Decreasing clinically significant adverse events using feedback to emergency physicians of telephone follow-up outcomes

doi:10.1016/j.annemergmed.2004.08.012

Annals of Emergency Medicine

Volume 45, Issue 1, January 2005, Pages 15-23

https://doi.org/10.1016/j.annemergmed.2004.08.012 Get rights and content

Study objective

We evaluate the effect on adverse events of a telephone follow-up quality improvement program.

Methods

This was a before-and-after intervention comparison based on prospectively collected data in a tertiary care hospital emergency department (ED) (82,000 visits per year). The first half (April 15 to July 31, 2001) served as control, and the second half (August 1 to November 15, 2001) served as intervention with feedback to physicians on telephone follow-up outcomes of discharged patients and resident training about the uncertain presentations of serious diseases and the need to use additional evaluation on selected patients (observation unit, hospital admission). Telephone follow-up of the high-risk patients and retrospective review of 3-day return visits were used to quantify outcome measures: return visits to EDs and clinically significant adverse events (return visits with serious misdiagnoses or an erroneous management plan). The differences in proportions of outcomes were measured with 95% confidence intervals (CIs).

Results

High-risk patients were enrolled: 566 (13.7%) of 4,139 discharged patients in the before-intervention period and 397 (11.3%) of 3,507 in the after-intervention period. The quality improvement initiative decreased return visits on enrolled patients from 10.1% (57/566) to 4.9% (19/397) (5.2% difference with 95% CI 1.8% to 8.8%) and decreased clinically significant adverse events from 4.1% (23/566) to 1.5% (6/397) (2.6% difference with 95% CI 0.3% to 4.8%). For all ED discharged patients, clinically significant adverse events decreased from 0.9% (39/4,139) to 0.4% (15/3,507) (0.5% difference with 95% CI 0.1% to 0.9%). During the study, the observation rate increased 4.3% (95% CI 2.8% to 5.7%), and the admission rate increased 3.4% (95% CI 2.1% to 4.8%).

Conclusion

A quality improvement program with feedback to physicians of telephone follow-up and resident education can decrease clinically significant adverse events in ED discharged patients.

Introduction

Failure to diagnose and thus treat patients with serious diseases is a major cause of poor outcome in emergency medicine. For patients evaluated for abdominal pain, the diagnosis is missed in 20% of patients who subsequently are diagnosed with appendicitis, which doubles the abscess formation and perforation rate.¹ The diagnosis is missed in up to 80% of patients who are later found to have acute cholecystitis, which significantly increases the complication rate.² For patients evaluated with chest pain, the diagnosis is missed in 5% of patients who are later diagnosed with acute myocardial infarction, which doubles mortality.3, 4

Emergency physicians fail to diagnose serious diseases for multiple reasons. Many patients present atypically to the emergency department (ED), which makes clinical diagnosis for the physician much more difficult.5, 6 Physicians who are inexperienced are at increased risk of missing the patient's diagnosis because they have not learned that many patients present atypically.5, 6, 7 Crowding in EDs also worsens physician diagnostic performance, with increased return visits and resulting adverse events.⁸ Miro et al⁸ have demonstrated that crowding in the ED increased the return visit rate, as has Hu.⁹ In many teaching hospitals in Taiwan, there is a shortage of inpatient beds, and crowding occurs in the ED despite efforts to decrease hospital admissions with the use of ED observation units. Inexperienced physicians (residents) in the ED face the pressure of overwhelming patient load and may inadvertently discharge high-risk patients.¹⁰ We speculated that methods focusing on improving identification of serious diseases (telephone follow-up, early scheduled returned visit, resident education) may reduce adverse events. In this study, we examined the benefit of telephone follow-up and resident education.

Our hypothesis was that adverse events would decrease with a quality improvement initiative that identifies patients at high risk of adverse events, conducts telephone follow-up on these patients the next day, provides physician feedback on outcome identified during telephone follow-up, and educates residents on atypical or uncertain presentations of many diseases and the need for the use of additional evaluation resources (observation unit, hospital admission).

Section snippets

Materials and methods

This was a quality improvement initiative at an academic, tertiary care hospital during a 7-month period. The study design was a before-and-after intervention comparison based on prospectively collected data. Patients were selected for telephone follow-up according to predetermined high-risk criteria (see Discussion). The before-intervention period was from April 15 to July 31, 2001, and the after-intervention period was from August 1 to November 15, 2001. Direct feedback on patient outcomes

Results

During the study period, there were 7,112 ED patients in the before period and 6,952 in the after period. The patients in 2 phases were comparable in age, sex, and disease severity using triage criteria (Table 2). In the before-intervention phase of the study, a total of 4,139 discharged eligible cases were reviewed; in the after-intervention phase, a total of 3,507 discharged eligible cases were reviewed. The average daily number of discharged ED patients was 78 (range 42 to 123). Of those

Limitations

There are several potential limitations to our study. Our follow-up was done the next day. A further follow-up at 30 days might have detected additional adverse events. We did do retrospective medical record review to find more adverse events within 3 days after ED discharge. Although previous research has found that most ED returned visits occur within 72 hours after ED discharge,⁹ additional adverse events might be identified with a longer follow-up interval. An additional limitation was that

Discussion

Researchers have shown that physician performance can be improved by quality improvement initiatives using multiple change concepts. A single clinical lecture or audit with feedback is usually not effective.22, 23 Espinosa and Nolan²⁴ have demonstrated a two thirds decrease in radiologic reading errors by use of continuous feedback to physicians of their radiograph reading errors. Wolff and Bourke²⁵ reduced adverse events in the ED by implementing a medical record audit process and then reduced

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There were 1139 patients eligible. Call back was attempted for 893 patients of which 716 (80%) were contacted. Deterioration was identified in 34 of 716 (5%) patients, two were advised to attend their general practitioner, and 32 were directed to present to an Emergency Department. Of the 32 recalled patients, 26 represented to the original Emergency Department and 12 were admitted following the call back, an admission rate of 46% (95% CI:28.7–64.5) of those that represented.
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Of 33,224 adult non-trauma ward admissions from the ED, 100 admissions (0.3%) met the study criteria. Incidence rate was 2% and 15% for errors and adverse events, respectively. In admissions involving error, all were preventable and the error type was overlooked of severity. In admissions that involved adverse events, 93.3% were preventable. There were 20% of admissions that resulted in death and 60% developed with severe physical injury. The adverse event types were diagnosis issues (53.3%), management issues (40%), and medication adverse events (6.7%).
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We adhered to the PRISMA statement to conduct a systematic review of the literature from January 1994 to January 2014 related to audit and feedback of physicians in the ED. We searched Medline, EMBASE, PsycINFO, and PubMed databases. We included studies that were conducted in the ED and reported quantitative outcomes with interventions using both audit and feedback. For included studies, 2 reviewers independently assessed methodological quality using the validated Downs and Black checklist for nonrandomized studies. Treatment effect and heterogeneity were to be reported via meta-analysis and the I² inconsistency index.
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The literature on audit and feedback in the ED reports positive results for interventions across numerous clinical conditions but without standardized reporting sufficient for meta-analysis. Characteristics of audit and feedback interventions that were used in a majority of studies were feedback that targeted errors of omission and that was explicit with measurable instruction and a plan for change delivered in the clinical setting greater than 1 week after the audited performance using a combination of media and types at both the individual and group levels. Future work should use standardized reporting to identify the specific aspects of audit or feedback that drive effectiveness in the ED.
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Author contributions: CHC conceived the study, designed the trial, and obtained the research funding. CHC, CKH, LMW, and CHL were involved in the performance of the trial and data collection. CHC analyzed the data. CHC and LG drafted the manuscript, and all authors contributed substantially to its revision. CHC takes responsibility for the paper as a whole.

Presented at the American College of Emergency Physicians Research Forum, Seattle, WA, October 2002.

This study was supported by 2001-2002 Education Improvement Grant of Veterans General Hospital–Taipei (grant numbers 375-6 and V90-439-3).

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Original ResearchDecreasing clinically significant adverse events using feedback to emergency physicians of telephone follow-up outcomes

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Limitations

Discussion

Am J Emerg Med

Am J Cardiol

Am J Emerg Med

J Am Coll Cardiol

Am J Emerg Med

J Emerg Med

Ann Emerg Med

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Am J Cardiol

Emerg Med Clin North Am

Ann Emerg Med

False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery

Acad Emerg Med

Missed diagnosis of acute cardiac ischemia in the emergency department

N Engl J Med

Litigation against the emergency physician: common features in cases of missed myocardial infarct

Ann Emerg Med

Decreased health quality associated with emergency department overcrowding

Eur J Emerg Med

Original Research
Decreasing clinically significant adverse events using feedback to emergency physicians of telephone follow-up outcomes