Objective Return visits to the paediatric emergency department (PED) are an important measure of quality of healthcare and are associated with patients’ and parents’/guardians’ satisfaction. Previous studies have been limited to describing characteristics and factors related to return visits. The objectives of this study were to develop new clinical practices to reduce return visits to the PED and to see whether implementation of these practices had the desired effect.
Patients and methods This was a controlled before-and-after study. New clinical practices were developed by analysing data for patients visiting in 2011 (before) and by surveying emergency physicians and nurses in the PED. New clinical practices were implemented between 16 July and 4 November 2012 (after). The rate of return visits and admission rates after return visits were compared between matched periods in 2011 and 2012. We also investigated return visits at three independent hospitals to overcome the limitation of the intervention application to a single hospital.
Results The new clinical practices included five protocols: set orders for common symptoms; management plans for patients at high risk of a return visit; a daily physician feedback system; protocolised discharge instructions; early planned visits to clinics. After implementation, the rate of return visits was reduced significantly, from 4.4% to 2.6% (p<0.01). The admission rate for return visits was also reduced, but not significantly so, from 22.3% to 17.5% (p=0.37). Return visits at the other hospitals were similar or significantly increased in 2012 compared with 2011.
Conclusions The development and implementation of clinical practices were effective in reducing return visits of paediatric patients to the ED.
- Quality Assurance
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What is already known on this subject?
There were many studies for return visits for pediatric patients. However, most of them were descriptive or investigated the factors for revisit.
What might this study add?
We showed that the development and implementation of clinical practices to reduce return visit could decrease the return visit rate.
Early return visits to the emergency department (ED) contribute to ED overcrowding and increase healthcare costs and patient waiting times.1–4 Because return visits are also related to medical errors in previous visits, they have been used as a hospital quality indicator.3 ,5–8
Although there is some variation in the definition of the period for return visits, most studies define the timing of return visits as within 72 h.3 ,4 ,6 ,7 ,9 The rate of return visits within 72 h reported previously has ranged from 2.7% to 5.2% in the paediatric ED (PED)1 ,3 ,8 ,10 and 1.4–5.5% in the adult ED.7 ,9 ,11 Most studies of return visits have shown only characteristics of and factors related to return visits.1–3 ,5 ,12 Some studies have demonstrated efforts to reduce return visits, but these efforts were limited to post-discharge management or to adult patients.13–16 Guttman et al16 revealed that a discharge-plan coordinator for elderly patients reduced return visits and increased satisfaction. The studies for paediatric patients included only post-discharge management such as drugs or telephone call.13 ,14 Yang and Chen13 showed a reduced rate of return visits in children when telephone calls were used after discharge. Sturm et al14 demonstrated that use of ondansetron for children with vomiting after head trauma could reduce the rate of return visits.
We decided that new practices were needed for paediatric patients to improve PED overcrowding and quality of care. The objectives of this study were thus to develop new clinical practices for reducing return visits of paediatric patients and to compare the rate of return visits before and after their implementation.
Design and setting
This study was a time-series controlled trial for reducing return visits in the PED. It was conducted in a single academic, urban ED with an annual census of 17 000 paediatric patients, 41 000 adult patients and 18 000 injured patients in 2011. Triage nurses assigned injured patients to the trauma ED, non-injured patients under 16 years of age to the PED, and the remaining patients to the adult ED. Because injured patients under 16 years old were treated in the trauma ED, they were not included in this study. The patients were managed by emergency physicians supervised by board-certified emergency attending physicians. If emergency physicians judged that the patients required admission, they consulted physicians in other departments using the electronic medical record system.
This study was approved by the institutional review board of our hospital.
Patients visiting the PED between 1 January and 31 December 2011 and between 2 July and 4 November 2012 were included. Return visits were defined as revisits within 72 h after the first discharge from our PED. We used electronic medical records for exact times. Patients who were discharged by physicians of other departments, admitted to the hospital, transported to another hospital, or discharged as dead from a first visit were excluded. Patients returning with problems unrelated to previous visits were also excluded.
We reviewed the electronic medical records of patients for data on gender, age, visits by transfer from another hospital, mode of arrival to ED (ambulance or not), mental status, outpatient department (OPD) appointments, discharge medications, ED length of stay (EDLOS) at first visit, return visits, and the consequences of return visits. The rate of return visits was calculated as the number of return visits divided by the total number of discharged patients. The admission rate after return visits was calculated as the number of admissions on return visits divided by the total number of return visits. Transfer of return-visit patients to another hospital for admission was considered an admission in the disposition categorisation.
A multidisciplinary team composed of emergency physicians, paediatric emergency physicians, and nurses convened once a week to develop clinical practices over 2 months. We reviewed the literature to identify the classification and reduction methods for return visits. We used two approaches to develop practices. First, we surveyed emergency physicians and nurses at the ED about causes of return visits. A diagram on each management step in the ED was used to select steps related to return visits (figure 1). We discussed the most problematic issues in developing methods for reducing return visits. Second, we analysed the patients who visited the PED in 2011 by first dividing them into two groups: return visits and non-return visits. Clinical variables in initial visits of the return-visits group were compared with those of the non-return-visits group to identify relevant factors. The patients in the return-visits group were analysed to identify factors involved in return visits. These were classified as disease-related, doctor-related and patient-related factors according to the main causes of return visits.7 Disease-related factors were defined as return visits resulting from progression or worsening of the disease, which could reasonably have been expected. Doctor-related factors were defined as return visits resulting from misdiagnoses or treatment errors made by treating physicians. Patient-related factors were defined as return visits caused by patients leaving against medical advice, poor compliance by guardians, or failure to keep arranged OPD appointments.7 The most important factors were selected by two team members. If the two team members disagreed with the classifications, other members arbitrated the classifications.
To overcome the limitations of the uncontrolled before-and-after study and the limitation of the intervention application to a single hospital, we investigated the rate of return visits in the ED of three independent tertiary academic hospitals in the study period to assess whether differences in return visits in the study hospital could be attributed to the intervention.
Patients visiting the PED in 2011
In total, 17 325 paediatric patients visited our PED in 2011. After exclusion of 3514 cases, 626 patients had return visits and 13 185 patients did not, giving a return-visit rate of 4.5% (626/13 811). Most return visits were associated with disease-related factors (557 patients, 89.0%). There were 49 return visits (7.8%) due to doctor-related factors, and 20 (3.2%) due to patient-related factors (figure 2). The admission rate after return visits was 23.8% (149/626).
Comparison of clinical variables between the return-visit and non-return-visit groups showed significant differences in age, visits by transfer from another hospital, and EDLOS. However, there was no significant difference between the groups in terms of gender, mode of arrival at the ED, mental status, OPD appointments, or discharge medications (table 1). Age younger than 36 months, transfer from another hospital, and EDLOS longer than 3 h were found to be high-risk factors for return visits.
Problematic issues identified in the survey included decision-making regarding discharge and the need for further examinations. We developed five clinical practices based on the survey and analysis of risk factors of return visits in our data.
Set orders for common symptoms
We established sets of guidelines for appropriate management/treatment of common diseases: attention points, laboratory tests, and appropriate drugs and dosages. The most common diseases were acute gastroenteritis (AGE), bronchiolitis, croup, pneumonia and seizure.
Management plan for patients at high risk of return visits
We identified risk factors for return visits after analysing returning patients in 2011. If the patients had these risk factors, it was recommended that senior physicians be engaged in the management of and decisions regarding discharge.
Daily physician feedback system
Multidisciplinary team members analysed return patients daily after application of the clinical practices. If there were medical errors, we used two approaches. One was to notify the involved physician directly about the errors. The second was to discuss it at morning conference to prevent the same errors from other physicians. Morning conference is held five times a week.
Protocolised discharge instructions
Physicians may fail to give full discharge information because of a crowed ED. Also, many guardians are exhausted and have difficulty concentrating on explanations from doctors at the time of discharge. We thought that these situations might contribute to more frequent return visits. To reduce these mistakes and to standardise discharge explanations and instructions, we used two strategies: protocolised discharge explanations and written discharge instructions. The protocolised discharge explanations included information on results of the examination, diagnosis, expected course and management of the disease, situations requiring a return visit, handling of unexpected situations, and confirmation of OPD appointments. After the explanation, the guardians received papers asking them to rank their satisfaction with the explanations. If the guardians indicated that the explanations were poor, the physicians were expected to explain the situation again. Written discharge instructions were made for fever and symptoms of AGE, such as nausea, vomiting and diarrhoea, because these were common chief complaints in return visits in 2011. The instructions concerned common diseases that might cause the symptoms, strategies for use of antipyretics and oral rehydration fluids, and symptoms requiring return visits. After discharge, the guardians could read the forms at home to be reminded of the instructions. In the case of fever, symptoms requiring return visits included respiratory difficulty, skin rash, poor oral intake, neck stiffness and localised pain with redness. Symptoms requiring return visits in the case of AGE included haematochezia, melaena, pain in the right lower quadrant, poor oral intake, dehydration, lethargy, cyclic irritability, bilious vomiting and seizure.
Early planned visit to clinics
It was hard to reserve early OPD appointments because of the generally crowded OPD in our hospital. Thus, patients might return to the ED before the scheduled OPD appointment. After discussing this problem with the paediatric department, ED patients were given priority for OPD appointments, and they could reserve OPD appointments early if follow-up at our hospital was required.
We informed the emergency physicians and nurses about the five clinical practices on 2 July 2012. Education sessions were held once a week to teach the practices, such as teaching about medical errors with returned patients. Because of the need to accommodate all physicians and nurses, we had a transition period of 2 weeks (2–15 July 2012). The period after application of the clinical practices, excluding the transition period, was defined as the post-practice period. The post-practice period, from 16 July to 4 November 2012, was compared with the matched pre-practice period in 2011.
The primary outcome was the rate of return visits in the post-practice period compared with the pre-practice period. We compared the return visits in the same period between 2011 and 2012 (16 July to 4 November). Secondary outcomes were admission rate after return visits and EDLOS of first visits in the post-practice and pre-practice periods.
For statistical analyses, we used SPSS V.19.0. Patients’ clinical data were compared using unpaired Student's t tests or χ2 tests, as appropriate. The return visit rate and admission rate after return visits during 2011 and 2012 were compared using χ2 tests. Differences with p<0.05 were considered significant.
Patients visiting the PED in the pre-practice period
In total, 5840 patients visited the PED during the pre-practice period, and 1242 patients were excluded. Of those remaining, 202 had return visits and 4396 did not (figure 3). The rate of return visits and admission after return visits during the pre-practice period were 4.4% (95% CI 3.8% to 5.1%) and 22.3% (95% CI 16.8% to 28.1%), respectively.
During the 2-week transition period, 2–15 July 2012, the rate of return visits was 3.5% (16/454), and admission rate after return visits was 18.8% (3/16).
We applied the new practices for 16 weeks, from July 16 to 4 November 2012. During this period, 4366 patients visited our ED, and 633 patients were excluded. Of the 3733 remaining, 97 patients had a return visit, for a return-visit rate of 2.6% (95% CI 2.1% to 3.1%) (figure 4). Comparison of clinical variables between the pre- and post-practice period showed significant differences in terms of age, transfers from another hospital, OPD appointments, and discharge medications. The admission rate after return visits in the post-practice period were 17.5% (95% CI 10.5% to 25.4%). The rate of return visits in the post-practice period was significantly reduced compared with that in the pre-practice period (pre-practice, 4.4% vs post-practice, 2.6%, p<0.01). Although the admission rate for return visits was reduced, the difference was not statistically significant. However, EDLOS increased significantly in the post-practice compared with the pre-practice period (p<0.01; table 2).
The rates of return visits from 16 July to 4 November 2011 in other hospitals were 3.1% in hospital A, 2.7% in hospital B and 2.1% in hospital C, and the rates of return visits from 16 July to 4 November 2012 were 3.1%, 2.2% and 3.0%, respectively. The rates of return visits for hospitals A and B were similar in 2012 compared with 2011. The rate of return visits for hospital C was significantly increased in 2012 compared with 2011 (p<0.01).
This study showed that the implementation of the new practices succeeded in significantly decreasing the rate of return visits in the PED, from 4.4% to 2.6%. The admission rate after return visits was also reduced but not significantly so. However, EDLOS was significantly increased after implementation of the new clinical practices. We might suggest that more careful management to reduce return visits prolonged EDLOS. However, considering the small difference and safety issues involved, this increase could be tolerated.
Many studies have been conducted to identify rates and causes of return visits, because these rates are considered to be a hospital quality indicator.8 ,13–15 ,17 However, few trials have been designed to reduce return visits, and these studies were conducted with limited ages and concerned after-discharge management.13 ,14 ,16 They did not consider risk factors related to return visits. We developed and applied new clinical practices considering these limitations. Our hospital already operated a follow-up telephone call system. Nurses called guardians to identify the course of diseases and to ask whether a return visit was needed. This system was implemented in an effort to prevent significant consequences associated with medical errors.
After analysing patient return visits in 2011, we developed set orders for common symptoms, a management plan for patients at high risk of a return visit, and a daily physician feedback system. The set order systems facilitated ordering laboratory tests and medications and reduced the risk of error in tests and prescriptions. The management plans for high-risk patients allowed senior physicians to give real-time feedback to junior physicians about medical errors. In the daily feedback system, multidisciplinary team members analysed daily return-visit cases to identify medical errors and to provide feedback to physicians. Any identified medical errors were also discussed at daily morning conferences. These systems influenced physicians in several ways. They raised physician awareness of return-visit issues and facilitated discussion of common mistakes, which can both contribute to reducing medical errors.
Other studies have shown that disease progression is the cause of most return visits in the PED.4 ,10 Progression of disease does not necessarily mean that the patients should be treated in the ED. About 75% of children returning to our ED were discharged home and not admitted. We considered that clear instructions on the symptoms requiring emergency treatment could reduce avoidable return visits. Thus, we provided protocolised discharge explanations and written discharge instructions. Real-time feedback about the explanations to guardians may contribute to a lower rate of missed information and increase satisfaction. Written discharge instructions for fever and AGE were provided because these are common problems in the ED.18 ,19 Klein-Kremer and Goldman6 found that high fever and long duration of fever contributed to return visits. They proposed that effective education on symptoms warranting return visits, other than level and duration of fever, might decrease the rate of return visits.6 Goldman et al1 also demonstrated that it was important to provide clear discharge instructions, including the signs and symptoms requiring a return visit in febrile infants. Our PED discharge instructions provided common causes of disease, strategies for antipyretic and oral rehydration fluid use, and symptoms requiring return visit. Guardians could read these instructions and be reminded of explanations after discharge.
Early planned visits to clinics may have contributed to the reduction in return visits. If the disease progressed or other symptoms occurred, prescriptions could be added to the ED medications early in the OPD. If guardians misunderstand normal disease progression as poor recovery, physicians in the OPD can reassure them.
A before-and-after study can be conducted relatively easily, but it has some limitations. First, it is difficult to attribute improvement to the intervention because of the possibility of secular trends or short-term changes in the index under study.20 To overcome this, we adopted a controlled before-and-after study design. The rate of return visits at independent hospitals did not decrease and may have increased during the same period, consistent with our interpretation that the intervention had an impact on the reduction in return visits. The rate of return visits in hospital B was lower than in the other hospitals. Furthermore, it was lower than the intervention period in the study hospital. We infer that return visits can be influenced by many factors—for example, overcrowding, disease severity, multiple systems involved in clinical practice in each hospital—which we cannot investigate.
There are several other limitations to this study. Because the clinical practices developed were all applied simultaneously, we could not identify which ones contributed to the reduced return-visit rate. However, we think that the causes of return visits are complex and require a multifaceted approach. In that sense, we think that all the methods used here may have played a role. Also, because the data were from a single hospital, these clinical practices may not be applicable to other hospitals, limiting the generalisability of our findings. However, considering the diverse aetiology of return visits, we think that protocols used in our institution could be prototype tools to prevent return visits in other institutions. The patients visiting during the two periods did not have the same severity of disease. Patients visiting in the post-practice period were younger and had a lower rate of transfer from other hospitals compared with those in the pre-practice period. Young age might be associated with increased severity, and it is already a known risk factor for return visits because of the difficulty of communicating with younger children and the greater concern of their guardians.3 ,8 In our study, younger patients had more frequent return visits. A decreased rate of transfers from other hospitals might also be associated with lower severity.
The development and implementation of clinical practices were effective in reducing return visits of paediatric patients to the ED.
JHJ and SSH contributed equally to this study.
Contributors JHJ and SSH: conceptualised and designed the study, acquired and analysed data, drafted the initial manuscript, and critically reviewed and approved the final manuscript as submitted. KK and JHL: conceptualised and designed the study, coordinated and supervised data collection, and critically reviewed and approved the final manuscript as submitted. JER: conceptualised and designed the study and critically reviewed and approved the final manuscript as submitted. CK, SHL and HK: designed the study, and critically reviewed and approved the final manuscript as submitted. YSI, BL and YIB and JSL: interpreted data, and critically reviewed and approved the final manuscript as submitted.
Funding This study was supported by Grant No 11-2018-033 SNUBH (Seoul National University Bundang Hospital) Research Fund. Funding didn't influence the study design, the collection, analysis and interpretation data, writing of the report, or the decision to submit the paper for publication.
Competing interests None.
Ethics approval Seoul National University Bundang Hospital.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data can be obtained by emailing the corresponding author.