Improving Reassessment Documentation in Patients With Prolonged Emergency Department Length of Stay

Patients with prolonged emergency department (ED) length of stay (LOS) are at an increased risk of clinical deterioration and adverse medication events, often due to missed doses of home medications . We evaluated the impact of a reassessment focused documentation intervention on frequency and depth of reassessment documentation among patients with prolonged ED LOS and examined changes in ordering of high-risk home medications.

We conducted a pre/post quality improvement study of ED encounters with extended ED LOS (>8 hours) before and after standardized smart phrases containing reassessment language/components and a visual ED trackboard indicator highlighting patients in the 6-10 hours LOS reassessment window. Reassessment documentation was identified used text-based keyword matching for “reassess” and related variants and excluded those include in hand-off or sign out notes . Outcomes included the proportion of encounters with reassessment documentation, number of reassessments notes per encounter, and documentation depth using word-count threshold. A secondary measure looked at ordering rates of selected medication commonly omitted during prolonged ED stays with potential adverse effects (insulin, antiepileptics, anti-rejection medications).

A total of 4,201 encounters were analyzed pre-intervention and 4,552 post interventions. The proportion of encounters with documented reassessment increased from 33.3% to 88.9% (95% CI 53.3-57.9). Encounters with reassessment notes exceeding 20 words increased from 26.7% to 85.1% (95% CI 56.0-60.7), and those exceeding 40 words increased from 13.3% to 34.5% (95% CI 19.4-23.1). The total number of reassessment notes increased from 1,1917 to 5,728. Lantus Ordering increased from 1.81% to 2.75% (95% CI 0.05-1.81), while changes in other medications were not statistically significant.

A multifaceted approach aimed at structuring patient reassessment in those with prolonged ED LOS led to substantial increase in frequency and depth of assessment. In addition, a statistically significant increase in Lantus ordering indicates that improved reassessment can improve the ordering of home medications, which can reduce downstream adverse events due to missed home medications. events due to missed home medications.