The prevalence of quality issues and adverse outcomes among 72-hour return admissions in the emergency department.

BACKGROUND: Records of patients discharged from the Emergency Department (ED) who return within 72 h and are admitted are often reviewed for potential quality issues. OBJECTIVES: We explored 72-h return admissions and determined the prevalence and predictors for substandard management on the initial visit or any adverse outcome. METHODS: Retrospective review of quality assurance data from 72-h return admissions in three hospitals from 2006-2010 was performed. Any substandard quality on the first visit or change in outcome on the return admission was considered "low quality." Multivariate logistic regression was used to assess the relationship between cases judged as low quality vs. not low quality. RESULTS: Of 741,132 ED visits across 5 years, 3682 (0.5%) were 72-h return admissions. Of those, 192 (5%) were low quality. In 158 (4%) and 8 (0.2%) there were moderate and severe deviations from care standards, respectively. Similarly, in 53 (1%) and 14 (0.4%) there were moderate and severe changes in outcome. In adjusted analysis, there were higher rates of low-quality 72-h return admissions in ambulance arrivals (odds ratio [OR] 1.5, 95% confidence interval (CI) 1.1-2.1); and lower rates in Medicaid patients (OR 0.3, 95% CI 0.2-0.7). There were higher rates in low-quality 72-h return admissions in hospital 1 (OR 3.6, 95% CI 2.2-6.1) and hospital 3 (OR 3.2, 95% CI 2.0-4.7) compared to hospital 2. CONCLUSIONS: Poor care on the initial visit or any poor outcome upon returning in 72-h return admissions is relatively rare in the ED. Reporting 72-h return admissions without chart review may not be a good way to measure clinical quality.

Improving door-to-antibiotic time in severely septic emergency department patients.

BACKGROUND: The Surviving Sepsis Campaign (SSC) guidelines recommend that broad-spectrum antibiotics be administered to severely septic patients within 3 h of emergency department (ED) admission. Despite the well-established evidence regarding the benefit of timely antibiotics, adoption of the SSC recommendation into daily clinical practice has been slow and sporadic. STUDY OBJECTIVE: To study the impact of storing broad-spectrum antibiotics in an ED automated dispensing cabinet (ADC) on the timeliness of antibiotic administration in severely septic patients presenting to the ED. METHODS: Retrospective observational study of timeliness of antibiotic administration in severely septic patients presenting to a community ED before and after adding broad-spectrum antibiotics to the ED ADC. Data on 56 patients before and 54 patients after the intervention were analyzed. The primary outcome measure was mean order-to-antibiotic time. Secondary outcome measures included mean door-to-antibiotic time and percentage of patients receiving antibiotics within 3 h. RESULTS: The final analysis was on 110 patients. Order-to-antibiotic administration time was reduced by 29 min post-intervention (55 min vs. 26 min, 95% confidence interval [CI] 12.5-45.19). Mean door-to-antibiotic time was also reduced by 70 min (167 min vs. 97 min, 95% CI 37.53-102.29). The percentage of severely septic patients receiving antibiotics within 3h of arrival to the ED increased from 65% pre-intervention to 93% post-intervention (95% CI 0.12-0.42). CONCLUSION: Storing key antibiotics in an institution's severe sepsis antibiogram in the ED ADC can significantly reduce order-to-antibiotic times and increase the percentage of patients receiving antibiotics within the recommended 3 h of ED arrival.