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48 hour representations

This presentation by Dr. Scott Pearson examines the factors behind "unscheduled" patient representations within 48 hours of emergency department attendance. It discusses data collection methods, including monthly audits sent to responsible clinicians, and highlights trends in patient reattendances over several years. The presentation also explores real-life patient cases to illustrate issues with initial discharge appropriateness and the importance of continuous feedback and education within the emergency department. Key recommendations focus on improving discharge policies and enhancing staff training.

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48 hour representations

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  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

  4. 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

  5. 48 hour representationsInappropriate discharge vs appropriate

  6. 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

  7. What happens to the returning patients?

  8. 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

  9. 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

  10. 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

  11. 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

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

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