Characteristics and determinants of high-risk unscheduled return visits to the emergency department

Abstract

BackgroundHigh-risk unscheduled return visits (HRURVs), defined as return visits within 72 hours that require admission or die in the emergency department (ED) on representation, are a key quality metric in the ED. The objective of this study was to determine the incidence and describe the characteristics and predictors of HRURVs to the ED.MethodsCase–control study, conducted between 1 November 2014 and 31 October 2015. Cases included all HRURVs over the age of 18 that presented to the ED. Controls were selected from patients who were discharged from the ED during the study period and did not return in the next 72 hours. Controls were matched to cases based on gender, age (±5 years) and date of presentation.ResultsOut of 38 886 ED visits during the study period, 271 are HRURVs, giving an incidence of HRURV of 0.70% (95% CI 0.62% to 0.78%). Our final analysis includes 270 HRURV cases and 270 controls, with an in-ED mortality rate of 0.7%, intensive care unit admission of 11.1% and need for surgical intervention of 22.2%. After adjusting for other factors, HRURV cases are more likely to be discharged with a diagnosis related to digestive system or infectious disease (OR 1.64, 95% CI 1.02 to 2.65 and OR 2.81, 95% CI 1.05 to 7.51, respectively). Furthermore, presentation to the ED during off-hours is a significant predictor of HRURV (OR 1.64, 95% CI 1.11 to 2.43) as is the presence of a handover during the patient visit (OR 1.68, 95% CI 1.02 to 2.75).ConclusionHRURV is an important key quality outcome metric that reflects a subgroup of ED patients with specific characteristics and predictors. Efforts to reduce this HRURV rate should focus on interventions targeting patients discharged with digestive system, kidney and urinary tract and infectious diseases diagnosis as well as exploring the role of handover tools in reducing HRURVs.

Inpatient Outcomes Following a Return Visit to the Emergency Department: A Nationwide Cohort Study

“…It is estimated that only 5-10% of return ED visits are associated with potential deficiencies in care. [7][8][9][10] More recent studies have examined patient outcomes after return ED visits as an alternative quality metric, such as hospitalization rates after ED revisits [11][12][13][14][15][16] or even inpatient outcomes during the hospitalization after an ED revisit. 17,18 Hospitalization rates after an ED revisit may also be problematic because ED admission rates per se are highly variable across EDs.…”

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

“…Prior to the emergence of Covid-19, several studies assessing return admission indicated associations with increasing age, disease severity, ambulance transport, gastrointestinal or infectious disease symptoms, and prolonged time in the ED. [ [23] , [24] , [25] , [26] , [27] ] Many of these previous conclusions also appear to remain significant to 72-h return admission in the setting of Covid-19. Gastrointestinal symptoms predominate, for example, while increasing age, triage acuity, and ED length of stay all remain significant.…”

Accuracy of telephone triage for predicting adverse outcomes in suspected COVID-19: an observational cohort study

“…Patients with early representation after discharge from the ED are considered clinically high risk for adverse outcomes and misdiagnosis and this is likely to be reflected in patients who contact NHS 111. 41 This finding has been fed back to the telephone triage service provided by YAS and is likely to be applicable to telephone triage in different settings.…”