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. 2020 Sep 25;5(5):e342.
doi: 10.1097/pq9.0000000000000342. eCollection 2020 Sep-Oct.

Seventy-two-hour Return Initiative: Improving Emergency Department Discharge to Decrease Returns

Nidhya Navanandan  1 , Sarah K Schmidt  1 , Natasha Cabrera  2 , Irina Topoz  1 , Michael C DiStefano  1 , Rakesh D Mistry  1
Affiliations

Seventy-two-hour Return Initiative: Improving Emergency Department Discharge to Decrease Returns

Nidhya Navanandan et al. Pediatr Qual Saf. .

Abstract

Unscheduled return visits within 72 hours of discharge account for 4% of pediatric emergency department (ED) visits each year and are a quality indicator of ED care. This project aimed to reduce the unexpected 72-hour return visit rate for a network of ED and urgent cares (UC) by improving discharge processes.

Methods: A multidisciplinary team conducted a quality improvement initiative in the EDs/UCs of a tertiary children's hospital network. The team developed discharge interventions through successive Plan-Do-Study-Act cycles. They included standardization of the electronic health record discharge workflow and implementation of "mini-after care instructions" and teach-back education. The team used a statistical process control chart to follow the 72-hour return rate, and a chi-square test to compare the pre- and post-intervention 72-hour return rate.

Results: The ED/UC network discharged 219,196 patients during the study, 12/2014-4/2016. The baseline 72-hour return rate was 3.5% before interventions. The team implemented discharge interventions from 12/14 to 9/15. After the implementation of mini-after care instructions (4/15), 8 consecutive points fell below the mean on the statistical process control chart, and there was an 8.2% reduction in the 72-hour return rate (P < 0.01). Admission rates of 72-hour return patients remained stable throughout the study (27% pre-intervention and 28% post-intervention). Improvements to the ED/UC discharge process resulted in the estimated prevention of 600 ED/UC visits annually throughout the network.

Conclusions: Quality improvement methodology and multidisciplinary enhancement of discharge processes significantly decreased 72-hour return rates across a network of pediatric EDs and UCs.

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Conflict of interest statement

The authors have no financial interest to declare in relation to the content of this article.

Figures

Fig. 1.
Fig. 1.
Fishbone analysis of causes of unexpected 72-hour returns.
Fig. 2.
Fig. 2.
Key driver diagram of 72-hour unexpected return initiative.
Fig. 3.
Fig. 3.
Example of a mini-ACI.
Fig. 4.
Fig. 4.
Teach-back discharge script.
Fig. 5.
Fig. 5.
P-chart of 72-hour returns with QI interventions.
See this image and copyright information in PMC

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