Unplanned re-attendance in the accident and emergency department

An Analysis of Unscheduled Return Visits to the Accident and Emergency Department of a General Public Hospital

Objectives

To identify the reasons for unscheduled return visits to a public emergency department and possible strategies to reduce unscheduled return visits.

Design

Cross-sectional survey.

Setting

A public emergency department in Hong Kong.

Patients

Unscheduled return visits within 48 hours in a three-month period from 14 January 2000 to 15 April 2000.

Main outcome measures

Patients' epidemiological characteristics, reasons, complaints and outcome of the unscheduled return visits.

Results

During the study period, 3.3% (1,060) of the attendance was unscheduled return visits within 48 hours as recorded in the computerized A&E Information System of the hospital. However, only 738 patients (70%) responded to the questionnaire. These 738 patients formed the study population for further analysis. Illness-related factors accounted for 87% of the total unscheduled return visits. Patient-related factors were responsible for about 10% of unscheduled return visits. Doctor-related factors accounted for about 3% of unscheduled return visits. There was only one system-related unscheduled return visit. For the outcome of return visits, about 76% (559) was discharged after the second consultation. About 5% (40) was referred to specialist clinics. Around 24% (179) of patients was admitted. Of those admitted, 78% (140) was illness-related, 13% (23) was patient-related and 9% (16) was doctor-related. Upper respiratory tract infection was the most frequent complaint (34%), followed by painful conditions (23%) and injuries (10%). For children at or below 10 years of age, upper respiratory tract infection (60%) and febrile illness (15%) were the most frequent complaints.

Conclusions

The study found that the reasons for return visits were multiple. These “unscheduled return visits” should not be automatically regarded as poor indicator of service. Better patient education, organized family practice system, upgrading of professional training and targeted audit are possible means to reduce unscheduled return visits.

Social deprivation and adult blunt chest trauma: A retrospective study

INTRODUCTION

The relationship between socioeconomic status and various components of health is well established. Research has also highlighted that social deprivation can affect patterns of injury and outcome after trauma. The interaction between outcomes following blunt chest trauma and socioeconomic status has received limited attention in trauma research. The aim of this study was to investigate the relationship between socioeconomic factors, mechanisms of injury and outcomes following blunt chest trauma using deprivation measures calculated on the basis of domicile postcodes.

METHODS

A retrospective study design was used in order to examine the medical notes of all blunt chest wall trauma patients who presented to the ED of a large regional trauma centre in South West Wales in 2012 and 2013. Baseline characteristics were presented as median and interquartile range or numbers and percentages. Differences between the baseline characteristics were analysed using Mann-Whitney U test and Fisher's exact test. Odds ratios and 95% confidence intervals were presented from the univariable analysis. Multivariable logistic regression analysis was used to identify significant predictors for the development of complications.

RESULTS

Patients in the 'more deprived' group were more likely to be the victims of assault (p < 0.001) and were more likely to have an unplanned re-attendance at the Emergency Department than the patients in the 'less deprived' group (p < 0.001). On multivariable analysis, social deprivation was not a risk factor for the development of complications, but it was a significant risk factor for prolonged length of stay (p < 0.05).

CONCLUSIONS

This is the first study in which social deprivation has been investigated as a risk factor for complications following isolated blunt chest wall trauma. Residing in a 'more deprived' area in South West Wales is not associated with the development of complications following isolated blunt chest wall trauma.

Unscheduled return visits (URV) in adults to the emergency department (ED): a rapid evidence assessment policy review

Unscheduled return visits (URV) to the emergency department (ED) may be an important quality indicator of performance of individual clinicians as well as organisations and systems responsible for the delivery of emergency care. The aim of this study was to perform a rapid evidence assessment policy-based literature review of studies that have looked at URVs presenting to the ED. A rapid evidence assessment using SCOPUS and PUBMED was used to identify articles looking at unplanned returns to EDs in adults; those relating to specific complaints or frequent attenders were not included. After exclusions, we identified 26 articles. We found a reported URV rate of between 0.4% and 43.9% with wide variation in the time period defined for a URV, which ranged from 24 h to undefined. Thematic analysis identified four broad subtypes of URVs: related to patient factors, to the illness, to the system or organisation and to the clinician. This review informed the development of national clinical quality indicators for England. URV rates may serve as an important indicator of quality performance within the ED. However, review of the literature shows major inconsistencies in the way URVs are defined and measured. Furthermore, the review has highlighted that there are potentially at least four subcategories of URVs (patient related, illness related, system related and clinician related). Further work is in progress to develop standardised definitions and methodologies that will allow comparable research and allow URVs to be used reliably as a quality indicator for the ED.

Characteristics and diagnoses of neonates who revisit a pediatric emergency center

OBJECTIVE

Families with neonates may utilize emergency centers (ECs) for nonurgent complaints. We sought to describe the demographic and clinical characteristics of neonates evaluated in an urban tertiary children's EC more than once in a 5-day period and to determine the frequency of serious illnesses and admission at the second visit.

METHODS

We conducted a retrospective case series of neonates (aged <29 days) who visited the EC, were discharged home, and returned within 5 days during a 3-year period.

RESULTS

There were 147 study neonates (2.4% of all newborn EC patients) with an average age of 16 days at the first visit and a median 3 days between visits. Sixteen patients (11% of returning patients) returned with fever (≥38 °C); 15 patients (10%) returned with respiratory distress or hypoxemia, and 56 (38%) required admission at the second visit. Patients diagnosed with gastroesophageal reflux and/or vomiting at the first visit had a high frequency of admission (55%) and pyloric stenosis (26%) at the second visit.

CONCLUSIONS

Of neonates discharged from the EC with nonurgent medical issues, more than a third of those revisiting the EC required admission within 5 days. The risk of fever, respiratory distress, and admission was higher in neonates who originally presented with infectious symptoms than neonates who presented with noninfectious process. Of neonates presenting twice with gastroesophageal reflux and/or vomiting, almost a third had pyloric stenosis, indicating that close follow-up of vomiting neonates is needed.

Unscheduled return visits to the emergency department: consequences for triage

OBJECTIVES

The objective was to conduct a survey of unscheduled revisits (URs) to the emergency department (ED) within 8 days of a prior visit, to test the hypothesis that patients making these URs are disproportionately likely to suffer short-term mortality or manifest a need for any admission to the hospital (adverse events [AEs]) at the time of the UR, compared to patients triaged at the same level who did not have an unscheduled ED revisit within 8 days.

METHODS

This was a 1-year retrospective study of patients with an UR to the ED of an urban, 1,600-bed tertiary care center and teaching hospital. The criteria for inclusion as an UR were: 1) making an emergency visit to our adult ED during 2008, without being admitted to our hospital nor being transferred to another hospital; and 2) subsequently making an UR to the same ED within 8 days following the first one. Patients who were contacted by members of our staff and specifically asked to make return visits to our ED (such as those who returned for wound care follow-up visits), and those who made more than five visits to our ED during 2008, were excluded. AEs were defined as death or hospitalization within 8 days of the second visit.

RESULTS

During 2008, there were 946 patients with URs (2% of patients treated and released after the first ED visit), and 931 were analyzed (n = 15 missing values). Associated with the second visit, an AE was noted for 276 (30%) patients. Eight variables were significantly associated with AE: age ≥ 65 years, previously diagnosed cancer, previously diagnosed cardiac disease, previously diagnosed psychiatric disease, presence of a relative at the time of the UR, arrival with a letter from a general practitioner at the time of the UR, a higher level of severity assigned at triage for the UR than for the first ED visit, and having had blood sample analysis performed during the first visit. The median triage score for the UR was not significantly different from that group's median triage score for the first ED visit, whereas the proportion of admissions to the hospital (29%) or to the intensive care unit (ICU; 2%) was greater overall in the UR group than in the patients making their first ED visit.

CONCLUSIONS

The authors observed that 2% of patients had an UR. This UR population was at greater risk of AE at the time of their URs compared to their initial visits, but the median triage nurse score was not significantly different between the first visit and the UR. This suggests that the triage score should be systematically upgraded for UR patients.

Unscheduled returns to the emergency department: an outcome of medical errors?

BACKGROUND

The causes of unscheduled returns to the emergency department (ED) within 72 hours of discharge are unclear. A study was undertaken to identify factors associated with this quality care indicator.

METHODS

250 cases and 250 controls from the ED were prospectively studied. Outcomes measured were unscheduled returns, post-ED destination, and patient dissatisfaction. Possible medical errors (in diagnosis, treatment, prognosis or patient information) and errors in follow up care were identified. Other factors examined included chief complaint at presentation, discharge diagnosis, level of triage, category of treating physician, observation or not, application of emergency treatment, ancillary studies, accessibility to ED, ED time band or work shift, day of the week, past medical history, and demographic data (age, sex, educational level and economic status).

RESULTS

The main factor associated with unscheduled returns was error in prognosis (odds ratio 18.62, 95% CI 9.60 to 36.09). Advanced age and a chief complaint of dyspnoea were also associated with unscheduled returns and with admission to hospital. Post-ED destination worsened by 0.61 (95% CI 0.33 to 0.90) with diagnostic errors and by 0.60 (95% CI 0.30 to 0.90) with errors in follow up care. Patient dissatisfaction increased by 0.68 (95% CI 0.55 to 0.80) with information errors, by 0.63 (95% CI 0.17 to 1.09) with errors in follow up care, and by 0.52 (95% CI 0.09 to 0.94) with diagnostic errors.

CONCLUSION

Unscheduled returns are associated with medical errors in prognosis, treatment, follow up care, and information. A worse post-ED destination is associated with these medical errors and patient factors (dyspnoea and advanced age). Patient dissatisfaction is associated with medical errors, level of triage or care zone, patient educational level and ED time work shift. Most of these factors are modifiable.

[Quality assessment in Emergency Department: behavior respect to attendance demand]

BACKGROUND

We sought to evaluate whether the quality markers used to assess the outcomes of emergency care are modified by emergency department (ED) overcrowding.

PATIENTS AND METHOD

The study was performed during 4 consecutive years (208 weeks) at the Internal Medicine Unit (IMU) of ED of a third level urban hospital. To quantify attendance requirement we used the number of weekly visits to the IMU as marker. The markers used to quantify quality of care were the weekly percentage of the following: a) patients who leave ED the department without being seen by a physician (LWBS); b) those who leave ED against medical advice (AMA); c) return visits to the department before 72 hours of previous discharge (revisited, R), and d) those who died in the IMU (dead, D). We quantified also the percentage of registered complaints (C). We considered the use of the IMU to be adequate when less than 700 patients/week, to be excessive if was between 701 and 800, and to have the overcrowded IMU if was more than 800.

RESULTS

We registered a mean of 723 (60) weekly visits. LWBS, AMA, R, D and C indexes were 0.90% (CI: 0.76-1.03%), 0.19% (CI: 0.15-0.22%), 1.77% (CI: 1.69-1.86%), 0-87% (CI: 0.80-0.91%) and 0.24% (CI: 0.21-0.27%), respectively. In 38% of weeks the use of the IMU was adequate, in 51% was excessive, and in 11% was overcrowded. When we compared quality markers in relation to the level of occupation, we found a significant increase in LWBS, R and D indexes during the weeks of excessive occupation or overcrowding in relation to the weeks of adequate occupation (p < 0.0001; p < 0.0001, and p < 0.05, respectively). We also found a significant positive correlation between the number of weekly visits to IMU and LWBS, AMA R and D values (p < 0.0001; p = 0.002; p = 0.0001, and p < 0.05, respectively).

CONCLUSION

ED overcrowding is associated to a decrease in the majority of quality markers.

Randomised controlled trial of general practitioner versus usual medical care in an urban accident and emergency department: process, outcome, and comparative cost

OBJECTIVE

To see whether care provided by general practitioners to non-emergency patients in an accident and emergency department differs significantly from care by usual accident and emergency staff in terms of process, outcome, and comparative cost.

DESIGN

A randomised controlled trial.

SETTING

A busy inner city hospital's accident and emergency department which employed three local general practitioners on a sessional basis.

PATIENTS

All new attenders categorised by the triage system as "semiurgent" or "delay acceptable." 66% of all attenders were eligible for inclusion.

MAIN OUTCOME MEASURES

Numbers of patients undergoing investigation, referral, or prescription; types of disposal; consultation satisfaction scores; reattendance to accident and emergency department within 30 days of index visit; health status at one month; comparative cost differences.

RESULTS

4684 patients participated. For semiurgent patients, by comparison with usual accident and emergency staff, general practitioners investigated fewer patients (relative difference 20%; 95% confidence interval 16% to 25%), referred to other hospital services less often (39%; 28% to 47%), admitted fewer patients (45%; 32% to 56%), and prescribed more often (41%; 30% to 54%). A similar trend was found for patients categorised as delay acceptable and (in a separate analysis) by presenting complaint category. 393 (17%) patients who had been seen by general practitioner staff reattended the department within 30 days of the index visit; 418 patients (18%) seen by accident and emergency staff similarly reattended, 435 patients (72% of those eligible) completed the consultation satisfaction questionnaire and 258 (59% of those eligible) provided health status information one month after consultation. There were no differences between patients managed by general practitioners and those managed by usual staff regarding consultation satisfaction questionnaire scores or health status. For all patients seen by general practitioners during the study, estimated marginal and total savings were Ir1427 pounds and Ir117,005 pounds respectively.

CONCLUSION

General practitioners working as an integral part of an accident and emergency department manage non-emergency accident and emergency attenders safely and use fewer resources than do usual accident and emergency staff.