WBB's Thought Leadership

Quality Improvement Could Reduce Deaths after ED Discharge

February 6

10,093 patients die per year within 7 days of discharge from an Emergency Department (ED), the study suggests that quality improvement could reduce the number

Leading causes of post-discharge death were atherosclerotic heart disease (13.6%), acute myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%)


Excerpt: “A growing number of patients visit emergency departments every year: nearly 20% of the US population each year,1 or 400 visits per 1000 population in the UK.2 As a result, the decision to admit or discharge a patient from the department is made hundreds of thousands of times a day.”

“Many Medicare beneficiaries die shortly after discharge from emergency departments, despite no obvious life limiting illnesses recorded in their claims. Hospitals with low admission rates and low patient volumes, and patients with high risk diagnoses at discharge, could represent targets for clinical research and quality improvement efforts.”

“In a nationally representative 20% sample Medicare beneficiaries, we identified 28 086 293 visits to an emergency department over 2007-12. We excluded 12 091 966 (43%), mostly because of life limiting illnesses diagnosed in the department (such as acute myocardial infarction) or illness diagnosed in the year before the visits (such as malignancy); age ≥90; and non-fee for service (see fig A in appendix 2). Table 1 shows baseline characteristics of remaining visits, of which 37% involved admission or transfer of the patient.”

“Among those discharged, 0.12% (12 375/10 093 678, in the 20% sample over 2007-12) died within seven days or 10 093 per year nationally. Average age at death was 69; 50.3% were men, and 80.9% were white. There were small decreases in rates of early death after discharge from 2007-12, 4-5% annually (fig B in appendix 2).

“Death certificates identified atherosclerotic heart disease (13.6%), acute myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%) as most common causes of death. Figure 1 shows top causes of death and their antecedent diagnoses on discharge. Narcotic overdose was the eighth most common cause of death (2.3%); the most common antecedent discharge diagnoses were back pain (15%) and superficial injuries (10%).”

“Among discharged patients, mortality declined non-linearly with increasing admission rate. Hospitals in the lowest fifth of admission rates discharged 85% of patients, compared with 44% in the highest fifth (1.9 times more, 95% confidence interval 1.9 to 1.9). But the seven day mortality rate after discharge in hospitals in the lowest fifth was far higher: 3.4 times (0.27% v 0.08%; 95% confidence interval 3.3 to 3.3).”

Source: The BMJ

WBB Take: Quality Improvement (QI) has tangible benefits in reducing excess death. The periods during patient handoff, transfer, and discharge are known to carry higher risks. So too does the period following discharge. The number of avoidable deaths after discharge can be significantly reduced through structured QI approaches that identify risks, issues, and opportunities, and help to shape and monitor improvements. QI can be a valuable tool for improving policy implementation, health IT implementation, and administrative and clinical workflow optimization. Using workflow mapping, root cause analysis, and process improvement tools, QI can identify targets for improvement, guide interventions, and monitor effects.

Matthew Loxton

Matthew Loxton



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