Dr Scott Pearson Emergency Physician Christchurch Hospital.
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48 hour representations Dr Scott Pearson Emergency Physician Christchurch Hospital
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Transcript of Dr Scott Pearson Emergency Physician Christchurch Hospital.
48 hour representations
Dr Scott PearsonEmergency PhysicianChristchurch Hospital
Decision Support at CDHB send monthly report to clinician responsible for audit
List of NHIs of patients who have had “unscheduled” representations within 48 hours of first attendance at Emergency
Usually 40-60 patients/ month- <1% of total
Includes patients who ◦ return and are then discharged home again from ED. ◦ are admitted by an inpatient team who are discharged, then
return within 48 hours of discharge
How do we collect the data?
Once ED reattendances who are admitted are isolated, usually ~10 patients per month
Electronic/ paper clinical records reviewed
Assessment about appropriateness of initial discharge and advice
2-3 hours of SMO time per month
How do we collect the data?
High number of patients on original data that are not ED specific◦ Clerical staff code reattendance as “unscheduled”◦ Unscheduled if reattendance for same clinical
problem◦ Inpatient discharges are included also
Very small number of inappropriate discharges
Problems with process
May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-130
2
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InappropriateAppropriate
48 hour representationsInappropriate discharge vs appropriate
April 2009- March 2010 Average monthly unscheduled returns = 24
April 2012- March 2013 Average monthly unscheduled returns = 43
April 2013- March 2014 Average monthly unscheduled returns = 53
Trend analysis
EDObs Gen Surg Gen Med Urology Plastics Gynae Paeds Other
Aug-13 0 2 0 2 0 1 NaN 4
Sep-13 2 1 1 0 1 2 1 NaN
Oct-13 2 3 3 0 0 0 1 7
Nov-13 2 1 1 1 0 0 2 0
Dec-13 2 2 3 2 0 1 0 2
Jan-14 7 3 1 2 0 1 0 2
Feb-14 4 1 0 2 1 0 0 0
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What happens to the returning patients?
Feedback to staff involved Provide education around “themes” Provides information on trends Acts as a marker/ quality indicator of
◦ ED senior supervision◦ Capacity of the hospital◦ Pressure to discharge◦ Inadequate knowledge/ change of RMO staff?◦ Other processes in the community
What do we do with the information?
18 yr old man, car crash, brought in 2345 hrs◦ Observed 6 hours CT abdo normal◦ Vital signs stable, mobilised comfortably◦ Discharged 0545hr
Returned same day. Back pain and vomiting. CT abdo reviewed- crush fractures L1-4, free air, admitted General Surgery, observed, discharged 48 hrs later
ACTION- review discharge policy during night, radiology reporting process
Young male, punched in face when in city in evening. Swollen face. Xrays misinterpreted. Recalled after alerted by radiologist. Blowout fracture orbit.
ACTION- further RMO education about facial Xray interpretation
Patient examples
72 year old◦ Lethargy and SOB◦ WCC 22◦ CXR misinterpreted
Returned with NSTEMI ACTION- feedback to RMO, senior supervision
38 yr old woman◦ Abdo pain, bariatric surgery 2 mths previous◦ Diagnosis of UTI
Returned with ongoing pain- CT diagnosis- gastric prolapse- laparotomy
ACTION- further education about complications of bariatric surgery
Patient examples
40 yr old male◦ Ureteric calculus, 4mm◦ Discharged appropriately for non operative management◦ Returns with ongoing pain, pain managed and discharged
Frequent cause for reattendance to ED ACTION- review management with Urology Service
5 month female◦ Clinical diagnosis bronchiolitis◦ Discharged appropriately after senior discussion and
parent education◦ Appropriate reattendance after poor feeding◦ Admitted to Paediatrics
ACTION- nil
Patient examples- appropriate discharge
Monthly audit- continuous or occasional?
Minimal amount of SMO time
Useful to review all ED discharges returning within 48 hours.
Conclusion
