ORIGINAL CONTRIBUTION repeat visits, emergency department

"Bounces": An Analysis of Short-Term Return Visits to a Public Hospital Emergency Department From July through September 1987, our emergency department registered 17,214 patients, of whom 569 (3%) returned within two days of initial registration. Cases were reviewed to identify factors associated with return visits. Patient-related factors were responsible for a majority of repeat visits (267 cases, 53%). Illness-related factors, particularly evolution of disease under close outpatient observation, prompted return in 68 cases (13%). An additional 60 patients (12%) returned with n e w problems unrelated to their initial presentation. Physician-related factors were the prim a r y reason for return in 92 cases (18%). Problems with our public health-care system prompted return in 18 cases (4%). Eighty-seven returning patients (19%) required emergency hospitalization, including 28 discharged due to physician errors. Regular case review of short-term returns to the ED should be included in a comprehensive ED-based program of quality assurance. /Pierce JM, Ke]lerman AL, Oster C: "'Bounces": A n analysis of short-term return visits to a public hospital emergency department. Ann Emerg Med July 1990;19:752-757.]

INTRODUCTION When patients return to the emergency department shortly after being seen, it is generally assumed that their initial evaluation or treatment was inadequate. 1 However, the circumstances surrounding these repeat visits are poorly understood. Many short-term return visits may be medically unnecessary because it is known that substantial numbers of patients use EDs for nonemergency problems. 2-9 Patients with little formal education may be unable to read standard ED discharge materials,10 and economic or bureaucratic barriers can hamper timely outpatient follow-up31 Lack of continuity of care can also be a serious problem, especially for patients with chronic medical diseases that are best managed by a personal physician.12,13 To clarify the circumstances and significance of short-term returns, we identified over a three-month period all patients who returned to our ED within two days of being seen. We were particularly interested in answering the following questions. What percentage of ED patients return within two days of being seen? What proportion of return visits are due to physician-related errors versus other factors? Can systematic study of short-term returns to the ED enhance current Joint Commission on Accreditation of Healthcare Organizations-mandated approaches to quality control?

John M Pierce, MD Arthur L Kellerman, MD, MPH Catherine Oster, MD Memphis, Tennessee From the Division of Emergency Medicine, Department of Medicine, University of Tennessee, Memphis. Received for publication June 28, 1989. Revision received December 7, 1989. Accepted for publication January 8, 1990. Presented at the University Association for Emergency Medicine Annual Meeting in Cincinnati, Ohio, May 1988. Address for reprints: John M Pierce, MD, Division of Emergency Medicine, Regional Medical Center, 877 Jefferson, Room G071, Memphis, Tennessee 38103.

METHODS The Regional Medical Center at Memphis is a 450-bed acute care hospital owned by Shelby County, operated by an independent nonprofit healthcare corporation, and staffed by residents and faculty of the University of Tennessee, Memphis. The ED provides emergency care to all in need, regardless of ability to pay. In 1987, the ED treated 65,000 patients, 11% of whom had private insurance, 30% of whom were covered by Medicare or Medicaid, and 58% of whom had no health insurance. Major trauma, burn, and obstetric patients in advanced stages of pregnancy were not included in these totals because these patients are treated in separate receiving areas. Pediatric emergency patients are treated at neighboring LeBonheur Children's Medical Center.

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Annals of Emergency Medicine

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RETURN VISITS Pierce, Kellerman & Oster

Patient-related return The reviewers felt the return visit was primarily the fault of the patient. There was no evidence of deficiencies in emergency medical care or arrangement of follow-up care.

Noncompliance. There is evidence on the chart that the patient did not follow instructions, or there is documented evidence of previous noncompliance or history, suggesting a pattern of noncompliance related to this return visit.

Psychiatric disorder. The patient has a psychiatric disorder that causes him to repeatedly visit the ED for the same or similar nonurgent problems. Mentally, the patient is in a chronic stable state that could be treated by the mental health clinic at a later date.

Substance abuse. The recurrent use of illegal drugs or alcohol causes the patient to return to the ED because of either acute intoxication or problems caused by these substances. Social issues. The patient's primary reason for ED visit was the need for food or shelter. Left AMA on first visit. The patient was seen by a physician and left the ED against medical advice or left before being instructed to do so.

Left without being seen by a physician. The patient was registered in the ED but left before being seen by a physician. Habitual use of the ED for nonurgent problems. The patient presented with the same or similar nonurgent problem on return visit or the patient frequently returns for very minor problems. Arlxiety. The patient's anxiety caused him to return to the ED for same or similar nonurgent problem. Missed clinic follow-up. The patient returned to the ED for treatment of a nonurgent problem and was already scheduled for outpatient follow-up for same problem but did not go. Malingering. There is evidence suggesting that patient's complaint(s) were factitious or the patient was seeking secondary gain.

Physician-related return The physician was primarily responsible for the patient returning to the ED because of one of the following reasons. Misdiagnosis. Chart review reveals a diagnosis or problem missed by the physician who saw the patient on the first visit. Treatment error. The original physician made the right diagnosis but made an error in treatment. Admission indicated on initial visit. There is evidence in the records that the patient should have been admitted on the initial visit because of severity of illness. 1

FIGURE 1. Categories of return visits

and definitions. The acute a m b u l a t o r y care area of the ED is staffed by full-time faculty

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Psychiatric admission indicated. The ED record revealed signs suggesting that the patient should have been committed on the initial visit. In most cases, the patient was released from the ED but returned within two days and required commitment to a psychiatric ward. Instructed to return. The patient was given instructions to return for re-evaluation.

Called back because of missed radiograph abnormalities. A radiographic finding was lost or misread. Called back. The patient was called back after case review. No pain medication prescription. The disease or injury warranted pain medication but no prescription was given. The patient returned primarily because of continued pain.

Health-care system-related return The health-care system was primarily responsible for the patient returning for one of four reasons.

The patient was unable to get medication. The patient was unable to get the prescriptions filled due to lack of money or access to a pharmacy. Clinic sent. The patient was referred from clinic or private physician's office, but there is little evidence that it was indicated. MMHI sent back. The Memphis Mental Health Institute (MMHI), a state psychiatric hopsital, sent the patient back for re-evaluation of a possible medical problem that did not require ED evaluation or treatment. CSU sent for treatment and evaluation. The Crisis Stabilization Unit (an acute care psychiatric shelter) sent the patient for evaluation of a nonurgent medical problem.

Illness-related return The patient received appropriate emergency medical care, but the evolution of disease prompted the patient to return. Progression of disease. The charts reveal that the patient was treated appropriately on the initial visit and that admission was not indicated. Appropriate follow-up was arranged, but the patient's disease or problem got worse, and he returned to the ED as instructed. Recurrent disease process. The patient has a disease that tends to have recurrent exacerbations (ie, asthma, sickle cell disease). The patient was treated appropriately during initial ED visit, with resolution of symptoms but later returned with a second exacerbation of the disease. Complication. The patient was treated appropriately during initial visit but returned to the ED because of a complication of the disease or unpredictable side effect of treatment (eg, allergic drug reaction). New problem. The patient presented with a new problem unrelated to the prior visit, which also warrants treatment in the ED.

of the U n i v e r s i t y of T e n n e s s e e and rotating interns from the departm e n t s of internal medicine, surgery, and obstetrics and gynecology. Additional faculty and senior internal m e d i c i n e residents care for the m o r e

Annals of Emergency Medicine

s e r i o u s l y ill in t h e a d j a c e n t e m e r g e n c y / o b s e r v a t i o n area of t h e ED. D i r e c t a t t e n d i n g s u p e r v i s i o n is provided in the ED on a 24-hour-a-day basis, but housestaff are n o t required to sign o u t every p a t i e n t to an at19:7 July 1990

FIGURE 2. Return visits to the ED

3.56%

w i t h i n two days.

nal visit had been picked up by our daily ED record review. The n u m b e r and severity of adverse clinical outcomes after short-term returns were also defined.

25.35°/,

52.87%

18.;

II

Patient-related returns (267) Physician-related returns (92) Disease-related returns (128) System-related returns (18) 2

tending. All ED records are reviewed each morning by the ED director. If p o t e n t i a l p r o b l e m s w i t h care are identified, patients are contacted for return to the ED or expedited followup at one of the hospital's outpatient clinics. Between July 1 and September 30, 1987, we used a computer-generated ED registration file to identify all patients r e t u r n i n g to the ED w i t h i n two calendar days of initially being seen. Copies of each patient's original ED record and nurse's notes were then obtained. When the return visit resulted in hospital a d m i s s i o n and the ED record did not yield adequate information, a copy of the dictated d i s c h a r g e s u m m a r y w a s also requested. These files were reviewed by all three coauthors working independently of one another. Each assigned a primary (and if necessary, a second-

19:7 July 1990

ary) reason for the return visit based on explicit criteria (Figure 1). Reasons for r e t u r n were further grouped as physician-related (ie, related to an error in diagnosis or treatment or the return was scheduled by the treating physician), illness-related (ie, due to evolution of disease, a new problem or an unforeseeable complication), health-care system-related (eg, sent back to the ED inappropriately, unable to get a prescription filled), or patient-related (ie, patient initiated w i t h o u t clear evidence of m e d i c a l need). W h e n two or more reviewers independently agreed on the major reason for return, that was the reason assigned. If no agreement was noted, the case was discussed and a cons e n s u s was reached. P h y s i c i a n - r e lated return visits were also crossindexed w i t h our quality assurance file to determine whether the origiAnnals of Emergency Medicine

RESULTS During the three-month study period, 17,214 patient visits were made to the ED. A total of 569 patients (3%) r e t u r n e d w i t h i n t w o days of their original visit. Multiple searches of our m e d i c a l records d e p a r t m e n t yielded 513 charts (90%); these cases formed the basis for our review. In 44% of cases, all three reviewers agreed on the primary reason for the return visit. In an additional 46%, two reviewers agreed. In 41 of the 49 cases (10%) in w h i c h the reviewers i n i t i a l l y disagreed, c o n s e n s u s w a s easily reached. In only eight cases (2%) were the reasons for return un~ clear. In more than half of the 513 cases reviewed, one or more patient-related factors were thought to be responsible for the repeat visit (Figure 2). L e a v i n g w i t h o u t b e i n g s e e n or against medical advice at the time of the first visit accounted for 87 cases, more than 33% of patient-related returns and 17% of return visits overall. Forty of these patients returned with an urgent or e m e r g e n c y m e d i c a l problem. Twenty of these were eventually admitted, 16 were treated and released, and four left against medical advice again. Fifty patient-related r e t u r n s were p r o m p t e d by a n x i e t y about persistent s y m p t o m s of a nonserious medical problem. Chronic n o n d i s a b l i n g p s y c h i a t r i c disorders were involved in an additional 34 return visits. Forty patients ( 8 % ) h a d multiple reasons for returning, including generalized anxiety (24), habitual ED use (35), noncompliance with prescribed medications (11), and other factors. Problems related to substance abuse accounted for 19 return visits. Other reasons for patient-related returns included noncompliance, malingering, -.and,social problems (Figure 3). Illness-related factors a c c o u n t e d for 128 return visits (25% of the total). Of these, 60 returned with a new illness or. injury that was unrelated to their original ED visit. Almost all of

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RETURN VISITS Pierce, Kellerman & Oster

F I G U R E 3. Primary factor accounting for patient-related return visits.

these returns were thought to be appropriate ED visits. In 41 cases (8% of total returns), patients returned w i t h p r o g r e s s i o n of t h e i r d i s e a s e u n d e r close o u t p a t i e n t supervision. Even in r e t r o s p e c t , n o n e of t h e s e p a t i e n t s w e r e t h o u g h t to h a v e c l e a r l y warranted a d m i s s i o n at the t i m e of their o r i g i n a l v i s i t . In 15 cases, p a t i e n t s w h o w e r e t r e a t e d and observed and clearly i m p r o v e d at the t i m e of their original ED discharge experienced recurrence of a chronic disease process (eg, a s t h m a e x a c e r b a t i o n , r e c u r r e n t sickle cell crisis, or another seizure). Twelve additional patients returned w i t h w h a t was judged to be an unf o r e s e e a b l e c o m p l i c a t i o n of t h e i r original t r e a t m e n t (eg, d r u g - i n d u c e d gastritis or a rash). H e a l t h - c a r e s y s t e m - r e l a t e d factors p r o m p t e d s h o r t - t e r m return visits by 18 patients (4%). Eleven were psychiatric p a t i e n t s s e n t b a c k from inpat i e n t m e n t a l h e a l t h u n i t s for a second (and unnecessary) ED evaluation. Five w e r e s e n t f r o m an o u t p a t i e n t c o u n t y c l i n i c for i n a p p r o p r i a t e reasons, and two returned because they lacked sufficient funds for necessary prescription medications. Contrary to our expectations, phys i c i a n - r e l a t e d factors were found to a c c o u n t for less t h a n one of e v e r y five s h o r t - t e r m returns to our ED. Of 92 return visits believed due to physician-related f a c t o r s , 30 w e r e thought to involve an error in diagnosis, 14 errors in treatment, 12 discharge d e s p i t e clear i n d i c a t i o n s for admission, and ten psychiatric disorders that w a r r a n t e d i n v o l u n t a r y comm i t m e n t at the t i m e of the initial ED v i s i t (Figure 4). E i g h t r e t u r n s involved patients who needed pain m e d i c a t i o n but did n o t receive any at the t i m e of t h e i r i n i t i a l visit. Eighteen a d d i t i o n a l p a t i e n t s were asked by a p h y s i c i a n to return for a second e v a l u a t i o n ; four w e r e s c h e d u l e d for s h o r t - t e r m return to the ED, six were called back by the ED director after m o r n i n g chart review, and eight were contacted to return for re-evaluation of p o t e n t i a l r a d i o g r a p h i c a b n o r malities that were subsequently found to be clinically insignificant. While physician-related returns comprised a m i n o r i t y of total cases, m a n y of t h e s e p a t i e n t s had serious 54/755

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"Bounces": an analysis of short-term return visits to a public hospital emergency department.

From July through September 1987, our emergency department registered 17,214 patients, of whom 569 (3%) returned within two days of initial registrati...
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