Original Contributions
Analysis of pediatric hospitalizations after emergency department release as a quality improvement tool*,**

https://doi.org/10.1067/mem.2002.116595Get rights and content

Abstract

Study Objective: We characterize repeat pediatric emergency department visits and determine the cause for such visits as an indicator of potential need for quality improvement. We hypothesized that most repeat ED visits resulting in hospitalization do not represent medical errors. Methods: The study was performed at a large, tertiary care, academic children's hospital. Patients who returned to the ED within 72 hours of a previous visit were identified by computerized registration data. The charts of these patients were then reviewed by a member of the ED medical staff to identify factors from the initial visit that contributed to the return visit. A multidisciplinary committee then reviewed each case until consensus was achieved regarding the cause for the repeat visit. In this study, we analyzed the quality improvement decisions from a 12-month period. Results: Over a 12-month period, during which there were a total of 51,195 visits, 285 (0.56%) patients were hospitalized after a repeat visit. The repeat visit was determined to be unrelated to the first visit in 12 (4.2%) patients. In 12 (4.2%) cases, the cause for repeat visit and hospitalization could not be determined. This resulted in a total of 261 patients for analysis. In 234 (90.0%) patients, the return visit was determined to be a result of the progression of illness (no medical error). Ten (3.8%) patients had a missed diagnosis, whereas 2 (0.8%) patients had errors in their treatment (likely medical error). An incomplete workup was cited in 7 (2.7%) patients (potential medical error). Parenting factors (refusing admission, not filling prescriptions, not giving prescribed medications) were noted in 5 (1.9%) cases. Three (1.1%) patients did not follow up with appropriate subspecialists. Conclusion: The overall rate of repeat visits resulting in hospitalization is small. In the majority of these cases (90.0%), the ED evaluation was appropriate and the admission was for progression of the patient's illness. Given the small number of patients and the infrequency of missed diagnoses, this may not be an efficient method for assessing ED performance. [DePiero AD, Ochsenschlager DW, Chamberlain JM. Analysis of pediatric hospitalizations after emergency department release as a quality improvement tool. Ann Emerg Med. February 2002;39:159-163.]

Introduction

The practice of tracking and evaluating repeat visits to emergency departments that require admission is considered an important quality improvement tool.1 These patients are considered to be at higher risk than nonrepeat patients for diagnostic and physician errors.2 As a result, these charts are routinely reviewed under quality improvement initiatives. The data regarding such visits and their validity as a quality improvement tool are limited to general EDs and rarely consider pediatrics specifically.1, 2, 3, 4, 5, 6

We performed this study to characterize our institutional experience with repeat ED visits as an indicator of areas potentially needing quality improvement. Specifically, we detailed the outcomes and determination of the cause for repeat ED utilization resulting in admission within 72 hours of an index visit. Based on our anecdotal experience with the performance improvement process, we hypothesized that most repeat ED visits resulting in hospitalization do not result from medical errors.

Section snippets

Materials and methods

This study was performed at Children's National Medical Center, a large university-affiliated tertiary care hospital serving the metropolitan Washington, DC, area. Patients returning to the ED within 72 hours of an index visit are identified by means of a search from computerized registration data as an ongoing quality improvement initiative. The visit resulting in hospitalization must occur through the ED to be identified in this search.

On a monthly basis, the charts of those patients who

Results

During the study period, there were a total of 51,195 visits, of which 285 (0.56%) patients were hospitalized after a return visit within 72 hours for a related complaint. Twenty-four (8.4%) cases were excluded from further analysis because either the cause for return visit was unrelated to the initial visit (12 cases [4.2%]) or because the cause for the repeat visit and hospitalization could not be determined (12 cases [4.2%]). These included 5 (1.8%) charts that could not be located in their

Discussion

The results of this analysis support the hypothesis that most repeat pediatric ED encounters that result in hospital admission are the result of disease progression rather than medical error. Repeat visits resulting in hospitalization were selected for study because we believe that they represent the most seriously ill patients and potentially the most serious errors. In most of these cases, the reason for admission was progression of illness unrelated to medical error. The number of patients

Acknowledgements

Author contributions: ADP and JMC conceived the study design. DWO supervised the data collection and provided advice on the study design. All authors analyzed the data. ADP and JMC drafted the manuscript, and all authors contributed substantially to its revision. ADP takes responsibility for the paper as a whole.

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*

Author contributions are provided at the end of this article.

**

Address for reprints: Andrew D. DePiero, MD, Division of Emergency Medicine, Children's National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010; 202-884-4177,fax 202-884-3573; E-mail,[email protected].

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