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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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Alshahrani M, Katbi F, Bahamdan Y, Alsaihati A, Alsubaie A, Althawadi D, Perlas-Asonto L. Frequency, Causes, and Outcomes of Return Visits to the Emergency Department Within 72 Hours: A Retrospective Observational Study. J Multidiscip Healthc 2020; 13:2003-2010. [PMID: 33376340 PMCID: PMC7764850 DOI: 10.2147/jmdh.s282192] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022] Open
Abstract
Background Emergency departments (EDs) serve as an accessible gateway to healthcare system wherein numerous patients consider it a prime choice for medical complaints. Frequency of ED revisits, causes, and its burden are necessary to assess quality of care provided to patients and identify factors that leads to revisit. Patients and Methods Electronic and printed medical records of all patients who revisited ED from January to May 2016 within 72 hours of initial visit were reviewed. Patients’ cause of revisit were classified to three categories: patient-, physician- and system-related factors. Common complaints that require revisits were also collected. Descriptive analysis was performed and categorical variables were represented by the frequency; percentages and continuous variables were presented as median, and range if data did not follow normal distribution. Results Of the 79,279 patients who visited ED during the study period, 1.3% (1000) patients revisited within 72 hours; 51.3% (n=513) were males, with a mean age of 31.5 years (SD=17.7 years) where majority (57.1%) had no comorbidity recorded. The most attributed factors for revisit were as follows: patient-related causes 635 patients (63.5%), physician-related factors 167 patients (16.7%), and system-related factors 42 patients (4.2%); 15.6% were found not related to the initial visit. Recurrence of the same complaint was the highest among patient-related factors (80.5%), inadequate management and no improvement of symptoms in 71.3% among the physician-related factors. The most common ED revisit complaint was fever 29.1% (n=291). Outcomes of the revisit were mainly patient discharge 96.7% (n=967), admission 1.2% (n=12) and death in 0.2% (n=2). Conclusion Recurrence of the same complaint with no symptoms improvement and suboptimal management of physicians contributed to most of the ED revisits within 72 hours. Encouraging physicians to provide clear instructions in educating patients on discharge regarding disease progression and its red flags as to when a return to ED, might help in reducing revisit rate.
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Affiliation(s)
- Mohammed Alshahrani
- Departments of Emergency and Critical Care, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, 31952, Kingdom of Saudi Arabia
| | - Faisal Katbi
- Department of Emergency Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Yazeed Bahamdan
- Department of General Pediatrics, Children's Hospital- King Saud Medical City, Riyadh, Saudi Arabia
| | - Ahrar Alsaihati
- Department of Dermatology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Aisha Alsubaie
- Department of Emergency, King Hamad University Hospital, Busaiteen, Kingdom of Bahrain
| | - Dana Althawadi
- Department of Emergency, King Hamad University Hospital, Busaiteen, Kingdom of Bahrain
| | - Laila Perlas-Asonto
- Department of Emergency and Critical Care Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
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Curran JA, Cassidy C, Bishop A, Wozney L, Plint AC, Ritchie K, Straus SE, Wong H, Newton A, Jabbour M, MacPhee S, Breneol S, Burns E, Chorney J, Lawton J, Doyle M, MacKay R, Zemek R, Penney T, Grimshaw J. Codesigning discharge communication interventions with healthcare providers, youth and parents for emergency practice settings: EDUCATE study protocol. BMJ Open 2020; 10:e038314. [PMID: 32398342 PMCID: PMC7223275 DOI: 10.1136/bmjopen-2020-038314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Discharge communication is an important aspect of patient care but frequently has shortcomings in emergency departments (EDs). In a paediatric context, youth or parents with young children often leave the ED with minimal opportunity to ask questions or to ensure comprehension of important information. Strategies for improving discharge communication have primarily targeted patients and/or parents, although neither group has been engaged in intervention design or implementation. Furthermore, ED healthcare providers (HCPs), important actors in discharge communication practice, are rarely consulted regarding intervention design decisions. We will generate evidence to enhance discharge communication by engaging youth, parents and HCPs in the codesign of ED discharge communication strategies (EDUCATE) for asthma and minor head injury. METHODS AND ANALYSIS This mixed methods study will take place at two academic paediatric EDs in Canada. The study will occur in two phases: (A) codesign and refinement of the intervention prototypes; and (B) usability testing of the prototypes. During the first phase, two codesign teams (one for each condition) will follow a series of structured design meetings based on the Behavior Change Wheel to develop the EDUCATE interventions. Each codesign team (composed of youth, parents, HCPs and study researchers) will collaborate to identify priority target behaviours and acceptable components to include in the interventions. During the second phase, we will conduct usability testing in two EDs with a group of youth, parents and HCPs to refine the interventions. Two cycles of usability testing will be conducted with intervention refinement occurring at the end of each cycle. ETHICS AND DISSEMINATION Informed consent will be obtained from all participants. Ethics approval for this study has been obtained from the Research Ethics Board, IWK Health Centre. Results from this study will form the basis of a future effectiveness implementation trial. Key findings will be presented at national and international conferences and published within peer-reviewed journals.
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Affiliation(s)
- Janet A Curran
- Department of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Christine Cassidy
- Department of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
- IWK Health Centre, Halifax, Nova Scotia, Canada
| | | | - Lori Wozney
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Amy C Plint
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Krista Ritchie
- Faculty of Education, Mount Saint Vincent University, Halifax, Nova Scotia, Canada
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute, Saint Mike's, Toronto, Ontario, Canada
| | - Helen Wong
- IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Amanda Newton
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Mona Jabbour
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Sydney Breneol
- Department of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
- IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Emma Burns
- IWK Health Centre, Halifax, Nova Scotia, Canada
| | | | | | | | | | - Roger Zemek
- Department of Pediatrics, CHEO, Ottawa, Ontario, Canada
| | | | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario, Canada
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Curran JA, Gallant AJ, Zemek R, Newton AS, Jabbour M, Chorney J, Murphy A, Hartling L, MacWilliams K, Plint A, MacPhee S, Bishop A, Campbell SG. Discharge communication practices in pediatric emergency care: a systematic review and narrative synthesis. Syst Rev 2019; 8:83. [PMID: 30944038 PMCID: PMC6446263 DOI: 10.1186/s13643-019-0995-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 03/22/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The majority of children receiving care in the emergency department (ED) are discharged home, making discharge communication a key component of quality emergency care. Parents must have the knowledge and skills to effectively manage their child's ongoing care at home. Parental fatigue and stress, health literacy, and the fragmented nature of communication in the ED setting may contribute to suboptimal parent comprehension of discharge instructions and inappropriate ED return visits. The aim of this study was to examine how and why discharge communication works in a pediatric ED context and develop recommendations for practice, policy, and research. METHODS We systematically reviewed the published and gray literature. We searched electronic databases CINAHL, Medline, and Embase up to July 2017. Policies guiding discharge communication were also sought from pediatric emergency networks in Canada, USA, Australia, and the UK. Eligible studies included children less than 19 years of age with a focus on discharge communication in the ED as the primary objective. Included studies were appraised using relevant Joanna Briggs Institute (JBI) checklists. Textual summaries, content analysis, and conceptual mapping assisted with exploring relationships within and between data. We implemented an integrated knowledge translation approach to strengthen the relevancy of our research questions and assist with summarizing our findings. RESULTS A total of 5095 studies were identified in the initial search, with 75 articles included in the final review. Included studies focused on a range of illness presentations and employed a variety of strategies to deliver discharge instructions. Education was the most common intervention and the majority of studies targeted parent knowledge or behavior. Few interventions attempted to change healthcare provider knowledge or behavior. Assessing barriers to implementation, identifying relevant ED contextual factors, and understanding provider and patient attitudes and beliefs about discharge communication were identified as important factors for improving discharge communication practice. CONCLUSION Existing literature examining discharge communication in pediatric emergency care varies widely. A theory-based approach to intervention design is needed to improve our understanding regarding discharge communication practice. Strengthening discharge communication in a pediatric emergency context presents a significant opportunity for improving parent comprehension and health outcomes for children. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42014007106.
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Affiliation(s)
- Janet A. Curran
- School of Nursing, Dalhousie University, 5869 University Ave., PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Allyson J. Gallant
- School of Nursing, Dalhousie University, 5869 University Ave., PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Roger Zemek
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada
| | - Amanda S. Newton
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Mona Jabbour
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada
| | - Jill Chorney
- IWK Health Center, 5850/5980 University Avenue, PO Box 9700, Halifax, NS B3K 6R8 Canada
| | - Andrea Murphy
- College of Pharmacy, Dalhousie University, 5869 University Avenue, PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Lisa Hartling
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Kate MacWilliams
- School of Nursing, Dalhousie University, 5869 University Ave., PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Amy Plint
- Department of Pediatrics, Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON K1H 8L1 Canada
| | - Shannon MacPhee
- IWK Health Center, 5850/5980 University Avenue, PO Box 9700, Halifax, NS B3K 6R8 Canada
| | - Andrea Bishop
- School of Nursing, Dalhousie University, 5869 University Ave., PO Box 15000, Halifax, NS B3H 4R2 Canada
| | - Samuel G. Campbell
- Charles V. Keating Emergency and Trauma Centre, QEII Health Sciences Centre, 1796 Summer St, Halifax, NS B3H 3A7 Canada
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Schnapp BH, Sun JE, Kim JL, Strayer RJ, Shah KH. Cognitive error in an academic emergency department. ACTA ACUST UNITED AC 2018; 5:135-142. [PMID: 30016277 DOI: 10.1515/dx-2018-0011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/18/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Medical error is a leading cause of death nationwide. While systems issues have been closely investigated as a contributor to error, little is known about the cognitive factors that contribute to diagnostic error in an emergency department (ED) environment.
Methods
Eight months of patient revisits within 72 h where patients were admitted on their second visit were examined. Fifty-two cases of confirmed error were identified and classified using a modified version of the Australian Patient Safety Foundation classification system for medical errors by a group of trained physicians.
Results
Faulty information processing was the most frequently identified category of error (45% of cases), followed by faulty verification (31%). Faulty knowledge (6%) and faulty information gathering (18%) occurred relatively infrequently. “Misjudging the salience of a finding” and “premature closure” were the individual errors that occurred most frequently (13%).
Conclusions
Despite the complex nature of diagnostic reasoning, cognitive errors of information processing appear to occur at higher rates than other errors, and in a similar pattern to an internal medicine service despite a different clinical environment. Further research is needed to elucidate why these errors occur and how to mitigate them.
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Affiliation(s)
- Benjamin H Schnapp
- University of Wisconsin, BerbeeWalsh Department of Emergency Medicine, 800 University Bay Drive, Madison, WI 53705, USA
| | - Jean E Sun
- The Mount Sinai Hospital, Department of Emergency Medicine, New York, NY, USA
| | - Jeremy L Kim
- St. David's South Austin Medical Center, Department of Emergency Medicine, Austin, TX, USA
| | - Reuben J Strayer
- Maimonidies Medical Center, Department of Emergency Medicine, New York, NY, USA
| | - Kaushal H Shah
- The Mount Sinai Hospital, Department of Emergency Medicine, New York, NY, USA
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6
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Ng CP. Acute Appendicitis: A Continuing Diagnostic Challenge to Emergency Physicians. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790701400201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Crafford L, Jenkins LS. Why seek a second consultation at an emergency centre? A qualitative study. Afr J Prim Health Care Fam Med 2017; 9:e1-e8. [PMID: 28828871 PMCID: PMC5566171 DOI: 10.4102/phcfm.v9i1.1397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 04/11/2017] [Accepted: 04/25/2017] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The inappropriate use of emergency centres (ECs) is an expanding problem globally. The high attendance of non-urgent return presentations to ECs is recognised as part of the problem, placing an unnecessary demand on limited staff and resources. Of unscheduled returns 34% of cases had no change to diagnosis or treatment with the conclusion that 80% of re-attendance could be attributed to deficiencies in the initial consultation. This study aimed to evaluate the reasons why patients sought an early second consultation for the same complaint at a hospital EC in South Africa, by exploring the patient's experience and shortcomings in the first consultation. METHOD A qualitative study was conducted using in-depth, semi-structured interviews with 20 purposively selected participants who presented to a rural regional provincial hospital's EC within 7 days of a prior consultation for the same complaint. Verbatim transcripts were analysed using the framework method. RESULTS The main reasons for a second consultation were symptom related factors and the need for diagnostic certainty. The major themes around patient experience of the initial consultation were shortcomings in effective evaluation and management of pain, diagnostic uncertainty including poor examination, poor explanation, uncertain access and follow-up and societal encouragement to utilise a hospital EC. CONCLUSION Further interventions should explore pain as a presenting symptom of the illness experience, and promote competence in addressing physical and psychological causative factors within a patient-centred approach for all health staff, especially in primary care services.
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Affiliation(s)
| | - Louis S Jenkins
- Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, University of Stellenbosch.
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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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Curran JA, Bishop A, Plint A, MacPhee S, Zemek R, Chorney J, Jabbour M, Porter S, Sawyer S. Understanding discharge communication behaviours in a pediatric emergency care context: a mixed methods observation study protocol. BMC Health Serv Res 2017; 17:276. [PMID: 28412951 PMCID: PMC5392912 DOI: 10.1186/s12913-017-2204-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 03/30/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND One of the most important transitions in the continuum of care for children is discharge to home. Optimal discharge communication between healthcare providers and caregivers (e.g., parents or other guardians) who present to the emergency department (ED) with their children is not well understood. The lack of policies and considerable variation in practice regarding discharge communication in pediatric EDs pose a quality and safety risk for children and their parents. METHODS The aim of this mixed methods study is to better understand the process and structure of discharge communication in a pediatric ED context to contribute to the design and development of discharge communication interventions. We will use surveys, administrative data and real-time video observation to characterize discharge communication for six common illness presentations in a pediatric ED: (1) asthma, (2) bronchiolitis, (3) abdominal pain, (4) fever, (5) diarrhea and vomiting, and (6) minor head injury. Participants will be recruited from one of two urban pediatric EDs in Canada. Video recordings will be analyzed using Observer XT. We will use logistic regression to identify potential demographic and visit characteristic cofounders and multivariate logistic regression to examine association between verbal and non-verbal behaviours and parent recall and comprehension. DISCUSSION Video recording of discharge communication will provide an opportunity to capture important data such as temporality, sequence and non-verbal behaviours that might influence the communication process. Given the importance of better characterizing discharge communication to identify potential barriers and enablers, we anticipate that the findings from this study will contribute to the development of more effective discharge communication policies and interventions.
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Affiliation(s)
- Janet A. Curran
- School of Nursing, Dalhousie University, Halifax, Nova Scotia B3H 4R2 Canada
| | - Andrea Bishop
- School of Nursing, Dalhousie University, Halifax, Nova Scotia B3H 4R2 Canada
| | - Amy Plint
- Department of Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Ontario K1H 8M5 Canada
- Children’s Hospital of Eastern Ontario Research Insititute, Ottawa, Ontario Canada
| | - Shannon MacPhee
- Department of Emergency Medicine, IWK Health Centre, Halifax, Nova Scotia B3H 4R2 Canada
| | - Roger Zemek
- Department of Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Ontario K1H 8M5 Canada
- Children’s Hospital of Eastern Ontario Research Insititute, Ottawa, Ontario Canada
| | - Jill Chorney
- Department of Anesthesia, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia B3H 4R2 Canada
| | - Mona Jabbour
- Department of Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Ontario K1H 8M5 Canada
- Children’s Hospital of Eastern Ontario Research Insititute, Ottawa, Ontario Canada
| | - Stephen Porter
- Division Of Emergency Medicine, Hospital for Sick Children, Toronto, M5G 1X8 Ontario Canada
| | - Scott Sawyer
- Pediatric Emergency Medicine, Manitoba Children’s Hospital, Winnipeg, Manitoba R3A 1S1 Canada
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Chan AHS, Ho SF, Fook-Chong SMC, Lian SWQ, Liu N, Ong MEH. Characteristics of patients who made a return visit within 72 hours to the emergency department of a Singapore tertiary hospital. Singapore Med J 2017; 57:301-6. [PMID: 27353286 DOI: 10.11622/smedj.2016104] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION 72-hour emergency department (ED) reattendance is a widely-used quality indicator for quality of care and patient safety. It is generally assumed that patients who return within 72 hours of ED discharge (72-hour re-attendees) received inadequate treatment or evaluation. The current literature also suggests considerable variation in probable causes of 72-hour ED reattendances internationally. This study aimed to understand the characteristics of these patients at the ED of a Singapore tertiary hospital. METHODS We conducted a retrospective cohort study on all ED visits between 1 January 2013 and 31 December 2013. 72-hour re-attendees were compared against non-re-attendees based on patient demographics, mode of arrival, patient acuity category status (i.e. P1/P2/P3/P4), seniority ranking of doctor-in-charge and medical diagnoses. Multivariate analysis using the generalised linear model was conducted on variables associated with 72-hour ED re-attendance. RESULTS Among 104,751 unique patients, 3,065 (2.93%) were in the 72-hour re-attendees group. Multivariate analysis showed that the following risk factors were associated with higher risk of returning within 72 hours: male gender, older age, arrival by ambulance, triaged as P2, diagnoses of heart problems, abdominal pain or viral infection (all p < 0.001), and Chinese ethnicity (p = 0.006). There was no significant difference in the seniority ranking of the doctor-in-charge between both groups (p = 0.419). CONCLUSION Several patient and event factors were associated with higher risk of being a 72-hour re-attendee. This study forms the basis for hypothesis generation and further studies to explore reasons behind reattendances so that interventions can be developed to target high-risk groups.
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Affiliation(s)
- Amy Hui Sian Chan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | | | | | - Nan Liu
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
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Jiménez-Puente A, Del Río-Mata J, Arjona-Huertas JL, Mora-Ordóñez B, Martínez-Reina A, Martínez Del Campo M, Nieto-de Haro L, Lara-Blanquer A. Which unscheduled return visits indicate a quality-of-care issue? Emerg Med J 2016; 34:145-150. [PMID: 27671021 DOI: 10.1136/emermed-2015-205603] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 08/24/2016] [Accepted: 09/05/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND The rate of unscheduled return visits is often used as a quality-of-care indicator in EDs, although its validity is not yet fully established. Our aim was to identify the characteristics of return visits that may be attributed to problems in quality of care. METHODS Retrospective paired review of medical charts in a random sample of return visits during the 72 hours following discharge from the ED in three hospitals of Andalusia, Spain in 2013. Charts were reviewed by senior medical physicians to determine which return visits reflected quality-of-care problems. Time frame for return visit, index and return visit acuity, disposition and diagnosis were compared with determine which variables were associated with a quality problem. Sensitivity and specificity for each variable to indicate a quality problem were determined. RESULTS We studied the causes of 895 return visits, finding that 65 (7.3%) were due to inadequate quality of care in the index visit. Potentially avoidable return visits were more common in more severely ill patients, in those with greater severity in the return than in the index visit and in patients hospitalised after the return. The combination of this three variables presented sensitivity 66% and specificity 68% in identification of quality-related returns. CONCLUSIONS The overall level of return visits cannot be considered a valid indicator of quality of care. However, certain specific variables, including the level of severity of the patient's condition or the discharge destination following the return visits, could be considered valid in this respect.
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Affiliation(s)
- Alberto Jiménez-Puente
- Evaluation Unit, Costa del Sol Public Health Care Agency, Marbella, Málaga, Spain.,Health Services Research on Chronic Patients Network (REDISSEC), Marbella, Spain
| | - José Del Río-Mata
- Medical Documentation Department, Virgen de la Victoria University Hospital, Málaga, Spain
| | | | - Begoña Mora-Ordóñez
- Emergency Department, Virgen de la Victoria University Hospital, Málaga, Spain
| | - Alfonso Martínez-Reina
- Medical Documentation Department, Virgen de la Victoria University Hospital, Málaga, Spain
| | | | | | - Antonio Lara-Blanquer
- Medical Documentation Department, Costa del Sol Public Health Care Agency, Marbella, Málaga, Spain
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12
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Predicting Factors and Risk Stratification for Return Visits to the Emergency Department Within 72 Hours in Pediatric Patients. Pediatr Emerg Care 2015; 31:819-24. [PMID: 25875996 DOI: 10.1097/pec.0000000000000417] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES A return visit (RV) to the emergency department (ED) is usually used as a quality indicator for EDs. A thorough comprehension of factors affecting RVs is beneficial to enhancing the quality of emergency care. We performed this study to identify pediatric patients at high risk of RVs using readily available characteristics during an ED visit. METHODS We retrospectively collected data of pediatric patients visiting 6 branches of an urban hospital during 2007. Potential variables were analyzed using a multivariable logistic regression analysis to determine factors associated with RVs and a classification and regression tree technique to identify high-risk groups. RESULTS Of the 35,435 visits from which patients were discharged home, 2291 (6.47%) visits incurred an RV within 72 hours. On multivariable analysis, younger age, weekday visits, diagnoses belonging to the category of symptoms, signs, and ill-defined conditions, and being seen by a female physician were associated with a higher probability of RVs. Children younger than 6.5 years who visited on weekdays or between midnight and 8:00 AM on weekends or holidays had the highest probability of returning to the ED within 72 hours. CONCLUSIONS Our study reexamined several important factors that could affect RVs of pediatric patients to the ED and identified high-risk groups of RVs. Further intervention studies or qualitative research could be targeted on these at-risk groups.
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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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Curran JA, Murphy A, Newton M, Zemek R, Hartling L, Plint A, Chorney J, MacPhee S, Campbell SG, Jabbour M, Boliver D, Petrie D, Colwell R, MacWilliams K, Nolan A. Discharge instructions for caregivers in the context of pediatric emergency care: a narrative synthesis protocol. Syst Rev 2014; 3:26. [PMID: 24628948 PMCID: PMC3995555 DOI: 10.1186/2046-4053-3-26] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 02/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The period following discharge from a pediatric emergency department (ED) can be a time of significant vulnerability for caregivers who provide ongoing care to their child when they return home. Discharge communication practice varies widely at the individual practitioner and departmental level. At present, there are no nationally accepted guidelines for discharge communication for children and/or their caregivers in the ED.The primary objective of this knowledge synthesis is to understand how and why discharge instructions work and under what conditions. We will also examine the contextual factors and barriers and facilitators associated with discharge communication across varied ED settings. METHODS/DESIGN Using an integrated narrative approach, we will synthesize different types of evidence and explore relationships within and between included studies to develop a theory-based and knowledge user-informed discharge communication practice guideline. We will follow key principles for knowledge synthesis including: (1) involvement of a multidisciplinary team (for example, information specialists, statisticians, and content experts); (2) developing focused and answerable questions in collaboration with the knowledge users; (3) using a systematic method including specific tools and techniques appropriate for answering questions concerned with effectiveness and the implementation of interventions; and, (4) involving knowledge users throughout the process in an integrated knowledge translation approach. DISCUSSION This collaborative and narrative approach will be a determining factor in increasing the reliability, validity and relevance of the study findings for healthcare practice and policy decision-makers. TRIAL REGISTRATION PROSPERO registration number: CRD42014007106.
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Affiliation(s)
- Janet A Curran
- IWK Health Center, Dalhousie University, 5869 University Avenue, PO Box 15000, Halifax, NS B3H 4R2, Canada.
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