The Risks of Premature Discharge from the ED

In a service area where diagnostic ambiguity ismore the rule than the exception, the physiciansand nurses discharging patients rarely hear the endof the patient’s story. For Emergency Medicinephysicians—the inevitable sending of a patient home,to an inpatient service, or to a PCP—generally limitsmeaningful feedback about the accuracy of theirdiagnosis and treatment plan. Are you concernedabout any of these potential risks in your ED?

• test results received in the ED post-discharge
• incomplete or unspecific discharge or follow-up instructions
• patient’s (or family’s) incomplete comprehension of instructions
• patient’s PCP unaware of ED visit and/or need for follow up
• discharge accelerated due to ED production pressure
• discharge without reconciliation of concerning symptoms or test results
• patient abandoned between ED discharge and inpatient admission (i.e., boarders)

Without formal and consistent direct feedback, EDphysicians have to contend with a certain amountof anxiety about these and other post-encounterrisks—and where to focus patient safety attentionand resources.

Systematic input from the patient population, theprimary care community, and hospital-baseddepartments can provide ED leaders with a realtimeunderstanding of strengths and weaknesses inthe ED’s discharge process. Combining that insightwith aggregated, comparative analysis of deeplycoded malpractice claims from Candello opens a windowinto your most critical vulnerabilities.

Case Example: Discharge

A 30-year-old female presented to the ED with history of severe,bilateral lower abdominal pain with nausea and vomiting over theprevious three days. Medical record documentation revealed alimited abdominal exam with findings of possible supra pubic painand no abdominal tenderness. There was no documentation ofany abdominal rebounding, or tenderness to the kidney area. Nogynecological exam was performed. Labs, urinalysis, and bloodcultures revealed possible UTI: white and red blood cells in the urineand elevated white blood cell count with left shift (but specimencontamination was suspected). An abdominal X-ray was negative.The patient was diagnosed with a UTI, prescribed antibiotics, anddischarged—despite a 102.3 temperature and no resolution of herabdominal pain or a Urology consult for possible kidney infection.

Two days later, urine cultures returned “no growth,” confirmingspecimen contamination, and invalidating the diagnosis of a UTI.That same day, the patient was admitted with a ruptured appendix.(Case settled: $50K)