Original Contribution
Patient safety analysis of the ED care of patients with heart failure and COPD exacerbations: a multicenter prospective cohort study,☆☆

https://doi.org/10.1016/j.ajem.2013.09.013Get rights and content

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.

Introduction

Acute exacerbations of heart failure and chronic obstructive pulmonary disease (COPD) are common complaints for patients visiting the emergency department (ED). Combined, these conditions account for over 1.2 million annual ED visits in the United States [1], [2]. These patients can be challenging to treat in the ED setting due to frequent co-morbid diseases, complex medication regimens, inconsistency in outpatient specialist care and ED crowding [1], [3]. The decision to admit or discharge patients with these conditions is currently not guided by evidence as there are no ED-based clinical practice guidelines for the acute care of heart failure or acute exacerbations of COPD. Existing international and national clinical practice guidelines for these conditions address limited components of acute care but there are few ED specific recommendations [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]. This creates challenges when evaluating the quality of emergency care for acute exacerbations of both of these conditions since the assessment and management is specific and differs from chronic maintenance care.

One widely cited quality indicator for ED care is unplanned return visits [15], [16], [17]. Previously, researchers have documented a high frequency of return ED visits within 30 days for patients with heart failure (14%-25%) and COPD (27%-43%) [18], [19], [20], [21]. This raises potential patient safety concerns. Furthermore, a large population-based study has identified that heart failure patients discharged from the ED are at high risk of early death [19].

It is not known what proportion of return ED visits for these patients are related to health care received on the index visit, thus representing adverse events. The overall aim of this study was to evaluate patient safety concerns for this ED population and seek areas for improvement. Specifically, our objectives were to determine: (1) the frequency of adverse events following discharge from the ED for patients with acute exacerbations of heart failure or COPD; (2) the frequency of adherence to evidence-based care for these populations; and (3) any association between lack of adherence to evidence-based care and the occurrence of adverse events.

Section snippets

Methods

We conducted our study with patients discharged from five EDs with acute exacerbations of heart failure and COPD. We evaluated the ED management of these patients for adherence to evidence-based care and the occurrence of adverse events.

Results

Overall, 228 (21.2%) patients of the 1718 enrolled discharged patients returned to the ED within 14 days. Fig. 1 illustrates study patient flow.

Of the 122 flagged outcomes, over half of the patients (65, 53.3%) were discharged home at the return ED visit and a smaller proportion (52, 42.6%) were admitted (see Table 1). Five patients (4.1%) died. We compared the patient characteristics of our cohort with the 953 patients not eligible for the patient safety analysis and there were no significant

Main findings

We found that a significant proportion of ED patients discharged with the diagnoses of acute heart failure and acute exacerbations of COPD returned to the ED within 14 days. We noted strong adherence to evidence based care for heart failure and moderate adherence for COPD. Of those who returned to the ED, 10% experienced adverse events, 100% of which were deemed preventable. Despite higher adherence to evidence based care for patients with acute heart failure, the majority of adverse events

Conclusions

This study confirms that there are high rates of return ED visits for patients with acute heart failure or COPD exacerbations. Despite this, we found that only a small proportion is related to index ED care. We believe disposition decision making for both conditions needs to be improved to reduce the highly preventable and clinically significant adverse events we found. Development and implementation of evidence-based, emergency-specific guidelines for the management of these patient conditions

Acknowledgments

Thank you to Laura Carr for her assistance in coordinating data collection, Angela Marcantonio for her assistance with REB applications and grant preparation and MyLinh Tran for assistance with data analysis. Thank you to Ria Cagaanan for assistance with manuscript preparation. Thank you also to the members of our expert panel: Drs. Curtis Lavoie, Shena Riff, Elizabeth Shouldice and Nicholas Chagnon. Thank you also to all the site investigators for overseeing data collection and for the

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      Disagreements (such as 1 reviewer assigned a 5/6 and others less than 3/6) were resolved by consensus. We defined adverse event types (eg, diagnostic error, management error, unsafe disposition decision, adverse drug reaction) in accordance with previous adverse event studies.10,15,17 Adverse events could be of more than one type.

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      Prior study with return ED visits as a trigger demonstrated that 58% of adverse events resulted in transient minor disability and 1% resulted in death [13]. Another study pertaining to patient safety analysis of ED patients with heart failure and chronic obstructive pulmonary disease found that 75% adverse events were with symptoms only and 8.3% resulted in death [21]. We found three sentinel events with mortality.

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    Competing interests: none to declare.

    ☆☆

    Funding: Physician Services Incorporated and University of Ottawa Department of Emergency Medicine.

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