Objective The emergency department (ED) is an inherently high-risk setting. Early death after an ED evaluation is a rare and devastating outcome which the understanding of can potentially help improve patient care and outcomes. Using administrative data from an integrated health system, we describe characteristics and predictors of patients who experience 7-day death after ED discharge. Methods Administrative data from 12 hospitals were used to identify death after discharge in adults age 18 or older within 7 days of ED presentation from 1/1/07 to 12/31/08. Patients who were non members of the health system, in hospice care, or seen at out of network EDs were excluded. Predictors of 7-day post-discharge death were identified using multivariable logistic regression. Results The study cohort contained a total of 475,829 members with 728,312 discharges from Kaiser Permanente Southern California (KPSC) EDs in 2007 and 2008. Death within 7 days of discharge occurred in 357 cases (0.05%). Increasing age, male gender, and number of pre-existing co-morbidities were associated with increased risk of death. The top 3 primary discharge diagnoses predictive of 7-day death after discharge include non-infectious lung disease (OR 7.1, 95% CI 2.9-17.4), renal disease (OR 5.6, 95% CI 2.2-14.2), and ischemic heart disease (OR 3.8, 95%CI 1.0-13.6). Conclusions Our study suggests that 50 in 100,000 patients in the U.S. die within 7-days after discharge from an emergency department. Our study is the first to identify potentially “high risk” discharge diagnoses in patients who suffer a short-term death after discharge.

Background Emergency department (ED) crowding has been identified as a major threat to public health. Objectives We assessed patient transit times and ED system crowding measures based on their associations with outcomes. Research Design Retrospective cohort study. Subjects We accessed electronic health record data on 136,740 adults with a visit to any of 13 health system EDs from January 2008 to December 2010. Measures Patient transit times (waiting, evaluation and treatment, boarding) and ED system crowding [nonindex patient length-of-stay (LOS) and boarding, bed occupancy] were determined. Outcomes included individual inpatient mortality and admission LOS. Covariates included demographic characteristics, past comorbidities, severity of illness, arrival time, and admission diagnoses. Results No patient transit time or ED system crowding measure predicted increased mortality after control for patient characteristics. Index patient boarding time and lower bed occupancy were associated with admission LOS (based on nonoverlapping 95% CI vs. the median value). As boarding time increased from none to 14 hours, admission LOS increased an additional 6 hours. As mean occupancy decreased below the median (80% occupancy), admission LOS decreased as much as 9 hours. Conclusions Measures indicating crowded ED conditions were not predictive of mortality after case-mix adjustment. The first half-day of boarding added to admission LOS rather than substituted for it. Our findings support the use of boarding time as a measure of ED crowding based on robust prediction of admission LOS. Interpretation of measures based on other patient ED transit times may be limited to the timeliness of care.

Study objective We assess whether a panel of emergency department (ED) crowding measures, including 2 reported by the Centers for Medicare & Medicaid Services (CMS), is associated with inpatient admission and death within 7 days of ED discharge. Methods We conducted a retrospective cohort study of ED discharges, using data from an integrated health system for 2008 to 2010. We assessed patient transit-level (n=3) and ED system-level (n=6) measures of crowding, using multivariable logistic regression models. The outcome measures were inpatient admission or death within 7 days of ED discharge. We defined a clinically important association by assessing the relative risk ratio and 95% confidence interval (CI) difference and also compared risks at the 99th percentile and median value of each measure. Results The study cohort contained a total of 625,096 visits to 12 EDs. There were 16,957 (2.7%) admissions and 328 (0.05%) deaths within 7 days. Only 2 measures, both of which were patient transit measures, were associated with the outcome. Compared with a median evaluation time of 2.2 hours, the evaluation time of 10.8 hours (99th percentile) was associated with a relative risk of 3.9 (95% CI 3.7 to 4.1) of an admission. Compared with a median ED length of stay (a CMS measure) of 2.8 hours, the 99th percentile ED length of stay of 11.6 hours was associated with a relative risk of 3.5 (95% CI 3.3 to 3.7) of admission. No system measure of ED crowding was associated with outcomes. Conclusion Our findings suggest that ED length of stay is a proxy for unmeasured differences in case mix and challenge the validity of the CMS metric as a safety measure for discharged patients.

Objective Early death after 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. Our goal in this hypothesis-generating study was to identify patient and process of care-level themes that may provide possible explanations for early post-discharge mortality. Methods We conducted a qualitative analysis of medical records of adult patients who visited any of six hospitals in an integrated health system (Kaiser Permanente Southern California – KPSC) ED and died within 7 days of discharge in 2007 and 2008. We excluded non-members, visits to non-health plan hospitals, patients receiving or referred to hospice care, and patient with Do Not Resuscitate or Do Not Intubate orders. Under the guidance of two qualitative research scientists, a team of three emergency physicians utilized grounded theory techniques to identify patient clinical presentations and processes of care that serve as potential explanations for poor outcome after discharge. Results The source population consisted of a total of 290,092 members with 446,120 discharges from 6 Kaiser Permanente Southern California 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 exam, and change of discharge plan by a third party, such as a consulting or admitting physician. Conclusions In this hypothesis-generating study, we used qualitative research techniques to identify clinical and process of care factors in patients who die within 7-days after discharge from an ED. These potential predictors will be formally tested in a future quantitative study.

Study objective The emergency department (ED) is an inherently high-risk setting. Our objective is to identify the factors associated with the combined poor outcome of either death or an ICU admission shortly after ED discharge in older adults. Methods We conducted chart review of 600 ED visit records among adults older than 65 years that resulted in discharge from any of 13 hospitals within an integrated health system in 2009 to 2010. We randomly chose 300 patients who experienced the combined outcome within 7 days of discharge and matched case patients to controls who did not experience the outcome. Two emergency physicians blinded to the outcome reviewed the records and identified whether a number of characteristics were present. Predictors of the outcome were identified with conditional logistic regression. Results Of 1,442,594 ED visits to Kaiser Permanente Southern California in 2009 to 2010, 300 unique cases and 300 unique control records were randomly abstracted. Characteristics associated with the combined poor outcome included cognitive impairment (adjusted odds ratio [AOR] 2.10; 95% confidence interval [CI] 1.19 to 3.56), disposition plan change (AOR 2.71; 95% CI 1.50 to 4.89), systolic blood pressure less than 120 mm Hg (AOR 1.48; 95% CI 1.00 to 2.20), and pulse rate greater than 90 beats/min (AOR 1.66; 95% CI 1.02 to 2.71). Conclusion We found that older patients discharged from the ED with a change in disposition from “admit” to “discharge,” cognitive impairment, systolic blood pressure less than 120 mm Hg, and pulse rate greater than 90 beats/ min were at increased risk of death or ICU admission shortly after discharge. Increased awareness of these high-risk characteristics may improve ED disposition decisionmaking.