Lisa Calder1, Sarah Tierney2, Yue Jiang3, Austin Gagné3, Andrew Gee3, Elisabeth Hobden3, Christian Vaillancourt4, Jeffrey Perry4, Ian Stiell4, Alan Forster5. 1. Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada K1Y 4E9; Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital-Civic Campus, Ottawa, Ontario, Canada K1Y 4E9. Electronic address: lcalder@ohri.ca. 2. Department of Medicine, Queens University, Etherington Hall, Kingston, Ontario, Canada K7L 3N6. 3. Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada K1Y 4E9. 4. Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada K1Y 4E9; Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital-Civic Campus, Ottawa, Ontario, Canada K1Y 4E9. 5. Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital-Civic Campus, Ottawa, Ontario, Canada K1Y 4E9; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5.
Abstract
OBJECTIVES: For emergency department (ED) patients with acute exacerbations of heart failure and chronic obstructive pulmonary disease (COPD), we aimed to assess the adherence to evidence-based care and determine the proportion that experienced adverse events. METHODS: An expert panel identified critical actions for ED care of heart failure and COPD patients based on clinical practice guidelines. We collected outcome data for discharged ED patients >age 50 with acute heart failure or COPD in a multicenter prospective cohort study at five academic EDs. We measured 3 flagged outcomes: return ED visit, admission, or death within 14 days. Three trained physician reviewers reviewed case summaries for adverse event determination (flagged outcomes related to healthcare received). We evaluated health records for adherence to the critical actions for each condition. RESULTS: We identified 122 (7.0%) flagged outcomes among 1,718 enrolled patients (61 heart failure, 59 COPD and 2 dual diagnoses). The mean age was 74.2 (SD 10.4) and 44.3% were female. Among 10 critical actions for heart failure and 13 for COPD, a mean proportion of 9.4/10 and 11.0/13 were adhered to respectively. We identified 12 adverse events (9.8%, 95%CI: 5.6-16.5%), all of which were deemed preventable, including 1 death. The most common contributors were unsafe disposition decisions (10/12, 83.3%) and diagnostic issues (5/12, 41.7%). Patients who died with heart failure were statistically significantly less likely to have guideline adherent care (P = .02). CONCLUSIONS: A small proportion of return ED visits were related to index care. We believe there is need for improvement around disposition decision making for both conditions to reduce the highly preventable and clinically significant adverse events we found.
OBJECTIVES: For emergency department (ED) patients with acute exacerbations of heart failure and chronic obstructive pulmonary disease (COPD), we aimed to assess the adherence to evidence-based care and determine the proportion that experienced adverse events. METHODS: An expert panel identified critical actions for ED care of heart failure and COPDpatients based on clinical practice guidelines. We collected outcome data for discharged ED patients >age 50 with acute heart failure or COPD in a multicenter prospective cohort study at five academic EDs. We measured 3 flagged outcomes: return ED visit, admission, or death within 14 days. Three trained physician reviewers reviewed case summaries for adverse event determination (flagged outcomes related to healthcare received). We evaluated health records for adherence to the critical actions for each condition. RESULTS: We identified 122 (7.0%) flagged outcomes among 1,718 enrolled patients (61 heart failure, 59 COPD and 2 dual diagnoses). The mean age was 74.2 (SD 10.4) and 44.3% were female. Among 10 critical actions for heart failure and 13 for COPD, a mean proportion of 9.4/10 and 11.0/13 were adhered to respectively. We identified 12 adverse events (9.8%, 95%CI: 5.6-16.5%), all of which were deemed preventable, including 1 death. The most common contributors were unsafe disposition decisions (10/12, 83.3%) and diagnostic issues (5/12, 41.7%). Patients who died with heart failure were statistically significantly less likely to have guideline adherent care (P = .02). CONCLUSIONS: A small proportion of return ED visits were related to index care. We believe there is need for improvement around disposition decision making for both conditions to reduce the highly preventable and clinically significant adverse events we found.