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Kim G, Han S, Bae SP, Lee J, Heo NH, Lee D, Kim HJ. Lactate Levels as a Predictor of Emergency Department Revisits in Infants With Acute Bronchiolitis. Pediatr Emerg Care 2024:00006565-990000000-00443. [PMID: 38713833 DOI: 10.1097/pec.0000000000003220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
OBJECTIVE This study aimed to identify predictive biomarkers for unscheduled emergency department (ED) revisits within 24 hours of discharge in infants diagnosed with acute bronchiolitis (AB). METHODS A retrospective observational study was conducted on infants diagnosed with AB who visited 3 emergency medical centers between January 2020 and December 2022. The study excluded infants with comorbidities, congenital diseases, and prematurity and infants who revisited the ED after 24 hours of discharge. Demographic data, vital signs, and laboratory results were collected from the medical records. Univariable and multivariable logistic regression analyses were performed on factors with P of less than 0.1 in univariable analysis. Receiver operator curve analysis was used to assess the accuracy of lactate measurements in predicting ED revisits within 24 hours of discharge. RESULTS Out of 172 participants, 100 were in the revisit group and 72 in the discharge group. The revisit group was significantly younger and exhibited higher lactate levels, lower pH values, and higher pCO2 levels compared to the discharge group. Univariable logistic regression identified several factors associated with revisits. Multivariable analysis found that only lactate was a variable correlated with predicting ED revisits (odds ratio, 18.020; 95% confidence interval [CI], 5.764-56.334). The receiver operator curve analysis showed an area under the curve of 0.856, with an optimal lactate cutoff value of 2.15. CONCLUSION Lactate value in infants diagnosed with AB were identified as a potential indicator of predicting unscheduled ED revisits within 24 hours of discharge. The predictive potential of lactate levels holds promise for enhancing prognosis prediction, reducing health care costs, and alleviating ED overcrowding. However, given the study's limitations, a more comprehensive prospective investigation is recommended to validate these findings.
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Affiliation(s)
- Gihyeon Kim
- From the Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Sangsoo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Seong Phil Bae
- Department of Pediatrics, Soonchunhyang University Hospital, Seoul, Republic of Korea
| | - Jungwon Lee
- Department of Emergency Medicine, Soonchunhyang University Gumi Hospital, Gumi, Republic of Korea
| | - Nam Hun Heo
- Department of Biostatistics, Clinical Trial Center, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Dongwook Lee
- From the Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Hyun Joon Kim
- From the Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
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Palungwachira P, Montimanutt G, Musikatavorn K, Savatmongkorngul S. Reducing 48-h emergency department revisits and subsequent admissions: a retrospective study of increased emergency medicine resident floor coverage. Int J Emerg Med 2022; 15:66. [PMID: 36474146 PMCID: PMC9724369 DOI: 10.1186/s12245-022-00471-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/19/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Early unexpected hospital admission after emergency department (ED) discharge is an important topic regarding effective preventive measures. Reducing avoidable return visits can improve ED effectiveness and emergency care. This study evaluated the effects of an increase in the number of physicians and the 24-h coverage of emergency physicians on 48-h ED revisits with subsequent hospital admission. The characteristics and risk factors of the patients were also investigated. RESULTS This was a retrospective analysis performed 2 years before and 2 years after the implementation of an intervention in a tertiary care hospital in Thailand. The medical records of adult patients who revisited the ED within 48 h for related complaints were reviewed. The effect of the intervention was analyzed, and a prediction model was developed based on logistic regression. After implementing the intervention, the hospital admission rate at the second ED visit decreased from 44.5 to 41.1%; no significant difference was found (95% confidence interval (CI) - 5.05 to 11.78). Patients who required hospital admission had a significantly higher comorbidity score, more ED visits, and more hospitalizations within the past 12 months. A significantly higher hospital admission rate was also observed among patients older than 60 years, those who had an initial infectious diagnosis, and those who had a higher triage severity level (ESI II) at their first visit. The odds ratio (OR) showed lower odds of hospital admission at the second visit in the postintervention period; this difference was not significant (OR 0.87; 95% CI 0.61 to 1.23). CONCLUSION Our intervention did not significantly decrease the incidence of admission at an ED revisit. However, some factors identified in this study seem to have some benefits and might be helpful for preventing errors and constructing a standard discharge care plan for patients with these risk factors.
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Affiliation(s)
- Pakhawadee Palungwachira
- grid.419934.20000 0001 1018 2627Department of Emergency Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330 Thailand
| | - Gunnaree Montimanutt
- grid.419934.20000 0001 1018 2627Department of Emergency Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330 Thailand
| | - Khrongwong Musikatavorn
- grid.419934.20000 0001 1018 2627Department of Emergency Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330 Thailand
| | - Sorravit Savatmongkorngul
- grid.10223.320000 0004 1937 0490Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400 Thailand
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Ling DA, Sung CW, Fang CC, Ko CH, Chou E, Herrala J, Lu TC, Huang CH, Tsai CL. High-risk Return Visits to United States Emergency Departments, 2010–2018. West J Emerg Med 2022; 23:832-840. [DOI: 10.5811/westjem.2022.7.57028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Although factors related to a return visit to the emergency department (ED) have been reported, only a few studies have examined “high-risk” ED revisits with serious adverse outcomes. In this study we aimed to describe the incidence and trend of high-risk ED revisits in United States EDs and to investigate factors associated with these revisits.
Methods: We obtained data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010–2018. Adult ED revisits within 72 hours of a previous discharge were identified using a mark on the patient record form. We defined high-risk revisits as revisits with serious adverse outcomes, including intensive care unit admissions, emergency surgery, cardiac catheterization, or cardiopulmonary resuscitation (CPR) during the return visit. We performed analyses using descriptive statistics and multivariable logistic regression, accounting for NHAMCS’s complex survey design.
Results: Over the nine-year study period, there were an estimated 37,700,000 revisits, and the proportion of revisits in the entire ED population decreased slightly from 5.1% in 2010 to 4.5% in 2018 (P for trend = 0.02). By contrast, there were an estimated 827,000 high-risk ED revisits, and the proportion of high-risk revisits in the entire ED population remained stable at approximately 0.1%. The mean age of these high-risk revisit patients was 57 years, and 43% were men. Approximately 6% of the patients were intubated, and 13% received CPR. Most of them were hospitalized, and 2% died in the ED. Multivariable analysis showed that older age (65+ years), Hispanic ethnicity, daytime visits, and arrival by ambulance during the revisit were independent predictors of high-risk revisits.
Conclusion: High-risk revisits accounted for a relatively small fraction (0.1%) of ED visits. Over the period of the NHAMCS survey between 2010-2018, this fraction remained stable. We identified factors during the return visit that could be used to label high-risk revisits for timely intervention.
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Affiliation(s)
- Dean-An Ling
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Chih-Wei Sung
- College of Medicine, National Taiwan University, Department of Emergency Medicine, Taipei, Taiwan
| | - Cheng-Chung Fang
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan; College of Medicine, National Taiwan University, Department of Emergency Medicine, Taipei, Taiwan
| | - Chia-Hsin Ko
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Eric Chou
- Baylor Scott and White All Saints Medical Center, Department of Emergency Medicine, Fort Worth, Texas
| | - Jeffrey Herrala
- Highland Hospital-Alameda Health System, Department of Emergency Medicine, Oakland, California
| | - Tsung-Chien Lu
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan; College of Medicine, National Taiwan University, Department of Emergency Medicine, Taipei, Taiwan
| | - Chien-Hua Huang
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan; College of Medicine, National Taiwan University, Department of Emergency Medicine, Taipei, Taiwan
| | - Chu-Lin Tsai
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan; College of Medicine, National Taiwan University, Department of Emergency Medicine, Taipei, Taiwan
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Namgung M, Lee DH, Bae SJ, Chung HS, Park JY, Kim K, Lee CA, Kim DH, Kim EC, Lim JY, Han SS, Choi YH. A Comparison of Emergency Department Revisit Rates of Pediatric Patients between Pre-COVID-19 and COVID-19 Periods. CHILDREN 2022; 9:children9071003. [PMID: 35883987 PMCID: PMC9322694 DOI: 10.3390/children9071003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/29/2022] [Indexed: 11/24/2022]
Abstract
Unscheduled revisits to emergency departments (EDs) are important because they indicate the quality of emergency care. However, the characteristics of pediatric patients visiting EDs changed during the coronavirus disease (COVID-19) pandemic, and these changes may have affected their revisit patterns. Therefore, we aimed to compare the ED revisit patterns of pediatric patients between the pre-COVID-19 and COVID-19 periods. This retrospective multicenter study included patients aged below 18 years who visited the ED in the pre-COVID-19 and COVID-19 periods. ED revisit rates were analyzed using five age groups and three visit-revisit intervals. In the pre-COVID-19 period, the revisit rates decreased with increasing age. In the COVID-19 period, the revisit rates were the lowest for the group aged 4–6 years, and the rates increased for those aged ≥7 years. In conclusion, there were changes in the patterns of revisit rates of pediatric patients according to age between the pre-COVID-19 and COVID-19 periods. Therefore, it is necessary to identify the reasons for revisits according to age and establish strategies to reduce the revisit rates of pediatric patients.
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Affiliation(s)
- Myeong Namgung
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul 06973, Korea;
| | - Dong Hoon Lee
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
- Correspondence: ; Tel.: +82-2-2610-6751
| | - Sung Jin Bae
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
| | - Ho Sub Chung
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong-si 14353, Korea; (S.J.B.); (H.S.C.)
| | - Ji Young Park
- Department of Pediatrics, College of Medicine, Chung-Ang University, Seoul 06973, Korea;
| | - Keon Kim
- Department of Emergency Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Korea;
| | - Choung Ah Lee
- Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si 18450, Korea;
| | - Duk Ho Kim
- Department of Emergency Medicine, Eulji University, Seoul 01830, Korea;
| | - Eui Chung Kim
- CHA Bundang Medical Center, Department of Emergency Medicine, Seongnam-si 13496, Korea;
| | - Jee Yong Lim
- Department of Emergency Medicine, Seoul St. Mary’s Hospital, Seoul 06591, Korea;
| | - Sang Soo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon-si 14584, Korea;
| | - Yoon Hee Choi
- Department of Emergency Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, Seoul 07985, Korea;
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Intravenous antibiotics at the index emergency department visit as an independent risk factor for hospital admission at the return visit within 72 hours. PLoS One 2022; 17:e0264946. [PMID: 35303001 PMCID: PMC8932564 DOI: 10.1371/journal.pone.0264946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 02/20/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Although infection was the most common symptom in patients returning to the ED, whether intravenous antibiotic administration at the index visit could serve as an indicator of patients with infectious diseases at high risk for hospital admission after returning to the ED within a short period of time remains unclear. The study aimed to investigate the potential risk factors for hospital admission in patients returning to the ED within 72 hours with a final diagnosis of infectious diseases. Material and methods This retrospective cohort study analyzed return visits to the ED from January to December 2019. Adult patients aged >20 years who had a return visit to the ED within 72 hours with an infectious disease were included herein. In total, 715 eligible patients were classified into the intravenous antibiotics and non-intravenous antibiotics group (reference group). The outcome studied was hospital admission to general ward and intensive care unit (ICU) at the return visits. Results Patients receiving intravenous antibiotics at index visits had significantly higher risk—approximately two times—for hospital admission at the return visits than those did not (adjusted odds ratio = 2.47, 95% CI = 1.34–4.57, p = 0.004). For every 10 years increase in age, the likelihood for hospital admission increased by 38%. Other factors included abnormal respiratory rate and high C-reactive protein levels. Conclusions Intravenous antibiotic administration at the index visit was an independent risk factor for hospital admission at return visits in patients with an infection disease. Physicians should consider carefully before discharging patients receiving intravenous antibiotics.
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Hutchinson CL, Curtis K, McCloughen A, Qian S, Yu P, Fethney J. Predictors and outcomes of patients that return unplanned to the Emergency Department and require critical care admission: A multicenter study. Australas Emerg Care 2021; 25:88-97. [PMID: 33994336 DOI: 10.1016/j.auec.2021.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/21/2021] [Accepted: 04/15/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the incidence, characteristics (including timeframe) and predictors of patients discharged from the Emergency Department (ED) that later return and require admission. METHODS A retrospective cross-sectional study examining all return visits to three EDs in Sydney, Australia, over a 12-month period. Patients returning within 28 days from ED discharge with the same or similar complaint were classified as a return visit to ensure capture of all return visits. Descriptive and inferential statistics were used to analyse the data and logistic regression was performed to predict factors associated with return visits with general admission, and return visits admitted to critical care. RESULTS There were 1,798 (30%) return visits which resulted in admission, mostly to a non-critical care area (1,679, 93%). The current NSW 48 -h time frame used to define a return visit in NSW captured half of all admitted returns (49.5%) and just over half (59.2%) of critical care admissions. Variables associated with an admission to critical care were age (OR 1.02, 95% CI 1.01, 1.03), initial presentation (index visit) made to a lower level ED (OR 3.76 95% CI 2.06, 6.86), Triage Category 2 (OR 3.67 95% CI 2.04, 6.60) and a cardiac diagnosis (OR 5.76, 95% CI 3.01, 11.01). This model had adequate discriminant ability with AUROC = 0.825. CONCLUSION A small number of return visits result in admission, especially to critical care. These patients are at risk of poor outcomes. As such, clinicians should have increased index of suspicion for patients who return that are older, present with cardiac problems, or have previously presented to a lower level ED. Revision of the current timeframe that defines a return visit ought to be considered by policy makers to improve the accuracy of this widely used key performance indicator.
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Affiliation(s)
- Claire L Hutchinson
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Emergency Department, Canterbury Hospital, Campsie, Sydney, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Illawarra Shoalhaven Local Health District, NSW, Australia; Illawarra Health and Medical Research Institute, NSW, Australia
| | - Andrea McCloughen
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
| | - Siyu Qian
- Centre for IT-enabled Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Australia
| | - Ping Yu
- Centre for IT-enabled Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Australia; Illawarra Health and Medical Research Institute, NSW, Australia
| | - Judith Fethney
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
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Lin CF, Huang YS, Tsai MT, Wu KH, Lin CF, Chiu IM. In-Hospital Outcomes in Patients Admitted to the Intensive Care Unit after a Return Visit to the Emergency Department. Healthcare (Basel) 2021; 9:healthcare9040431. [PMID: 33917232 PMCID: PMC8067995 DOI: 10.3390/healthcare9040431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Intensive care unit (ICU) admission following a short-term emergency department (ED) revisit has been considered a particularly undesirable outcome among return-visit patients, although their in-hospital prognosis has not been discussed. We aimed to compare clinical outcomes between adult patients admitted to the ICU after unscheduled ED revisits and those admitted during index ED visits. Method: This retrospective study was conducted at two tertiary medical centers in Taiwan from 1 January 2016 to 31 December 2017. All adult non-trauma patients admitted to the ICU directly via the ED during the study period were included and divided into two comparison groups: patients admitted to the ICU during index ED visits and those admitted to the ICU during return ED visits. The outcomes of interest included in-hospital mortality, mechanical ventilation (MV) support, profound shock, hospital length of stay (HLOS), and total medical cost. Results: Altogether, 12,075 patients with a mean (standard deviation) age of 64.6 (15.7) years were included. Among these, 5.3% were admitted to the ICU following a return ED visit within 14 days and 3.1% were admitted following a return ED visit within 7 days. After adjusting for confounding factors for multivariate regression analysis, ICU admission following an ED revisit within 14 days was not associated with an increased mortality rate (adjusted odds ratio (aOR): 1.08, 95% confidence interval (CI): 0.89 to 1.32), MV support (aOR: 1.06, 95% CI: 0.89 to 1.26), profound shock (aOR: 0.99, 95% CI: 0.84 to 1.18), prolonged HLOS (difference: 0.04 days, 95% CI: −1.02 to 1.09), and increased total medical cost (difference: USD 361, 95% CI: −303 to 1025). Similar results were observed after the regression analysis in patients that had a 7-day return visit. Conclusion: ICU admission following a return ED visit was not associated with major in-hospital outcomes including mortality, MV support, shock, increased HLOS, or medical cost. Although ICU admissions following ED revisits are considered serious adverse events, they may not indicate poor prognosis in ED practice.
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Affiliation(s)
- Chun-Fu Lin
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Rd. Niaosong Dist., Kaohsiung 83301, Taiwan; (C.-F.L.); (Y.-S.H.); (M.-T.T.); (K.-H.W.); (C.-F.L.)
| | - Yi-Syun Huang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Rd. Niaosong Dist., Kaohsiung 83301, Taiwan; (C.-F.L.); (Y.-S.H.); (M.-T.T.); (K.-H.W.); (C.-F.L.)
| | - Ming-Ta Tsai
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Rd. Niaosong Dist., Kaohsiung 83301, Taiwan; (C.-F.L.); (Y.-S.H.); (M.-T.T.); (K.-H.W.); (C.-F.L.)
| | - Kuan-Han Wu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Rd. Niaosong Dist., Kaohsiung 83301, Taiwan; (C.-F.L.); (Y.-S.H.); (M.-T.T.); (K.-H.W.); (C.-F.L.)
| | - Chien-Fu Lin
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Rd. Niaosong Dist., Kaohsiung 83301, Taiwan; (C.-F.L.); (Y.-S.H.); (M.-T.T.); (K.-H.W.); (C.-F.L.)
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Rd. Niaosong Dist., Kaohsiung 83301, Taiwan; (C.-F.L.); (Y.-S.H.); (M.-T.T.); (K.-H.W.); (C.-F.L.)
- Department of Computer Science and Engineering, National Sun Yet-Sen University, Kaohsiung 804, Taiwan
- Correspondence: or
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Physician-related factors associated with unscheduled revisits to the emergency department and admission to the intensive care unit within 72 h. Sci Rep 2020; 10:13060. [PMID: 32747730 PMCID: PMC7400515 DOI: 10.1038/s41598-020-70021-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/17/2020] [Indexed: 11/08/2022] Open
Abstract
Investigation of physician-related causes of unscheduled revisits to the emergency department (ED) within 72 h with subsequent admission to the intensive care unit (ICU) is an important parameter of emergency care quality. Between 2012 and 2017, medical records of all adult patients who visited the ED and returned within 72 h with subsequent ICU admission were retrospectively reviewed by three experienced emergency physicians. Study parameters were categorized into "input" (Patient characteristics), "throughput" (Time spent on first ED visit and seniority of emergency physicians, and "output" (Charlson Comorbidity Index). Of the 147 patients reviewed for the causes of ICU admission, 35 were physician-related (23.8%). Eight belonged to more urgent categories, whereas the majority (n = 27) were less urgent. Patients who spent less time on their first ED visits before discharge (< 2 h) were significantly associated with physician-related causes of ICU admission, whereas there was no significant difference in other "input," "throughput," and "output" parameters between the "physician-related" and "non-physician-related" groups. Short initial management time was associated with physician-related causes of ICU admission in patients with initial less urgent presentations, highlighting failure of the conventional triage system to identify potentially life-threatening conditions and possibility of misjudgement because of the patients' apparently minor initial presentations.
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Aaronson E, Jansson P, Wittbold K, Flavin S, Borczuk P. Unscheduled return visits to the emergency department with ICU admission: A trigger tool for diagnostic error. Am J Emerg Med 2019; 38:1584-1587. [PMID: 31699427 DOI: 10.1016/j.ajem.2019.158430] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/30/2019] [Accepted: 09/06/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND It is believed that patients who return to the Emergency Department (ED) and require admission are thought to represent failures in diagnosis, treatment or discharge planning. Screening readmission rates or patients who return within 72 h have been used in ED Quality Assurance efforts. These metrics require significant effort in chart review and only rarely identify care deviations. OBJECTIVE This study was conducted to evaluate the yield of reviewing ED return visits that resulted in an ICU admission. This study was conducted to evaluate the yield of reviewing ED return visits that resulted in an ICU admission. We planned to assess if the return visits with ICU admission were associated with deviations in care, and secondarily, to understand the common causes of error in this group. METHODS Retrospective review of patients presenting to a university affiliated ED between January 1, 2005 and December 31, 2015 and returned within 14 days requiring ICU admission. RESULTS From 1,106,606 ED visits, 511 patients returned within 14 days and were admitted to an ICU. 223 patients returned for a reason related to the index visit (43.6%). Of these related returns, 31 (13.9%) had a deviation in care on the index visit. When a standard diagnostic process of care framework was applied to these 31 cases, 47.3% represented failures in the initial diagnostic pathway. CONCLUSION Reviewing 14-day returns leading to ICU admission, while an uncommon event, has a higher yield in the understanding of quality issues involving diagnostic as well as systems errors.
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Affiliation(s)
- Emily Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, United States of America; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, United States of America
| | - Paul Jansson
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, United States of America
| | - Kelley Wittbold
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, United States of America; Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, United States of America
| | - Stephanie Flavin
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, United States of America; Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, United States of America
| | - Pierre Borczuk
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, United States of America.
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Chiang CY, Cheng FJ, Huang YS, Chen YL, Wu KH, Chiu IM. ICU admission following an unscheduled return visit to the pediatric emergency department within 72 hours. BMC Pediatr 2019; 19:268. [PMID: 31375075 PMCID: PMC6676510 DOI: 10.1186/s12887-019-1644-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 07/22/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The purpose of this study was to describe the demographic characteristics and prognosis of children admitted to the intensive care unit (ICU) after a pediatric emergency department (PED) return visit within 72 h. METHOD We conducted this retrospective study from 2010 to 2016 in the PED of a tertiary medical center in Taiwan and included patients under the age of 18 years old admitted to the ICU after a PED return visit within 72 h. Clinical characteristics were collected to perform demographic analysis. Pediatric patients who were admitted to the ICU on an initial visit were also enrolled as a comparison group for outcome analysis, including mortality, ventilator use, and length of hospital stay. RESULTS We included a total of 136 patients in this study. Their mean age was 3.3 years old, 65.4% were male, and 36.0% had Chronic Health Condition (CHC). Disease-related return (73.5%) was by far the most common reason for return. Compared to those admitted on an initial PED visit, clinical characteristics, including vital signs at triage and laboratory tests on return visit with ICU admission, demonstrated no significant differences. Regarding prognosis, ICU admission on return visit has a higher likelihood of ventilator use (aOR:2.117, 95%CI 1.021~4.387), but was not associated with increased mortality (aOR:0.658, 95%CI 0.150~2.882) or LOHS (OR:-1.853, 95%CI -4.045~0.339). CONCLUSION Patients who were admitted to the ICU on return PED visits were associated with an increased risk of ventilator use but not mortality or LOHS compared to those admitted on an initial visit.
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Affiliation(s)
- Charng-Yen Chiang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, No.123, Dapi Rd. Niaosong Dist, Kaohsiung City, 83301, Taiwan, Republic of China
| | - Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, No.123, Dapi Rd. Niaosong Dist, Kaohsiung City, 83301, Taiwan, Republic of China
| | - Yi-Syun Huang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, No.123, Dapi Rd. Niaosong Dist, Kaohsiung City, 83301, Taiwan, Republic of China
| | - Yu-Lun Chen
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, No.123, Dapi Rd. Niaosong Dist, Kaohsiung City, 83301, Taiwan, Republic of China
| | - Kuan-Han Wu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, No.123, Dapi Rd. Niaosong Dist, Kaohsiung City, 83301, Taiwan, Republic of China
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, No.123, Dapi Rd. Niaosong Dist, Kaohsiung City, 83301, Taiwan, Republic of China.
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Incidence, characteristics and outcomes of patients that return to Emergency Departments. An integrative review. Australas Emerg Care 2019; 22:47-68. [PMID: 30998872 DOI: 10.1016/j.auec.2018.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Unplanned return visits account for up to 5% of Emergency Department presentations in Australia and have been associated with adverse events and increased costs. A large number of studies examine the incidence, characteristics and outcomes of unplanned return visits but few studies examine the reasons for return from a patient perspective. The objective of this integrative review was to determine the incidence, characteristics, outcomes and reasons for unplanned return visits to Emergency Departments. METHOD An integrative literature review design was employed to conduct a structured search of the literature using the databases CINAHL, MEDLINE, PubMed, ProQuest and EMBASE (inception to June 2018). Results were screened using predefined criteria and final studies collated and appraised using a quality assessment tool. RESULTS Fifty-two primary research articles were included in the review. The timeframe used to capture unplanned return visits varied and the incidence ranged between 0.07% and 33%. The majority of patients who return unplanned to the Emergency Department are subsequently discharged (51% and 90%) without an adverse event. CONCLUSION There is no consensus on the timeframe employed to classify unplanned return visits to the Emergency Department and the commonly used 72h lacks evidence. Routine statewide data linkage to capture return visits to other facilities is needed to ensure accurate data about this vulnerable patient group. Further research that focuses on patient and clinician perspectives is required to facilitate the development of local strategies to reduce the incidence of avoidable unplanned return visits.
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Ahmed AE, AlBuraikan DA, Almazroa HR, Alrajhi MN, ALMuqbil BI, Albaijan MA, Alsalamah MA, Al-Jahdali H. Seventy-two-hour emergency department revisits among adults with chronic diseases: a Saudi Arabian study. Ther Clin Risk Manag 2018; 14:1423-1428. [PMID: 30147326 PMCID: PMC6098417 DOI: 10.2147/tcrm.s168763] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Despite the increase in adult emergency department (ED) utilization in Saudi Arabia, no studies have evaluated the 72-hour revisits. This study estimates the rate of 72-hour ED revisits and identifies its reasons and predictive factors among adults with chronic diseases. Patients and methods A hospital-based retrospective study that included 24,206 ED discharges for adults with chronic diseases at the adult ED of King Abdulaziz Medical City, Riyadh between September 13, 2015 and July 29, 2017 was performed. We extracted data on demographic information, reasons for ED visits/revisits, health insurance coverage, weekend ED arrival, and mortality. Results A sample of 24,206 ED discharges for 19,697 adults with at least one chronic disease was included in the analysis. The rate of 72-hour revisits in this study population was high: 3,144/24,206 (13%) had the first revisit and 319/3,144 (10.1%) had the second ED revisit within 72 hours. Diseases of the circulatory (19%) and genitourinary (15.8%) systems were the major reasons for the first ED revisit. The adjusted relative rate (aRR) of 72-hour ED revisits was higher in adults with chronic diseases and aged ≥60 years (aRR=1.360, 95% CI: 1.41–1.83; P=0.001), patients of female gender (aRR=1.24, 95% CI: 1.09–1.41; P=0.001), patients with health insurance coverage (aRR=4.23, 95% CI: 2.60–6.90; P=0.001), patients arriving to ED on a weekend (aRR=2.13, 95% CI: 1.03–4.41; P=0.041), and new patients (aRR=1.47, 95% CI: 1.25–1.73; P=0.001). Conclusion The rate of 72-hour revisits is high among adults with chronic diseases. Advancing age, female gender, health insurance coverage, weekend ED arrival, and new patients are the important predictive factors of the high rate of 72-hour revisits. Continuous quality assessment and monitoring of factors related to patients are needed to reduce the frequency of early ED revisits after discharge.
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Affiliation(s)
- Anwar E Ahmed
- King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia, .,King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, Riyadh, Saudi Arabia,
| | - Doaa A AlBuraikan
- King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, Riyadh, Saudi Arabia,
| | - Hend R Almazroa
- King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, Riyadh, Saudi Arabia,
| | - Manair N Alrajhi
- King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, Riyadh, Saudi Arabia,
| | - Bashayr I ALMuqbil
- King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, Riyadh, Saudi Arabia,
| | - Monirah A Albaijan
- King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia,
| | - Majid A Alsalamah
- King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, Riyadh, Saudi Arabia,
| | - Hamdan Al-Jahdali
- King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia, .,King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, Riyadh, Saudi Arabia,
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Ahmed AE, ALMuqbil BI, Alrajhi MN, Almazroa HR, AlBuraikan DA, Albaijan MA, Nasim M, Alsalamah MA, McClish DK, AL-Jahdali H. Emergency department 72-hour revisits among children with chronic diseases: a Saudi Arabian study. BMC Pediatr 2018; 18:205. [PMID: 29945589 PMCID: PMC6020430 DOI: 10.1186/s12887-018-1186-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 06/21/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Emergency Department (ED) revisits have often been used as an indicator of medical care quality. This study aimed to quantify the frequency of ED revisits within 72 h of discharge and identify its factors among children with chronic diseases. METHODS We designed a retrospective cohort study of children with at least one chronic disease who were also under 18 years of age and had attended and were discharged from the ED at King Abdullah Specialist Children's Hospital (KASCH-RD), Riyadh, Saudi Arabia between April 19, 2015 and July 29, 2017. The outcome measure was the frequency of ED revisits during a period of 72 h after discharge. RESULTS The study included 11,057 ED discharges of children with at least one chronic disease. Their revisit rate was 1211 (11%), with 83 (6.9%) having had a second ED revisit within 72 h of ED discharge. According to ICD-10 codes, the most common causes of ED revisits were respiratory, digestive, genitourinary, symptoms, and external causes. Factors of frequent ED revisits within 72 h were young age, institutional health insurance coverage, year of new health information system (2015), external causes, and genitourinary. CONCLUSION The rate of 72-h ED revisits after discharge of children with chronic diseases treated at KASCH-RD was relatively high, and was associated with young age, institutional health insurance coverage, year of a new health information system implementation, and external causes of ED visit. These study findings amplify the need for intervention to reduce the rate of early ED revisits among children with chronic diseases.
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Affiliation(s)
- Anwar E. Ahmed
- King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, P.O. Box 22490, Riyadh, 11426 Saudi Arabia
- Pulmonary Division Medical Director of sleep disorders, Center King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Bashayr I. ALMuqbil
- King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, P.O. Box 22490, Riyadh, 11426 Saudi Arabia
| | - Manair N. Alrajhi
- King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, P.O. Box 22490, Riyadh, 11426 Saudi Arabia
| | - Hend R. Almazroa
- King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, P.O. Box 22490, Riyadh, 11426 Saudi Arabia
| | - Doaa A. AlBuraikan
- King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, P.O. Box 22490, Riyadh, 11426 Saudi Arabia
| | - Monirah A. Albaijan
- King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | - Maliha Nasim
- King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | - Majid A. Alsalamah
- King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, P.O. Box 22490, Riyadh, 11426 Saudi Arabia
| | - Donna K. McClish
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Box 980032, Richmond, VA 23298 USA
| | - Hamdan AL-Jahdali
- King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, P.O. Box 22490, Riyadh, 11426 Saudi Arabia
- McGill University, Montreal, Canada
- Pulmonary Division Medical Director of sleep disorders, Center King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Pellerin G, Gao K, Kaminsky L. Predicting 72-hour emergency department revisits. Am J Emerg Med 2017; 36:420-424. [PMID: 28855065 DOI: 10.1016/j.ajem.2017.08.049] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To develop a predictive model that hospitals or healthcare systems can use to identify patients at high risk of revisiting the ED within 72h so that appropriate interventions can be delivered. METHODS This study employed multivariate logistic regression in developing the predictive model. The study data were from four Veterans medical centers in Upstate New York; 21,141 patients in total with ED visits were included in the analysis. Fiscal Year (FY) 2013 data were used to predict revisits in FY 2014. The predictive variables were patient demographics, prior year healthcare utilizations, and comorbidities. To avoid overfitting, we validated the model by the split-sample method. The predictive power of the model is measured by c-statistic. RESULTS In the first model using only patient demographics, the c-statistics were 0.55 (CI: 0.52-0.57) and 0.54 (95% CI: 0.51-0.56) for the development and validation samples, respectively. In the second model with prior year utilization added, the c-statistics were 0.70 (95% CI: 0.68-0.72) for both samples. In the final model where comorbidities were added, the c-statistics were 0.74 (CI: 0.72-0.76) and 0.73 (95% CI: 0.71-0.75) for the development and validation samples, respectively. CONCLUSIONS Reducing ED revisits not only lowers healthcare cost but also shortens wait time for those who critically need ED care. However, broad intervention for every ED visitor is not feasible given limited resources. In this study, we developed a predictive model that hospitals and healthcare systems can use to identify "frequent flyers" for early interventions to reduce ED revisits.
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Affiliation(s)
- Gene Pellerin
- US Department of Veterans Affairs, Stratton VA Medical Center, 113 Holland Ave., Albany, NY 12208, United States.
| | - Kelly Gao
- US Department of Veterans Affairs, Stratton VA Medical Center, 113 Holland Ave., Albany, NY 12208, United States.
| | - Laurence Kaminsky
- US Department of Veterans Affairs, Stratton VA Medical Center, 113 Holland Ave., Albany, NY 12208, United States.
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