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Smith K, Smith HL, Wittry A, Conley G, Leech J, Kluesner N. Characterization of Emergency Department Quality Assurance Cases Seen Within a Midwestern United States Health System. J Healthc Qual 2024:01445442-990000000-00074. [PMID: 38833570 DOI: 10.1097/jhq.0000000000000447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
BACKGROUND Hospital quality-assurance (QA) processes, including peer-review committees, seek to identify high-risk areas. PURPOSE To characterize emergency department (ED) cases sent for QA review. METHODS A retrospective observational study was conducted of ED cases sent to a QA committee from November 2018 through July 2022 at three midwestern US hospitals. The QA records analyzed for these cases included the original incident report, case summary, and the committee determinations. RESULTS One hundred and forty-seven cases were reviewed by the ED QA Committee. The most frequent referrals came from physicians. Common diagnostic categories included infectious (21%), cardiac (16%), gastrointestinal (11%), and neurologic (10%) concerns. Of the cases, 51% were considered nonpreventable, 33% were potentially preventable, and 9% were preventable. Inpatient boarding in the ED was explicitly implicated as a contributing factor in 6% of case reports. CONCLUSIONS Peer physician reporting represent the largest referral source sent for review with the most frequent diagnostic categories, including infectious, cardiac, gastrointestinal, and neurological conditions. Preventable concerns were rare. IMPLICATIONS This study provides a better understanding of the referral sources, diagnostic categories, and committee determinations in ED quality concerns. These results can target future investigations into case reporting and patient safety.
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Grabinski Z, Woo KM, Akindutire O, Dahn C, Nash L, Leybell I, Wang Y, Bayer D, Swartz J, Jamin C, Smith SW. Evaluation of a Structured Review Process for Emergency Department Return Visits with Admission. Jt Comm J Qual Patient Saf 2024:S1553-7250(24)00079-5. [PMID: 38653614 DOI: 10.1016/j.jcjq.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis. METHODS The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests. RESULTS The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (p < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (p < 0.001) but not by language (p = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (p = 0.446) or language (p = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education. CONCLUSION The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.
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Choi Y, Lee DH, Choi YH, Choi JY, Lim JY, Bae SJ. Predictors for emergency readmission in patients with ureteral calculi: a focus on pain management and stone location. World J Urol 2024; 42:119. [PMID: 38446234 DOI: 10.1007/s00345-024-04813-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/16/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The management of patients with ureteral calculi in the emergency department (ED) remains challenging due to high revisit rates. PURPOSE To identify predictors of revisits among patients with ureteral calculi in the ED. DESIGN, SETTING, AND PARTICIPANTS Data from patients who presented at a tertiary academic hospital in Seoul, Republic of Korea, between February 2018 and December 2019, were analyzed retrospectively. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Variables, including the respiratory rate (RR), estimated glomerular filtration rate (eGFR), duration of pain, number of analgesic doses, location of ureteral calculi, and ED length of stay (LOS) were examined using logistic regression. We also examined some additional variables included in the STONE and CHOKAI scoring systems to examine their association with revisit. RESULTS Significant predictors of revisits included the number of analgesic doses and the location of ureteral calculi. Patients who required multiple analgesic doses or those with proximal or mid-ureteral calculi were more likely to revisit the ED. Although the STONE and CHOKAI scores could predict uncomplicated ureteral calculi, we found that the CHOKAI score is a valuable tool for predicting the likelihood of patient revisits (p = 0.021). CONCLUSIONS Effective pain management and consideration of calculi location are important for predicting patient revisits. More research is required to validate findings, develop precise predictive models, and empower tailored care for high-risk patients. In patients with ureteral calculi in the ED, the number of analgesics given and stone location predict return visits. Proximal ureteral calculi on CT may require early urologic intervention to prevent pain-related revisits.
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Affiliation(s)
- Yunhyung Choi
- Department of Emergency Medicine, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Seoul, Chung-Ang University, 110, Deokan-Ro, Gwangmyeong-Si, 14353, Gyeonggi-do, Republic of Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Seoul, Chung-Ang University, 110, Deokan-Ro, Gwangmyeong-Si, 14353, Gyeonggi-do, Republic of Korea
| | - Yoon Hee Choi
- Department of Emergency Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University, 1071, Anyangcheon-Ro, Yangcheon-Gu, 07985, Seoul, Republic of Korea
| | - Jae Young Choi
- Department of Urology, College of Medicine, Yeungnam University, 170, Hyeonchung-Ro, Nam-Gu, 42415, Daegu, Republic of Korea
| | - Ji Yeon Lim
- Department of Emergency Medicine, College of Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University, 260, Gonghang-Daero, Gangseo-Gu, 07804, Seoul, Republic of Korea
| | - Sung Jin Bae
- Department of Emergency Medicine, Chung-Ang University Gwangmyeong Hospital, College of Medicine, Seoul, Chung-Ang University, 110, Deokan-Ro, Gwangmyeong-Si, 14353, Gyeonggi-do, Republic of Korea.
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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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Kelen GD, Kaji AH. The AHRQ Report on Diagnostic Errors in the Emergency Department: The Wrong Answer to the Wrong Question. Ann Emerg Med 2023; 82:336-340. [PMID: 37306635 DOI: 10.1016/j.annemergmed.2023.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/22/2023] [Accepted: 03/27/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Gabor D Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD; American College of Emergency Physicians, Irving, TX.
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; Society for Academic Emergency Medicine, Des Plaines, IL
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Hanna FA, Shavit I, Campisi-Pinto S, Chayen G, Jacob R. Early unplanned return visits to pediatric emergency departments in Israel during the SARS-CoV-2 pandemic. Am J Emerg Med 2023; 68:102-105. [PMID: 36963176 PMCID: PMC10020128 DOI: 10.1016/j.ajem.2023.03.021] [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: 02/09/2023] [Revised: 02/12/2023] [Accepted: 03/11/2023] [Indexed: 03/19/2023] Open
Abstract
INTRODUCTION During the SARS-CoV-2 pandemic there was a considerable drop in the number of visits to Pediatric Emergency Departments (PED). Unplanned return visits (URV) might represent inadequate emergency care. We assessed the impact of the pandemic on early URV to PEDs in Israel. METHODS This multicenter cross-sectional study analyzed the 72-h URV to PEDs among patients under the age of 18 years during a one-year pandemic period (March 1st, 2020, to February 28th, 2021), and compared them with the 72-h URV of the corresponding pre-pandemic period (March 1st, 2019, to February 28th, 2020). Data was extracted from Clalit Health Services (CHS), the largest public health care organization in Israel. RESULTS The pandemic and pre-pandemic early URV rates were 5465 (5.1%) and 8775 (5.6%), respectively (OR = 0.90, 95% CI 0.92-0.99). The rate of return-visit admissions to hospital wards during these periods were 29.5% and 32.1%, respectively (OR = 0.83, 95% CI 0.86-0.98). The rate of return-visit admissions to ICUs during these periods were 0.64% and 0.52%, respectively (OR = 1.11, 95% CI 0.67-1.62). On return-visit, 3 (0.055%) and 5 (0.057%) URV patients were declared dead on arrival during the pandemic and pre-pandemic periods, respectively (OR = 0.96, 95% CI 0.23-4.03). The distributions of the time interval from index visit to return visit remained consistent between the periods. DISCUSSION In our study, early URV to PED's were only mildly influenced by the SARS-CoV-2 pandemic.
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Affiliation(s)
- Firas Abu Hanna
- Pediatric Department, Ha'Emek Medical Center, Afula, Israel.
| | - Itai Shavit
- Division of Pediatrics, Pediatric Emergency Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | | | - Gilad Chayen
- Pediatric Emergency Department, Ha'Emek Medical Center, Afula, Israel.
| | - Ron Jacob
- Pediatric Emergency Department, Ha'Emek Medical Center, Afula, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
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Cordasco KM, Gable AR, Tan GJ, Yuan AH, Yip K, Khafaf M, Hays RD, Faiz JP, Chawla N, Ganz DA. Veteran knowledge, perceptions, and receipt of care following visits to VA emergency departments for ambulatory care sensitive conditions. Acad Emerg Med 2022; 30:252-261. [PMID: 36578158 DOI: 10.1111/acem.14649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/22/2022] [Accepted: 12/22/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Receipt of follow-up care after emergency department (ED) visits for chronic ambulatory care sensitive conditions (ACSCs)-asthma, chronic obstructive pulmonary disease, heart failure, diabetes, and/or hypertension-is crucial. We assessed Veterans' follow-up care knowledge, perceptions, and receipt of care after visits to Veterans Health Administration (VA) EDs for chronic ACSCs. METHODS Using explanatory sequential mixed methods, we interviewed Veterans with follow-up care needs after ACSC-related ED visits, and manually reviewed ED notes, abstracting interviewees' documented follow-up needs and care received. RESULTS We interviewed and reviewed ED notes of 35 Veterans, 12-27 (mean 19) days after ED visits. Follow-up care was completely received/scheduled in 20, partially received/scheduled in eight, and not received in seven Veterans. Among those who received care, it was received within specified time frames half the time. However, interviewees often did not recall these time frames or reported them to be longer than specified in the ED notes. Veterans who had not yet received or scheduled follow-up care commonly did not recall follow-up care instructions, believed that they did not need this care since they were not currently having symptoms, or thought that such care would be difficult to obtain due to appointment unavailability and/or difficulties communicating with follow-up care providers. Among the 28 Veterans in whom all or some follow-up care had been received/scheduled, for 25 cases VA staff reached out to the Veteran or the appointment was scheduled prior to or during the ED visit. CONCLUSIONS VA should prioritize implementing processes for EDs to efficiently communicate Veterans' needs to follow-up care providers and systems for reaching out to Veterans and/or arranging for care prior to Veterans leaving the ED. VA should also enhance practices using multimodal approaches for educating Veterans about recommended ED follow-up care and improve mechanisms for Veterans to communicate with follow-up care providers.
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Affiliation(s)
- Kristina M Cordasco
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Alicia R Gable
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Gracielle J Tan
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Anita H Yuan
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Kathleen Yip
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Mana Khafaf
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA
| | - Ron D Hays
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA.,RAND Corporation, Santa Monica, California, USA
| | - Jessica P Faiz
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,National Clinician Scholars Program, University of California, Los Angeles, Los Angeles, California, USA
| | - Neetu Chawla
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - David A Ganz
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California, USA.,RAND Corporation, Santa Monica, California, USA
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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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Chen KCJ, Elliott CG, Nemnom MJ, Ouyang Y, Fitzpatrick T. The impact of learner involvement in emergency department patient assessments on short-term return visits requiring hospital admission: a cross-sectional study. CAN J EMERG MED 2022; 24:606-610. [PMID: 35666370 DOI: 10.1007/s43678-022-00325-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 05/04/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Learners, either medical students or residents, often perform the initial assessment of patients visiting the emergency department (ED). It is unclear, however, if learners affect the rate of short-term unscheduled return visits. The objective of this study was to determine if the involvement of learners in ED visits increases the rate of return visits. METHODS This was a retrospective cross-sectional analysis of ED visit data at a single tertiary care centre over a 1-year period. Return visits were defined as those presenting within 72 h of discharge from an initial non-admit ED visit and resulting in an admission on the second visit. A generalized linear mixed model was used to determine the odds ratios of return visits, adjusting for prespecified co-variates, with and without learners involved during the initial visit. Secondary analyses assessed for associations between learner level of training, program of study and return visits. RESULTS Return visits occurred after 658 (1.3%) of 51,149 encounters involving learners and 701 (0.8%) of 83,310 encounters with no learner involvement. Involvement of learners in ED initial visits was not associated with increased odds of return visits (adjusted OR 1.13 [95% CI 0.71-1.81]), although the point estimates were heterogeneous over learner level of training, with clerkship students (medical student years 3 and 4) and senior residents (post-graduate years 4 and 5) trending towards reduced odds of a return visit. Resident program of study did not independently predict return visits. CONCLUSIONS This study demonstrated that the involvement of learners in ED patient assessments is not associated with increased odds of short-term unscheduled return visits.
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Affiliation(s)
- Kuan-Chin Jean Chen
- Department of Emergency Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Christopher G Elliott
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Yongdong Ouyang
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Tania Fitzpatrick
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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Sah R, Murmu LR, Aggarwal P, Bhoi S. Characteristics of an Unscheduled Emergency Department Revisit Within 72 hours of Discharge. Cureus 2022; 14:e23975. [PMID: 35541288 PMCID: PMC9083376 DOI: 10.7759/cureus.23975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2022] [Indexed: 11/28/2022] Open
Abstract
Background An unscheduled emergency department (ED) revisit is defined as a patient presenting to the ED with the same problem within 72 hours of discharge. The revisits result in overcrowding and compromise the care provided by the ED. We assume that the poor quality of care provided by the ED is the reason for revisiting. However, the circumstances surrounding these revisits are not well-understood. We conducted this study to understand the characteristics associated with the revisits. Objectives We aimed to identify the common causes of ED revisits within 72 hours of discharge and determine the outcome of these patients during the revisit. Methods We conducted a prospective observational study at a tertiary care center from July 2015 to June 2017, including patients presenting at the ED within 72 hours after their first visit. Our study selected 50 patients using a simple random sampling method and identified the leading causes of revisit as doctor-related, patient-related, and illness-related. Results We found that 56% (28/50) of patients returned to the ED for illness-related reasons, 26% (13/50) for doctor-related reasons, and 18% (9/50) for patient-related reasons. In addition, we found that 62% (31/50) of patients who returned to the ED within 72 hours required in-patient admission. Conclusion The most common cause of ED revisit was illness-related causes, and more than half of the patients during a revisit required in-patient admission. The modifiable causes of the ED revisit, such as doctor-related and patient-related factors, were discovered in this study. These findings may aid in reducing ED revisits and improving the ED quality.
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Ben-Assuli O, Vest JR. Return visits to the emergency department: An analysis using group based curve models. Health Informatics J 2022; 28:14604582221105444. [PMID: 35676746 DOI: 10.1177/14604582221105444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stratification modeling in health services is useful to identify differential patient risk groups, or latent classes. Given the frequency and costs, repeated emergency department (ED) may be an appropriate candidate for risk stratification modeling. We applied a method called group-based trajectory modeling (GBTM) to a sample of 37,416 patients who visited an urban, safety-net ED between 2006 and 2016. Patients had up to 10 ED visits during the study period. Data sources included the hospital's electronic health record (EHR), the state-wide health information exchange system, and area-level social determinants of health factors. Results revealed three distinct trajectory groups. Trajectories with a higher risk of revisit were marked by more patients with behavioral diagnoses, injuries, alcohol & substance abuse, stroke, diabetes, and other factors. The application of advanced computational techniques, like GBTM, provides opportunities for health care organizations to better understand the underlying risks of their large patient populations. Identifying those patients who are likely to be members of high-risk trajectories allows healthcare organizations to stratify patients by level of risk and develop early targeted interventions.
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Affiliation(s)
| | - Joshua R Vest
- Richard M. Fairbanks School of Public Health, 1772Indiana University, Indianapolis, IN, USA
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12
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Intravenous antibiotics at the index emergency department visit as an independent risk factor for hospital admission at the return visit within 72 hours. PLoS One 2022; 17:e0264946. [PMID: 35303001 PMCID: PMC8932564 DOI: 10.1371/journal.pone.0264946] [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: 07/08/2021] [Accepted: 02/20/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Although infection was the most common symptom in patients returning to the ED, whether intravenous antibiotic administration at the index visit could serve as an indicator of patients with infectious diseases at high risk for hospital admission after returning to the ED within a short period of time remains unclear. The study aimed to investigate the potential risk factors for hospital admission in patients returning to the ED within 72 hours with a final diagnosis of infectious diseases. Material and methods This retrospective cohort study analyzed return visits to the ED from January to December 2019. Adult patients aged >20 years who had a return visit to the ED within 72 hours with an infectious disease were included herein. In total, 715 eligible patients were classified into the intravenous antibiotics and non-intravenous antibiotics group (reference group). The outcome studied was hospital admission to general ward and intensive care unit (ICU) at the return visits. Results Patients receiving intravenous antibiotics at index visits had significantly higher risk—approximately two times—for hospital admission at the return visits than those did not (adjusted odds ratio = 2.47, 95% CI = 1.34–4.57, p = 0.004). For every 10 years increase in age, the likelihood for hospital admission increased by 38%. Other factors included abnormal respiratory rate and high C-reactive protein levels. Conclusions Intravenous antibiotic administration at the index visit was an independent risk factor for hospital admission at return visits in patients with an infection disease. Physicians should consider carefully before discharging patients receiving intravenous antibiotics.
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Shah MN, Jacobsohn GC, Jones CMC, Green RK, Caprio TV, Cochran AL, Cushman JT, Lohmeier M, Kind AJ. Care transitions intervention reduces ED revisits in cognitively impaired patients. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2022; 8:e12261. [PMID: 35310533 PMCID: PMC8919246 DOI: 10.1002/trc2.12261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/13/2021] [Accepted: 01/11/2022] [Indexed: 01/25/2023]
Abstract
Introduction About half of older adults with impaired cognition who are discharged home from the emergency department (ED) return for further care within 30 days. We tested the effect of an adapted Care Transitions Intervention (CTI) at reducing ED revisits in this vulnerable population. Methods We conducted a pre-planned subgroup analysis of community-dwelling, cognitively impaired older (age ≥60 years) participants from a randomized controlled trial testing the effectiveness of the CTI adapted for ED-to-home transitions. The parent study recruited ED patients from three university-affiliated hospitals from 2016 to 2019. Subjects eligible for this sub-analysis had to: (1) have a primary care provider within these health systems; (2) be discharged to a community residence; (3) not receive care management or hospice services; and (4) be cognitively impaired in the ED, as determined by a score >10 on the Blessed Orientation Memory Concentration Test. The primary outcome, ED revisits within 30 days of discharge, was abstracted from medical records and evaluated using logistic regression. Results Of our sub-sample (N = 81, 36 control, 45 treatment), 57% were female and the mean age was 78 years. Multivariate analysis, adjusted for the presence of moderate to severe depression and inadequate health literacy, found that the CTI significantly reduced the odds of a repeat ED visit within 30 days (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.07 to 0.90) but not 14 days (OR 1.01, 95% CI 0.26 to 3.93). Multivariate analysis of outpatient follow-up found no significant effects. Discussion Community-dwelling older adults with cognitive impairment receiving the CTI following ED discharge experienced fewer ED revisits within 30 days compared to usual care. Further studies must confirm and expand upon this finding, identifying features with greatest benefit to patients and caregivers.
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Affiliation(s)
- Manish N. Shah
- BerbeeWalsh Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA,Department of Medicine (Geriatrics and Gerontology)University of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA,Department of Population Health SciencesUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA,Center for Health Disparities ResearchUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA,Wisconsin Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Gwen C. Jacobsohn
- BerbeeWalsh Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Courtney MC Jones
- Department of Emergency MedicineUniversity of Rochester Medical CenterRochesterNew YorkUSA,Department of Public Health SciencesUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Rebecca K. Green
- BerbeeWalsh Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Thomas V. Caprio
- Department of Medicine, Division of GeriatricsUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Amy L. Cochran
- Department of Population Health SciencesUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA,Department of MathematicsUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Jeremy T. Cushman
- Department of Emergency MedicineUniversity of Rochester Medical CenterRochesterNew YorkUSA,Department of Public Health SciencesUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Michael Lohmeier
- BerbeeWalsh Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Amy J.H. Kind
- Department of Medicine (Geriatrics and Gerontology)University of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA,Center for Health Disparities ResearchUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA,Wisconsin Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA,William S. Middleton VA Geriatrics Research Education and Clinical Center (GRECC)MadisonWisconsinUSA
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14
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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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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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16
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De Jesus O, Rodríguez Beato F, de Jesús Espinosa A. 90-Day Return Visit to the Emergency Department After an Initial Neurosurgical Evaluation. World Neurosurg 2021; 158:e283-e286. [PMID: 34732382 DOI: 10.1016/j.wneu.2021.10.175] [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: 09/15/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study evaluated emergency department (ED) neurosurgical reevaluation rates and their causes. Identifying the most significant reasons that make patients return to the ED for a neurosurgical reevaluation can help implement changes to reduce the economic and medical burden of patient turnover. METHODS All patients undergoing neurosurgical reevaluation at our institution's ED after an initial neurosurgical evaluation were enrolled in a prospective 3-month longitudinal registry. Inclusion criteria were all adult patients 21 years of age or older previously evaluated by neurosurgery at our institution's ED who return within 90 days for a neurosurgical reevaluation. RESULTS We found an overall 90-day ED neurosurgical return visit rate of 2.1%. During the study, 34 patients returned to the ED for a neurosurgical reevaluation. Patients returned for a neurosurgical reevaluation at a median of 23.5 days after the initial neurosurgery evaluation. The principal causes for a return visit were altered mental status, headache, and wound infections. Among the returning patients, 59% required hospitalization and 50% required an operation. CONCLUSIONS To our knowledge, this is the first study to prospectively collect data to estimate the 90-day ED return visit rate for a neurosurgical reevaluation following an initial ED neurosurgical evaluation. Some patients still use the ED to get continued care of their condition despite having access to their primary care physician. Better communication, social worker coordination, and prompt follow-up appointments at the neurosurgical outpatient clinic may reduce return visits.
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Affiliation(s)
- Orlando De Jesus
- Section of Neurosurgry, Department of Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico, USA.
| | - Freddie Rodríguez Beato
- Section of Neurosurgry, Department of Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico, USA
| | - Aixa de Jesús Espinosa
- Section of Neurosurgry, Department of Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico, USA
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Chen RF, Cheng KC, Lin YY, Chang IC, Tsai CH. Predicting Unscheduled Emergency Department Return Visits Among Older Adults: Population-Based Retrospective Study. JMIR Med Inform 2021; 9:e22491. [PMID: 34319244 PMCID: PMC8367131 DOI: 10.2196/22491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 01/11/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022] Open
Abstract
Background Unscheduled emergency department return visits (EDRVs) are key indicators for monitoring the quality of emergency medical care. A high return rate implies that the medical services provided by the emergency department (ED) failed to achieve the expected results of accurate diagnosis and effective treatment. Older adults are more susceptible to diseases and comorbidities than younger adults, and they exhibit unique and complex clinical characteristics that increase the difficulty of clinical diagnosis and treatment. Older adults also use more emergency medical resources than people in other age groups. Many studies have reviewed the causes of EDRVs among general ED patients; however, few have focused on older adults, although this is the age group with the highest rate of EDRVs. Objective This aim of this study is to establish a model for predicting unscheduled EDRVs within a 72-hour period among patients aged 65 years and older. In addition, we aim to investigate the effects of the influencing factors on their unscheduled EDRVs. Methods We used stratified and randomized data from Taiwan’s National Health Insurance Research Database and applied data mining techniques to construct a prediction model consisting of patient, disease, hospital, and physician characteristics. Records of ED visits by patients aged 65 years and older from 1996 to 2010 in the National Health Insurance Research Database were selected, and the final sample size was 49,252 records. Results The decision tree of the prediction model achieved an acceptable overall accuracy of 76.80%. Economic status, chronic illness, and length of stay in the ED were the top three variables influencing unscheduled EDRVs. Those who stayed in the ED overnight or longer on their first visit were less likely to return. This study confirms the results of prior studies, which found that economically underprivileged older adults with chronic illness and comorbidities were more likely to return to the ED. Conclusions Medical institutions can use our prediction model as a reference to improve medical management and clinical services by understanding the reasons for 72-hour unscheduled EDRVs in older adult patients. A possible solution is to create mechanisms that incorporate our prediction model and develop a support system with customized medical education for older patients and their family members before discharge. Meanwhile, a reasonably longer length of stay in the ED may help evaluate treatments and guide prognosis for older adult patients, and it may further reduce the rate of their unscheduled EDRVs.
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Affiliation(s)
- Rai-Fu Chen
- Department of Information Management, Chia-Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Kuei-Chen Cheng
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - Yu-Yin Lin
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - I-Chiu Chang
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - Cheng-Han Tsai
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan.,Department of Emergency, Chiayi Branch, Taichung Veterans General Hospital, Chiayi City, Taiwan
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Poh XE, Wu KH, Chen CC, Huang JB, Cheng FJ, Chiu IM. Outcomes for Patients with Urinary Tract Infection After an Initial Intravenous Antibiotics Dose Before Emergency Department Discharge. Infect Dis Ther 2021; 10:1479-1489. [PMID: 34121165 PMCID: PMC8322380 DOI: 10.1007/s40121-021-00469-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/25/2021] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION To investigate the effect of single-dose intravenous antibiotics before emergency department (ED) discharge on the outcomes of patients with urinary tract infections (UTIs). METHODS This is a retrospective study conducted at the EDs of three medical centers. Patients aged over 18 years who presented to the ED with UTI and were discharged without admission between January 1, 2016 and December 31, 2017 were evaluated. The study group received a single dose of effective intravenous antibiotics on the basis of urine culture during the index ED visit following oral antibiotics, while the comparison group received oral antibiotics only. The primary outcomes were ED revisit within 72 h and admission following the return visit. RESULTS A total of 8168 patients were included. Of these, 20.9% received intravenous antibiotics before ED discharge. Patients who received effective intravenous antibiotics before ED discharge were associated with less than 72-h ED revisit (adjusted odds ratio [OR] 0.791, 95% confidence interval [CI] 0.640-0.979]), but not decreased admission following the return visit (adjusted OR 0.921, 95% CI [0.731-1.153]). In subgroup analysis, parenteral antibiotic use during the index ED visit was associated with decreased admission following ED revisit in patients who presented with fever (adjusted OR 0.605; 95% CI 0.443-0.932). CONCLUSION For patients with UTI and clinically well to be discharged from the ED, a single dose of effective intravenous antibiotics before ED discharge was associated with decreased 72-h ED revisit. In patients with febrile UTI, initial intravenous antibiotics were associated with decreased revisit leading to admissions.
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Affiliation(s)
- Xue-Er Poh
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan
| | - Kuan-Han Wu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan
| | - Chien-Chih Chen
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan
| | - Jyun-Bin Huang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan
| | - Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan.
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Hutchinson CL, Curtis K, McCloughen A, Qian S, Yu P, Fethney J. Predictors and outcomes of patients that return unplanned to the Emergency Department and require critical care admission: A multicenter study. Australas Emerg Care 2021; 25:88-97. [PMID: 33994336 DOI: 10.1016/j.auec.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/21/2021] [Accepted: 04/15/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the incidence, characteristics (including timeframe) and predictors of patients discharged from the Emergency Department (ED) that later return and require admission. METHODS A retrospective cross-sectional study examining all return visits to three EDs in Sydney, Australia, over a 12-month period. Patients returning within 28 days from ED discharge with the same or similar complaint were classified as a return visit to ensure capture of all return visits. Descriptive and inferential statistics were used to analyse the data and logistic regression was performed to predict factors associated with return visits with general admission, and return visits admitted to critical care. RESULTS There were 1,798 (30%) return visits which resulted in admission, mostly to a non-critical care area (1,679, 93%). The current NSW 48 -h time frame used to define a return visit in NSW captured half of all admitted returns (49.5%) and just over half (59.2%) of critical care admissions. Variables associated with an admission to critical care were age (OR 1.02, 95% CI 1.01, 1.03), initial presentation (index visit) made to a lower level ED (OR 3.76 95% CI 2.06, 6.86), Triage Category 2 (OR 3.67 95% CI 2.04, 6.60) and a cardiac diagnosis (OR 5.76, 95% CI 3.01, 11.01). This model had adequate discriminant ability with AUROC = 0.825. CONCLUSION A small number of return visits result in admission, especially to critical care. These patients are at risk of poor outcomes. As such, clinicians should have increased index of suspicion for patients who return that are older, present with cardiac problems, or have previously presented to a lower level ED. Revision of the current timeframe that defines a return visit ought to be considered by policy makers to improve the accuracy of this widely used key performance indicator.
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Affiliation(s)
- Claire L Hutchinson
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Emergency Department, Canterbury Hospital, Campsie, Sydney, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Illawarra Shoalhaven Local Health District, NSW, Australia; Illawarra Health and Medical Research Institute, NSW, Australia
| | - Andrea McCloughen
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
| | - Siyu Qian
- Centre for IT-enabled Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Australia
| | - Ping Yu
- Centre for IT-enabled Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Australia; Illawarra Health and Medical Research Institute, NSW, Australia
| | - Judith Fethney
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
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Northgraves M, Cohen J, Allgar V, Currow D, Hart S, Hird K, Hodge A, Johnson M, Mason S, Swan F, Hutchinson A. A feasibility cluster randomised controlled trial of a paramedic-administered breathlessness management intervention for acute-on-chronic breathlessness (BREATHE). ERJ Open Res 2021; 7:00955-2020. [PMID: 33816602 PMCID: PMC8005684 DOI: 10.1183/23120541.00955-2020] [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: 12/18/2020] [Accepted: 01/07/2021] [Indexed: 11/19/2022] Open
Abstract
Chronic breathlessness, persistent and disabling despite optimal treatment of underlying causes, is a prevalent and frightening symptom and is associated with many emergency presentations and admission to hospital. Breathlessness management techniques used by paramedics may reduce the need for conveyance to hospital. The Breathlessness RElief AT HomE study (BREATHE) aims to explore the feasibility of conducting a definitive cluster randomised controlled trial (cRCT) for people with acute-on-chronic breathlessness who have called an ambulance, to evaluate the effectiveness and cost-effectiveness of a paramedic-administered non-pharmacological breathlessness intervention. The trial is a mixed-methods feasibility cRCT. Eight paramedics will be randomised 1:1 to deliver either the BREATHE intervention in addition to usual care or usual care alone at call-outs for acute-on-chronic breathlessness. Sixty participants will be recruited to provide access to routine data relating to the index call-out with optional follow-up questionnaires at 14 days, 1 month and 6 months. An in-depth interview will be conducted with a subgroup. Feasibility outcomes relating to recruitment, data quality (especially candidate primary outcomes), and intervention acceptability and fidelity will be collected as well as providing data to estimate a sample size for a definitive trial. Yorkshire and The Humber–Sheffield Research Ethics Committee approved the trial protocol (19/YH/0314). The study results will inform progression to, or not, and design of a main trial according to predetermined stop-go criteria. Findings will be disseminated to relevant stakeholders and submitted for publication in a peer-reviewed journal. Acute-on-chronic breathlessness initiates many emergency presentations. The BREATHE protocol describes a feasibility, cluster randomised controlled trial of a paramedic breathlessness management intervention.https://bit.ly/2LZg72w
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Affiliation(s)
| | - Judith Cohen
- Hull Health Trials Unit, University of Hull, Hull, UK
| | - Victoria Allgar
- Hull York Medical School / Health Sciences, University of York, York, UK
| | - David Currow
- Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Simon Hart
- Respiratory Research Group, Hull York Medical School, Cottingham, UK
| | - Kelly Hird
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Andrew Hodge
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Miriam Johnson
- Wolfson Palliative Care Research Group, Hull York Medical School, Hull, UK
| | - Suzanne Mason
- CURE group, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Flavia Swan
- Wolfson Palliative Care Research Group, Hull York Medical School, Hull, UK
| | - Ann Hutchinson
- Wolfson Palliative Care Research Group, Hull York Medical School, Hull, UK
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Penney LS, Moreau JL, Miake-Lye I, Lewis D, D'Amico A, Lee K, Scott B, Kirsh S, Cordasco KM. Spreading the Veterans Health Administration's emergency department rapid access clinics (ED-RAC) innovation: Role of champions and local contexts. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 9:100516. [PMID: 33384257 DOI: 10.1016/j.hjdsi.2020.100516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 09/11/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Champions frequently facilitate change in healthcare, but the literature lacks specificity regarding champion activities and interactions with local contexts. The Veterans' Health Administration (VA) Emergency Department (ED) Rapid Access Clinic (ED-RAC) initiative used champions to spread an innovation aimed at achieving timely specialty follow-up care for ED patients. We assessed the roles champions and local contexts played in successful ED-RAC spread in the initiative's first year. METHODS Our mixed method formative evaluation included serial questionnaires, fieldnotes from meetings, and champion interviews. We analyzed qualitative data from spread site rapid and non-rapid implementers, assessing champion and contextual factors. RESULTS Among 24 participating VA sites, 11 were rapid implementers (i.e., implemented ED-RAC in first year), 13 were not. Site champions at rapid sites described crossing multiple organizational units to get tasks accomplished (e.g., gaining buy-in, requesting resources); champions at non-rapid sites experienced inter-departmental communication challenges and competing demands. Champions at rapid and non-rapid sites encountered similar context-related barriers (e.g. scheduling complexities) and facilitators (e.g. enthusiastic buy-in), but differed in leadership and resource barriers. CONCLUSIONS Identifying site champions was not enough to assure rapid innovation spread. Interdependencies between ED-RAC implementation requirements (e.g., boundary spanning, resources) and champion and contextual factors helped explain variations in progress. IMPLICATIONS Tailoring spread support to champion and contextual factors may facilitate more rapid spread of innovations.
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Affiliation(s)
- Lauren S Penney
- Veterans Evidence-Based Research Dissemination Implementation Center, South Texas Veterans Health Care System, San Antonio, TX, USA; Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA.
| | - Jessica L Moreau
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Isomi Miake-Lye
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Davis Lewis
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | | | - Kelli Lee
- VA Office of Healthcare Transformation, Pittsburgh, PA, USA
| | - Brianna Scott
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; VA Office of Healthcare Transformation, Pittsburgh, PA, USA
| | - Susan Kirsh
- Office of Veterans Access to Care, Veterans Health Administration, Washington, DC, USA; Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Kristina M Cordasco
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Bressan S, Berlese P, Arpone M, Steiner I, Titomanlio L, Da Dalt L. Missed intracranial injuries are rare in emergency departments using the PECARN head injury decision rules. Childs Nerv Syst 2021; 37:55-62. [PMID: 32424442 DOI: 10.1007/s00381-020-04660-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/30/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The PECARN head trauma (HT) prediction rules have been developed to guide computed tomography-related decision-making for children with minor HT (mHT). There are currently limited data on the rate of unscheduled revisits to emergency departments (EDs), and initially missed intracranial injuries, in children with mHT initially assessed using the PECARN rules. This study aimed to fill this gap in knowledge. METHODS Clinical charts of children assessed for mHT over a 5-year period at two EDs that implemented the PECARN rules in Italy and France were reviewed retrospectively. Children who returned to EDs for mHT-related, or potentially related complaints, within 1 month of initial assessment were included. RESULTS The total number of children with mHT presenting for the first time to the EDs of both sites was 11,749. Overall, 180 (1.5%) unscheduled revisits to the EDs occurred for mHT-related or potentially related complaints. Twenty-three of these 180 patients underwent neuroimaging, and seven had an intracranial injury (including one ischemic stroke). Of these, three were hospitalized and none needed neurosurgery or intensive care. CONCLUSION Unscheduled revisits for mHT in EDs using the PECARN rules were very uncommon. Initially missed intracranial injuries were rare, and none needed neurosurgery or intensive care.
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Affiliation(s)
- Silvia Bressan
- Division of Pediatric Emergency Medicine, Department of Women's and Children's Health, University of Padova, Via Giustiniani 3, 35128, Padova, Italy.
| | - Paola Berlese
- Division of Pediatric Emergency Medicine, Department of Women's and Children's Health, University of Padova, Via Giustiniani 3, 35128, Padova, Italy.,Pediatric Emergency Department, Robert Debré Hospital, Paris, France
| | - Marta Arpone
- Division of Pediatric Emergency Medicine, Department of Women's and Children's Health, University of Padova, Via Giustiniani 3, 35128, Padova, Italy
| | - Ivan Steiner
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Luigi Titomanlio
- Pediatric Emergency Department, Robert Debré Hospital, Paris, France
| | - Liviana Da Dalt
- Division of Pediatric Emergency Medicine, Department of Women's and Children's Health, University of Padova, Via Giustiniani 3, 35128, Padova, Italy
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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: 2] [Impact Index Per Article: 0.5] [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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Tangkulpanich P, Yuksen C, Kongchok W, Jenpanitpong C. Clinical Predictors of Emergency Department Revisits within 48 Hours of Discharge; a Case Control Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2020. [PMID: 33313568 PMCID: PMC7720856 DOI: 10.22037/aaem.v9i1.891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Emergency department (ED) revisits increase overcrowding and predicting which patients may need to revisit could increase patient safety. This study aimed to identify clinical variables that could be used to predict the probability of revisiting ED within 48 hours of discharge. METHODS A retrospective case-control study was conducted between July 2018 and January 2019 at the Emergency Medicine Department in Ramathibodi Hospital, Bangkok, Thailand. Patients who revisited the ED within 48 hours of discharge (case group) and patients who did not (control group) participated. The predictive factors for ED revisit were identified through multivariate logistic regression analysis. RESULTS The case group consisted of 372 patients, who revisited the ED within 48 hours, and the control group consisted of 1488 patients. The most common reason for revisiting the ED was recurring gastrointestinal illness, in 107 patients (28.76%). According to the multivariate data analysis , five factors influenced the probability of revisiting the ED: age of more than 60 years (p < 0.001, OR = 2.04, 95%CI: 1.51-2.77), initial Emergency Severity Index (ESI) triage level of 2 (p = 0.007, OR = 1.20, 95%CI: 0.93-1.56), ED stay duration of 4 hours or longer (p = 0.013, OR = 1.12, 95%CI: 0.87-1.44), body temperature of ≥37.5ºC on discharge (p = 0.034, OR = 1.34, 95%CI: 1.00-1.80), and pulse rate of less than 60 (OR = 1.55, 95%CI: 0.87-2.77) or more than 100 beats/minute (OR = 1.53, 95%CI: 1.10-2.11) (p = 0.011). CONCLUSION According to the findings, the most important and independent predictive factor of ED revisit within 48 hours of discharge were, age ≥ 60 years, ESI triage level 2, ED length of stay ≥ 4 hours, temperature ≥ 37.5 C, and 60 > pulse rate ≥ 100 beats/minute.
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Affiliation(s)
- Panvilai Tangkulpanich
- Department of Emergency Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chaiyaporn Yuksen
- Department of Emergency Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. ,Corresponding Author: Chaiyaporn Yuksen; 270 Rama VI Road, Thung Phaya Thai, Ratchathewi, Bangkok, Thailand, 10400. Phone number: (+66)8-9472-6911,
| | - Wanchalerm Kongchok
- Department of Emergency Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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25
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Sheikh S, Booth-Norse A, Smotherman C, Kalynych C, Lukens-Bull K, Guerrido E, Henson M, Gautam S, Hendry P. Predicting Pain-Related 30-Day Emergency Department Return Visits in Middle-Aged and Older Adults. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:2748-2756. [PMID: 32875332 PMCID: PMC8557807 DOI: 10.1093/pm/pnaa213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The objective of this study was to determine predictive factors for pain-related emergency department returns in middle-aged and older adults. Design, Setting, and Subjects. This was a subanalysis of patients > 55 years of age enrolled in a prospective observational study of adult patients presenting within 30 days of an index visit to a large, urban, academic center. METHODS Demographic and clinical data were collected and compared to determine significant differences between patients who returned for pain and those who did not. Multiple logistic regressions were used to determine significant predictive variables for return visits. RESULTS The majority of the 130 enrolled patients > 55 years of age returned for pain (57%), were African American (78%), were younger (55-64 years old, 67%), had a high emergency department acuity level (level 1 or 2) at their index visit (56%), had low health literacy (Rapid Estimate of Adult Literacy in Medicine [REALM] score, 62%), lived in an area of extreme deprivation (69%), and were admitted (61%) during their index visit. Age (odds ratio [OR] = 0.9, 95% CI = 0.8-0.9, P = 0.047), health literacy (REALM scores; OR = 3.1, 95% CI = 1.3-7.5, P = 0.011), and index visit pain scores (OR = 1.1, 95% CI = 1.0-1.2, P = 0.004) were predictive of emergency department returns for pain in middle-aged and older adults. CONCLUSIONS The likelihood of emergency department return visits for pain in middle-aged and older adults decreased with older age, increased with higher health literacy (REALM scores), and increased with increase in pain scores.
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Affiliation(s)
- Sophia Sheikh
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Ashley Booth-Norse
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Carmen Smotherman
- Center for Health Equity and Quality Research, University of Florida College of Medicine, Jacksonville, Florida
| | - Colleen Kalynych
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Katryne Lukens-Bull
- Center for Health Equity and Quality Research, University of Florida College of Medicine, Jacksonville, Florida
| | - Erika Guerrido
- Center for Health Equity and Quality Research, University of Florida College of Medicine, Jacksonville, Florida
| | - Morgan Henson
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Shiva Gautam
- Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Phyllis Hendry
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
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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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27
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Physician-related factors associated with unscheduled revisits to the emergency department and admission to the intensive care unit within 72 h. Sci Rep 2020; 10:13060. [PMID: 32747730 PMCID: PMC7400515 DOI: 10.1038/s41598-020-70021-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/17/2020] [Indexed: 11/08/2022] Open
Abstract
Investigation of physician-related causes of unscheduled revisits to the emergency department (ED) within 72 h with subsequent admission to the intensive care unit (ICU) is an important parameter of emergency care quality. Between 2012 and 2017, medical records of all adult patients who visited the ED and returned within 72 h with subsequent ICU admission were retrospectively reviewed by three experienced emergency physicians. Study parameters were categorized into "input" (Patient characteristics), "throughput" (Time spent on first ED visit and seniority of emergency physicians, and "output" (Charlson Comorbidity Index). Of the 147 patients reviewed for the causes of ICU admission, 35 were physician-related (23.8%). Eight belonged to more urgent categories, whereas the majority (n = 27) were less urgent. Patients who spent less time on their first ED visits before discharge (< 2 h) were significantly associated with physician-related causes of ICU admission, whereas there was no significant difference in other "input," "throughput," and "output" parameters between the "physician-related" and "non-physician-related" groups. Short initial management time was associated with physician-related causes of ICU admission in patients with initial less urgent presentations, highlighting failure of the conventional triage system to identify potentially life-threatening conditions and possibility of misjudgement because of the patients' apparently minor initial presentations.
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Hutchinson A, Galvin K, Johnson MJ. "So, I try not to go …" Acute-On-Chronic Breathlessness and Presentation to the Emergency Department: In-depth Interviews With Patients, Carers, and Clinicians. J Pain Symptom Manage 2020; 60:316-325. [PMID: 32247055 DOI: 10.1016/j.jpainsymman.2020.03.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 03/12/2020] [Accepted: 03/17/2020] [Indexed: 12/31/2022]
Abstract
CONTEXT People with acute-on-chronic breathlessness due to cardiorespiratory conditions frequently present to the emergency department (ED) causing burden for the person concerned, their care takers, and emergency services. OBJECTIVE To understand the reasons for ED presentation for acute-on-chronic breathlessness and how optimal care might avoid presentations. METHODS Qualitative in-depth linked interviews were conducted as part of a mixed-methods study. Transcripts of audio-recordings were subjected to thematic analysis. Consenting patients presenting to a single tertiary hospital ED with acute-on-chronic breathlessness able to be interviewed were eligible. Patient-participants (n = 18) were purposively sampled for maximum variation. Patient-participant-nominated carers (n = 9) and clinicians (n = 8) were recruited. RESULTS Theme 1: "The context for the decision to present to the ED" is the experience of acute-on-chronic breathlessness, in which a person faces an existential crisis not knowing where the next breath is coming from, and previous help-seeking experiences. Theme 2 ("Reasons for presentation"): Some were reluctant to seek help until crisis when family carers were often involved in the decision to present. Others had previous poor experiences of help-seeking for breathlessness in the community and turned to the ED by default. Some had supportive primary clinicians and presented to the ED either on their clinician's recommendation or because their clinician was unavailable. CONCLUSIONS The decision to present to the ED is made in the context of serious crisis and previous experiences. Discussion of the reason for presentation may enable better management of chronic breathlessness and reduce the need for future emergency presentation.
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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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Kim DU, Park YS, Park JM, Brown NJ, Chu K, Lee JH, Kim JH, Kim MJ. Influence of Overcrowding in the Emergency Department on Return Visit within 72 Hours. J Clin Med 2020; 9:jcm9051406. [PMID: 32397560 PMCID: PMC7290478 DOI: 10.3390/jcm9051406] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 11/16/2022] Open
Abstract
This study was conducted to determine whether overcrowding in the emergency department (ED) affects the occurrence of a return visit (RV) within 72 h. The crowding indicator of index visit was the average number of total patients, patients under observation, and boarding patients during the first 1 and 4 h from ED arrival time and the last 1 h before ED departure. Logistic regression analysis was conducted to determine whether each indicator affects the occurrence of RV and post-RV admission. Of the 87,360 discharged patients, 3743 (4.3%) returned to the ED within 72 h. Of the crowding indicators pertaining to total patients, the last 1 h significantly affected decrease in RV (p = 0.0046). Boarding patients were found to increase RV occurrence during the first 1 h (p = 0.0146) and 4 h (p = 0.0326). Crowding indicators that increased the likelihood of admission post-RV were total number of patients during the first 1 h (p = 0.0166) and 4 h (p = 0.0335) and evaluating patients during the first 1 h (p = 0.0059). Overcrowding in the ED increased the incidence of RV and likelihood of post-RV admission. However, overcrowding at the time of ED departure was related to reduced RV.
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Affiliation(s)
- Dong-uk Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (D.-u.K.); (Y.S.P.); (J.H.L.); (J.H.K.)
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (D.-u.K.); (Y.S.P.); (J.H.L.); (J.H.K.)
| | - Joon Min Park
- Department of Emergency Medicine, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do 10380, Korea;
| | - Nathan J. Brown
- Emergency and Trauma Centre, Royal Brisbane and Women’s Hospital, Butterfield Street, Herston QLD 4029, Australia; (N.J.B.); (K.C.)
- Faculty of Medicine, The University of Queensland, Brisbane QLD 4072, Australia
| | - Kevin Chu
- Emergency and Trauma Centre, Royal Brisbane and Women’s Hospital, Butterfield Street, Herston QLD 4029, Australia; (N.J.B.); (K.C.)
- Faculty of Medicine, The University of Queensland, Brisbane QLD 4072, Australia
| | - Ji Hwan Lee
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (D.-u.K.); (Y.S.P.); (J.H.L.); (J.H.K.)
| | - Ji Hoon Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (D.-u.K.); (Y.S.P.); (J.H.L.); (J.H.K.)
| | - Min Joung Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (D.-u.K.); (Y.S.P.); (J.H.L.); (J.H.K.)
- Correspondence: ; Tel.: +82-2-2228-2460; Fax: +82-2-2227-7908
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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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The Application of GSCM in Eliminating Healthcare Waste: Hospital EDC as an Example. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16214087. [PMID: 31652898 PMCID: PMC6862180 DOI: 10.3390/ijerph16214087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/18/2019] [Accepted: 10/20/2019] [Indexed: 11/26/2022]
Abstract
Eliminating unnecessary healthcare waste in hospitals and providing better healthcare quality are the core issues of green supply chain management (GSCM). Hence, this study used a hospital’s emergency department crowding (EDC) problem to illustrate how to establish an emergency medicine service (EMS) simulation system to obtain a robust parameters setting for solving hospitals’ EDC and waste problems, thereby increasing healthcare quality. Inappropriate resource allocation results in more serious EDC; more serious EDC results in increasing operating costs. Therefore, in the healthcare system, waste includes inappropriate costs and inappropriate resource allocation. The EMS of a medical center in central Taiwan was the object of the study. In this study, the dynamic Taguchi method was used to set the signal factor, noise factor, and control factors to simulate the EMS system to obtain the optimal parameters setting. The performance was set to Emergency Department Work Index (EDWINC) and system time (waiting time and service time) per patient. The signal factor was set to the number of physicians; the noise factor was set to patient arrival rate; the control factors included persuading Triage 4 and Triage 5 outpatients, checkup process, bed occupation rate in the emergency department (ED), and medical checkup sequence for Triage 4 and Triage 5 patients. This study makes two significant contributions. First, the study introduces the GSCM concept to the healthcare setting to bring green innovation to hospitals. Hospital administrators may hence design better GSCM activities to facilitate healthcare processes to provide better healthcare outcomes. Second, the study applied the dynamic Taguchi method to the EMS and neural network (NN) to construct a computational model revealing the cause (factors) and effect (performances) relationship. In addition, the genetic algorithm (GA), a solution method, was used to obtain the optimal parameters setting of the EDC in Taiwan. Hence, after obtaining the solutions, the unnecessary waste in EDC—inappropriate costs and inappropriate resource allocation—is reduced.
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Montoy JCC, Tamayo-Sarver J, Miller GA, Baer AE, Peabody CR. Predicting Emergency Department "Bouncebacks": A Retrospective Cohort Analysis. West J Emerg Med 2019; 20:865-874. [PMID: 31738713 PMCID: PMC6860392 DOI: 10.5811/westjem.2019.8.43221] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 08/16/2019] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION The short-term return visit rate among patients discharged from emergency departments (ED) is a quality metric and target for interventions. The ability to accurately identify which patients are more likely to revisit the ED could allow EDs and health systems to develop more focused interventions, but efforts to reduce revisits have not yet found success. Whether patients with a high number of ED visits are at increased risk of a return visit remains underexplored. METHODS This was a population-based, retrospective, cohort study using administrative data from a large physician partnership. We included patients discharged from EDs from 80 hospitals in seven states from July 2014 - June 2016. We performed multivariable logistic regression of short-term return visits on patient, visit, hospital, and community characteristics. The primary outcome was the proportion of patients who had a return visit within 14 days of an index ED visit. RESULTS Among 6,699,717 index visits, the overall risk of 14-day revisit was 12.6%. Frequent visitors accounted for 18.7% of all visits and 40.2% of all 14-day revisits. Frequent visitor status was associated with the highest odds of a revisit (odds ratio [OR] 3.06; 95% confidence interval [CI], 3.041 - 3.073). Other predictors of revisits were cellulitis (OR 2.131; 95% CI, 2.106 - 2.156), alcohol-related disorders (OR 1.579; 95%CI, 1.548 - 1.610), congestive heart failure (OR 1.175; 95% CI, 1.126 - 1.226), and public insurance (Medicaid OR 1.514; 95% CI, 1.501 - 1.528; Medicare OR 1.601; 95% CI, 1.583 - 1.620). CONCLUSION Previous ED use - even a single previous visit - was a stronger predictor of a return visit than any other patient, hospital, or community characteristic. Clinicians should consider previous ED use when considering treatment decisions and risk of return visit, as should stakeholders targeting patients at risk of a return visit.
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Affiliation(s)
- Juan Carlos C Montoy
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | | | | | - Amy E Baer
- Vituity Healthcare, Emeryville, California
| | - Christopher R Peabody
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
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Sheikh S. Risk Factors Associated with Emergency Department Recidivism in the Older Adult. West J Emerg Med 2019; 20:931-938. [PMID: 31738721 PMCID: PMC6860386 DOI: 10.5811/westjem.2019.7.43073] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/29/2019] [Accepted: 07/28/2019] [Indexed: 01/09/2023] Open
Abstract
Our objective was to review risk factors predictive of older adult recidivism in the emergency department. Certain risk factors and themes commonly occurred in the literature. These recurring factors included increasing age, male gender, certain diagnoses (abdominal pain, traumatic injuries, and respiratory complaints), psychosocial factors (depression, anxiety, poor social support, and limited health literacy), and poor general health (cognitive health and physical functioning). Many of the identified risk factors are not easily modifiable posing a significant challenge in the quest to develop and implement effective intervention strategies.
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Affiliation(s)
- Sophia Sheikh
- University of Florida-Jacksonville, Department of Emergency Medicine, Jacksonville, Florida
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Greenwald PW, Stern M, Clark S, Hafeez B, Gogia K, Hsu H, Mulcare M, Sharma R. A Novel Emergency Department-Based Telemedicine Program: How Do Older Patients Fare? Telemed J E Health 2019; 25:966-972. [DOI: 10.1089/tmj.2018.0162] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Peter W. Greenwald
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Michael Stern
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Sunday Clark
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Baria Hafeez
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Kriti Gogia
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Hanson Hsu
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Mary Mulcare
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Rahul Sharma
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
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Tan C, Tai MM, Kam JW. Emergency department asthma guideline adherence, 72-h return rates and disposition trends: Comparing data 10 years apart. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907919878336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: (1) To compare adherence of Ministry of Health Singapore Guidelines of Acute Asthma in the emergency department, in data 10 years apart, and ascertain if any difference observed impacted 72-h return rates and (2) to describe enhancement in hospital and community medical services for asthma, and its effect on disposition trends. Methods: A retrospective comparison in guideline adherence with regard to systemic steroids administration, anti-cholinergic administration in moderately severe exacerbations and patient education in discharged patients was done. Rates of unscheduled 72-h returns were compared. A description of new community and hospital services was described, and disposition trends were compared. Results In total, 630 patients 10 years ago and 635 patients in the current year were studied, after exclusions and systematic sampling applied. Steroid administration improved by 29% (adjusted p < 0.001). Steroids started in the emergency department improved by 43% (adjusted p < 0.001). Ipratropium addition to second nebulizer improved by 63% (adjusted p < 0.001). Patient education improved by 66% (adjusted p < 0.001). Unscheduled 72-h returns rate were unchanged at 4.2% (adjusted p = 0.912). Although there was no significant difference in the admission and discharge disposition (adjusted p = 0.173), there was a trend towards admission to the short stay unit as an admission option and referral to the primary healthcare provider for discharged patients. Conclusion: Although guideline adherence improved in the current year, rates of 72-h unscheduled returns were similar. Disposition trends reflected emphasis and availability of healthcare services in the community and hospital.
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Affiliation(s)
- Camlyn Tan
- Department of Emergency Medicine, Changi General Hospital, Singapore
| | | | - Jia Wen Kam
- Clinical Trials & Research Unit, Changi General Hospital, Singapore
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Aaronson E, Jansson P, Wittbold K, Flavin S, Borczuk P. Unscheduled return visits to the emergency department with ICU admission: A trigger tool for diagnostic error. Am J Emerg Med 2019; 38:1584-1587. [PMID: 31699427 DOI: 10.1016/j.ajem.2019.158430] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/30/2019] [Accepted: 09/06/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND It is believed that patients who return to the Emergency Department (ED) and require admission are thought to represent failures in diagnosis, treatment or discharge planning. Screening readmission rates or patients who return within 72 h have been used in ED Quality Assurance efforts. These metrics require significant effort in chart review and only rarely identify care deviations. OBJECTIVE This study was conducted to evaluate the yield of reviewing ED return visits that resulted in an ICU admission. This study was conducted to evaluate the yield of reviewing ED return visits that resulted in an ICU admission. We planned to assess if the return visits with ICU admission were associated with deviations in care, and secondarily, to understand the common causes of error in this group. METHODS Retrospective review of patients presenting to a university affiliated ED between January 1, 2005 and December 31, 2015 and returned within 14 days requiring ICU admission. RESULTS From 1,106,606 ED visits, 511 patients returned within 14 days and were admitted to an ICU. 223 patients returned for a reason related to the index visit (43.6%). Of these related returns, 31 (13.9%) had a deviation in care on the index visit. When a standard diagnostic process of care framework was applied to these 31 cases, 47.3% represented failures in the initial diagnostic pathway. CONCLUSION Reviewing 14-day returns leading to ICU admission, while an uncommon event, has a higher yield in the understanding of quality issues involving diagnostic as well as systems errors.
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Affiliation(s)
- Emily Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, United States of America; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, United States of America
| | - Paul Jansson
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, United States of America
| | - Kelley Wittbold
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, United States of America; Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, United States of America
| | - Stephanie Flavin
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, United States of America; Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, United States of America
| | - Pierre Borczuk
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, United States of America.
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Risk Factors for Emergency Department Unscheduled Return Visits. ACTA ACUST UNITED AC 2019; 55:medicina55080457. [PMID: 31405058 PMCID: PMC6723936 DOI: 10.3390/medicina55080457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/06/2019] [Accepted: 08/06/2019] [Indexed: 11/17/2022]
Abstract
Background and Objectives: This study aims to identify reasons for unscheduled return visits (URVs), and risk factors for diagnostic errors leading to URVs, with comparisons to data from a similar study conducted in the same institution 9 years ago. Materials and Methods: This retrospective study included adult patients who attended the emergency department (ED) of a tertiary hospital in Singapore between January 2014 and June 2014, with re-attendance within 72 h for the same or similar complaint. The primary outcome was wrong or delayed diagnoses. Secondary outcomes include admission to the ED observation unit or ward on return visit. Findings were compared with the previous study performed in 2005 to identify trends. Results: Of 67,422 attendances, there were 1298 (1.93%) URVs from 1207 patients (median age 34, interquartile range 24 to 52 years; 59.7% male). The most common presenting complaint was abdominal pain (22.2%). One hundred ninety-one (15.8%) patients received an initial wrong or delayed diagnosis. Factors (adjusted odds ratio; 95% CI) associated with this were: presenting complaints of abdominal pain (2.99; 2.12–4.23), fever (1.60; 1.1–2.33), neurological deficit (4.26; 1.94–9.35), and discharge without follow-up (1.61; 1.1–2.26). Among re-attendances, 459 (38.0%) required admission. Factors (adjusted odds ratio; 95% CI) associated with admission were: male gender (1.88; 1.42 to 2.48); comorbidities of diabetes mellitus (2.07; 1.29–3.31), asthma (5.23; 1.59–17.26), and renal disease (7.48; 2.00–28.05); presenting complaints of abdominal pain (1.83; 1.32–2.55), fever (3.05; 2.10–4.44), and giddiness or vertigo (2.17; 1.26–3.73). There was a reduction in URV rate compared to the previous study in 2005 (1.93% versus 2.19%). Abdominal pain at the index visit remains a significant cause of URVs (22.2% versus 25.1%). Conclusions: Presenting complaints of neurological deficits, abdominal pain, fever, and discharge without follow-up were associated with wrong or delayed diagnoses among URVs.
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Hong WS, Haimovich AD, Taylor RA. Predicting 72-hour and 9-day return to the emergency department using machine learning. JAMIA Open 2019; 2:346-352. [PMID: 31984367 PMCID: PMC6951979 DOI: 10.1093/jamiaopen/ooz019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/18/2019] [Accepted: 05/22/2019] [Indexed: 12/23/2022] Open
Abstract
Objectives To predict 72-h and 9-day emergency department (ED) return by using gradient boosting on an expansive set of clinical variables from the electronic health record. Methods This retrospective study included all adult discharges from a level 1 trauma center ED and a community hospital ED covering the period of March 2013 to July 2017. A total of 1500 variables were extracted for each visit, and samples split randomly into training, validation, and test sets (80%, 10%, and 10%). Gradient boosting models were fit on 3 selections of the data: administrative data (demographics, prior hospital usage, and comorbidity categories), data available at triage, and the full set of data available at discharge. A logistic regression (LR) model built on administrative data was used for baseline comparison. Finally, the top 20 most informative variables identified from the full gradient boosting models were used to build a reduced model for each outcome. Results A total of 330 631 discharges were available for analysis, with 29 058 discharges (8.8%) resulting in 72-h return and 52 748 discharges (16.0%) resulting in 9-day return to either ED. LR models using administrative data yielded test AUCs of 0.69 (95% confidence interval [CI] 0.68–0.70) and 0.71(95% CI 0.70–0.72), while gradient boosting models using administrative data yielded test AUCs of 0.73 (95% CI 0.72–0.74) and 0.74 (95% CI 0.73–0.74) for 72-h and 9-day return, respectively. Gradient boosting models using variables available at triage yielded test AUCs of 0.75 (95% CI 0.74–0.76) and 0.75 (95% CI 0.74–0.75), while those using the full set of variables yielded test AUCs of 0.76 (95% CI 0.75–0.77) and 0.75 (95% CI 0.75–0.76). Reduced models using the top 20 variables yielded test AUCs of 0.73 (95% CI 0.71–0.74) and 0.73 (95% CI 0.72–0.74). Discussion and Conclusion Gradient boosting models leveraging clinical data are superior to LR models built on administrative data at predicting 72-h and 9-day returns.
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Affiliation(s)
- Woo Suk Hong
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Richard Andrew Taylor
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Hutchinson A, Johnson MJ, Currow D. Acute-on-Chronic Breathlessness: Recognition and Response. J Pain Symptom Manage 2019; 57:e4-e5. [PMID: 30710626 DOI: 10.1016/j.jpainsymman.2019.01.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 01/22/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Ann Hutchinson
- Hull York Medical School, University of Hull, York, United Kingdom.
| | - Miriam J Johnson
- Hull York Medical School, University of Hull, York, United Kingdom
| | - David Currow
- Hull York Medical School, University of Hull, York, United Kingdom; University of Technology Sydney, Sydney, NSW, Australia
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Durbin A, Balogh R, Lin E, Wilton AS, Selick A, Dobranowski KM, Lunsky Y. Repeat Emergency Department Visits for Individuals With Intellectual and Developmental Disabilities and Psychiatric Disorders. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2019; 124:206-219. [PMID: 31026200 DOI: 10.1352/1944-7558-124.3.206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Although individuals with intellectual and developmental disabilities (IDD) and psychiatric concerns are more likely than others to visit hospital emergency departments (EDs), the frequency of their returns to the ED within a short time is unknown. In this population-based study we examined the likelihood of this group returning to the ED within 30 days of discharge and described these visits for individuals with IDD + psychiatric disorders (n = 3,275), and persons with IDD only (n = 1,944) compared to persons with psychiatric disorders only (n = 41,532). Individuals with IDD + psychiatric disorders, and individuals with IDD alone were more likely to make 30-day repeat ED visits. Improving hospital care and postdischarge community linkages may reduce 30-day returns to the ED among adults with IDD.
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Affiliation(s)
- Anna Durbin
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Robert Balogh
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Elizabeth Lin
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Andrew S Wilton
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Avra Selick
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Kristin M Dobranowski
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Yona Lunsky
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
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Cordasco KM, Frayne SM, Kansagara D, Zulman DM, Asch SM, Burke RE, Post EP, Fihn SD, Klobucar T, Meyer LJ, Kirsh SR, Atkins D. Coordinating Care Across VA Providers and Settings: Policy and Research Recommendations from VA's State of the Art Conference. J Gen Intern Med 2019; 34:11-17. [PMID: 31098966 PMCID: PMC6542870 DOI: 10.1007/s11606-019-04970-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.
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Affiliation(s)
- Kristina M Cordasco
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Department of Medicine, University of California Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, CA, USA.
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA.,Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
| | - Devan Kansagara
- VA Portland Healthcare System, Portland, OR, USA.,Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Donna M Zulman
- Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,VA Portland Healthcare System, Portland, OR, USA
| | - Steven M Asch
- Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,VA Portland Healthcare System, Portland, OR, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward P Post
- VA Center for Clinical Management Research, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephan D Fihn
- VA Office of Clinical System Development and Evaluation, Seattle, WA, USA.,VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services and Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Laurence J Meyer
- VA Office of Specialty Care Services, Washington, DC, USA.,VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Susan R Kirsh
- Office of Veterans Access to Care, Washington, DC, USA.,Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.,Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - David Atkins
- VA Office of Research and Development, Health Services Research and Development, Washington, DC, USA
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The ED-PACT Tool Initiative: Communicating Veterans' Care Needs After Emergency Department Visits. J Healthc Qual 2019; 42:157-165. [PMID: 31008828 DOI: 10.1097/jhq.0000000000000195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Communication failures between providers threaten patient safety. PURPOSE We developed, implemented, and formatively evaluated the ED-PACT Tool, which uses the Veterans Health Administration's (VA) electronic health record to send messages from emergency department (ED) providers to primary care patient-aligned care team (PACT) registered nurses (RNs) for Veterans discharged home from the ED with urgent or specific follow-up needs. METHODS We used Plan-Do-Study-Act quality improvement methodology. RESULTS Between November 1, 2015, and November 30, 2017, the tool was used to send 4,899 messages in one local VA healthcare system (ED and associated primary care clinics). Formative evaluation revealed that providers and RNs perceive the tool as providing substantial benefit for coordinating post-ED care. Patient-aligned care team leaders reported that RN training and "buy-in" facilitated tool implementation, while insufficient staffing posed a barrier. Emergency department providers noted the advantage of having a standardized and reliable system for communicating with PACTs. CONCLUSIONS/IMPLICATIONS The ED-PACT Tool encapsulates several best practices (standardized processes, "closed-loop" communication, embedding into workflow) to facilitate communication between VA ED and follow-up care providers. Our development process illustrates key lessons in quality improvement and innovation implementation including the value of using rapid-cycle improvement methodology, with interprofessional collaboration and representatives from intended spread sites.
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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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Loi SL, Hj Fauzi MH, Md Noh AY. Unscheduled early revisit to emergency department. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907918767012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Unscheduled revisits to the emergency department may present a considerable additional workload. Objectives: This study investigated the risk factors contributing to adverse event during unscheduled early revisit to Emergency Department Hospital Universiti Sains Malaysia. Methods: A retrospective cohort study was conducted from January 2014 to January 2015 to character the nature of unscheduled early revisits to Emergency Department Hospital Universiti Sains Malaysia. It included all patients 18 years old and above, revisited emergency department within 9 days post discharge from emergency department. Results: Data were collected from 492 case records. The rate of emergency department unplanned revisits within 9 days of previous emergency department discharge was 0.66% for the study period. Risk factors for revisit included advance age, pre-existing co-morbidities, duration spent during first emergency department visit and health care system–related error. The independent predictors of morbidity were diabetes mellitus (odds ratio, 2.07; 95% confidential interval, 1.08–3.96), respiratory disease (odds ratio, 2.42; 95% confidential interval, 1.18–4.98), gastrointestinal disease (odds ratio, 5.93; 95% confidential interval: 1.29, 27.35), nervous system disease (odds ratio, 4.65; 95% confidential interval: 1.27, 17.02), duration spent more than 6 h during first emergency department visit (odds ratio, 3.05; 95% confidential interval: 1.53, 6.07), and medical error leading to admission (odds ratio, 8.85; 95% confidential interval: 4.43, 17.67). The overall mortality rate was 0.2% (1/492). Conclusion: Emergency department physicians need to be extra vigilant when managing patients with risk factors, particularly the modifiable risk factors, to curb emergency department revisit.
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Affiliation(s)
- Siew Ling Loi
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Mohd Hashairi Hj Fauzi
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Abu Yazid Md Noh
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia
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Michelson KA, Lyons TW, Bachur RG, Monuteaux MC, Finkelstein JA. Timing and Location of Emergency Department Revisits. Pediatrics 2018; 141:peds.2017-4087. [PMID: 29650806 DOI: 10.1542/peds.2017-4087] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Emergency department (ED) revisits are used as a measure of care quality. Many EDs measure only revisits to the same facility, underestimating true rates. We sought to determine the frequency, location, and predictors of ED revisits to the same or a different ED. METHODS We studied ED discharges for children <18 years old in Maryland and New York in the statewide ED and inpatient databases. Revisits were defined as ED visits within 7 days of an index visit. Our primary outcome was the proportion of revisits that were different-hospital revisits (DHRs). We measured the underestimation of total revisits when only same-hospital revisits were measured. We determined the risk of DHR by quartile of annual ED pediatric volume, adjusting for case mix, insurance, state, and urban location. RESULTS Revisits across 261 EDs occurred after 5.9% of 4.3 million discharges. A per-ED median 21.9% of revisits were DHRs (interquartile range 14.2%-34.6%). Measuring only same-hospital revisits underestimated total revisits by 17.4%. The proportions of revisits that were DHRs by increasing volume quartile were 28.1%, 25.5%, 22.6%, and 14.5%. The adjusted risk of DHR was lower for increasing quartiles of pediatric volume (adjusted odds ratio for highest versus lowest quartile 0.27; 95% confidence interval, 0.19-0.36). CONCLUSIONS Measuring ED revisits only at the index ED significantly underestimates total revisits. Lower pediatric volume is associated with higher DHRs as a proportion of revisits. When using revisits as a measure of emergency care quality, effort should be made to assess revisits to different EDs.
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50
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Kang C, Kim K, Lee J, Jo Y, Park J, Lee S, Kim Y, Rhee J, Kim D. Predictors of Revisit and Admission after Discharge from an Emergency Department in Acute Pyelonephritis. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791502200304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction The aim of this study is to construct clinical prediction models to predict emergency department (ED) return visit following initial discharge for acute pyelonephritis (APN) and the need for hospital re-admission upon ED return visits. Method A retrospective analysis included 1250 discharged women with APN. Independent risk factors for revisit and subsequent admission after revisit were determined by multivariate analysis, and a prediction model for revisit and subsequent admission after revisit was constructed. Results Independent risk factors for revisit were nausea (2 points), age ≥ 65 years (2 points), C-reactive protein >20 mg/dL (2 points), serum albumin <3.3 g/dL (3 points) and urine white blood cell count ≥ 30/high power field (2 points). Re-visit risk scores were categorised to five groups and the re-visit rate was 5.4%, 8.6%, 12.2%, 19.1% and 43.8%, respectively, showing an area under curve (AUC) of 0.62. Risk factors for subsequent admission after revisit were vomiting (1 point), hypertension (2 points), serum creatinine <1.5 mg/dL (2 points), C-reactive protein >20 mg/dL (2 points) and serum albumin <3.3 g/dL (4 points). The subsequent admission after revisit risk scores were classified to three groups and subsequent admission after revisit rate was 3.5%, 15.0%, and 38.2%, respectively. Conclusion The developed model can identify a group of patients at high risk for a return visit and for requiring subsequent hospital admission, and might be used to improve initial disposition decision and discharge instructions. (Hong Kong j.emerg. med. 2015;22:154-162)
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Affiliation(s)
- C Kang
- Seoul National University Bundang Hospital, Department of Emergency Medicine, Seongnam, Korea
- Gyeongsang National University Hospital, Department of Emergency Medicine, Jinju, Korea
| | - K Kim
- Seoul National University Bundang Hospital, Department of Emergency Medicine, Seongnam, Korea
| | - Jh Lee
- Seoul National University Bundang Hospital, Department of Emergency Medicine, Seongnam, Korea
| | - Yh Jo
- Seoul National University Bundang Hospital, Department of Emergency Medicine, Seongnam, Korea
| | - Jw Park
- James Cook University, Sixth Year Medicine (Undergraduate), Queensland, Australia
| | - Sh Lee
- Seoul National University Bundang Hospital, Department of Emergency Medicine, Seongnam, Korea
- Gyeongsang National University Hospital, Department of Emergency Medicine, Jinju, Korea
| | - Yj Kim
- Seoul National University Bundang Hospital, Department of Emergency Medicine, Seongnam, Korea
| | - Je Rhee
- Seoul National University Bundang Hospital, Department of Emergency Medicine, Seongnam, Korea
| | - Dh Kim
- Gyeongsang National University Hospital, Department of Emergency Medicine, Jinju, Korea
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