International
Notes
Analysisof PatientRevisits to the Emergency Department SHENG-CHUAN
HU, MD
Nowadays, overcrowding in the emergency department (ED) is a high priority issue, and is common in most famous and large hospitals in the United States like New York, San Francisco, and Los Angeles,‘** influencing the quality of care available to emergency patients.3*4 Because emergency physicians and nurses are called on to provide ongoing inpatient and intensive care service in the ED, in addition to their responsibility to other emergency patients, emergency efficiency is considerably decreased. Our previous study showed that patients staying overnight in the observation room amounted to more than 100 on average per day. Among these, 30 to 60 were waiting for admission.’ This overwhelming patient load would be expected to decrease our quality of care. Quality assurance (QA) activity then becomes a necessary procedure to improve and maintain service at a high level. Auditing patients who return early to the ED is one of the newly developed and very important QA activities. Although our ED provides emergency care to all in need, regardless of their ability to pay, our main users are elderly veterans, a large number of whom are single and live alone. Elderly patients suffering from cardiovascular disease, infectious disease, neurologic, or endocrinologic disorders often present with atypical or trivial manifestations which may result in a misdiagnosis or early release from the ED, prompting a revisit to the ED shortly after being discharged.6-” The reasons for these revisits, such as inadequate medical care, disease type, personality differences, inadequate discharge instructions, or a failure of the medical care system, are issues of interest for many investigators.‘2M’4 The purpose of this study is to identify the reasons prompting the early ED revisit. We are particularly interested in answering the questions. What are the primary chief complaints? Which physical or laboratory examinations are
From the Division of Emergency Medicine, Emergency Department, Veterans General Hospital-Taipei, Yung Ming Medical College, Taipei, Taiwan, Republic of China. Manuscript received November 19, 1991; revision accepted January 29, 1992. This study was sponsored by Veterans General HospitalNational Tsin Hwa University Joint Research Program-ROC (VGHTH-80-039-1). Address reprint requests to Dr Hu, Chief, Emergency Medicine, Veterans General Hospital-Taipei, 201, Set 2, Shih-Pai Rd, Shih-Pai, Taipei, Taiwan, Republic of China. Copyright 0 1992 by W.B. Saunders Company 0735-8757/92/l 004-0022$500/O 366
crucial to avoid revisits? We are hoping to provide better emergency care by targeting these factors and strengthening on-the-job training to all ED staff members. Recently, two papers have talked about ED revisits,‘3,‘4 mainly regarding the length of time elapsed before the return visit and the factors accounting for the return visit. This study was undertaken in a different way, oriented by the chief complaint, past history, and laboratory or physical examination, to identify the crucial factors needing correction to avoid revisits. These issues have never been addressed in the literature previously. We conducted this study to find high-risk patients, or pitfalls in the ED, to allow us to improve the quality of care in the ED. MATERIALSAND METHODS Veterans General Hospital-Taipei (Taiwan) is a busy teaching hospital with 2,700 in-hospital beds and a busy ED handling 92,126 patient visits in 1990. The ED is staffed by full-time emergency physicians and rotating senior residents from the department of internal medicine, chest medicine, neurology, surgery, and orthopedics. Basically, residents primarily see all the patients and are supervised by attending physicians. They have the authority to sign out any patient if they have confidence in their management. Upon arrival at ED, patients were initially triaged by trained nurses and then taken to registration. Clerks keyed in each patient’s name, sex, and age, producing “sticker” marked with the patient’s general data. Patients presenting to ED twice within a 7-day period were identified by the computer with a “dollar” sign on the “sticker”, a sign easily recognized by a research assistant. While these patients were being examined, incharge residents completed the registration forms. A research assistant then collected all the patient records and transferred all necessary data to a special chart. Upon completion, all material was given to two ED attending physicians to determine the cause for the revisit. The same physicians reviewed all charts. All data were entered into a personal computer and later analyzed by computer. Data collected included the following assessment and management information: chief complaint, body system, routine laboratory examination (for example, blood and urine routine, chest x-ray, blood sugar, and electrolyte), arrival time, discharge time, and final diagnosis. Compliance with physician instructions and taking medications as well as the frequency of discharge instructions provided by the nurse were also recorded on the special chart. These special charts were then reviewed to determine whether the initial
SHENG-CHUAN
HU n REVISITS
TO THE EMERGENCY
367
DEPARTMENT
visit and revisit were for related problems and whether the revisit was scheduled or unscheduled, avoidable or unavoidable. In any case of revisit, the actual reason was listed. For the sake of convenience, we designed an algorithm (Figure 1) which was completed by two attending physicians working independently of each other and reviewed for agreement regarding the reason for revisit. If no agreement was noted, the case was discussed in the monthly held mortality and morbidity conference and a consensus was reached. The detinitions of the reasons for revisit as outlined on the algorithm were as follows:
Reasons for Unavoidable Revisit 1. The patient was seen by a physician and left the ED against medical advice or the patient was registered in the ED but left before being seen by a physician.
8hrs-72hrs
24hrs-48hrs
2. The patient received appropriate emergency medical care, but either the evolution of the disease, progression of disease, or recurrent disease, which were deemed unavoidable, prompted the patient to return. with the same or similar 3. The patient presented nonurgent problems which could be appropriately managed in the outpatient department. The patients’ concept of emergency was incorrect, intending to use the ED as a shortcut to resolve trivial problems.
FIGURE 2.
Length of time until avoidable revisit.
4. The patient presented repeatedly with problems due to chronic illnesses which would be more appropriately cared for in a convalescent hospital. This is basically a health care system problem which is responsible for the patient returning.
nosed cases to see if any improvement could avoid a repetition. We were focusing on some crucial procedures including complete physical examination, complete neurologic examination, white blood cell count, electrolyte concentration, electrocardiogram, blood sugar, chest x-ray and routine urinalysis.
5. The patient presented atypical manifestations or the diagnosis was considered difficult to make by using standard medical knowledge and laboratory examination. This resulted in a wrong diagnosis and the patient revisiting for the same problems.
The patient should have been admitted but received treatment in the observation room due to no bed available; or the wrong drugs or treatment were given.
6. The patients were treated appropriately during the initial visit but returned to the ED because of an unpredictable side effect of treatment. 7. Other: the patient’s situation could not be classified into the above categories.
Reasons for Avoidable Revisit 1. A chart review revealed wrong. We retrospectively
that the diagnosis was discussed the misdiag-
The patient left without adequate discharge instructions from the nurses or doctors. The patient did not take medications physician’s prescription.
according to the
This study was conducted between August 1, 1990 and February 28, 1991. There were 1,099 revisits within 7 days of their initial discharge from the ED. The total patient number was 22,471 during this same period.
RESULTS During the study period, the revisit rate was 4.9% (1,099/ 22,471). Of the 1,099 revisits, 889 (80.9%) were related to the initial visits. Of the 889 related return patient visits, 856 (%.3%) were unscheduled and 33 (3.7%) were scheduled. Among unscheduled revisits, only 70 (8.2%) were avoidable and 786 (91.8%) were unavoidable. Of the 70 avoidable revisits, 32 (45.7%) returned within 24 hours, 22 (31.4%) between 24 and 48 hours, 11(15.7%) between 48 and 72 hours, and only live (7.1%) after 72 hours (Figure 2). Table 1 shows the classification of avoidable revisits in terms of discipline. The chief complaints implicated most often in the avoidable revisits are shown in Table 2, and the final diagnoses of avoidable revisits are shown in Table 3. Of the 70 avoidable revisits, medical deficiencies including
AMERICAN
388
TABLE 1.
Classification
of Avoidable
Body System
JOURNAL
Revisits
TABLE 3. No. (%)
Gastrointestinal General surgery Cardiovascular Chest medicine Neurology Genitourinary Infection Metabolism Ear, nose, throat Oncology Total
19 15 10 8 5 4 3 3 2 1 70
(27.1%) (21.4%) (14.3%) (11.4%) (7.1%) (5.7%) (4.3%) (4.3%) (2.9%) (1.4%)
diagnosis and treatment accounted for 34 (48.6%) and 32 (45.7%), respectively (Table 4). The other two reasons were patient education, three (4.3%); and patient compliance, one (1.4%). When analyzing avoidable revisits in view of the diagnostic deficiencies, we saw that physical examination, white cell count determination, and chest x-ray still play an important role in avoiding the recurrence of visit (Table 5). Of the 786 unavoidable revisits, reasons for return were classified into the following seven groupings; the disease itself, 622 (79.1%); nonmedical factors, 58 (7.4%); personality factors, 55 (7.0%); against medical advice or left without being seen, 24 (3.1%); difficult to diagnose, 20 (2.5%); complications, four (0.5%) and others, three (0.4%). The leading 10 diseases causing unavoidable revisits were: chronic obstructive pulmonary disease (10.7%), benign prostate hypertrophy (6.7%), urolithiasis (6.6%), bronchial asthma (4.5%), coronary artery disease (A) (4.3%), cerebral vascular accident (4.1%), carcinoma of lung (3.4%), peptic ulcer (2.7%), upper gastrointestinal bleeding (2.7%), and congestive heart failure (2.5%). DlSCUSSlDN Due to the soaring number of patients presenting to the ED, assuring a high level of quality care has become increasingly important in the administrative management of emergency medicine.15*16 It is generally blamed on poor quality of service when patients return to the ED shortly after being treated.” Establishing a policy of chart audits to review return-visit patients’ emergency records to find and correct TABLE 2.
High-Risk
Avoidable
Chief Complaint Fever Abdominal pain Chest pain Stomache Nausea, vomiting Dizziness Shortness of breath Tarry stool Weakness Hematemesis Acid regurgitation Others Total
OF EMERGENCY
Revisits No. (%) 10 10 8 7 5 5 5 3 2 2 2 11 70
(14.3%) (14.3%) (11.4%) (10%) (7.1%) (7.1%) (7.1%) (4.3%) (2.9%) (2.9%) (2.9%) (15.7%)
MEDICINE
Final Diagnosis
n Volume
10, Number
of Avoidable
4 n July 1992
Revisits
Diagnosis Congestive heart failure Pneumonia Acute cholecystitis Intestinal obstruction Urinary tract infection Acute myocardial infarction Chronic obstructive pulmonary Gallstone Carcinoma of stomach Acute pancreatitis Coronary artery disease Cerebral vascular accident Diabetes mellitus Cirrhosis of liver Prepylorus obstruction Perforation of peptic ulcer Upper gastrointestinal bleeding Others Total
No. (%) 5 4 4 4 4 3 3 3 3 2 2 2 2 2 2 2 2 21 70
disease
(7.1%) (5.7%) (5.7%) (5.7%) (5.7%) (4.3%) (4.3%) (4.3%) (4.3%) (2.9%) (2.9%) (2.9%) (2.9%) (2.9%) (2.9%) (2.9%) (2.9%) (30.0%)
medical deficiencies is becoming more popular with ED directors. 13,i4 Previous studies chiefly focused on the time between two visits, the discipline of the high-risk revisit, and the etiologic analysis of patients’ revisits. Correlating chief complaints and the factors inducing revisits along with how to avoid the problem are the real answers we are concerned about. In the study by Keith et al, l3 of the avoidable revisits, 80% returned within 48 hours. Keith and colleagues suggested that using a computer to monitor 48-hour unscheduled return patient visits would be an efficient QA tool. Our study, however, showed that 90% of avoidable revisits returned within 72 hours. I recommend a computer protocol set up to recognize patient revisits within 3 days to be appropriate. The key point in discussing the avoidable revisit is to identify the high-risk patient. We found that most (76%) of our avoidable revisit patients had complaints relating to gastroenterology, general surgery, cardiovascular, and chest medicine. Likewise, patients with chief complaints of fever, abdominal pain, chest pain, stomach ache, nausea, vomiting, dizziness, and shortness of breath should be carefully examined because they accounted for a 71.3% of avoidable revisits. This was different from Keith and colleagues’ study, who specified that toxicologic, cardiovascular, psychiatric, trauma, metabolic, and neurologic patients represented a high-yield population for revisit.13 The variant statistical method accounts for these two different results in regard to the high-risk discipline. The method they used was the ratio of avoidable cases to the unscheduled cases on the basis of TABLE 4.
Deficiency
Analysis
Deficiency Treatment Diagnosis Patient education Patient compliance Total
of Avoidable
Revisits No. (%) 34 32 3 1 70
(48.8%) (45.7%) (4.3%) (1.4%)
SHENG-CHUAN HU n REVISITS TO THE EMERGENCY DEPARTMENT
TABLE5.
369
Diagnostic Deficiency by Classification of Body System
Classification Gastrointestinal General surgery Infection Cardiovascular Chest medicine Genitourinary Neurology Oncology Total ABBREVIATIONS: WBC,
Physical Examination 4 6 2 0 0 0 0
13
WBC Count 6 5 0 1 2 1 0 1 16
Chest X-ray
Neurologic Examination
Urine Routine
3 1 0 0 1 0 0 0 5
1 0 0 0 0 0 0 0 1
0 0 1 0 0 0 0 0 1
ECG
Electrolyte
white blood cell; ECG, electrocardiogram.
the same discipline. The final diagnosis often seen in our avoidable revisit patients were congestive heart failure, pneumonia, acute cholecystitis, intestinal obstruction, and urinary tract infection. All the above patients should have been admitted. They were treated, unfortunately, in the observation room, due to the shortage of in-hospital beds, and discharged prematurely after partial treatment due to overcrowding of the ED. In an etiologic analysis of 70 avoidable revisits (Table 4), 92.8% were caused by medical deficiencies, a result greatly different from previous studies.‘2-‘4 Keith et al reported a 32.3% avoidable return visit rate with almost 40% due to medical deficiencies, 20.8% due to poor patient education, and 36.5% due to poor patient compliance. Pierce et al reported that 18% (921513) of avoidable patient revisits were due to medical deficiency. Among these, 32.6% were due to diagnostic error and 15.2% due to treatment error, compared with our 45.7% and 48.6%, respectively.14 Lerman and Kobernick reported similar results in a study of return visits to the ED in 1987.r2 Although our avoidable revisit rate (8.2%) was much lower than that in western countries (around one third), our percent of revisits due to medical error cases was much greater. This is probably due to culture. Traditionally, Asian people love to take any kind of drugs. Therefore, the incidence of poor patient compliance is quite low, resulting in a low avoidable revisit rate. On the other hand, the higher medical deficiency rate in our study in part resulted from premature discharge of the patients. Patients were primarily discharged early to alleviate the severe overcrowding, which unavoidably decreases the quality of care. For the sake of space and gurney availability for further incoming emergency patients, the attending physicians discharged patients home despite their not being completely stabilized, leading to increased return visits. A careful analysis suggested that if we had performed a thorough physical examination and paid more attention to the data of white blood cell count and chest x-ray findings, a large portion of revisits could have been avoided. These details have been taught us since internship, but neglected. From now on, we will try not to ignore these aspects. Comparing the reasons for unavoidable revisits between our study and that of Pierce et al, the disease itself was the cause 79% and 31% of the time, respectively. It is the main factor, making patient revisit unavoidable, which I believe is common around the world. The leading 10 diseases causing unavoidable revisits could explain why so many patients re-
visited unavoidably. Because our ED served mainly the elderly, many of our revisiting patients had chronic and incurable diseases, with characteristically repeated attacks. Therefore, their revisits could be attributed to either progression of diseases or recurrence of disease, especially for those patients with urolithiasis, bronchial asthma, coronary artery disease, cerebrovascular accident, upper gastrointestinal bleeding, and congestive heart failure. Patients with chronic obstructive pulmonary disease also merit mention here. Some patients’ dyspnea was brought under control soon after seeing a doctor, but reattacked after leaving the ED. This is what we called “discharge syndrome.” Possibly psychological factors played a role in their repeatedly visiting the ED with symptom of shortness of breath. Dr Stehr et al reported this phenomenon in 1991.” Patients with benign prostate hypertrophy presented to the ED with acute urine retention. They were discharged after inserting a Foley catheter, which frequently leaked or had an obstruction, prompting them to return to the ED often. Another reason for unavoidable revisits, unique to our country, is the health care system. We lack enough necessary convalescent hospitals, causing numerous single, lonely patients to present to the ED with almost the same chronic problem. Statistical data from Graff and Rusnak et al revealed that a senior physician could provide better service in the ED and lessen the chance of patient revisits.“.20 One of the drawbacks of our study was that we did not do an analysis based on physician seniority. Additionally, due to the shortage of manpower, we did not conduct a control study to compare an equivalent number of nonrevisit patients, another weakness. Several other limitations to our study warrant comment. Our charts were not reviewed by three or more attending physicians working independently of one another. In the evaluation of the revisit, this may have introduced a degree of subjective bias despite the fact that our two reviewers tried to judge the reasons for patient return objectively. Fear of the possibility of visiting another ED shortly after being seen in our ED could have influenced the accuracy of our study. We believe this number was small because a majority of our patients were military veterans who must visit our ED due to economic reasons. CONCLUSION In conclusion, setting a chart audit policy and using a computer to monitor 72-hour revisiting patients in a busy ED is
370
AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 10, Number 4 n July 1992
a feasible way, and an important
QA activity, to improve the quality of service in the ED. In addition, although substantive conclusion cannot be made in view of the unique character of our ED and therefore our data, some suggestions are offered to prevent avoidable unscheduled revisits. (1) Highrisk patients, such as patients with a chief complaint of fever, abdominal pain, chest pain, stomach ache, nausea, vomiting, dizziness, and shortness of breath should be examined carefully to avoid missed diagnoses and revisits. (2) A complete physical examination, white blood cell count, and chest x-ray examination are still crucial. Avoidable revisits will markedly decline if the doctor in charge pays attention to these examinations and values their results. Because our case number is limited, further studies are warranted. (3) A convalescent hospital must be established in this country. The author thanks Wen-Tai Zan for kindly designing the computer program.
REFERENCES 1. Lynn SG, Margulies JL: Emergency care in the U.S. facing major crisis. Am Coll Emerg Physicians News 1989;8:2-3 2. Lynn SG, Hockberger RS, Kellermann A, et al: A Report From the American College of Emergency Physicians Task Force on Hospital Overcrowding and Emergency Department Overload. Dallas, TX. American College of Emergency Physi. cians, September 1989 3. Lynn SG, Kellermann AL: Critical decision making: Managing the emergency department in an overcrowded hospital. Ann Emerg Med 1991;20:287-292 4. American College of Emergency Physicians: Hospital and emergency department overcrowding. Ann Emerg Med 1990;19: 336 5. Hu SC: Clinical and demographic characteristics of 13,911 medical emergency patients. J Formosan Med Assoc 1991;90:675-680
6. Tresch DD: Atypical presentations of cardiovascular disorders in the elderly. Geriatrics 1987;42:31-46 7. Decker-t J, Ham R: Cardiovascular disease in the elderly: Diagnostic dilemmas. Geriatrics 1983;38:49-58 8. Fox RA: Atypical presentation of geriatric infections. Geriatrics 1988;43:58-68 9. O’dell C: Atypical presentations of neurological illness in the elderly. Geriatrics 1988;43:35-37 10. Gambert SR, Escher JE: Atypical presentation of endocrine disorders in the elderly. Geriatrics 1988;43:69-78 11. Gupta KL, Dworkin B, Gambert SR: Common nutritional disorders in the elderly: Atypical manifestations. Geriatrics 1988;43:87-97 12. Lerman B, Kobernick MS: Return visits to the emergency department. J Emerg Med 1987;5:359-362 13. Keith KD, Bocka JJ, Kobernick MS, et al: Emergency department revisits. Ann Emerg Med 1989;18:964-968 14. Pierce JM, Kellerman AL, Oster C: “Bounces”: An analysis of short-term return visit to a public hospital emergency department. Ann Emerg Med 1990;19:752-757 15. Flint LS, Hammett WH, Martens K: Quality assurance in the emergency department. Ann Emerg Med 1985;14:134-138 16. Whitcomb JE, Stueven H, Tonsfeldt D, et al: Quality assurance in the emergency department. Ann Emerg Med 1985;14: 1199-l 204 17. Rogers JT: Risk Management in Emergency Medicine. Dallas, TX, American College of Emergency Physicians, 1985, pp 7-8 18. Stehr DE, Klein BJ, Murata GH: Emergency department return visits in chronic obstructive pulmonary disease: The importance of psychosocial factors. Ann Emerg Med 1991;20: 1113-1116 19. Graff L, Mucci D, Radford MJ: Decision to hospitalize: Objective diagnosis-related group criteria versus clinical judgment. Ann Emerg Med 1988;17:943-952 20. Rusnak RA, Stair TO, Hansen K, et al: Litigation against the emergency physician: Common features in cases of missed myocardial infarction. Ann Emerg Med 1989;18:1029-1034
Notes
Analysisof PatientRevisits to the Emergency Department SHENG-CHUAN
HU, MD
Nowadays, overcrowding in the emergency department (ED) is a high priority issue, and is common in most famous and large hospitals in the United States like New York, San Francisco, and Los Angeles,‘** influencing the quality of care available to emergency patients.3*4 Because emergency physicians and nurses are called on to provide ongoing inpatient and intensive care service in the ED, in addition to their responsibility to other emergency patients, emergency efficiency is considerably decreased. Our previous study showed that patients staying overnight in the observation room amounted to more than 100 on average per day. Among these, 30 to 60 were waiting for admission.’ This overwhelming patient load would be expected to decrease our quality of care. Quality assurance (QA) activity then becomes a necessary procedure to improve and maintain service at a high level. Auditing patients who return early to the ED is one of the newly developed and very important QA activities. Although our ED provides emergency care to all in need, regardless of their ability to pay, our main users are elderly veterans, a large number of whom are single and live alone. Elderly patients suffering from cardiovascular disease, infectious disease, neurologic, or endocrinologic disorders often present with atypical or trivial manifestations which may result in a misdiagnosis or early release from the ED, prompting a revisit to the ED shortly after being discharged.6-” The reasons for these revisits, such as inadequate medical care, disease type, personality differences, inadequate discharge instructions, or a failure of the medical care system, are issues of interest for many investigators.‘2M’4 The purpose of this study is to identify the reasons prompting the early ED revisit. We are particularly interested in answering the questions. What are the primary chief complaints? Which physical or laboratory examinations are
From the Division of Emergency Medicine, Emergency Department, Veterans General Hospital-Taipei, Yung Ming Medical College, Taipei, Taiwan, Republic of China. Manuscript received November 19, 1991; revision accepted January 29, 1992. This study was sponsored by Veterans General HospitalNational Tsin Hwa University Joint Research Program-ROC (VGHTH-80-039-1). Address reprint requests to Dr Hu, Chief, Emergency Medicine, Veterans General Hospital-Taipei, 201, Set 2, Shih-Pai Rd, Shih-Pai, Taipei, Taiwan, Republic of China. Copyright 0 1992 by W.B. Saunders Company 0735-8757/92/l 004-0022$500/O 366
crucial to avoid revisits? We are hoping to provide better emergency care by targeting these factors and strengthening on-the-job training to all ED staff members. Recently, two papers have talked about ED revisits,‘3,‘4 mainly regarding the length of time elapsed before the return visit and the factors accounting for the return visit. This study was undertaken in a different way, oriented by the chief complaint, past history, and laboratory or physical examination, to identify the crucial factors needing correction to avoid revisits. These issues have never been addressed in the literature previously. We conducted this study to find high-risk patients, or pitfalls in the ED, to allow us to improve the quality of care in the ED. MATERIALSAND METHODS Veterans General Hospital-Taipei (Taiwan) is a busy teaching hospital with 2,700 in-hospital beds and a busy ED handling 92,126 patient visits in 1990. The ED is staffed by full-time emergency physicians and rotating senior residents from the department of internal medicine, chest medicine, neurology, surgery, and orthopedics. Basically, residents primarily see all the patients and are supervised by attending physicians. They have the authority to sign out any patient if they have confidence in their management. Upon arrival at ED, patients were initially triaged by trained nurses and then taken to registration. Clerks keyed in each patient’s name, sex, and age, producing “sticker” marked with the patient’s general data. Patients presenting to ED twice within a 7-day period were identified by the computer with a “dollar” sign on the “sticker”, a sign easily recognized by a research assistant. While these patients were being examined, incharge residents completed the registration forms. A research assistant then collected all the patient records and transferred all necessary data to a special chart. Upon completion, all material was given to two ED attending physicians to determine the cause for the revisit. The same physicians reviewed all charts. All data were entered into a personal computer and later analyzed by computer. Data collected included the following assessment and management information: chief complaint, body system, routine laboratory examination (for example, blood and urine routine, chest x-ray, blood sugar, and electrolyte), arrival time, discharge time, and final diagnosis. Compliance with physician instructions and taking medications as well as the frequency of discharge instructions provided by the nurse were also recorded on the special chart. These special charts were then reviewed to determine whether the initial
SHENG-CHUAN
HU n REVISITS
TO THE EMERGENCY
367
DEPARTMENT
visit and revisit were for related problems and whether the revisit was scheduled or unscheduled, avoidable or unavoidable. In any case of revisit, the actual reason was listed. For the sake of convenience, we designed an algorithm (Figure 1) which was completed by two attending physicians working independently of each other and reviewed for agreement regarding the reason for revisit. If no agreement was noted, the case was discussed in the monthly held mortality and morbidity conference and a consensus was reached. The detinitions of the reasons for revisit as outlined on the algorithm were as follows:
Reasons for Unavoidable Revisit 1. The patient was seen by a physician and left the ED against medical advice or the patient was registered in the ED but left before being seen by a physician.
8hrs-72hrs
24hrs-48hrs
2. The patient received appropriate emergency medical care, but either the evolution of the disease, progression of disease, or recurrent disease, which were deemed unavoidable, prompted the patient to return. with the same or similar 3. The patient presented nonurgent problems which could be appropriately managed in the outpatient department. The patients’ concept of emergency was incorrect, intending to use the ED as a shortcut to resolve trivial problems.
FIGURE 2.
Length of time until avoidable revisit.
4. The patient presented repeatedly with problems due to chronic illnesses which would be more appropriately cared for in a convalescent hospital. This is basically a health care system problem which is responsible for the patient returning.
nosed cases to see if any improvement could avoid a repetition. We were focusing on some crucial procedures including complete physical examination, complete neurologic examination, white blood cell count, electrolyte concentration, electrocardiogram, blood sugar, chest x-ray and routine urinalysis.
5. The patient presented atypical manifestations or the diagnosis was considered difficult to make by using standard medical knowledge and laboratory examination. This resulted in a wrong diagnosis and the patient revisiting for the same problems.
The patient should have been admitted but received treatment in the observation room due to no bed available; or the wrong drugs or treatment were given.
6. The patients were treated appropriately during the initial visit but returned to the ED because of an unpredictable side effect of treatment. 7. Other: the patient’s situation could not be classified into the above categories.
Reasons for Avoidable Revisit 1. A chart review revealed wrong. We retrospectively
that the diagnosis was discussed the misdiag-
The patient left without adequate discharge instructions from the nurses or doctors. The patient did not take medications physician’s prescription.
according to the
This study was conducted between August 1, 1990 and February 28, 1991. There were 1,099 revisits within 7 days of their initial discharge from the ED. The total patient number was 22,471 during this same period.
RESULTS During the study period, the revisit rate was 4.9% (1,099/ 22,471). Of the 1,099 revisits, 889 (80.9%) were related to the initial visits. Of the 889 related return patient visits, 856 (%.3%) were unscheduled and 33 (3.7%) were scheduled. Among unscheduled revisits, only 70 (8.2%) were avoidable and 786 (91.8%) were unavoidable. Of the 70 avoidable revisits, 32 (45.7%) returned within 24 hours, 22 (31.4%) between 24 and 48 hours, 11(15.7%) between 48 and 72 hours, and only live (7.1%) after 72 hours (Figure 2). Table 1 shows the classification of avoidable revisits in terms of discipline. The chief complaints implicated most often in the avoidable revisits are shown in Table 2, and the final diagnoses of avoidable revisits are shown in Table 3. Of the 70 avoidable revisits, medical deficiencies including
AMERICAN
388
TABLE 1.
Classification
of Avoidable
Body System
JOURNAL
Revisits
TABLE 3. No. (%)
Gastrointestinal General surgery Cardiovascular Chest medicine Neurology Genitourinary Infection Metabolism Ear, nose, throat Oncology Total
19 15 10 8 5 4 3 3 2 1 70
(27.1%) (21.4%) (14.3%) (11.4%) (7.1%) (5.7%) (4.3%) (4.3%) (2.9%) (1.4%)
diagnosis and treatment accounted for 34 (48.6%) and 32 (45.7%), respectively (Table 4). The other two reasons were patient education, three (4.3%); and patient compliance, one (1.4%). When analyzing avoidable revisits in view of the diagnostic deficiencies, we saw that physical examination, white cell count determination, and chest x-ray still play an important role in avoiding the recurrence of visit (Table 5). Of the 786 unavoidable revisits, reasons for return were classified into the following seven groupings; the disease itself, 622 (79.1%); nonmedical factors, 58 (7.4%); personality factors, 55 (7.0%); against medical advice or left without being seen, 24 (3.1%); difficult to diagnose, 20 (2.5%); complications, four (0.5%) and others, three (0.4%). The leading 10 diseases causing unavoidable revisits were: chronic obstructive pulmonary disease (10.7%), benign prostate hypertrophy (6.7%), urolithiasis (6.6%), bronchial asthma (4.5%), coronary artery disease (A) (4.3%), cerebral vascular accident (4.1%), carcinoma of lung (3.4%), peptic ulcer (2.7%), upper gastrointestinal bleeding (2.7%), and congestive heart failure (2.5%). DlSCUSSlDN Due to the soaring number of patients presenting to the ED, assuring a high level of quality care has become increasingly important in the administrative management of emergency medicine.15*16 It is generally blamed on poor quality of service when patients return to the ED shortly after being treated.” Establishing a policy of chart audits to review return-visit patients’ emergency records to find and correct TABLE 2.
High-Risk
Avoidable
Chief Complaint Fever Abdominal pain Chest pain Stomache Nausea, vomiting Dizziness Shortness of breath Tarry stool Weakness Hematemesis Acid regurgitation Others Total
OF EMERGENCY
Revisits No. (%) 10 10 8 7 5 5 5 3 2 2 2 11 70
(14.3%) (14.3%) (11.4%) (10%) (7.1%) (7.1%) (7.1%) (4.3%) (2.9%) (2.9%) (2.9%) (15.7%)
MEDICINE
Final Diagnosis
n Volume
10, Number
of Avoidable
4 n July 1992
Revisits
Diagnosis Congestive heart failure Pneumonia Acute cholecystitis Intestinal obstruction Urinary tract infection Acute myocardial infarction Chronic obstructive pulmonary Gallstone Carcinoma of stomach Acute pancreatitis Coronary artery disease Cerebral vascular accident Diabetes mellitus Cirrhosis of liver Prepylorus obstruction Perforation of peptic ulcer Upper gastrointestinal bleeding Others Total
No. (%) 5 4 4 4 4 3 3 3 3 2 2 2 2 2 2 2 2 21 70
disease
(7.1%) (5.7%) (5.7%) (5.7%) (5.7%) (4.3%) (4.3%) (4.3%) (4.3%) (2.9%) (2.9%) (2.9%) (2.9%) (2.9%) (2.9%) (2.9%) (2.9%) (30.0%)
medical deficiencies is becoming more popular with ED directors. 13,i4 Previous studies chiefly focused on the time between two visits, the discipline of the high-risk revisit, and the etiologic analysis of patients’ revisits. Correlating chief complaints and the factors inducing revisits along with how to avoid the problem are the real answers we are concerned about. In the study by Keith et al, l3 of the avoidable revisits, 80% returned within 48 hours. Keith and colleagues suggested that using a computer to monitor 48-hour unscheduled return patient visits would be an efficient QA tool. Our study, however, showed that 90% of avoidable revisits returned within 72 hours. I recommend a computer protocol set up to recognize patient revisits within 3 days to be appropriate. The key point in discussing the avoidable revisit is to identify the high-risk patient. We found that most (76%) of our avoidable revisit patients had complaints relating to gastroenterology, general surgery, cardiovascular, and chest medicine. Likewise, patients with chief complaints of fever, abdominal pain, chest pain, stomach ache, nausea, vomiting, dizziness, and shortness of breath should be carefully examined because they accounted for a 71.3% of avoidable revisits. This was different from Keith and colleagues’ study, who specified that toxicologic, cardiovascular, psychiatric, trauma, metabolic, and neurologic patients represented a high-yield population for revisit.13 The variant statistical method accounts for these two different results in regard to the high-risk discipline. The method they used was the ratio of avoidable cases to the unscheduled cases on the basis of TABLE 4.
Deficiency
Analysis
Deficiency Treatment Diagnosis Patient education Patient compliance Total
of Avoidable
Revisits No. (%) 34 32 3 1 70
(48.8%) (45.7%) (4.3%) (1.4%)
SHENG-CHUAN HU n REVISITS TO THE EMERGENCY DEPARTMENT
TABLE5.
369
Diagnostic Deficiency by Classification of Body System
Classification Gastrointestinal General surgery Infection Cardiovascular Chest medicine Genitourinary Neurology Oncology Total ABBREVIATIONS: WBC,
Physical Examination 4 6 2 0 0 0 0
13
WBC Count 6 5 0 1 2 1 0 1 16
Chest X-ray
Neurologic Examination
Urine Routine
3 1 0 0 1 0 0 0 5
1 0 0 0 0 0 0 0 1
0 0 1 0 0 0 0 0 1
ECG
Electrolyte
white blood cell; ECG, electrocardiogram.
the same discipline. The final diagnosis often seen in our avoidable revisit patients were congestive heart failure, pneumonia, acute cholecystitis, intestinal obstruction, and urinary tract infection. All the above patients should have been admitted. They were treated, unfortunately, in the observation room, due to the shortage of in-hospital beds, and discharged prematurely after partial treatment due to overcrowding of the ED. In an etiologic analysis of 70 avoidable revisits (Table 4), 92.8% were caused by medical deficiencies, a result greatly different from previous studies.‘2-‘4 Keith et al reported a 32.3% avoidable return visit rate with almost 40% due to medical deficiencies, 20.8% due to poor patient education, and 36.5% due to poor patient compliance. Pierce et al reported that 18% (921513) of avoidable patient revisits were due to medical deficiency. Among these, 32.6% were due to diagnostic error and 15.2% due to treatment error, compared with our 45.7% and 48.6%, respectively.14 Lerman and Kobernick reported similar results in a study of return visits to the ED in 1987.r2 Although our avoidable revisit rate (8.2%) was much lower than that in western countries (around one third), our percent of revisits due to medical error cases was much greater. This is probably due to culture. Traditionally, Asian people love to take any kind of drugs. Therefore, the incidence of poor patient compliance is quite low, resulting in a low avoidable revisit rate. On the other hand, the higher medical deficiency rate in our study in part resulted from premature discharge of the patients. Patients were primarily discharged early to alleviate the severe overcrowding, which unavoidably decreases the quality of care. For the sake of space and gurney availability for further incoming emergency patients, the attending physicians discharged patients home despite their not being completely stabilized, leading to increased return visits. A careful analysis suggested that if we had performed a thorough physical examination and paid more attention to the data of white blood cell count and chest x-ray findings, a large portion of revisits could have been avoided. These details have been taught us since internship, but neglected. From now on, we will try not to ignore these aspects. Comparing the reasons for unavoidable revisits between our study and that of Pierce et al, the disease itself was the cause 79% and 31% of the time, respectively. It is the main factor, making patient revisit unavoidable, which I believe is common around the world. The leading 10 diseases causing unavoidable revisits could explain why so many patients re-
visited unavoidably. Because our ED served mainly the elderly, many of our revisiting patients had chronic and incurable diseases, with characteristically repeated attacks. Therefore, their revisits could be attributed to either progression of diseases or recurrence of disease, especially for those patients with urolithiasis, bronchial asthma, coronary artery disease, cerebrovascular accident, upper gastrointestinal bleeding, and congestive heart failure. Patients with chronic obstructive pulmonary disease also merit mention here. Some patients’ dyspnea was brought under control soon after seeing a doctor, but reattacked after leaving the ED. This is what we called “discharge syndrome.” Possibly psychological factors played a role in their repeatedly visiting the ED with symptom of shortness of breath. Dr Stehr et al reported this phenomenon in 1991.” Patients with benign prostate hypertrophy presented to the ED with acute urine retention. They were discharged after inserting a Foley catheter, which frequently leaked or had an obstruction, prompting them to return to the ED often. Another reason for unavoidable revisits, unique to our country, is the health care system. We lack enough necessary convalescent hospitals, causing numerous single, lonely patients to present to the ED with almost the same chronic problem. Statistical data from Graff and Rusnak et al revealed that a senior physician could provide better service in the ED and lessen the chance of patient revisits.“.20 One of the drawbacks of our study was that we did not do an analysis based on physician seniority. Additionally, due to the shortage of manpower, we did not conduct a control study to compare an equivalent number of nonrevisit patients, another weakness. Several other limitations to our study warrant comment. Our charts were not reviewed by three or more attending physicians working independently of one another. In the evaluation of the revisit, this may have introduced a degree of subjective bias despite the fact that our two reviewers tried to judge the reasons for patient return objectively. Fear of the possibility of visiting another ED shortly after being seen in our ED could have influenced the accuracy of our study. We believe this number was small because a majority of our patients were military veterans who must visit our ED due to economic reasons. CONCLUSION In conclusion, setting a chart audit policy and using a computer to monitor 72-hour revisiting patients in a busy ED is
370
AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 10, Number 4 n July 1992
a feasible way, and an important
QA activity, to improve the quality of service in the ED. In addition, although substantive conclusion cannot be made in view of the unique character of our ED and therefore our data, some suggestions are offered to prevent avoidable unscheduled revisits. (1) Highrisk patients, such as patients with a chief complaint of fever, abdominal pain, chest pain, stomach ache, nausea, vomiting, dizziness, and shortness of breath should be examined carefully to avoid missed diagnoses and revisits. (2) A complete physical examination, white blood cell count, and chest x-ray examination are still crucial. Avoidable revisits will markedly decline if the doctor in charge pays attention to these examinations and values their results. Because our case number is limited, further studies are warranted. (3) A convalescent hospital must be established in this country. The author thanks Wen-Tai Zan for kindly designing the computer program.
REFERENCES 1. Lynn SG, Margulies JL: Emergency care in the U.S. facing major crisis. Am Coll Emerg Physicians News 1989;8:2-3 2. Lynn SG, Hockberger RS, Kellermann A, et al: A Report From the American College of Emergency Physicians Task Force on Hospital Overcrowding and Emergency Department Overload. Dallas, TX. American College of Emergency Physi. cians, September 1989 3. Lynn SG, Kellermann AL: Critical decision making: Managing the emergency department in an overcrowded hospital. Ann Emerg Med 1991;20:287-292 4. American College of Emergency Physicians: Hospital and emergency department overcrowding. Ann Emerg Med 1990;19: 336 5. Hu SC: Clinical and demographic characteristics of 13,911 medical emergency patients. J Formosan Med Assoc 1991;90:675-680
6. Tresch DD: Atypical presentations of cardiovascular disorders in the elderly. Geriatrics 1987;42:31-46 7. Decker-t J, Ham R: Cardiovascular disease in the elderly: Diagnostic dilemmas. Geriatrics 1983;38:49-58 8. Fox RA: Atypical presentation of geriatric infections. Geriatrics 1988;43:58-68 9. O’dell C: Atypical presentations of neurological illness in the elderly. Geriatrics 1988;43:35-37 10. Gambert SR, Escher JE: Atypical presentation of endocrine disorders in the elderly. Geriatrics 1988;43:69-78 11. Gupta KL, Dworkin B, Gambert SR: Common nutritional disorders in the elderly: Atypical manifestations. Geriatrics 1988;43:87-97 12. Lerman B, Kobernick MS: Return visits to the emergency department. J Emerg Med 1987;5:359-362 13. Keith KD, Bocka JJ, Kobernick MS, et al: Emergency department revisits. Ann Emerg Med 1989;18:964-968 14. Pierce JM, Kellerman AL, Oster C: “Bounces”: An analysis of short-term return visit to a public hospital emergency department. Ann Emerg Med 1990;19:752-757 15. Flint LS, Hammett WH, Martens K: Quality assurance in the emergency department. Ann Emerg Med 1985;14:134-138 16. Whitcomb JE, Stueven H, Tonsfeldt D, et al: Quality assurance in the emergency department. Ann Emerg Med 1985;14: 1199-l 204 17. Rogers JT: Risk Management in Emergency Medicine. Dallas, TX, American College of Emergency Physicians, 1985, pp 7-8 18. Stehr DE, Klein BJ, Murata GH: Emergency department return visits in chronic obstructive pulmonary disease: The importance of psychosocial factors. Ann Emerg Med 1991;20: 1113-1116 19. Graff L, Mucci D, Radford MJ: Decision to hospitalize: Objective diagnosis-related group criteria versus clinical judgment. Ann Emerg Med 1988;17:943-952 20. Rusnak RA, Stair TO, Hansen K, et al: Litigation against the emergency physician: Common features in cases of missed myocardial infarction. Ann Emerg Med 1989;18:1029-1034
