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The Effect of Diagnosis-Specific Computerized Discharge Instructions on 72-Hour Return Visits to the Pediatric Emergency Department

Lawrence, Laurie M. MD*; Jenkins, Cathy A. MS†; Zhou, Chuan PhD‡§; Givens, Timothy G. MD¶

doi: 10.1097/PEC.0b013e3181bec817
Original Articles

Objective: The number of patients returning to the pediatric emergency department (PED) within 72 hours of discharge is frequently cited as a benchmark for quality patient care. The purpose of this study was to determine whether the introduction of diagnosis-specific computer-generated discharge instructions would decrease the number of medically unnecessary return visits to the PED.

Methods: A retrospective chart review of patients who returned to the PED within 72 hours of discharge was performed. Charts were reviewed from 2 comparable periods: September 2004 to February 2005, when handwritten discharge instructions were issued to each patient, and September 2005 to February 2006, when each patient received computer-generated diagnosis-specific discharge instructions. The patient's age, primary care provider, insurance status, chief complaint, vital signs, history, physical examination, plan of care, and diagnosis at each visit were recorded. Cases were excluded if the patient left against medical advice or without being seen, was admitted to the hospital on the first visit, or had incomplete or missing records. The medical necessity of the return visit was rated as "yes," "no," or "indeterminate" based on review of the visit noting reason for return, history and physical examination, diagnosis, and interventions or changes in the initial care plan.

Results: Of all return visits to the PED within 72 hours of discharge, 13% were deemed unnecessary for patients receiving handwritten instructions compared with 15% for patients receiving computer-generated instructions (P = 0.5, not significant). For each additional year of age, the return visit was 1.07 times as likely to be medically appropriate (95% confidence interval, 1.03-1.12; P = 0.002). Patients who returned to the PED more than once were 2.69 times more likely to have a medically appropriate visit as were those with only 1 return visit (95% confidence interval, 0.95-7.58; P = 0.062).

Conclusions: Computer-generated diagnosis-specific discharge instructions do not decrease the number of medically unnecessary repeat visits to the PED.

From the *Division of Pediatric Emergency Medicine, Department of Pediatrics; †Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN; ‡Seattle Children's Hospital Research Intitute; §Department of Pediatrics, University of Washington, Seattle, WA; and ¶Section of Emergency Medicine, University of Colorado School of Medicine, Denver, CO.

Reprints: Laurie M. Lawrence, MD, Pediatrics and Emergency Medicine, 703 Oxford House, Vanderbilt University Medical Center, Nashville, TN 37232 (e-mail: laurie.lawrence@vanderbilt.edu).

© 2009 Lippincott Williams & Wilkins, Inc.