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48 hour representations. Dr Scott Pearson Emergency Physician Christchurch Hospital. How do we collect the data?. Decision Support at CDHB send monthly report to clinician responsible for audit

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48 hour representations

48 hour representations

Dr Scott Pearson

Emergency Physician

Christchurch Hospital

how do we collect the data
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
how do we collect the data1
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
problems with process
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
trend analysis
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
what do we do with the information
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
patient examples
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
patient examples1
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
patient examples appropriate discharge
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
conclusion
Conclusion
  • Monthly audit- continuous or occasional?
  • Minimal amount of SMO time
  • Useful to review all ED discharges returning within 48 hours.