Background

Unplanned returns to the emergency department (ED) and readmission rates following orthopaedic surgery are important markers for quality of care. A recent quality improvement project at Duke Health revealed that Black patients were more likely to present to the ED after orthopaedic surgery without a difference in readmission rates compared to white patients. 

While a return to the ED may be appropriate in the case of surgical complications, it can also represent a lapse in quality or inadequate discharge counseling, especially when the patient isn’t readmitted to the hospital. Furthermore, these return visits are costly to both patients and the healthcare system. 

This data suggests a need to examine current discharge practices and institute an intervention that mitigates a racial disparity in unplanned returns to the ED. 

Project Description

The aim of this project is to characterize clinical details for return to ED within 30 and 90 days after orthopaedic surgery, and to adjust clinical practice and discharge counseling in order to help combat this underlying racial disparity. 

This team will seek to classify what issues cause patients to return to the ED following orthopaedic surgery and identify any that may disproportionately affect vulnerable or marginalized populations. Using this data, the team will design an intervention for predischarge counseling or follow-up to help mitigate underlying drivers of disparities in ED return, with continued measurement of ED return rates. 

The team will study deidentified medical records and demographic data from adults who underwent orthopedic surgery from 2017-2021 in the Duke University Health System and presented to the ED within 30-90 days postoperatively (approximately 400 patients total). Chief complaints in the ED will be collected and categorized. 

After examining demographic data (race, age, sex, ethnicity, zip code, financial class) and clinical data (patient history, type of surgery, complications, details of return to ED), the team will work to understand clinical drivers of disparity in ED return. In light of their findings, team members will develop tools to improve postoperative and predischarge counseling, then implement these interventions and assess their effectiveness.

Anticipated Outputs

Improved guidance for patients discharged from orthopaedic surgery; implementation of other interventions to decrease disparities in return to ED; manuscript for publication; research posters and presentations

Student Opportunities

Ideally, this team will include 3-5 graduate and 3-5 undergraduate students. Students from a variety of disciplines who are interested in addressing healthcare disparities are encouraged to apply. Medical students may particularly benefit from participation on this team.

Team members will have the opportunity to work with orthopedic surgeons, nurses, case managers, physical therapists and emergency medicine physicians from Duke University Hospital. They will gain experience in quality improvement research — such as study design, survey collection, intervention implantation, quality metrics and manuscript writing — while working to address health disparities that affect the Durham community.

This project includes an optional summer component during Summer 2023. This summer work can be done virtually, and the time commitment will be flexible. Some team members may have the opportunity to travel to an orthopaedic surgery conference in Summer 2024.

Kiera Lunn and Jay Swayambunathan will serve as project managers.

In Fall 2023, this team will meet on Wednesdays from 6:00 to 7:00 p.m.

Timing

Summer 2023 – Spring 2024

• Summer 2023 (optional): Work to obtain IRB approval and begin processing data
• Fall 2023: Analyze data; draft and submit manuscript for publication; design tools to address ED returns 
• Spring 2024: Implement tools; measure outcomes

Crediting

Academic credit available for fall and spring semesters; summer funding available

Foot and Ankle Orthopaedic Surgeon Andrew Hanselman, MD, examines a patient’s achilles during an appointment at Duke Orthopaedics Heritage, by Erin Hull/Duke Health