Unplanned return presentations of older patients to the emergency department: a root cause analysis

Abstract

Background In line with demographic changes, there is an increase in ED presentations and unplanned return presentations by older patients (≥70 years). It is important to know why these patients return to the ED shortly after their initial presentation. Therefore, the aim of this study was to provide insight into the root causes and potential preventability of unplanned return presentations (URP) to the ED within 30 days for older patients. Methods A prospective observational study was conducted from February 2018 to November 2018 in an academic hospital in Amsterdam. We included 83 patients, aged 70 years and older, with an URP to the ED within 30 days of the initial ED presentation. Patients, GPs and doctors at the ED were interviewed by trained interviewers and basic administrative data were collected in order to conduct a root cause analysis using the PRISMA-method. Results One hundred fifty-one root causes were identified and almost half (49%) of them were disease-related. Fifty-two percent of the patients returned to the ED within 7 days after the initial presentation. In 77% of the patients the URP was related to the initial presentation. Patients judged 17% of the URPs as potentially preventable, while doctors at the ED judged 25% and GPs 23% of the URPs as potentially preventable. In none of the cases, there was an overall agreement from all three perspectives on the judgement that an URP was potentially preventable. Conclusion Disease-related factors were most often identified for an URP and half of the patients returned to the ED within 7 days. The majority of the URPs was judged as not preventable. However, an URP should trigger healthcare workers to focus on the patient’s process of care and their needs and to anticipate on potential progression of disease. Future research should assess whether this may prevent that patients have to return to the ED.

Effectiveness of a care transitions intervention for older adults discharged home from the emergency department: A randomized controlled trial

“…Some researchers 12,18,29 contend that care transition interventions may only prove effective when targeted to those at highest risk of return or experiencing care fragmentation, such as those with advanced age, medical complexity, cognitive impairment, mental health issues, low health literacy, low social support 2,6,10,19,42,47,48 . Others argue that interventions targeting patients with modifiable risk factors would be more effective than using an undifferentiated approach 11,49,50 …”

“…Extending that point leads us to question whether 30‐day ED revisits is really an appropriate or meaningful outcome measure for assessing quality care transitions. Unplanned revisits frequently result from disease progression or symptom exacerbation 49 or involve nonmodifiable risk factors related to chronic conditions or particular types of diagnoses/chief complaints, making them difficult to prevent. We may need to expand our definition and measurement of successful care transitions outcomes, potentially including more comprehensive, patient‐centered, and/or longitudinal utilization approaches, and evaluate programs against those measures 2,18 .…”

Using Dominance Analysis to Identify the Most Important Dimensions of Safety Culture for Predicting Patient Safety

“…Hospital administrators and unit managers should implement policies that promote a learning culture in which staff members are willing to share their experiences and errors so that all can learn from them. Such policies will create opportunities for healthcare organizations to strengthen safety-related systems by systematically analyzing the root causes of safety problems [40] and then taking corrective action. Additionally, policies and guidelines for providing routine patient safety training-not only for staff but also for leaders at all levels-are needed to maintain and enhance a culture of safety.…”

Telephone follow‐up to reduce unplanned hospital returns for older emergency department patients: A randomized trial

“…[1][2][3][5][6][7] In general, ED return visits and hospital admissions are viewed as unfavorable and have been identified as a quality indicator of care. 3,[8][9][10] Although unplanned ED return visits could be solely considered as an indicator of functional decline, 3,11 they may also be a result of inadequate care transitions from the ED to home. 1,2,12,13 The transition to home after ED discharge involves communication of complex information concerning the diagnosis, discharge instructions, medication use, and follow-up care at a time when patients are easily distracted by anxiety, stress, or discomfort, causing difficulties in perceiving and processing this information.…”