|Ahead of print publication
Factors correlated with unavoidable 72-h emergency department return visits: A retrospective cohort study
R Ajay Christopher, Darpanarayan Hazra, Aparna Lohanathan, Ankita Chowdary Nekkanti, Rathijit Pal, Kundavaram Paul Prabhakar Abhilash
Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||13-Jul-2021|
|Date of Decision||24-Oct-2021|
|Date of Acceptance||24-Oct-2021|
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Emergency department (ED) revisits are an important measure of health-care quality provided by any medical center. This study analyzes the profile and outcome of patients revisiting the ED within 72 h at a tertiary care center in South India. Methods: This was a retrospective cohort study done on all patients presenting to ED within 72 h of their first visit over 5 months. Unavoidable revisits and the factors associated with them were categorized, coded, and analyzed. Results: The ED revisit rate was 2.9% (900/30409). Based on standard triaging criteria, patients during their first visit were triaged as follows: 8.2% as priority 1, 32% as priority 2, and 58.2% as priority 3. During the revisit, they were triaged as follows: 12.9% (+3.7% increase) as priority 1, 36.9% (+4.9% increase) as priority 2 and 49.1% (-9.1% decrease) as priority 3. Approximately a quarter (27%) of the patients had to be prioritized higher on their revisit. Abdominal pain (18.3%), vomiting/diarrhea (11.7%), bleeding from the previous wound site (10.5%), and fever (9%) were the most common presenting complaints. Avoidable revisits included 13.4% (n = 121) patients. Multivariate logistic regression analysis showed age >40 years (adjusted odds ratio [OR]: 1.60; 95% confidence interval [CI]: 1.04–2.46; P: 0.031) and abdominal pain (adjusted OR: 2.07;95% CI: 1.40–3.08; P: <0.001) to be independent predictors of unavoidable ED revisits. In addition, age >40 years (adjusted OR: 3.53; 95% CI: 2.12–5.88; P: <0.001) and fever (adjusted OR: 0.57;95% CI: 0.37–0.90; P: 0.015) were found to be independent risk factors for patients revisiting as priority 1 versus other priorities. Among the revisiting patients, 15.4% required admission. Conclusion: Gastrointestinal symptoms and fever were found to be the most common symptoms that warranted a revisit. Abdominal pain and age >40 years were found to be associated with higher odds of an unavoidable revisit. In addition, age >40 years and fever were associated with sicker patients on revisits.
Keywords: 72 h emergency department revisit, abdominal pain, emergency department revisit, emergency care, gastrointestinal diseases
|How to cite this URL:|
Christopher R A, Hazra D, Lohanathan A, Nekkanti AC, Pal R, Prabhakar Abhilash KP. Factors correlated with unavoidable 72-h emergency department return visits: A retrospective cohort study. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=339388
| Introduction|| |
Some vital quality control indicators of any health-care system include emergency department (ED) revisits, the mortality rate in ED, patient waiting time, and the time interval to initiate medical care and plan further management.,, Although there is no uniform definition of acute ED revisit, often taken as ED presentation within 24 h–72 h., Revisits to the ED within 72 h are often considered a sign of inefficient or inadequate diagnosis and treatment in the initial visit., In fact, ED revisit rates of over 5% are found to be a poor indicator of quality ED management. Having to revisit the hospital has negative psychological and economical effects on the patients, besides the physical worsening of disease that brings them back. On the other hand, lack of proper counseling on the part of ED physicians/treating units regarding expectations of the disease progression in the days following discharge also contributes to anxiety among patients about otherwise expected symptoms. Studies from the South-East Asian countries and Australia have shown their ED revisit rates to be ranging between 0.8% and 5.8%.,,,, A study done among the Massachusetts population showed more than 50% of patients required multiple ED visits and that 1% had 5 or more ED visits. Whereas a study was done in the ED of a tertiary care center in Saudi Arabia showed that a quarter of them warranted an ED revisit and couldn't be managed by the primary health physician.
Emergency medicine is a relatively new branch in developing countries with highly inadequate numbers of trained physicians, nurses, and technicians. India is one such country, where specialized ED facilities are already in short supply and resources limited, ED revisits only worsen the existing burden. Our ED setup is one of the largest in the country, catering to almost 70,000 patients a year. Being a leading tertiary care center, our ED receives patients not just from the locality but also from all over the country and some neighboring countries as well. Our goal with this study was to take advantage of this massive patient influx and hopefully use it as a guide to determine the characteristics and risk factors of ED revisit, to better equip our own as well as other centers to handle these emergencies.
| Methods|| |
We conducted a retrospective observational cohort study in the ED of a tertiary care center in South India. Our ED is a 49-bed department and caters to the need of around 300 trauma and non-trauma patients per day. All adult emergency cases (>15 years), as well as pediatric trauma cases, are managed in our ED, whereas all other pediatric emergencies are managed in pediatric ED. All patients who had revisited the ED within 72 h of their first consultation from January 2019 to May 2019 (5 months) were included in the study. Patients with incomplete documentation or missing data were excluded. Patient charts were retrieved from the ED triage registry software and clinical workstation. These charts were reviewed and the relevant details of history, clinical findings, laboratory investigations, radiological investigations, and triage priority levels in both visits were documented in the study form. Further units medical/surgical teams other than the ED team involved in managing patients were also noted. Triaging was done by standard Canadian triage system depending on the hemodynamic status of the patient in each visit. Level 1 included patients with a threat to life or limb requiring urgent resuscitation, whereas patients with a potential threat to life, limb or function or a serious condition that require emergency intervention were triaged as level 2. Level 3 included patients with conditions that relate to distress or potential complications that would benefit from intervention and 4 included patients with a nonurgent complaint or that may be part of a chronic problem. A revisit was categorized as unavoidable if the patient was diagnosed correctly and managed appropriately during the first visit or if the patient presented with an unrelated illness within 72 h. Whether acute or new complaints, missed diagnoses or advertent causes were noted as were the outcomes of patients from the ED whether they required admission in the second visit, or were discharged safely, or were discharged against medical advice, or succumbed to their illness were also recorded in the form. As ours is a private tertiary care hospital, some patients requiring admission were referred to other centers due to financial constraints or unavailability of in-patient beds following primary care in ED. All referred patients were discharged with a medical report summarizing the symptoms, course of illness, provisional diagnosis, results of laboratory, and radiological investigations and suggested further plan of care.
Statistical Package for the Social Sciences (SPSS) for Windows, Version 23.0, IBM Corp. Released 2015, (Armonk, New York, USA).
Data were summarized using mean along with standard deviation (SD) for the continuous variables and frequencies along with percentages for the categorical variables. Some of the variables such as age, presenting complaints, presenting with same complaints or within 72 h of initial presentation, history of trauma, discharged by ED registrars, or unfit of discharge in the first visit were categorized and coded. A bivariate analysis was done to identify the relationship between these variables and prediction of avoidable and nonavoidable ED revisit or patients revisiting in triage priority 1 versus others. All possible determinants with P ≤ 0.05 in the bivariate analysis were used as candidates for multivariate logistic regression analysis to determine their significant association simultaneously.
This was a retrospective study approved by the Institution Review Board and waiver of patient's consent was obtained. Patient confidentiality was maintained using unique identifiers and by password-protected data entry software with restricted users.
| Results|| |
The ED attended to a total of 30,409 patients during the 5 months study period. The prevalence of ED revisits was 2.9% (n = 900) [Figure 1]. The mean age of this cohort was 46.4 (SD: 17.3) years with majority (57.1%–514/900) being males. Based on their hemodynamic stability, majority, i.e., 58.2% (n = 524) were initially categorized as priority 3, 32% (n = 288) as priority 2, and 8.2% (n = 74) as priority 1. During the revisit, 49.1% (n = 442) (-9.1% decrease) were priority 3 patients, 36.9% (n = 332) (+4.9% increase) were priority 2 and 12.8% (n = 116) (+3.7% increase) were priority 1. Baseline characteristics and monthly variation of revisits are given in [Table 1]. Most common comorbidities included hypertension (26.9%: n = 242), diabetes mellitus (24%: n = 216), and malignancy (13.8%: n = 124).
|Table 1: Baseline characteristics and monthly distribution of patients presenting to the emergency department within 72 h (n=900)|
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Majority (81%: n = 729) presented with the same complaint as their first visit while approximately two-fifths (19%: n = 171) presented with new complaints. Nearly one-fourth (24.9%: n = 224) of the population presented with acute complaints and the rest (75.1%: n = 676) with chronic complaints. The chief presenting complaints in the first visit included abdominal pain (18.3%: n = 165), vomiting or diarrhea (11.7%: n = 106), bleeding from previous wound site (10.5%: n = 95), and fever (9.0%: n = 81) [Figure 2]. During the revisit, 27% (n = 247) had to be prioritized higher, 17% (n = 148) were deprioritized and rest remained in the same triage priority level. Avoidable revisits included 13.4% (n = 121) patients and unavoidable revisits included 86.6% (n = 779).
|Figure 2: Most common presenting symptoms during the first emergency department visit|
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Bivariate and multivariate logistic regression analysis for prediction of avoidable and nonavoidable ED revisit showed age >40 years (adjusted odds ratio [OR]: 1.60 (95% confidence interval [CI]: 1.04–2.46); P: 0.031) and abdominal pain (adjusted OR: 2.07 [95% CI: 1.40–3.08]; P: <0.001) to be independent and statistically significant risk factors for unavoidable revisits [Table 2]. In addition, age >40 years (adjusted OR: 3.53 [95% CI: 2.12–5.88]; P: <0.001) and fever (adjusted OR: 0.57 [95% CI: 0.37-–0.90]; P: 0.015) had higher odds of patients revisiting in triage priority 1 versus others [Table 3].
|Table 2: Bivariate and multivariate logistic regression analysis for prediction of avoidable and nonavoidable emergency department revisit|
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|Table 3: Bivariate and multivariate logistic regression analysis of factors associated with patients revisiting in triage priority 1 versus others|
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The ED team was involved in the primary evaluation and management of all the patients and after obtaining a provisional diagnosis, they were handed over to specialized medical or surgical units. Departments involved in the management and discharge during the first visit are shown in [Figure 3]. ED disposition during the first visit was as follows: 78.5% (n = 707) patients were discharged stable from the ED, 19.5% (n = 175) left against medical advice, and 2% (n = 18) were referred to the outpatient department of specialized units. ED disposition during the second visit was as follows: 80.8% (n = 727) patients were discharged stable from the ED, 15.4% (n = 139) were admitted and the remaining 3.8% (n = 34) left against medical advice.
|Figure 3: Departments involved in managing patients and discharge in the initial emergency department visit|
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| Discussion|| |
Our study showed the prevalence of ED revisits to be 2.9% which is in keeping with the rates seen in many developed countries and is indicative of a satisfactory level of emergency care.,,, However, a similar study done in our department in 2014–2015 showed a prevalence of only 0.8%, which sounds alarming but could be at least partially explained by the increase in emergency beds and patient influx since then. Another factor that is probably closer to the truth is the lack of effective computerized systems at the time which could have led to a significant loss of data.
A triage system is a crucial part of any ED setup to assign relatively scarce resources to unlimited medical needs.,, Our triage system was the first of its kind to be established in India and is renowned for its integration of both highly trained triage nurses and doctors to accurately evaluate and prioritize each patient on presentation. This, no doubt contributed to the low rates of revisits in our study. In general, the common contributing factors to ED revisits are either illness related, patient related, or physician related. Illness-related factors encompass actual worsening of recurrence of disease or diseases that have atypical presentations and are considered unavoidable revisits in our study. Physician-related factors are avoidable and include doling out suboptimal treatment or missing a diagnosis that should have been made. Patient-related factors usually stem from the patients' anxiety related to the disease which urges them to present to the ED without any real worsening of symptoms.,, These also include patients that have been discharged against medical advice who subsequently change their mind regarding management. It can be seen in our study that a large proportion of the revisits were by patients with similar complaints as their first visit, or due to chronic complaints that weren't always emergent. The culprit for this could be insufficient counseling of the patients during their first visit while getting discharged with inadequate management of expectations and knowledge about the course of the disease. Abdominal symptoms were the most common cause of revisits, as echoed in other studies in the past.,,, While sometimes seemingly trivial, abdominal pain is frequently an insidious symptom that requires thorough workup and evaluation. Treating patients symptomatically does not solve the underlying issue and requires them to revisit the ED when symptoms recur.
A fourth of the patients in our study population had to be prioritized at a higher level during the subsequent visit, which is cause for concern as it could point to physician-related factors as also seen in similar studies done in the past.,,,, An overworked health-care system with a large patient population could be blamed for this and must be taken into consideration and changes in the department made accordingly. Our study shows a large number of these patients were upgraded from priority 3 to priority 2, which warrants a keen and thorough evaluation of priority 3 patients.
This study works primarily as an audit of our health-care system to reveal flaws and weak links to better equip our ED with the capacity to lower the rates of revisits and to better manage them without overloading it. The presence of several sub-specialty departments in our tertiary care center likely aided care and helped to keep the revisit rate as low as it is. We hope this also serves as a guideline to other such centers, to motivate them to find inconsistencies within their departments and make positive changes toward a common goal.
Suggestions for future research
More studies are warranted to evaluate for psychological and economic impacts of these revisits on both patients and the health-care system. In addition, there needs to be reliable data on whether the revisits are seeing deteriorating health in the patients or requiring interventions in the form of management.
This being a retrospective study, the exposure or outcome assessment could not be assessed and instead relied on others for accurate record keeping. Since our hospital has separate setups for pediatric emergencies and patients presenting with chest pain/acute coronary syndrome, our study population is limited to an extent to only adult emergencies and pediatric traumas.
| Conclusion|| |
Abdominal symptoms are the most overlooked causes of these revisits and require thorough evaluation. Abdominal pain and age >40 years were found to be associated with higher odds of an unavoidable revisit. In addition, age >40 years and fever were associated with sicker patients on revisits.
Research quality and ethics statement
This study was approved by the Institutional Review Board/Ethics Committee at Christian Medical College and Hospital, Vellore, Tamil Nadu (IRB Min no: 13781 dated January 27, 2021). The authors followed the applicable EQUATOR Network (http://www.equator-network.org/) guidelines, specifically the STROBE guidelines, during the conduct of this research project. We also certify that we have not plagiarized the contents in this submission and have done a plagiarism check.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]