48 hour representations

1. 48 hour representations Dr Scott Pearson Emergency Physician Christchurch Hospital

2. How do we collect the data? • Decision Support at CDHB send monthly report to clinician responsible for audit • List of NHIs of patients who have had “unscheduled” representations within 48 hours of first attendance at Emergency • Usually 40-60 patients/ month- <1% of total • Includes patients who • return and are then discharged home again from ED. • are admitted by an inpatient team who are discharged, then return within 48 hours of discharge

3. How do we collect the data? • Once ED reattendances who are admitted are isolated, usually ~10 patients per month • Electronic/ paper clinical records reviewed • Assessment about appropriateness of initial discharge and advice • 2-3 hours of SMO time per month

6. Problems with process • High number of patients on original data that are not ED specific • Clerical staff code reattendance as “unscheduled” • Unscheduled if reattendance for same clinical problem • Inpatient discharges are included also • Very small number of inappropriate discharges

7. 48 hour representationsInappropriate discharge vs appropriate

8. Trend analysis • April 2009- March 2010 • Average monthly unscheduled returns = 24 • April 2012- March 2013 • Average monthly unscheduled returns = 43 • April 2013- March 2014 • Average monthly unscheduled returns = 53

9. What happens to the returning patients?

10. What do we do with the information? • Feedback to staff involved • Provide education around “themes” • Provides information on trends • Acts as a marker/ quality indicator of • ED senior supervision • Capacity of the hospital • Pressure to discharge • Inadequate knowledge/ change of RMO staff? • Other processes in the community

11. Patient examples • 18 yr old man, car crash, brought in 2345 hrs • Observed 6 hours CT abdo normal • Vital signs stable, mobilised comfortably • Discharged 0545hr • Returned same day. Back pain and vomiting. CT abdo reviewed- crush fractures L1-4, free air, admitted General Surgery, observed, discharged 48 hrs later • ACTION- review discharge policy during night, radiology reporting process • Young male, punched in face when in city in evening. Swollen face. Xrays misinterpreted. Recalled after alerted by radiologist. Blowout fracture orbit. • ACTION- further RMO education about facial Xray interpretation

12. Patient examples • 72 year old • Lethargy and SOB • WCC 22 • CXR misinterpreted • Returned with NSTEMI • ACTION- feedback to RMO, senior supervision • 38 yr old woman • Abdo pain, bariatric surgery 2 mths previous • Diagnosis of UTI • Returned with ongoing pain- CT diagnosis- gastric prolapse- laparotomy • ACTION- further education about complications of bariatric surgery

13. Patient examples- appropriate discharge • 40 yr old male • Ureteric calculus, 4mm • Discharged appropriately for non operative management • Returns with ongoing pain, pain managed and discharged • Frequent cause for reattendance to ED • ACTION- review management with Urology Service • 5 month female • Clinical diagnosis bronchiolitis • Discharged appropriately after senior discussion and parent education • Appropriate reattendance after poor feeding • Admitted to Paediatrics • ACTION- nil

14. Conclusion • Monthly audit- continuous or occasional? • Minimal amount of SMO time • Useful to review all ED discharges returning within 48 hours.