Do Return ED Visits Signal Lower Quality of Care?

When a patient makes a return visit to the emergency department, you may draw the conclusion that quality of care the first time wasn’t great. But a study recently published in the Journal of the American Medical Association offers data that may contend otherwise.

The study’s authors acknowledge that return visits to the ED “are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care.” So they set out to find whether or not these return visits, which led to in-patient admission, were evidence of a lower quality of care from the ED that initially treated the patient. The pervading question being, that if a patient is ultimately admitted to the hospital, shouldn’t it occur during their first visit to the ED, and not the second or third?

Researchers looked at in-hospital mortality, intensive care unit admission, length of stay, and inpatient costs to determine whether a patient returning to the ED was a reliable measure of quality of care within that ED. The results were surprising.

“Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay,” researchers concluded. “These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.”

Let’s look closely at the numbers. Patients discharged from an ED and subsequently admitted to the hospital upon a return visit experienced:

  • An in-hospital mortality rate of 1.85 percent vs. 2.48 percent for those patients admitted during their initial visit to the ED.
  • An ICU admission rate nearly six percent less (23.3 percent vs 29 percent).
  • The cost of care for these patients was also less ($10,169 vs. $10,799), even though their length of stay was slightly higher (5.16 days vs. 4.97 days).

And for those patients admitted to the hospital within 14 and 30 days of their ED visit? Similar outcomes were experienced.

But what about those patients readmitted to the hospital after hospital discharge and a return visit to the ED?

“In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit,” researchers found.

What do you think? Are return visits to the ED an adequate measure of quality of care? Please comment below or feel free to drop me a line.

The Journal of the American Medical Association: “In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department”

Opioids: Which Intervention Works Best in EDs?

Distressed Patient

Emergency departments are on the front lines of the opioid epidemic. EDs have everything to gain by doing more than just stabilizing patients or denying prescriptions. A more proactive approach can not only help the patient but can improve long wait times, overcrowding and low patient satisfaction.    

EDs can begin the intervention process for patients presenting with symptoms of opioid dependence. A study published last year in the Journal of the American Medical Association looked at three interventions and their efficacy.

3 Intervention Approaches and Their Effectiveness

1. Referral
This study involved over 300 opioid-dependent patients at an urban teaching hospital, each randomly assigned to three types of intervention, and studied over the course of 30 days. After screening, this first group was provided a handout with names, locations and telephone numbers of local treatment services, which varied by type and intensity. Patients were also allowed to call a clinician or treatment facility of their choice from the ED. By merely providing patients with information and tools for treatment, researchers saw that 37 percent of participants were engaged in addiction treatment at the 30-day mark.

2. Brief Intervention
In this group, patients received a brief negotiation interview (10 to 15 minutes) from a research associate containing four components:

  •      Raise the subject.
  •      Provide feedback.
  •      Enhance motivation.
  •      Negotiate and advise. 

Treatment options were then discussed, with similar information provided that those patients in the referral group received. With this more focused intervention, 45 percent of patients were engaged in addiction treatment at the 30-day mark.

3. Buprenorphine Treatment
In this final group, patients received the same brief negotiation interview as those in the brief intervention group received. If symptoms of moderate to severe opioid withdrawal were apparent, then ED-initiated treatment with buprenorphine was started. Patients were given enough medication to take home until an appointment in the hospital’s primary care center, when a 10-week course of treatment of buprenorphine was introduced. At the conclusion of the 10 weeks, patients continued treatment in a community program, clinician-lead program or a two-week detox program.

At day 30, 78-percent of patients were still engaged in addiction treatment and illicit opioid use dropped from 5.4 days per week, to just under one. (The referral group saw a reduction of illicit opioid use to 2.3 days per week and the brief intervention to 2.4 days per week.)

All three interventions increased engagement in treatment for opioid-dependent patients, but it’s clear a more intensive, hands-on intervention with medication treatment offered to this study’s third group proved more effective. The authors say that there still needs to be more studies.

Does your ED have an intervention strategy it implements for opioid-dependant patients? If so, I’d love to hear about it. Please comment below and share what has or hasn’t worked for you or feel free to drop me a line. If you’d like an assist with fine-tuning your ED's operation, no matter which challenges you’re facing, check out my company’s website to see if we may be a fit for you.


The Journal of the American Medical Association: “Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence.”

Emphasize Teamwork and Communication to Increase Patient Safety

Nurses Consulting

The potential for risk is great in emergency departments. In the hospital setting, EDs rank as high-risk as intensive care units and operating rooms. In all three of those settings, staff members have to work together and communicate clearly to ensure patient safety.

EDs that place a strong emphasis on teamwork, and have in place an effective communication strategy, are able to counteract the inherent risk associated with a patient’s visit to the ED.

Previous studies in health care settings indicate that upwards of 80 percent of medical errors are related to “interpersonal interaction issues,” or more simply, miscommunication. By placing a focus on teamwork and effective communication, an ED will increase not just patient safety, but patient satisfaction, quality of care and staff morale.

Check out these three ways to improve communication and increase teamwork within the emergency department:

1. Implement an Open Door Policy

Effective leaders flatten the hierarchy, create familiarity and make it feel safe to speak up and participate.  — M. Leonard, S. Graham and D. Bonacum

Within EDs, it’s crucial that staff feel comfortable bringing concerns and ideas to their immediate supervisors and those in charge. A sense of strict hierarchy and power structure can discourage your staff from speaking up, but open door policies can counteract those effects and improve communication and enhance teamwork among staff.

2. Standardize Practices

The lack of standardised communication and procedures in medicine increases the importance that team members invest in creating a common mental model; otherwise, there is limited ability to predict and monitor what is supposed to happen. — M. Leonard, S. Graham and D. Bonacum

In many EDs, staff members possess varied levels of experience and responsibility, as well as different personalities and beliefs. To improve communication and foster an environment centered on teamwork among such a diverse group, start by standardizing procedures, practices and communication models. By emphasizing structure within those methods of care, ED staff will all be on the same page and know how and when to communicate concerns or other vital information to their colleagues and those in positions of authority.

3. Be Deliberate

Communication failures are the leading cause of inadvertent patient harm. Analysis of 2,455 sentinel events reported to the Joint Commission for Hospital Accreditation revealed that the primary root cause in over 70% was communication failure. Reflecting the seriousness of these occurrences, approximately 75% of these patients died. — M. Leonard, S. Graham and D. Bonacum

As an ED or hospital leader, when you focus on communication and teamwork, in many instances, you will be changing the culture of your ED. Although the correlation that exists between patient safety and effective communication and teamwork is strong — and benefits, such as improved quality of care and increased patient satisfaction will result — a long-term strategy should be used to implement changes because this type of change takes time and dedication. It’s wise to conduct a deep analysis of every new strategy incorporated, since each step of the process has influence on the overall course of action. Be deliberate and create a schedule with the help of your staff to increase effectiveness.

The positive impact on patient safety, quality of care, patient satisfaction and staff morale that result from improved communication is something I’ve witnessed in many of the EDs Donovan and Partners has had the pleasure of working with. If your ED could benefit from improved communication and enhanced teamwork, feel free to get in touch. Contact Donovan & Partners today at or 651-260-9918. I'd be happy to do a personalized assessment of your ED and provide actionable solutions. For more information on the services we offer, visit our website.

Nursing Economics: “Measuring teamwork and patient safety attitudes of high-risk areas.”

BMJ Quality and Safety: “The human factor: the critical importance of effective teamwork and communication in providing safe care.”

Troubleshoot Triage to Improve Patient Flow

Emergency Waiting Room Donovan Partners

Seven years ago — from December 2008 through February 2009 — approximately 13 percent of patients who visited the emergency department at Hahnemann University Hospital in Philadelphia left without ever being seen. Over a three-month time period, the 31-bed ED had more than 8,800 visits — overcrowding was a significant problem.

The very next year, over the same three-month time frame, Hahnemann’s ED saw almost 800 more patients — close to nine more per day — but the LWBS rate dropped significantly. Even with the increased patient volume, the ED’s LWBS rate decreased by more than three percent. Three months later, the LWBS rate had dropped even lower to six percent.

But how?

In June 2008, Hahnemann’s ED leadership made a commitment to improve patient flow, and soon partnered with the Urgent Matters Learning Network II — a 6-hospital collaborative that worked with one another to improve patient flow and alleviate overcrowding. Through the consortium, they were able to develop a triage process that worked for their specific hospital given its size, staffing structure and urban location. (ED leaders at Hahnemann ultimately decided to implement the ESI 5-level triage system; introduce a policy of bringing patients to an open bed for triage and registration; and dedicate resources, staff and space for patient fast tracking. And it worked.)

For Hahnemann, implementing an improved patient flow process at triage resulted in lower LWBS rates, less overcrowding and increased morale among its staff. Higher patient satisfaction scores soon followed.

A more recent example of what can result when an ED prioritizes patient flow is Florida Hospital Tampa (FHT), an ED that had been experiencing a nearly 40-percent annual spike in patient volume as it suffered from a 21-percent staff turnover rate. And if that wasn’t enough, patients were ranking its doctors in the bottom ninth percentile nationwide.

An analysis by the Healthcare Financial Management Association outlines how FHT was able to develop and implement a flexible patient flow process combining two proven strategies: team triage and immediate bedding. Dubbed Doc1stER, the new patient flow triage strategy produced quick results — after two months FTH was the most improved ED in its 41-hospital system.

No two EDs are the same and strategies to improve patient flow aren’t one-size-fits-all — staffing, location and space are just a few factors that have to be considered. ED leaders wanting to improve patient flow triage need a plan tailored specific to their ED. With a proven record of being able to identify and develop patient flow strategies, Donovan and Partners can help you examine and improve your current triage process, and then help you implement a plan to improve patient flow in your ED. Contact us today at or 651-260-9918. To learn more about the complete set of health care consulting we offer, please visit


Healthcare Financial Management Association: “7 Tips for Improving Emergency Department Patient Flow.”

Hospitals in Pursuit of Excellence: “Improving ED Flow through the UMLN II.”

3 Important Characteristics of Emergency Department Nurses and Why We Love Them


It’s easy to take emergency department nurses for granted. Even though they’re what I consider the eyes and ears of any busy ED, they don’t always receive the credit and appreciation they deserve.

Friday marked the beginning of National Nurses Week, reminding us to honor and celebrate these nurses who are so instrumental in providing safe, quality care in the ED. But what makes nurses so amazing? Here are just a few reasons to salute these hardworking women and men who are vital to a successful ED..

Uncommon Agility

You would be hard pressed to find any other profession where agility is so crucial to success. Being agile in an ED means always being on your toes, anticipating the needs of patients, their families and doctors. Agile nurses know what a patient or doctor needs before they themselves know they need it and the right questions to ask. Nurses in many ways have the keen ability to see in the future, which is vital when a life is on the line.

Superb Communication Skills

Anticipating the needs of patients, family members and doctors is one thing — being able to communicate with each of these very distinct groups is another.

First and foremost, great nurses are incredible listeners. They absorb directives from doctors that could easily be drowned out by the bustle of a busy ED. They also connect with patients and caregivers, listening to them in a way that help give the patient a voice in their care.

But listening is only half of communication. Nurses also have to speak with patients in a clear, concise way that’s easy to understand. One minute they may be talking to a 6-year-old boy with a broken arm, and the next, a 50-year-old man with an addiction to prescription painkillers. I can’t think of another profession where one communicates with so many different types of people, across so many demographics and socio-economic groups.

Enduring Empathy

Nurses care about the wellbeing of their patients — though they hope they never see them again, in the ED at least.

Empathy is the reason nurses are able to be considerate and sensitive when setting expectations regarding recovery. Empathy is also the reason why nurses return to work after a hard shift.

The strong sense of empathy that runs through each and every emergency department nurse isn’t always obvious, but we can rest assured it’s there — empathy is the reason nurses show up to work each and every day.

If the emergency department is the front door of a hospital, ED nurses are the ones making the very first impression and make sure that door is open to those who need it most.

One week really isn’t enough time to honor nurses and the important work they do, but National Nurses Week is a nice reminder for hospital leaders, doctors, patients and their families to show their appreciation for everything nurses do.

To learn more about what my company Donovan + Partners does, please check out our new website

The Importance of a Strong Discharge Checklist


The moment a patient is discharged from the emergency department (ED) should be a moment marked with confidence for both the patient and ED staff. Each party should be satisfied with the care provided and that the chance of a return visit to the ED in the near future are low.

A visit to the ED is typically stressful for a patient and their families. From the time they walk in your door until they get to discharge can be an arduous experience. But by engaging patients with effective communication throughout thier experience and especially before the leave they’ll be empowered with the necessary knowledge to ultimately take control of their care.  

One important tool for effective communication every ED should utilize is the discharge checklist.

According to the Robert Wood Johnson Foundation, patients should have a solid understanding of these six things prior to discharge:

  1. Their overall care plan;
  2. Where they will be going after discharge;
  3. If transferred, who to contact if a problem arises;
  4. Medication instructions along with potential side effects;
  5. What symptoms to be on the lookout for;
  6. And any necessary follow-up appointments.

This is a lot of information for a person or family to absorb, especially when they find themselves in the ED. A strong discharge checklist will provide this essential information in a way that’s easy for patients and caregivers to understand as the ED staff person reviews it with them and once they take it home. Just as important, a strong discharge checklist will instill confidence among the ED staff that all pertinent information has been shared with the patient.

So, what does a strong discharge checklist look like?

The best discharge checklists are educational in nature and address social and medical risk factors that could result in a return visit to the ED. If the patient is homeless, a list of area agencies that offer housing assistance should be included. The same goes for patients who have issues involving substance abuse.

Strong discharge checklists should also be simple in form and created with the demographics of the community the ED serves in mind. If there is a high population of Spanish-language speakers in the community, it’s best to have the checklist available in Spanish as well.

Discharge checklists of course can’t be tailored to every individual patient, but a strong checklist will cover the necessary bases to ensure discharge is successful for the vast majority of patients.

The Robert Wood Johnson Foundation offers a good model for what a strong discharge checklist should look like, as does The important element these two checklists share is that they both empower patients and caregivers with points of action.

For example:

I understand what symptoms I need to watch out for and whom to call should I notice them.

This is a good example of how proper wording places the primary responsibility of care on the patient with ED staff acting as a guide. Nurses aren’t checking off the box when they relay necessary information to patients. Instead, patients and caregivers are checking the box off when they have a firm grasp on the information that’s been presented to them.

The discharge process for every ED is different, but the one tool each should be utilizing is a strong discharge checklist. While there’s not a “one-size-fits-all” checklist out there, Donovan and Partners is available to assess your ED and help you develop a tailored discharge checklist to lower return rates and improve the discharge process.  Contact us today at or 651-260-9918.

Robert Wood Johnson Foundation: “Care About Your Care Discharge Checklist & Care Transition Plan.” "Your Discharge Planning Checklist."

American College of Emergency Physicians: “Improving the ED Discharge Process.”