Emergency department care-related causal factors of in-patient deterioration

Abstract

Objective: The aim of this study was to determine factors related to emergency department (ED) care causing in-patient deterioration. Methods: This retrospective cohort study examined in-patient records using the human factors classification framework for patient safety in a regional health service in New South Wales, Australia, between March 2016 and February 2017. Deterioration was defined as either the initiation of a medical emergency team call, cardiac arrest or unplanned admission to the intensive care unit. Results: Of the 1074 patients who deteriorated within 72 hours of admission via the ED, the care received in the ED was a contributing factor for 101 patients (9%). The most common human causal factors were poor communication between staff, medical management errors, delayed treatment, medical documentation errors, nursing management errors and unclear policies or guidelines. Communication issues occurred the most when patients had more comorbidities (P = 0.039) and were more likely to occur in the presence of a medical documentation error (odds ratio 4.4; 95% confidence interval 1.7-11.3). Unclear policies or guidelines as a factor was most frequent with a surgical diagnosis (34.5% vs 15.7% for surgical vs medical, respectively; P = 0.038) and in patients ≥80 years of age (30.0% vs 21.8% for age ≥80 vs <80 years, respectively; P = 0.027). Conclusion: Quality monitoring and interventions that consider human factors are required to address preventable in-patient deterioration. What is known about the topic?: The ED represents the hospital's point of contact for potentially life-Threatening conditions. Adverse event rates for emergency admissions are more than double those of non-emergency admissions. Patients are at particular risk of deterioration on discharge from the ED to the ward in the first 72 hours. Predicting which patients will deteriorate following transfer to the ward remains challenging, with care in the ED hypothesised to play a role. What does this paper add?: This paper reveals that in-patient deterioration relating to ED care could be reduced through the routine identification of causal factors within a human factors framework in any patient deterioration event and subsequent evidence-informed interventions to address these factors. It is also extrapolated that the implementation of any intervention should be informed by behaviour-change principles. What are the implications for practitioners?: It is implied that there is a need for the clarification and revision of policies and guidelines pertaining to the management of elderly patients, education regarding the critical importance of the often clinically masked vital sign deviations in younger patients and improved communication between staff, especially regarding patients with more comorbidities. Reviews of adverse events, such as patient deterioration, should incorporate a human factors analysis. Regular collation of data following adverse events should occur, with interventions considering all aspects of the factors that led to the event.