72 h returns: A trigger tool for diagnostic error

Neutrophil-to-lymphocyte ratio as a predictor for outcomes in patients with short-term emergency department revisits

BACKGROUND

Analysis of short-term emergency department (ED) revisits is a common emergency care quality assurance practice. Previous studies have explored various risk factors of ED revisits; however, laboratory data were usually omitted. This study aimed to evaluate the prognostic significance of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte (PLR), and systemic immune-inflammation index (SII) in predicting outcomes of patients revisiting the ED.

METHODS

This retrospective observational cohort study investigated short-term ED revisit patients. The primary outcome measure was high-risk ED revisit, a composite of in-hospital mortality or intensive care unit (ICU) admission after 72-hour ED revisit. The NLR, PLR, and SII were investigated as potential prognostic predictors of ED revisit outcomes.

RESULTS

A total of 1916 encounters with short-term ED revisit patients were included in the study; among these, 132 (6.9%) encounters, comprising 57 in-hospital mortalities and 95 ICU admissions, were high-risk revisits. High-risk revisit patients had significantly higher NLR, PLR, and SII (11.6 vs 6.6, p < 0.001; 26.2 vs 18.9, p = 0.004; 2209 vs 1486, p = 0.002, respectively). Multiple regression analysis revealed revisit-NLR as an independent factor for predicting poor outcomes post-ED revisits (odds ratio: 1.031, 95% CI: 1.017-1.045, p < 0.001); an optimal cut-off value of 7.9 was proven for predicting high-risk ED revisit.

CONCLUSION

The intensity of the inflammatory response expressed by NLR was an independent predictor for poor outcomes of ED revisits and should be considered when ED revisits occur. Future prediction models for ED revisit outcomes can include revisit-NLR as a potential predictor to reflect the progressive conditions in ED patients.

Evaluation of a Structured Review Process for Emergency Department Return Visits with Admission

BACKGROUND

Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis.

METHODS

The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests.

RESULTS

The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (p < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (p < 0.001) but not by language (p = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (p = 0.446) or language (p = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education.

CONCLUSION

The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.

Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network

Background

Diagnostic errors, reframed as missed opportunities for improving diagnosis (MOIDs), are poorly understood in the paediatric emergency department (ED) setting. We investigated the clinical experience, harm and contributing factors related to MOIDs reported by physicians working in paediatric EDs.

Methods

We developed a web-based survey in which physicians participating in the international Paediatric Emergency Research Network representing five out of six WHO regions, described examples of MOIDs involving their own or a colleague’s patients. Respondents provided case summaries and answered questions regarding harm and factors contributing to the event.

Results

Of 1594 physicians surveyed, 412 (25.8%) responded (mean age=43 years (SD=9.2), 42.0% female, mean years in practice=12 (SD=9.0)). Patient presentations involving MOIDs had common undifferentiated symptoms at initial presentation, including abdominal pain (21.1%), fever (17.2%) and vomiting (16.5%). Patients were discharged from the ED with commonly reported diagnoses, including acute gastroenteritis (16.7%), viral syndrome (10.2%) and constipation (7.0%). Most reported MOIDs (65%) were detected on ED return visits (46% within 24 hours and 76% within 72 hours). The most common reported MOID was appendicitis (11.4%), followed by brain tumour (4.4%), meningitis (4.4%) and non-accidental trauma (4.1%). More than half (59.1%) of the reported MOIDs involved the patient/parent–provider encounter (eg, misinterpreted/ignored history or an incomplete/inadequate physical examination). Types of MOIDs and contributing factors did not differ significantly between countries. More than half of patients had either moderate (48.7%) or major (10%) harm due to the MOID.

Conclusions

An international cohort of paediatric ED physicians reported several MOIDs, often in children who presented to the ED with common undifferentiated symptoms. Many of these were related to patient/parent–provider interaction factors such as suboptimal history and physical examination. Physicians’ personal experiences offer an underexplored source for investigating and mitigating diagnostic errors in the paediatric ED.

Use of e-triggers to identify diagnostic errors in the paediatric ED

BACKGROUND

Diagnostic errors (DxEs) are an understudied source of patient harm in children rarely captured in current adverse event reporting systems. Applying electronic triggers (e-triggers) to electronic health records shows promise in identifying DxEs but has not been used in the emergency department (ED) setting.

OBJECTIVES

To assess the performance of an e-trigger and subsequent manual screening for identifying probable DxEs among children with unplanned admission following a prior ED visit and to compare performance to existing incident reporting systems.

DESIGN/METHODS

Retrospective single-centre cohort study of children ages 0-22 admitted within 14 days of a previous ED visit between 1 January 2018 and 31 December 2019. Subjects were identified by e-trigger, screened to identify cases where index visit and hospital discharge diagnoses were potentially related but pathophysiologically distinct, and then these screened-in cases were reviewed for DxE using the SaferDx Instrument. Cases of DxE identified by e-trigger were cross-referenced against existing institutional incident reporting systems.

RESULTS

An e-trigger identified 1915 unplanned admissions (7.7% of 24 849 total admissions) with a preceding index visit. 453 (23.7%) were screened in and underwent review using SaferDx. 92 cases were classified as likely DxEs, representing 0.4% of all hospital admissions, 4.8% among those selected by e-trigger and 20.3% among those screened in for review. Half of cases were reviewed by two reviewers using SaferDx with substantial inter-rater reliability (Cohen's κ=0.65 (95% CI 0.54 to 0.75)). Six (6.5%) cases had been reported elsewhere: two to the hospital's incident reporting system and five to the ED case review team (one reported to both).

CONCLUSION

An e-trigger coupled with manual screening enriched a cohort of patients at risk for DxEs. Fewer than 10% of DxEs were identified through existing surveillance systems, suggesting that they miss a large proportion of DxEs. Further study is required to identify specific clinical presentations at risk of DxEs.

Comparison of outcomes in emergency department revisiting patients before and after coronavirus disease 2019 epidemic

BACKGROUND AND IMPORTANCE

The outbreak of COVID-19 challenged the global health system and specifically impacted the emergency departments (EDs). Studying the quality indicators of ED care under COVID-19 has been a necessary task, and ED revisits have been used as an indicator to monitor ED performance.

OBJECTIVES

The study investigated whether discrepancies existed among ED revisiting cases before and after COVID-19 and whether the COVID-19 epidemic was a predictor of poor outcomes of ED revisits.

DESIGN

Retrospective study.

SETTINGS AND PARTICIPANTS

We used electronic health records data from a tertiary medical center. Data of patients with 72-h ED revisit after the COVID-19 epidemic were collected from February 2020 to June 2020 and compared with those of patients before COVID-19, from February 2019 to June 2019.

OUTCOME MEASURES AND ANALYSIS

The investigated outcomes included hospital admission, ICU admission, out-of-hospital cardiac arrest, and subsequent inhospital mortality. Univariate and multivariate logistic regression models were used to identify independent predictors of 72-h ED revisit outcomes.

MAIN RESULTS

In total, 1786 patients were enrolled in our study - 765 in the COVID group and 1021 in the non-COVID group. Compared with the non-COVID group, patients in the COVID group were younger (53.9 vs. 56.1 years old; P = 0.002) and more often female (66.1% vs. 47.3%; P < 0.001) and had less escalation of triage level (11.6% vs. 15.0%; P = 0.041). The hospital admission and inhospital mortality rates in the COVID and non-COVID groups were 33.9% vs. 32.0% and 2.7% vs. 1.5%, respectively. In the logistic regression model, the COVID-19 period was significantly associated with inhospital mortality (adjusted odds ratio, 2.289; 95% confidence interval, 1.059-4.948; P = 0.035).

CONCLUSION

Patients with 72-h ED revisits showed distinct demographic and clinical patterns before and after the COVID-19 epidemic; the COVID-19 period was an independent predictor of increased inhospital mortality.

Under-triage: A New Trigger to Drive Quality Improvement in the Emergency Department

The emergency department (ED) is a care setting with a high risk for medical error. In collaboration with our nursing colleagues, we identified a new trigger, under-triage, and demonstrated how its implementation could detect and reduce medical errors in the ED.

Intravenous antibiotics at the index emergency department visit as an independent risk factor for hospital admission at the return visit within 72 hours

Introduction

Although infection was the most common symptom in patients returning to the ED, whether intravenous antibiotic administration at the index visit could serve as an indicator of patients with infectious diseases at high risk for hospital admission after returning to the ED within a short period of time remains unclear. The study aimed to investigate the potential risk factors for hospital admission in patients returning to the ED within 72 hours with a final diagnosis of infectious diseases.

Material and methods

This retrospective cohort study analyzed return visits to the ED from January to December 2019. Adult patients aged >20 years who had a return visit to the ED within 72 hours with an infectious disease were included herein. In total, 715 eligible patients were classified into the intravenous antibiotics and non-intravenous antibiotics group (reference group). The outcome studied was hospital admission to general ward and intensive care unit (ICU) at the return visits.

Results

Patients receiving intravenous antibiotics at index visits had significantly higher risk—approximately two times—for hospital admission at the return visits than those did not (adjusted odds ratio = 2.47, 95% CI = 1.34–4.57, p = 0.004). For every 10 years increase in age, the likelihood for hospital admission increased by 38%. Other factors included abnormal respiratory rate and high C-reactive protein levels.

Conclusions

Intravenous antibiotic administration at the index visit was an independent risk factor for hospital admission at return visits in patients with an infection disease. Physicians should consider carefully before discharging patients receiving intravenous antibiotics.

A Framework for Quality Assurance of Pediatric Revisits to the Emergency Department

BACKGROUND

Emergency department return visits significantly impact medical costs and patient flow. A comprehensive approach to understanding these patients is required to identify deficits in care, system level inefficiencies, and improve diagnosis specific management protocols. We aimed to identify factors needed to successfully analyze return visits to explore root causes leading to unplanned returns and inform system-level improvements.

METHODS

A multidisciplinary committee collaborated to develop a quality review process for return visits within 72 hours to our pediatric emergency department that were then subsequently admitted to the hospital. The committee developed methodology and a web-based tool for chart review and analysis.

RESULTS

Of 197,076 ED visits (159,164 discharged at initial visit), 5390 (3.4%) patients were discharged and represented to the ED within 72 hours and 1658 (1.0%) of those resulted in admission. Using defined criteria, approximately one third (n = 564) of revisits with admission were identified for chart review. Reason for revisit included natural progression of disease (67.6%), new condition or problem (11.2%), diagnostic error (6.9%), and scheduled or planned readmissions (3.5%). All diagnostic errors had not been previously identified by ED leadership. Of the reviewed cases, most were not preventable (84.0%); however, a number of system-level actions resulted from discussion of the potentially preventable revisits.

CONCLUSIONS

Seventy-two-hour ED revisits were efficiently and systematically categorized with determination of root causes and preventability. This process resulted in shared provider-level feedback, identifying trends in revisits, and implementation of system-level actions, therefore, encouraging other institutions to adopt a similar process.

A Review of Interprofessional Variation in Education: Challenges and Considerations in the Growth of Advanced Practice Providers in Emergency Medicine

The employment and utilization of advanced practice providers (APPs) in the emergency department has been steadily increasing. Physicians, physician assistants (PAs), and nurse practitioners (NPs) have vastly different requirements for admission to graduate programs, clinical exposure, and postgraduate training. It is important that as supervisory physicians, patients, hospital administrators, and lawmakers, we understand the differences to best create a collaborative, supportive, and educational framework within which PAs/NPs can work effectively as part of a care team. This paper reviews the trends, considerations, and challenges of an evolving clinician workforce in the specialty of emergency medicine (EM). Subsequently, the following parameters of APP training are examined and discussed: the divergence in physician, PA, and NP education and training; requirements of PA and NP degree programs; variation in clinical contact hours; degree-specific licensing and postgraduate EM certification; opportunities for specialty training; and the evolution and availability of residency programs for APPs. The descriptive review is followed by a discussion of contemporary and timely issues that impact EM and considerations brought forth by the expansion of APPs in EM such as the current drive to independent practice and the push for reimbursement parity. We review current position statements from pertinent professional organizations regarding PA and NP capabilities, responsibilities, and physician oversight as well as billing implications, care outcomes and medicolegal implications.

The Emergency Department Trigger Tool: Validation and Testing to Optimize Yield

OBJECTIVE

Recognized as a premier approach for adverse event (AE) detection, trigger tools have been developed for multiple clinical settings outside the emergency department (ED). We recently derived and tested an ED trigger tool (EDTT) with enhanced features for high-yield detection of harm, consisting of 30 triggers associated with AEs. In this study, we validate the EDTT in an independent sample and compare record selection approaches to optimize yield for quality improvement.

METHODS

This is a retrospective observational study using data from 13 months of visits to an urban, academic ED by patients aged ≥ 18 years (92,859 records). We conducted standard two-tiered trigger tool reviews on an independent validation sample of 3,724 records with at least one of the 30 triggers found associated with AEs in our previous derivation sample (N = 1,786). We also tested three new candidate triggers and reviewed 72 records with no triggers for comparison purposes. We compare derivation and validation samples on: 1) triggers showing persistent associations with AEs, 2) AE yield (AEs detected/records reviewed), and 3) representativeness of AE types detected. We use bivariate associations of triggers with AEs as the basis for trigger selection. We then use multivariable modeling in the combined derivation and validation samples to determine AE risk scores using trigger weights. This allows us to predict occurrence of AEs and derive population prevalence estimates. Finally, we compare yield for detection of AEs under three record selection strategies (random selection, trigger counts, weighted trigger counts).

RESULTS

Twenty-four of the 30 triggers were confirmed to be associated with AEs on bivariate testing. Three previously marginal triggers and two of three new candidate triggers were also found to be associated with AEs. The presence of any of these 29 triggers was associated with an AE rate of 10% in our selected sample (compared to 1.1% for none, p < 0.001). The risk of an AE increased with number of triggers. Combining data from both phases, we identified 461 AEs in 429 unique visits in 5,582 records reviewed. Our multivariable model (which emphasized parsimony) retained 12 triggers with a ROC AUC of 82% in both samples. Selecting records for review based on number of triggers improves yield to 14% for 4+ triggers (top 10% of visits) and to 28% for 8+ (top 1%). A weighted trigger count has corresponding yields of 18 and 38%. The method for selecting records for review did not appear to affect event-type representativeness, with similar distributions of event types and severities detected.

CONCLUSIONS

In this single-site study of the EDTT we observed high levels of validity in trigger selection, yield, and representativeness of AEs, with yields that are superior to estimates for traditional approaches to AE detection. Record selection using weighted triggers outperforms a trigger count threshold approach and far outperforms random sampling from records with at least one trigger. The EDTT is a promising efficient and high-yield approach for detecting all-cause harm to guide quality improvement efforts in the ED.

Identifying trigger concepts to screen emergency department visits for diagnostic errors

OBJECTIVES

The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm.

METHODS

We conducted a literature review and surveyed ED directors to compile a list of potential electronic health record (EHR) trigger (e-triggers) and non-EHR based concepts. We convened a multidisciplinary expert panel to build consensus on trigger concepts to identify and reduce preventable diagnostic harm in the ED.

RESULTS

Six e-trigger and five non-EHR based concepts were selected by the expert panel. E-trigger concepts included: unscheduled ED return to ED resulting in hospital admission, death following ED visit, care escalation, high-risk conditions based on symptom-disease dyads, return visits with new diagnostic/therapeutic interventions, and change of treating service after admission. Non-EHR based signals included: cases from mortality/morbidity conferences, risk management/safety office referrals, ED medical director case referrals, patient complaints, and radiology/laboratory misreads and callbacks. The panel suggested further refinements to aid future research in defining diagnostic error epidemiology in ED settings.

CONCLUSIONS

We identified a set of e-trigger concepts and non-EHR based signals that could be developed further to screen ED visits for diagnostic safety events. With additional evaluation, trigger-based methods can be used as tools to monitor and improve ED diagnostic performance.

Quality Assurance in the Emergency Department

Quality assurance (QA) of care in the emergency department encompasses activities ensuring that the care provided meets applicable standards. Health care delivery is complex and many factors affect quality of care. Thus, quantification of health care quality is challenging, especially with regard to attribution of outcomes to various factors contributing to such care. A critical component of the process of QA is determination of quality health care and the concept of (unjustified) deviation from the reference applicable standard of care.

Using trigger tools to identify triage errors by ambulance dispatch nurses in Sweden: an observational study

OBJECTIVES

This study aimed to assess whether trigger tools were useful identifying triage errors among patients referred to non-emergency care by emergency medical dispatch nurses, and to describe the characteristics of these patients.

DESIGN

An observational study of patients referred by dispatch nurses to non-emergency care.

SETTING

Dispatch centres in two Swedish regions.

PARTICIPANTS

A total of 1089 adult patients directed to non-emergency care by dispatch nurses between October 2016 and February 2017. 53% were female and the median age was 61 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was a visit to an emergency department within 7 days of contact with the dispatch centre. Secondary outcomes were (1) visits related to the primary contact with the dispatch centre, (2) provision of care above the primary level (ie, interventions not available at a typical local primary care centre) and (3) admission to hospital in-patient care.

RESULTS

Of 1089 included patients, 260 (24%) visited an emergency department within 7 days. Of these, 209 (80%) were related to the dispatch centre contact, 143 (55%) received interventions above the primary care level and 99 (38%) were admitted to in-patient care. Elderly (65+) patients (OR 1.45, 95% CI 1.05 to 1.98) and patients referred onwards to other healthcare providers (OR 1.58, 95% CI 1.15 to 2.19) had higher likelihoods of visiting an emergency department. Six avoidable patient harms were identified, none of which were captured by existing incident reporting systems, and all of which would have received an ambulance if the decision support system had been strictly adhered to.

CONCLUSION

The use of these patient outcomes in the framework of a Global Trigger Tool-based review can identify patient harms missed by incident reporting systems in the context of emergency medical dispatching. Increased compliance with the decision support system has the potential to improve patient safety.

Predictors of Admission in Adult Unscheduled Return Visits to the Emergency Department

Introduction

The 72-hour unscheduled return visit (URV) of an emergency department (ED) patient is often used as a key performance indicator in emergency medicine. We sought to determine if URVs with admission to hospital (URVA) represent a distinct subgroup compared to unscheduled return visits with no admission (URVNA).

Methods

We performed a retrospective cohort study of all 72-hour URVs in adults across 10 EDs in the Edmonton Zone (EZ) over a one-year period (January 1, 2015 - December 31, 2015) using ED information-system data. URVA and URVNA populations were compared, and a multivariable analysis identified predictors of URVA.

Results

Analysis of 40,870 total URV records, including 3,363 URVAs, revealed predictors of URVA on the index visit including older age (>65 yrs, odds ratio [OR] 3.6), higher disease acuity (Canadian Emergency Department Triage and Acuity Scale [CTAS] 2, OR 2.6), gastrointestinal presenting complaint (OR 2.2), presenting to a referral hospital (OR 1.4), fewer annual ED visits (<4 visits, OR 2.0), and more hours spent in the ED (>12 hours, OR 2.0). A decrease in CTAS score (increase in disease acuity) upon return visit also increased the risk of admission (-1 CTAS level, OR 2.6). ED crowding at the index visit, as indicated by occupancy level, was not a predictor.

Conclusion

We demonstrate that URVA patients comprise a distinct subgroup of 72-hour URV patients. Risk factors for URVA are present at the index visit suggesting that patients at high risk for URVA may be identifiable prior to admission.