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OBJECTIVES: Early death after emergency department (ED) discharge may signal opportunities to improve care. Prior studies are limited by incomplete mortality ascertainment and lack of clinically important information in administrative data. The goal in this hypothesis-generating study was to identify patient and process of care themes that may provide possible explanations for early postdischarge mortality. METHODS: This was a qualitative analysis of medical records of adult patients who visited the ED of any of six hospitals in an integrated health system (Kaiser Permanente Southern California [KPSC]) and died within 7 days of discharge in 2007 and 2008. Nonmembers, visits to non-health plan hospitals, patients receiving or referred to hospice care, and patients with do not attempt resuscitation or do not intubate orders (DNAR/DNI) were excluded. Under the guidance of two qualitative research scientists, a team of three emergency physicians used grounded theory techniques to identify patient clinical presentations and processes of care that serve as potential explanations for poor outcome after discharge. RESULTS: The source population consisted of a total of 290,092 members with 446,120 discharges from six KPSC EDs in 2007 and 2008. A total of 203 deaths occurred within 7 days of ED discharge (0.05%). Sixty-one randomly chosen cases were reviewed. Patient-level themes that emerged included an unexplained persistent acute change in mental status, recent fall, abnormal vital signs, ill-appearing presentation, malfunctioning indwelling device, and presenting symptoms remaining at discharge. Process-of-care factors included a discrepancy in history of present illness, incomplete physical examination, and change of discharge plan by a third party, such as a consulting or admitting physician. CONCLUSIONS: In this hypothesis-generating study, qualitative research techniques were used to identify clinical and process-of-care factors in patients who died within days after discharge from an ED. These potential predictors will be formally tested in a future quantitative study.

ObjectivesEarly death after emergency department (ED) discharge may signal opportunities to improve care. Prior studies are limited by incomplete mortality ascertainment and lack of clinically important information in administrative data. The goal in this hypothesis-generating study was to identify patient and process of care themes that may provide possible explanations for early postdischarge mortality.MethodsThis was a qualitative analysis of medical records of adult patients who visited the ED of any of six hospitals in an integrated health system (Kaiser Permanente Southern California [KPSC]) and died within 7 days of discharge in 2007 and 2008. Nonmembers, visits to non-health plan hospitals, patients receiving or referred to hospice care, and patients with do not attempt resuscitation or do not intubate orders (DNAR/DNI) were excluded. Under the guidance of two qualitative research scientists, a team of three emergency physicians used grounded theory techniques to identify patient clinical presentations and processes of care that serve as potential explanations for poor outcome after discharge.ResultsThe source population consisted of a total of 290,092 members with 446,120 discharges from six KPSC EDs in 2007 and 2008. A total of 203 deaths occurred within 7 days of ED discharge (0.05%). Sixty-one randomly chosen cases were reviewed. Patient-level themes that emerged included an unexplained persistent acute change in mental status, recent fall, abnormal vital signs, ill-appearing presentation, malfunctioning indwelling device, and presenting symptoms remaining at discharge. Process-of-care factors included a discrepancy in history of present illness, incomplete physical examination, and change of discharge plan by a third party, such as a consulting or admitting physician.ConclusionsIn this hypothesis-generating study, qualitative research techniques were used to identify clinical and process-of-care factors in patients who died within days after discharge from an ED. These potential predictors will be formally tested in a future quantitative study.

Background: This study sought to describe the activities and participation of adolescents with autism spectrum disorders (ASD) in Singapore and to examine the suitability of the Activity and Participation component of the International Classification of Functioning, Disability and Health for achieving this purpose. This information may guide the development of intervention programmes for adolescents and adults as well as the provision of a means to document meaningful outcomes. Methods: Parents of 20 adolescents with ASD attending special schools in Singapore were interviewed using the Vineland Adaptive Behavioural Scales-Second Edition and the Activities and Participation Rating Scale (APRS), which was developed for this study. Results: The adolescents with ASD were rated to have more difficulties with participation than with the engagement of activities. Individual domain analyses indicate no difficulties with mobility and mild difficulties with self-care. The performance of general tasks and demands were rated as less problematic than domestic, major life areas, communication and interpersonal interactions. The adolescents with ASD were rated to have more difficulties in communication and community environments than in at home. In addition, analysis of associations between the APRS and Vineland Adaptive Behavioural Scales-Second Edition reveal a pattern of strong relationships between sub-tests. Conclusion: This study highlights the imperative for researchers and practitioners alike to develop a focus on strengths, generalisation and the quality of life of adolescents with ASD. The APRS also shows promise in helping document outcomes for adolescents with ASD in Asia and further development of this instrument is needed.

This study aimed to investigate the effect of a computerized visual perception and visual-motor integration training program to enhance Chinese handwriting performance among children with learning difficulties, particularly those with handwriting problems. Participants were 26 primary-one children who were assessed by educational psychologists and occupational therapists to have handwriting difficulties. They were matched according to their age and then randomly assigned into either the control group or the experimental group. Subjects in the experimental group (n = 13) would receive eight sessions of computerized visual perception and visual-motor integration training together with a home training program while those in the control group (n = 13) would only receive conventional handwriting training by teachers, which focused mainly on remedial handwriting exercises. Results from repeated measure ANOVA revealed that children in the experimental group showed improvements in their visual perception skills as well as in their handwriting time. Both the "On Paper" time and "In Air" time of this group were improved when compared to the control group. However, no significant differences were found in visual-motor integration skill and handwriting legibility between the two groups after the intervention. This computerized training program focusing on visual perception and visual-motor integration training appeared to be effective in enhancing the handwriting time among children with handwriting difficulties. However, the training program did not seem to improve the legibility of children. (Contains 2 tables and 3 figures.)

This paper focuses on the representation of a proper fraction "a"/"b" by a decimal number base "n" where "n" is any integer greater than 1. The scope is narrowed to look at only fractions where "a","b" are positive integers with "a" less than "b" and "b" not equal to 0 nor equal to 1. Some relationships were found between "b" and "n", which determine whether the representation will become either finite decimal, pure recurring decimal or mixed decimal base "n". Three theorems have been proven to indicate the deciding factors and the relationships. In addition, the length of the finite decimal numbers base "n" was further explored.