This study aims to answer the critically important question we want to answer for every single patient – if we send them home, will they come back dead?
This is a retrospective medical record review of Kaiser health plan patients presenting to Kaiser Permanente hospitals in California who were discharged from the Emergency Department – and then died within 7 days. They excluded hospice, DNR, and DNI patients from this analysis, and identified 446,120 discharges over the course of two years resulting in 203 deaths (0.05%). These authors performed a qualitative chart review of 61 patients evaluating for common features.
A few highlights from their common themes:
- Unexplained persistent acute mental status change – probably a difficult discharge to justify.
- Documentation of “ill-appearing” or “moderate distress” – certainly some folks improve, but not the 89 year-old reviewed by these authors.
- Abnormal vital signs – the classic cautionary tale, which ought to have been easier in a hypoxic 69 year-old.
- Misdiagnoses due to inadequate differential diagnosis – the other classic, unavoidable, human error.
- Admission plan changed – a potentially risky play to discharge when another physician feels a patient warrants admission.
This is simply a basic descriptive study. The elements described herein should not be implied to be specific causal factors, but hypothesis generating for future work. It is, however, a fascinating topic and part of the ultimate question at the root of nearly all our patient encounters.
“Qualitative Factors in Patients Who Die Shortly After Emergency Department Discharge”