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Namgung M, Lee DH, Bae SJ, Chung HS, Kim K, Lee CA, Kim DH, Kim EC, Lim JY, Han SS, Choi YH. The impact of COVID-19 pandemic on revisits to emergency department. Australas Emerg Care 2023; 26:221-229. [PMID: 36717326 PMCID: PMC9874043 DOI: 10.1016/j.auec.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/21/2022] [Accepted: 01/23/2023] [Indexed: 01/26/2023]
Abstract
AIM This study presents the impact of COVID-19 on revisits to the emergency department comparing revisit rates and characteristics between the pre-COVID-19 and COVID-19 periods. METHODS This multi-center retrospective study included patients over 18 years of age who visited emergency departments during the pre-COVID-19 period and the COVID-19 pandemic. The revisit rates were analyzed according to five age groups; 18-34, 35-49, 50-64, 65-79, and ≥ 80 years, and three revisit time intervals; 3, 9, and 30 days. Also, we compared the diagnosis and disposition at revisit between the study periods. RESULTS The revisit rates increased with age in both study periods and the revisit rates among all age groups were higher in the COVID-19 period. The proportion of infectious and respiratory diseases decreased during the COVID-19 period. The ICU admission rate and mortality at the revisit among patients aged ≥ 80 years were lower in the COVID-19 period than in the pre-COVID-19 period. CONCLUSION The revisit rates increased with age in both study periods and there were several changes in the diagnosis and disposition at the revisit in the COVID-19 period.
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Affiliation(s)
- Myeong Namgung
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Dong Hoon Lee
- Department of emergency medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gyeonggi-do, South Korea.
| | - Sung Jin Bae
- Department of emergency medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gyeonggi-do, South Korea
| | - Ho Sub Chung
- Department of emergency medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gyeonggi-do, South Korea
| | - Keon Kim
- Department of Emergency Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Choung Ah Lee
- Department of emergency medicine, Hallym univ. Dongtan Sacred Heart Hospital, Hwaseong, South Korea
| | - Duk Ho Kim
- Department of Emergency Medicine, Eulji University, Seoul, South Korea
| | - Eui Chung Kim
- Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Jee Yong Lim
- Department of emergency medicine, Seoul St. Mary's Hospital, Seoul, South Korea
| | - Sang Soo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Yoon Hee Choi
- Department of Emergency Medicine, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, South Korea
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Supples MW, Liao M, O'Donnell DP, Duszynski TJ, Glober NK. Descriptive analysis of emergency medical services 72-hour repeat patient encounters in a single, Urban Agency. Am J Emerg Med 2023; 65:113-117. [PMID: 36608394 DOI: 10.1016/j.ajem.2022.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Emergency department unscheduled return visits within 72-h of discharge, called a "bounceback", have been used as a metric of quality of care. We hypothesize that specific demographics and dispositions may be associated with Emergency Medical Services (EMS) 72-h bouncebacks. METHODS For all patient encounters within one calendar year from a large, urban EMS agency, we recorded demographics (name, date of birth, race, gender), primary impression, disposition, and vital signs for EMS encounters. A bounceback was defined as a patient, identified by matching first name, last name and date of birth, with more than one EMS encounter within 72 h. We performed descriptive statistics for patients that did and did not have a subsequent bounceback using median (interquartile range) and Wilcoxon Rank Sum test for age and frequency (percent) and chi square test for gender, race and run disposition. For patients with a bounceback, we describe the frequency and percentage of EMS professional primary impressions on initial encounter. RESULTS 98,043 encounters from January 1, 2021 to December 31, 2021, were analyzed. The median age was 50 years (IQR 32-65); 49.4% (46,147) were female and 50.7% (47,376) were White patients. 3951 encounters had a subsequent bounceback, and compared to those without bouncebacks, they were more often male patients (58.7% versus 50.2%, p < 0.001) and more commonly not transported (22.3% versus 15.5%, p < 0.001). A multivariable logistic regression model estimated the odds of bounceback were lower for females [OR 0.64 (95% CI 0.61-0.68)], Asian and Latino patients compared to White patients [OR 0.33 (95% CI 0.21-0.53) and 0.42 (95% CI 0.34-0.51)], respectively, no significant difference for Black patients compared to White patients, and higher for non-transported patients [OR 1.25 (95% CI 1.16-1.34)]. The The most common EMS primary impression for initial and subsequent encounters was mental health [576 (14.7%) and 944 (17.0%), respectively]. For subsequent encounters, the primary impression was cardiac arrest or death in 67 (1.2%) of cases. CONCLUSION Bouncebacks were common in this single year study of a high-volume urban EMS agency. Male and non-transported patients most often experienced bouncebacks. The most common primary impression for encounters with bounceback was mental health related. Out-of-hospital cardiac arrest occurred in 1 % of bounceback cases. Further study is necessary to understand the effect on patient-centered outcomes.
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Affiliation(s)
- Michael W Supples
- Department of Emergency Medicine, Wake Forest University School of Medicine, United States of America.
| | - Mark Liao
- Department of Emergency Medicine, Indiana University School of Medicine, United States of America
| | - Daniel P O'Donnell
- Department of Emergency Medicine, Indiana University School of Medicine, United States of America
| | - Thomas J Duszynski
- Fairbanks School of Public Health, Indiana University Purdue University Indianapolis, United States of America
| | - Nancy K Glober
- Department of Emergency Medicine, Indiana University School of Medicine, United States of America
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Zuluaga Quintero M, Indrasena BSH, Fox L, Subedi P, Aylott J. Upstreamist leaders: how risk factors for unscheduled return visits (URV) to the emergency department can inform integrated healthcare. Leadersh Health Serv (Bradf Engl) 2022; ahead-of-print. [PMID: 36573622 DOI: 10.1108/lhs-06-2022-0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE This paper aims to report on research undertaken in an National Health Service (NHS) emergency department in the north of England, UK, to identify which patients, with which clinical conditions are returning to the emergency department with an unscheduled return visit (URV) within seven days. This paper analyses the data in relation to the newly introduced Integrated Care Boards (ICBs). The continued upward increase in demand for emergency care services requires a new type of "upstreamist", health system leader from the emergency department, who can report on URV data to influence the development of integrated care services to reduce further demand on the emergency department. DESIGN/METHODOLOGY/APPROACH Patients were identified through the emergency department symphony data base and included patients with at least one return visit to emergency department (ED) within seven days. A sample of 1,000 index visits between 1 January 2019-31 October 2019 was chosen by simple random sampling technique through Excel. Out of 1,000, only 761 entries had complete data in all variables. A statistical analysis was undertaken using Poisson regression using NCSS statistical software. A review of the literature on integrated health care and its relationship with health systems leadership was undertaken to conceptualise a new type of "upstreamist" system leadership to advance the integration of health care. FINDINGS Out of all 83 variables regressed with statistical analysis, only 12 variables were statistically significant on multi-variable regression. The most statistically important factor were patients presenting with gynaecological disorders, whose relative rate ratio (RR) for early-URV was 43% holding the other variables constant. Eye problems were also statistically highly significant (RR = 41%) however, clinically both accounted for just 1% and 2% of the URV, respectively. The URV data combined with "upstreamist" system leadership from the ED is required as a critical mechanism to identify gaps and inform a rationale for integrated care models to lessen further demand on emergency services in the ED. RESEARCH LIMITATIONS/IMPLICATIONS At a time of significant pressure for emergency departments, there needs to be a move towards more collaborative health system leadership with support from statistical analyses of the URV rate, which will continue to provide critical information to influence the development of integrated health and care services. This study identifies areas for further research, particularly for mixed methods studies to ascertain why patients with specific complaints return to the emergency department and if alternative pathways could be developed. The success of the Esther model in Sweden gives hope that patient-centred service development could create meaningful integrated health and care services. PRACTICAL IMPLICATIONS This research was a large-scale quantitative study drawing upon data from one hospital in the UK to identify risk factors for URV. This quality metric can generate important data to inform the development of integrated health and care services. Further research is required to review URV data for the whole of the NHS and with the new Integrated Health and Care Boards, there is a new impetus to push for this metric to provide robust data to prioritise the need to develop integrated services where there are gaps. ORIGINALITY/VALUE To the best of the authors' knowledge, this is the first large-scale study of its kind to generate whole hospital data on risk factors for URVs to the emergency department. The URV is an important global quality metric and will continue to generate important data on those patients with specific complaints who return back to the emergency department. This is a critical time for the NHS and at the same time an important opportunity to develop "Esther" patient-centred approaches in the design of integrated health and care services.
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Affiliation(s)
- Martha Zuluaga Quintero
- Department of Emergency Medicine, Doncaste and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Buddhike Sri Harsha Indrasena
- Institute for Quality Improvement, World Academy of Medical Leadership, Sheffield, UK and Department of General Surgery, Provincial General Hospital, Badulla, Sri Lanka
| | - Lisa Fox
- Health Informatics Department, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Prakash Subedi
- Department of Emergency Medicine, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Institute of Medicine, QiMET International, Doncaster, UK, and
| | - Jill Aylott
- Institute for Quality Improvement, World Academy of Medical Leadership, Sheffield, UK and Institute of Medicine, QiMET Medical Institute (QMI), QiMET International Ltd., Sheffield, UK
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Namgung M, Lee DH, Bae SJ, Chung HS, Park JY, Kim K, Lee CA, Kim DH, Kim EC, Lim JY, Han SS, Choi YH. A Comparison of Emergency Department Revisit Rates of Pediatric Patients between Pre-COVID-19 and COVID-19 Periods. CHILDREN 2022; 9:children9071003. [PMID: 35883987 PMCID: PMC9322694 DOI: 10.3390/children9071003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/29/2022] [Indexed: 11/24/2022]
Abstract
Unscheduled revisits to emergency departments (EDs) are important because they indicate the quality of emergency care. However, the characteristics of pediatric patients visiting EDs changed during the coronavirus disease (COVID-19) pandemic, and these changes may have affected their revisit patterns. Therefore, we aimed to compare the ED revisit patterns of pediatric patients between the pre-COVID-19 and COVID-19 periods. This retrospective multicenter study included patients aged below 18 years who visited the ED in the pre-COVID-19 and COVID-19 periods. ED revisit rates were analyzed using five age groups and three visit-revisit intervals. In the pre-COVID-19 period, the revisit rates decreased with increasing age. In the COVID-19 period, the revisit rates were the lowest for the group aged 4–6 years, and the rates increased for those aged ≥7 years. In conclusion, there were changes in the patterns of revisit rates of pediatric patients according to age between the pre-COVID-19 and COVID-19 periods. Therefore, it is necessary to identify the reasons for revisits according to age and establish strategies to reduce the revisit rates of pediatric patients.
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Affiliation(s)
- Myeong Namgung
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul 06973, Korea;
| | - Dong Hoon Lee
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
- Correspondence: ; Tel.: +82-2-2610-6751
| | - Sung Jin Bae
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
| | - Ho Sub Chung
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
| | - Ji Young Park
- Department of Pediatrics, College of Medicine, Chung-Ang University, Seoul 06973, Korea;
| | - Keon Kim
- Department of Emergency Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Korea;
| | - Choung Ah Lee
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si 18450, Korea;
| | - Duk Ho Kim
- Department of Emergency Medicine, Eulji University, Seoul 01830, Korea;
| | - Eui Chung Kim
- CHA Bundang Medical Center, Department of Emergency Medicine, Seongnam-si 13496, Korea;
| | - Jee Yong Lim
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, Seoul 06591, Korea;
| | - Sang Soo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon-si 14584, Korea;
| | - Yoon Hee Choi
- Department of Emergency Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, Seoul 07985, Korea;
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Feral-Pierssens AL, Morris J, Marquis M, Daoust R, Cournoyer A, Lessard J, Berthelot S, Messier A. Safety assessment of a redirection program using an electronic application for low-acuity patients visiting an emergency department. BMC Emerg Med 2022; 22:71. [PMID: 35488215 PMCID: PMC9052637 DOI: 10.1186/s12873-022-00626-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/01/2022] [Indexed: 11/25/2022] Open
Abstract
Background Emergency departments (EDs) are operating at or above capacity, which has negative consequences on patients in terms of quality of care and morbi-mortality. Redirection strategies for low-acuity ED patients to primary care practices are usually based on subjective eligibility criteria that sometimes necessitate formal medical assessment. Literature investigating the effect of those interventions is equivocal. The aim of the present study was to assess the safety of a redirection process using an electronic clinical support system used by the triage nurse without physician assessment. Methods A single cohort observational study was performed in the ED of a level 1 academic trauma center. All low-acuity patients redirected to nearby clinics through a clinical decision support system (February–August 2017) were included. This system uses different sets of medical prerequisites to identify patients eligible to redirection. Data on safety and patient experience were collected through phone questionnaires on day 2 and 10 after ED visit. The primary endpoint was the rate of redirected patients returning to any ED for an unexpected visit within 48 h. Secondary endpoints were the incidence of 7-day return visit and satisfaction rates. Results A total of 980 redirected low-acuity patients were included over the period: 18 patients (2.8%) returned unexpectedly to an ED within 48 h and 31 patients (4.8%) within 7 days. No hospital admission or death were reported within 7 days following the first ED visit. Among redirected patients, 81% were satisfied with care provided by the clinic staff. Conclusion The implementation of a specific electronic-guided decision support redirection protocol appeared to provide safe deferral to nearby clinics for redirected low-acuity patients. EDs are pivotal elements of the healthcare system pathway and redirection process could represent an interesting tool to improve the care to low-acuity patients.
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Affiliation(s)
- Anne-Laure Feral-Pierssens
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada. .,CR-CSIS, Sherbrooke University, Longueuil, Québec, Canada. .,Health Educations and Promotion Laboratory (LEPS EA3412), University Sorbonne Paris Nord, Bobigny, France. .,SAMU 93 - Emergency Department, Avicenne Hospital, Assistance Publique Hôpitaux de Paris, Bobigny, France.
| | - Judy Morris
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
| | - Martin Marquis
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada
| | - Raoul Daoust
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
| | - Alexis Cournoyer
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada.,Hôpital Maisonneuve-Rosemont, CIUSSS-EIM, Montréal, Québec, Canada.,Corporation d'Urgences-santé, Montréal, Québec, Canada
| | - Justine Lessard
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
| | - Simon Berthelot
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada.,Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
| | - Alexandre Messier
- Hôpital du Sacré-Cœur de Montréal, CIUSSS-NIM, 5400 boulevard Gouin Ouest, Montréal, Québec, H4J 1C5, Canada.,Département médecine de famille et médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
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Paganini M, Pizzato M, Weinstein E, Vecchiato E, Bitetti A, Compostella C, Onesto C, Favaro A. Implementation of a nurse-led alternate care site for the management of the surge of patients with COVID-19 in an Italian emergency department. Emerg Med J 2022; 39:554-558. [PMID: 35321885 DOI: 10.1136/emermed-2021-212056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/14/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND To accommodate and separate the large numbers of patients going to hospital with COVID-19, many EDs had to create new pathways for patients. We describe the outcomes of patients treated in a nurse-led alternate care site (ACS) at our hospital. METHODS This was a retrospective study of outcomes of patients managed at the ACS of 'San Bassiano' Hospital ED, Bassano del Grappa, Italy between 9 March and 16 April 2020. Self-presenting patients aged 5 years and older, suspected of having COVID-19, were initially diverted to the ACS. Patients with a National Early Warning Score ≥5 or with a desaturation ≥4% after the walking test were sent back to the main ED COVID-19 path for further evaluation and medical attention and were not further followed up. In the ACS, patients received a CXR, blood samples and a nasopharyngeal swab to test for SARS-CoV-2, and were sent home. An emergency physician reviewed the results later and called the patient back 5-6 hours later with instructions to return for medical evaluation of abnormal findings, or to seek their general practitioner's attention. Patients received a follow-up phone call 15 days later to learn of their course. RESULTS A total of 487 patients were fully managed in the ACS and discharged home. Of the 392 (80.5%) patients with no abnormalities after the workup and instructed to stay at home, 29 reattended the ED in the next 15 days, and 13 were admitted. Among the 95 patients asked to return and receive medical attention, 20 were admitted and of those discharged, 3 reattended the ED within 15 days. At 15 days, no patient was deceased or received invasive ventilation; one admitted patient received non-invasive ventilation. CONCLUSIONS A nurse-led ACS diverted a substantial proportion of patients from main ED resources without associated negative clinical outcomes.
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Affiliation(s)
- Matteo Paganini
- Department of Biomedical Sciences, Universita degli Studi di Padova, Padova, Italy .,Emergency Department, San Bassiano Hospital, ULSS7 Pedemontana, Bassano del Grappa, Italy.,Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy
| | - Michele Pizzato
- Emergency Department, San Bassiano Hospital, ULSS7 Pedemontana, Bassano del Grappa, Italy
| | - Eric Weinstein
- Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy
| | - Elena Vecchiato
- Emergency Department, San Bassiano Hospital, ULSS7 Pedemontana, Bassano del Grappa, Italy
| | - Andrea Bitetti
- Emergency Department, San Bassiano Hospital, ULSS7 Pedemontana, Bassano del Grappa, Italy
| | - Caterina Compostella
- Emergency Department, San Bassiano Hospital, ULSS7 Pedemontana, Bassano del Grappa, Italy
| | - Caterina Onesto
- Emergency Department, San Bassiano Hospital, ULSS7 Pedemontana, Bassano del Grappa, Italy
| | - Andrea Favaro
- Emergency Department, San Bassiano Hospital, ULSS7 Pedemontana, Bassano del Grappa, Italy
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Hutchinson CL, Curtis K, McCloughen A, Fethney J, Wiseman G, Hutchinson L. Clinician perspectives on reasons for, implications and management of unplanned patient returns to the Emergency Department: A descriptive study. Int Emerg Nurs 2021; 60:101125. [PMID: 34953437 DOI: 10.1016/j.ienj.2021.101125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Unplanned return visits to the emergency department (ED) have been associated with adverse outcomes and may reflect the quality of care delivered. Several studies speculate the reasons for return and suggest clinician behaviour as potentially influencing a patient's decision to return to the ED. There is little research about this issue from the clinician's perspective, which is necessary to inform future practice improvement. METHODS A descriptive cross sectional design was employed to ascertain perspectives on identification and management of return visits occurring within 48 hours of discharge. An electronic survey was distributed to all medical, nursing, and clerical staff at one ED. Descriptive statistics were used for quantitative data and content analysis was performed on textual data. Results were categorised as barriers or facilitators, then mapped to the Theoretical Domains Framework. RESULTS A response rate of 59.7% (n=86/144) was achieved. Staff reported increased levels of concern for this patient group but not all staff were aware of the policy for managing return patients (40.7%). Five barriers and three facilitators were identified that mapped to eight influencers of behaviour including knowledge, memory and environmental factors. CONCLUSION Overall, staff were aware of return patients but lacked familiarity with policy and processes to identify and commence relevant protocols. Further review of current practice as well as the patient perspective is required before any intervention to improve practice is developed.
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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
| | - Judith Fethney
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
| | - Glen Wiseman
- Emergency Department, Canterbury Hospital, Campsie, Sydney, Australia
| | - Laura Hutchinson
- Emergency Department, Canterbury Hospital, Campsie, Sydney, Australia
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8
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Gill S, Mills PD, Watts BV, Paull DE, Tomolo A. A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration. J Patient Saf 2021; 17:e898-e903. [PMID: 32084094 DOI: 10.1097/pts.0000000000000636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous work assessing the frequency of adverse events in emergency medicine has been limited. The emergency department (ED) provides an initial point of care for millions of patients. Given the volume of patient encounters and the complexity of medical conditions treated in the ED, it is necessary to determine the system-based issues and associated contributing factors impacting patient safety. OBJECTIVES The aim of this retrospective study were to use root cause analysis reports of adverse events occurring in Veterans Health Administration EDs to understand the range of events that were happening and to determine the primary causes of these events as well as actions to prevent them. METHODS Retrospective safety reports from EDs from Veterans Health Administration medical centers across the nation for a 2-year period (2015-2016) were coded by event type, root cause, and recommended actions. RESULTS One hundred forty-four cases were included for analysis. The most common adverse events were as follows: delays in care (n = 38, 26.4%), elopements (n = 21, 14.6%), suicide attempts and deaths by suicide (n = 15, 10.4%), inappropriate discharges (n = 15, 10.4%), and errors in following procedures (n = 14, 9.7%). Overall, the most common root cause categories leading to adverse events were knowledge/educational deficits (11.4%), policies/procedures needing improvement (11.1%), and lack of standardized policies/procedures (9.4%). DISCUSSION Root cause analysis reports are a useful tool to determine the primary systems-based factors of common adverse events in the ED. Recommendations made in this article for addressing these root causes and potentially ameliorating these events will be useful to EDs and related health systems.
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Affiliation(s)
| | - Peter D Mills
- Veterans Affairs National Center for Patient Safety Field Office, VA Medical Center, White River Junction, Vermont
| | | | | | - Anne Tomolo
- Atlanta VA Healthcare System, Decatur, Georgia
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9
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Ahn Y, Hong GS, Park KJ, Lee CW, Lee JH, Kim SO. Impact of diagnostic errors on adverse outcomes: learning from emergency department revisits with repeat CT or MRI. Insights Imaging 2021; 12:160. [PMID: 34734321 PMCID: PMC8566620 DOI: 10.1186/s13244-021-01108-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 10/10/2021] [Indexed: 01/10/2023] Open
Abstract
Background To investigate diagnostic errors and their association with adverse outcomes (AOs) during patient revisits with repeat imaging (RVRIs) in the emergency department (ED). Results Diagnostic errors stemming from index imaging studies and AOs within 30 days in 1054 RVRIs (≤ 7 days) from 2005 to 2015 were retrospectively analyzed according to revisit timing (early [≤ 72 h] or late [> 72 h to 7 days] RVRIs). Risk factors for AOs were assessed using multivariable logistic analysis. The AO rate in the diagnostic error group was significantly higher than that in the non-error group (33.3% [77 of 231] vs. 14.8% [122 of 823], p < .001). The AO rate was the highest in early revisits within 72 h if diagnostic errors occurred (36.2%, 54 of 149). The most common diseases associated with diagnostic errors were digestive diseases in the radiologic misdiagnosis category (47.5%, 28 of 59) and neurologic diseases in the delayed radiology reporting time (46.8%, 29 of 62) and clinician error (27.3%, 30 of 110) categories. In the matched set of the AO and non-AO groups, multivariable logistic regression analysis revealed that the following diagnostic errors contributed to AO occurrence: radiologic error (odds ratio [OR] 3.56; p < .001) in total RVRIs, radiologic error (OR 3.70; p = .001) and clinician error (OR 4.82; p = .03) in early RVRIs, and radiologic error (OR 3.36; p = .02) in late RVRIs. Conclusion Diagnostic errors in index imaging studies are strongly associated with high AO rates in RVRIs in the ED. Supplementary Information The online version contains supplementary material available at 10.1186/s13244-021-01108-0.
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Affiliation(s)
- Yura Ahn
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Gil-Sun Hong
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Kye Jin Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Choong Wook Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Ju Hee Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Seon-Ok Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Republic of Korea
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10
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Tsai CL, Ling DA, Lu TC, Lin JCC, Huang CH, Fang CC. Inpatient Outcomes Following a Return Visit to the Emergency Department: A Nationwide Cohort Study. West J Emerg Med 2021; 22:1124-1130. [PMID: 34546889 PMCID: PMC8463058 DOI: 10.5811/westjem.2021.6.52212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/04/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Emergency department (ED) revisits are traditionally used to measure potential lapses in emergency care. However, recent studies on in-hospital outcomes following ED revisits have begun to challenge this notion. We aimed to examine inpatient outcomes and resource use among patients who were hospitalized following a return visit to the ED using a national database. Methods This was a retrospective cohort study using the National Health Insurance Research Database in Taiwan. One-third of ED visits from 2012–2013 were randomly selected and their subsequent hospitalizations included. We analyzed the inpatient outcomes (mortality and intensive care unit [ICU] admission) and resource use (length of stay [LOS] and costs). Comparisons were made between patients who were hospitalized after a return visit to the ED and those who were hospitalized during the index ED visit. Results Of the 3,019,416 index ED visits, 477,326 patients (16%) were directly admitted to the hospital. Among the 2,504,972 patients who were discharged during the index ED visit, 229,059 (9.1%) returned to the ED within three days. Of them, 37,118 (16%) were hospitalized. In multivariable analyses, the inpatient mortality rates and hospital LOS were similar between the two groups. Compared with the direct-admission group, the return-admission group had a lower ICU admission rate (adjusted odds ratio, 0.78; 95% confidence interval [CI], 0.72–0.84), and lower costs (adjusted difference, −5,198 New Taiwan dollars, 95% CI, −6,224 to −4,172). Conclusion Patients who were hospitalized after a return visit to the ED had a lower ICU admission rate and lower costs, compared to those who were directly admitted. Our findings suggest that ED revisits do not necessarily translate to poor initial care and that subsequent inpatient outcomes should also be considered for better assessment.
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Affiliation(s)
- Chu-Lin Tsai
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Dean-An Ling
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Tsung-Chien Lu
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Jasper Chia-Cheng Lin
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Chien-Hua Huang
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Cheng-Chung Fang
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
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11
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Kim K, Lee CA, Park SH, Kim DH, Kim EC, Lim JY, Han S, Choi YH, Bae SJ, Lee DH. Age-related differences in revisits to the emergency departments of eight Korean university hospitals. Arch Gerontol Geriatr 2021; 97:104489. [PMID: 34332235 DOI: 10.1016/j.archger.2021.104489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/07/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Keon Kim
- Ewha Womans University Seoul Hospital, Department of Emergency Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea; Department of Emergency Medicine, College of Medicine, Graduate School of Chung-Ang University, Seoul, Republic of Korea
| | - Choung Ah Lee
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do 18450, South Korea
| | - Sang Hyun Park
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 10, 63-ro, Yeongdeungpo-gu, Seoul 07345, South Korea
| | - Duk Ho Kim
- Department of Emergency Medicine, Eulji University, 68, Hangeulbiseok-ro, Nowon-gu, Seoul 01830, South Korea
| | - Eui Chung Kim
- Department of Emergency Medicine, CHA Bundang Medical Center, Seongnam, CHA University, 16, Yatap-ro 65beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13496, South Korea
| | - Jee Yong Lim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, 222 Banpo-daero, Seocho-Gu, Seoul 137-701, South Korea
| | - Sangsoo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, 170, Jomaru-ro, Bucheon-si, Gyeonggi-do 1899-5700, South Korea
| | - Yoon Hee Choi
- Department of Emergency Medicine, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University Medical Center, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul 07985, South Korea
| | - Sung Jin Bae
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, 102, Heukseok-ro, Dongjak-gu, Seoul, South Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Hospital, 102, Heukseok-ro, Dongjak-gu, Seoul, South Korea.
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12
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Kasick RT, Melvin JE, Perera ST, Perry MF, Black JD, Bode RS, Groner JI, Kersey KE, Klamer BG, Bai S, McClead RE. A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain. Diagnosis (Berl) 2021; 8:209-217. [PMID: 31677376 DOI: 10.1515/dx-2019-0054] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 10/17/2019] [Indexed: 12/02/2023]
Abstract
BACKGROUND Pediatric abdominal pain is challenging to diagnose and often results in unscheduled return visits to the emergency department. External pressures and diagnostic momentum can impair physicians from thoughtful reflection on the differential diagnosis (DDx). We implemented a diagnostic time-out intervention and created a scoring tool to improve the quality and documentation rates of DDx. The specific aim of this quality improvement (QI) project was to increase the frequency of resident and attending physician documentation of DDx in pediatric patients admitted with abdominal pain by 25% over 6 months. METHODS We reviewed a total of 165 patients admitted to the general pediatrics service at one institution. Sixty-four history and physical (H&P) notes were reviewed during the baseline period, July-December 2017; 101 charts were reviewed post-intervention, January-June 2018. Medical teams were tasked to perform a diagnostic time-out on all patients during the study period. Metrics tracked monthly included percentage of H&Ps with a 'complete' DDx and quality scores (Qs) using our Differential Diagnosis Scoring Rubric. RESULTS At baseline, 43 (67%) resident notes and 49 (77%) attending notes documented a 'complete' DDx. Post-intervention, 59 (58%) resident notes and 69 (68%) attending notes met this criteria. Mean Qs, pre- to post-intervention, for resident-documented differential diagnoses increased slightly (2.41-2.47, p = 0.73), but attending-documented DDx did not improve (2.85-2.82, p = 0.88). CONCLUSIONS We demonstrated a marginal improvement in the quality of resident-documented DDx. Expansion of diagnoses considered within a DDx may contribute to higher diagnostic accuracy.
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Affiliation(s)
- Rena T Kasick
- Department of Pediatrics, Division of Hospital Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jennifer E Melvin
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sajithya T Perera
- Department of Pediatrics, Division of Hospital Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Michael F Perry
- Department of Pediatrics, Division of Hospital Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joshua D Black
- Department of Pediatrics, Division of Hospital Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ryan S Bode
- Department of Pediatrics, Division of Hospital Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jonathan I Groner
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kelly E Kersey
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH, USA
| | - Brett G Klamer
- Biostatistics Resources, Nationwide Children's Hospital, Columbus, OH, USA
- Center for Biostatistics, The Ohio State University, Columbus, OH, USA (B.G. Klamer) (S. Bai)
| | - Shasha Bai
- Biostatistics Resources, Nationwide Children's Hospital, Columbus, OH, USA
- Center for Biostatistics, The Ohio State University, Columbus, OH, USA (B.G. Klamer) (S. Bai)
| | - Richard E McClead
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
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13
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Mahajan P, Pai CW, Cosby KS, Mollen CJ, Shaw KN, Chamberlain JM, El-Kareh R, Ruddy RM, Alpern ER, Epstein HM, Giardina TD, Graber ML, Medford-Davis LN, Medlin RP, Upadhyay DK, Parker SJ, Singh H. Identifying trigger concepts to screen emergency department visits for diagnostic errors. Diagnosis (Berl) 2020; 8:340-346. [PMID: 33180032 DOI: 10.1515/dx-2020-0122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 09/17/2020] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Prashant Mahajan
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Chih-Wen Pai
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Karen S Cosby
- Department of Emergency Medicine, Cook County Hospital (Stroger), Rush Medical College, Chicago, IL, USA
| | - Cynthia J Mollen
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathy N Shaw
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - James M Chamberlain
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Robert El-Kareh
- UCSD Health Department of Biomedical Informatics, University of California San Diego, La Jolla, CA, USA
| | - Richard M Ruddy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Elizabeth R Alpern
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Helene M Epstein
- Board of Directors, Brightpoint Care, New York, NY, USA (Subsidiary, Sun River Health, Peekskill, NY, USA)
| | - Traber D Giardina
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Mark L Graber
- Society to Improve Diagnosis in Medicine, RTI International, Plymouth, MA, USA
| | | | - Richard P Medlin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Divvy K Upadhyay
- Division of Quality, Safety and Patient Experience, Geisinger, Danville, PA, USA
| | - Sarah J Parker
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
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14
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Curcio J, Little A, Bolyard C, Gupta A, Secic M, Sharkey M. Emergency Department "Bounce-Back" Rates as a Function of Emergency Medicine Training Year. Cureus 2020; 12:e10503. [PMID: 33094046 PMCID: PMC7571604 DOI: 10.7759/cureus.10503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Since the 1990s, the emergency department (ED) unscheduled return visit (URV), or “bounce-back,” has been used as a quality of care measurement. During that time, resident training was also scrutinized and uncovered a need for closer resident supervision, especially of second-year residents. Over the years, bounce-backs have continued to be analyzed with vigor, but research on residency training and supervision has lagged with few studies concurrently investigating residency supervision and bounce-backs. Other literature on resident supervision suggests that with adequate attending supervision, resident performance is equivalent to attending performance. With that in mind, it was hypothesized that resident bounce-back rates will be equivalent to attending bounce-back rates, and there will be no change among residency years. The primary objective of this study was to determine the rate at which patients are seen as a bounce-back visit within 72 hours of their initial visit to a community hospital ED during the study time frame. The secondary aims were to evaluate if the ED bounce-back rate is impacted by training level (residents or attending) and to describe bounce-back patient characteristics, including primary complaint/disease, age, comorbidities and issues with compliance. Methods: A retrospective chart review of 1000 charts was conducted from September 2015 to September 2017. Charts were randomly selected by the Quality & Patient Safety (QPS) team and, after applying inclusion/exclusion criteria, 732 charts were analysed. Inclusion criteria included age ≥ 18 years, patients treated by an Emergency Medicine (EM) resident during their initial visit and patients with a “discharge” disposition. Exclusion criteria included patients seen as a scheduled return visit (e.g., two-day return for blood pregnancy recheck, wound check, etc.). Demographics, initial visit variables, comorbidities and bounce-back data were collected based on electronic record query or chart review. Data was analysed using means, standard deviations, medians and ranges for continuous variables. Logistic regression modelling techniques were used to examine factors that affect whether the patient had a bounce-back visit. Results: The rate of URVs within 72 hours of the patient's initial visit was 4.65%. PGY1 and PGY2's bounce-back rate was 3.8% and 3.6%, respectively, and PGY3 and PGY4's bounce-back rate was 5.7% and 5.6%, respectively (p-value=.63). There was no statistically significant change among residency years. Most bounce-back characteristics analysed including primary complaint, age, and comorbidities demonstrated no statistical significance in the increased rate of bounce-back except for patients with a history of tobacco abuse, alcohol abuse and chronic pain. Current smokers were 6.5 times more likely to bounce back than former smokers (odds ratio=6.485, 95% confidence interval = 2.089 to 20.133, p-value=0.0012) and those with chronic pain were 2.5 times more likely to bounce back than those without chronic pain (odds ratio=2.518, 95% confidence interval =1.029 to 6.164, p=0.0431). Conclusion: EM residency training year does not increase the frequency of bounce-backs in a community hospital ED. Finally, patients with substance abuse and chronic pain were more likely to bounce back.
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Affiliation(s)
- Janine Curcio
- Emergency Medicine, OhioHealth Doctors Hospital, Columbus, USA
| | - Andrew Little
- Emergency Medicine, OhioHealth Doctors Hospital, Columbus, USA
| | | | - Anand Gupta
- Biostatistics, OhioHealth Research Institute, Columbus, USA
| | - Michelle Secic
- Biostatistics, OhioHealth Research Institute, Columbus, USA
| | - Meenal Sharkey
- Emergency Medicine, OhioHealth Doctors Hospital, Columbus, USA
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15
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Sarasa Cabezuelo A. Application of Machine Learning Techniques to Analyze Patient Returns to the Emergency Department. J Pers Med 2020; 10:E81. [PMID: 32784609 PMCID: PMC7563563 DOI: 10.3390/jpm10030081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/22/2020] [Accepted: 08/06/2020] [Indexed: 11/17/2022] Open
Abstract
The study of the quality of hospital emergency services is based on analyzing a set of indicators such as the average time of first medical attention, the average time spent in the emergency department, degree of completion of the medical report and others. In this paper, an analysis is presented of one of the quality indicators: the rate of return of patients to the emergency service less than 72 h from their discharge. The objective of the analysis was to know the variables that influence the rate of return and which prediction model is the best. In order to do this, the data of the activity of the emergency service of a hospital of a reference population of 290,000 inhabitants were analyzed, and prediction models were created for the binary objective variable (rate of return to emergencies) using the logistic regression techniques, neural networks, random forest, gradient boosting and assembly models. Each of the models was analyzed and the result shows that the best model is achieved through a neural network with activation function tanh, algorithm levmar and three nodes in the hidden layer. This model obtains the lowest mean squared error (MSE) and the best area under the curve (AUC) with respect to the rest of the models used.
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Affiliation(s)
- Antonio Sarasa Cabezuelo
- Department of Computer Systems and Computing, School of Computer Science, Complutensian University of Madrid, 28040 Madrid, Spain
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16
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Model-Based Recursive Partitioning of Patients' Return Visits to Multispecialty Clinic During the 2009 H1N1 Pandemic Influenza (pH1N1). Online J Public Health Inform 2020; 12:e4. [PMID: 32577153 DOI: 10.5210/ojphi.v12i1.10576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background During the 2009 H1N1 influenza pandemic (pH1N1), the proportion of outpatient visits to emergency departments, clinics and hospitals became elevated especially during the early months of the pandemic due to surges in sick, 'worried well' or returning patients seeking care. We determined the prevalence of return visits to a multispecialty clinic during the 2009 H1N1 influenza pandemic and identify subgroups at risk for return visits using model-based recursive partitioning technique. Methods This study was a retrospective analysis of ILI-related medical care visits to multispecialty clinic in Houston, Texas obtained as part of the Houston Health Department Influenza Sentinel Surveillance Project (ISSP) during the 2009 H1N1 pandemic influenza (April 2009 - March 2010). The data comprised of 2680 individuals who made a total of 2960 clinic visits. Return visit was defined as any visit following the index visit after the wash-out phase prior to the study period. We applied nominal logistic regression and recursive partitioning models to determine the independent predictors and the response probabilities of return visits. The sensitivity and specificity of the outcomes probabilities were determined using receiver operating characteristic (ROC) curve. Results Overall, 4.56% (Prob. 0.0%-17.5%) of the cohort had return visits with significant variations observed attributed to age group (76.0%), type of vaccine received by patients (18.4%) and Influenza A (pH1N1) test result (5.6%). Patients in age group 0-4 years were 9 times (aOR: 8.77, 95%CI: 3.39-29.95, p<0.0001) more likely than those who were 50+ years to have return visits. Similarly, patients who received either seasonal flu (aOR: 1.59, 95% CI 1.01-2.50, p=0.047) or pH1N1 (aOR: 1.74, 95%CI: 1.09-2.75, p=0.022) vaccines were about twice more likely to have return visits compared to those with no vaccination history. Model-based recursive partitioning yielded 19 splits with patients in subgroup I (patients of age group 0-4 years, who tested positive for pH1N1, and received both seasonal flu and pH1N1 vaccines) having the highest risk of return visits (Prob.=17.5%). The area under the curve (AUC) for both return and non-return visits was 72.9%, indicating a fairly accurate classification of the two groups. Conclusions Return visits in our cohort were more prevalent among children and young adults, and those that received either seasonal flu or pH1N1 or both vaccines. Understanding the dynamics in care-seeking behavior during pandemic would assist policymakers with appropriate resource allocation, and in the design of initiatives aimed at mitigating surges and recurrent utilization of the healthcare system.
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Hutchinson CL, Curtis K, McCloughen A, Qian S, Yu P, Fethney J. Identifying return visits to the Emergency Department: A multi-centre study. Australas Emerg Care 2020; 24:34-42. [PMID: 32593525 DOI: 10.1016/j.auec.2020.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 05/27/2020] [Accepted: 05/27/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Patients who return to the Emergency Department (ED) for the same complaint are known to be at risk of adverse events. Monitoring of return visits is considered a way to measure the quality of care provided in the ED, although the most commonly used benchmark of 48h lacks evidence. This study aimed to describe the incidence, characteristics and outcomes of patients with unplanned return visits. The study also aimed to determine the capture rate of the 48-h benchmark using an all-inclusive method of return visit identification. METHODS A retrospective cross-sectional study was conducted across three EDs in Sydney, New South Wales from July 1st, 2017 to June 30th, 2018. Visits that occurred within 28 days with the same or similar presenting complaint following discharge from the ED were classified as a return visit. Data were grouped by index and return visit. Descriptive statistics were used to summarise incidence, patient characteristics and outcomes for all presentations. Categorical data were analysed using Chi square tests. Continuous data were analysed using Mann-Whitney when data were not normally distributed and t-tests when normally distributed. RESULTS Of all ED presentations (n=164,598), 5860 (3.6%) were identified as a return visit. Return patients were younger than non-return patients, but those that required admission were older (43 vs 33 years, p=<0.01). Abdominal problems were the most common reason for return followed by urological and mental health. The median time to return was 64:51h (IQR 20:35-226:37). Only 43% of return visits occurred within 48h. Return visits to a different ED accounted for 13.2% of return visits. CONCLUSION More than half of ED return visits are missed when the existing benchmark of 48h is used. Current policy makers should consider increasing the 48-h benchmark to more accurately reflect the incidence of return visits. Further investigation into the causal factors for return visits is warranted, particularly in patients with abdominal, urological or mental health complaints.
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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
| | - 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
| | - Judith Fethney
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
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19
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Spangler D, Edmark L, Winblad U, Colldén-Benneck J, Borg H, Blomberg H. Using trigger tools to identify triage errors by ambulance dispatch nurses in Sweden: an observational study. BMJ Open 2020; 10:e035004. [PMID: 32198303 PMCID: PMC7103813 DOI: 10.1136/bmjopen-2019-035004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- Douglas Spangler
- Department of Surgical Sciences-Anesthesia and Intensive Care, Uppsala Center for Prehospital Research, Uppsala University, Uppsala, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Lennart Edmark
- Department of Anesthesia and Intensive Care, Västmanlands sjukhus Västerås, Vasteras, Sweden
| | - Ulrika Winblad
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Jessica Colldén-Benneck
- Department of Surgical Sciences-Anesthesia and Intensive Care, Uppsala Center for Prehospital Research, Uppsala University, Uppsala, Sweden
| | - Helena Borg
- Ambulance Department, Västmanlands sjukhus Västerås, Vasteras, Sweden
| | - Hans Blomberg
- Department of Surgical Sciences-Anesthesia and Intensive Care, Uppsala Center for Prehospital Research, Uppsala University, Uppsala, Sweden
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Guo DY, Chen KH, Chen IC, Lu KY, Lin YC, Hsiao KY. The Association Between Emergency Department Revisit and Elderly Patients. J Acute Med 2020; 10:20-26. [PMID: 32995151 PMCID: PMC7517912 DOI: 10.6705/j.jacme.202003_10(1).0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Emergency department (ED) revisits may be associated with a higher percentage of adverse events and increased costs. Our hospital is a university affiliation hospital accepted regional referral patients, and located in the region in Taiwan with the highest percentage of elderly people. In this study, we attempted to identify whether old age was a risk factor of ED revisit. METHODS Patients who visited the ED from July 2011 to June 2016 were included. Factors associated with revisit were collected from medical information database. A total of 239,405 patients were included in our study, with 13,272 having ED revisits within 72 hours. Chi square and independent t test were applied for univariable factors, and a logistic regression model was used for multivariable analysis. RESULTS Old age (age ≥ 65 years) was found to be a risk factor for ED revisit (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.09-1.19). Diagnosis, pulse rate, diastolic blood pressure, fever, pain management, paracentesis, triage level, registration category, male gender, discharge status, and major illness may have some effect on ED revisit. CONCLUSIONS In our patients, old age is a risk factor for ED revisit; however, only a weak association was found.
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Affiliation(s)
- Di-You Guo
- Chang Gung Memorial Hospital, Chiayi Department of Emergency Medicine Chiayi Taiwan
| | - Kai-Hua Chen
- Chang Gung Memorial Hospital Department of Physical Medicine and Rehabilitation Chiayi Taiwan
| | - I-Chuan Chen
- Chang Gung Memorial Hospital, Chiayi Department of Emergency Medicine Chiayi Taiwan
- Chang Gung University of Science and Technology Department of Nursing Chiayi Taiwan
| | - Kuan-Yu Lu
- Chang Gung Memorial Hospital Department of Physical Medicine and Rehabilitation Chiayi Taiwan
| | - Yu-Ching Lin
- Chang Gung University of Science and Technology Department of Respiratory Care Chiayi Taiwan
- Chang Gung Memorial Hospital Division of Pulmonary and Critical Care Medicine Chiayi Taiwan
- Chang Gung University School of Medicine Taoyuan Taiwan
| | - Kuang-Yu Hsiao
- Chang Gung Memorial Hospital, Chiayi Department of Emergency Medicine Chiayi Taiwan
- Shu-Zen Junior College of Medicine and Management Department of Optometry Taiwan
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Hiti EA, Tamim H, Makki M, Geha M, Kaddoura R, Obermeyer Z. Characteristics and determinants of high-risk unscheduled return visits to the emergency department. Emerg Med J 2019; 37:79-84. [PMID: 31806725 PMCID: PMC7027026 DOI: 10.1136/emermed-2018-208343] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 10/16/2019] [Accepted: 11/21/2019] [Indexed: 11/29/2022]
Abstract
Background High-risk unscheduled return visits (HRURVs), defined as return visits within 72 hours that require admission or die in the emergency department (ED) on representation, are a key quality metric in the ED. The objective of this study was to determine the incidence and describe the characteristics and predictors of HRURVs to the ED. Methods Case–control study, conducted between 1 November 2014 and 31 October 2015. Cases included all HRURVs over the age of 18 that presented to the ED. Controls were selected from patients who were discharged from the ED during the study period and did not return in the next 72 hours. Controls were matched to cases based on gender, age (±5 years) and date of presentation. Results Out of 38 886 ED visits during the study period, 271 are HRURVs, giving an incidence of HRURV of 0.70% (95% CI 0.62% to 0.78%). Our final analysis includes 270 HRURV cases and 270 controls, with an in-ED mortality rate of 0.7%, intensive care unit admission of 11.1% and need for surgical intervention of 22.2%. After adjusting for other factors, HRURV cases are more likely to be discharged with a diagnosis related to digestive system or infectious disease (OR 1.64, 95% CI 1.02 to 2.65 and OR 2.81, 95% CI 1.05 to 7.51, respectively). Furthermore, presentation to the ED during off-hours is a significant predictor of HRURV (OR 1.64, 95% CI 1.11 to 2.43) as is the presence of a handover during the patient visit (OR 1.68, 95% CI 1.02 to 2.75). Conclusion HRURV is an important key quality outcome metric that reflects a subgroup of ED patients with specific characteristics and predictors. Efforts to reduce this HRURV rate should focus on interventions targeting patients discharged with digestive system, kidney and urinary tract and infectious diseases diagnosis as well as exploring the role of handover tools in reducing HRURVs.
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Affiliation(s)
- Eveline A Hiti
- Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Tamim
- Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maha Makki
- Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mirabelle Geha
- Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rima Kaddoura
- Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ziad Obermeyer
- Department of Emergency Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
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Blakoe M, Gamst-Jensen H, von Euler-Chelpin M, Collatz Christensen H, Møller T. Sociodemographic and health-related determinants for making repeated calls to a medical helpline: a prospective cohort study. BMJ Open 2019; 9:e030173. [PMID: 31482858 PMCID: PMC6720138 DOI: 10.1136/bmjopen-2019-030173] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To identify sociodemographic and health-related characteristics of callers' making repeated calls within 48 hours to a medical helpline, compared with those who only call once. SETTING In the Capital Region of Denmark people with acute, non-life-threatening illnesses or injuries are triaged through a single-tier medical helpline for acute, healthcare services. PARTICIPANTS People who called the medical helpline between 18 January and 9 February 2017 were invited to participate in the survey. During the period, 38 787 calls were handled and 12 902 agreed to participate. Calls were excluded because of the temporary civil registration number (n=78), the call was not made by the patient or a close relative (n=699), or survey responses were incomplete (n=19). Hence, the analysis included 12 106 calls, representing 11.131 callers' making single calls and 464 callers' making two or more calls within 48 hours. Callers' data (age, sex and caller identification) were collected from the medical helpline's electronic records. Data were enriched using the callers' self-rated health, self-evaluated degree of worry, and registry data on income, ethnicity and comorbidities. The OR for making repeated calls was calculated in a crude, sex-adjusted and age-adjusted analysis and in a mutually adjusted analysis. RESULTS The crude logistic regression analysis showed that age, self-rated health, self-evaluated degree of worry, income, ethnicity and comorbidities were significantly associated with making repeated calls. In the mutually adjusted analysis associations decreased, however, odds ratios remained significantly decreased for callers with a household income in the middle (OR=0.71;95% CI 0.54 to 0.92) or highest (OR=0.68;95% CI 0.48 to 0.96) quartiles, whereas immigrants had borderline significantly increased OR (OR=1.34;95% CI 0.96 to 1.86) for making repeated calls. CONCLUSIONS Findings suggest that income and ethnicity are potential determinants of callers' need to make additional calls within 48 hours to a medical helpline with triage function.
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Affiliation(s)
- Mitti Blakoe
- Emergency Medical Services Copenhagen, Emergency Medical Services Copenhagen, Ballerup, Denmark
- University of Copenhagen Faculty of Health Sciences, Copenhagen, Denmark
| | - Hejdi Gamst-Jensen
- Emergency Medical Services Copenhagen, Emergency Medical Services Copenhagen, Ballerup, Denmark
| | - My von Euler-Chelpin
- Department of Public Health, University of Copenhagen Faculty of Health Sciences, Copenhagen, Denmark
| | | | - Tom Møller
- University of Copenhagen Faculty of Health Sciences, Copenhagen, Denmark
- The University Hospitals Centre for Health Research, Copenhagen, Denmark
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Huggins C, Robinson RD, Knowles H, Cizenski J, Mbugua R, Laureano-Phillips J, Schrader CD, Zenarosa NR, Wang H. Large observational study on risks predicting emergency department return visits and associated disposition deviations. Clin Exp Emerg Med 2019; 6:144-151. [PMID: 31036785 PMCID: PMC6614047 DOI: 10.15441/ceem.18.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 07/04/2018] [Indexed: 11/23/2022] Open
Abstract
Objective A common emergency department (ED) patient care outcome metric is 72-hour ED return visits (EDRVs). Risks predictive of EDRV vary in different studies. However, risk differences associated with related versus unrelated EDRV and subsequent EDRV disposition deviations (EDRVDD) are rarely addressed. We aim to compare the potential risk patterns predictive of related and unrelated EDRV and further determine those potential risks predictive of EDRVDD. Methods We conducted a large retrospective observational study from September 1, 2015 through June 30, 2016. ED Patient demographic characteristics and clinical metrics were compared among patients of 1) related; 2) unrelated; and 3) no EDRVs. EDRVDD was defined as obvious disposition differences between initial ED visit and return visits. A multivariate multinomial logistic regression was performed to determine the independent risks predictive of EDRV and EDRVDD after adjusting for all confounders. Results A total of 63,990 patients were enrolled; 4.65% were considered related EDRV, and 1.80% were unrelated. The top risks predictive of EDRV were homeless, patient left without being seen, eloped, or left against medical advice. The top risks predictive of EDRVDD were geriatric and whether patients had primary care physicians regardless as to whether patient returns were related or unrelated to their initial ED visits. Conclusion Over 6% of patients experienced ED return visits within 72 hours. Though risks predicting such revisits were multifactorial, similar risks were identified not only for ED return visits, but also for return ED visit disposition deviations.
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Affiliation(s)
- Charles Huggins
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, USA
| | - Richard D Robinson
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, USA
| | - Heidi Knowles
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, USA
| | - Jennalee Cizenski
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, USA
| | - Rosalia Mbugua
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, USA
| | - Jessica Laureano-Phillips
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, USA
| | - Chet D Schrader
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, USA
| | - Nestor R Zenarosa
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, USA
| | - Hao Wang
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, USA
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Outcomes From Referrals and Unscheduled Visits From Community Emergency Departments to a Regional Pediatric Emergency Department in Canada. Pediatr Emerg Care 2019; 35:185-189. [PMID: 28072666 DOI: 10.1097/pec.0000000000001013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Existing pediatric literature describing repeat visits to the emergency department (ED) for the same medical complaint has yet to report on patient flow patterns from general EDs (GEDs) to a pediatric ED (PED). We sought to characterize the population of patients who are treated in a GED and subsequently present to a PED for further care. METHODS We conducted a retrospective cohort study reviewing all pediatric visits (age < 17 y) at 5 GEDs in Vancouver. Our primary outcome measure was the proportion of visits with a subsequent visit to a PED (<7 days) during the 2012 to 2013 fiscal year. Secondary outcomes included reasons for PED consultation, the clinical services accessed, and disposition at the PED. RESULTS During the study period, 581 (3.3%) of the 17,824 children seen at GEDs subsequently presented to the PED within 7 days. The top 3 diagnoses among these were fracture, viral infection, and musculoskeletal complaints. Of the 581 children with a visit to the PED, 180 (31.0%) were referred to the PED for a consultation, whereas the rest were family initiated. Referred visits were more frequently associated with pediatric subspecialist consultation than family-initiated visits (45.0% vs 19.5%, P < 0.01). The referred group more frequently resulted in a surgical procedure (13.9% vs 2.5%, P < 0.01) or hospital admission (51.7% vs 8.7%, P < 0.01). CONCLUSIONS Knowing the proportion, management, and outcomes of children who are treated in a GED and subsequently at a PED may provide an important quality measure and opportunities to improve the management of common pediatric emergencies in the community.
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Incidence, characteristics and outcomes of patients that return to Emergency Departments. An integrative review. Australas Emerg Care 2019; 22:47-68. [PMID: 30998872 DOI: 10.1016/j.auec.2018.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Unplanned return visits account for up to 5% of Emergency Department presentations in Australia and have been associated with adverse events and increased costs. A large number of studies examine the incidence, characteristics and outcomes of unplanned return visits but few studies examine the reasons for return from a patient perspective. The objective of this integrative review was to determine the incidence, characteristics, outcomes and reasons for unplanned return visits to Emergency Departments. METHOD An integrative literature review design was employed to conduct a structured search of the literature using the databases CINAHL, MEDLINE, PubMed, ProQuest and EMBASE (inception to June 2018). Results were screened using predefined criteria and final studies collated and appraised using a quality assessment tool. RESULTS Fifty-two primary research articles were included in the review. The timeframe used to capture unplanned return visits varied and the incidence ranged between 0.07% and 33%. The majority of patients who return unplanned to the Emergency Department are subsequently discharged (51% and 90%) without an adverse event. CONCLUSION There is no consensus on the timeframe employed to classify unplanned return visits to the Emergency Department and the commonly used 72h lacks evidence. Routine statewide data linkage to capture return visits to other facilities is needed to ensure accurate data about this vulnerable patient group. Further research that focuses on patient and clinician perspectives is required to facilitate the development of local strategies to reduce the incidence of avoidable unplanned return visits.
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Hayward J, Hagtvedt R, Ma W, Gauri A, Vester M, Holroyd BR. Predictors of Admission in Adult Unscheduled Return Visits to the Emergency Department. West J Emerg Med 2018; 19:912-918. [PMID: 30429921 PMCID: PMC6225947 DOI: 10.5811/westjem.2018.8.38225] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/26/2018] [Accepted: 08/11/2018] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Jake Hayward
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Reidar Hagtvedt
- University of Alberta, Alberta School of Business, Edmonton, Alberta, Canada
| | - Warren Ma
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Aliyah Gauri
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Michael Vester
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Brian R. Holroyd
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
- Alberta Health Services, Emergency Strategic Clinical Network, Edmonton, Alberta, Canada
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Hayward J, Hagtvedt R, Ma W, Gauri A, Vester M, Holroyd B. Predictors of Admission in Adult Unscheduled Return Visits to the Emergency Department. West J Emerg Med 2018. [DOI: 10.5811/westjem.2018.38225] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jake Hayward
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Reidar Hagtvedt
- University of Alberta, Alberta School of Business, Edmonton, Alberta, Canada
| | - Warren Ma
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Aliyah Gauri
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Michael Vester
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada
| | - Brian Holroyd
- University of Alberta, Department of Emergency Medicine, Edmonton, Alberta, Canada; Alberta Health Services, Emergency Strategic Clinical Network, Edmonton, Alberta, Canada
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De Stefano C, Philippon AL, Krastinova E, Hausfater P, Riou B, Adnet F, Freund Y. Effect of emergency physician burnout on patient waiting times. Intern Emerg Med 2018; 13:421-428. [PMID: 28677043 DOI: 10.1007/s11739-017-1706-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 06/29/2017] [Indexed: 11/29/2022]
Abstract
Burnout is common in emergency physicians. This syndrome may negatively affect patient care and alter work productivity. We seek to assess whether burnout of emergency physicians impacts waiting times in the emergency department. Prospective study in an academic ED. All patients who visited the main ED for a 4-month period in 2016 were included. Target waiting times are assigned by triage nurse to patients on arrival depending on their severity. The primary endpoint was an exceeded target waiting time for ED patients. All emergency physicians were surveyed by a psychologist to assess their level of burnout using the Maslach Burnout Inventory. We defined the level of burnout of the day in the ED as the mean burnout level of the physicians working that day (8:30 to the 8:30 the next day). A logistic regression model was performed to assess whether burnout level of the day was independently associated with prolonged waiting times, along with previously reported predictors. Target waiting time was exceeded in 7524 patients (59%). Twenty-six emergency physicians were surveyed. Median burnout score was 35 [Interquartile (24-49)]. A burnout level of the day higher than 35 was independently associated with an exceeded target waiting time (adjusted odds ratio 1.54, 95% confidence interval 1.39-1.70), together with previously reported predictors (i.e., day of the week, time of the day, trauma, age and daily census). Burnout of emergency physicians was independently associated with a prolonged waiting time for patients visiting the ED.
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Affiliation(s)
- Carla De Stefano
- Emergency Department, Hopital Avicenne, Assistance Publique-Hôpitaux de Paris (APHP), Bobigny, France
- Université Sorbonne Paris Cité, Paris XIII Nord, Bobigny, France
| | - Anne-Laure Philippon
- Emergency Department, service d'accueil des urgences, Hôpital Pitié-Salpêtrière, APHP, 47-83 bd de l'hôpital, 75013, Paris, France
- Paris Sorbonne Universités, UPMC Univ Paris 06, Paris, France
| | - Evguenia Krastinova
- Plateforme de recherche Clinique de l'est Parisien (URCEST-CRCEST), APHP, Hôpital St Antoine, Paris, France
| | - Pierre Hausfater
- Emergency Department, service d'accueil des urgences, Hôpital Pitié-Salpêtrière, APHP, 47-83 bd de l'hôpital, 75013, Paris, France
- Paris Sorbonne Universités, UPMC Univ Paris 06, Paris, France
| | - Bruno Riou
- Emergency Department, service d'accueil des urgences, Hôpital Pitié-Salpêtrière, APHP, 47-83 bd de l'hôpital, 75013, Paris, France
- Paris Sorbonne Universités, UPMC Univ Paris 06, Paris, France
| | - Frederic Adnet
- Emergency Department, Hopital Avicenne, Assistance Publique-Hôpitaux de Paris (APHP), Bobigny, France
- Université Sorbonne Paris Cité, Paris XIII Nord, Bobigny, France
| | - Yonathan Freund
- Emergency Department, service d'accueil des urgences, Hôpital Pitié-Salpêtrière, APHP, 47-83 bd de l'hôpital, 75013, Paris, France.
- Paris Sorbonne Universités, UPMC Univ Paris 06, Paris, France.
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Pellerin G, Gao K, Kaminsky L. Predicting 72-hour emergency department revisits. Am J Emerg Med 2017; 36:420-424. [PMID: 28855065 DOI: 10.1016/j.ajem.2017.08.049] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To develop a predictive model that hospitals or healthcare systems can use to identify patients at high risk of revisiting the ED within 72h so that appropriate interventions can be delivered. METHODS This study employed multivariate logistic regression in developing the predictive model. The study data were from four Veterans medical centers in Upstate New York; 21,141 patients in total with ED visits were included in the analysis. Fiscal Year (FY) 2013 data were used to predict revisits in FY 2014. The predictive variables were patient demographics, prior year healthcare utilizations, and comorbidities. To avoid overfitting, we validated the model by the split-sample method. The predictive power of the model is measured by c-statistic. RESULTS In the first model using only patient demographics, the c-statistics were 0.55 (CI: 0.52-0.57) and 0.54 (95% CI: 0.51-0.56) for the development and validation samples, respectively. In the second model with prior year utilization added, the c-statistics were 0.70 (95% CI: 0.68-0.72) for both samples. In the final model where comorbidities were added, the c-statistics were 0.74 (CI: 0.72-0.76) and 0.73 (95% CI: 0.71-0.75) for the development and validation samples, respectively. CONCLUSIONS Reducing ED revisits not only lowers healthcare cost but also shortens wait time for those who critically need ED care. However, broad intervention for every ED visitor is not feasible given limited resources. In this study, we developed a predictive model that hospitals and healthcare systems can use to identify "frequent flyers" for early interventions to reduce ED revisits.
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Affiliation(s)
- Gene Pellerin
- US Department of Veterans Affairs, Stratton VA Medical Center, 113 Holland Ave., Albany, NY 12208, United States.
| | - Kelly Gao
- US Department of Veterans Affairs, Stratton VA Medical Center, 113 Holland Ave., Albany, NY 12208, United States.
| | - Laurence Kaminsky
- US Department of Veterans Affairs, Stratton VA Medical Center, 113 Holland Ave., Albany, NY 12208, United States.
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Sentinel visits in emergency department patients with diabetes mellitus as a warning sign for hyperglycemic emergencies. CAN J EMERG MED 2017; 20:230-237. [DOI: 10.1017/cem.2017.338] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
ABSTRACTObjectivesPatients with poorly controlled diabetes mellitus may have a sentinel emergency department (ED) visit for a precipitating condition prior to presenting for a hyperglycemic emergency, such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). This study’s objective was to describe the epidemiology and outcomes of patients with a sentinel ED visit prior to their hyperglycemic emergency visit.MethodsThis was a 1-year health records review of patients≥18 years old presenting to one of four tertiary care EDs with a discharge diagnosis of hyperglycemia, DKA, or HHS. Trained research personnel collected data on patient characteristics, management, disposition, and determined whether patients came to the ED within the 14 days prior to their hyperglycemia visit. Descriptive statistics were used to summarize the data.ResultsOf 833 visits for hyperglycemia, 142 (17.0%; 95% CI: 14.5% to 19.6%) had a sentinel ED presentation within the preceding 14 days. Mean (SD) age was 50.5 (19.0) years and 54.4% were male; 104 (73.2%) were discharged from this initial visit, and 98/104 (94.2%) were discharged either without their glucose checked or with an elevated blood glucose (>11.0 mmol/L). Of the sentinel visits, 93 (65.5%) were for hyperglycemia and 22 (15.5%) for infection. Upon returning to the ED, 61/142 (43.0%) were admitted for severe hyperglycemia, DKA, or HHS.ConclusionIn this unique ED-based study, diabetic patients with a sentinel ED visit often returned and required subsequent admission for hyperglycemia. Clinicians should be vigilant in checking blood glucose and provide clear discharge instructions for follow-up and glucose management to prevent further hyperglycemic emergencies from occurring.
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Yan JW, Gushulak KM, Columbus MP, van Aarsen K, Hamelin AL, Wells GA, Stiell IG. Risk factors for recurrent emergency department visits for hyperglycemia in patients with diabetes mellitus. Int J Emerg Med 2017; 10:23. [PMID: 28702883 PMCID: PMC5507935 DOI: 10.1186/s12245-017-0150-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 07/05/2017] [Indexed: 12/04/2022] Open
Abstract
Background Patients with poorly controlled diabetes mellitus may present repeatedly to the emergency department (ED) for management and treatment of hyperglycemic episodes, including diabetic ketoacidosis and hyperosmolar hyperglycemic state. The objective of this study was to identify risk factors that predict unplanned recurrent ED visits for hyperglycemia in patients with diabetes within 30 days of initial presentation. Methods We conducted a 1-year health records review of patients ≥18 years presenting to one of four tertiary care EDs with a discharge diagnosis of hyperglycemia, diabetic ketoacidosis, or hyperosmolar hyperglycemic state. Trained research personnel collected data on patient characteristics and determined if patients had an unplanned recurrent ED visit for hyperglycemia within 30 days of their initial presentation. Multivariate logistic regression models using generalized estimating equations to account for patients with multiple visits determined predictor variables independently associated with recurrent ED visits for hyperglycemia within 30 days. Results There were 833 ED visits for hyperglycemia in the 1-year period. 54.6% were male and mean (SD) age was 48.8 (19.5). Of all visitors, 156 (18.7%) had a recurrent ED visit for hyperglycemia within 30 days. Factors independently associated with recurrent hyperglycemia visits included a previous hyperglycemia visit in the past month (odds ratio [OR] 3.5, 95% confidence interval [CI] 2.1–5.8), age <25 years (OR 2.6, 95% CI 1.5–4.7), glucose >20 mmol/L (OR 2.2, 95% CI 1.3–3.7), having a family physician (OR 2.2, 95% CI 1.0–4.6), and being on insulin (OR 1.9, 95% CI 1.1–3.1). Having a systolic blood pressure between 90–150 mmHg (OR 0.53, 95% CI 0.30–0.93) and heart rate >110 bpm (OR 0.41, 95% CI 0.23–0.72) were protective factors independently associated with not having a recurrent hyperglycemia visit. Conclusions This unique ED-based study reports five risk factors and two protective factors associated with recurrent ED visits for hyperglycemia within 30 days in patients with diabetes. These risk factors should be considered by clinicians when making management, prognostic, and disposition decisions for diabetic patients who present with hyperglycemia. Electronic supplementary material The online version of this article (doi:10.1186/s12245-017-0150-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Justin W Yan
- The Division of Emergency Medicine, Department of Medicine, London Health Sciences Centre, London, ON, Canada. .,Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
| | - Katherine M Gushulak
- The Division of Emergency Medicine, Department of Medicine, London Health Sciences Centre, London, ON, Canada.,Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Melanie P Columbus
- The Division of Emergency Medicine, Department of Medicine, London Health Sciences Centre, London, ON, Canada.,Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Kristine van Aarsen
- The Division of Emergency Medicine, Department of Medicine, London Health Sciences Centre, London, ON, Canada.,Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Alexandra L Hamelin
- The Department of Emergency Medicine, The University of Ottawa, Ottawa, ON, Canada
| | - George A Wells
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ian G Stiell
- The Department of Emergency Medicine, The University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Abstract
OBJECTIVE The aim of this study was to evaluate the influence of primary care office hours of operation on 48-hour return visits (RVs) to a pediatric emergency department (ED). We compared characteristics of patients who return with those who follow up outpatient to determine the feasibility of opening off-hour clinics to decrease the RV rate. METHODS The study was a retrospective chart review of patients presenting to a pediatric ED for a 3-year period. A subset of patients with a hospital-affiliated primary care provider was evaluated to compare those with 48-hour ED RVs with those with office follow-up. RESULTS Patients with a hospital-affiliated primary care provider had 30,231 visits, of whom 842 had a 48-hour return (2.79%). A significant number (48.5%) of those who returned had seen their primary care doctor between emergency visits. The percentage of RVs occurring at night (55.7%) was slightly lower than the percentage of all visits occurring off hours (58.1%). Patients with more acute presentation at initial visit (emergency severity index level acuity 2, >20 orders placed) were more likely to follow up with their provider than return to the ED. CONCLUSIONS The findings from this study show no significant increase in RVs during the evening and overnight hours and many patients with outpatient follow-up before returning to the ED. Opening a clinic at our hospital during nontraditional hours would not likely significantly decrease RV rate.
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Hu YH, Tai CT, Chen SCC, Lee HW, Sung SF. Predicting return visits to the emergency department for pediatric patients: Applying supervised learning techniques to the Taiwan National Health Insurance Research Database. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2017; 144:105-112. [PMID: 28494994 DOI: 10.1016/j.cmpb.2017.03.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/26/2017] [Accepted: 03/24/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND AND OBJECTIVE Return visits (RVs) to the emergency department (ED) consume medical resources and may represent a patient safety issue. The occurrence of unexpected RVs is considered a performance indicator for ED care quality. Because children are susceptible to medical errors and utilize considerable ED resources, knowing the factors that affect RVs in pediatric patients helps improve the quality of pediatric emergency care. METHODS We collected data on visits made by patients aged ≤18years to EDs from the National Health Insurance Research Database. The outcome of interest was a RV within 3days of the initial visit. Potential factors were categorized into demographics, medical history, features of ED visits, physician characteristics, hospital characteristics, and treatment-seeking behavior. A multivariate logistic regression was used to identify independent predictors of RVs. We compared the performance of various data mining techniques, including Naïve Bayes, classification and regression tree (CART), random forest, and logistic regression, in predicting RVs. Finally, we developed a decision tree to stratify the risk of RVs. RESULTS Of 125,940 visits, 6,282 (5.0%) were followed by a RV within 3 days. Predictors of RVs included younger age, higher acuity, intravenous fluid, more examination types, complete blood count, consultation, lower hospital level, hospitalization within one week before the initial visit, frequent ED visits in the past one year, and visits made in Spring or on Saturdays. Patients with allergic diseases and those underwent ultrasound examination were less likely to return. Decision tree models performed better in predicting RVs in terms of area under curve. The decision tree constructed using the CART technique showed that the number of ED visits in the past one year, diagnosis category, testing of complete blood count, and age were important discriminators of risk of RVs. CONCLUSIONS We identified several factors which are associated with RVs to the ED in pediatric patients. The knowledge of these factors may help assess risk of RVs in the ED and guide physicians to reevaluate and provide interventions to children belonging to the high risk groups before ED discharge.
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Affiliation(s)
- Ya-Han Hu
- Department of Information Management and Institute of Healthcare Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - Chun-Tien Tai
- Department of Information Management and Institute of Healthcare Information Management, National Chung Cheng University, Chiayi County, Taiwan; Chiayi Chang Gung Memorial Hospital, Chiayi County, Taiwan
| | - Solomon Chih-Cheng Chen
- Heng Chun Christian Hospital, Pingtung County, Taiwan; Department of Pediatrics, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hai-Wei Lee
- Department of Information Management and Institute of Healthcare Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - Sheng-Feng Sung
- Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, 539 Zhongxiao Rd., Chiayi City, 60002 Taiwan.
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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]
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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.
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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
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Cervellin G, Mora R, Ticinesi A, Meschi T, Comelli I, Catena F, Lippi G. Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:362. [PMID: 27826565 DOI: 10.21037/atm.2016.09.10] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute abdominal pain (AAP) accounts for 7-10% of all Emergency Department (ED) visits. Nevertheless, the epidemiology of AAP in the ED is scarcely known. The aim of this study was to investigate the epidemiology and the outcomes of AAP in an adult population admitted to an urban ED. METHODS We made a retrospective analysis of all records of ED visits for AAP during the year 2014. All the patients with repeated ED admissions for AAP within 5 and 30 days were scrutinized. Five thousand three hundred and forty cases of AAP were analyzed. RESULTS The mean age was 49 years. The most frequent causes were nonspecific abdominal pain (NSAP) (31.46%), and renal colic (31.18%). Biliary colic/cholecystitis, and diverticulitis were more prevalent in patients aged >65 years (13.17% vs. 5.95%, and 7.28% vs. 2.47%, respectively). Appendicitis (i.e., 4.54% vs. 1.47%) and renal colic (34.48% vs. 20.84%) were more frequent in patients aged <65 years. NSAP was the most common cause in both age classes. Renal colic was the most frequent cause of ED admission in men, whereas NSAP was more prevalent in women. Urinary tract infection was higher in women. Overall, 885 patients (16.57%) were hospitalized. Four hundred and eighty-five patients had repeated ED visits throughout the study period. Among these, 302 patients (6.46%) were readmitted within 30 days, whereas 187 patients (3.82%) were readmitted within 5 days. Renal colic was the first cause for ED readmission, followed by NSAP. In 13 cases readmitted to the ED within 5 days, and in 16 cases readmitted between 5-30 days the diagnosis was changed. CONCLUSIONS Our study showed that AAP represented 5.76% of total ED visits. Two conditions (i.e., NSAP and renal colic) represented >60% of all causes. A large use of active clinical observations during ED stay (52% of our patients) lead to a negligible percentage of changing diagnosis at the second visit.
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Affiliation(s)
| | - Riccardo Mora
- Postgraduate Emergency Medicine School, University of Parma, Parma, Italy
| | - Andrea Ticinesi
- Postgraduate Emergency Medicine School, University of Parma, Parma, Italy
| | - Tiziana Meschi
- Postgraduate Emergency Medicine School, University of Parma, Parma, Italy
| | - Ivan Comelli
- Emergency Department, Academic Hospital of Parma, Parma, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Academic Hospital of Parma, Parma, Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
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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.
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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
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Saidi K, Paquet A, Goulet H, Ameur F, Bouhaddou A, Nion N, Riou B, Hausfater P. Effets de la création d’un circuit court au sein d’un service d’urgence adulte. ANNALES FRANCAISES DE MEDECINE D URGENCE 2015. [DOI: 10.1007/s13341-015-0593-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Medford-Davis L, Park E, Shlamovitz G, Suliburk J, Meyer AND, Singh H. Diagnostic errors related to acute abdominal pain in the emergency department. Emerg Med J 2015; 33:253-9. [PMID: 26531859 DOI: 10.1136/emermed-2015-204754] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 09/05/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Diagnostic errors in the emergency department (ED) are harmful and costly. We reviewed a selected high-risk cohort of patients presenting to the ED with abdominal pain to evaluate for possible diagnostic errors and associated process breakdowns. DESIGN We conducted a retrospective chart review of ED patients >18 years at an urban academic hospital. A computerised 'trigger' algorithm identified patients possibly at high risk for diagnostic errors to facilitate selective record reviews. The trigger determined patients to be at high risk because they: (1) presented to the ED with abdominal pain, and were discharged home and (2) had a return ED visit within 10 days that led to a hospitalisation. Diagnostic errors were defined as missed opportunities to make a correct or timely diagnosis based on the evidence available during the first ED visit, regardless of patient harm, and included errors that involved both ED and non-ED providers. Errors were determined by two independent record reviewers followed by team consensus in cases of disagreement. RESULTS Diagnostic errors occurred in 35 of 100 high-risk cases. Over two-thirds had breakdowns involving the patient-provider encounter (most commonly history-taking or ordering additional tests) and/or follow-up and tracking of diagnostic information (most commonly follow-up of abnormal test results). The most frequently missed diagnoses were gallbladder pathology (n=10) and urinary infections (n=5). CONCLUSIONS Diagnostic process breakdowns in ED patients with abdominal pain most commonly involved history-taking, ordering insufficient tests in the patient-provider encounter and problems with follow-up of abnormal test results.
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Affiliation(s)
- Laura Medford-Davis
- Department of Emergency Medicine, Robert Wood Johnson Foundation Clinical Scholars, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth Park
- Section of Emergency Medicine, Baylor College of Medicine and Harris Health System, Ben Taub General Hospital Emergency Center, Houston, Texas, USA
| | - Gil Shlamovitz
- Department of Emergency Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - James Suliburk
- Michael E DeBakey Department of Surgery, Baylor College of Medicine and Harris Health System, Houston, Texas, USA
| | - Ashley N D Meyer
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
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Freund Y, Rousseau A, Berard L, Goulet H, Ray P, Bloom B, Simon T, Riou B. Cross-checking to reduce adverse events resulting from medical errors in the emergency department: study protocol of the CHARMED cluster randomized study. BMC Emerg Med 2015; 15:21. [PMID: 26340941 PMCID: PMC4560890 DOI: 10.1186/s12873-015-0046-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 08/18/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Medical errors and preventable adverse events are a major cause of concern, especially in the emergency department (ED) where its prevalence has been reported to be roughly of 5-10% of visits. Due to a short length of stay, emergency patients are often managed by a sole physician - in contrast with other specialties where they can benefit from multiples handover, ward rounds and staff meetings. As some studies report that the rate and severity of errors may decrease when there is more than one physician involved in the management in different settings, we sought to assess the impact of regular systematic cross-checkings between physicians in the ED. DESIGN The CHARMED (Cross-checking to reduce adverse events resulting from medical errors in the emergency department) study is a multicenter cluster randomized study that aim to evaluate the reduction of the rate of severe medical errors with implementation of systematic cross checkings between emergency physician, compared to a control period with usual care. This study will evaluate the effect of this intervention on the rate of severe medical errors (i.e. preventable adverse events or near miss) using a previously described two-level chart abstraction. We made the hypothesis that implementing frequent and systematic cross checking will reduce the rate of severe medical errors from 10 to 6% - 1584 patients will be included, 140 for each period in each center. DISCUSSION The CHARMED study will be the largest study that analyse unselected ED charts for medical errors. This could provide evidence that frequent systematic cross-checking will reduce the incidence of severe medical errors. TRIAL REGISTRATION Clinical Trials, NCT02356926.
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Affiliation(s)
- Yonathan Freund
- Paris Sorbonne Université, UPMC univ-Paris 6, Paris, France.
- Emergency Department, Hopital Pitie-Salpetriere, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
| | - Alexandra Rousseau
- APHP, GH HUEP, Hôpital St Antoine, Plateforme de recherche Clinique de l'est Parisien (URCEST-CRCEST), Paris, France.
| | - Laurence Berard
- APHP, GH HUEP, Hôpital St Antoine, Plateforme de recherche Clinique de l'est Parisien (URCEST-CRCEST), Paris, France.
| | - Helene Goulet
- Emergency Department, Hopital Pitie-Salpetriere, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
| | - Patrick Ray
- Paris Sorbonne Université, UPMC univ-Paris 6, Paris, France.
- Emergency Department, Hopital Tenon, APHP, Paris, France.
| | - Benjamin Bloom
- Emergency Department, Royal London Hospital, Barts Health NHS Trust, London, UK.
| | - Tabassome Simon
- Paris Sorbonne Université, UPMC univ-Paris 6, Paris, France.
- APHP, GH HUEP, Hôpital St Antoine, Plateforme de recherche Clinique de l'est Parisien (URCEST-CRCEST), Paris, France.
| | - Bruno Riou
- Paris Sorbonne Université, UPMC univ-Paris 6, Paris, France.
- Emergency Department, Hopital Pitie-Salpetriere, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
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Sun Y, Heng BH, Tay SY, Tan KB. Unplanned 3-day re-attendance rate at Emergency Department (ED) and hospital's bed occupancy rate (BOR). Int J Emerg Med 2015; 8:82. [PMID: 26304858 PMCID: PMC4547977 DOI: 10.1186/s12245-015-0082-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 08/07/2015] [Indexed: 11/23/2022] Open
Abstract
Background Unplanned re-attendance at the Emergency Department (ED) is often monitored as a quality indicator of the care accorded to patients during their index ED visit. High bed occupancy rate (BOR) has been considered as a matter of reduced patient comfort and privacy. Most hospitals in Singapore operate under BORs above 85 %. This study aims to explore factors associated with the unplanned 3-day ED re-attendance rate and, in particular, if higher BOR is associated with higher 3-day unplanned ED re-attendance rate. Methods This was a multicenter retrospective study using time series data. Three acute tertiary hospitals were selected from all six adult public hospitals in Singapore based on data availability. Daily data from year 2008 to 2013 were collected from the study hospitals’ information systems. These included: ED visit date, day of week, month, year, public holiday, daily hospital BOR, daily bed waiting time (BWT) at ED (both median and 95th percentile), daily ED admission rate, and 3-day ED re-attendance rate. The primary outcome of the study was unplanned 3-day ED re-attendance rate from all reasons. Both univariate analysis and generalized linear regression were respectively applied to study the crude and adjusted association between the unplanned 3-day ED re-attendance rate and its potential associated factors. All analyses were conducted using SPSS 18 (PASW 18, IBM). Results The average age of patients who visited ED was 35 years old (SD = 2), 37 years old (SD = 2), and 40 years old (SD = 2) in hospitals A, B, and C respectively. The average 3-day unplanned ED re-attendance rate was 4.9 % (SE = 0.47 %) in hospital A, 3.9 % (SE = 0.35 %) in hospital B, and 4.4 % (SE = 0.30 %) in hospital C. After controlling for other covariates, the unplanned 3-day ED re-attendance rates were significantly associated with hospital, time trend, day of week, daily average BOR, and ED admission rate. Strong day-of-week effect on early ED re-attendance rate was first explored in this study. Thursday had the lowest re-attendance rate, while Sunday has the highest re-attendance rate. The patients who visited at ED on the dates with higher BOR were more likely to re-attend the ED within 3 days for hospitals A and B. There was no significant association between BOR and ED re-attendance rate in hospital C. Conclusions A study using time series data has been conducted to explore the factors associated with the unplanned 3-day ED re-attendance rate. Strong day-of-week effect was first reported. The association between BOR and the ED re-attendance rate varied with hospital.
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Affiliation(s)
- Yan Sun
- Department of Health Services & Outcomes Research, National Healthcare Group, 3 Fusionopolis Link, #03-08 Nexus@one-north, 138543, Singapore,
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Elder E, Johnston ANB, Crilly J. Improving emergency department throughput: An outcomes evaluation of two additional models of care. Int Emerg Nurs 2015. [PMID: 26208424 DOI: 10.1016/j.ienj.2015.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to explore the impact of incorporating a physician at triage (PAT) and the implementation of a medical assessment unit (MAU) on emergency department (ED) patient throughput. METHODS A retrospective comparative analysis of two additional models of care (standard care, T1; PAT, T2 and PATplusMAU, T3) was undertaken. Patient presentations to a large public teaching hospital in South-East Queensland between 10th January 2013 and 25th February 2013, and the same time period in 2012, were included. The impact of these care models on ED length of stay and other outcomes (time to be seen by a clinician, time from bed request to ward transfer, meeting 4 hour transit targets, admission rates and the proportion of patients who did not wait) were compared. RESULTS Compared to standard care, ED length of stay appeared to decrease with the introduction of both models, but was only significantly decreased after PATplusMAU was implemented (2013; T1, 186 min; T2, 181 min; T3, 175 min: T1 vs T3, P < 0.001). Outcomes that improved included: time to be seen by a clinician, proportion of patients who did not wait; increase in meeting 4-hour length of stay target for both admitted and not-admitted patients. CONCLUSION Placing a physician at triage and implementing a medical assessment unit were viable models of care that promoted patient flow and helped meet several time-sensitive health service targets.
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Affiliation(s)
- Elizabeth Elder
- School of Nursing & Midwifery, Griffith Health, Gold Coast Campus, Griffith University, QLD 4222, Australia.
| | - Amy N B Johnston
- Department of Emergency Medicine & Griffith Health Institute, Gold Coast Hospital and Health Service & Griffith University, Southport, QLD 4215, Australia
| | - Julia Crilly
- Department of Emergency Medicine & Griffith Health Institute, Gold Coast Hospital and Health Service & Griffith University, Southport, QLD 4215, Australia
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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]
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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.
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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
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Predictive value of S100-B and copeptin for outcomes following seizure: the BISTRO International Cohort Study. PLoS One 2015; 10:e0122405. [PMID: 25849778 PMCID: PMC4388444 DOI: 10.1371/journal.pone.0122405] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/20/2015] [Indexed: 11/30/2022] Open
Abstract
Objective To evaluate the performance of S100-B protein and copeptin, in addition to clinical variables, in predicting outcomes of patients attending the emergency department (ED) following a seizure. Methods We prospectively included adult patients presented with an acute seizure, in four EDs in France and the United Kingdom. Participants were followed up for 28 days. The primary endpoint was a composite of seizure recurrence, all-cause mortality, hospitalization or rehospitalisation, or return visit in the ED within seven days. Results Among the 389 participants included in the analysis, 156 (40%) experienced the primary endpoint within seven days and 195 (54%) at 28 days. Mean levels of both S100-B (0.11 μg/l [95% CI 0.07–0.20] vs 0.09 μg/l [0.07–0.14]) and copeptin (23 pmol/l [9–104] vs 17 pmol/l [8–43]) were higher in participants meeting the primary endpoint. However, both biomarkers were poorly predictive of the primary outcome with a respective area under the receiving operator characteristic curve of 0.57 [0.51–0.64] and 0.59 [0.54–0.64]. Multivariable logistic regression analysis identified higher age (odds ratio [OR] 1.3 per decade [1.1–1.5]), provoked seizure (OR 4.93 [2.5–9.8]), complex partial seizure (OR 4.09 [1.8–9.1]) and first seizure (OR 1.83 [1.1–3.0]) as independent predictors of the primary outcome. A second regression analysis including the biomarkers showed no additional predictive benefit (S100-B OR 3.89 [0.80–18.9] copeptin OR 1 [1.00–1.00]). Conclusion The plasma biomarkers S100-B and copeptin did not improve prediction of poor outcome following seizure. Higher age, a first seizure, a provoked seizure and a partial complex seizure are independently associated with adverse outcomes.
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Akenroye AT, Thurm CW, Neuman MI, Alpern ER, Srivastava G, Spencer SP, Simon HK, Tejedor-Sojo J, Gosdin CH, Brennan E, Gottlieb LM, Gay JC, McClead RE, Shah SS, Stack AM. Prevalence and predictors of return visits to pediatric emergency departments. J Hosp Med 2014; 9:779-87. [PMID: 25338705 DOI: 10.1002/jhm.2273] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 09/10/2014] [Accepted: 10/03/2014] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the rate of return visits to pediatric emergency departments (EDs) and identify patient- and visit-level factors associated with return visits and hospitalization upon return. DESIGN AND SETTING Retrospective cohort study of visits to 23 pediatric EDs in 2012 using data from the Pediatric Health Information System. PARTICIPANTS Patients <18 years old discharged following an ED visit. MEASURES The primary outcomes were the rate of return visits within 72 hours of discharge from the ED and of return visits within 72 hours resulting in hospitalization. RESULTS 1,415,721 of the 1,610,201 ED visits to study hospitals resulted in discharge. Of the discharges, 47,294 patients (3.3%) had a return visit. Of these revisits, 9295 (19.7%) resulted in hospitalization. In multivariate analyses, the odds of having a revisit were higher for patients with a chronic condition (odds ratio [OR]: 1.91, 95% confidence interval [CI]: 1.86-1.96), higher severity scores (OR: 1.42, 95% CI: 1.40-1.45), and age <1 year (OR: 1.32, 95% CI: 1.22-1.42). The odds of hospitalization on return were higher for patients with higher severity (OR: 3.42, 95% CI: 3.23-3.62), chronic conditions (OR: 2.92, 95% CI: 2.75-3.10), age <1 year (1.7-2.5 times the odds of other age groups), overnight arrival (OR: 1.84, 95% CI: 1.71-1.97), and private insurance (OR: 1.47, 95% CI: 1.39-1.56). Sickle cell disease and cancer patients had the highest rates of return at 10.7% and 7.3%, respectively. CONCLUSIONS Multiple patient- and visit-level factors are associated with revisits. These factors may provide insight in how to optimize care and decrease avoidable ED utilization.
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Affiliation(s)
- Ayobami T Akenroye
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Strayer RJ, Shy BD, Shearer PL. A novel program to improve patient safety by integrating peer review into the emergency medicine residency curriculum. J Emerg Med 2014; 47:696-701.e2. [PMID: 25281175 DOI: 10.1016/j.jemermed.2014.07.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 06/13/2014] [Accepted: 07/01/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evaluating the quality of care as part of a quality improvement process is required in many clinical environments by accrediting bodies. It produces metrics used to evaluate department and individual provider performance, provides outcomes-based feedback to clinicians, and identifies ways to reduce error. DISCUSSION To improve patient safety and train our residents to perform peer review, we expanded our quality assurance program from a narrow, administrative process carried out by a small number of attendings to an educationally focused activity of much greater scope incorporating all residents on a monthly basis. We developed an explicit system by which residents analyze sets of high-risk cases and record their impressions onto structured databases, which are reviewed by faculty. At monthly meetings, results from the month's case reviews are presented, learning points discussed, and corrective actions are proposed. CONCLUSION By integrating Clinical Quality Review (CQR) as a core, continuous component of the residency curriculum, we increased the number of cases reviewed more than 10-fold and implemented a variety of clinical process improvements. An anonymous survey conducted after 2 years of resident-led CQR indicated that residents value their exposure to the peer review process and feel it benefits them as clinicians, but also that the program requires a significant investment of time that can be burdensome.
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Affiliation(s)
- Reuben J Strayer
- Department of Emergency Medicine, Mt. Sinai School of Medicine, New York, New York
| | - Bradley D Shy
- Department of Emergency Medicine, Mt. Sinai School of Medicine, New York, New York
| | - Peter L Shearer
- Department of Emergency Medicine, Mt. Sinai School of Medicine, New York, New York
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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.
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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
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Blom MC, Jonsson F, Landin-Olsson M, Ivarsson K. Associations between in-hospital bed occupancy and unplanned 72-h revisits to the emergency department: a register study. Int J Emerg Med 2014; 7:25. [PMID: 25045408 PMCID: PMC4080705 DOI: 10.1186/s12245-014-0025-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Accepted: 06/11/2014] [Indexed: 11/21/2022] Open
Abstract
Background A possible downstream effect of high in-hospital bed occupancy is that patients in the emergency department (ED) who would benefit from in-hospital care are denied admission. The present study aimed at evaluating this hypothesis through investigating associations between in-hospital bed occupancy at the time of presentation in the ED and the probability for unplanned 72-hour (72-h) revisits to the ED among patients discharged at index. A second outcome was unplanned 72-h revisits resulting in admission. Methods All visits to the ED of a 420-bed emergency hospital in southern Sweden between 1 January 2011 and 31 December 2012, which did not result in admission, death, or transfer to another hospital were included. Revisiting fractions were computed for in-hospital occupancy intervals <85%, 85% to 90%, 90% to 95%, 95% to 100%, 100% to 105%, and ≥105%. Multivariate models were constructed in an attempt to take confounding factors from, e.g., presenting complaints, age, referral status, and triage priority into account. Results Included in the study are 81,878 visits. The fraction of unplanned 72-h revisits/unplanned 72-h revisits resulting in admission was 5.8%/1.4% overall, 6.2%/1.4% for occupancy <85%, 6.4%/1.5% for occupancy 85% to 90%, 5.8%/1.4% for occupancy 90% to 95%, 6.0%/1.6% for occupancy 95% to 100%, 5.4%/1.6% for occupancy 100% to 105%, and 4.9%/1.4% for occupancy ≥105%. In the multivariate models, a trend to lower probability of unplanned 72-h revisits was observed at occupancy ≥105% compared to occupancy <95% (OR 0.88, CI 0.76 to 1.01). No significant associations between in-hospital occupancy at index and the probability of making unplanned 72-h revisits resulting in admission were observed. Conclusions The lack of associations between in-hospital occupancy and unplanned 72-h revisits does not support the hypothesis that ED patients are inappropriately discharged when in-hospital beds are scarce. The results are reassuring as they indicate that physicians are able to make good decisions, also while resources are constrained.
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Affiliation(s)
- Mathias C Blom
- Department of Clinical Science Lund, Lund University, Hs 32, EA-blocket, Plan 2, Lund 22185, Sweden
| | - Fredrik Jonsson
- Department of Emergency, Helsingborg Hospital, S Vallgatan 5, Helsingborg 25187, Sweden
| | - Mona Landin-Olsson
- Department of Clinical Science Lund, Lund University, Hs 32, EA-blocket, Plan 2, Lund 22185, Sweden
| | - Kjell Ivarsson
- Department of Clinical Science Lund, Lund University, Hs 32, EA-blocket, Plan 2, Lund 22185, Sweden
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Freund Y, Vincent-Cassy C, Bloom B, Riou B, Ray P. Association Between Age Older Than 75 Years and Exceeded Target Waiting Times in the Emergency Department: A Multicenter Cross-Sectional Survey in the Paris Metropolitan Area, France. Ann Emerg Med 2013; 62:449-456. [DOI: 10.1016/j.annemergmed.2013.04.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 04/08/2013] [Accepted: 04/18/2013] [Indexed: 12/19/2022]
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