There has been little research done to date on re-attendance rates in the emergency department, on why patients re-attend the emergency department and what if anything can be done to prevent re-attendance.1^–3

Eze et al1 specifically audited cases of re-attendance in patients with epistaxis in the emergency department and found that the provision of adequate verbal and written advice to patients with epistaxis resulted in a 9% reduction in re-attendance rates.

Murphy et al2 conducted a cohort study in which they hypothesised that having a general practitioner working in the emergency department would have a beneficial effect on re-attendance rates; however, this was not supported by their data, whereas a further study looking at re-attendance rates in the elderly population merely concluded that more research was needed into this issue.3

In view of the above, we carried out an audit in our emergency department to analyze the reasons why patients re-attend and to see if we could improve our service.

METHODS

All of the case notes of patients re-attending at an emergency department (50 000 new attendances per year), from 1 to 31 December 2006 were analyzed (excluding patients for whom a repeat visit was organised). In each case information was extracted from the notes including: the patient demographics, the grade of doctor assessing the patient at first presentation, the time delay between original presentation and re-attendance and the reason for their re-attendance.

The data were then analyzed looking specifically at who re-attends (age and gender), why they re-attend, whether the grade of doctor who originally saw them influences the re-attendance rate and the medical condition with which they re-attended.

Part of the audit information was accessed from the REMASS computer system used in the emergency department. The REMASS system is used to store patient demographics and to log information on every patient attendance to the department. The information available on the computer system for each patient attendance includes the presenting complaint and initial triage category of the patient, the doctor or nurse practitioner they are seen by, the time spent in the department and their final diagnosis and outcome.

RESULTS

In total, 3872 patients were seen in December in the emergency department and 89 of these cases were re-attendances (2.3% re-attendance rate). Forty-seven per cent of the re-attenders were male and the largest age group to re-attend was the 20–39 years age group (37% of the re-attendances). Most patients re-attended within the first 1–2 days after their original presentation.

Most patients chose to re-attend as a result of continued symptoms (50%) and the majority of patients who re-attended had been diagnosed with either a medical condition (32%) or minor soft tissue injury (30%) at their initial presentation.

There are currently eight junior doctors working in this emergency department (three foundation year 2 doctors (FY2), five “old style” senior house officers (SHO) 6-month jobs and four middle grades (three specialist registrars and one staff grade)). The figures from REMASS from 1 to 31 December showed that the middle grades saw on average 236 patients each, the “old style” SHO saw 198 patients each and the FY2 saw 188 patients each. Therefore the FY2 are seeing on average 10 fewer patients per month than the “old style” SHO.

Our audit figures also showed that the SHO and FY2 had a higher level of re-attendance than the middle-grade tier, accounting for 50% of the re-attendances (see table 1, re-attendance data).

The difference between middle grades and SHO/FY2 re-attendance was analyzed using a χ² test and was found not to be statistically significant (p = 0.52).

The number of patients and re-attendances by the emergency nurse practitioners (ENP) were also analyzed and interestingly the ENP had lower re-attendance rates than both the middle grades and the SHO (see table 1); however, again the difference in re-attendance between the SHO/FY2 and ENP was not statistically significant (p = 0.30).

DISCUSSION

The impact of modernising medical careers in the emergency department has been analysed in an emergency department in Edinburgh with an average attendance of 80 000–85 000 patients per year. A 30% drop in productivity was found in the FY2 group compared with the SHO group.

The results from our audit reinforce the evidence from the above study as the results show that the FY2 are seeing on average 10 fewer patients per month than the traditional SHO. The SHO and FY2 in our department are on the same shift rota and both attend the same weekly afternoon teaching session, so this difference cannot be explained by fewer shop floor hours worked by the FY2.

It is also interesting to note from our results that the SHO/FY2 had a higher level of re-attendance than the middle-grade tier, despite the middle grades seeing on average more patients than either of them. Although this difference was not statistically significant, only a small sample population was used in our audit, so this may well represent a type 1 error. The middle grades in the emergency department have more protected teaching time/study days than the SHO so again the difference in the number of patients seen cannot be explained by fewer shop floor hours worked by the SHO.

One of the most common problems with which patients re-attended was “minor soft tissue injuries”. Our data from REMASS showed that each grade of doctor (FY2, “old style” SHO and middle grades) had a caseload with approximately 50% of patients seen in triage category 4, which is made up mainly of minor soft tissue injuries.

Croft et al4 designed a questionnaire for junior doctors working in the emergency department to elicit areas of confidence and subjective competence and found that junior doctors felt least competent working with patients with minor injuries.

Ironically the “old style” SHO and FY2 working in our emergency department saw more patients in triage category 4 than any other triage category but as already stated minor soft tissue injuries had a large re-attendance rate.

Our re-attendance figures for soft tissue injuries may reflect either a lack of confidence by the “old style” SHO and FY2 in managing these conditions, or a lack of adequate training in soft tissue injuries. This results in a misdiagnosis of these conditions or not offering the patients adequate advice or reassurance.

This does raise the issue of whether FY2 should be managing soft tissue injuries or whether they should be left to the emergency nurse practitioner? Ezra et al5 proposed, in their study published in this journal in 2005, that ENP should see all eye emergencies presenting to the emergency department. They analyzed 67 patients presenting to an emergency department with eye emergencies over a one-month period. They found that the ENP were more accurate than the A&E SHO in history taking, recording visual acuity, describing ocular anatomy and making provisional diagnoses.5 It is interesting to note from our data that the ENP had a lower re-attendance rate than either the middle grades or the SHO/FY2, and again with a larger sample size this may well prove to be a statistically significant difference.

Our audit was only looking at a small population but it does raise some issues about current medical training. Not only does it appear that the FY2 have poor training in certain areas of emergency medicine, but they also have high re-attendance rates and are seeing fewer numbers of patients in the emergency department compared with their old SHO counterparts. This is bound to impact on the service provided and targets within the emergency department.

Although the debate about modernising medical careers rages on, maybe some of these issues need to be specifically addressed with regard to emergency medicine training?