. Ling
- Department of Surgery, Stanford University, Stanford, California, United States of America
- * E-mail:
| |
Collapse
|
81
|
Griffey RT, Kennedy SK, D'Agostino McGowan L, McGownan L, Goodman M, Kaphingst KA. Is low health literacy associated with increased emergency department utilization and recidivism? Acad Emerg Med 2014; 21:1109-15. [PMID: 25308133 PMCID: PMC4626077 DOI: 10.1111/acem.12476] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 04/25/2014] [Accepted: 06/19/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to determine whether patients with low health literacy have higher emergency department (ED) utilization and higher ED recidivism than patients with adequate health literacy. METHODS The study was conducted at an urban academic ED with more than 95,000 annual visits that is part of a 13-hospital health system, using electronic records that are captured in a central data repository. As part of a larger, cross-sectional, convenience sample study, health literacy testing was performed using the short test of functional health literacy in adults (S-TOFHLA) and standard test thresholds identifying those with inadequate, marginal, and adequate health literacy. The authors collected patients' demographic and clinical data, including items known to affect recidivism. This was a structured electronic record review directed at determining 1) the median number of total ED visits in this health system within a 2-year period and 2) the proportion of patients with each level of health literacy who had return visits within 3, 7, and 14 days of index visits. Descriptive data for demographics and ED returns are reported, stratified by health literacy level. The Mantel-Haenszel chi-square was used to test whether there is an association between health literacy and ED recidivism. A negative binomial multivariable model was performed to examine whether health literacy affects ED use, including variables significant at the 0.1 alpha level on bivariate analysis and retaining those significant at an alpha of 0.05 in the final model. RESULTS Among 431 patients evaluated, 13.2% had inadequate, 10% had marginal, and 76.3% had adequate health literacy as identified by S-TOFHLA. Patients with inadequate health literacy had higher ED utilization compared to those with adequate health literacy (p = 0.03). Variables retained in the final model included S-TOFHLA score, number of medications, having a personal doctor, being a property owner, race, insurance, age, and simple comorbidity score. During the study period, 118 unique patients each made at least one return ED visit within a 14-day period. The proportion of patients with inadequate health literacy making at least one return visit was higher than that of patients with adequate health literacy at 14 days, but was not significantly higher within 3 or 7 days. CONCLUSIONS In this single-center study, higher utilization of the ED by patients with inadequate health literacy when compared to those with adequate health literacy was observed. Patients with inadequate health literacy made a higher number of return visits at 14 days but not at 3 or 7 days.
Collapse
Affiliation(s)
- Richard T Griffey
- The Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO
| | | | | | | | | | | |
Collapse
|
82
|
Rising KL, Victor TW, Hollander JE, Carr BG. Patient returns to the emergency department: the time-to-return curve. Acad Emerg Med 2014; 21:864-71. [PMID: 25154879 DOI: 10.1111/acem.12442] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 03/03/2014] [Accepted: 03/13/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Although 72-hour emergency department (ED) revisits are increasingly used as a hospital metric, there is no known empirical basis for this 72-hour threshold. The objective of this study was to determine the timing of ED revisits for adult patients within 30 days of ED discharge. METHODS This was a retrospective cohort study of all nonfederal ED discharges in Florida and Nebraska from April 1, 2010, to March 31, 2011, using data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP). ED discharges were followed forward to identify ED revisits occurring at any hospital within the same state within 30 days. The cumulative hazard of an ED revisit was plotted. Parametric and nonparametric modeling was performed to characterize the rate of ED revisits. RESULTS There were 4,782,045 ED discharges, with 7.5% (95% confidence interval [CI] = 7.4% to 7.5%) associated with 3-day revisits, and 22.4% (95% CI = 22.3% to 22.4%) associated with 30-day revisits, inclusive of the 3-day revisits. A double-exponential model fit the data best (p < 0.0001), and a single hinge point at 9 days (multivariate adaptive regression splines [MARS] model) yielded the best linear fit to the data, suggesting 9 days as the most reasonable cutoff for identification of acute ED revisits. Multiple stratified and subgroup analyses produced similar results. Future work should focus on identifying primary reasons for potentially avoidable return ED visits instead of on the revisit occurrence itself, thus more directly measuring potential lapses in delivery of high-quality care. CONCLUSIONS Almost one-quarter of ED discharges are linked to 30-day ED revisits, and the current 72-hour ED metric misses close to 70% of these patients. Our findings support 9 days as a more inclusive cutoff for studies of ED revisits.
Collapse
Affiliation(s)
- Kristin L. Rising
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | - Timothy W. Victor
- Graduate School of Education; Department Biostatistics and Epidemiology; University of Pennsylvania; Philadelphia PA
- Kantar Health; Philadelphia PA
| | - Judd E. Hollander
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | - Brendan G. Carr
- Department of Emergency Medicine; University of Pennsylvania; Philadelphia PA
- Department Biostatistics and Epidemiology; University of Pennsylvania; Philadelphia PA
| |
Collapse
|
83
|
van der Linden MC, Lindeboom R, de Haan R, van der Linden N, de Deckere ER, Lucas C, Rhemrev SJ, Goslings JC. Unscheduled return visits to a Dutch inner-city emergency department. Int J Emerg Med 2014; 7:23. [PMID: 25045407 PMCID: PMC4100563 DOI: 10.1186/s12245-014-0023-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 05/23/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Unscheduled return visits to the emergency department (ED) may reflect shortcomings in care. This study characterized ED return visits with respect to incidence, risk factors, reasons and post-ED disposition. We hypothesized that risk factors for unscheduled return and reasons for returning would differ from previous studies, due to differences in health care systems. METHODS All unscheduled return visits occurring within 1 week and related to the initial ED visit were selected. Multivariable logistic regression was conducted to determine independent factors associated with unscheduled return, using patient information available at the initial visit. Reasons for returning unscheduled were categorized into illness-, patient- or physician-related. Post-ED disposition was compared between patients with unscheduled return visits and the patients who did not return. RESULTS Five percent (n = 2,492) of total ED visits (n = 49,341) were unscheduled return visits. Patients with an urgent triage level, patients presenting during the night shift, with a wound or local infection, abdominal pain or urinary problems were more likely to return unscheduled. Reasons to revisit unscheduled were mostly illness-related (49%) or patient-related (41%). Admission rates for returning patients (16%) were the same as for the patients who did not return (17%). CONCLUSIONS Apart from abdominal complaints, risk factors for unscheduled return differ from previous studies. Short-term follow-up at the outpatient clinic or general practitioner for patients with urgent triage levels and suffering from wounds or local infections, abdominal pain or urinary problem might prevent unscheduled return.
Collapse
Affiliation(s)
| | - Robert Lindeboom
- Division of Clinical Methods and Public Health, Master Evidence Based Practice, Academic Medical Centre, University of Amsterdam, Amsterdam 1100 DD, The Netherlands
| | - Rob de Haan
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, J1b-118, Amsterdam 1100 DD, The Netherlands
| | - Naomi van der Linden
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam 3000 DR, The Netherlands
| | - Ernie Rjt de Deckere
- Accident and Emergency Department, Medical Centre Haaglanden, The Hague 2501 CK, The Netherlands
| | - Cees Lucas
- Division of Clinical Methods and Public Health, Master Evidence Based Practice, Academic Medical Centre, University of Amsterdam, Amsterdam 1100 DD, The Netherlands
| | - Steven J Rhemrev
- Accident and Emergency Department, Medical Centre Haaglanden, The Hague 2501 CK, The Netherlands
| | - J Carel Goslings
- Department of Surgery, Trauma Unit, Academic Medical Centre, University of Amsterdam, Amsterdam 1100 DD, The Netherlands
| |
Collapse
|
84
|
Jeong JH, Hwang SS, Kim K, Lee JH, Rhee JE, Kang C, Lee SH, Kim H, Im YS, Lee B, Byeon YI, Lee JS. Implementation of clinical practices to reduce return visits within 72 h to a paediatric emergency department. Emerg Med J 2014; 32:426-32. [DOI: 10.1136/emermed-2013-203382] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 06/01/2014] [Indexed: 11/04/2022]
|
85
|
McDevitt J, Melby V. An evaluation of the quality of Emergency Nurse Practitioner services for patients presenting with minor injuries to one rural urgent care centre in the UK: a descriptive study. J Clin Nurs 2014; 24:523-35. [DOI: 10.1111/jocn.12639] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Joe McDevitt
- Urgent Care and Treatment Centre; Tyrone County Hospital; Omagh UK
| | - Vidar Melby
- School of Nursing; University of Ulster; Magee Campus; Derry UK
| |
Collapse
|
86
|
Dumkow LE, Kenney RM, MacDonald NC, Carreno JJ, Malhotra MK, Davis SL. Impact of a Multidisciplinary Culture Follow-up Program of Antimicrobial Therapy in the Emergency Department. Infect Dis Ther 2014; 3:45-53. [PMID: 25134811 PMCID: PMC4108117 DOI: 10.1007/s40121-014-0026-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Indexed: 12/21/2022] Open
Abstract
Introduction Antimicrobial prescribing in the emergency department is predominantly empiric, with final microbiology results either unavailable or reported after most patients are discharged home. Systematic follow-up processes are needed to ensure appropriate antimicrobial therapy at this transition of care. The objective of this study was to assess the impact of a culture follow-up (CFU) program on the frequency of emergency department (ED) revisits within 72 h and hospital admissions within 30 days compared to the historical standard of care (SOC). Additionally, infection characteristics and antimicrobial therapy were compared. Methods A single group, pre-test post-test quasi-experimental study was conducted comparing a retrospective SOC group to a prospective CFU group. CFU was implemented using computerized decision-support software and a multidisciplinary team of pharmacists and emergency physician staff. Results Over the four-month intervention period the CFU group evaluated 197 cultures and modified antimicrobial therapy in 25.5%. The rate of combined ED revisits within 72 h and hospital admissions within 30 days was 16.9% in the SOC group and 10.2% in the CFU group (p = 0.079). When evaluating the uninsured population alone, revisits to the ED within 72 h were reduced from 15.3% in the SOC group to 2.4% in the CFU group (p = 0.044). Conclusion Implementation of a multidisciplinary CFU program was associated with a reduction in ED revisits within 72 h and hospital admissions within 30 days. One-fourth of patients required post-discharge intervention, representing a large need for antimicrobial stewardship expansion to ED practice models. Electronic supplementary material The online version of this article (doi:10.1007/s40121-014-0026-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Lisa E. Dumkow
- Mercy Health St. Mary’s, Grand Rapids, MI USA
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI USA
| | - Rachel M. Kenney
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI USA
| | | | - Joseph J. Carreno
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University and Henry Ford Hospital, 259 Mack Ave, Detroit, MI 48201 USA
- Albany College of Pharmacy and Health Sciences, Albany, NY USA
| | - Manu K. Malhotra
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI USA
| | - Susan L. Davis
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI USA
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University and Henry Ford Hospital, 259 Mack Ave, Detroit, MI 48201 USA
| |
Collapse
|
87
|
Antibiotic Prescriptions for Upper Respiratory Infection in the Emergency Department: A Population-Based Study. ACTA ACUST UNITED AC 2014. [DOI: 10.1155/2014/461258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Study Objective. Antibiotics prescriptions for upper respiratory infections (URI) are not uncommon, but the benefits for these groups had seldom been evaluated. We aimed to utilize a sampled National Health Insurance (NHI) claims data containing one million beneficiaries to explore if the use of antibiotics could reduce the possibility of unscheduled returns. Methods. We identified patients presented to ambulatory clinics with the discharged diagnoses of URI. The prescriptions of antibiotics were identified. We further matched each patient in the antibiotic group to the patient in the control group by selected covariates using a standard propensity score greedy-matching algorithm. The risks of unscheduled revisits were compared between the two groups. Results. A total of 6915140 visits were identified between 2005 and 2010. The proportions of antibiotics prescriptions are similar among these years, ranging from 9.99% to 13.38 %. In the propensity score assignment, 9190 patients (4595 in each group) were further selected. The odds ratio of unscheduled revisits among antibiotics group and control group was 0.92 (95% CI, 0.70–1.22) with P value equal to 0.569. Conclusions. Overall, antibiotics prescriptions did not seem to decrease the unscheduled revisits in patients presented to the ED with URI. Emergency physicians should reduce the unnecessary prescriptions and save antibiotics to patients with real benefits.
Collapse
|
88
|
Johnson MJ, Currow DC, Booth S. Prevalence and assessment of breathlessness in the clinical setting. Expert Rev Respir Med 2014; 8:151-61. [DOI: 10.1586/17476348.2014.879530] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
89
|
Hsia RY, Asch SM, Weiss RE, Zingmond D, Gabayan G, Liang LJ, Han W, McCreath H, Sun BC. Is emergency department crowding associated with increased "bounceback" admissions? Med Care 2013; 51:1008-14. [PMID: 24036997 DOI: 10.1097/mlr.0b013e3182a98310] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Emergency department (ED) crowding is linked with poor quality of care and worse outcomes, including higher mortality. With the growing emphasis on hospital performance measures, there is additional concern whether inadequate care during crowded periods increases a patient's likelihood of subsequent inpatient admission. We sought to determine if ED crowding during the index visit was associated with these "bounceback" admissions. METHODS We used comprehensive, nonpublic, statewide ED and inpatient discharge data from the California Office of Statewide Health Planning and Development from 2007 to identify index outpatient ED visits and bounceback admissions within 7 days. We further used ambulance diversion data collected from California local emergency medical services agencies to identify crowded days using intrahospital daily diversion hour quartiles. Using a hierarchical logistic regression model, we then determined if patients visiting on crowded days were more likely to have a subsequent bounceback admission. RESULTS We analyzed 3,368,527 index visits across 202 hospitals, of which 596,471 (17.7%) observations were on crowded days. We found no association between ED crowding and bounceback admissions. This lack of relationship persisted in both a discrete (high/low) model (OR, 1.01; 95% CI, 0.99, 1.02) and a secondary model using ambulance diversion hours as a continuous predictor (OR, 1.00; 95% CI, 1.00, 1.00). CONCLUSIONS Crowding as measured by ambulance diversion does not have an association with hospitalization within 7 days of an ED visit discharge. Therefore, bounceback admission may be a poor measure of delayed or worsened quality of care due to crowding.
Collapse
Affiliation(s)
- Renee Y Hsia
- *Department of Emergency Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco †VA Palo Alto Health Care System, Center for Healthcare Evaluation, Menlo Park ‡Department of Biostatistics, UCLA Fielding School of Public Health §Department of Medicine ∥Department of Medicine, Division of Geriatrics, University of California, Los Angeles, Los Angeles, CA ¶Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | | | | | | | | | | | | | | | | |
Collapse
|
90
|
Trivedy CR, Cooke MW. Unscheduled return visits (URV) in adults to the emergency department (ED): a rapid evidence assessment policy review. Emerg Med J 2013; 32:324-9. [PMID: 24165201 DOI: 10.1136/emermed-2013-202719] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Unscheduled return visits (URV) to the emergency department (ED) may be an important quality indicator of performance of individual clinicians as well as organisations and systems responsible for the delivery of emergency care. The aim of this study was to perform a rapid evidence assessment policy-based literature review of studies that have looked at URVs presenting to the ED. A rapid evidence assessment using SCOPUS and PUBMED was used to identify articles looking at unplanned returns to EDs in adults; those relating to specific complaints or frequent attenders were not included. After exclusions, we identified 26 articles. We found a reported URV rate of between 0.4% and 43.9% with wide variation in the time period defined for a URV, which ranged from 24 h to undefined. Thematic analysis identified four broad subtypes of URVs: related to patient factors, to the illness, to the system or organisation and to the clinician. This review informed the development of national clinical quality indicators for England. URV rates may serve as an important indicator of quality performance within the ED. However, review of the literature shows major inconsistencies in the way URVs are defined and measured. Furthermore, the review has highlighted that there are potentially at least four subcategories of URVs (patient related, illness related, system related and clinician related). Further work is in progress to develop standardised definitions and methodologies that will allow comparable research and allow URVs to be used reliably as a quality indicator for the ED.
Collapse
Affiliation(s)
- Chetan R Trivedy
- Division of Health Sciences, Warwick Medical School, Coventry, UK Emergency Department, Heart of England NHS Foundation Trust, West Midlands, UK
| | - Matthew W Cooke
- Division of Health Sciences, Warwick Medical School, Coventry, UK Emergency Department, Heart of England NHS Foundation Trust, West Midlands, UK
| |
Collapse
|
91
|
Cheng SY, Wang HT, Lee CW, Tsai TC, Hung CW, Wu KH. The characteristics and prognostic predictors of unplanned hospital admission within 72 hours after ED discharge. Am J Emerg Med 2013; 31:1490-4. [PMID: 24029494 DOI: 10.1016/j.ajem.2013.08.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 07/28/2013] [Accepted: 08/03/2013] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES The aims of this study were (1) to identify the characteristics of patients who return to the emergency department (ED) within 72 hours and are admitted to the hospital and (2) to identify the characteristics and predictors of in-hospital mortality subgroup. METHODS This study was conducted in a tertiary teaching hospital to identify characteristics of adult nontraumatic revisit-admission patients from January 1 to December 31, 2011. Demographic data, cause of revisit, and the underlying diseases as well as the in-hospital complications were reviewed. RESULTS Of the 72188 ED discharged patients, 690 revisit-admission patients were enrolled. The top 3 disease classifications were infection (38.7%), neurology (11.3%), and gastroenterology (11.2%). The etiology of the revisit included recurrent symptoms (72%), disease complications (15.8%), and inadequate diagnosis (12.1%). A total of 150 patients (21.7%) had complications, including receiving operation (17.2%), intensive care unit admission (4.2%), and cardiovascular conditions (2.5%). Forty-nine patients (7.1%) died during hospitalization owing to sepsis (57.1%), malignancy (34.7%), cardiogenic diseases (4.1%), and cerebrovascular conditions (4.1%). The nonsurvival group was older (64.1 ± 15.3 vs 55.7 ± 17.8; P < .001), had more patients with a diagnosis of moderate to severe liver disease (18.4% vs 4.8%; P < .001), malignancy (69.3% vs 20.1%; P < .001), and metastatic solid tumor (38.8% vs 6.2%; P < .001). CONCLUSIONS Age and diagnosis with malignancy, metastatic tumors, or moderate-to-severe liver disease were predictors of in-hospital mortality among 72-hour revisit-admission patients.
Collapse
Affiliation(s)
- Shih-Yu Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung County 833, Taiwan
| | | | | | | | | | | |
Collapse
|
92
|
|
93
|
Sauvin G, Freund Y, Saïdi K, Riou B, Hausfater P. Correction: Unscheduled Return Visits to the Emergency Department: Consequences for Triage. Acad Emerg Med 2013. [DOI: 10.1111/acem.12124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Gabrielle Sauvin
- Emergency Department; Centre Hospitalo-Universitaire (CHU) Pitié-Salpêtrière; Assistance-Publique Hôpitaux de Paris; Université Pierre et Marie Curie-Paris 6; Paris France
| | - Yonathan Freund
- Emergency Department; Centre Hospitalo-Universitaire (CHU) Pitié-Salpêtrière; Assistance-Publique Hôpitaux de Paris; Université Pierre et Marie Curie-Paris 6; Paris France
| | - Khaled Saïdi
- Emergency Department; Centre Hospitalo-Universitaire (CHU) Pitié-Salpêtrière; Assistance-Publique Hôpitaux de Paris; Université Pierre et Marie Curie-Paris 6; Paris France
| | - Bruno Riou
- Emergency Department; Centre Hospitalo-Universitaire (CHU) Pitié-Salpêtrière; Assistance-Publique Hôpitaux de Paris; Université Pierre et Marie Curie-Paris 6; Paris France
| | - Pierre Hausfater
- Emergency Department; Centre Hospitalo-Universitaire (CHU) Pitié-Salpêtrière; Assistance-Publique Hôpitaux de Paris; Université Pierre et Marie Curie-Paris 6; Paris France
| |
Collapse
|
94
|
Gabayan GZ, Asch SM, Hsia RY, Zingmond D, Liang LJ, Han W, McCreath H, Weiss RE, Sun BC. Factors associated with short-term bounce-back admissions after emergency department discharge. Ann Emerg Med 2013; 62:136-144.e1. [PMID: 23465554 DOI: 10.1016/j.annemergmed.2013.01.017] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Revised: 01/04/2013] [Accepted: 01/08/2013] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE Hospitalizations that occur shortly after emergency department (ED) discharge may reveal opportunities to improve ED or follow-up care. There currently is limited, population-level information about such events. We identify hospital- and visit-level predictors of bounce-back admissions, defined as 7-day unscheduled hospital admissions after ED discharge. METHODS Using the California Office of Statewide Health Planning and Development files, we conducted a retrospective cohort analysis of adult (aged >18 years) ED visits resulting in discharge in 2007. Candidate predictors included index hospital structural characteristics such as ownership, teaching affiliation, trauma status, and index ED size, along with index visit patient characteristics of demographic information, day of service, against medical advice or eloped disposition, insurance, and ED primary discharge diagnosis. We fit a multivariable, hierarchic logistic regression to account for clustering of ED visits by hospitals. RESULTS The study cohort contained a total of 5,035,833 visits to 288 facilities in 2007. Bounce-back admission within 7 days occurred in 130,526 (2.6%) visits and was associated with Medicaid (odds ratio [OR] 1.42; 95% confidence interval [CI] 1.40 to 1.45) or Medicare insurance (OR 1.53; 95% CI 1.50 to 1.55) and a disposition of leaving against medical advice or before the evaluation was complete (OR 1.90; 95% CI 1.89 to 2.0). The 3 most common age-adjusted index ED discharge diagnoses associated with a bounce-back admission were chronic renal disease, not end stage (OR 3.3; 95% CI 2.8 to 3.8), end-stage renal disease (OR 2.9; 95% CI 2.4 to 3.6), and congestive heart failure (OR 2.5; 95% CI 2.3 to 2.6). Hospital characteristics associated with a higher bounce-back admission rate were for-profit status (OR 1.2; 95% CI 1.1 to 1.3) and teaching affiliation (OR 1.2; 95% CI 1.0 to 1.3). CONCLUSION We found 2.6% of discharged patients from California EDs to have a bounce-back admission within 7 days. We identified vulnerable populations, such as the very old and the use of Medicaid insurance, and chronic or end-stage renal disease as being especially at risk. Our findings suggest that quality improvement efforts focus on high-risk individuals and that the disposition plan of patients consider vulnerable populations.
Collapse
Affiliation(s)
- Gelareh Z Gabayan
- Department of Medicine, University of California-Los Angeles, Los Angeles, CA, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
95
|
Sauvin G, Freund Y, Saïdi K, Riou B, Hausfater P. Unscheduled return visits to the emergency department: consequences for triage. Acad Emerg Med 2013; 20:33-9. [PMID: 23570476 DOI: 10.1111/acem.12052] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 05/24/2012] [Accepted: 07/31/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The objective was to conduct a survey of unscheduled revisits (URs) to the emergency department (ED) within 8 days of a prior visit, to test the hypothesis that patients making these URs are disproportionately likely to suffer short-term mortality or manifest a need for any admission to the hospital (adverse events [AEs]) at the time of the UR, compared to patients triaged at the same level who did not have an unscheduled ED revisit within 8 days. METHODS This was a 1-year retrospective study of patients with an UR to the ED of an urban, 1,600-bed tertiary care center and teaching hospital. The criteria for inclusion as an UR were: 1) making an emergency visit to our adult ED during 2008, without being admitted to our hospital nor being transferred to another hospital; and 2) subsequently making an UR to the same ED within 8 days following the first one. Patients who were contacted by members of our staff and specifically asked to make return visits to our ED (such as those who returned for wound care follow-up visits), and those who made more than five visits to our ED during 2008, were excluded. AEs were defined as death or hospitalization within 8 days of the second visit. RESULTS During 2008, there were 946 patients with URs (2% of patients treated and released after the first ED visit), and 931 were analyzed (n = 15 missing values). Associated with the second visit, an AE was noted for 276 (30%) patients. Eight variables were significantly associated with AE: age ≥ 65 years, previously diagnosed cancer, previously diagnosed cardiac disease, previously diagnosed psychiatric disease, presence of a relative at the time of the UR, arrival with a letter from a general practitioner at the time of the UR, a higher level of severity assigned at triage for the UR than for the first ED visit, and having had blood sample analysis performed during the first visit. The median triage score for the UR was not significantly different from that group's median triage score for the first ED visit, whereas the proportion of admissions to the hospital (29%) or to the intensive care unit (ICU; 2%) was greater overall in the UR group than in the patients making their first ED visit. CONCLUSIONS The authors observed that 2% of patients had an UR. This UR population was at greater risk of AE at the time of their URs compared to their initial visits, but the median triage nurse score was not significantly different between the first visit and the UR. This suggests that the triage score should be systematically upgraded for UR patients.
Collapse
Affiliation(s)
- Gabrielle Sauvin
- Emergency Department; Centre Hospitalo-Universitaire Pitié-Salpêtrière; Assistance-Publique Hôpitaux de Paris; Université Pierre et Marie Curie-Paris 6; Paris France
| | - Yonathan Freund
- Emergency Department; Centre Hospitalo-Universitaire Pitié-Salpêtrière; Assistance-Publique Hôpitaux de Paris; Université Pierre et Marie Curie-Paris 6; Paris France
| | - Khaled Saïdi
- Emergency Department; Centre Hospitalo-Universitaire Pitié-Salpêtrière; Assistance-Publique Hôpitaux de Paris; Université Pierre et Marie Curie-Paris 6; Paris France
| | - Bruno Riou
- Emergency Department; Centre Hospitalo-Universitaire Pitié-Salpêtrière; Assistance-Publique Hôpitaux de Paris; Université Pierre et Marie Curie-Paris 6; Paris France
| | - Pierre Hausfater
- Emergency Department; Centre Hospitalo-Universitaire Pitié-Salpêtrière; Assistance-Publique Hôpitaux de Paris; Université Pierre et Marie Curie-Paris 6; Paris France
| |
Collapse
|
96
|
Ooi CK, Foo CL, Vasu A, Seow E. Community Stepdown Care: A Safe Alternative for Selected Elderly Patients Attending Emergency Department? ACTA ACUST UNITED AC 2012. [DOI: 10.5402/2012/410931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background. The Community Stepdown Care Initiative attempts to provide right siting of care for elderly emergency department attendees whose main need is rehabilitation. Objectives. The aim of this study was to compare reattendance and rehospitalisation rates, length of stay, medical complication rates, and discharge destination between the community hospital cohort and the acute hospital cohort. Methods. A retrospective cohort study was conducted from June 2007 to November 2008. Results. Two hundred and thirty patients were enrolled in the study. 68 patients were successfully transferred to stepdown care; 162 patients were admitted to acute hospital. The odds ratio of reattendance was similar in both cohorts at 2 weeks, 6 months, and 12 months. The odds ratio of rehospitalisation was similar in both cohorts at 2 weeks, 3 months, 6 months, and 12 months. There was no statistical difference in the medical complication rates between the cohorts. Patients were more likely to be discharged home from the community hospital compared to acute hospital (adjusted OR 4.11, P=0.03). 14% of patients from the acute hospital cohort was discharged to community hospital. Conclusions. For selective elderly emergency department attendees whose predominant need is rehabilitation, stepdown care is a safe alternative compared to usual acute hospital care.
Collapse
Affiliation(s)
- Chee Kheong Ooi
- Emergency Department, Tan Tock Seng Hospital, Singapore 308433
| | - Chik Loon Foo
- Emergency Department, Tan Tock Seng Hospital, Singapore 308433
| | - Alicia Vasu
- Emergency Department, Tan Tock Seng Hospital, Singapore 308433
| | - Eillyne Seow
- Emergency Department, Tan Tock Seng Hospital, Singapore 308433
| |
Collapse
|
97
|
Hu KW, Lu YH, Lin HJ, Guo HR, Foo NP. Unscheduled Return Visits With and Without Admission Post Emergency Department Discharge. J Emerg Med 2012; 43:1110-8. [DOI: 10.1016/j.jemermed.2012.01.062] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 05/30/2011] [Accepted: 01/19/2012] [Indexed: 11/28/2022]
|
98
|
Wen LS, Kosowsky JM, Gurrola ER, Camargo CA. The provision of diagnosis at emergency department discharge: a pilot study: Table 1. Emerg Med J 2012; 30:801-3. [DOI: 10.1136/emermed-2012-201749] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
99
|
Curran J, McD Taylor D. National Coroners Information System: a valuable source of lessons for emergency medicine. Emerg Med Australas 2012; 24:442-50. [PMID: 22862763 DOI: 10.1111/j.1742-6723.2012.01575.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2012] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To interrogate the National Coroners Information System (NCIS) to determine the recurrent themes among coroners' recommendations that aimed to increase the safety of ED care. METHODS This was a retrospective analysis of NCIS closed cases, from Queensland, New South Wales, Tasmania, Victoria, Australian Capital Territory, South Australia and North Territory, entered since its inception in 2000. The keyword 'emergency department' returned 1645 cases, of which 180 were found to be relevant. The primary outcomes were the number and nature of cases where recommendations for improvements in ED care had been made and the recurrent themes of these recommendations that could inform education initiatives. RESULTS Of the 180 cases, 108 (60.0%) were of deceased men and subject age ranged from 2 days to 91 years. The commonest causes of death were trauma (26.7%), infection (24.4%), cardiac events (15.0%) and poisoning (8.9%). No coronial recommendations were required in 19 cases. For the remainder, recommendation themes related to issues of risk management/medico-legal, diagnostic/therapeutic error, education, documentation/communication and re-presentation. The themes associated with the different doctor designations (consultant, registrar, resident/intern) were similar, although registrars and residents/interns tended towards more diagnostic/therapeutic errors. The themes associated with hospital type (referral, urban, regional/rural) were also similar. Although theme analysis is important, some individual cases were particularly instructive. CONCLUSION The NCIS data theme analysis identifies important high-risk patients and presenting complaints. These should be incorporated into emergency physician training. EDs should review the coronial recommendations to ensure that, where possible, they have been adopted.
Collapse
Affiliation(s)
- Justin Curran
- Emergency Department, Austin Health, Heidelberg, VIC 3084, Australia
| | | |
Collapse
|
100
|
Egan DJ, Pare JR. Clinical pathologic conference: A 65-year-old male with left-sided chest pain. A case of an unexpected occupational hazard. Acad Emerg Med 2012; 19:e1-6. [PMID: 22320376 DOI: 10.1111/j.1553-2712.2011.01269.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The authors present a case of a 65-year-old male who presented four times to the emergency department (ED) with left-sided chest pain. On the first three visits, the patient was admitted with a different diagnosis related to his chest pain. On the final visit, an abnormality on an imaging study performed in the ED led to the ultimate diagnostic test revealing the cause of the patient's symptoms. The patient's clinical presentation and ultimate clinical course are summarized, and a discussion of the differential diagnoses of his condition is presented.
Collapse
Affiliation(s)
- Daniel J Egan
- Department of Emergency Medicine, St. Luke's Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.
| | | |
Collapse
|