Death after discharge: emergency department errors and opportunities

“Over 10,000 Medicare beneficiaries die each year across US within 7 days of discharge from emergency departments, despite mean age of 69 and no obvious life limiting illnesses.”

This finding from a new study in the BMJ underscores the importance of disposition and discharge planning in the emergency department. Death after discharge is rare but devastating for patients, families and health providers, and carries a high medico-legal cost. It also includes potentially preventable errors and opportunities to improve patient care.

Here’s a brief summary of five articles on this topic, in chronological order, followed by a summary and safe discharge checklist.

ARTICLE SUMMARIES

Kefer et al. Death after discharge from the emergency department. Ann Emerg Med 1994;24:1102-7

This one year retrospective chart review in a US urban county found 42 deaths within 7 days of discharge (13 per 100,000)—of which 78% were unexpected. The authors compared the discharge diagnosis with the cause of death, which were either directly or not directly related:

  • Not directly related
    • eg diagnose head lac or rib fracture or hip pain –> die of complications of fall
    • eg diagnose epigastric pain or weakness –> die of MI
    • eg diagnose cancer pain –> die of narcotic overdose
  • Directly related
    • eg diagnose pneumonia –> die of PE
    • eg diagnose flank or groin pain –> die of AAA
    • eg diagnose nasal injury –> die of intracranial bleed

 

Sklar et al. Unanticipated death after discharge home from the emergency department. Ann Emerg Med 2007;49:735-45

This 10 year retrospective cohort from urban tertiary-case ED found 117 deaths within seven days of discharge (30 per 100,000). Half were unexpected but related to the presentation, of which 60% had a possible error—and the authors analyzed these errors:

  • Possible medical error
    • Abnormal vital signs
    • Chronic disease with decompensation
      • eg diagnose seizure/etoh –> die of subdural
      • eg diagnose COPD –> die of MI
    • Atypical presentation
      • eg diagnose arm/neck pain –> die of MI
      • eg diagnose flank pain/dizzy –> die of PE
      • eg diagnose gastro or constipation –> die of mesenteric ischemia
      • eg diagnose internal hemorrhoids –> die of upper GI bleed
    • Disability/psychiatric/substance use reducing likeliness of return
  • Non-error unexpected related to repeated event
    • eg diagnose seizure –> die of drowning
    • eg diagnose back pain –> die of narcotic overdose
    • eg diagnose drug/alcohol overdose –> die of repeated overdose

 

Gabayan et al. Qualitative factors in aptients who die shortly after emergency department discharge. Acad Emerg Med 2013;20:778-85

This 2 year retrospective chart review of 6 hospitals in California found 203 daths within 7 days of discharge (50 per 100,000) and looked at 61 of these in order to explore patient and process of care themes:

*Patient theme

  1. unexplained mental status change
  2. recent fall in the elderly
  3. abnormal vital signs
  4. ill appearance
  5. malfunctioning device
  6. persisting symptoms

*Process of care theme

  1. discrepant history
  2. incomplete exam
  3. misdiagnosis due to narrow DDx
  4. correct diagnosis but underestimation of sickness level
  5. change of discharge plan by consultant

 

Gabayan et al. Poor outcomes after emergency department discharge of the elderly: a case-control study. Ann Emerg Med 2016;68:43-51

This four year retrospective chart review in southern California found 1055 poor outcomes (death or ICU admission within 7 days of ED discharge for patients >65 years) and examined 300 of them matched with controls to find high-risk features:

  1. disposition change from admit to discharge
  2. cognitive impairment
  3. abnormal vitals: HR>90, BP <120

 

Obermeyer et al. Early death after discharge from the emergency departments: analysis of national US insurance claims data. BMJ 2017;356:239, 1-9

This five year national sample, from which the introductory quote from this post was taken, found 0.12% deaths with 7 days, and examined differences amongst hospitals, leading causes of death and high risk discharge diagnoses

*Hospital rate: hospitals with the lowest admission rates had 3.4 times higher rate of death, and small increases in admission rate were linked to large decreases in risk. But as the authors caution, “These data should not be viewed as evidence of error. Indeed, some of the variation in outcomes we identified could be linked to the geographic and socioeconomic context of emergency care. First, access to resources varies dramatically across hospitals…Second, patients attending emergency departments with higher mortality after discharge probably differed in important ways that we could not measure.”

*Leading causes of death:  13.6% atherosclerosis, 10.3% AMI, 9.6% COPD, 6.2% diabetic complication, 3.1% CHF, 3.0% hypertension complication, 2.6% pneumonia, 2.3% narcotic od (15% after back pain, 10% after superficial injuries)

*Risk ratios of discharge diagnoses

  1. Syndromic: 4.4 AMS, 3.1 dyspnea, 3.0 malaise/fatigue
  2. Outpt manage for low-risk: 1.8 CHF, 1.6 COPD, 1.6 pneumonia

 

SUMMARY

The rate of death after discharge is not a marker of quality of care to compare hospitals, but considering the factors that put patients at risk of death after discharge can help health providers provide better patient care.

  • High risk patient
    • Elderly
    • Chronic lung/heart/renal/liver/heme/onc
    • Fall
    • Mental status change
    • Abnormal vitals
    • Limited history (language, psychiatric, mental disability, intoxicated)
  • High risk diagnosis
    • Limited history and physical
    • PE: consider in dyspnea, dizzy, ‘pneumonia’, back pain, flank pain
    • MI: consider in dyspnea, chest pain, weak, epigastric pain, neck/arm pain
    • Upper GI bleed: consider in rectal bleed
    • AAA: consider in abdo pain, flank pain, back pain, groin pain
    • Mesenteric ischemia: consider in abdo pain, vomiting, constipation
    • Intracranial/intra-abdominal bleed: consider in fall, seizure, alcohol
  • High risk discharge
    • Elderly
    • Psychiatric, mental disability, substance use
    • New persisting symptoms, unexplained dyspnea/malaise/altered
    • Abnormal vitals
    • Narcotic prescription

 

SAFE DISCHARGE CHECKLIST

Death after discharge is an inevitable risk in the emergency department and there’s no fool-proof way to prevent. But for patient safety and medicol-legal risk management, before writing D/C HOME it’s worthwhile pausing to consider:

Your differential/stratification: is there an alternate diagnosis or a worse prognosis?

  • Differential diagnosis: eg flank pain from PE/AAA, weak from MI
  • Complications: eg seizure/etoh with ICH, pneumonia with sepsis

Patient re-examination: are there signs of occult pathology or potential decompensation?

  • Heart rate: document normal vitals
  • Oriented: document baseline mental status

Patient education: is the patient at risk for harm or not returning if they decompensate?

  • Medication/drug: counsel on risks of opioids, drugs, alcohol
  • Educate follow up, when to return and  capacity to do so

discharge

 

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s