Short-term Unscheduled Return Visits of Adult Patients to the Emergency Department

Background

Emergency department (ED) crowding is a major international concern that affects patients and providers.

Study Objective

We describe the characteristics of patients who had an unscheduled related return visit to the ED and investigate its relation to ED crowding.

Methods

Retrospective medical record review of all unscheduled related ED return visits by patients older than 16 years of age over a 1-year period. The top quartile of ED occupancy rates was defined as ED crowding.

Results

Eight hundred thirty-seven patients (1.9%) made an unscheduled related return visit. Length of stay (LOS) at the ED for the index visit and the LOS for the return visit (5 h, 54 min vs. 6 h, 51 min) were significantly different, as were the percent admitted (11.6% vs. 46.1%). Of these patients, 85.1% and 12.0% returned due to persistence or a wrong initial diagnosis, of their initial illness, respectively, and 2.9% returned due to an adverse event related to the treatment initially received. Patients presented the least frequently with an alcohol-related complaint during the index visit (480 patients), but they had the highest number of unscheduled return visits (45 patients; 9.4%). Unscheduled related return visits were not associated with ED crowding.

Conclusion

Return visits impose additional pressure on the ED, because return patients have a significantly longer LOS at the ED. However, the rate of unscheduled return visits and ED crowding was not related. Because this parameter serves as an essential quality assurance tool, we can assume that the studied hospital scores well on this particular parameter.     

Emergency Department Return Visits Within a Large Geographic Area

Background

Return visits to the emergency department (RTED) contribute to overcrowding and may be a quality of care indicator. Previous studies focused on factors predicting returns to and from the same center. Little is known about RTEDs across a range of community and specialty hospitals within a large geographic area.

Recently Discharged Inpatients as a Source of Emergency Department Overcrowding

OBJECTIVE: To assess the impact on the emergency department (ED) of recently discharged inpatients and how they contribute to and worsen the current situation of ED overcrowding. METHODS: Retrospective, observational study of medical records and billing data of all patients presenting to the ED within seven days of inpatient discharge from the hospital ("returns") in September 2000. The data were collected from electronic logs. Billing charges were used to estimate ED resources. Medical records were reviewed to classify visits: 1) new problem, 2) related problem, likely preventable, 3) related problem, not likely preventable, 4) unable to classify, or 5) incomplete chart. RESULTS: One-hundred seventy-four returns occurred among 6,290 total ED visits (3%). Significant differences between returns and total ED patients were noted for length of stay (LOS) (6.58 vs 5.22 hours, p = 0.000), percent admitted (47% vs 19%, p = 0.000), and ED billing (1,415.67 dollars vs 391.00 dollars, p = 0.000). The highest rate of admission was for patients presenting 48-72 hours after inpatient discharge (65.4%). Admission rate was higher for patients presenting >48 hours than <48 hours (54% vs 33%, p = 0.01). A review of the medical records (117/174) revealed: 15 new problems (13%); 16 related, likely preventable (14%); 72 related, not likely preventable (62%); 4 unable to assess (2%); and 10 incomplete charts (9%). CONCLUSIONS: The ED is appropriately utilized as a safety net for discharged inpatients. Though "returns" are a small percentage of ED patients, they have longer LOSs, have higher ED charges, and are more frequently admitted. Returns increase the strain on an already overcrowded ED.     

An Emergency Department–Based Nurse Discharge Coordinator for Elder Patients: Does It Make a Difference?

OBJECTIVES: To evaluate the impact of an emergency department (ED)-based nurse discharge plan coordinator (NDPC) on unscheduled return visits within 14 days of discharge, satisfaction with discharge recommendations, adherence with discharge instructions, and perception of well-being of elder patients discharged from the ED. METHODS: Patients aged 75 years and older discharged from the ED of the Sir Mortimer B. Davis-Jewish General Hospital were recruited in a pre/post study. During the pre (control) phase, study patients (n = 905) received standard discharge care. Patients in the post (intervention) phase (n = 819) received the intervention of an ED-based NDPC. The intervention included patient education, coordination of appointments, patient education, telephone follow-up, and access to the NDPC for up to seven days following discharge. RESULTS: Patients in the two groups were similar with respect to gender and age. However, the patients managed by the ED NDPC appeared to be, at baseline, less autonomous, frailer, and sicker. The unadjusted relative risk for unscheduled return visits within 14 days of discharge was 0.79 (95% confidence interval [95% CI] = 0.62 to 1.02). A relative risk reduction of 27% (95% CI = 0% to 44%) for unscheduled return visits was observed for up to eight days postdischarge, and a relative risk reduction of 19% (95% CI = -2% to 36%) for unscheduled return visits was observed for up to 14 days postdischarge. Significant increases in satisfaction with the clarity of discharge information and perceived well-being were also noted. CONCLUSIONS: An ED-based NDPC, dedicated specifically to the discharge planning care of elder patients, reduces the proportion of unscheduled ED return visits and facilitates the transition from ED back home and into the community health care network.     

A Brief Risk-stratification Tool to Predict Repeat Emergency Department Visits and Hospitalizationsin Older Patients Discharged from the Emergency Department

OBJECTIVES: To evaluate the predictive ability of a simple six-item triage risk screening tool (TRST) to identify elder emergency department (ED) patients at risk for ED revisits, hospitalization, or nursing home (NH) placement within 30 and 120 days following ED discharge. METHODS: Prospective cohort study of 650 community-dwelling elders (age 65 years or older) presenting to two urban academic EDs. Subjects were prospectively evaluated with a simple six-item ED nursing TRST. Participants were interviewed 30 and 120 days post-ED index visit and the utilization of EDs, hospitals, or NHs was recorded. Main outcome measurement was the ability of the TRST to predict the composite endpoint of subsequent ED use, hospital admission, or NH admission at 30 and 120 days. Individual outcomes of ED use, hospitalization, and NH admissions were also examined. RESULTS: Increasing cumulative TRST scores were associated with significant trends for ED use, hospital admission, and composite outcome at both 30 and 120 days (p < 0.0001 for all, except 30-day ED use, p = 0.002). A simple, unweighted five-item TRST ("lives alone" item removed after logistic regression modeling) with a cut-off score of 2 was the most parsimonious model for predicting composite outcome (AUC = 0.64) and hospitalization at 30 days (AUC = 0.72). Patients defined as high-risk by the TRST (score > or = 2) were significantly more likely to require subsequent ED use (RR = 1.7; 95% CI = 1.2 to 2.3), hospital admission (RR = 3.3; 95% CI = 2.2 to 5.1), or the composite outcome (RR = 1.9; 95% CI 1.7 to 2.9) at both 30 days and 120 days than the low-risk cohort. CONCLUSIONS: Older ED patients with two or more risk factors on a simple triage screening tool were found to be at significantly increased risk for subsequent ED use, hospitalization, and nursing home admission.     

Rapid Emergency Medicine Score Can Predict Long-term Mortality in Nonsurgical Emergency Department Patients

OBJECTIVES: To examine the Rapid Emergency Medicine Score (REMS) as a predictor of long-term (4.7 years) mortality in the nonsurgical emergency department (ED). METHODS: This was a prospective cohort study. A total of 12,006 nonsurgical patients consecutively presenting to an adult ED at a 1,200-bed university hospital during a period of one year were enrolled. REMS (including blood pressure, respiratory rate, pulse rate, Glasgow Coma Scale score, peripheral oxygen saturation, and patient age) was calculated for all patients admitted to the ED. The statistical associations between REMS and long-term mortality were examined. RESULTS: REMS could predict mortality over 4.7 years (hazard ratio, 1.26; p < 0.0001). Similar results were obtained in the major patient groups (chest pain, stroke, coma, dyspnea, and diabetes). CONCLUSIONS: REMS was a powerful predictor of long-term mortality in patients attending the ED for a wide range of common nonsurgical disorders.     

Risk Factors for Mortality of Bacteremic Patients in the Emergency Department

Objectives: Patients with bacteremia have a high mortality and generally require urgent treatment. The authors conducted a study to describe bacteremic patients in emergency departments (EDs) and to identify risk factors for mortality. Methods: Bacteremic patients in EDs were identified retrospectively at a university hospital from January 2007 to December 2007. Demographic characteristics, underlying illness, clinical conditions, microbiology, and the source of bacteremia were collected and analyzed for their association with 28-day mortality. Results: During the study period, 621 cases (50.2% male) were included, with a mean (±SD) age of 62.8 (±17.4) years. The most common underlying disease was diabetes mellitus (39.3%). Escherichia coli (39.2%) was the most frequently isolated pathogen. The most common source of bacteremia was urinary tract infection (41.2%), followed by primary bacteremia (13.2%). The overall 28-day mortality rate was 12.6%. Multivariate stepwise logistic regression analysis showed age > 60 years (odds ratio [OR] = 2.52, 95% confidence interval [CI] = 1.29 to 4.92, p = 0.007), malignancy (OR = 2.66, 95% CI = 1.44 to 4.91, p = 0.002), liver cirrhosis (OR = 2.08, 95% CI = 1.02 to 4.26, p = 0.044), alcohol use (OR = 5.73, 95% CI = 2.10 to 15.63, p = 0.001), polymicrobial bacteremia (OR = 3.99, 95% CI = 1.75 to 9.10, p = 0.001), anemia (OR = 2.33, 95% CI = 1.34 to 4.03, p = 0.003), and sepsis (OR = 1.94, 95% CI = 1.16 to 3.37, p = 0.019) were independent risk factors for 28-day mortality. Conclusions: Bacteremic patients in the ED have a high mortality, particularly with these risk factors. It is important for physicians to recognize the factors that potentially contribute to mortality of bacteremic patients in the ED.     

Predictors of Repeat Emergency Department Visits by Elders

Objective: To determine which characteristics of older patients who use a hospital ED are associated with repeat visits during the 90 days following the index visit.
Methods: The study was conducted in the ED of a 400-bed university-affiliated acute care community hospital in Montreal. Patients aged ≥75 years who visited the ED between 08:00 and and 16:00 on a convenience sample of days over an 8-week period (July and August 1994) were assessed using a questionnaire, physical and cognitive status instruments, and a functional problem checklist. The hospital's administrative database was used to identify repeat visits during the 90 days following the ED visit. The representativeness of the sample was assessed by analyses of ED visits made by 4,466 persons aged ≥65 years during a 12-month period (September 1993 to August 1994) using the hospital's administrative database.
Results: 256 patients aged ≥75 years visited the ED during the study period and 167 were assessed. Of these, 54 (32%) were admitted to the hospital. Among the 113 patients released from the ED, 27 (24%) made repeat visits during the next 90 days. In univariate analyses, repeat visits were significantly associated with the number of functional problems, cognitive impairment, and previous ED visits. In multiple logistic regression, male gender, living alone, and number of functional problems were independent predictors of repeat visits. In the administrative data analyses, nighttime arrival to the ED for the index visit was significantly associated with repeat visits.
Conclusions: Self-reported risk factors can help to identify a group of elders likely to make repeated ED visits; the development of a screening instrument incorporating questions on these problems and implementation of appropriate interventions might improve these patients' quality of life and reduce the demand for further ED care in this age group.     

Unscheduled Return Visits With and Without Admission Post Emergency Department Discharge

Background

Monitoring unscheduled return visits to the Emergency Department (ED) is useful to identify medical errors.

Objective

To investigate the differences between unscheduled return visit admissions (URVA) and unscheduled return visit no admissions (URVNA) after ED discharge.

Methods

From January 1, 2008 to March 31, 2008, URVA and URVNA patients who returned within 3 days after ED discharge were enrolled in the study. We compared the clinical characteristics, underlying diseases, ED crowding indicators, staff experience at the patient's first visit, and several other risk factors. We used multivariate logistic regression to evaluate differences between the two groups and to identify predictors of admission from unscheduled return visits.

Results

The unscheduled return visit rate was 3.1%. Of the 413 patients included, 147 patients (36%) were admitted, and had a mortality rate of 4.1%. The most common reason for the return visit was an illness-based factor (47.9%). Compared to URVNA patients, unscheduled return visit admissions had higher prevalence rates for old age, non-ambulatory status, high-grade triage, and underlying diseases (e.g., malignancy, diabetes mellitus, hypertension, coronary artery disease, heart failure, and chronic obstructive pulmonary disease). The independent predictors for URVA were: age ≥ 65 years (adjusted odds ratio [OR] 2.2, 95% confidence interval [CI] 1.4–3.5); high-grade triage (adjusted OR 2.1, 95% CI 1.3–3.2); and doctor-based factors (adjusted OR 3.5, 95% CI 2.0–6.1). More advanced staff experience (p = 0.490) and ED crowding were not significant predictors (p = 0.498 for whole-day number of patients, p = 0.095 for whole-shift number of patients).

Conclusion

Old age, high-grade triage, and doctor-based factors were found to be significant predictors for URVA, whereas advanced staff experience and ED crowding were not.     

The Significance of Marijuana Use Among Alcohol-using Adolescent Emergency Department Patients

Objectives:  The objective was to determine if adolescents presenting to a pediatric emergency department (PED) for an alcohol-related event requiring medical care differ in terms of substance use, behavioral and mental health problems, peer relationships, and parental monitoring based on their history of marijuana use.
Methods:  This was a cross-sectional comparison of adolescents 13–17 years old, with evidence of recent alcohol use, presenting to a PED with a self-reported history of marijuana use. Assessment tools included the Adolescent Drinking Inventory, Adolescent Drinking Questionnaire, Young Adult Drinking and Driving Questionnaire, Center for Epidemiologic Studies Depression Scale, Behavioral Assessment System for Children, and Peer Substance Use and Tolerance of Substance Use Scale.
Results:  Compared to adolescents using alcohol only (AO), adolescents who use alcohol and marijuana (A+M) have higher rates of smoking ( F =  23.62) and binge drinking ( F =  11.56), consume more drinks per sitting ( F =  9.03), have more externalizing behavior problems ( F =  12.53), and report both greater peer tolerance of substance use ( F =  12.99) and lower parental monitoring ( F =  7.12).
Conclusions:  Adolescents who use A+M report greater substance use and more risk factors for substance abuse than AO-using adolescents. Screening for a history of marijuana use may be important when treating adolescents presenting with an alcohol-related event. A+M co-use may identify a high-risk population, which may have important implications for ED clinicians in the care of these patients, providing parental guidance, and planning follow-up care.
ACADEMIC EMERGENCY MEDICINE 2010; 17:63–71 © 2010 by the Society for Academic Emergency Medicine     

Methamphetamine-related Psychiatric Visits to an Urban Academic Emergency Department: An Observational Study

Background

Methamphetamine, a stimulant of abuse, is associated with a significant number of Emergency Department (ED) visits. Methamphetamine use may produce psychiatric symptoms including acute psychosis, depression, and anxiety disorders.

Study Objectives

To characterize psychiatric emergencies either directly or indirectly attributable to methamphetamine use in an urban academic ED.

Methods

We analyzed a database of patients determined to have an ED visit that was either methamphetamine related or non-methamphetamine related. We retrospectively reviewed the records of the subset of ED visits from this database with psychiatric diagnoses. We compared the characteristics of patients with methamphetamine-related psychiatric visits (MRPVs) and non-methamphetamine-related psychiatric visits (non-MRPVs).

Results

We identified 130 patients with MRPVs. This represented 7.6% (130 of 1709) of all psychiatric visits. Patients with MRPV, compared to non-MRPV patients, were younger (34.4 years vs. 39.1 years, respectively, p = 0.0005), more likely to be uninsured (55% vs. 37%, respectively, p = 0.001), and less likely to have a past history of depression (10% vs. 19%, respectively, p = 0.011). Many characteristics between the two groups (MRPV vs. non-MRPV) were similar: likelihood of patient being placed on a psychiatric hold; hospital charges; previous histories of psychiatric visits; and history of anxiety, bipolar disorder, or schizophrenia.

Conclusions

Methamphetamine may be related to a significant proportion (7.6%) of psychiatric ED visits. Furthermore, patients with methamphetamine-associated psychiatric visits are younger, have lower rates of depression, are more likely to be uninsured, and are less likely to have a substance abuse-related chief complaint than patients with non-methamphetamine-associated ED psychiatric visits.     

External Causes of Pediatric Injury-related Emergency Department Visits in the United States

OBJECTIVES: To characterize the types and external causes of pediatric injury-related visits (IRVs) to emergency departments (EDs), in particular, sports-related injuries. To compare the characteristics of children with IRVs with those with non-IRVs, specifically, differences in IRV rates by race and ethnicity and by health insurance. METHODS: This was a stratified random-sample survey of EDs in the National Hospital Ambulatory Medical Care Survey (NHAMCS), including all IRVs for patients less than 19 years of age in 1998 (n = 2,656). National estimates of pediatric IRVs were obtained using the assigned patient visit weights in the NHAMCS databases and SUDAAN analyses. Measures of association between predictor variables (patient and health insurance characteristics) and whether a child had an IRV were calculated using multivariate logistic regression analyses to determine adjusted odds ratios with 95% confidence intervals. RESULTS: Pediatric IRVs accounted for more than 11 million ED visits annually. The most common diagnoses for IRVs were open wounds, contusions, sprains and strains, and fractures and dislocations. The leading external causes of IRVs were sports-related injuries, accidental falls, being struck by objects, and motor vehicle collisions. Children with IRVs differed from those who presented for non-IRVs in many characteristics: they were more likely to be male, to be older, to be of white race, and to have private insurance, and less likely to be of Asian or Hispanic ethnicity. CONCLUSIONS: Sports and recreation are the leading external causes of pediatric IRVs to EDs in the United States. There are different patterns of IRVs according to gender, age, race, ethnicity, and insurance. Identification of specific patterns of injury is necessary for the design of effective prevention strategies.     

A Multicenter Study of Depression among Emergency Department Patients

Objectives: The authors sought to determine the 12‐month prevalence of depression among emergency department (ED) patients using a single‐question screen. Methods: This cross‐sectional study was conducted in four Boston‐area EDs. For two 24‐hour periods, consecutive patients aged 18 years or older were interviewed, excluding those who were severely ill, potential victims of sexual assault, or emotionally disturbed. During the interview, patients were asked “Have you had any of the following problems during the past 12 months?” Patients answered “yes” or “no” to a list of health problems that included depression. In a validation study, the authors found that this simple approach correlated well with results from the validated Center for Epidemiologic Studies Depression Scale. Results: Of 752 eligible patients, 539 (72%) were interviewed. Of these patients, 30% (95% confidence interval = 26% to 34%) reported depression within the past 12 months. Compared with their nondepressed counterparts, depressed patients were more likely middle‐aged, female, and of lower socioeconomic status. Depressed patients were more likely to be smokers and to report a diagnosis of asthma or arthritis/rheumatism. In a multivariate analysis, factors that were independently associated with depression were lower level of education, smoking, and self‐reported anxiety, chronic fatigue, and back problems. Conclusions: A 30% 12‐month prevalence of depression among ED patients was found. Depressed patients had a distinct sociodemographic and health profile. In the future, awareness of risk factors for depression in the ED setting and use of simple screening instruments could aid in the recognition of depression, with subsequent referral to mental health services.     

Causes of Emergency Department Overcrowding and Blockage of Access to Critical Services in Beijing: A 2-Year Study

Background

Emergency department (ED) overcrowding is a serious issue worldwide.