RESUMO
BACKGROUND: Emergency department return visits significantly impact medical costs and patient flow. A comprehensive approach to understanding these patients is required to identify deficits in care, system level inefficiencies, and improve diagnosis specific management protocols. We aimed to identify factors needed to successfully analyze return visits to explore root causes leading to unplanned returns and inform system-level improvements. METHODS: A multidisciplinary committee collaborated to develop a quality review process for return visits within 72 hours to our pediatric emergency department that were then subsequently admitted to the hospital. The committee developed methodology and a web-based tool for chart review and analysis. RESULTS: Of 197,076 ED visits (159,164 discharged at initial visit), 5390 (3.4%) patients were discharged and represented to the ED within 72 hours and 1658 (1.0%) of those resulted in admission. Using defined criteria, approximately one third (n = 564) of revisits with admission were identified for chart review. Reason for revisit included natural progression of disease (67.6%), new condition or problem (11.2%), diagnostic error (6.9%), and scheduled or planned readmissions (3.5%). All diagnostic errors had not been previously identified by ED leadership. Of the reviewed cases, most were not preventable (84.0%); however, a number of system-level actions resulted from discussion of the potentially preventable revisits. CONCLUSIONS: Seventy-two-hour ED revisits were efficiently and systematically categorized with determination of root causes and preventability. This process resulted in shared provider-level feedback, identifying trends in revisits, and implementation of system-level actions, therefore, encouraging other institutions to adopt a similar process.
Assuntos
Serviço Hospitalar de Emergência , Readmissão do Paciente , Criança , Hospitalização , Hospitais , Humanos , Alta do Paciente , Estudos RetrospectivosAssuntos
Certificação/normas , Pediatria/normas , Melhoria de Qualidade/organização & administração , Certificação/métodos , Certificação/organização & administração , Competência Clínica/normas , Educação Médica Continuada/organização & administração , Hospitais/normas , Humanos , Pediatria/educação , Pediatria/organização & administração , Autoavaliação (Psicologia) , Estados UnidosRESUMO
OBJECTIVES: To determine the incidence of return visits (RVs), types of RVs, and factors associated with RVs to a pediatric emergency department (ED). METHODS: : Retrospective cohort study of patients seen in an urban, tertiary care pediatric ED. MAIN OUTCOME: RV within 48 hours, identified from a computerized log. RESULTS: The total RV rate was 3.5% (95% confidence interval, 3.3-3.6), similar to rates (2.4% to 3.4%) reported in general EDs. Most (78.5%) RVs were unscheduled, 17% were scheduled, and 4% were called back to the ED. Infectious disease (45%), respiratory (16%), and trauma (16%) accounted for most RV diagnoses. When compared with the overall ED population, RV patients were more likely to be younger than 2 years [relative risk, 1.3 (1.2-1.4)], to be admitted to the hospital [relative risk, 1.3 (1.2-1.5)], and to be triaged as acute [relative risk, 1.1 (1.0-1.2)]. Patients called back to the ED were younger, more likely to be triaged as acute, and more likely to be admitted than other RV patients. Significant diagnoses were made at RV in 7 (0.4%; 95% confidence interval, 0.1-0.7) patients, half of whom were called back to the ED or had a scheduled RV. CONCLUSION: Similarities between our pediatric ED RV rate and other published research implies that benchmarking and quality improvement tools for RV can be used and compared in both pediatric and general EDs. Focusing on systems to call patients back to the ED when necessary may be an efficient way to reduce medical error and adverse patient outcomes.