Qualitative Factors in Patients Who Die Shortly After Emergency Department Discharge

Abstract

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.

Poor Outcomes After Emergency Department Discharge of the Elderly: A Case-Control Study

“…In accordance with previous literature 2,4,5 and clinical judgment, we then matched all case patients to eligible controls 1:1, using a daisy cluster algorithm that allows all variable types to be matched, not just numeric variables, 10 without replacement according to the following parameters: age, sex, Emergency Severity Index 11 score, Charlson comorbidity index score, 12 and discharge diagnosis. Sex, Emergency Severity Index score, and discharge diagnosis were perfect matches.…”

“…according to previous work conducted by G.Z.G. 2,3 and to previous literature. 13–16 We considered only measures that could be ascertained reliably by the 2 chart abstractors through the review of clinical records and that had a κ>0.6.…”

“…Previous studies conducted by our study team, 2–5 as well as other authors, 6,7 used clinical data to identify predictors of poor outcomes after ED discharge and were an important first step in understanding this association. Yet these studies were limited in that they were qualitative and were hypothesis generating or the researchers did not have direct access to patient records and could not identify patient and process-of-care characteristics that were inherent to the encounter.…”

“…Yet these studies were limited in that they were qualitative and were hypothesis generating or the researchers did not have direct access to patient records and could not identify patient and process-of-care characteristics that were inherent to the encounter. 2,3,6,7 The objective of this study was to extract data from patient records by using a matched case-control review analysis and identify patient and process-of-care factors that may be associated with early death or ICU admission within 7 days of discharge from the ED visit.…”

The Association Between Emergency Department Crowding and the Disposition of Patients With Transient Ischemic Attack or Minor Stroke

“…Across health systems, crowding has been associated with more frequent ambulance diversions and with deficiencies in other performance measures . More recently, ED crowding has been linked to higher rates of inpatient mortality and subsequent admissions to hospital in a large population‐based study and several smaller studies . Crowding not only affects ED quality of care, but has also been associated with inpatient mortality, increased LOS across all hospitalized patients, and overall higher costs …”