Identifying and Reducing Complications After Emergency Room Discharge

By Paul B. Hofmann, DrPH, FACHE, and James P. Bagian, MD, PE

When an inpatient experiences an adverse incident or a near miss, hospitals with appropriate patient safety and quality assurance programs determine through an explicit risk-based prioritization methodology whether they should conduct a thorough investigation. The principal goal of that investigation, of course, is to determine what should be done to prevent or reduce the likelihood of a similar incident in the future (Bagian et al., 2001; Bagian, 2005; Bagian, Lee, & Cole, 1999; National Patient Safety Foundation, 2015; Hofmann, 1986). As shown by innumerable studies, such efforts have reduced the most common problems, such as medication- and transfusion-associated adverse events, patient injury due to falls, incorrect surgery, retained surgical items, miscommunication of critical diagnostic results, and a variety of other adverse events.

In 2012, Medicare began reducing hospital reimbursement for cases involving patients re-admitted for the same condition within 30 days of discharge (Section 3015 of the Affordable Care Act added section 1886(q) to the Social Security Act). Predictably, hospitals have become much more thorough and comprehensive in their discharge planning activities. Phone calls are frequently made to ensure patients are scheduling recommended follow-up diagnostic procedures and physician office visits, managing medications properly, complying with diet restrictions, and taking other actions to maintain or improve their health status.

Finally, economic incentives have accelerated the shift from volume-based to value-based delivery of health services and placed greater emphasis on population health management. All of these developments should encourage hospitals and health systems to examine opportunities to further enhance their focus on quality and patient safety improvement efforts across the continuum of services.

A neglected priority for improving patient care

Many hospitals have recognized that a large percentage of emergency room visits are often made by a relatively small number of patients (Minemyer, 2016). As a result, these institutions have analyzed their high-volume patients and promoted interventional programs focusing on individuals with chronic conditions, including asthma, chronic obstructive pulmonary disease, hypertension, diabetes, congestive heart disease, and/or mental illness, to reduce their inordinate use of emergency services.

One critical initiative remains underused: devoting more attention to exploring why some patients experience a complication or death after being treated in the emergency room. There are several possible explanations for this. Clinical staff juggle multiple complex ER patients, which can be chaotic. ER physicians or other healthcare personnel may not have time to do a detailed medication reconciliation. Moreover, not all ER staff will be fully aware of community resources available to newly discharged patients. For example, they may not have a lot of experience arranging for ancillary services such as homecare, ordering durable medical equipment like walkers, and so forth.