Decreasing clinically significant adverse events using feedback to emergency physicians of telephone follow-up outcomes

Study objective: We evaluate the effect on adverse events of a telephone follow-up quality improvement program. Methods: This was a before-and-after intervention comparison based on prospectively collected data in a tertiary care hospital emergency department (ED) (82,000 visits per year). The first half (April 15 to July 31, 2001) served as control, and the second half (August 1 to November 15, 2001) served as intervention with feedback to physicians on telephone follow-up outcomes of discharged patients and resident training about the uncertain presentations of serious diseases and the need to use additional evaluation on selected patients (observation unit, hospital admission). Telephone follow-up of the high-risk patients and retrospective review of 3-day return visits were used to quantify outcome measures: return visits to EDs and clinically significant adverse events (return visits with serious misdiagnoses or an erroneous management plan). The differences in proportions of outcomes were measured with 95% confidence intervals (CIs). Results: High-risk patients were enrolled: 566 (13.7%) of 4,139 discharged patients in the before-intervention period and 397 (11.3%) of 3,507 in the after-intervention period. The quality improvement initiative decreased return visits on enrolled patients from 10.1% (57/566) to 4.9% (19/397) (5.2% difference with 95% CI 1.8% to 8.8%) and decreased clinically significant adverse events from 4.1% (23/566) to 1.5% (6/397) (2.6% difference with 95% CI 0.3% to 4.8%). For all ED discharged patients, clinically significant adverse events decreased from 0.9% (39/4,139) to 0.4% (15/3,507) (0.5% difference with 95% CI 0.1% to 0.9%). During the study, the observation rate increased 4.3% (95% CI 2.8% to 5.7%), and the admission rate increased 3.4% (95% CI 2.1% to 4.8%). Conclusion: A quality improvement program with feedback to physicians of telephone follow-up and resident education can decrease clinically significant adverse events in ED discharged patients.