The Prevalence of Quality Issues and Adverse Outcomes among 72-Hour Return Admissions in the Emergency Department

doi:10.1016/j.jemermed.2012.11.012

The Journal of Emergency Medicine

Volume 45, Issue 2, August 2013, Pages 281-288

https://doi.org/10.1016/j.jemermed.2012.11.012 Get rights and content

Abstract

Background

Records of patients discharged from the Emergency Department (ED) who return within 72 h and are admitted are often reviewed for potential quality issues.

Objectives

We explored 72-h return admissions and determined the prevalence and predictors for substandard management on the initial visit or any adverse outcome.

Methods

Retrospective review of quality assurance data from 72-h return admissions in three hospitals from 2006–2010 was performed. Any substandard quality on the first visit or change in outcome on the return admission was considered “low quality.” Multivariate logistic regression was used to assess the relationship between cases judged as low quality vs. not low quality.

Results

Of 741,132 ED visits across 5 years, 3682 (0.5%) were 72-h return admissions. Of those, 192 (5%) were low quality. In 158 (4%) and 8 (0.2%) there were moderate and severe deviations from care standards, respectively. Similarly, in 53 (1%) and 14 (0.4%) there were moderate and severe changes in outcome. In adjusted analysis, there were higher rates of low-quality 72-h return admissions in ambulance arrivals (odds ratio [OR] 1.5, 95% confidence interval (CI) 1.1–2.1); and lower rates in Medicaid patients (OR 0.3, 95% CI 0.2–0.7). There were higher rates in low-quality 72-h return admissions in hospital 1 (OR 3.6, 95% CI 2.2–6.1) and hospital 3 (OR 3.2, 95% CI 2.0–4.7) compared to hospital 2.

Conclusions

Poor care on the initial visit or any poor outcome upon returning in 72-h return admissions is relatively rare in the ED. Reporting 72-h return admissions without chart review may not be a good way to measure clinical quality.

Introduction

According to data from the National Hospital Ambulatory Medical Care Survey, more than 4% of the Emergency Department (ED) visits are “bouncebacks”: patients seen within 72 h from the initial ED visit at the same ED (1). The clinical significance of these returns is unknown. Some may be planned returns for wound checks or other issues such as rabies vaccinations. However, because one of the goals of ED care is to ensure that proximal care needs are sufficiently met to prevent people from returning and requiring additional ED treatment, some of these return visits may represent quality issues. Reviews of early return visits to the ED are used for quality assurance, and some returns do occur due to a misdiagnosis, an incorrect choice of initial disposition, or poor discharge planning 2, 3, 4, 5, 6, 7, 8, 9, 10, 11.

Among 72-h returns, the highest-risk group is people who return within 72 h and are admitted to the hospital. From a quality perspective, 72-h return admissions have been suggested as a potential quality indicator in Emergency Medicine (11). Several studies have reported the prevalence of 72-h return admissions, which ranged from 0.5% to 1.2% of all visits 7, 8, 9, 10. Reported risk factors for return admissions include older age, living alone, insurance status, and certain diagnoses such as mental disorders, genitourinary disorders, symptom-based diagnoses such as abdominal pain and chest pain, dehydration, and septicemia 9, 10. In addition, several initial ED visit characteristics have been associated with higher risks of return admission, including arrival by ambulance, weekend visits, patients who arrive in the afternoon, and patients discharged in the evening (9). However, only one study, which looked at intensive care unit return admissions, directly examined 72-h return admissions and reported that 0.019% involved potential medical errors in a single hospital in Taiwan (12).

We explored 72-h return admissions across three United States (US) hospitals and assessed the prevalence of both substandard management during the initial visit and whether there was any change in outcome apparent during the second visit where the patient was admitted. Secondarily, we tested whether there are any demographic predictors associated with either substandard management or changes in outcomes in 72-h return admissions.

Section snippets

Study Design, Setting, and Population

We conducted a retrospective review of a quality assurance program for all patients who visited the ED, were discharged, and then returned within 72 h from the first visits and were admitted to inpatient units from three hospitals. The hospitals included were all within a single health system, and date ranges corresponded to dates when a quality assurance program was present in those hospitals for 72-h return admissions. The hospitals included Hospital 1 (H1) from January 2008 to July 2010,

Main Results

There were 741,132 visits in the three EDs over the study period. After excluding patients who left without being seen, left against medical advice, or were transferred or admitted during the index visit, the rate of 72-h return visits was 23,224 (3.1%). Of those, 3682 (0.5% of total ED visits) were 72-h return admissions and included in the analysis (Figure 1).

In 3511 (95%) 72-h return admissions, standard of care was met; in 158 (4.2%) and 8 (0.2%), there were moderate to severe deviations

Discussion

In our study, rates of 72-h returns and return admissions were 3.1% and 0.5%, respectively, which is similar to other studies 4, 5, 9, 10, 11, 14. Of the 72-h return admissions, we found that, in fact, a very low percentage of these encounters were associated with previous visits where the quality was either substandard or there was any difference in outcome (about 5%), suggesting that quality issues in 72-h return admissions are relatively rare.

It has been suggested in a previous study that

Conclusions

Low-quality 72-h return admissions in the three EDs over the study period were only 5% of all 72-h return admissions. Due to this low prevalence, it is important to include chart reviews to determine if care standards were not met or outcomes were worsened when using 72-h return admission data for internal or external quality measurement purposes.

Article Summary

1. Why is this topic important?

Seventy-two-hour return admissions are used to assess quality in emergency care and may be useful in local or public reporting of quality information.

2. What does this study attempt to show?

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Citation Excerpt :
Given the large sample size studied, it is unlikely that either of these limitations significantly impacted the outcomes. This study relied on 48-h returns as a surrogate marker for adverse ED outcomes despite previous data suggesting that return visits are not the best measure of quality of care [29], resource utilization, or severity of illness [30]. Until a validated marker for adverse outcomes is available, it would be impractical to manually review charts of every ED patient and thus, it was assumed that any patient with clinically significant adverse outcomes would likely return to the hospital within that time frame and be captured in our study.
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We conducted a retrospective cohort study of children discharged from 2 pediatric EDs with abnormal VS between July 2018–June 2019. We queried electronic health records (EHR) for children ages 0–18 years discharged from the ED with abnormal last recorded VS. VS were considered erroneously entered and thus excluded from analysis if heart rate was <30 or ≥ 300, respiratory rate was 0 or ≥ 100 or oxygen saturation was <50. Patients who were declared deceased at index visit were excluded. Demographic, clinical, and outcome data including return visits within 48 h and adverse outcomes after the initial ED discharge were obtained.
Of the 97,824 children evaluated in the EDs during the study period, 17,661 (18.1%) were discharged with abnormal VS. 404 (2.28%) returned to the ED, of which 95 (23.5%) were admitted for the same chief complaint within 48 h. In comparison, the 48-h return rate for children discharged with normal VS was 2.45% (p = 0.219). Children discharged with abnormal VS were more likely to return if they had 2 or more abnormal VS (OR 1.6; 95% CI 1.23–2.07), were less than 3 years old (OR 1.69, 95% CI 1.39–2.06) or their initial acuity level was high (OR 1.34; 95% CI 1.1–1.63). Higher initial acuity level and age less than 3 years were also associated with admission at revisit (OR 2.58; 95% CI 1.59–4.2; OR 2.20, 95% CI 1.36–3.55). Four of the children who returned required PICU admission, but none died, required CPR or endotracheal intubation.
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Administration of Emergency MedicineThe Prevalence of Quality Issues and Adverse Outcomes among 72-Hour Return Admissions in the Emergency Department

Abstract

Background

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Study Design, Setting, and Population

Main Results

Discussion

Conclusions

Article Summary

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

J Emerg Med

Am J Emerg Med

Ann Emerg Med

Administration of Emergency Medicine
The Prevalence of Quality Issues and Adverse Outcomes among 72-Hour Return Admissions in the Emergency Department