Lots of patients we see in the ED do not require hospital admission and this is especially true of the paediatric ED where children often attend with parents seeking advice for management of viral illnesses or treatment for minor injuries. Communication and reassurance is a huge part of our role, especially where children are concerned and assessment is that much more tricky.
At RMCH we are keen to provide support beyond the ED attendance; we have close links to our local Children’s Community Nurses, health visitors and midwives and encourage our clinicians to consider whether referral to these community services might be beneficial. It can help us to remember that few people (parents especially!) want to be in the Emergency Department but have brought their child because they are concerned about something. The conversations we have in these situations – safety netting, explaining what sort of clinical course we expect the illness or injury to take, “red flag” symptoms which would indicate a need to return to ED – are also key in preventing complaints and informing future healthcare access decision-making.
Of course, we have an interest beyond ensuring that patients, parents and carers get what they need from their ED attendance; one of CEM’s quality indicators is a reduction in unplanned reattendance rates. CEM states that reattendance rates are a “very useful surrogate marker of the quality care that an ED delivers.” We want people to get the care they need on their first attendance.
So what if we could further reduce our reattendance rates with a follow-up phone call? It would mean we could answer those questions people think of just after they’ve left, reiterate our safety netting advice and provide guidance on alternative healthcare access points in the community – right?
This paper from Canada asks exactly that. Have a look at the abstract below and then go online to read the full article (it’s paywall protected sadly, but you can’t have everything).
[DDET What kind of study was this?]
A single-centre, pseudo-randomised controlled trial based in British Columbia. Patients were identified as likely to be discharged from PED and then recruited to either receive standard care (no follow-up) or a follow-up phone call within 12-24h of PED discharge, where a medical student asked about the child’s condition and whether the caregiver had any questions (although they didn’t actually answer them!).
It’s not clear what pseudo randomisation means in this paper; it seems to imply that allocation to control or intervention was determined by the time of attendance which could be a major confounder. Crucially, parents were blinded to the specific outcome of the study to avoid observation bias (the Hawthorne effect). [/DDET]
[DDET Do these patients sound like ours?]
British Columbia and its healthcare systems are likely to be similar in quality to the UK although funding of healthcare systems is insurance-driven and access to primary care may not be equal. However the results section reveals some interesting subject demographics; average patient age was 5.7 years and average parental age 38.3 years – I don’t know for certain but I’d be surprised if average parental age in our ED wasn’t quite a bit lower. This may carry some implications in the context of social class and parental experience but of course this is simply speculation. [/DDET]
[DDET What did they find?]
Reattendances were higher in the intervention group –
24/171 in the study group reattended within 72h (14%)
14/200 in the control group reattended within 72h (7%)
This seems to suggest that phoning people actually makes them more likely to reattend. [/DDET]
[DDET Does this make sense?]
It might do – remember that these phone calls necessitated the articulation of concerns about their child’s condition and any associated unanswered questions, without that all-important opportunity for answers and reassurance. It’s certainly possible that if you phone someone and remind them that they are a bit worried about their child, they might decide to reattend! [/DDET]
[DDET Are there any other methodological issues or unanswered questions?]
Yes, quite a few. It’s not clear how the outcome measure was actually measured – both groups had a follow-up call at 96h so it may be that the outcome was determined by parental reporting at this time. This might have been more reliable if an objective method such as the ED’s own records was used. The study also lacks a power calculation so we’re not sure if there were sufficient subjects to be able to detect a difference between the groups occurring beyond random chance.
Of course, the outcome should also be clinically relevant and unfortunately we don’t know what happened to those who reattended. Imagine that of the 24 in the intervention group, 14 were admitted to PICU and the other 10 were discharged. In the control group, all 14 were immediately discharged from ED. This is an extreme example but it would put a totally different interpretation on the results – so I’m not sure we can take these numbers at face value. [/DDET]
[DDET So what now?]
This study plants the seed of a great idea and in some ways it’s helpful to know that there’s no role for non-healthcare professional telephone follow-up. But what if we got healthcare professionals to make the calls? Would this be cost-effective? Would it work? It would be a great little study to look at reattendances and their ultimate outcomes… [/DDET]
So, no reason to start calling all the discharged patients – yet. But the study certainly throws up some interesting questions and I wonder what we would find if we delved a little deeper.
If you are thinking about the FCEM Critical Appraisal paper, head on over to the PEMLit version of this post which includes an FCEM-style abstract.
[DDET Try these FCEM style questions]
- 1. What does a p value of 0.03 mean?
- 2. Are the results of this study transferrable to your practice? Explain why.
- 3. Calculate the number needed to treat (perhaps number needed to phone) to produce one additional return vist to the ED.