P120: Characteristics and outcomes of patients with neurologic complaints who have an unscheduled return visit to the emergency department within 72 hours

Introduction: Patients with neurologic presenting complaints comprised 12.5% of total University of Alberta Emergency Department (ED) visits in 2017. This group of patients has high rates of EMS utilization, admission, and ED resources including diagnostic imaging and consult services. We sought to analyze the characteristics and outcomes of the patients with neurologic complaints who have an unscheduled return visit (URV) to the ED within 72 hours to identify opportunities for improvement in quality and safety of patient care. Methods: Data was extracted from the Emergency Department Information System (EDIS) and National Ambulatory Care System databases to select adult patients presenting to the University of Alberta hospital in 2017 with neurologic complaints as defined by the Canadian Triage and Acuity Scale (CTAS). We additionally selected for return visits to Edmonton Zone EDs within 72 hours. Using standard descriptive statistics, we examined demographic and clinical characteristics of patients with 72-hour URV. Results: Of 8,770 total visits, 674 (7.69%) had a 72-hour URV to an Edmonton zone ED. The URV rate was 9.0% in patients seen by a physician and discharged with approval and 23.4-33.3% in patients who left against medical advice (LAMA), prior to completion of treatment (LPCT), or without being seen by a physician (LWBS). The mean age of URV patients was 45.6 years, 56.5% were male, with a mean ED length of stay of 7.37 hours. The top 5 diagnoses for URV patients were headache, migraine, alcohol related disorders, concussion, and transient ischemic attack. 14.7% of URV patients were admitted, 13.5% LWBS, 1.6% LAMA, 1.6% LPCT, and 66.1% were discharged. Conclusion: The majority of neurologic complaint patients with URV within 72 hours are those who LAMA, LPTC, or LWBS at index visit. The admission rate for URV patients (14.7%) is lower than for the index ED visit (55%), however these patients have high LWBS rates. Identifying strategies to limit the LWBS rate for these patients would reduce return visits and improve the quality and safety of patient care.

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P119: Characteristics and outcomes of patients with neurologic complaints who leave the emergency department without being seen

CJEM ◽

10.1017/cem.2019.310 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S107

Author(s):

A. Schouten ◽

A. Gauri ◽

M. Bullard

Keyword(s):

Emergency Department ◽

Head Injury ◽

Sensory Loss ◽

Quality And Safety ◽

Diagnostic Uncertainty ◽

University Of Alberta ◽

Chief Complaints ◽

Discharged Patients ◽

Return Visits ◽

The University

Introduction: Patients with neurologic chief complaints comprised 12.5% of total visits to the University of Alberta Emergency Department (ED) in 2017. Symptoms are often subjective, transient, or atypical, leading to diagnostic uncertainty. Serious diagnoses require timely intervention to mitigate morbidity and mortality, however the proportion of patients who leave the ED without being seen (LWBS) has increased over time. We sought to analyze the characteristics and outcomes of patients with neurologic complaints who LWBS to identify opportunities for improvement in quality and safety of patient care. Methods: Data was extracted from the Emergency Department Information System (EDIS) and National Ambulatory Care Reporting System database to select adult patients presenting to the University of Alberta Hospital in 2017 with neurologic complaints as defined by the Canadian Triage Acuity Scale (CTAS). Using standard descriptive statistics we examined demographic and clinical characteristics to compare LWBS patients to all others. Results: Of 8,726 total visits 7.54% patients LWBS. These patients tended to be younger on average (39 vs 55 years), with a larger proportion presenting at night (37.69%) and on Monday. The majority were triaged CTAS 3 (68.69%). Their mean length of stay was shorter than all other visits (3.70 vs 9.51 hours). Headache (22.74%), extremity weakness/symptoms of CVA (20.19%), head injury (14.32%), seizure (8.28%), and sensory loss/paresthesia (8.14%) comprised the top 5 neurologic complaints, and were disproportionately presented in LWBS patients; headache (31.76%), head injury (23.71%), sensory loss/paresthesia (12.01%), seizure (11.25%). Patients who LWBS also re-presented to the ED within 72 hours (21.43%), more often than those discharged by a physician (8.29%). Conclusion: Patients presenting with neurologic complaints who LWBS are younger, tend to arrive at night, with less acute presentations, however they more frequently return to the ED within 72 hours than those seen and discharged. Patients who LWBS may benefit from education, physician assessment or closer nurse reassessment at triage to increase the quality and safety of care in the ED, reduce return visits and ED utilization.

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

Western Journal of Emergency Medicine ◽

10.5811/westjem.2021.6.52212 ◽

2021 ◽

Vol 22 (5) ◽

pp. 1124-1130

Author(s):

Chu-Lin Tsai ◽

Dean-An Ling ◽

Tsung-Chien Lu ◽

Jasper Lin ◽

Chien-Hua Huang ◽

...

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Resource Use ◽

Admission Rate ◽

National Database ◽

Return Visit ◽

Icu Admission ◽

Inpatient Outcomes ◽

Ed Visits ◽

Admission Group

Introduction: Emergency department (ED) revisits are traditionally used to measure potential lapses in emergency care. However, recent studies on in-hospital outcomes following ED revisits have begun to challenge this notion. We aimed to examine inpatient outcomes and resource use among patients who were hospitalized following a return visit to the ED using a national database. Methods: This was a retrospective cohort study using the National Health Insurance Research Database in Taiwan. One-third of ED visits from 2012–2013 were randomly selected and their subsequent hospitalizations included. We analyzed the inpatient outcomes (mortality and intensive care unit [ICU] admission) and resource use (length of stay [LOS] and costs). Comparisons were made between patients who were hospitalized after a return visit to the ED and those who were hospitalized during the index ED visit. Results: Of the 3,019,416 index ED visits, 477,326 patients (16%) were directly admitted to the hospital. Among the 2,504,972 patients who were discharged during the index ED visit, 229,059 (9.1%) returned to the ED within three days. Of them, 37,118 (16%) were hospitalized. In multivariable analyses, the inpatient mortality rates and hospital LOS were similar between the two groups. Compared with the direct-admission group, the return-admission group had a lower ICU admission rate (adjusted odds ratio, 0.78; 95% confidence interval [CI], 0.72-0.84), and lower costs (adjusted difference, -5,198 New Taiwan dollars, 95% CI, -6,224 to -4,172). Conclusion: Patients who were hospitalized after a return visit to the ED had a lower ICU admission rate and lower costs, compared to those who were directly admitted. Our findings suggest that ED revisits do not necessarily translate to poor initial care and that subsequent inpatient outcomes should also be considered for better assessment.

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An electronic audit tool to track the donning and doffing practices of personal protective equipment in the emergency department

Canadian Journal of Emergency Nursing ◽

10.29173/cjen135 ◽

2021 ◽

Vol 44 (2) ◽

pp. 11-12

Author(s):

Ramya Sridhar ◽

Jennifer Woods ◽

Maya Jusza ◽

Sharon Drury

Keyword(s):

Emergency Department ◽

Data Collection ◽

Patient Care ◽

Personal Protective Equipment ◽

Infection Prevention ◽

Protective Equipment ◽

Audit Tool ◽

University Of Alberta ◽

The University

An electronic audit tool to track the donning and doffing practices of personal protective equipment in the emergency department Maya Jusza, Ramya Sridhar, Jennifer Woods, Sharon Drury Background: Maintaining the safety of patients and healthcare professionals is a priority in all healthcare settings. Infection prevention measures such as donning and doffing practices of personal protective equipment (PPE) have become even more imperative in light of the SARS-CoV-2 pandemic. Potential PPE breaches and the degree of frontline compliance are currently being analyzed through the use of paper PPE audit tools which can be laborious and time-consuming. The development of an electronic alternative would improve frontline safety and enhance the efficiency of data collection, while optimizing the ability to share these observations with the frontline team in real time. Two nursing leadership students from the University of Alberta were tasked with developing an electronic PPE audit tool prototype for the University of Alberta Hospital’s emergency department. Implementation: An electronic PPE audit tool prototype was developed using Google Forms which provided a user-friendly interface. Google applications were used as no confidential or patient data was collected during PPE audits. The prototype auto-populated the data entries into linked spreadsheets and interactive data dashboards that visualized the data using graphs in real time. This enabled users to easily identify trends and direct educational interventions as required. Instructional one pagers and screencast videos were also created to accompany the prototype. The prototype was reviewed by and received extensive support from: Unit Managers, Patient Care Managers, Process Improvement Nurses, Infection Prevention Control (IPC), the Executive Director of the University of Alberta Hospital and Stollery emergency department and Edmonton Zone medicine programs, and the University of Alberta Hospital and Mazankowski Executive Leadership Team. Several changes and improvements were made using the Plan-Do-Study-Act cycle. This prototype has currently been replicated onto an Alberta Health Services (AHS) server and has completed the formal testing phase with a planned application launch date. Evaluation Methods: Plan-Do-Study-Act cycles were used to guide the implementation of this audit tool prototype. After development, the prototype was tested and revised which included six rounds of audit trials at the University of Alberta Hospital’s emergency department and on some inpatient medicine units. This prototype was consistently evaluated at various stages of development and changes were made to include feedback. After approval was received to recreate this prototype onto an AHS compatible server, additional changes were made to ensure functionality. These changes included adding designations and simplifying certain questions. IPC was consulted to ensure the steps outlined for donning and doffing in the prototype were accurate and reflected requirements in the clinical environment. Results: This audit tool prototype has gathered tremendous support through various demonstrations of its ability to streamline data collection in the healthcare setting. This data is relevant to the safety of both frontline workers and patients as it identifies inconsistencies in donning and doffing practices. In addition, the prototype also complements the Edmonton zone-wide PPE coaching initiative by allowing for a quantitative measurement of its efficacy. This has prompted the fast-tracked replication of an AHS compatible version with the assistance of a dedicated team that includes the creators of the prototype tool, IPC, Quality Assurance, Information Technology, and Clinical Services Development. This version has a scheduled launch date on March 22, 2021 and is to be initially rolled out to University of Alberta’s emergency department and medicine units. The objective is to eventually make this the standardized PPE audit tool throughout Alberta. Advice and Lessons Learned: 1) In order to be sustainable and implemented site-wide, an AHS compatible tool isrequired. The use of Google applications is not preferred as data will be stored outside ofthe AHS server. Even though there is no confidential information, wide-spread use mayoverwhelm the Google platform and a Gmail account is required to view data. An in-house AHS alternative has been developed. 2) Several discussions took place regarding discretions on what steps can be auditedaccording to IPC protocols. For example, some clinical nurse educators prefer handhygiene to be completed between donning steps, while this is not mandatory or auditableaccording to IPC. In addition, several discussions took place to identify the operationaland business owners of this tool which are required to support the AHS compatibleversion of the application. 3) PPE audits are vital across all hospital departments to improve the quality of healthcare.The use of PPE during patient care has grown exponentially due to the SARS-CoV2pandemic and has amplified the need for an electronic alternative to the existing paperPPE audit tool. The electronic audit tool offers an innovative way to accurately andefficiently collect and display data which will promote an improved quality of care.

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Injuries and frequent use of emergency department services: a systematic review

BMJ Open ◽

10.1136/bmjopen-2020-040272 ◽

2020 ◽

Vol 10 (12) ◽

pp. e040272

Author(s):

Catherine Laferté ◽

Andréa Dépelteau ◽

Catherine Hudon

Keyword(s):

Systematic Review ◽

Emergency Department ◽

Cohort Studies ◽

Eligibility Criteria ◽

Geriatric Population ◽

Physical Injuries ◽

Frequent Use ◽

Different Types ◽

Ed Visits ◽

Return Visits

ObjectiveTo review all studies having examined the association between patients with physical injuries and frequent emergency department (ED) attendance or return visits.DesignSystematic review.Data sourceMedline, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO databases were searched up to and including July 2019.Eligibility criteriaEnglish and French language publications reporting on frequent use of ED services (frequent attendance and return visits), evaluating injured patients and using regression analysis.Data extraction and synthesisTwo independent reviewers screened the search results, and assessed methodological quality using the Joanna Briggs Institute tool for prevalence studies. Results were collated and summarised using a narrative synthesis. A sensitivity analysis was performed to evaluate the repercussions of removing a study that did not meet the quality criteria.ResultsOf the 2184 studies yielded by this search, 1957 remained after the removal of duplicates. Seventy-eight studies underwent full-text screening leaving nine that met the eligibility criteria and were included in this study: five retrospective cohort studies; two prospective cohort studies; one cross-sectional study; and one case-control study. Different types of injuries were represented, including fractures, trauma and physical injuries related to falls, domestic violence or accidents. Sample sizes ranged from 200 to 1 259 809. Six studies included a geriatric population while three addressed a younger population. Of the four studies evaluating the relationship between injuries and frequent ED use, three reported an association. Additionally, of the five studies in which the dependent variable was return ED visits, three articles identified a positive association with injuries.ConclusionsPhysical injuries appear to be associated with frequent use of ED services (frequent ED attendance as well as return ED visits). Further research into factors including relevant youth-related covariates such as substance abuse and different types of traumas should be undertaken to bridge the gap in understanding this association.

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In-Hospital Outcomes in Patients Admitted to the Intensive Care Unit after a Return Visit to the Emergency Department

Healthcare ◽

10.3390/healthcare9040431 ◽

2021 ◽

Vol 9 (4) ◽

pp. 431

Author(s):

Chun-Fu Lin ◽

Yi-Syun Huang ◽

Ming-Ta Tsai ◽

Kuan-Han Wu ◽

Chien-Fu Lin ◽

...

Keyword(s):

Intensive Care Unit ◽

Emergency Department ◽

Regression Analysis ◽

Intensive Care ◽

Medical Cost ◽

Total Medical Cost ◽

Hospital Outcomes ◽

Return Visit ◽

Icu Admission ◽

Ed Visits

Background: Intensive care unit (ICU) admission following a short-term emergency department (ED) revisit has been considered a particularly undesirable outcome among return-visit patients, although their in-hospital prognosis has not been discussed. We aimed to compare clinical outcomes between adult patients admitted to the ICU after unscheduled ED revisits and those admitted during index ED visits. Method: This retrospective study was conducted at two tertiary medical centers in Taiwan from 1 January 2016 to 31 December 2017. All adult non-trauma patients admitted to the ICU directly via the ED during the study period were included and divided into two comparison groups: patients admitted to the ICU during index ED visits and those admitted to the ICU during return ED visits. The outcomes of interest included in-hospital mortality, mechanical ventilation (MV) support, profound shock, hospital length of stay (HLOS), and total medical cost. Results: Altogether, 12,075 patients with a mean (standard deviation) age of 64.6 (15.7) years were included. Among these, 5.3% were admitted to the ICU following a return ED visit within 14 days and 3.1% were admitted following a return ED visit within 7 days. After adjusting for confounding factors for multivariate regression analysis, ICU admission following an ED revisit within 14 days was not associated with an increased mortality rate (adjusted odds ratio (aOR): 1.08, 95% confidence interval (CI): 0.89 to 1.32), MV support (aOR: 1.06, 95% CI: 0.89 to 1.26), profound shock (aOR: 0.99, 95% CI: 0.84 to 1.18), prolonged HLOS (difference: 0.04 days, 95% CI: −1.02 to 1.09), and increased total medical cost (difference: USD 361, 95% CI: −303 to 1025). Similar results were observed after the regression analysis in patients that had a 7-day return visit. Conclusion: ICU admission following a return ED visit was not associated with major in-hospital outcomes including mortality, MV support, shock, increased HLOS, or medical cost. Although ICU admissions following ED revisits are considered serious adverse events, they may not indicate poor prognosis in ED practice.

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P035: Development of a province-wide audit program for return visits to the emergency department

CJEM ◽

10.1017/cem.2017.237 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S89-S90

Author(s):

L.B. Chartier ◽

O. Ostrow ◽

I. Yuen ◽

S. Kutty ◽

B. Davis ◽

...

Keyword(s):

Emergency Department ◽

Patient Care ◽

Quality Care ◽

Improve Patient Care ◽

Lessons Learned ◽

Quality And Safety ◽

Term Care ◽

Clinical Observations ◽

Quality Program ◽

Physician Leaders

Introduction: Routine auditing of charts of patients with an emergency department (ED) return visit (RV) resulting in hospital admission can uncover quality and safety gaps in care. This feedback can be helpful to clinicians, administrators, and leaders working to improve clinical outcomes, increase patient satisfaction, and promote high-value care. Health Quality Ontario (HQO) has been tasked by Ontario’s Ministry of Health and Long-Term Care (MOHLTC) to manage the newly created ED RV Quality Program (RVQP), which mandates EDs participating in the Pay-for-Results (P4R) program to audit a minimum of 25-50 RVs/year. The goal of the first-ever ED-specific province-wide Quality Improvement (QI) initiative of this kind is to promote a culture of QI that will lead to improved patient care. Methods: Participating hospitals receive quarterly confidential reports from Access to Care (ATC) that show their and other hospitals’ rates of RVs, as well as identifying information for patients meeting RV inclusion criteria at their ED (within 72 hrs of index visit, or within 7 days with specific diagnoses). HQO has partnered with QI experts and ED physician-leaders to develop various guidance materials. These materials have been disseminated through various media. Hospitals are conducting audits to identify underlying quality issues, take steps to address the underlying causes, and submit reports to HQO. A taskforce will then analyze clinical observations, summarize key findings and lessons learned, and share improvements at a provincial level through an annual report. Results: Since its launch in April 2016, 73 P4R and 16 voluntarily enrolled non-P4R hospitals (which collectively receive approximately 90% of ED visits in the province) are participating in the RVQP. ED leaders have engaged their hospital’s leadership to leverage interest and resources to improve patient care in the ED. To date, hospitals have conducted thousands of audits and have identified quality and safety gaps to address, which will be analyzed in February 2017 for reporting shortly thereafter. These will inform QI endeavours locally and provincially, and be the largest source of such data ever created in Ontario. Conclusion: The ED RVQP aims to create a culture of continuous QI in the Ontario health care system, which provides care to over 13.8 million people. Other jurisdictions can replicate this model to promote high-quality care.

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Emergency Department Management of Children with Sickle Cell Disease.

Blood ◽

10.1182/blood.v104.11.1660.1660 ◽

2004 ◽

Vol 104 (11) ◽

pp. 1660-1660

Author(s):

Melissa J. Frei-Jones ◽

Amy L. Baxter ◽

Charles T. Quinn ◽

George R. Buchanan

Keyword(s):

Emergency Department ◽

Steady State ◽

Sickle Cell Disease ◽

Hospital Admission ◽

Sickle Cell ◽

Admission Rate ◽

Categorical Variables ◽

Continuous Variables ◽

Cell Disease ◽

Ed Visits

Abstract Vaso-occlusive crises (VOC) are a common cause of emergency department (ED) visits for children with sickle cell disease (SCD). To better understand our patient population and compare with reports from other centers, we sought to describe the presentation, management, and disposition of children with VOC at our center’s ED. We also aimed to identify predictors of hospital admission. We retrospectively reviewed hospital records of all patients with SCD, age 8–19 years, who presented to our urban pediatric ED in 2003 with a chief complaint of pain. We identified all subjects diagnosed with VOC and not another cause of pain. We obtained the following data for each: SCD genotype; duration of VOC and treatment prior to ED presentation; the nature of analgesia and use of intravenous fluids (IVF) in the ED; hemoglobin (Hgb) concentration; and disposition (admitted, discharged, discharged with subsequent ED visit for same crisis). Categorical variables were evaluated by the χ2 and Fisher exact tests and continuous variables by the t-test. Odds ratios (OR) and 95% confidence intervals (CI) were calculated where appropriate. In 2003, there were 320 ED visits for patients with SCD and pain. Among these, there were 279 diagnoses of VOC in 105 individual patients: 45 had one visit, 25 two visits, and 16 ≥5 visits. Mean number of visits per patient was 2.7; 23 (22%) patients accounted for 145 (55%) visits. Homozygous sickle cell anemia (Hgb SS) was present in 73/105 patients, accounting for 222 (79%) ED visits. Overall admission rate was 179/279 (64%), with 167/179 admitted on their first visit and 12 on their return visit. Subjects with Hgb SS accounted for 147/179 (82%) admissions. Among those discharged who later returned to the ED during the same VOC, the admission rate was 86% (5 returned in 24 hours, 5 in 48 hours, 3 in 72 hours, and one 4 days later). Pre-ED home opioid use was reported in 75% of visits and was associated with increased likelihood of discharge (OR 1.63, CI 0.94–2.84, p=0.082). Duration of VOC before presentation did not significantly affect admission rate and averaged 53.2 hours for admitted patients and 49.7 hours for those discharged (p=0.689). Patients who received IVF in the ED (219/279; 79%) were less likely to be admitted (31% vs 56%, p<0.001). Hgb concentration was increased in 61%, decreased in 36% and unchanged in 3% of patients from steady-state values and was not associated with admission. After receiving 2 doses of morphine, 31 patients were discharged from the ED, while only 5 patients were discharged after receiving 3 or 4 doses of morphine. A departmental VOC protocol was followed for 25.4% of patients, with no impact on admission rate (p=0.290). In this retrospective analysis of a large series of pediatric sickle cell ED visits, patients presented later in their VOC, and admission rate was higher than previously reported. A small proportion of older patients with SCD accounted for most ED visits and hospitalizations. Hgb variation from steady-state was neither clinically significant nor predictive of admission or discharge. In contrast to previous studies, receiving IVF in the ED was associated with a greater likelihood of discharge. Home opioids prior to ED presentation seemed to decrease hospital admission. Adherence to our center’s VOC protocol did not appear to influence disposition from the ED.

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Patterns and Results of Triage Advice Before Emergency Department Visits Made by Patients With Cancer

JCO Oncology Practice ◽

10.1200/op.20.00617 ◽

2021 ◽

pp. OP.20.00617

Author(s):

Arthur S. Hong ◽

Hannah Chang ◽

D. Mark Courtney ◽

Hannah Fullington ◽

Simon J. Craddock Lee ◽

...

Keyword(s):

Emergency Department ◽

Acute Care ◽

Emergency Department Visits ◽

University Hospital ◽

Urgent Care ◽

Telephone Triage ◽

Patients With Cancer ◽

Oncology Care ◽

Ed Visits ◽

The University

PURPOSE: Patients with cancer undergoing treatment frequently visit the emergency department (ED) for commonly anticipated complaints (eg, pain, nausea, and vomiting). Nearly all Medicare Oncology Care Model (OCM) participants prioritized ED use reduction, and the OCM requires that patients have 24-hour telephone access to a clinician, but actual reductions in ED visits have been mixed. Little is known about the use of telephone triage for acute care. METHODS: We identified adults aged 18+ years newly diagnosed with cancer, linked to ED visits from a single institution within 6 months after diagnosis, and then analyzed the telephone and secure electronic messages in the preceding 24 hours. We coded interactions to classify the reason for the call, the main ED referrer, and other attempted management. We compared the acuity of patient self-referred versus clinician-referred ED visits by modeling hospitalization and ED visit severity. RESULTS: From 2011 to 2018, 3,247 adults made 5,371 ED visits to the university hospital and self-referred to the ED 58.5% of the time. Clinicians referred to outpatient or oncology urgent care for 10.3% of calls but referred to the ED for 61.3%. Patient self-referred ED visits were likely to be hospitalized (adjusted Odds Ratio [aOR], 0.89, 95% CI, 0.64 to 1.22) and were not more severe (aOR, 0.75, 95% CI, 0.55 to 1.02) than clinician referred. CONCLUSION: Although patients self-referred for six of every 10 ED visits, self-referred visits were not more severe. When patients called for advice, clinicians regularly recommended the ED. More should be done to understand barriers that patients and clinicians experience when trying to access non-ED acute care.

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

Emergency Medicine Journal ◽

10.1136/emermed-2018-208343 ◽

2019 ◽

Vol 37 (2) ◽

pp. 79-84 ◽

Cited By ~ 1

Author(s):

Eveline A Hiti ◽

Hani Tamim ◽

Maha Makki ◽

Mirabelle Geha ◽

Rima Kaddoura ◽

...

Keyword(s):

Emergency Department ◽

High Risk ◽

Digestive System ◽

Case Control Study ◽

Final Analysis ◽

Quality Metric ◽

Ed Visits ◽

Return Visits ◽

Control Study

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.

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