P050: Unplanned return visits to the paediatric emergency department: Caregiver and physician perspectives

Introduction: Unplanned return visits to the pediatric emergency department contribute to overcrowding and are used as a quality measure. They have not been well characterized in the literature making it difficult to design interventions to reduce unnecessary return visits. The aim of this study was to understand the reasons for return from the caregiver and physician perspective. Methods: This was a cross sectional survey performed on a convenience sample of unplanned return visits within 72 hours at the IWK Health Centre ED between February and October 2016. Exclusion criteria were: planned return visit, admission during the index visit, or triaged as Canadian Triage and Acuity Score (CTAS) 1 on return visit. Caregiver and physician surveys were developed based on themes identified in published literature. The caregiver was approached to complete a survey after triage and the most responsible physician from the return visit was asked to complete a survey immediately after discharge of the patient from their care. Demographic and clinical data were collected from the ED record from the index and return visits. The primary outcome measure was most important reason for return from the caregiver perspective. Results: There were 461 return visits during the study period and 67 caregivers (14.5%) were included in the final analysis. The response rate for the physician survey was 71%. Caregivers and physicians reported that the most important reason for return was a perceived progression of illness requiring reassessment (79.1% and 66.7% respectively). The majority of caregivers had a family physician on record (95%) but a minority attempted to access their family physician (19.4%) or a walk-in clinic (11.9%). Of those who contacted their family physician only 3 (23%) were offered an appointment within 48 hours and of those who did not contact their family physician 21 (38.2%) stated they would not be able to get an appointment in a reasonable amount of time. Despite this 97% would have trusted their family physician to manage their child's illness. Physicians surveyed stated that the return visit was necessary in 64.6% of cases. Conclusion: Caregivers returned to the ED due to a perceived progression of disease. While some cases may have been appropriate for management in a primary care setting, perceived difficulty with timely access was a barrier. Improved caregiver education about the natural history of disease and the urgency of follow up may reduce return ED visits.