Background: Most older adults visit the emergency department (ED) near the end of life without advance care planning (ACP) and thus are at risk of receiving care that does not align with their wishes and values. ED GOAL is a behavioral intervention administered by ED clinicians, which is designed to engage seriously ill older adults in serious illness conversations in the ED. Seriously ill older adults found it acceptable in the ED. However, its potential to be used by nurses remains unclear. Objective: The aim of this study is to identify refinements to adapt an ED-based ACP intervention by eliciting the perspectives of nurses. Design: This is a qualitative study using semistructured interviews. Data were analyzed using axial coding methods. Setting/Subjects: We recruited a purposeful sample of ED nurses in one urban academic ED and one urban community ED in the northeastern region of the United States. Results: Twenty-five nurses were interviewed (mean age 46 years, 84% female, and mean clinical experience of 16 years). Emerging themes were identified within six domains: (1) nurses' prior experience with serious illness conversations, (2) overall impression of ED GOAL, (3) refinements to ED GOAL, (4) implementation of ED GOAL by ED nurses, (5) specially trained nursing model, and (6) use of telehealth with ED GOAL. Conclusions: ED nurses were generally supportive of using ED GOAL and provided insight into how to best adapt and implement it in their clinical practice. Empirical evidence for adapting ED GOAL to the nursing practice remains to be seen.

Specialist physicians have an important role in addressing ED utilization, especially at tertiary medical centers that treat highly specialized patients. We analyzed if reporting of ED utilization to pediatric specialist physicians can decrease ED visits. We analyzed if reporting of ED utilization rates of patients followed by pediatric specialists resulted in decreased ED use. Different pediatric specialist division received and discussed individualized ED use reports. Using control charts, we examined if our intervention decreased the rate of ED utilization. Pediatric neurology, hematology/oncology, infectious diseases and pulmonary received their ED use reports. Overall, for the four divisions specialty-related ED utilization decreased significantly during all hours, weekdays, and office hours. This was in the setting of ED utilization increasing for all diagnoses ED visits. Pediatric ED volume did not change during the study period. Physician-level reporting of ED utilization was associated with a reduction in ED use by patients followed by our pediatric specialists.

Patients who return to the emergency department (ED) and require admission is often seen as a surrogate for quality and used for quality assurance efforts. Despite this, recent study has suggested that this is low yield for identifying errors. We hypothesize that patients who return and are admitted to the ICU are more likely to represent medically complex patients with opportunities for improvement on their first visit. The objective of this study was to identify the prevalence of error-deficient care in patients who return and require ICU admission, as well as the types and severity of harm in these patients. Retrospective review of all patients who presented to an urban, university-affiliated ED between January 1, 2005-December 31, 2015 who were evaluated, discharged, and returned within 30 days requiring ICU admission. An emergency physician reviewer traced the care through a defined sequence of diagnostic steps. If an error was judged to have been present in any of these steps, the reviewer further classified the deviation in care and assigned a severity score. There were 1,016,606 ED visits during the 10-year study period, with 772 patients who were seen in the ED and then returned within 30 days requiring ICU admission (0.0076%). 341 of these patients were deemed to have a return visit related to the index visit. Of these, 11O cases (32.2%) were felt to represent a deviation from optimal care. When a standard diagnostic process of care framework was applied to these 110 encounters, the majority of cases represented failures in the initial diagnostic pathway (60 cases, 54.5%), including a failure to obtain a history and conduct a physical exam (13 cases, 11.8%), failure of ongoing monitoring of clinical status (3 cases, 2.7%), failure to establish a differential diagnosis (20 cases, 18.2%) and failure to order the appropriate diagnostic test (24 cases, 21.8%). The remainder of the cases represented failures in completing testing and results processing (23 cases, 20.9%), and failures in follow-up and coordination (27 cases, 24.5%). When the National Patient Safety Foundation's Error Severity Codes were applied to the 110 cases that represented deviations from optimal care, no harm in 16 (14.5%), 7 (6.4%) resulted in minor temporary harm, 72 (65.5%) in major temporary harm, 0 (0%) in minor permanent harm and 15 (13.6%) in major permanent harm. The most commonly missed diagnosis on initial visit where harm was attributed was an infectious disease diagnosis 72 (21.1%). Standard screening methodology of ICU returns resulting in admission has a higher yield in identifying suboptimal care than 72-hour returns, with 32.2% of cases reviewed representing deviations from standard care. Of these, the vast majority represent cognitive errors in the diagnostic pathway. Future study should focus on understanding the yield of other departmental QA triggers such as safety reports and morbidity and mortality conferences.

Through widespread implementation of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey over the past decade, the Centers for Medicare and Medicaid (CMS) has used patient-reported data on patient experiences in the inpatient setting to incentivize hospitals to improve their patients’ perceptions of their care. While no such tool currently exists within the emergency department (ED), the ongoing development and testing of the CMS ED Patient Experiences with Care Survey (EDPEC) will soon lead to similar incentives - and penalties - for EDs across the United States. In addition to the regulatory landscape, there is increasing literature suggesting a positive impact of patient experience on clinical outcomes, patient safety and efficiency. As such, our objective was to further investigate common themes in patient-reported experience data, with the goal of identifying the highest yield areas for potential improvement in ED patient experience. A mixed methods analysis was performed on one year of patient callback survey data (1/1/2015-12/31/2015) from a large, urban tertiary-care ED, using a modified grounded theory approach. Patients were asked to cite the best and worst aspects of their ED experience. Between 1/1/2015-12/31/2015 phone interviews were conducted with 2,969 patients. Of the 32 contributing factors, the most commonly cited factors contributing to positive experience were compassionate care (27.8%), appropriate care and disposition (13.8%), short wait time (12.2%), staff attentiveness (12.1%) and adequate communication (9.2%). The most commonly cited factors contributing to negative experience were prolonged wait time (35.2%), poor communication (14.8%), inadequate pain management (6.7%), suboptimal environment, including food and cleanliness (6.5%), and a lack of compassion (6.1%). Although timeliness of care, an often-cited component of care delivery in the ED, was a frequently reported contributing factor to both positive and negative experience, compassionate care and communication also ranked among the most influential factors identified by patients. These two domains, which have previously received significantly less attention in the emergency medicine literature, were principal contributing factors to both positive and negative experience in our study. Our results suggest that emergency department and hospital leaders may be well served by focusing on interventions that improve provider-patient communication and foster compassionate care.

Patients who return to the emergency department (ED) within 72 hours of discharge are thought to represent failures in diagnosis, treatment and discharge planning. As a result, this metric is often seen as a surrogate for quality and used for ED quality assurance efforts. Little is known about the yield of this kind of review and the types of errors it identifies. The objective of this study was to identify the prevalence of error deficient care in patients who return within 72 hours and require admission, as well as the types and severity of harm in these patients. Retrospective review of all patients who presented to an urban, university-affiliated ED between October 1st, 2012 and September 30th, 2015 who were evaluated, discharged, and returned within 72 hours requiring hospital admission. As a part of departmental quality assurance activities, the records were reviewed by attending physician members of the Quality and Safety Committee. Any visit felt to represent substandard care was flagged for further investigation. These cases then received a secondary review by a different ED attending who classified the deviation in care for this study, if present, using a standard classification system. There were 413,167 ED visits during the study period with 2001 (0.48%) patients who returned within 72 hours and were admitted to the hospital. An event requiring further investigation was identified in 59 of these patients (2.95% of all 72-hour returns), and 50 of them (2.49% of all 72-hour returns and 0.0119% of all ED visit) were deemed to represent a deviation from optimal care (see Figure 1). Of these cases, 48 (96%) represented diagnostic error. When a standard diagnostic process of care framework was applied to these 48 encounters, the majority of cases represented failures in the initial diagnostic pathway (29 cases, 60.4%), including a failure to obtain a complete history and conduct a complete physical exam (3 cases, 6.2%), failure of ongoing monitoring of clinical status (4 cases, 8.3%), failure to establish a differential diagnosis (20 cases, 41.6%) and failure to order the appropriate diagnostic test (2 cases, 4.1%). The remainder of the cases represented failures in completing testing and results processing (13 cases, 27%), and failures in follow-up and coordination (6 cases, 12.5%). When the National Patient Safety Foundation's Error Severity Codes were applied to the 50 cases that represented deviations from optimal care, 12 (24%) resulted in minor temporary harm, 30 (60%) in major temporary harm, 4 (8%) in minor permanent harm, 1 (2%) in major permanent harm and 3 (6%) resulted in death. Standard screening methodology of 72-hour ED returns resulting in admission has relatively low yield in identifying suboptimal care, with less than 3% of cases reviewed representing deviations from standard care. Of these, the majority represent cognitive errors in the diagnostic pathway. As such, these reviews may be useful as a tool for ongoing professional practice evaluation of individual clinicians, however likely serve less value in identifying departmental systems issues contributing to unsafe care. Future study should focus on understanding the yield of other departmental QA triggers such as safety reports and morbidity and mortality conferences.

Seventy-two-hour returns to the emergency department (ED) have been used as a method to identify medical errors, missed diagnoses and failure of treatment or discharge planning. This approach has been criticized as arbitrary however, citing the lack of evidence to support its heterogeneous application to all organ system-based complaints, and the unclear implication of returns. Given the significant burden of gastrointestinal (GI)-related illness, our objective was to determine if an audit of 72-hour returns appropriately captures patients who return with a concerning diagnosis (CD) on their second visit. All patients with a GI disorder according to the Ninth Revision of the International Classification of Diseases (ICD-9) presenting to an urban, university-affiliated 100,000 annual visit ED from July 2013 to December 2013 were included in this study. Ten emergency physicians were surveyed and a list of concerning, "not to be missed," diagnoses were generated. Demographic, selected physical exam findings, laboratory, radiology data as well as patient disposition were collected on this retrospective cohort. There were 6,625 patient visits during the study period, and included 5,070 patients with single visits and 626 patients with one or more return visits. The mean number of return visits in this group was 2.95 (range 2-21); 107 (17.1%) of these patients returned within 72 hours and 519 returned in greater than 72 hours. Of patients who were discharged with a non-concerning diagnosis and returned, those who returned within 72 hours were more likely to have a concerning diagnosis than those who returned at a later time (23.5% versus 3.8%, P<.0001). Patients who returned within 72 hours were no more likely to be admitted than those who returned at a later date (44% versus 36%, P=. 21). The top five concerning diagnoses on return were: small bowel obstruction (35%), pancreatitis (23%), appendicitis (13%), diverticulitis (9.7%), and hepatic encephalopathy (6.5%). Review of 72-hour returns, when applied to patients with a gastrointestinal diagnosis, appropriately identifies patients who are at high risk of harboring a concerning diagnosis. It does not, however, identify those patients who are more likely to require admission. This study shows that 72-hour returns is a useful metric for quality assurance. Further study is needed to understand if patients with other organ-based complaints (such as chest pain) that return within 72 hours are similarly at higher risk of having a concerning diagnoses.

Abdominal pain is the most common indication for computed tomography (CT) and ultrasonography (US) in the emergency department (ED), as well as a common reason for patients to present to the ED. While the majority of patients that present to the ED with abdominal pain are definitively diagnosed, up to 25% of these patients will ultimately be discharged with a diagnosis of non-specific abdominal pain. In the face of uncertainty, emergency physicians often order CT scans and US studies in the hopes of identifying an etiology of the abdominal complaints, or with the belief that negative imaging will reassure both provider and patient and will prevent future return. Our objective was to determine whether patients who receive imaging with no identifiable cause of their abdominal pain are less likely to return to the ED. All patients with an ICD9 code that corresponded to non-specific abdominal pain (789.0-789.1) presenting to an urban academic ED from 7/2013-12/2013 were included in this study. Clinical and demographic data was collected and analyzed. Chi squared analysis was used. There were 1,937 patients during the study period who were discharged with a non-specific GI diagnostic code. Of these patients, 49 (2.5%) returned within 72 hours of treatment. There was no difference in the frequency of imaging in the group of patients that returned versus those that did not return (42.8% versus 37%; OR 1.27, 95% CI .72-2.26). Return rate was not affected by the specific use of CT scanning (OR 0.68, 95% CI 0.36 -1.3) or US (OR 1.16, 0.56-2.42) during their first visit. Despite the common provider belief that knowledge of a negative study will reassure patients and ultimately prevent a return visit, to the contrary, this study shows that imaging patients with non-specific abdominal pain does not prevent return. Imaging should be reserved for answering specific clinical questions, and should not be considered a means to preventing a return visit in patients with non-specific abdominal pain.

Gastrointestinal (GI) pathologies are among the most common clinical entities in emergency medicine and account for 8 million emergency department (ED) visits annually. Prior study has suggested that these patients are at higher risk of leaving without completing treatment (LWCT); however, little is known about their likelihood of return. Seventy-two hour return is a well-established metric in emergency medicine, and is recognized as an indicator of both the quality of care and cost related to duplicative assessment and testing. Our objective was to determine if patients with abdominal complaints who leave without completing treatment are more likely to return within 72 hours. All patients with a GI ICD9 code presenting to an urban, university-affiliated ED from July 2013 to December 2013 were included in this study. Clinical and demographic data were collected and analyzed. Comparisons were evaluated with chi squared analysis and T-test where appropriate. There were 6,625 patient visits during the study period, including 232 (3.5%) patients who LWCT. Among this group, there were 12 (5.2%) returns within 72 hours. Patients who LWCT were more likely to return within 72 hours than patients who stayed to complete their treatment (5.2% versus 1.5%, P<.0001). The group that completed treatment was more likely to get blood testing (CBC) than the group that LWCT (90% versus 50%, P<.0001). There was no difference in the use of CT or US imaging in the two groups (35% versus 37%, P=.6). The LWCT group was younger than those who completed treatment (40.3 versus 44.3; P=.007), but there was no difference in sex (40.4% male versus 47.2 female; P=1). There were no statistically significant differences in insurance types between the two groups (47% LWCT and 53% completed evaluation, P=.07); however the group that completed treatment trended towards private insurance. Those who LWCT had lower acuity, with 14% of patients in this group harboring a concerning diagnosis as compared to 86% in the group that completed treatment (P=.0001). Patents who present to the ED with a GI complaint and LWCT are at higher risk of return within 72 hours. Although acuity in the LWCT group was low, the cost of duplicated assessment and resource utilization could perhaps have been avoided. Further research is needed to determine what factors lead to these patients leaving without completing treatment, if their second visit could have been avoided and how a system can be designed to help prevent this.