Unplanned reattendances at the paediatric emergency department within 72 hours: a one-year experience in KKH

Predictors of complicated influenza infection in children presenting in a tertiary hospital in a tropical country: A case-control study

Influenza causes significant healthcare burden globally1 with highest risks in children and the elderly. In children, multiple studies have identified risk factors for severe influenza such as young age (<5 years), presence of comorbidities, abnormal vital signs (e.g. hypoxia, shock) and bacterial coinfections.2-4 We found similar findings in our centre which included children during the influenza A (H1N1) 2009 pandemic with age <2 years and comorbidity as risk factors for complicated influenza.5

Development and Internal Validation of a Multivariable Prediction Model to Predict Repeat Attendances in the Pediatric Emergency Department: A Retrospective Cohort Study

OBJECTIVE

Unplanned reattendances to the pediatric emergency department (PED) occur commonly in clinical practice. Multiple factors influence the decision to return to care, and understanding risk factors may allow for better design of clinical services. We developed a clinical prediction model to predict return to the PED within 72 hours from the index visit.

METHODS

We retrospectively reviewed all attendances to the PED of Royal Manchester Children's Hospital between 2009 and 2019. Attendances were excluded if they were admitted to hospital, aged older than 16 years or died in the PED. Variables were collected from Electronic Health Records reflecting triage codes. Data were split temporally into a training (80%) set for model development and a test (20%) set for internal validation. We developed the prediction model using LASSO penalized logistic regression.

RESULTS

A total of 308,573 attendances were included in the study. There were 14,276 (4.63%) returns within 72 hours of index visit. The final model had an area under the receiver operating characteristic curve of 0.64 (95% confidence interval, 0.63-0.65) on temporal validation. The calibration of the model was good, although with some evidence of miscalibration at the high extremes of the risk distribution. After-visit diagnoses codes reflecting a nonspecific problem ("unwell child") were more common in children who went on to reattend.

CONCLUSIONS

We developed and internally validated a clinical prediction model for unplanned reattendance to the PED using routinely collected clinical data, including markers of socioeconomic deprivation. This model allows for easy identification of children at the greatest risk of return to PED.

Early reattenders to the paediatric emergency department: A prospective cohort study and multivariate analysis

AIMS

The rate of unplanned reattendances is used as an indicator of the quality of care delivered in a paediatric emergency department (PED). With early reattendance in the UK well above the national target of 1-5%, we aimed to identify the factors which predict unplanned early reattendance to the PED.

METHODS

This is a prospective, single-centre cohort study undertaken over 12 months. Data were collected on all patients who reattended the PED within 7 days of their initial visit as well as for a comparative cohort of patients with no visit in the preceding or subsequent 7 days. Multiple patient and departmental variables were recorded and analysed using a multivariate regression model.

RESULTS

There were a total of 19 420 index visits to the PED, of which 1461 patients had an unscheduled reattendance within 7 days - a rate of 7.5%. Factors associated with unplanned but related reattendance include young age and diagnosis with a respiratory or other medical illness. Interestingly, the grade of clinician appeared to be relevant with patients seen by junior members of the medical team less likely to reattend. Acuity of illness was not a significant factor. A substantial number of unplanned early reattenders (36.3%) would have been missed had a time period of 72 h been used rather than 7 days.

CONCLUSIONS

This study identifies the typical patient who will have an unplanned, related early reattendance to a PED. This study also supports the use of a 7-day time period when using early reattendance as a performance indicator.

Factors Associated with Unscheduled Emergency Department Revisits in Children with Acute Lower Respiratory Tract Diseases

Purpose

To identify factors associated with unscheduled emergency department (ED) revisits within 72 hours in children with acute dyspnea from lower respiratory tract diseases.

Patients and Methods

This retrospective cohort study included pediatric patients (age group: one month to 15 years old) who visited the ED with acute lower respiratory tract diseases between January 1st, 2017 and February 28th, 2019. The medical records were reviewed and discharged patients were dichotomized into revisit and non-revisit groups, based on whether the patients needed a revisit or not. Baseline characteristics, vital signs, diagnosis, treatment, pediatrician consultation, ED length of stay, and primary doctor of both groups were compared. Univariate and multivariate analyses by logistic regression were used to determine the significant factors associated with the revisits.

Results

Medical records of 918 eligible pediatric patients (1417 visits) were reviewed. Factors significantly associated with the revisits were history of asthma or current controller use (odds ratio [OR]: 3.08: 95% confidence interval [CI]: 1.86-5.1). Not prescribing systemic corticosteroids (P < 0.001), or prescribing them upon discharge without first dose in the ED (P = 0.022) were significantly associated with revisits.

Conclusion

No prescription of systemic corticosteroids or prescription upon discharge, without an immediate dose at the ED, in children with history of asthma or current controller use were associated with revisits.

Evaluation of the Pattern of Use of a Pediatric Emergency Department in Italy

OBJECTIVES

The aim of this study was to evaluate access to a pediatric emergency department (PED) in a large hospital, in particular to estimate the prevalence of potentially avoidable accesses and the characteristics of return visits.

METHODS

Clinical health records from the PED of San Gerardo Hospital, Monza, Italy, were retrospectively reviewed. The study population was composed of subjects younger than 18 years who attended the PED during the period from October 1, 2017, to November 30, 2017.Accesses were defined nonurgent if characterized by white or green triage codes and patient's discharge as the outcome and were defined potentially avoidable if nonurgent and with no diagnostic/therapeutic procedures performed except a visit by the ED pediatrician.Return visits were defined as accesses that occurred within 72 hours of the first index visit.

RESULTS

A total of 2064 children and adolescents younger than 18 years had at least 1 ED attendance between October and November 2017, for a total of 2364 accesses.The most frequent diagnoses were upper respiratory tract infections (29.5% of accesses), followed by gastroenteritis (7.0%) and abdominal pain (7.0%). In all, 1810 accesses (88%) were classified as "nonurgent," and 1228 (60%) potentially avoidable, 373 of which were probably avoidable because they occurred when the primary care physician was available.The number of return visits was 98 (5% of the accesses): 74 were nonurgent, 31 of which potentially avoidable. On 17 occasions, both index and return visits were potentially avoidable.

CONCLUSIONS

We confirm that most of the accesses to a PED are nonurgent and potentially avoidable. Interventions are needed to improve the appropriateness of use of emergency services.

A clinical prediction model to identify children at risk for revisits with serious illness to the emergency department: A prospective multicentre observational study

Background

To develop a clinical prediction model to identify children at risk for revisits with serious illness to the emergency department.

Methods and findings

A secondary analysis of a prospective multicentre observational study in five European EDs (the TRIAGE study), including consecutive children aged <16 years who were discharged following their initial ED visit (‘index’ visit), in 2012–2015. Standardised data on patient characteristics, Manchester Triage System urgency classification, vital signs, clinical interventions and procedures were collected. The outcome measure was serious illness defined as hospital admission or PICU admission or death in ED after an unplanned revisit within 7 days of the index visit. Prediction models were developed using multivariable logistic regression using characteristics of the index visit to predict the likelihood of a revisit with a serious illness. The clinical model included day and time of presentation, season, age, gender, presenting problem, triage urgency, and vital signs. An extended model added laboratory investigations, imaging, and intravenous medications. Cross validation between the five sites was performed, and discrimination and calibration were assessed using random effects models. A digital calculator was constructed for clinical implementation. 7,891 children out of 98,561 children had a revisit to the ED (8.0%), of whom 1,026 children (1.0%) returned to the ED with a serious illness. Rates of revisits with serious illness varied between the hospitals (range 0.7–2.2%). The clinical model had a summary Area under the operating curve (AUC) of 0.70 (95% CI 0.65–0.74) and summary calibration slope of 0.83 (95% CI 0.67–0.99). 4,433 children (5%) had a risk of > = 3%, which was useful for ruling in a revisit with serious illness, with positive likelihood ratio 4.41 (95% CI 3.87–5.01) and specificity 0.96 (95% CI 0.95–0.96). 37,546 (39%) had a risk <0.5%, which was useful for ruling out a revisit with serious illness (negative likelihood ratio 0.30 (95% CI 0.25–0.35), sensitivity 0.88 (95% CI 0.86–0.90)). The extended model had an improved summary AUC of 0.71 (95% CI 0.68–0.75) and summary calibration slope of 0.84 (95% CI 0.71–0.97). As study limitations, variables on ethnicity and social deprivation could not be included, and only return visits to the original hospital and not to those of surrounding hospitals were recorded.

Conclusion

We developed a prediction model and a digital calculator which can aid physicians identifying those children at highest and lowest risks for developing a serious illness after initial discharge from the ED, allowing for more targeted safety netting advice and follow-up.

Characteristics and outcomes of patients with an unscheduled return visit within 72 hours to the Paediatric Emergency Centre at a Private Tertiary Referral Hospital in Kenya

Introduction

Patients’ unscheduled return visits (URVs) to the paediatric emergency Centre (PEC) contribute to overcrowding and affect health service delivery and overall quality of care. This study assessed the characteristics and outcomes of paediatric patients with URVs (within 72 hours) to the PEC at a private tertiary hospital in Kenya.

Methods

We conducted a retrospective chart review of all URVs within 72 hours among paediatric patients aged ≤15 years between 1 July and 31 December 2018 at the tertiary hospital in Nairobi, Kenya.

Results

During the study period, 1.6% (n=172) of patients who visited the PEC returned within 72 hours, with 4.7% revisiting the PEC more than once. Patients’ median age was 36 months (interquartile range: 42 months); over half were male (51.7%), 55.8% were ambulatory and 84.3% were insured. In addition, 21% (n=36) had chronic diseases and 7% (n=12) had drug allergies. Respiratory (59.5%) and gastrointestinal (21.5%) tract infections were the most common diagnoses. Compared with the first visit, more patients with URVs were classified as urgent (1.7% vs. 5.2%) and were non-ambulatory (44.2% vs. 49.5%, p=<0.001); 18% of these patients were admitted. Of these 58% were male, 83.9% were aged 0–5 years, 12.9% were classified as urgent, 64.5% had respiratory tract infections and 16.1% had gastrointestinal tract infections. Being admitted was associated with patient acuity (p=0.004), laboratory tests (p=<0.001) and ambulatory status (p=0.041).

Conclusion

The URV rate is low in our setting. Patients who returned to the PEC within 72 hours tended to be male, under 5 years old and insured. Many were non-urgent cases with diagnoses of respiratory and gastrointestinal tract infections. The findings suggest that some URVs were necessary and may have contributed to better care and improved outcomes while others highlight a need for effective patient education and comprehensive initial assessment.

Predictors and outcomes of patients that return unplanned to the Emergency Department and require critical care admission: A multicenter study

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.

Identifying return visits to the Emergency Department: A multi-centre study

BACKGROUND

Patients who return to the Emergency Department (ED) for the same complaint are known to be at risk of adverse events. Monitoring of return visits is considered a way to measure the quality of care provided in the ED, although the most commonly used benchmark of 48h lacks evidence. This study aimed to describe the incidence, characteristics and outcomes of patients with unplanned return visits. The study also aimed to determine the capture rate of the 48-h benchmark using an all-inclusive method of return visit identification.

METHODS

A retrospective cross-sectional study was conducted across three EDs in Sydney, New South Wales from July 1st, 2017 to June 30th, 2018. Visits that occurred within 28 days with the same or similar presenting complaint following discharge from the ED were classified as a return visit. Data were grouped by index and return visit. Descriptive statistics were used to summarise incidence, patient characteristics and outcomes for all presentations. Categorical data were analysed using Chi square tests. Continuous data were analysed using Mann-Whitney when data were not normally distributed and t-tests when normally distributed.

RESULTS

Of all ED presentations (n=164,598), 5860 (3.6%) were identified as a return visit. Return patients were younger than non-return patients, but those that required admission were older (43 vs 33 years, p=<0.01). Abdominal problems were the most common reason for return followed by urological and mental health. The median time to return was 64:51h (IQR 20:35-226:37). Only 43% of return visits occurred within 48h. Return visits to a different ED accounted for 13.2% of return visits.

CONCLUSION

More than half of ED return visits are missed when the existing benchmark of 48h is used. Current policy makers should consider increasing the 48-h benchmark to more accurately reflect the incidence of return visits. Further investigation into the causal factors for return visits is warranted, particularly in patients with abdominal, urological or mental health complaints.

Incidence, characteristics and outcomes of patients that return to Emergency Departments. An integrative review

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.

Use of a standardized asthma severity score to determine emergency department disposition for paediatric asthma: A cohort study

Background

We recently introduced a clinical practice pathway for the management of asthma that uses the Pediatric Respiratory Assessment Measure (PRAM) to guide emergency department (ED) treatment and disposition. The pathway recommends discharge for patients who achieve improvement to PRAM <4 at 1 hour after the last bronchodilator. We evaluated practice variation and patient outcomes associated with PRAM-directed disposition recommendations.

Methods

We conducted a retrospective cohort study of children aged 2 to 17 years treated for moderate asthma (PRAM score 4-7) using our asthma clinical pathway. We measured 1) the proportion of children discharged per pathway criteria who returned to our ED within 24 hours and 2) the proportion of children observed beyond the pathway discharge criteria who deteriorated (PRAM ≥4).

Results

We analyzed 385 patient records from September 2013 to February 2015. Among 145 (37.7%) patients discharged per pathway criteria, 4 (4/145; 2.8%) returned within 24 hours. The remaining 240 (62.2%) were observed beyond the pathway discharge criteria; 76/240 (31.7%) had a subsequent deterioration (PRAM score ≥ 4) and 25/240 (10.4%) were hospitalized. Of those who deteriorated, 46/76 (60.5%) worsened within the first additional hour of observation.

Conclusion

We observed significant deviation from our PRAM-directed pathway discharge criteria and that a significant proportion of observed patients experienced clinical deterioration beyond the first hour of observation. We recommend observing children with moderate asthma for 2 or 3 hours from last bronchodilator therapy if PRAM < 4 is maintained, to capture the majority (97.7% or 99.7%) of patients who require further intervention and hospitalization.

Seventy-two-hour emergency department revisits among adults with chronic diseases: a Saudi Arabian study

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.

Emergency department 72-hour revisits among children with chronic diseases: a Saudi Arabian study

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.