Unscheduled return visits to a Dutch inner-city emergency department

Evaluation of a Structured Review Process for Emergency Department Return Visits with Admission

BACKGROUND

Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis.

METHODS

The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests.

RESULTS

The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (p < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (p < 0.001) but not by language (p = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (p = 0.446) or language (p = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education.

CONCLUSION

The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.

Frequencies and reasons for unplanned emergency department return visits by older adults: a cohort study

BACKGROUND

As unplanned Emergency Department (ED) return visits (URVs) are associated with adverse health outcomes in older adults, many EDs have initiated post-discharge interventions to reduce URVs. Unfortunately, most interventions fail to reduce URVs, including telephone follow-up after ED discharge, investigated in a recent trial. To understand why these interventions were not effective, we analyzed patient and ED visit characteristics and reasons for URVs within 30 days for patients aged ≥ 70 years.

METHODS

Data was used from a randomized controlled trial, investigating whether telephone follow-up after ED discharge reduced URVs compared to a satisfaction survey call. Only observational data from control group patients were used. Patient and index ED visit characteristics were compared between patients with and without URVs. Two independent researchers determined the reasons for URVs and categorized them into: patient-related, illness-related, new complaints and other reasons. Associations were examined between the number of URVs per patient and the categories of reasons for URVs.

RESULTS

Of the 1659 patients, 222 (13.4%) had at least one URV within 30 days. Male sex, ED visit in the 30 days before the index ED visit, triage category "urgent", longer length of ED stay, urinary tract problems, and dyspnea were associated with URVs. Of the 222 patients with an URV, 31 (14%) returned for patient-related reasons, 95 (43%) for illness-related reasons, 76 (34%) for a new complaint and 20 (9%) for other reasons. URVs of patients who returned ≥ 3 times were mostly illness-related (72%).

CONCLUSION

As the majority of patients had an URV for illness-related reasons or new complaints, these data fuel the discussion as to whether URVs can or should be prevented.

TRIAL REGISTRATION

For this cohort study, we used data from a randomized controlled trial (RCT). This trial was pre-registered in the Netherlands Trial Register with number NTR6815 on the 7^th of November 2017.

Characteristics of an Unscheduled Emergency Department Revisit Within 72 hours of Discharge

Background

An unscheduled emergency department (ED) revisit is defined as a patient presenting to the ED with the same problem within 72 hours of discharge. The revisits result in overcrowding and compromise the care provided by the ED. We assume that the poor quality of care provided by the ED is the reason for revisiting. However, the circumstances surrounding these revisits are not well-understood. We conducted this study to understand the characteristics associated with the revisits.

Objectives

We aimed to identify the common causes of ED revisits within 72 hours of discharge and determine the outcome of these patients during the revisit.

Methods

We conducted a prospective observational study at a tertiary care center from July 2015 to June 2017, including patients presenting at the ED within 72 hours after their first visit. Our study selected 50 patients using a simple random sampling method and identified the leading causes of revisit as doctor-related, patient-related, and illness-related.

Results

We found that 56% (28/50) of patients returned to the ED for illness-related reasons, 26% (13/50) for doctor-related reasons, and 18% (9/50) for patient-related reasons. In addition, we found that 62% (31/50) of patients who returned to the ED within 72 hours required in-patient admission.

Conclusion

The most common cause of ED revisit was illness-related causes, and more than half of the patients during a revisit required in-patient admission. The modifiable causes of the ED revisit, such as doctor-related and patient-related factors, were discovered in this study. These findings may aid in reducing ED revisits and improving the ED quality.

The Impacts of COVID-19 on Healthcare Quality in Tertiary Medical Centers-A Retrospective Study on Data from Taiwan Clinical Performance Indicators System

To date, COVID-19 is by far the most impactful contagious disease of the 21st century and it has had a devastating effect on public health in countries around the globe. Elective medical services have declined markedly since the outbreak of the COVID-19 pandemic. Few studies have compared changes in healthcare quality before and during the outbreak of COVID-19 in Eastern Asian countries. We aimed to explore the impacts of COVID-19 on healthcare quality among medical centers in Taiwan. This was a retrospective study that collected anonymized data from the Taiwan Clinical Performance Indicator system, which was founded by the Joint Commission of Taiwan, an organization to promote, execute, and certify the nation’s healthcare quality policies. We explored quality indicators reported by more than three-quarters of medical centers in Taiwan from January 2019 to December 2020. The year 2019 was defined as the baseline period and 2020 was defined as the period after the start of the outbreak of COVID-19. Quality indicators from different regions were analyzed. Unscheduled returns of emergency patients within 72 h of their discharge, unscheduled returns of hospitalized patients within 14 days of their discharge, and unscheduled returns of surgical patients to the operating room during hospitalization all declined during the COVID-19 outbreak. Interestingly, the proportion of acute ischemic stroke patients receiving intravenous tissue-type plasminogen activator (IV-tPA) increased during outbreak of COVID-19. There were significant regional variations in healthcare quality indicators among medical centers in northern and middle/southern Taiwan. The outbreak of COVID-19 changed different patterns of healthcare systems. Although healthcare quality seemed to improve, further investigation is warranted to better understand whether those who were in need of returning to the emergency room or hospital were reluctant or were prevented from travel by the shelter-in-place policy.

UNPLANNED REPRESENTATION TO HOSPITAL BY PATIENTS WITH DIABETES: DEVELOPMENT AND PILOT FEASIBILITY TESTING OF A SCREENING TOOL

BackgroundUnplanned representation of patients with diabetes recently discharged from emergency department or in-patient hospitals is a common but complex problem worldwide. This study set out to examine the feasibility of a risk screening interview and whether component characteristics may be associated with unplanned representation of patients with diabetes to a tertiary metropolitan hospital.MethodsA screening interview comprised of demographic, social and clinical characteristics was developed and piloted using prospective cross-sectional survey design. A convenience sample of 55 patients was recruited and screened. Outcomes were the occurrence of unplanned representation to hospital within 28 or 90 days of hospital discharge from the index presentation.ResultsThe screening interview was shown to be broadly feasible and acceptable for use by staff and patients, with identified areas for modification. Seventeen participants (30.9%) experienced unplanned representation within 90 days of hospital discharge; for 13 participants (23.6%) this occurred within 28 days. Characteristics linked with unplanned representation to hospital were identified.ConclusionsPreliminary data indicated the feasibility of tool use and informed refinement for future testing of the ability of the screening interview to predict those patients with diabetes at high risk of unplanned representation to hospital to enhance effective care planning.

Risk factors of admission in 72-h return visits to emergency department

Objective:

Return visit to emergency department (ED) is a common phenomenon and has been a clinical indicator of quality of care in ED. Most of previous articles focused on the characteristics of the patients returning within 72 h after ED discharge, while those on subsequent admission are numbered. This study's purpose is to identify risk factors for admission among 72-h return visit in the ED adult population.

Materials and Methods:

This retrospective cohort study was conducted at a medical center in Eastern Taiwan. The study period was from January 1, 2013, to December 31, 2013. We excluded patients who left against medical advice or without being seen, who was admitted or transferred at the index ED visit, whose medical records were incomplete, and whose age was below 18 years old. Significant variables were selected based on univariate analysis and later entered into multivariate logistic regression analysis to identify risk factors for 72-h return admission.

Results:

We identified 1575 eligible visits, and there were 1,119 visits entering into the final analysis. Male gender (odds ratio [OR] = 1.44), ambulance-transport at return visit (OR = 3.68), senior staff (OR = 1.52), work-up (OR = 3.03), and longer length of stay (LOS) were associated with higher risks of admission among ED 72-h return visits. Age, comorbidity, mode of transport at index visit, consultation, triage, type of illness, outpatient department visit between ED visits, and interval between index and return visits were not significantly associated with return admission.

Conclusion:

Gender, mode of transportation, staff experience, check-up, and LOS are associated with ED return admission.

Emergency department medication dispensing reduces return visits and admissions

OBJECTIVES

Return visits to the emergency department (ED) and subsequent readmissions are common for patients who are unable to fill their prescriptions. We sought to determine if dispensing medications to patients in an ED was a cost-effective way to decrease return ED visits and hospital admissions for skin and soft tissue infections (SSTIs).

METHODS

A retrospective review of ED visits for SSTIs, during the 24 weeks before and after the implementation of a medication dispensing program, was conducted. Charts were analyzed for both ED return visits and hospital admissions within 7 days and 30 days of the initial ED visit. Return visits were further reviewed to determine if the clinical conditions on subsequent visits were related to the initial ED presentation. A cost analysis comparing the cost of treatment to cost savings for return visits was also performed.

RESULTS

Before the implementation of the medication dispensing program, the return rate in 7 days for the same condition was 9.1% and the rate of admission was 2.8%. The return rate for the same condition in 8-30 days was 2.1% and the rate of admission was 1.0%. After the implementation of the medication dispensing program, the return rate for the same condition in 7 days was 8.0%, and the admission rate was 1.7%. The return rate for the same condition in 8-30 days was 0.8%, and the admission rate was 0%. The total cost of dispensed medications was $4050, while total cost savings were estimated to be $95,477.

CONCLUSION

A medication dispensing program in the ED led to a reduction in return visits and admissions for SSTIs at both 7 days and 30 days. For a cost of only $4050, an estimated total of $95,477 was saved. A medication dispensing program is a cost-effective way to reduce return visits to the ED and subsequent admissions for certain conditions.

Discharge in Pandemic: Suspected Covid-19 patients returning to the Emergency Department within 72 hours for admission

INTRODUCTION

Coronavirus disease 2019 (Covid-19) has led to unprecedented healthcare demand. This study seeks to characterize Emergency Department (ED) discharges suspected of Covid-19 that are admitted within 72 h.

METHODS

We abstracted all adult discharges with suspected Covid-19 from five New York City EDs between March 2nd and April 15th. Those admitted within 72 h were then compared against those who were not using descriptive and regression analysis of background and clinical characteristics.

RESULTS

Discharged ED patients returning within 72 h were more often admitted if suspected of Covid-19 (32.9% vs 12.1%, p < .0001). Of 7433 suspected Covid-19 discharges, the 139 (1.9%) admitted within 72 h were older (55.4 vs. 45.6 years, OR 1.03) and more often male (1.32) or with a history of obstructive lung disease (2.77) or diabetes (1.58) than those who were not admitted (p < .05). Additional associations included non-English preference, cancer, heart failure, hypertension, renal disease, ambulance arrival, higher triage acuity, longer ED stay or time from symptom onset, fever, tachycardia, dyspnea, gastrointestinal symptoms, x-ray abnormalities, and decreased platelets and lymphocytes (p < .05 for all). On 72-h return, 91 (65.5%) subjects required oxygen, and 7 (5.0%) required mechanical ventilation in the ED. Twenty-two (15.8%) of the study group have since died.

CONCLUSION

Several factors emerge as associated with 72-h ED return admission in subjects suspected of Covid-19. These should be considered when assessing discharge risk in clinical practice.

Application of Machine Learning Techniques to Analyze Patient Returns to the Emergency Department

The study of the quality of hospital emergency services is based on analyzing a set of indicators such as the average time of first medical attention, the average time spent in the emergency department, degree of completion of the medical report and others. In this paper, an analysis is presented of one of the quality indicators: the rate of return of patients to the emergency service less than 72 h from their discharge. The objective of the analysis was to know the variables that influence the rate of return and which prediction model is the best. In order to do this, the data of the activity of the emergency service of a hospital of a reference population of 290,000 inhabitants were analyzed, and prediction models were created for the binary objective variable (rate of return to emergencies) using the logistic regression techniques, neural networks, random forest, gradient boosting and assembly models. Each of the models was analyzed and the result shows that the best model is achieved through a neural network with activation function tanh, algorithm levmar and three nodes in the hidden layer. This model obtains the lowest mean squared error (MSE) and the best area under the curve (AUC) with respect to the rest of the models used.

Model-Based Recursive Partitioning of Patients' Return Visits to Multispecialty Clinic During the 2009 H1N1 Pandemic Influenza (pH1N1)

Background During the 2009 H1N1 influenza pandemic (pH1N1), the proportion of outpatient visits to emergency departments, clinics and hospitals became elevated especially during the early months of the pandemic due to surges in sick, 'worried well' or returning patients seeking care. We determined the prevalence of return visits to a multispecialty clinic during the 2009 H1N1 influenza pandemic and identify subgroups at risk for return visits using model-based recursive partitioning technique. Methods This study was a retrospective analysis of ILI-related medical care visits to multispecialty clinic in Houston, Texas obtained as part of the Houston Health Department Influenza Sentinel Surveillance Project (ISSP) during the 2009 H1N1 pandemic influenza (April 2009 - March 2010). The data comprised of 2680 individuals who made a total of 2960 clinic visits. Return visit was defined as any visit following the index visit after the wash-out phase prior to the study period. We applied nominal logistic regression and recursive partitioning models to determine the independent predictors and the response probabilities of return visits. The sensitivity and specificity of the outcomes probabilities were determined using receiver operating characteristic (ROC) curve. Results Overall, 4.56% (Prob. 0.0%-17.5%) of the cohort had return visits with significant variations observed attributed to age group (76.0%), type of vaccine received by patients (18.4%) and Influenza A (pH1N1) test result (5.6%). Patients in age group 0-4 years were 9 times (aOR: 8.77, 95%CI: 3.39-29.95, p<0.0001) more likely than those who were 50⁺ years to have return visits. Similarly, patients who received either seasonal flu (aOR: 1.59, 95% CI 1.01-2.50, p=0.047) or pH1N1 (aOR: 1.74, 95%CI: 1.09-2.75, p=0.022) vaccines were about twice more likely to have return visits compared to those with no vaccination history. Model-based recursive partitioning yielded 19 splits with patients in subgroup I (patients of age group 0-4 years, who tested positive for pH1N1, and received both seasonal flu and pH1N1 vaccines) having the highest risk of return visits (Prob.=17.5%). The area under the curve (AUC) for both return and non-return visits was 72.9%, indicating a fairly accurate classification of the two groups. Conclusions Return visits in our cohort were more prevalent among children and young adults, and those that received either seasonal flu or pH1N1 or both vaccines. Understanding the dynamics in care-seeking behavior during pandemic would assist policymakers with appropriate resource allocation, and in the design of initiatives aimed at mitigating surges and recurrent utilization of the healthcare system.

Influence of Overcrowding in the Emergency Department on Return Visit within 72 Hours

This study was conducted to determine whether overcrowding in the emergency department (ED) affects the occurrence of a return visit (RV) within 72 h. The crowding indicator of index visit was the average number of total patients, patients under observation, and boarding patients during the first 1 and 4 h from ED arrival time and the last 1 h before ED departure. Logistic regression analysis was conducted to determine whether each indicator affects the occurrence of RV and post-RV admission. Of the 87,360 discharged patients, 3743 (4.3%) returned to the ED within 72 h. Of the crowding indicators pertaining to total patients, the last 1 h significantly affected decrease in RV (p = 0.0046). Boarding patients were found to increase RV occurrence during the first 1 h (p = 0.0146) and 4 h (p = 0.0326). Crowding indicators that increased the likelihood of admission post-RV were total number of patients during the first 1 h (p = 0.0166) and 4 h (p = 0.0335) and evaluating patients during the first 1 h (p = 0.0059). Overcrowding in the ED increased the incidence of RV and likelihood of post-RV admission. However, overcrowding at the time of ED departure was related to reduced RV.

Assessing healthcare service quality using routinely collected data: Linking information systems in emergency care

Emergency departments need to continuously calculate quality indicators in order to perform structural improvements, improvements in the daily routine, and ad-hoc improvements in everyday life. However, many different actors across multiple disciplines collaborate to provide emergency care. Hence, patient-related data is stored in several information systems, which in turn makes the calculation of quality indicators more difficult. To address this issue, we aim to link and use routinely collected data of the different actors within the emergency care continuum. In order to assess the feasibility of linking and using routinely collected data for quality indicators and whether this approach adds value to the assessment of emergency care quality, we conducted a single case study in a German academic teaching hospital. We analyzed the available data of the existing information systems in the emergency continuum and linked and pre-processed the data. Based on this, we then calculated four quality indicators (Left Without Been Seen, Unplanned Reattendance, Diagnostic Efficiency, and Overload Closure). Lessons learned from the calculation and results of the discussions with staff members that had multiple years of work experience in the emergency department provide a better understanding of the quality of the emergency department, the related challenges during the calculation, and the added value of linking routinely collected data.

Outpatient Parenteral Antimicrobial Therapy and Judicious Use of Pediatric Emergency Resources

BACKGROUND

Pediatric returns to the emergency department (RTED) vary between 3% and 13% of the total ED volume of visits. However, the incidence and contribution of scheduled RTED on pediatric emergency department (PED) utilization is less clear. Antimicrobial stewardship programs on inpatient wards have been shown to improve judicious use of outpatient parenteral antimicrobial therapy (OPAT) in upon discharge. The implementation of such programs in PEDs has yet to be reported. The objectives of this study are to quantify the burden of scheduled RTED for OPAT on PED utilization and to examine how frequently OPAT use are supported by published practice standards for 3 common pediatric infections-cellulitis, pneumonia, and urinary tract infections.

METHODS

We conducted a single-center retrospective cohort study of all visits made to the British Columbia Children's Hospital PED from May 1, 2012, to April 30, 2013. We identified scheduled RTEDs and characterized those associated with OPAT use with regard to their measures of PED utilization and clinical features.

RESULTS

Of 3904 RTED visits, 1310 (33.6%) were scheduled, of which 1029 were OPAT related. Among the latter, 749 RTEDs (69%) were for cellulitis, pneumonia, or urinary tract infections. The median length of stay for OPAT-related RTEDs was 2.0 hours. For 75 (24%) of 317 index visits and 213 (28%) of 749 subsequent RTEDs, oral antibiotic therapy would have been an appropriate option and OPAT could have been avoided.

CONCLUSIONS

Our findings suggest that OPAT poses a sizable burden on PED utilization, with a proportion of them potentially preventable.

Characteristics of Febrile Children Admitted to the ICU Following an Unscheduled ED Revisit Within 72 h, a Case-Control Study

Objective: The purpose of this article was to demonstrate related characteristics of intensive care unit (ICU) admission after an unscheduled revisit by febrile children visiting the emergency department (ED). Method: We performed a retrospective study in a tertiary medical center from 2010 to 2016. Patients whose chief complaint was fever and who were admitted to the ICU following a 72-h return visit to the ED were included, and we selected patients who were discharged from the same emergency department for comparison. Results: During the study period, 54 (0.03%) patients met the inclusion criteria, and 216 patients were selected for the matched control group. Regarding clinical variables on initial ED visit, visiting during the night shift (66.7 vs. 46.8%, p = 0.010), shorter length of 1st ED stay (2.5 ± 2.63 vs. 3.5 ± 3.44 h, p = 0.017), and higher shock index (SI) (1.6 ± 0.07 vs. 1.4 ± 0.02, p = 0.008) were associated with ICU admission following a return visit. On the return ED visit, we found that clinical variables such as elevated heart rate, SI, white blood cell count, and C-reactive protein level were all associated with ICU admission. Furthermore, elevated SI and pediatric age-adjusted (SIPA) values were observed in the study group in both the initial (42.2 vs. 20.1%, OR:2.3 (1.37-4.31), p = 0.002) and return ED visits (29.7 vs. 6.9%, OR: 4.6 (2.42-8.26), p < 0.001). Conclusion: For children who visited the emergency department with a febrile complaint, elevated SIPA values on the initial ED visit were associated with ICU admission following an unscheduled ED revisit within 72 h.

Large observational study on risks predicting emergency department return visits and associated disposition deviations

Objective

A common emergency department (ED) patient care outcome metric is 72-hour ED return visits (EDRVs). Risks predictive of EDRV vary in different studies. However, risk differences associated with related versus unrelated EDRV and subsequent EDRV disposition deviations (EDRVDD) are rarely addressed. We aim to compare the potential risk patterns predictive of related and unrelated EDRV and further determine those potential risks predictive of EDRVDD.

Methods

We conducted a large retrospective observational study from September 1, 2015 through June 30, 2016. ED Patient demographic characteristics and clinical metrics were compared among patients of 1) related; 2) unrelated; and 3) no EDRVs. EDRVDD was defined as obvious disposition differences between initial ED visit and return visits. A multivariate multinomial logistic regression was performed to determine the independent risks predictive of EDRV and EDRVDD after adjusting for all confounders.

Results

A total of 63,990 patients were enrolled; 4.65% were considered related EDRV, and 1.80% were unrelated. The top risks predictive of EDRV were homeless, patient left without being seen, eloped, or left against medical advice. The top risks predictive of EDRVDD were geriatric and whether patients had primary care physicians regardless as to whether patient returns were related or unrelated to their initial ED visits.

Conclusion

Over 6% of patients experienced ED return visits within 72 hours. Though risks predicting such revisits were multifactorial, similar risks were identified not only for ED return visits, but also for return ED visit disposition deviations.

Usefulness of bounce-back admission in monitoring the quality of practice in the emergency department

Background: Recently, unscheduled readmissions after discharge from the emergency department (ED) (bounce-back admissions, BBAs) have been monitored as a hospital performance measure in countries other than Japan. It has been suggested that BBAs may be caused by errors in diagnoses or treatments.

Purpose: This retrospective cohort study aimed to evaluate BBAs and improve the quality of medical care in the ED of Showa University Hospital by analyzing the data of adult patients (≥18 years) with index visits to the ED of Showa University Hospital between June 2011 and May 2013 (n=15,069).

Patients and methods: Patients were registered and followed up for unscheduled admissions to this hospital within 7 days. In order to understand the reasons for BBAs, individual diagnoses upon BBA were compared to the corresponding diagnoses upon discharge.

Results: Among the 11,669 discharged patients, 180 patients were admitted within 3 days after discharge (3-day BBAs), and 257 were admitted within 7 days after discharge (7-day BBAs). The main diagnoses upon admission (BBA) were pneumonia or exacerbation of chronic obstructive pulmonary disease (COPD) or asthma (n=40, 16%), cholecystitis or cholangitis (n=21, 8.2%), and urinary tract infection (n=16, 6.2%). Among the 7-day BBA cases, 117 patients had similar and 110 patients had different diagnoses upon discharge and admission; in the remaining 30 cases, the results could not be ascertained owing to incomplete diagnostic data. In the cases of pneumonia, exacerbation of COPD or asthma, and colitis or enterocolitis, there was a significantly higher “similar” diagnoses than “different”, while the reverse was true for cases of stroke, ileus or bowel obstruction, and meningitis. These results were shared with the ED staff, and similar surveillances were periodically conducted. The frequency of admission within 7 days after discharge continuously declined from 2013 to 2016.

Conclusion: Analyzing the discharge and admission diagnoses may help ED staff to understand the reasons for common errors in order to follow the plan-do-check-act cycle of medical care in the ED.

Incidence, characteristics and outcomes of patients that return to Emergency Departments. An integrative review

BACKGROUND

Unplanned return visits account for up to 5% of Emergency Department presentations in Australia and have been associated with adverse events and increased costs. A large number of studies examine the incidence, characteristics and outcomes of unplanned return visits but few studies examine the reasons for return from a patient perspective. The objective of this integrative review was to determine the incidence, characteristics, outcomes and reasons for unplanned return visits to Emergency Departments.

METHOD

An integrative literature review design was employed to conduct a structured search of the literature using the databases CINAHL, MEDLINE, PubMed, ProQuest and EMBASE (inception to June 2018). Results were screened using predefined criteria and final studies collated and appraised using a quality assessment tool.

RESULTS

Fifty-two primary research articles were included in the review. The timeframe used to capture unplanned return visits varied and the incidence ranged between 0.07% and 33%. The majority of patients who return unplanned to the Emergency Department are subsequently discharged (51% and 90%) without an adverse event.

CONCLUSION

There is no consensus on the timeframe employed to classify unplanned return visits to the Emergency Department and the commonly used 72h lacks evidence. Routine statewide data linkage to capture return visits to other facilities is needed to ensure accurate data about this vulnerable patient group. Further research that focuses on patient and clinician perspectives is required to facilitate the development of local strategies to reduce the incidence of avoidable unplanned return visits.

Cognitive error in an academic emergency department

Background

Medical error is a leading cause of death nationwide. While systems issues have been closely investigated as a contributor to error, little is known about the cognitive factors that contribute to diagnostic error in an emergency department (ED) environment.

Methods

Eight months of patient revisits within 72 h where patients were admitted on their second visit were examined. Fifty-two cases of confirmed error were identified and classified using a modified version of the Australian Patient Safety Foundation classification system for medical errors by a group of trained physicians.

Results

Faulty information processing was the most frequently identified category of error (45% of cases), followed by faulty verification (31%). Faulty knowledge (6%) and faulty information gathering (18%) occurred relatively infrequently. “Misjudging the salience of a finding” and “premature closure” were the individual errors that occurred most frequently (13%).

Conclusions

Despite the complex nature of diagnostic reasoning, cognitive errors of information processing appear to occur at higher rates than other errors, and in a similar pattern to an internal medicine service despite a different clinical environment. Further research is needed to elucidate why these errors occur and how to mitigate them.

An Evaluation of a Modified CTAS at an Accident and Emergency Department in a Developing Country

Objectives

To review the modified Canadian Triage and Acuity Scale used in an accident and emergency department in Trinidad and Tobago.

Design and Methods

A cross-sectional study was carried out. Times from assignment of triage category to being seen by a physician were collected from the patient notes on the days of presentation and compared to the reference standards. Times from decision to admit to obtaining a bed were also recorded.

Results

200 patients were included in the study. The median waiting time for patients in the immediate/blue category was 3 minutes (range = 3); for the red category, it was 31.2 minutes (range = 121.8); in the yellow category, it was 61.8 minutes (range = 805.2). The overall admission rate was 30.5%, with an admission rate of 25% for the blue category; 20% of patients in the red category waited more than 4 hours for a hospital bed.

Conclusion

The patients assigned to the blue category were being seen almost immediately. Less critical persons wait longer than the reference times and this may be due to structural factors such as staffing. The admission rates per category highlighted a low admission rate for the blue category (25%), which is unusual. This study highlights the need for a further study to review clinical presentation, assignment to triage category, and outcomes.

Characteristics of revisits of children at risk for serious infections in pediatric emergency care

In this study, we aimed to identify characteristics of (unscheduled) revisits and its optimal time frame after Emergency Department (ED) discharge. Children with fever, dyspnea, or vomiting/diarrhea (1 month-16 years) who attended the ED of Erasmus MC-Sophia, Rotterdam (2010-2013), the Netherlands, were prospectively included. Three days after ED discharge, we applied standardized telephonic questionnaires on disease course and revisits. Multivariable logistic regression analysis was used to identify independent characteristics of revisits. Young age, parental concern, and alarming signs and symptoms (chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea) were associated with revisits (n = 527) in children at risk for serious infections discharged from the ED (n = 1765). Children revisited the ED within a median of 2 days (IQR 1.0-3.0), but this was proven to be shorter in children with vomiting/diarrhea (1.0 day (IQR 1.0-2.0)) compared to children with fever or dyspnea (2.0 (IQR 1.0-3.0)).

CONCLUSION

Young age, parental concern, and alarming signs and symptoms (chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea) were associated with emergency health care revisits in children with fever, dyspnea, and vomiting/diarrhea. These characteristics could help to define targeted review of children during post-discharge period. We observed a disease specific and differential timing of control revisits after ED discharge. What is Known • Fever, dyspnea, and vomiting/diarrhea are major causes of emergency care attendance in children. • As uncertainty remains on uneventful recovery, patients at risk need to be identified on order to improve safety netting after discharge from the ED. What is New • In children with fever, dyspnea, and vomiting/diarrhea, young age, parental concern and chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea help to define targeted review of children during the post-discharge period. • A revisit after ED discharge is disease-specific and seems to be shorter for children with vomiting/diarrhea than others.

Association of socioeconomic status with outcomes in older adult community-dwelling patients after visiting the emergency department: a retrospective cohort study

OBJECTIVES

Older adults frequently visit the emergency department (ED). Socioeconomic status (SES) has an important impact on health and ED utilisation; however, the association between SES and ED utilisation in elderly remains unclear. The aim of this study was to investigate the association between SES in older adult patients visiting the ED on outcomes.

DESIGN

A retrospective study.

PARTICIPANTS

Older adults (≥65 years) visiting the ED, in the Netherlands. SES was stratified into tertiles based on average household income at zip code level: low (<€1800/month), intermediate (€1800-€2300/month) and high (>€2300/month).

PRIMARY OUTCOMES

Hospitalisation, inhospital mortality and 30-day ED return visits. Effect of SES on outcomes for all groups were assessed by logistic regression and adjusted for confounders.

RESULTS

In total, 4828 older adults visited the ED during the study period. Low SES was associated with a higher risk of hospitalisation among community-dwelling patients compared with high SES (adjusted OR 1.3, 95% CI 1.1 to 1.7). This association was not present for intermediate SES (adjusted OR 1.1, 95% CI 0.95 to 1.4). Inhospital mortality was comparable between the low and high SES group, even after adjustment for age, comorbidity and triage level (low OR 1.4, 95% CI 0.8 to 2.6, intermediate OR 1.3, 95% CI 0.8 to 2.2). Thirty-day ED revisits among community-dwelling patients were also equal between the SES groups (low: adjusted OR 1.0, 95% CI 0.7 to 1.4, and intermediate: adjusted OR 0.8, 95% CI 0.6 to 1.1).

CONCLUSION

In older adult ED patients, low SES was associated with a higher risk of hospitalisation than high SES. However, SES had no impact on inhospital mortality and 30-day ED revisits after adjustment for confounders.

Factors Affecting Unscheduled Return Visits to the Emergency Department among Minor Head Injury Patients

Study Objectives

Differences between returning and non-returning minor head injury (MHI) emergency department (ED) patients, between the characteristics of the first visit and revisit, and between admitted and nonadmitted returning patients were investigated.

Methods

This was a retrospective study. All discharged ED patients with ICD-9 codes 850.0 to 850.9, 920, and 959.01 in 2013 were enrolled. Patients' demographic data, vital signs, Glasgow Coma Scale, ED diagnosis, length of stay, triage levels, ED examinations performed, and comorbidities were recorded for analysis.

Results

A total of 2,815 patients were enrolled. Of 57 (2%) patients who revisited the ED, 47 (82%) were discharged from the ED and ten (18%) were admitted to the hospital. Patients who returned to the ED were older, and they exhibited more comorbidities. Those who presented with vomiting, triage level of 1 or 2, and GCS score of <15 and who received more blood tests during their first visit were more likely to be admitted when they returned to the ED.

Conclusions

Discharging MHI patients who are older or exhibit comorbidities only when symptoms and concerns are relieved completely, providing clear discharge instructions, and arranging timely clinical follow-ups may help reduce such patients' return rate.

Emergency Department Return Visits Within a Large Geographic Area

BACKGROUND

Return visits to the emergency department (RTED) contribute to overcrowding and may be a quality of care indicator. Previous studies focused on factors predicting returns to and from the same center. Little is known about RTEDs across a range of community and specialty hospitals within a large geographic area.

OBJECTIVE

We sought to measure the frequency of pediatric RTEDs and describe their directional pattern across centers in a large catchment area.

METHODS

We conducted a multicenter, retrospective cross-sectional study of pediatric emergency visits in the Vancouver lower mainland within 1 year. Visits were linked across study sites, including one pediatric quaternary care referral center and 17 sites ranging from large regional centers to smaller community emergency departments (EDs). Returns were defined as subsequent visits to any site with a compatible diagnosis within 7 days of an index visit.

RESULTS

Among a total of 139,278 index ED visits by children, 12,133 (8.7% [95% confidence interval 8.6-8.9%]) were associated with 14,645 return visits to an ED. Three quarters of all index visits occurred at a general ED center, of which 8.9% had at least one RTED and 22% of these returns occurred at the pediatric ED (PED). Among PED index visits, 8.2% had at least one RTED and 13.6% of these returned to a general center. Overall, 38.9% of all RTEDs occurred at the PED. Multivariate regression did not identify any statistically significant association between ED crowding measures and likelihood of RTEDs.

CONCLUSIONS

Compared to single-center studies, this study linking hospitals within a large geographic area identified a higher proportion of RTEDs with a disproportionate burden on the PED.

Which unscheduled return visits indicate a quality-of-care issue?

BACKGROUND

The rate of unscheduled return visits is often used as a quality-of-care indicator in EDs, although its validity is not yet fully established. Our aim was to identify the characteristics of return visits that may be attributed to problems in quality of care.

METHODS

Retrospective paired review of medical charts in a random sample of return visits during the 72 hours following discharge from the ED in three hospitals of Andalusia, Spain in 2013. Charts were reviewed by senior medical physicians to determine which return visits reflected quality-of-care problems. Time frame for return visit, index and return visit acuity, disposition and diagnosis were compared with determine which variables were associated with a quality problem. Sensitivity and specificity for each variable to indicate a quality problem were determined.

RESULTS

We studied the causes of 895 return visits, finding that 65 (7.3%) were due to inadequate quality of care in the index visit. Potentially avoidable return visits were more common in more severely ill patients, in those with greater severity in the return than in the index visit and in patients hospitalised after the return. The combination of this three variables presented sensitivity 66% and specificity 68% in identification of quality-related returns.

CONCLUSIONS

The overall level of return visits cannot be considered a valid indicator of quality of care. However, certain specific variables, including the level of severity of the patient's condition or the discharge destination following the return visits, could be considered valid in this respect.