Qualitative Factors in Patients Who Die Shortly After Emergency Department Discharge

Department of Medicine, University of California-Los Angeles, Los Angeles, CA
Academic Emergency Medicine (Impact Factor: 2.01). 08/2013; 20(8):778-85. DOI: 10.1111/acem.12181
Source: PubMed


Early death after emergency department (ED) discharge may signal opportunities to improve care. Prior studies are limited by incomplete mortality ascertainment and lack of clinically important information in administrative data. The goal in this hypothesis-generating study was to identify patient and process of care themes that may provide possible explanations for early postdischarge mortality.
This was a qualitative analysis of medical records of adult patients who visited the ED of any of six hospitals in an integrated health system (Kaiser Permanente Southern California [KPSC]) and died within 7 days of discharge in 2007 and 2008. Nonmembers, visits to non-health plan hospitals, patients receiving or referred to hospice care, and patients with do not attempt resuscitation or do not intubate orders (DNAR/DNI) were excluded. Under the guidance of two qualitative research scientists, a team of three emergency physicians used grounded theory techniques to identify patient clinical presentations and processes of care that serve as potential explanations for poor outcome after discharge.
The source population consisted of a total of 290,092 members with 446,120 discharges from six KPSC EDs in 2007 and 2008. A total of 203 deaths occurred within 7 days of ED discharge (0.05%). Sixty-one randomly chosen cases were reviewed. Patient-level themes that emerged included an unexplained persistent acute change in mental status, recent fall, abnormal vital signs, ill-appearing presentation, malfunctioning indwelling device, and presenting symptoms remaining at discharge. Process-of-care factors included a discrepancy in history of present illness, incomplete physical examination, and change of discharge plan by a third party, such as a consulting or admitting physician.
In this hypothesis-generating study, qualitative research techniques were used to identify clinical and process-of-care factors in patients who died within days after discharge from an ED. These potential predictors will be formally tested in a future quantitative study.

Download full-text


Available from: Jerome R Hoffman, May 16, 2014
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: We aimed to determine the rate of preventable death in patients that died early and unexpectedly following hospital admission from the Emergency Department (ED). We conducted a retrospective multicenter study in four centers from the Paris metropolitan area. Inclusion criteria were medical patients that died in hospital within 72 hours of ED attendance and were not admitted to the intensive care unit (unexpected death). Exclusion criteria were limitations of care determined by treating physicians. The existence of a limitation of care decision was adjudicated by two independent chart abstractors. Preventable death was defined as death occurring as a result of medical error. For each selected patient with unexpected death, charts were examined for medical errors and rated on a 1 to 5 preventability scale (from very unlikely to very likely) the preventability of the death. The primary endpoint was the likely preventable death, rated as 4 or 5 on the preventability scale. We retrieved 555 charts; 47 unexpected deaths were analysed; 24 (51%) were considered as preventable. There was a median number of medical errors of two. The most common process breakdowns were incorrect choice of treatment (47% of patients) and failure to order appropriate diagnostic tests (38% of patients). The most common medical error was a severe delay or absence of recommended treatment for severe sepsis, which occurred in ten (42%) patients. In our sample, more than half of unexpected deaths are related to a medical error, and could have been prevented.
    Full-text · Article · Apr 2015 · Critical care (London, England)
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Emergency department (ED) crowding has been associated with adverse events, including short-term death and hospitalization among discharged patients. The mechanisms are poorly understood, but may include altered physician decision-making about ED discharge of higher-risk patients. One example is patients with transient ischemic attack (TIA) and minor stroke, who are at high risk of subsequent stroke. While hospitalization is frequently recommended, little consensus exists on which patients require admission.Objectives The authors sought to determine the association of ED crowding with the disposition of patients with minor stroke or TIA.Methods This was a retrospective cohort study of prospectively collected data from the Registry of the Canadian Stroke Network at 12 EDs in Ontario, Canada, between 2003 and 2008, linked to administrative health databases. A hierarchical logistic regression model was used to determine the association between crowding at the time the patient was seen in the ED (defined as mean ED length of stay) and patient disposition (admission/discharge), after adjusting for patient and hospital-level variables.ResultsThe study cohort included 9,759 patients (4,607 with TIA and 5,152 with minor stroke); 49.5% were discharged from the ED. The mean (±SD) age of study patients was 70.78 (±13.40) years, with 52.9% being male, 37.3% arriving by emergency medical services, and 92.3% triaged as emergent or urgent. Greater severity of ED crowding was associated with a lower likelihood of discharge, regardless of ED size.Conclusions These results suggest that crowding may influence clinical decision-making in the disposition of patients with TIA or minor stroke and that, as crowding worsens, the likelihood of hospitalization increases.
    No preview · Article · Sep 2015 · Academic Emergency Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Regimented vital signs (VS) assessment for all emergency patients is a common practice in many US emergency departments despite the paucity of evidence supporting its utility. Nurse attitude may be a factor that maintains this ritualized practice. Understanding the relationship between attitudes, practices, and nurse demographic factors may be the first step to challenging this ritual in order to implement evidence-based practices. A 20-item questionnaire was developed to assess emergency nurse attitudes and practices related to VS. A convenience sample of emergency nurses from the mid-Atlantic region of the United States was used. Eighty-one emergency nurses participated. Results demonstrated wide variations in VS practice and attitudes, though some strongly held attitudes are inconsistent with the literature. Certification in emergency nursing had significant associations with beliefs that nurses' clinical judgment should be the determinant for VS frequency (p < .05) and that triage VS are not an accurate representation of patient condition (p < .05). The practice of assessing the patient first and reviewing VS after was also associated with certification (p < .05). This study begins to address emergency nurse attitudes and practices of VS so that evidence-based changes can be implemented and further research on VS frequency conducted. It also demonstrates the relationship between specialty certification and evidence-supported attitudes and practices.
    No preview · Article · Jan 2016 · International emergency nursing