The Association Between Emergency Department Revisit and Elderly Patients

Factors associated with overall and high-risk return visits to the emergency department: a vital sign trajectory approach

BACKGROUND

For patients and emergency department (ED) physicians, return visits to the ED represent a potentially detrimental issue. In this study, our goal was to examine factors associated with overall and high-risk ED revisits. Specifically, as vital signs during the ED stay may provide important clues for subsequent revisits, we also examined the association between vital sign trajectories and post-ED revisits.

METHODS

This retrospective cohort study utilized electronic clinical warehouse data from a tertiary medical center. We retrieved data from 454,330 ED visits over four years. The data included patient demographics, triage data, and repeated vital sign measurements. Group-based trajectory modeling was used to identify vital sign trajectories. A high-risk return ED visit was defined as a revisit within 72 h of the index visit with intensive care unit admission, receiving emergency surgery, or with in-hospital cardiac arrest. Multivariable logistic regression analysis was performed to evaluate the associations between vital sign trajectories and revisits.

RESULTS

A total of 39,138 potential index ED visits were analyzed. Of these, 3,201 resulted in revisits, accounting for an 8.2% overall revisit rate and a 0.2% high-risk revisit rate. A high but resolving body temperature trajectory was associated with overall revisits (adjusted odds ratio [aOR], 1.32; 95% confidence interval [95% CI], 1.13-1.53). By contrast, high-risk revisits were associated with a low/fluctuating oxygen saturation trajectory (aOR, 2.40; 95% CI, 1.15-4.99). Older age (aOR, 1.27 per 10-year increase; 95% CI, 1.11-1.46) and having a chronic major disease (aOR, 2.30; 95% CI, 1.38-3.84) were also associated with high-risk revisits.

CONCLUSIONS

In addition to older age and having a chronic major disease, a low and fluctuating oxygen saturation trajectory during the index ED stay may signal subsequent high-risk revisits. Thus, discharge decisions should be carefully re-evaluated in these high-risk populations.

Enhanced Diagnostic Precision in Revisited Emergency Patients via Point-of-Care Ultrasound: A Tool for Emergency Department Quality Management

PURPOSE

Unscheduled return visits to the emergency department (ED) were categorized into physician-related, illness-related, and patient-related factors, which are associated with an increased risk of adverse health outcomes, including patient dissatisfaction, infections, hospitalization, transfer to another facility, and mortality. Individuals within 48-72 hours of the initial visit are deemed at elevated risk for diagnostic or management-related errors. The Point-of-care ultrasound (POCUS) may serve as a bedside tool to reduce medical errors by enhancing diagnostic precision. This study aims to determine the diagnostic accuracy of POCUS for detecting various illnesses in revisited patients in the emergency department.

PATIENTS AND METHODS

A retrospective observational study was conducted on unplanned revisits by patients to the emergency department within 72 hours, spanning the period from January 2023 to September 2024. Sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were evaluated based on electronic emergency department medical records and ultrasound documentation.

RESULTS

Five hundred seventy patients were included in this study. POCUS demonstrated a diagnostic accuracy of 75.61% (95% CI 71.87, 79.09), a sensitivity of 81.87% (95% CI 77.65, 85.58), a specificity of 62.50% (95% CI 55.08, 69.51), a positive likelihood ratio of 2.18 (95% CI 1.80, 2.65), and a negative likelihood ratio of 0.29 (95% CI 0.23, 0.37).

CONCLUSION

POCUS demonstrated greater diagnostic accuracy, which may enhance diagnostic precision in revisited patients with various illnesses.

Predictors for emergency readmission in patients with ureteral calculi: a focus on pain management and stone location

BACKGROUND

The management of patients with ureteral calculi in the emergency department (ED) remains challenging due to high revisit rates.

PURPOSE

To identify predictors of revisits among patients with ureteral calculi in the ED.

DESIGN, SETTING, AND PARTICIPANTS

Data from patients who presented at a tertiary academic hospital in Seoul, Republic of Korea, between February 2018 and December 2019, were analyzed retrospectively.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Variables, including the respiratory rate (RR), estimated glomerular filtration rate (eGFR), duration of pain, number of analgesic doses, location of ureteral calculi, and ED length of stay (LOS) were examined using logistic regression. We also examined some additional variables included in the STONE and CHOKAI scoring systems to examine their association with revisit.

RESULTS

Significant predictors of revisits included the number of analgesic doses and the location of ureteral calculi. Patients who required multiple analgesic doses or those with proximal or mid-ureteral calculi were more likely to revisit the ED. Although the STONE and CHOKAI scores could predict uncomplicated ureteral calculi, we found that the CHOKAI score is a valuable tool for predicting the likelihood of patient revisits (p = 0.021).

CONCLUSIONS

Effective pain management and consideration of calculi location are important for predicting patient revisits. More research is required to validate findings, develop precise predictive models, and empower tailored care for high-risk patients. In patients with ureteral calculi in the ED, the number of analgesics given and stone location predict return visits. Proximal ureteral calculi on CT may require early urologic intervention to prevent pain-related revisits.

Healthcare risk stratification model for emergency departments based on drugs, income and comorbidities: the DICER-score

BACKGROUND

During the last decade, the progressive increase in age and associated chronic comorbidities and polypharmacy. However, assessments of the risk of emergency department (ED) revisiting published to date often neglect patients' pharmacotherapy plans, thus overseeing the Drug-related problems (DRP) risks associated with the therapy burden. The aim of this study is to develop a predictive model for ED revisit, hospital admission, and mortality based on patient's characteristics and pharmacotherapy.

METHODS

Retrospective cohort study including adult patients visited in the ED (triage 1, 2, or 3) of multiple hospitals in Catalonia (Spain) during 2019. The primary endpoint was a composite of ED visits, hospital admission, or mortality 30 days after ED discharge. The study population was randomly split into a model development (60%) and validation (40%) datasets. The model included age, sex, income level, comorbidity burden, measured with the Adjusted Morbidity Groups (GMA), and number of medications. Forty-four medication groups, associated with medication-related health problems, were assessed using ATC codes. To assess the performance of the different variables, logistic regression was used to build multivariate models for ED revisits. The models were created using a "stepwise-forward" approach based on the Bayesian Information Criterion (BIC). Area under the curve of the receiving operating characteristics (AUCROC) curve for the primary endpoint was calculated.

RESULTS

851.649 patients were included; 134.560 (15.8%) revisited the ED within 30 days from discharge, 15.2% were hospitalized and 9.1% died within 30 days from discharge. Four factors (sex, age, GMA, and income level) and 30 ATC groups were identified as risk factors and combined into a final score. The model showed an AUCROC values of 0.720 (95%CI:0.718-0.721) in the development cohort and 0.719 (95%CI.0.717-0.721) in the validation cohort. Three risk categories were generated, with the following scores and estimated risks: low risk: 18.3%; intermediate risk: 40.0%; and high risk: 62.6%.

CONCLUSION

The DICER score allows identifying patients at high risk for ED revisit within 30 days based on sociodemographic, clinical, and pharmacotherapeutic characteristics, being a valuable tool to prioritize interventions on discharge.

Differences in the characteristics and patterns of adult emergency department return visits before and after the coronavirus disease 2019 outbreak

BACKGROUND

Data about changes in the characteristics of ED return visits before and after the COVID-19 outbreak are limited. This study aimed to report the differences on utility in ED return visits after the COVID-19 outbreak.

METHODS

This retrospective cohort study was conducted from 2019 to 2020. Adult patients with ED return visits were included in the analysis. Variables including demographic characteristics, pre-comorbidities, triage levels, vital signs, chief complaints, management, and diagnosis were recorded and confirmed via a manual assessment.

RESULTS

The proportion of patients with ED visits decreased by 23%. Hence, that of patients with ED return visits also reduced from 2580 to 2020 patients (22%) after the COVID-19 outbreak. The average age (60-57.8 years) of patients with return visits was significantly younger, and the proportion of female patients decreased remarkably. Further, the proportion of patients with chronic pre-existing diseases at the return visit significantly differed after the COVID-19 outbreak. The proportion of patients with chief complaints including dizziness, dyspnea, cough, vomiting, diarrhea, and chills during the return visits significantly differed before and after the COVID-19 pandemic. In the multivariable logistic regression model, age, high triage level were significantly associated with unfavorable outcome return visit.

CONCLUSION

The use of services in the ED has changed since the COVID-19 outbreak. Hence, the proportion of patients with unplanned return visits within 72 h decreased. After the COVID-19 outbreak, people are now cautious whether they should return to the ED, as in the pre-pandemic situation, or just treat conservatively at home.

The adjusted impact of different severities of acute exacerbations and medications on the risk of developing dementia in COPD patients

BACKGROUND

Although a relationship between chronic obstructive pulmonary disease (COPD) and dementia has been reported, the initial severity upon emergency department (ED) visits and the medications used have not been well evaluated as risk factors for increased dementia occurrence. We aimed to analyze the risks of dementia development over 5 years among patients with COPD compared to matched controls (primary) and the impact of different severities of acute exacerbations (AEs) of COPD and medications on the risk of dementia development among COPD patients (secondary).

METHOD

This study used the Taiwanese government deidentified health care database. We enrolled patients during the 10-year study period (January 1, 2000, to December 31, 2010), and each patient was followed up for 5 years. Once these patients received a diagnosis of dementia or died, they were no longer followed up. The study group included 51,318 patients who were diagnosed with COPD and 51,318 matched (in terms of age, sex, and the number of hospital visits) non-COPD patients from the remaining patients as the control group. Each patient was followed up for 5 years to analyze the risk of dementia with Cox regression analysis. Data on medications (antibiotics, bronchodilators, corticosteroids) and severity at the initial ED visit (ED treatment only, hospital admission, or ICU admission) were collected for both groups, as well as demographics and baseline comorbidities, which were considered confounding factors.

RESULTS

In the study and control groups, 1,025 (2.0%) and 423 (0.8%) patients suffered from dementia, respectively. The unadjusted HR for dementia was 2.51 (95% CI: 2.24-2.81) in the study group. Bronchodilator treatment was associated with the HRs, especially among those who received long-term (> 1 month) treatment (HR = 2.10, 95% CI: 1.91-2.45). Furthermore, among 3,451 AE of COPD patients who initially visited the ED, patients who required ICU admission (n = 164, 4.7%) had a higher risk of dementia occurrence (HR = 11.05, 95% CI: 7.77-15.71).

CONCLUSION

Bronchodilator administration might be associated with a decreased risk of dementia development. More importantly, patients who suffered AEs of COPD and initially visited the ED and required ICU admission had a higher risk of developing dementia.

Impact of the COVID-19 Pandemic on the Loading and Quality of an Emergency Department in Taiwan: Enlightenment from a Low-Risk Country in a Public Health Crisis

The impact of the coronavirus disease 2019 (COVID-19) pandemic on health-care quality in the emergency department (ED) in countries with a low risk is unclear. This study aimed to explore the effects of the COVID-19 pandemic on ED loading, quality of care, and patient prognosis. Data were retrospectively collected from 1 January 2018 to 30 September 2020 at the ED of Tri-service general hospital. Analyses included day-based ED loading, quality of care, and patient prognosis. Data on triage assessment, physiological states, disease history, and results of laboratory tests were collected and analyzed. The number of daily visits significantly decreased after the pandemic, leading to a reduction in the time to examination. Admitted patients benefitted from the pandemic with a reduction of 0.80 h in the length of stay in the ED, faster discharge without death, and reduced re-admission. However, non-admitted visits with chest pain increased the risk of mortality after the pandemic. In conclusion, the COVID-19 pandemic led to a significant reduction in low-acuity ED visits and improved prognoses for hospitalized patients. However, clinicians should be alert about patients with chest pain due to their increased risk of mortality in subsequent admission.