Seventy-two-hour Return Initiative: Improving Emergency Department Discharge to Decrease Returns

Abstract

Introduction: Unscheduled return visits within 72 hours of discharge account for 4% of pediatric emergency department (ED) visits each year and are a quality indicator of ED care. This project aimed to reduce the unexpected 72-hour return visit rate for a network of ED and urgent cares (UC) by improving discharge processes. Methods: A multidisciplinary team conducted a quality improvement initiative in the EDs/UCs of a tertiary children's hospital network. The team developed discharge interventions through successive Plan-Do-Study-Act cycles. They included standardization of the electronic health record discharge workflow and implementation of "mini-after care instructions" and teach-back education. The team used a statistical process control chart to follow the 72-hour return rate, and a chi-square test to compare the pre- and post-intervention 72-hour return rate. Results: The ED/UC network discharged 219,196 patients during the study, 12/2014-4/2016. The baseline 72-hour return rate was 3.5% before interventions. The team implemented discharge interventions from 12/14 to 9/15. After the implementation of mini-after care instructions (4/15), 8 consecutive points fell below the mean on the statistical process control chart, and there was an 8.2% reduction in the 72-hour return rate (P < 0.01). Admission rates of 72-hour return patients remained stable throughout the study (27% pre-intervention and 28% post-intervention). Improvements to the ED/UC discharge process resulted in the estimated prevention of 600 ED/UC visits annually throughout the network. Conclusions: Quality improvement methodology and multidisciplinary enhancement of discharge processes significantly decreased 72-hour return rates across a network of pediatric EDs and UCs.