The Metrics of Acute Care Reentry and Emergency Department Visits by Recently Discharged Inpatients.

Research on acute care reentry by recently discharged inpatients has generally focused on hospital readmissions, with less attention given to presentations to the emergency department (ED). This omission results in underestimation of the extent of reentry and its impact on ED patient volumes and flow. This project involved an analysis of administrative data to examine the rate of ED presentations by recently discharged inpatients using 3 time metrics-within 0-3 days, 0-7 days, and 0-30 days of discharge. Descriptive-correlational analyses were conducted to examine the rates of reentry and ability to predict ED presentations using patient demographic (age and sex) and clinical profile (length of hospital stay and day of presentation). Approximately 12% of hospital discharges to home involved patients who presented to the ED within 30 days, and almost half occurred within the first week. Results of multivariable analyses suggest that the influences of ED presentations differ depending on the time metric examined. Emergency department presentations within 3 and 7 days of discharge compared with 30 days were not predicted by patient age or sex but were more likely to involve those with shorter hospital stays. A weekend presentation was also more likely among case patients presenting within 3 days of discharge. Only about one third of ED presentations resulted in readmission. Emergency department presentations are an important component of acute care reentry. Establishment of a common reentry metric for ED presentations would facilitate efforts to determine the impact of these events. Emergency nurses working in advanced practice roles are ideally positioned to assume a leadership role in addressing the needs of recently discharged inpatients who present to the ED. By reviewing these cases and collaborating with the inpatient unit staff, it may be possible to identify strategies for augmenting discharge planning and the provision of transitional care.

Clinical utility of scores on the Blaylock Risk Assessment Screen (BRASS): An analysis of administrative data.

PURPOSE: Project was undertaken to examine the utility of the Blaylock Risk Assessment Screen (BRASS) in identifying patients who may experience discharge complications as indicated by longer hospital stays or readmission within 30-days of a discharge to home. BACKGROUND: Before measures can be put in place to facilitate discharge planning and to prevent unplanned readmission by recently discharged patients, those at risk of such events must be identified. METHODS: Project involved an analysis of 13-months of administrative data from one tertiary care hospital. Utility of the BRASS was examined in terms of its sensitivity and specificity as well as its positive and negative predictive values. RESULTS: Majority (83%) of hospital discharges were to home. Approximately 7% of patients experienced at least one readmission within 30-days of being discharged to home. Using scores of 10 or higher as an indicator of risk, BRASS exhibited a high degree of specificity suggesting it is useful for 'ruling in' those who have the outcomes-of-interest. However low sensitivity indicates many who experienced the outcomes were incorrectly classified by the BRASS as low risk. The low positive predictive value for 30-day readmission also suggests many who were classified by the BRASS as being 'at risk' were not readmitted. CONCLUSION: The observed rate of 30-day readmission is likely conservative as the analysis involved data from only one acute care facility. One explanation for the low positive predictive value for 30-day readmission is that completion of the BRASS on admission enabled the implementation of preventive measures.

Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators.

STUDY OBJECTIVE: Point-of-care ultrasonography protocols are commonly used in the initial management of patients with undifferentiated hypotension in the emergency department (ED). There is little published evidence for any mortality benefit. We compare the effect of a point-of-care ultrasonography protocol versus standard care without point-of-care ultrasonography for survival and clinical outcomes. METHODS: This international, multicenter, randomized controlled trial recruited from 6 centers in North America and South Africa and included selected hypotensive patients (systolic blood pressure <100 mm Hg or shock index >1) randomized to early point-of-care ultrasonography plus standard care versus standard care without point-of-care ultrasonography. Diagnoses were recorded at 0 and 60 minutes. The primary outcome measure was survival to 30 days or hospital discharge. Secondary outcome measures included initial treatment and investigations, admissions, and length of stay. RESULTS: Follow-up was completed for 270 of 273 patients. The most common diagnosis in more than half the patients was occult sepsis. We found no important differences between groups for the primary outcome of survival (point-of-care ultrasonography group 104 of 136 patients versus standard care 102 of 134 patients; difference 0.35%; 95% binomial confidence interval [CI] -10.2% to 11.0%), survival in North America (point-of-care ultrasonography group 76 of 89 patients versus standard care 72 of 88 patients; difference 3.6%; CI -8.1% to 15.3%), and survival in South Africa (point-of-care ultrasonography group 28 of 47 patients versus standard care 30 of 46 patients; difference 5.6%; CI -15.2% to 26.0%). There were no important differences in rates of computed tomography (CT) scanning, inotrope or intravenous fluid use, and ICU or total length of stay. CONCLUSION: To our knowledge, this is the first randomized controlled trial to compare point-of-care ultrasonography to standard care without point-of-care ultrasonography in undifferentiated hypotensive ED patients. We did not find any benefits for survival, length of stay, rates of CT scanning, inotrope use, or fluid administration. The addition of a point-of-care ultrasonography protocol to standard care may not translate into a survival benefit in this group.