1. Dr Scott Pearson Emergency Physician Christchurch Hospital

2.  Decision Support at CDHB send monthly report to clinician responsible for audit  List of NHIs of patients who have had “unscheduled” representations within 48 hours of first attendance at Emergency  Usually 40-60 patients/ month- <1% of total  Includes patients who ◦ return and are then discharged home again from ED. ◦ are admitted by an inpatient team who are discharged, then return within 48 hours of discharge

3.  Once ED reattendances who are admitted are isolated, usually ~10 patients per month  Electronic/ paper clinical records reviewed  Assessment about appropriateness of initial discharge and advice  2-3 hours of SMO time per month

6.  High number of patients on original data that are not ED specific ◦ Clerical staff code reattendance as “unscheduled” ◦ Unscheduled if reattendance for same clinical problem ◦ Inpatient discharges are included also  Very small number of inappropriate discharges

8.  April 2009- March 2010  Average monthly unscheduled returns = 24  April 2012- March 2013  Average monthly unscheduled returns = 43  April 2013- March 2014  Average monthly unscheduled returns = 53

10.  Feedback to staff involved  Provide education around “themes”  Provides information on trends  Acts as a marker/ quality indicator of ◦ ED senior supervision ◦ Capacity of the hospital ◦ Pressure to discharge ◦ Inadequate knowledge/ change of RMO staff? ◦ Other processes in the community

11.  18 yr old man, car crash, brought in 2345 hrs ◦ Observed 6 hours CT abdo normal ◦ Vital signs stable, mobilised comfortably ◦ Discharged 0545hr  Returned same day. Back pain and vomiting. CT abdo reviewed- crush fractures L1-4, free air, admitted General Surgery, observed, discharged 48 hrs later  ACTION- review discharge policy during night, radiology reporting process  Young male, punched in face when in city in evening. Swollen face. Xrays misinterpreted. Recalled after alerted by radiologist. Blowout fracture orbit.  ACTION- further RMO education about facial Xray interpretation

12.  72 year old ◦ Lethargy and SOB ◦ WCC 22 ◦ CXR misinterpreted  Returned with NSTEMI  ACTION- feedback to RMO, senior supervision  38 yr old woman ◦ Abdo pain, bariatric surgery 2 mths previous ◦ Diagnosis of UTI  Returned with ongoing pain- CT diagnosis- gastric prolapse- laparotomy  ACTION- further education about complications of bariatric surgery

13.  40 yr old male ◦ Ureteric calculus, 4mm ◦ Discharged appropriately for non operative management ◦ Returns with ongoing pain, pain managed and discharged  Frequent cause for reattendance to ED  ACTION- review management with Urology Service  5 month female ◦ Clinical diagnosis bronchiolitis ◦ Discharged appropriately after senior discussion and parent education ◦ Appropriate reattendance after poor feeding ◦ Admitted to Paediatrics  ACTION- nil

14.  Monthly audit- continuous or occasional?  Minimal amount of SMO time  Useful to review all ED discharges returning within 48 hours.