3. McCue JD: Group G streptococcal pharyngitis. ]AMA 1982;248: 1333-1336. 4. Gerber MA, Randolph MF, Martin N, et ah Outbreak of group G beta hemolytic streptococcal pharyngitis. (Abstract 1052). Pediatr Rea 1989;25:178A. 5. Schwartz RH, Shuhnan ST: Group C and Group G streptococci. CIin Pediatr 1986;25:496-502. 6. Lain K, Bayer L: Serious infections due to group G streptococci. Am ] Med 1983;75:561-570. 7. AuckenthalerR, Hermans PE, WashingtonJAII: Group G streptococcal bacteremia: Clinical study and review of the literature. Rev Infect Dia
1983;5:196-204. 8. Ralston KVI: Group G streptococcal inlections. (editorial). Arch [nter~l Med 1986;146:857-858. 9. Gallis HA: Viridansand {B-hemolyticnon-groupA and B streptococci, in Mandell GL, Douglas RG Ir, Bennett IE (eds): Principles mid Practice of Infectious Di.sease.s, ed 3. New York, Churchill Livingstone, 1990, p 1563-1672. 10. Kaplan EL, Top FH Jr, Dudding BA: I)iagnosis of streptococcal pharyngitis: Diffcrentiation of active infection from the carrier state in thc symptomatic child. / Infect Dis 1971;123:490-501. 11. Levy S, Brodsky L, Stanievichl: Hemorrhagic tnnsillitis. LmTngoscope 1989;99:15-18.
Auditing Emergency Department Return Visits To the Editor: A review of an emergency department quality assurance auditing policy similar to that u n d e r t a k e n by Keith et al [September 1989;18:964-968] led our department to a conclusion opposite that of the authors. Formerly, we used unscheduled return visits w i t h i n 72 hours of a prior visit as the "flag" criterion for chart audit (as did the authors). Rather than s u b s e q u e n t l y adopt a 48-hour criterion, however, we have opted to extend our review to unscheduled revisits made w i t h i n one week of a prior visit. We d i s c o v e r e d t h a t a m o n g p a t i e n t s w h o " b o u n c e d back" between two and seven days after their initial visits were those w i t h the following final diagnoses: append i c i t i s (originally diagnosed as g a s t r o e n t e r i t i s , u r i n a r y tract infection, viral syndrome, or nonspecific abdominal pain); m y o c a r d i a l i n f a r e t i o n / i s c h e m i c chest pain (originally given one of several incorrect diagnoses); m e n i n g i t i s (particularly pediatric) (originally diagnosed as viral syndrome or otitis media); and w o u n d infection/foreign body (following ED w o u n d closu[e). These items should appear familiar to those who have read ACEP's m o n o g r a p h on Risk Management.~ Cases involving these diagnoses coll e c t i v e l y c o m p r i s e 45% of all s u c c e s s f u l m a l p r a c t i c e claims against EDs and 62% of a l l s e t t l e m e n t m o n e y s awarded. With possible exception of the final item, the risk posed to patients is great. It is therefore m a n d a t o r y that quality assurance/risk m a n a g e m e n t directors become aware of any such patients who surface by way of revisit so that i n d i v i d u a l p h y s i c i a n and s y s t e m i c d e p a r t m e n t a l deficiencies can be identified and corrected. As shown in their Figure 3 pie chart, a return visit auditing criterion of 48 hours would exclude from review 8% of initially m i s m a n a g e d returning patients. Is this acceptable? Were there any high-risk patients, as in 1, 2, and 3 above, among this 8%? (Could there have been? - yes. Given sufficient v o l u m e and time, will there be? - yes.) I agree w i t h the authors that c o m p l e t e review of all charts of unscheduled return visit patients (whatever the return time criterion adopted) is a c u m b e r s o m e and timec o n s u m i n g task and that l i m i t i n g the review to specific high-risk diagnostic groups m a y be one way to overcome this. I would, however, advocate that the review undertaken capture return visits made beyond 48 hours. Having ourselves adopted seven days as our criterion, one could 19:8 August 1990
equally well ask us, why not ten days, 14 days, one m o n t h , two months, etc? The ideal quality assurance system m a y be one in which all patient charts are systematically reviewed and subjected to comprehensive standards and criteria, among which would be the question: Was this a prev e n t a b l e " b o u n c e back?" U n f o r t u n a t e l y , excepting the "paperless," (fully computerized) ED, this "100% audit" is beyond the capacity of all but the lowest-volume departments. Peter ] Marioni, MD, FACEP Critical Care ~ Emergency Medicine S U N Y Health Science Center Syracuse, N e w York
I. Rogers JT: Risk management in cmergcncy medicine, in Hellstern EA {ed): Emezgency Medicine Otgmliz~tion mid Manogemenl Seriex. Dallas, American College of Emergency Physicians, 1985. h i Reply:
We appreciate Dr M a r i a n i ' s colrrn'mnts. In our s e t t i n g we have not found r e t u r n visits for appendicitis, m e n ingitis, or myocardial infarction that were truly related to the first emergency department visit to return seven days after initial evaluation. We feel that the natural course of these disease states precludes m a n y returns after such a prolonged period of time. Each ED, however, has its own unique quality assurance problems, and any audit performed therefore m u s t be tailored for that specific setting. We agree with Dr Mariani that the best audit would review each related return visit, but in our setting the 48-hour return audit serves as an excellent tool to uncover the great majority of our quality assurance deficiencies w i t h o u t generating an insurmc)untable n u m b e r of charts for review. Kinlberly D Keith, M D Emergency D e p a r t m e n t Winchester Medical Center Winchester, Virginia Ron~Tld L Kronle, M D D e p a r t m e n t of Ewlergency Medicine WilJianl Beounlont Hospital Royal Oe~k, Michignzl
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1983;5:196-204. 8. Ralston KVI: Group G streptococcal inlections. (editorial). Arch [nter~l Med 1986;146:857-858. 9. Gallis HA: Viridansand {B-hemolyticnon-groupA and B streptococci, in Mandell GL, Douglas RG Ir, Bennett IE (eds): Principles mid Practice of Infectious Di.sease.s, ed 3. New York, Churchill Livingstone, 1990, p 1563-1672. 10. Kaplan EL, Top FH Jr, Dudding BA: I)iagnosis of streptococcal pharyngitis: Diffcrentiation of active infection from the carrier state in thc symptomatic child. / Infect Dis 1971;123:490-501. 11. Levy S, Brodsky L, Stanievichl: Hemorrhagic tnnsillitis. LmTngoscope 1989;99:15-18.
Auditing Emergency Department Return Visits To the Editor: A review of an emergency department quality assurance auditing policy similar to that u n d e r t a k e n by Keith et al [September 1989;18:964-968] led our department to a conclusion opposite that of the authors. Formerly, we used unscheduled return visits w i t h i n 72 hours of a prior visit as the "flag" criterion for chart audit (as did the authors). Rather than s u b s e q u e n t l y adopt a 48-hour criterion, however, we have opted to extend our review to unscheduled revisits made w i t h i n one week of a prior visit. We d i s c o v e r e d t h a t a m o n g p a t i e n t s w h o " b o u n c e d back" between two and seven days after their initial visits were those w i t h the following final diagnoses: append i c i t i s (originally diagnosed as g a s t r o e n t e r i t i s , u r i n a r y tract infection, viral syndrome, or nonspecific abdominal pain); m y o c a r d i a l i n f a r e t i o n / i s c h e m i c chest pain (originally given one of several incorrect diagnoses); m e n i n g i t i s (particularly pediatric) (originally diagnosed as viral syndrome or otitis media); and w o u n d infection/foreign body (following ED w o u n d closu[e). These items should appear familiar to those who have read ACEP's m o n o g r a p h on Risk Management.~ Cases involving these diagnoses coll e c t i v e l y c o m p r i s e 45% of all s u c c e s s f u l m a l p r a c t i c e claims against EDs and 62% of a l l s e t t l e m e n t m o n e y s awarded. With possible exception of the final item, the risk posed to patients is great. It is therefore m a n d a t o r y that quality assurance/risk m a n a g e m e n t directors become aware of any such patients who surface by way of revisit so that i n d i v i d u a l p h y s i c i a n and s y s t e m i c d e p a r t m e n t a l deficiencies can be identified and corrected. As shown in their Figure 3 pie chart, a return visit auditing criterion of 48 hours would exclude from review 8% of initially m i s m a n a g e d returning patients. Is this acceptable? Were there any high-risk patients, as in 1, 2, and 3 above, among this 8%? (Could there have been? - yes. Given sufficient v o l u m e and time, will there be? - yes.) I agree w i t h the authors that c o m p l e t e review of all charts of unscheduled return visit patients (whatever the return time criterion adopted) is a c u m b e r s o m e and timec o n s u m i n g task and that l i m i t i n g the review to specific high-risk diagnostic groups m a y be one way to overcome this. I would, however, advocate that the review undertaken capture return visits made beyond 48 hours. Having ourselves adopted seven days as our criterion, one could 19:8 August 1990
equally well ask us, why not ten days, 14 days, one m o n t h , two months, etc? The ideal quality assurance system m a y be one in which all patient charts are systematically reviewed and subjected to comprehensive standards and criteria, among which would be the question: Was this a prev e n t a b l e " b o u n c e back?" U n f o r t u n a t e l y , excepting the "paperless," (fully computerized) ED, this "100% audit" is beyond the capacity of all but the lowest-volume departments. Peter ] Marioni, MD, FACEP Critical Care ~ Emergency Medicine S U N Y Health Science Center Syracuse, N e w York
I. Rogers JT: Risk management in cmergcncy medicine, in Hellstern EA {ed): Emezgency Medicine Otgmliz~tion mid Manogemenl Seriex. Dallas, American College of Emergency Physicians, 1985. h i Reply:
We appreciate Dr M a r i a n i ' s colrrn'mnts. In our s e t t i n g we have not found r e t u r n visits for appendicitis, m e n ingitis, or myocardial infarction that were truly related to the first emergency department visit to return seven days after initial evaluation. We feel that the natural course of these disease states precludes m a n y returns after such a prolonged period of time. Each ED, however, has its own unique quality assurance problems, and any audit performed therefore m u s t be tailored for that specific setting. We agree with Dr Mariani that the best audit would review each related return visit, but in our setting the 48-hour return audit serves as an excellent tool to uncover the great majority of our quality assurance deficiencies w i t h o u t generating an insurmc)untable n u m b e r of charts for review. Kinlberly D Keith, M D Emergency D e p a r t m e n t Winchester Medical Center Winchester, Virginia Ron~Tld L Kronle, M D D e p a r t m e n t of Ewlergency Medicine WilJianl Beounlont Hospital Royal Oe~k, Michignzl
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