What we can learn from Medicare data on early deaths after emergency department discharge

The effect of the employment of experienced physicians in the Emergency Department on quality of care and equality-a quasi-experimental retrospective cohort study

BACKGROUND

Increasing acute admissions in Emergency Departments (EDs) negatively affect quality of care, safety and flow. Thus, the Danish Health Authorities recommend the presence of experienced physicians in the ED. In 2016, consultant-led triage and continuous presence of consultants were introduced at a larger ED in Copenhagen, Denmark. This study investigated whether the employment of consultants in a Danish ED affected the quality of care for acutely admitted medical patients in terms of length of admission, readmission and mortality, as well as socioeconomic equality in quality of care delivery.

METHODS

Admission data were collected during two 7-month periods, one prior to and one after the organizational intervention, with 9869 adult medical patients admitted for up to 48 h in the ED. Linear regression and Cox proportional hazards regression analyses adjusted for age, sex, comorbidities, level of education and employment status were applied.

RESULTS

Following the employment of consultants, an overall 11% increase in index-admissions was observed, and 90% of patients were discharged by a consultant with a reduced mean length of admission by 1.4 h (95% CI: 1.0-1.9). No change was found in in-hospital mortality, readmission or mortality within 90 days after discharge. No change in distribution of quality indicators across patients' socioeconomic status was found.

CONCLUSIONS

Consultants in the ED was found to reduce length of hospitalization without a negative effect on the quality of care for ED-admitted medical patients in general or patients with lower socioeconomic status.

Risk of death within 7 days of discharge from emergency departments with different organizational models

OBJECTIVE

The aim of this study is to investigate the association between emergency department (ED) organizational models and the risk of death within 7 days of ED discharge.

PATIENTS AND METHODS

We included Danish ED discharges between 1 January 2011 and 24 December 2014 that led to death within 7 days of discharge. The inclusion criterion was age older than 18 years. The exclusion criterion was further in-hospital admission. First model (Virtual): other departments employ interns who perform ED tasks. They are responsible for ED patient care and prioritize their task order between their own department and the ED. Second model (Hybrid): the ED/other departments perform tasks; interns/consultants are employed by the ED/other departments. The ED/other departments have patient care responsibility. Third model (Independent): the ED performs all tasks; employs interns/consultants; and have patient care responsibility. Sex, age, Charlson Comorbidity Index score, and primary diagnosis were used to describe patient characteristics. We calculated the risk of death within 7 days of discharge using multiple logistic regression analysis.

RESULTS

In 805 out of 201 299 discharges included in the study, the patient died within 7 days. Compared with the Virtual model, the odds ratio for death within 7 days of discharge was 0.72 (95% confidence interval: 0.59-0.92) for the Independent model and 0.75 (95% confidence interval: 0.61-0.92) for the Hybrid+Virtual model. Increased risk was associated with male sex, older age, and a medium or a high Charlson Comorbidity Index score.

CONCLUSION

Compared with discharges from a Virtual model, the risk of death within 7 days of discharge was lower if the ED had an Independent or a Hybrid+Virtual model.