Administration of emergency medicine
Unplanned Emergency Department Revisits within 72 Hours to a Secondary Teaching Referral Hospital in Taiwan

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Abstract

Background: When patients return to the emergency department (ED) shortly after being seen, it is generally assumed that their initial evaluation or treatment was inadequate. Objectives: The purpose of this study was to determine the rates and causes of revisits to the ED of a 710-bed secondary teaching referral hospital (Kuang Tien General Hospital), to identify areas for improvement, and to define the initial ED presentations that are associated with such revisits. Methods: The study period was from January 1, 2006 to December 31, 2006. There were 34,714 patients seen and discharged in the ED; 1899 patients returned within 72 h. Monthly revisit rates were calculated. The patients who revisited the ED within 72 h were retrospectively identified by the authors, and their charts were examined to determine the causes of the revisits. Results: There were 1899 patients (5.47% of total) found to have revisited the ED within 72 h after their initial visit. The monthly revisit rates ranged from 2.85% to 6.25% (average, 5.47%). The rates of revisits that were related to factors of illness, patients, and doctors were 80.9%, 10.9%, and 8.2%, respectively. Among the factors related to doctors, 3.7% (70 cases) were misdiagnosis, and abdominal pain was the most common presentation (55.7%, 39/70). The most common initial ED presentations were for abdominal pain (12.9%), fever (12.6%), vertigo (4.5%), headache (2.1), and upper respiratory infection (2.1%). Conclusions: Unplanned ED revisits are associated with medical errors in prognosis, treatment, follow-up care, and information. Differentiation between the natural course of a disease, suboptimal therapy, over-anxious reaction of the patient, and medical errors is difficult. Although this study indicates that most revisits are illness-related, further prospective studies are needed to evaluate the most common and the most serious causes of revisits to see if improvements can be made.

Introduction

When patients return to the emergency department (ED) shortly after being seen, it is generally assumed that their initial evaluation or treatment was inadequate (1). An unplanned return is defined as a patient presentation for the same chief complaint within 72 h of discharge from the ED (2, 3). However, the circumstances surrounding these repeat visits are poorly understood. Previous researchers have demonstrated different results in different time frames. In 1990, Pierce et al. reported a rate of 3.0% in revisits within 2 days (4). Hu revealed a rate of 4.9% in revisits within 7 days (5). Gordon et al. revealed a rate of 2.7% in revisits within 3 days (6). Keith et al. revealed a rate of 3.4% in revisits within 72 h (7). In addition, Liaw et al. reported a rate of 1.9% in revisits within 3 days (8). Studying the quality assurance of emergency care becomes a necessary task to improve and maintain service at a high level. Auditing patients who return early to the ED is a newly developed and very important quality assurance activity. Liaw et al. suggested setting a baseline for monthly ED revisits at 2% for future computer programming audit filters in their ED (8).

Many short-term return visits may be medically unnecessary because it is known that substantial numbers of patients use EDs for non-emergency problems (9, 10, 11, 12). Patients revisiting the ED should not be regarded as patients who are abusing or misusing emergency service. The revisiting patients who do not turn to another hospital due to faith in previous practice are essentially giving the ED and the Emergency physicians a second chance to solve their problems (13). Special examinations, laboratory studies, physical examination, and detailed history-taking should be provided without prejudice.

A common disease may run an atypical course or have uncommon presentations that show the initial diagnosis may be wrong. Elderly patients suffering from cardiovascular disease, infectious disease, neurologic, or endocrinologic disorders often present with atypical or trivial manifestations that may result in a misdiagnosis or early release from the ED, prompting a revisit to the ED shortly after being discharged (14, 15, 16, 17, 18). The reasons for these revisits, such as inadequate medical care, disease type, personality differences, inadequate discharge instructions, or a failure of the medical care system, are issues of interest for many investigators (4, 7, 19). The purpose of our study was to identify common and serious causes of ED revisits within 72 h, and to find out the initial ED presentations that affect such revisits.

Section snippets

Methods

The study was conducted in a 710-bed, secondary teaching hospital that receives approximately 35,000 emergency visits per year in middle Taiwan. Emergency patients who visited and revisited the ED within 72 h from January 1, 2006 to December 31, 2006 were collected as study subjects. A pool of eight Emergency attending physicians and three Emergency residents staff the ED. All medical staff are required to enter patient admission data into a computer log. Data entry includes triage category,

Results

There were 34,714 patient visits to the Kuang Tien General Hospital ED from January 1, 2006 to December 31, 2006. Of these visits, 1899 (5.47%) represented return visits to the ED within 72 h, and monthly revisit rates ranged from 2.85% to 6.25% (average, 5.47%), with no particular seasonal or event-specific pattern (Table 1).

Included were 953 males and 946 females with a mean age of 47 years. The final dispositions (second visits) for patients to revisit the ED were: discharged, 1384 patients

Discussion

The incidence of 5.47% of ED revisits was high compared with most studies. Included were 953 males and 946 females with a mean age of 47 years. This is probably due to the culture and the convenience of medical insurance. In Taiwan, owing to the low cost of hospital visits, which is made possible by the national health insurance system, people are more likely go to teaching hospitals rather than local clinics. Disease-related factors accounted for 80.9% of the revisits, higher than the data

Limitations

This study has several important limitations. The data presented were all collected from a single ED and may not be generalizable in other regions. This retrospective study has the limitations of that methodology, in addition to those inherent to documentation and changing practice in a busy teaching hospital ED. All records of revisits were categorized into one of the classifications under the judgment of two of the authors independently. If the classifications of the two reviewers were

Conclusions

Unplanned ED revisits are associated with medical errors in prognosis, treatment, follow-up care, and information. Differentiation between the natural course of a disease, suboptimal therapy, over-anxious reaction, and medical errors is difficult. Although this study indicates that most revisits are illness-related, further prospective studies are needed to evaluate the most common and serious causes of revisits to see if improvements can be made.

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