Pediatric Emergency Department Return Visits

Abstract

Objectives Emergency department (ED) return visits (RVs) leading to hospital admission are a quality measure that can potentially signal gaps in patient care. Systematic capture and investigation of RVs at a case level can provide an understanding of patient- and visit-level factors associated with RVs, and thus inform system-level quality improvement (QI) opportunities. Our objective is to describe the development of a database that enables tracking and analyzing of all pediatric ED RVs, to understand recurring themes and inform QI initiatives. Methods A single-center retrospective cohort study was conducted at a quaternary care children's hospital during a 3-year period (December 2013 to November 2016). All 72-hour RVs were audited for patient- and visit-level variables and clinicians completed root-cause analyses of their RVs. Using descriptive statistics, variables associated with RVs and system-level quality themes were identified. Results Of 214,047 ED patient visits, 1546 (0.7%) patients returned within 72 hours and were admitted. The RV patients had higher acuity scores on both visits compared with all ED visits, and the RV group had a higher proportion of children younger than 12 months than the overall ED visit group (25.0% vs 16.2%). The underlying cause for the majority of RVs was determined to be natural disease progression (63%), whereas 9% were callbacks for positive blood cultures or discrepant radiology results, and 6% were categorized as misdiagnoses. Several successful QI initiatives were completed as a result of the program. Conclusions Systematic monitoring and investigation of all ED RVs provides an innovative and effective approach to seeking provider- and system-level improvement opportunities.

Return visit audits, quality improvement infrastructure, and a culture of safety: a theoretical model and practical assessment tool

“…We have developed and collaborated in novel strategies to break down these barriers. At the city-wide level, we collaborated with the Hospital for Sick Children on the development of routine audits [ 10 ], and with QIPS physician leads across the region (in both academic and community hospitals) to launch an Emergency Medicine Quality Improvement Digest [ 11 ]. At the provincial level, we have contributed to provincial webinars organized by Health Quality Ontario to share lessons to EDs across the province on how they can use their own return visits to build a culture of safety.…”

“… How can sharing return visit audits break down silos and build a broader culture of safety? For example, collaborate with other EDs or hospital departments to break down silos and normalize the discussion of return visits [ 10 ]. …”