title: Qualitative factors in patients who die shortly after emergency department discharge.
abstract: OBJECTIVE
  Early death after emergency department (ED) discharge may signal opportunities to improve care. Prior studies are limited by incomplete mortality ascertainment and lack of clinically important information in administrative data. The goal in this hypothesis-generating study was to identify patient and process of care themes that may provide possible explanations for early postdischarge mortality.
  
  
  METHODS
  This was a qualitative analysis of medical records of adult patients who visited the ED of any of six hospitals in an integrated health system (Kaiser Permanente Southern California [KPSC]) and died within 7 days of discharge in 2007 and 2008. Nonmembers, visits to non-health plan hospitals, patients receiving or referred to hospice care, and patients with do not attempt resuscitation or do not intubate orders (DNAR/DNI) were excluded. Under the guidance of two qualitative research scientists, a team of three emergency physicians used grounded theory techniques to identify patient clinical presentations and processes of care that serve as potential explanations for poor outcome after discharge.
  
  
  RESULTS
  The source population consisted of a total of 290,092 members with 446,120 discharges from six KPSC EDs in 2007 and 2008. A total of 203 deaths occurred within 7 days of ED discharge (0.05%). Sixty-one randomly chosen cases were reviewed. Patient-level themes that emerged included an unexplained persistent acute change in mental status, recent fall, abnormal vital signs, ill-appearing presentation, malfunctioning indwelling device, and presenting symptoms remaining at discharge. Process-of-care factors included a discrepancy in history of present illness, incomplete physical examination, and change of discharge plan by a third party, such as a consulting or admitting physician.
  
  
  CONCLUSIONS
  In this hypothesis-generating study, qualitative research techniques were used to identify clinical and process-of-care factors in patients who died within days after discharge from an ED. These potential predictors will be formally tested in a future quantitative study.
authors.affiliation: Department of Medicine, University of California-Los Angeles, Los Angeles, CA; Department of Medicine, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA; Emergency Medicine Center, Ronald Reagan UCLA, Los Angeles, CA.
authors.forename: Gelareh Z
authors.initials: GZ
authors.lastname: Gabayan
authors.forename: Benjamin C
authors.initials: BC
authors.lastname: Sun
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
authors.forename: Stefan
authors.initials: S
authors.lastname: Timmermans
authors.forename: Catherine
authors.initials: C
authors.lastname: Sarkisian
authors.forename: Sau
authors.initials: S
authors.lastname: Yiu
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Lancaster
authors.forename: K Trudy
authors.initials: KT
authors.lastname: Poon
authors.forename: Arthur L
authors.initials: AL
authors.lastname: Kellermann
authors.forename: Gery
authors.initials: G
authors.lastname: Ryan
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Miniel
authors.forename: Drew
authors.initials: D
authors.lastname: Flansbaum
authors.forename: Jerome R
authors.initials: JR
authors.lastname: Hoffman
authors.forename: Stephen F
authors.initials: SF
authors.lastname: Derose
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002140:California; D002423:Cause of Death; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data*; D036301:Qualitative Research; D012307:Risk Factors; D055815:Young Adult
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