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Hutchinson CL, Curtis K, McCloughen A, Qian S, Yu P, Fethney J. Predictors and outcomes of patients that return unplanned to the Emergency Department and require critical care admission: A multicenter study. Australas Emerg Care 2021; 25:88-97. [PMID: 33994336 DOI: 10.1016/j.auec.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/21/2021] [Accepted: 04/15/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the incidence, characteristics (including timeframe) and predictors of patients discharged from the Emergency Department (ED) that later return and require admission. METHODS A retrospective cross-sectional study examining all return visits to three EDs in Sydney, Australia, over a 12-month period. Patients returning within 28 days from ED discharge with the same or similar complaint were classified as a return visit to ensure capture of all return visits. Descriptive and inferential statistics were used to analyse the data and logistic regression was performed to predict factors associated with return visits with general admission, and return visits admitted to critical care. RESULTS There were 1,798 (30%) return visits which resulted in admission, mostly to a non-critical care area (1,679, 93%). The current NSW 48 -h time frame used to define a return visit in NSW captured half of all admitted returns (49.5%) and just over half (59.2%) of critical care admissions. Variables associated with an admission to critical care were age (OR 1.02, 95% CI 1.01, 1.03), initial presentation (index visit) made to a lower level ED (OR 3.76 95% CI 2.06, 6.86), Triage Category 2 (OR 3.67 95% CI 2.04, 6.60) and a cardiac diagnosis (OR 5.76, 95% CI 3.01, 11.01). This model had adequate discriminant ability with AUROC = 0.825. CONCLUSION A small number of return visits result in admission, especially to critical care. These patients are at risk of poor outcomes. As such, clinicians should have increased index of suspicion for patients who return that are older, present with cardiac problems, or have previously presented to a lower level ED. Revision of the current timeframe that defines a return visit ought to be considered by policy makers to improve the accuracy of this widely used key performance indicator.
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Affiliation(s)
- Claire L Hutchinson
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Emergency Department, Canterbury Hospital, Campsie, Sydney, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Illawarra Shoalhaven Local Health District, NSW, Australia; Illawarra Health and Medical Research Institute, NSW, Australia
| | - Andrea McCloughen
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
| | - Siyu Qian
- Centre for IT-enabled Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Australia
| | - Ping Yu
- Centre for IT-enabled Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Australia; Illawarra Health and Medical Research Institute, NSW, Australia
| | - Judith Fethney
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
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Chartier LB, Jalali H, Seaton MB, Ovens H, Borgundvaag B, McLeod SL, Dainty KN, Ostrow O. Qualitative evaluation of a mandatory provincial programme auditing emergency department return visits. BMJ Open 2021; 11:e044218. [PMID: 33827836 PMCID: PMC8031058 DOI: 10.1136/bmjopen-2020-044218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE The objective of this qualitative study was to evaluate the perceived impact and value of the Return Visit Quality Programme (RVQP), a mandatory province-wide emergency department audit programme. DESIGN We employed an interpretive descriptive qualitative approach with maximum variation sampling to ensure diverse representation across several geographical and institutional factors. RVQP programme leads were invited to participate in semistructured interviews and snowball sampling was used to reach non-lead physicians to capture the perspectives of those working within the programme. SETTING In Ontario's RVQP, participating emergency departments must audit their return visits resulting in admission to identify issues that can be addressed through quality improvement initiatives. PARTICIPANTS Between June and August 2018, we interviewed 32 participants (local programme leads and non-lead physicians) from 23 out of the 86 participating centres. RESULTS Participants' perceived impact and value of the programme was associated with the existence (or absence) and nature of the local quality improvement culture, the implementation approach of the programme within their emergency departments, and key aspects of the programme pertaining to medicolegal concerns and resource availability. CONCLUSIONS This study of an innovative, large-scale programme aimed at promoting continuous quality improvement in emergency departments showed that while its perceived impact has been meaningful, there are key structural and operational elements that support and hinder this aim. Healthcare leaders should consider these findings when looking to implement large-scale audit or quality improvement programmes.
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Affiliation(s)
- Lucas B Chartier
- Emergency Medicine, University Health Network, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Hanna Jalali
- University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - M Bianca Seaton
- Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
| | - Howard Ovens
- Department of Emergency Medicine, Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Bjug Borgundvaag
- Department of Emergency Medicine, Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Shelley L McLeod
- Department of Family and Community Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Katie N Dainty
- Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
| | - Olivia Ostrow
- Department of Pediatrics, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Department of Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
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Chartier LB, Ovens H, Hayes E, Davis B, Calder L, Schull M, Dreyer J, Ostrow O. Improving Quality of Care Through a Mandatory Provincial Audit Program: Ontario's Emergency Department Return Visit Quality Program. Ann Emerg Med 2020; 77:193-202. [PMID: 33199045 DOI: 10.1016/j.annemergmed.2020.09.449] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/31/2020] [Accepted: 09/23/2020] [Indexed: 11/28/2022]
Abstract
The Emergency Department Return Visit Quality Program was launched in Ontario, Canada, to promote a culture of quality. It mandates the province's largest-volume emergency departments (EDs) to audit charts of patients who had a return visit leading to hospital admission, including some of their 72-hour all-cause return visits with admission and all of their 7-day ones with sentinel diagnoses (ie, acute myocardial infarction, subarachnoid hemorrhage, and pediatric sepsis), and submit their findings to a governmental agency. This provides an opportunity to identify possible adverse events and quality issues, which hospitals can then address through quality improvement initiatives. A group of emergency physicians with quality improvement expertise analyzed the submitted audits and accompanying narrative templates, using a general inductive approach to develop a novel classification of recurrent quality themes. Since the Return Visit Quality Program launched in 2016, 125,698 return visits with admission have been identified, representing 0.93% of the 86 participating EDs' 13,559,664 visits. Overall, participating hospitals have conducted 12,852 detailed chart audits, uncovering 3,010 (23.4%) adverse events/quality issues and undertaking hundreds of quality improvement provincewide projects as a result. The inductive analysis revealed 11 recurrent themes, classified into 3 groupings: patient characteristics (ie, patient risk profile and elder care), ED team actions or processes (ie, physician cognitive lapses, documentation, handover/communication between providers, radiology, vital signs, and high-risk medications or medication interactions), and health care system issues (ie, discharge planning/community follow-up, left against medical advice/left without being seen, and imaging/testing availability). The Return Visit Quality Program is the largest mandatory audit program for EDs and provides a novel approach to identify local adverse events/quality issues to target for improved patient safety and quality of care. It provides a blueprint for health system leaders to enable clinicians to develop an approach to organizational quality, as well as for teams to construct an audit system that yields defined issues amenable to improvement.
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Affiliation(s)
- Lucas B Chartier
- Emergency Department, University Health Network, Toronto, Ontario, Canada; Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Howard Ovens
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Sinai Health System, Toronto, Ontario, Canada
| | - Emily Hayes
- Health Quality Ontario, Toronto, Ontario, Canada
| | | | - Lisa Calder
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michael Schull
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada; ICES and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jonathan Dreyer
- London Health Sciences Centre, London, Ontario, Canada; Department of Medicine, Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Olivia Ostrow
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
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Awareness of diagnosis and follow up care after discharge from the Emergency Department. Australas Emerg Care 2019; 22:221-226. [PMID: 31624010 DOI: 10.1016/j.auec.2019.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Patients currently receive discharge summaries including investigation results, medical assessment and follow up requirements with health professionals on discharge from the emergency department (ED). This study aimed to evaluate if a simplified discharge information card in addition to current care improved patients' awareness of their discharge diagnosis and requirements for follow-up appointment. METHODS A prospective pre-post design interventional study was conducted. The pre-intervention phase collected data from patients who did not receive the discharge card. The post-intervention phase occurred after implementing the discharge card. Participants underwent brief interviews to assess awareness of diagnosis and follow-up appointment requirements after discharge. Responses were compared to the plan in the medical notes and concordance determined. RESULTS There were 112 patients in the pre-intervention group and 117 in the post-intervention group. Awareness of discharge diagnosis improved from 73.2% (95% CI: 64.3-80.5) of pre-interventions participants to 89.7% (95% CI: 82.9-94.0) for participants receiving the discharge card (p<0.001; NNT 6.1 patients). Statistically significant improvements were observed regarding knowledge of follow-up destination and timing. CONCLUSION A short discharge information card improved awareness of discharge diagnoses and follow-up requirements. Such interventions that empower patients with knowledge about their health, should be considered prior to discharge from EDs.
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Kilicaslan O, Sönmez FT, Gunes H, Temizkan RC, Kocabay K, Saritas A. Short Term Unscheduled Revisits to Paediatric Emergency Department - A Six Year Data. J Clin Diagn Res 2017; 11:SC12-SC15. [PMID: 28511472 DOI: 10.7860/jcdr/2017/25098.9484] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 12/06/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Reviewing the reasons for return visits within 24 hours is a very important method of determining possible problems of emergency health care. Several causes stay behind unscheduled emergency return visits. Therefore, identifying these factors is crucial to set strategies in order to decrease the number of unnecessary visits. AIM To define the characteristics of the patients returning to the Paediatric Emergency Department (PED) within 24 hours via determining rate, number and demographic data of patients. MATERIALS AND METHODS The present study design involves retrospective data collection of patients who returned to PED within 24 hours after being discharged. Data was included over six year period and was collected from July 1, 2010 to June 30, 2016. The data was analysed with SPSS17.0 statistical package for windows. RESULTS A total of 1994 patients returned to PED within 24 hours from July 1, 2010 to June 30, 2016. The most common group of revisiting patients were toddlers (aged 0-2-year old), n=1168 (58.5%), and the least number represented young adolescents (aged 15-18-year old), n=82 (4.1%). Number of patients returning to PED in 24 hours has significantly increased within years from approximately 90 patients to 720 (p<0.05). This increase in number was observed in all and each age group (from 0-18 years of age) without any exception. Seasonal distribution of the patients showed no significant difference (p>0.05) for each age, but again, presented definite negative correlation with age (the older is the patient group, the less is the number of revisits). The most common time for revisits was 17-24 hours after first discharge from PED, n=1277 (64.04%). CONCLUSION The number of return visits is increasing over the years. The younger the patient is, more likely is the risk of unscheduled revisit to PED. Most of the patients returned to PED in 17 to 24 hours after discharge.
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Affiliation(s)
- Onder Kilicaslan
- Faculty, Department of Pediatric Emergency Medicine, Duzce University School of Medicine, Duzce, Turkey
| | - Feruza Turan Sönmez
- Faculty, Department of Emergency Medicine, Duzce University School of Medicine, Duzce, Turkey
| | - Harun Gunes
- Faculty, Department of Emergency Medicine, Duzce University School of Medicine, Duzce, Turkey
| | - Ramazan Cahit Temizkan
- Faculty, Department of Pediatric Emergency Medicine, Duzce University School of Medicine, Duzce, Turkey
| | - Kenan Kocabay
- Faculty, Department of Pediatric Emergency Medicine, Duzce University School of Medicine, Duzce, Turkey
| | - Ayhan Saritas
- Faculty, Department of Emergency Medicine, Duzce University School of Medicine, Duzce, Turkey
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Dinh MM, Berendsen Russell S, Bein KJ, Chalkley D, Muscatello D, Paoloni R, Ivers R. Trends and characteristics of short-term and frequent representations to emergency departments: A population-based study from New South Wales, Australia. Emerg Med Australas 2016; 28:307-12. [DOI: 10.1111/1742-6723.12582] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 03/07/2016] [Accepted: 03/28/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Michael M Dinh
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
- Discipline of Emergency Medicine; The University of Sydney; Sydney New South Wales Australia
| | - Saartje Berendsen Russell
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
- School of Nursing; The University of Sydney; Sydney New South Wales Australia
| | - Kendall J Bein
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - Dane Chalkley
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - David Muscatello
- School of Public Health and Community Medicine; University of New South Wales; Sydney New South Wales Australia
| | - Richard Paoloni
- Discipline of Emergency Medicine; The University of Sydney; Sydney New South Wales Australia
| | - Rebecca Ivers
- The George Institute for Global Health; The University of Sydney; Sydney New South Wales Australia
- School of Nursing and Midwifery; Flinders University; Adelaide South Australia Australia
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