On “Unanticipated Death After Discharge Home From the Emergency Department”

Abstract

I read Sklar et al’s article “Unanticipated Death After Discharge Home From the Emergency Department” with interest.1Sklar D.P. Crandall C.S. Loeliger E. et al.Unanticipated death after discharge home from the emergency department.Ann Emerg Med. 2007; 49: 735-745Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar In their retrospective case note analysis looking at 7-day mortality after discharge over a 10-year-7 month period I note that 186,859 individuals made up 387,334 department visits, thus indicating multiple attendances of some patients during this time period. However, this was not addressed within the article. Are the multiple attendances by many or only a few? Did these multiple attendances include: return to department in cardiac arrest/critically ill, multiple attendances with the same symptoms, or given the long study period, previous attendances with unrelated illnesses or trauma? With such a high re-attendance rate is it valid to calculate mortality rate based on patient visits rather than patient numbers without an analysis of these attendances? A calculation of patient visits allows a patient to attend on Saturday and Sunday with chest pain and then re-attend on Monday in cardiac arrest to be counted as 3 visits and subsequently under estimates the 7-day mortality. Whilst there departments 7-day mortality (30 per 100,000 discharges) is higher than Kefer it still reflects favorably to that in the UK of 70 per 100,000 (although this was not broken down into expected or unexpected).2Baker M. Clancy M. Can mortality rates for patients who die within the emergency department, within 30 days of discharge from the emergency department, or within 30 days of admission from the emergency department be easily measured?.Emergency Medicine Journal. 2006; 23: 601-603Crossref PubMed Scopus (16) Google Scholar It is also interesting to note the correlation of abnormal vital signs and subsequent death within a 7-day period. There are numerous scoring symptoms such as EWS (Early Warning System), MEWS (Modified Early Warning Score), RAPS (Rapid Acute Physiological Score) and REM (Rapid Emergency Medicine score) all of which suggest what is clinically often apparent--patients with abnormal vital signs are generally unwell and are likely to do badly if still abnormal on discharge and therefore appear to be a group of easily avoidable deaths. Unanticipated Death After Discharge Home From the Emergency DepartmentAnnals of Emergency MedicineVol. 49Issue 6PreviewWe measured the frequency of unanticipated death among patients discharged from the emergency department (ED) and reviewed these cases for patterns of potential preventable medical error. Full-Text PDF In replyAnnals of Emergency MedicineVol. 51Issue 2PreviewWe appreciate Mr. Baker’s interest in our article.1 He raises two interesting questions. The first involves whether to calculate death rates based upon numbers of visits or numbers of patients since the number of visits exceeded the number of patients by more than 2 to 1. We chose to use the number of visits because most visits represent discrete illness events and not multiple visits for a single illness. During the ten year period, 61% of patients had only 1 visit, 18% had 2 visits, 8% had 3 visits and 4% had 4 visits. Full-Text PDF