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Characteristics and determinants of high-risk unscheduled return visits to the emergency department
  1. Eveline A Hiti1,
  2. Hani Tamim2,
  3. Maha Makki1,
  4. Mirabelle Geha1,
  5. Rima Kaddoura1,
  6. Ziad Obermeyer3
  1. 1 Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
  2. 2 Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
  3. 3 Department of Emergency Medicine, Brigham & Women’s Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Eveline A Hiti, Emergency Medicine, American University of Beirut Medical Center, Beirut 1107, Lebanon; eh16{at}


Background High-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.

Methods Case–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.

Results Out 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).

Conclusion HRURV 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.

  • emergency department

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  • Presented at The results of this study were presented as a poster during the events of the American University of Beirut Biomedical Research Day, February 2017.

  • Contributors EAH, ZO and HT conceived and designed the study. EAH coordinated the study throughout. EAH had full access to all of the data in the study and takes responsibility for the integrity of the data. MG helped with proposal drafting, design and data extraction. HT and MM analysed and interpreted the data. EAH, HT and RK drafted the manuscript. All authors critically revised the manuscript and approved the final version. The lead author, EAH, affirms that this manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

  • Funding Research reported in this publication was supported by the National Institutes of Health under award number 4DP5OD012161-05.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the Institutional Review Board (IRB) of the American University of Beirut.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.

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