Purpose: Unscheduled return visits within 72 hours of discharge account for 4% of pediatric emergency department (ED) visits each year. As many of these visits are considered preventable, 72-hour returns are often used as a quality indicator for ED effectiveness. Objective: To reduce the 72-Hour unexpected return visit rate for a network of ED and Urgent Cares (UC) by improving the ED discharge process. Methods: This was a QI initiative conducted in the EDs and UCs of a tertiary-children’s hospital network. A multi-disciplinary team was convened to identify key process drivers for ED/UC discharge. Discharge interventions were developed through successive PDSA cycles. Discharge interventions included standardization of the electronic medical record discharge work flow, development of new health literate after care instructions (ACIs) and “mini”- ACIs with an emphasis on 4 key discharge components, and teach back education with skills check for all provider staff. We used a statistical process control (SPC) chart to follow the 72-hour return rate and t-test to compare the pre- and post- intervention mean 72-hour returns. Results: 204,358 patients were evaluated and discharged from our ED/UC network during the study period. Baseline weekly mean 72-hour return rate was 3.49% prior to intervention. Our discharge intervention was implemented 12/1/14. “Mini” ACI utilization is currently at 63% (baseline 0%). After implementation of the new ACIs, 8 consecutive points fell below the mean on the SPC chart. The SPC chart was staged and there was a 9% reduction in 72-hour return rate (p < 0.01). [Figure 1] Admission rates of 72-hour return patients remained stable throughout the duration of the study (27% pre-intervention; 28% post-intervention). Overall, improvements to the ED/UC discharge process and patient education resulted in an estimated 600 prevented ED/UC visits annually in our system. Conclusion: Using QI methodology, multidisciplinary enhancement of discharge processes significantly decreased 72-hour unexpected return rates across a network of pediatric EDs and UCs.
72-hour Return Quality Improvement (qi) Initiative: Improving the Discharge Process to Decrease Unexpected Returns
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Sarah Schmidt, Nidhya Navanandan, Natasha Cabrera, Rakesh Mistry, Michael DiStefano; 72-hour Return Quality Improvement (qi) Initiative: Improving the Discharge Process to Decrease Unexpected Returns. Pediatrics January 2018; 141 (1_MeetingAbstract): 335. 10.1542/peds.141.1MA4.335
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