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Slide Notes
Sick or not Sick? Is your patient safe for discharge? The high risk nature of ED care, hospital overcrowding, the pressure to discharge patients, lack of access to outpatient care, and the increasing age and illness complexity of our patient population all challenge our ability to safely discharge from the Emergency Department. Think twice about sending your patient home when your patient has any of these high risk features.
Reference:
Qualitative Factors in Patients Who Die Shortly After Emergency Department Discharge
http://onlinelibrary.wiley.com/doi/10.1111/acem.12181/pdf
Reference:
Qualitative Factors in Patients Who Die Shortly After Emergency Department Discharge
http://onlinelibrary.wiley.com/doi/10.1111/acem.12181/pdf
SICK or not SICK (Safe Discharge)
Published on Nov 18, 2015
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MORE DECKS TO EXPLORE
PRESENTATION OUTLINE
Sick or Not Sick
Surviving Discharge
Sick or not Sick? Is your patient safe for discharge? The high risk nature of ED care, hospital overcrowding, the pressure to discharge patients, lack of access to outpatient care, and the increasing age and illness complexity of our patient population all challenge our ability to safely discharge from the Emergency Department. Think twice about sending your patient home when your patient has any of these high risk features.
Reference:
Qualitative Factors in Patients Who Die Shortly After Emergency Department Discharge
http://onlinelibrary.wiley.com/doi/10.1111/acem.12181/pdf
Reference:
Qualitative Factors in Patients Who Die Shortly After Emergency Department Discharge
http://onlinelibrary.wiley.com/doi/10.1111/acem.12181/pdf
Photo by DWinton
High Risk Features
In that patient you want to discharge
The first line of this article says it all "early death after emergency department (ED) discharge may signal opportunities to improve
care." Consider these high risk findings in your patients before sending them home.
care." Consider these high risk findings in your patients before sending them home.
Altered Mental Status
An unexplained change
Altered Mental Status
- Don't dismiss family or caretaker reports of confusion.
- More concerning if AMS is unexplained after your evaluation
- Worry if your patient still confused at time of discharge
Unexplained Persistent Acute Change in Mental Status.
The mental status change was identified by either someone accompanying the patient or the EP and could not be explained based on the acquired history,
examination, or results of ancillary tests. In addition, all
patients with this presentation continued to be confused
at the time of discharge.
The mental status change was identified by either someone accompanying the patient or the EP and could not be explained based on the acquired history,
examination, or results of ancillary tests. In addition, all
patients with this presentation continued to be confused
at the time of discharge.
Recent Fall
- Within one week of ED visit
- Was it really a fall or a sign of something more serious?
- Consider treating a recent unexplained fall like syncope
A history of a recent fall in
a patient age 65 years or older, occurring within the week prior to the ED visit, in most cases was attributed to mechanical causes without mention of associated
symptoms
a patient age 65 years or older, occurring within the week prior to the ED visit, in most cases was attributed to mechanical causes without mention of associated
symptoms
Photo by i.tokaris
Abnormal Vital Signs
Abnormal Vital Signs
- Can you adequately explain the abnormal vital signs?
- Beware of abnormal vital signs that don't improve despite interventions
Cases in this category often had initial abnormal vital signs that persisted throughout the ED visit despite interventions.
Also, reasons for the abnormal vital signs were seldom addressed in the ED note. The vital sign abnormality most common to the cases was tachycardia.
Also, reasons for the abnormal vital signs were seldom addressed in the ED note. The vital sign abnormality most common to the cases was tachycardia.
Ill Appearing
Ill Appearing
- Did they look sick on arrival?
- Were there respiratory issues?
- Better after ED treatment doesn't always mean discharge...
"The determination of ill
appearance was based on documentation of “ill appearance” or “distressed” in the general portion of the physical examination. All of these patients also were found to have abnormal lung examinations of either respiratory distress or decreased breath sounds."
Patients who come in sick may look better after our care, prompting admitting teams to question the admission. Severity of illness at time of presentation is sometimes enough of a reason to admit a patient.
appearance was based on documentation of “ill appearance” or “distressed” in the general portion of the physical examination. All of these patients also were found to have abnormal lung examinations of either respiratory distress or decreased breath sounds."
Patients who come in sick may look better after our care, prompting admitting teams to question the admission. Severity of illness at time of presentation is sometimes enough of a reason to admit a patient.
Malfunctioning
Indwelling Device
"An indwelling device was defined as an external object not naturally contained in the body, such as a nasogastric tube, catheter, or shunt."
If possible, make sure the team who put in the device has been consulted and evaluated the device.
If possible, make sure the team who put in the device has been consulted and evaluated the device.
Presenting Symptoms
Remain at Discharge
If your patient still feels sick at the time of discharge take a moment to make certain the reason is well explained and that the outpatient plan of care address all issues. How to take medications, what to do if they feel worse, access to all medicines and follow up care.
Anchoring
Too Narrow a Differential
In these cases of anchoring, cases with potential misdiagnoses were often characterized by normal laboratory or imaging results that prematurely ended the consideration for a dangerous
condition.
condition.
He Said, She Said
Address all conflicting information from other providers
Discrepancy HPI.
Medicine is a team sport but often other healthcare providers involved in your patient's care don't always communicate directly. Make sure you know why the patient is in your ED. Particularly if sent in by another provider.
"The discrepancy occurred as a result of another practitioner providing additional or conflicting information when
compared to the EP note. In all cases, these practitioners saw the patient prior to (primary medical doctor) or during
(nurse) the patients’ stays in the ED and there is no acknowledgment in the ED notes of the third party assessments."
Medicine is a team sport but often other healthcare providers involved in your patient's care don't always communicate directly. Make sure you know why the patient is in your ED. Particularly if sent in by another provider.
"The discrepancy occurred as a result of another practitioner providing additional or conflicting information when
compared to the EP note. In all cases, these practitioners saw the patient prior to (primary medical doctor) or during
(nurse) the patients’ stays in the ED and there is no acknowledgment in the ED notes of the third party assessments."
Underestimating
Mismatched Clinical Assessment and Labs?
Cases that were found to have their sickness level underestimated had mismatches between their documented clinical assessments and objective abnormalities, such as vital signs, laboratory, or imaging results.
CHANGE OF PLAN
The change took place either by an inpatient admitting physician (seven out of nine) or by the patient wanting to leave against medical advice (two of nine). In all instances, the EP indicated in his or her notes that the patients appeared ill.
Change of Plan
- Remind the inpatient team (or patient) how sick they were when they came in.
Help your colleagues and your patients tired of waiting in the ED by reminding them of how sick the patient was when they came in. It's easy to see a well appearing patient hours after admission and wonder "what was that EP thinking?"
Did You Roadtest
Your patient?
I know it's busy in the ED, but after you've identified your high risk patients and you still want to send them home get one last set of vital signs and make sure they are walk, talking, eating, drinking. A patient that feels well, and is doing all these things without difficulty is another sign they are safe to go home. Don't discharge patients only to have the nurse come back to you and say your patient can't walk....
Photo by DeeAshley
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