Unscheduled Return Visits to the Emergency Department: Consequences for Triage

Abstract

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.ACADEMIC EMERGENCY MEDICINE 2013; 20:33-39 © 2013 by the Society for Academic Emergency Medicine S hort-term unscheduled revisits (URs) to the emergency department (ED) occur in 2% to 5% of patients.1,2 A UR differentiates a patient as being different from frequent users of the ED 3 and from patients making EDs visit after recently being discharged from the hospital. 4,5 The principal causes of URs to the ED are patient-related factors, illness-related factors, and medical errors. ...

Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases

“…Only one study has been performed in Italy to the best of our knowledge, and was mainly focused on evaluating resource utilization in management of AAP (19). The scarce information available so far is particularly concerning if one considers that abdominal pain represents one of the leading causes of repeated ED visits, often necessitating additional and expensive testing, and sometimes plagued by unfavorable outcomes (20)(21)(22)(23). Therefore, the aim of this study was to investigate the epidemiology of AAP in an adult patient population admitted to a large urban ED and, even more importantly, to analyze the clinical outcomes based on patients returning to the ED within 5 and 30 days after first admission and needing surgery.…”

Diagnostic errors related to acute abdominal pain in the emergency department

“…While unscheduled return visits to the ED within 72 h are commonly used as a trigger to find these errors,11 12 evidence suggests that the revisits associated with poor quality and error may occur up to 9 days after the initial visit 13. Reviews of unscheduled ED return visits estimate that 12%–25% of patients returning had an incorrect initial diagnosis 14 15…”

“…While several reviews of return visits have found abdominal pain to be a major factor associated with unscheduled returns (n=10),15 prior studies of repeat visits to the ED and adverse events have only focused on chest pain (n=13), psychiatric complaints (n=10) and chronic lung disease (n=8). Abdominal pain is the most common chief complaint16 and also a particular area of risk for the ED physician because several abdominal conditions can present with uncommon or unusual presentations.…”

Establishing an Integrated Quality Assurance and Patient's Safety Service in a Tertially, Academic Medical Center

“…Per cutaneous coronary catheterization (PCI) within 90 min in ST elevation myocardial infarction (STEMI) [4] Preventive aspirin therapy for patients with acute MI [5] Preventive statins therapy for patients with acute MI [6] Performance evaluation of risk of stroke in patients with atrial fibrillation [7] Evaluation of Padua score for prevention of venous thrombosis [8] Carotid arteries duplex within 72 h of admission to the emergency department due to transit ischemic attack [9] TPA or neuro-angiography after acute CVA [10] Preventive antibiotic treatment an hour before colectomy [11] Operation of hip fracture within 48 h of admission [12] Antibiotic prophylaxis before hip surgery [13] Preventive antibiotic treatment before Cesarean section [14] Preventive anti-thrombotic treatment before hysterectomy [15] Steroids therapy for women at risk of preterm delivery [16] Hospitalization within two weeks after gynecologic elective surgery [17] Hospitalization within two weeks after elective cesarean section [18] Readmissions to the emergency department within 24 h [19] Computing diagnosis in the emergency department, brain CT or MRI in acute CVA within 25 min of arrival to the emergency department [20] Chest x-rays interpretation NA Central line associated bloodstream sepsis (CLABSI) for 1,000 catheter-days [21] Clostridium difficile incidence for 1,000 hospitalization days [22] Falls for 1000 hospitalization days [23] Falls with severe damage for 1000 hospitalization days [24] Acquired pressure sore [24] Computing main diagnosis in the digital patient's file NA Longer hospitalization of more than 8 days following colectomy for colorectal cancer [25] Readmission within 2 weeks after trans urethral prostatectomy [26] Planned patient's discharge NA…”