title: Patient safety analysis of the ED care of patients with heart failure and COPD exacerbations: a multicenter prospective cohort study.
abstract: OBJECTIVE
  For emergency department (ED) patients with acute exacerbations of heart failure and chronic obstructive pulmonary disease (COPD), we aimed to assess the adherence to evidence-based care and determine the proportion that experienced adverse events.
  
  
  METHODS
  An expert panel identified critical actions for ED care of heart failure and COPD patients based on clinical practice guidelines. We collected outcome data for discharged ED patients >age 50 with acute heart failure or COPD in a multicenter prospective cohort study at five academic EDs. We measured 3 flagged outcomes: return ED visit, admission, or death within 14 days. Three trained physician reviewers reviewed case summaries for adverse event determination (flagged outcomes related to healthcare received). We evaluated health records for adherence to the critical actions for each condition.
  
  
  RESULTS
  We identified 122 (7.0%) flagged outcomes among 1,718 enrolled patients (61 heart failure, 59 COPD and 2 dual diagnoses). The mean age was 74.2 (SD 10.4) and 44.3% were female. Among 10 critical actions for heart failure and 13 for COPD, a mean proportion of 9.4/10 and 11.0/13 were adhered to respectively. We identified 12 adverse events (9.8%, 95%CI: 5.6-16.5%), all of which were deemed preventable, including 1 death. The most common contributors were unsafe disposition decisions (10/12, 83.3%) and diagnostic issues (5/12, 41.7%). Patients who died with heart failure were statistically significantly less likely to have guideline adherent care (P = .02).
  
  
  CONCLUSIONS
  A small proportion of return ED visits were related to index care. We believe there is need for improvement around disposition decision making for both conditions to reduce the highly preventable and clinically significant adverse events we found.
authors.affiliation: Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada K1Y 4E9; Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital-Civic Campus, Ottawa, Ontario, Canada K1Y 4E9. Electronic address: lcalder@ohri.ca.
authors.forename: Lisa
authors.initials: L
authors.lastname: Calder
authors.affiliation: Department of Medicine, Queens University, Etherington Hall, Kingston, Ontario, Canada K7L 3N6.
authors.forename: Sarah
authors.initials: S
authors.lastname: Tierney
authors.affiliation: Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada K1Y 4E9.
authors.forename: Yue
authors.initials: Y
authors.lastname: Jiang
authors.affiliation: Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada K1Y 4E9.
authors.forename: Austin
authors.initials: A
authors.lastname: Gagné
authors.affiliation: Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada K1Y 4E9.
authors.forename: Andrew
authors.initials: A
authors.lastname: Gee
authors.affiliation: Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada K1Y 4E9.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Hobden
authors.affiliation: Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada K1Y 4E9; Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital-Civic Campus, Ottawa, Ontario, Canada K1Y 4E9.
authors.forename: Christian
authors.initials: C
authors.lastname: Vaillancourt
authors.affiliation: Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada K1Y 4E9; Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital-Civic Campus, Ottawa, Ontario, Canada K1Y 4E9.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Perry
authors.affiliation: Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada K1Y 4E9; Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital-Civic Campus, Ottawa, Ontario, Canada K1Y 4E9.
authors.forename: Ian
authors.initials: I
authors.lastname: Stiell
authors.affiliation: Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital-Civic Campus, Ottawa, Ontario, Canada K1Y 4E9; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5.
authors.forename: Alan
authors.initials: A
authors.lastname: Forster
mesh_terms: D000368:Aged; D004636:Emergency Service, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D008297:Male; D061214:Patient Safety / Q000592:standards* / Q000706:statistics & numerical data; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000628:therapy*; D016896:Treatment Outcome