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EARLY REVISIT TO THE EMERGENCY DEPARTMENT: AN INTEGRATIVE REVIEW Authors: Chin-Yen Han, PhD, MSN, RN, Li-Chin Chen, MSN, RN, Alan Barnard, PhD, MA, BA, RN, Chun-Chih Lin, PhD, RN, Ya-Chu Hsiao, EdD, RN, Hsueh-Erh Liu, PhD, RN, and Wen Chang, MSN, RN, Taiwan, Republic of China, Brisbane, Australia
n unscheduled repeat visit by a patient within a short period after discharge from the emergency department is known as an early revisit. The early ED revisit rate is regarded as a quality of care indicator and a tool for improving the quality of care provided to ED patients. 1–4 ED staff who care for patients who make an early revisit are responsible for managing patients’ problems with discretion. Patients who make early ED revisits have increased mortality 5 and are at high risk of medical and legal problems arising from medical errors or patient dissatisfaction. 2 Such problems are particularly likely to occur when the early revisit is the result of medical error, earlier unsatisfactory care, or a serious condition requiring admission to an ICU. 6 Staff need to be aware of the potential legal ramifications of these cases. 2,3 In recent years, the number of initial ED visits has increased in many countries but is heavily reliant on the health care system design and available resources within countries. For example, the number of ED visits in Taiwan was 3 million in 1992 and increased to 12 million in 2012. 7 Taiwan has a medical system that relies less on local medical
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Chin-Yen Han is Assistant Professor, Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan, Republic of China. Li-Chin Chen is Deputy Director, Department of Nursing, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, Republic of China. Alan Barnard is Senior Lecturer, Queensland University of Technology, Brisbane, Australia. Chun-Chih Lin is Assistant Professor, Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan, Republic of China. Ya-Chu Hsiao is Associate Professor, Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan, Republic of China. Hsueh-Erh Liu is Professor, School of Nursing, Chang Gung University, Taoyuan, Taiwan, Republic of China. Wen Chang is Lecturer, Department of Nursing, Chang Gung University of Science and Technology, and Doctoral Student, Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taiwan, Republic of China. For correspondence, write: Wen Chang, MSN, RN, 261, Wen-hwa 1st Road, Kwei-Shan, Taoyuan, Taiwan, Republic of China, 33303; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.11.013
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practitioners in the community than on health care delivery through tertiary institutions. There is enormous pressure on ED departments in Taiwan, and fewer early ED revisits would reduce demand on resources and the associated national expenditure on health care. To date, relevant literature, which includes research findings on the rate and characteristics of early ED revisits and reports of intervention studies designed to reduce early ED revisits, remains widely dispersed. The aim of this integrative review was to provide a comprehensive understanding of this literature, thus providing ED staff with a unique resource for identifying and ameliorating the problems associated with early ED revisits. Methods SEARCH STRATEGY
This integrative review was conducted in accordance with the methodological strategies proposed by Whittemore and Knafl. 8 The search strategy involved using Medline, CINAHL, PubMed, Applied Social Sciences Index and Abstracts, The Cochrane Library, Cochrane Central Register of Controlled Trials, and the Chinese Periodicals Index database from 1987 to 2014. Multiple search terms were used to maximize the scope and depth of the investigation. The following search terms, linked with AND and OR, were used to search each of the databases: “unplanned revisit,” “unscheduled returns,” “return visits,” “early return,” “72-hour returns,” “48-hour returns,” “hospital,” “emergency department,” “emergency room,” and “emergency service.” According to Whittemore and Knafl, the inclusion of diverse data sources, including both empirical and theoretical studies, makes the process of data evaluation in an integrative review more complicated and may provide little value. 8 Therefore, both empirical and theoretical studies were included in the integrative review. All studies that met the inclusion criteria were handled in the same way in the present study. The “related articles” feature was used to search for additional sources. The article for each citation was reviewed manually for possible inclusion. Titles that were found to be unrelated to the literature review were excluded. When the citation could
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Records identified through database searching (n =104)
Additional records identified through other sources (n =59)
Records screened after duplicates removed (n =151)
Articles assessed for eligibility (n = 41)
Abstracts and poster-only articles excluded after search for full articles (n = 6)
All full articles included in synthesis (n = 35)
FIGURE The search strategy used to identify relevant articles relating to unplanned ED revisits (1987-2014).
not be excluded based on the title, the abstract was reviewed. Studies were reviewed in full when the abstract could not be excluded based on the content presented. STUDY SELECTION
The inclusion criteria were as follows: (1) studies that explored the rate and characteristics of early ED revisit; (2) outcomes measurement related to early ED revisit; (3) publications written in English or Chinese; and (4) articles retrieved in full text. Editorials, commentaries, guidelines, opinion pieces, and conference papers were excluded. Results SEARCH RESULTS
An initial search of the literature produced 151 articles for potential inclusion in the study. Of these 151 articles, 41 abstracts met the inclusion criteria. Full texts of 35 articles were retrieved for further evaluation in this review (Figure). In 23 reviewed articles, the rate and patient characteristics of unplanned ED revisits were discussed. The methods used to
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investigate the rate and characteristics of unplanned ED revisits were entered into the Retrospective Chart Review and Statistical Computer System for Emergency Medicine (Table 1). Additionally, 12 research articles were related to intervention studies aiming to reduce the rate of early ED revisits (Table 2). The studies covered in the 35 articles were conducted in Belgium, Canada, Hong Kong, New Zealand, Netherlands, Singapore, Spain, Thailand, Taiwan, and the United States. EARLY ED REVISIT RATE
Interestingly, consistency with regard to what constitutes an early revisit is lacking. Depending on the time frame within which the early revisit occurred (from 48 hours to 90 days) and the particular department involved, reported results ranged from 0.39% to 27%. 1–3,7,9–25 Worldwide, most surveys focused on early ED revisits that occurred within 48 to 72 hours. 2,3,6,9,10,12–14,16–19,21,22,24–27 Using this criterion, an early US study found that the rate of early ED revisit was 3.96%. 3 In New Zealand, the rate of early ED revisit within 7 days was 2%, 18 but in the Netherlands, the rate was based on 7 days and was 5.0%. 21 In Taiwan the
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rate of early ED revisit was calculated within 72 hours and was between 1.9% and 6.19%. 2,9,16,17,25–27 Elderly patients had higher revisit rates. A study found that 16% of elderly patients had an unplanned ED revisit, hospitalization, or death within 30 days, and this rate increased to 27% within 90 days. 11 Studies have also investigated the rate of unplanned revisits to pediatric emergency departments. The reported rates of unplanned pediatric revisits ranged from 1.1% to 6.19% 1,13,14,25 and also lacked consistency about an agreed-upon time frame, but of those revisiting pediatric patients, 60.4% of revisits were within 24 hours. CHARACTERISTICS OF EARLY ED REVISITS
Four categories of precipitating factors that influence early ED revisits were identified: patient-related, illness-related, health care system–related, and other factors. The patientrelated factors that were investigated included gender, age, race, socioeconomic status, insurance status, inability to understand or comply with discharge planning, and misuse of emergency services. Pediatric patients have higher revisit rates as a patient group, and children younger than 5 years were found to have higher rates. 1,13,14,25 Elderly patients with chronic diseases also had higher early revisit rates, with more than 80% being admitted to the ICU after their early revisits. 28 In some countries uninsured patients or those receiving public insurance had a higher incidence of ED repeated use. 28 Illness-related factors include the worsening of an existing condition, acute exacerbation of a chronic condition, complications arising from disease, and new health problems. Patients with respiratory, gastrointestinal, and infectious diseases have higher revisit rates. 10 Common complaints and symptoms exhibited by revisit patients on their first visit to the emergency department are fever, abdominal pain, or pain in other parts of the body. 26 Persistent diseases or symptoms and progressive conditions also contributed to early revisits. 29 Nontrauma patients had higher revisit rates and shorter stays at the first ED visit than did trauma patients. 27 Two types of health care system–related factors were identified: staff related and hospital related. Misdiagnosis, malpractice, inadequate communication between health care providers and patients, and lack of subsequent referral services or continuity of care were identified as major issues. 10,20,22,27 In terms of other factors, studies indicated that when the appropriateness of emergency service use was examined from the perspective of emergency care workers, many early revisits were seen to be unnecessary. A significant proportion of all early ED revisits (57% to 72%) were categorized as nonurgent. 30,31 Clearly many
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countries have a culture of use of the emergency department for nonurgent problems, or patients were unwilling to return to an outpatient department or their local health care provider. 10,20,22,27 ED DISCHARGE PLANNING TO REDUCE THE EARLY REVISIT RATE
Providing patients with comprehensive discharge planning helps reduce the number of early ED revisits and results in better health outcomes for patients. 29,32–40 The emergency department is a multidisciplinary environment, and patients present with multiple diseases. Studies demonstrate that effective discharge planning is a clinical pathway for effective continuing care and smooth transition from hospital to home. 41,42 In Australia, patients discharged from the emergency department are provided with risk screening and discharge planning by specialized community nurses. Their results show a decrease in early ED revisit rates from 21% to 5% and a decrease in the readmission rate from 10.2% to 4.7%. 35 A US study conducted among elderly ED patients who were provided with integrated discharge planning by hospital-based discharge coordinators reported a decrease in the risk of early ED revisits and an increase in patient satisfaction. 43 It would appear that integration of ED discharge education and provision of comprehensive discharge planning improves continuity of care. Patients return home and the early revisit rate is reduced. Studies indicate that one third of early ED revisits can be avoided by comprehensive discharge planning and appropriate medical intervention. 19,22 Twenty-five years ago, investigators found that 32.3% of early ED revisits occurring within 72 hours after discharge could be avoided. 19 Of the avoidable revisits, 40% were the result of some form of insufficient care. 19 Pierce et al 22 concurred, suggesting that ED revisits result from inadequate assessment and management at the first visit to the emergency department and a lack of postdischarge information from the emergency department. A more recent study added that illness-related factors are the number one cause of early ED revisits, accounting for 79.7% of these early revisits. 44 For these patients, early return to the emergency department as a result of unimproved symptoms and new problems emerging after discharge are the central reasons for their behavior. It is suggested that early ED revisit caused by inadequate medical management and misconceptions about the use of emergency resources could be avoided by improving ED discharge planning. 44 Other studies have demonstrated that effective discharge planning can result in fewer admissions and hospital revisits. 35,45 Therefore, early ED revisits could be avoided by improving discharge
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TABLE 1
Summary of the rate and characteristics of unplanned ED revisits by chart review or retrospective study
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Study
Time frame Sample
Sample size Results
Easter and Bachur, 2013 1
96 h
ED pediatric patients
97374
Fan et al, 2005 9
72 h
ED patients
152072
Foran et al, 2010 10
72 h 7d
ED patients
9935
Friedmann et al, 2001 11
30 d, 90 d ED patients aged 65+ y
463
Gordon et al, 1998 12 Goldman et al, 2006 13 Goldman et al, 2011 14
72 h
ED patients
52553
72 h
ED pediatric patients
37725
72 h
ED pediatric patients
47655
Hu, 1992 15 Hu et al, 2012 16
7d 72 h
ED patients ED patients aged N 14 y
22471 13361
Hung et al, 2004 17
72 h
Nontrauma, nonpediatric patients
5423
Imsuwan, 2011 18
48 h
ED patients
33370
Keith et al, 1989 19
72 h
ED patients
13264
1.1% (1091) returned to the emergency department and were admitted; 72% of those were due to progression of disease, 12% to potential deficiency, and 16% to other causes 3.3% revisit rate; 0.076% of those (116/152072) were admitted to the ICU after unplanned ED revisits (116/5064); 80% of those (93/116) were elderly patients 2.9% revisit rate for 72 hours; 4.5% revisit rate for 7 days; the most common CTAS score was CTASIV (45.3%); the most common diagnosis was unspecified abdominal pain (4%); most patients (88.6%) were discharged home 16% and 27% experienced ED revisit, hospitalization, or death within 30 days and 90 days, respectively 2.9% revisit rate; dehydration (15%) was the most common problem 5.2% revisit rate; a quarter of the children who returned were younger than 1 y 4.4% revisit rate; a quarter of the children who returned were younger than 1 y; progression of illness resulting in higher acuity 4.9% revisit rate; 8.2% of revisits were avoidable 3.1% revisit rate; of these patients, 36% were admitted and had a mortality rate of 4.1% 5.8% revisit rate; 14.2% had patient-related factors, 62.1% had illness-related factors, and 23.7% had health care system–related factors; 9.0% (21 cases) had experienced misdiagnosis; abdominal pain was the most common presentation (66.7%, 14/21) 0.92% revisit rate; 8.5% had patient-related factors, 60.6% had illness-related factors, and 28.3% had health care system–related factors 3.4% revisit rate; 32.3% of revisits were avoidable; 39.6% had medical management deficiencies, 14.6% had inappropriate prescribed follow-up, 20.8% had not been given proper education, and 36.5% were related to patient noncompliance continued
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Table 1 Continued Study
Kelly et al, 1993
Time frame Sample 20
7d
Sample size Results
ED patients
Lerman & Kobernick, 72 h 1987 3 72 h Liaw et al, 1999 2
ED patients
64336
ED patients
25526
Martin-Gill and Reiser, 2004 21
72 h
ED patients
104584
Nuñez et al, 2006 6
72 h
ED patients aged N 32523 14 y and nonobstetric gynecological emergencies
Pierce et al, 1990 22
48 h
ED patients
17214
van der Linden et al, 2014 23 Verelst et al, 2014 24
7d
ED patients
49341
72 h
ED patients N 16 y
44574
Wang et al, 2007 25
72 h
ED pediatric patients
9135
Wu et al, 2008 26
72 h
ED patients
34716
Yen et al, 2003 27
72 h
ED patients
5467
2% revisit rate; 27% had patient-related factors, 61% had illness-related factors, and 12% had health care system–related factors 0.39% revisit rate; 32.5% of returns were avoidable 1.9% revisit rate; 79% had illness-related factors, 9.1% had patient-related factors, and 10.5% had health care system–related factors; other 1.4% 0.47% revisit rate; highest risk diagnosis categories: mental disorder, genitourinary system, and symptom-based diagnosis No revisit rate given; the main factor associated with unscheduled returns was error in prognosis (OR 18.62, 95% CI 9.60-36.09); advanced age and a chief complaint of dyspnea were associated with unscheduled returns and admission to the hospital 3.0% revisit rate; 53% had patient-related factors, 25% had illness-related factors, and 22% had health care system–related factors; 19% were admitted 5.0% revisit rate; 49% had illness-related factors and 41% had patient-related factors 2.7% revisit rate; 85.1% of revisits were due to patients’ persistence, 12% to a wrong initial diagnosis, and 2.9% to an adverse event related to the treatment initially received 6.19% revisit rate; reasons for revisit: symptoms not relieved (71%); most common diagnoses were acute respiratory infection (46.9%) and fever (7.4%); admission rate after revisit was 64.1% 5.47% revisit rate; 10.9% had patient-related factors, 80.9% had illness-related factors, and 8.2% had health care system–related factors 3.8% revisit rate; 40.6% had patient-related factors, 30.9% had illness-related factors, and 28.5% had health care system–related factors
CI, Confidence interval; CTAS, Canadian Triage and Acuity Scale; OR, odds ratio.
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TABLE 2
Summary of studies to reduce unplanned ED revisits Study
Time frame
Patient characteristics
Sample size
Intervention
Results
Baker et al, 2009 32
—
Caregivers of children aged 3-36 mo whose chief complaint included fever and no obvious source of fever at triage (nonemergency)
280 (140 intervention group, 140 control group)
Intervention group watched an 11-minute video about home management of fever; control group watched a video about child safety
Cardin & Collet, 2003 46
7d
Patients discharged from the emergency department and from the hospital
Intervention group had significantly improved knowledge and attitudes about childhood fever; no statistical difference between intervention and control groups in return visits No difference in incidence of return visits between the periods before and after implementation of intervention (either emergency department or hospital)
Chande et al, 1996 47
6 mo
Chern et al, 2005 33
3d
Hayes et al, 2012 34
7d
Hegney et al, 2006 35
—
4701 Increased emergency (1935 emergency physician coverage, department, 2766 designation of physician hospital ward) coordinators, and new hospital policies regarding laboratory, consultation, and admission procedures by physicians ED pediatric patients 130 (69 Intervention group received intervention specialized educational group, 61 materials (10-minute control group) videotape on pediatric health care issues and an information booklet); control group received standard pediatric ED discharge instructions High-risk conditions 963 (556 before Feedback to physicians on (including neurologic, intervention, telephone follow-up cardiovascular, pulmonary, 397 after outcomes of ED discharged gastroenteric, infections, intervention) patients and resident intoxication, and abnormal training (about the uncertain laboratory data) presentation of serious diseases and the need to use additional evaluation on selected patients) Adult patients with 4257 (243 To-go medications provided cellulitis, UTI, and intervention (free, full-course antimicrobial dental infections group, 4014 therapy upon ED discharge) control group) N 70 y
2139
Risk-screened (face to face in the emergency department or via telephone) and given community services referrals when necessary by a specialist community nurse
No significant difference in returns to the pediatric emergency department within 6 mo
Decreased return visits from 10.1% to 4.9% and decreased clinically significant adverse events from 4.1% to 1.5%
50% reduction in ED return visits for patients who received to-go medications (2.5% vs 5.9%) ED re-presentation rate decreased 16%
continued
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Table 2 Continued Study
Time frame
Patient characteristics
Sample size
Intervention
Results
Lin et al, 2010 29
72 h
Adults with acute gastroenteritis
940
Unplanned ED revisit rate decreased from 5.38% to 3.3%
McQuaid et al, 2012 36
—
Smokers who were caregivers of a child with asthma
224
ED nurses provided discharge follow-up including telephone interview, patient’s medical condition follow-up, and discharge patient education Asthma education and smoking counseling (3 home visits) by a nurse
Sockrider et al, 2006 37
9 and Children with acute 12 mo asthma symptoms
464 (263 intervention group, 201 control group)
Tsai et al, 2005 38
72 h
Febrile pediatric patients
110
Wong et al, 2004 39
30 d
Patients with fever or a respiratory or gastrointestinal condition
395 intervention group, 400 control group
Woods et al, 2012 40
—
Children with asthma
283 (through ED visits or hospitalizations)
TEDAS pediatric asthma educational intervention used a computer-based resource, follow-up telephone call, and asthma education hotline to provide a customized asthma action plan and educational summary ED nurses provided health education about febrile pediatrics to children’s family, follow-up and consultation by telephone Planned telephone consultations by an experienced ED nurse
Nurse case management (face-to-face visits during hospitalization or through telephone contact) and home visits
12-mo data showed a significant reduction in mean annual ED visits Return ED visits were significantly lower in the intervention group; caregiver self-confidence and well-visit follow-up were significantly effective in the intervention group
Unplanned ED revisit rate decreased from 6.8% to 4.9%
Health outcome and 30-day ED revisits were significantly improved in the intervention group 12-mo data showed a significant decrease in any (≥1) asthma ED visits and hospitalizations
TEDAS, Texas Emergency Department Asthma Surveillance; UTI, urinary tract infection.
planning and providing better education in the emergency department. This knowledge is especially important given that in countries such as Taiwan, huge numbers of persons present to emergency departments on a daily basis. Although discharge planning is seen as an effective way to decrease patient revisits or readmissions, some nonpositive outcomes were also reported. A Canadian study evaluated the effect of interventions to decrease ED
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crowding on the incidence of return revisits to the emergency department or a hospital ward. Interventions included increased ED physician coverage, the designation of physician coordinators, and new hospital policies regarding laboratory, consultation, and admission procedures. 46 Their results showed no difference in the incidence of return visits between the periods before and after implementation of the intervention, either for patients
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discharged from the emergency department (all returns: 11.0% versus 12.4%; unscheduled-related returns: 6.5% versus 5.8%) or the hospital (all returns: 6.8% versus 6.6%; unscheduled-related returns: 4.2% versus 4.0%). The intervention to decrease crowding reduced the mean length of stay for patients discharged from the emergency department from 13.8 to 5.9 hours, without resulting in increased return visits to the emergency department or hospital readmission. 46 Two studies demonstrated that pediatric patients have higher rates of early ED revisits compared with adult patients. 26,38 In Taiwan, the implementation of an education program for pediatric fever management produced a decrease in the 72-hour revisit rate from 6.8% to 4.9%. 26 Another Taiwanese project focused on ED pediatric patients with fever by providing an educational program to the primary caregiver. After implementation of the project, the rate of ED revisits within 72 hours after discharge decreased from 6.81% to 4.9%. 38 It would appear that predischarge education delivered appropriately and at a timely moment can make a difference in revisit rates. However, it is important to note the reasons for use of ED resources. In the US, a prospective, randomized controlled trial involved one-time educational interventions targeting the primary care providers of ED pediatric patients. 47 The results showed no significant difference in returns to the pediatric emergency department within a 6-month period for both the intervention group (30%) and the control group (26%). The study suggested that one-time educational interventions may not alter long-term ED utilization habits because these have more to do with the health care system and the culture of use than with the ability of ED staff to address a patient’s health care concerns at any one time.
hospital. Studies show that telephone follow-up can reduce the revisit or readmission rate and increase patient satisfaction. 29 In Taiwan, for instance, the results of a telephone follow-up project are especially promising because patient re-presentation after discharge from the emergency department has shown a decrease in the revisit rate from 5.38% to 3.3% and an increase in patient satisfaction. 18 A similar study in Hong Kong reported that patients who were interviewed via telephone perceived an improvement in their health and had a lower revisit rate. 39 In the US, a study using pharmacists to make follow-up telephone calls to patients after discharge from the emergency department found that patients had higher satisfaction with discharge instructions and a lower ED revisit rate. During the course of the study, 15 of 756 patients were helped in solving problems associated with their medication. 49 In general, people like to receive attention from others and feel that someone is taking care of them. 29 Telephone follow-up on a patient’s condition after discharge could be a nursing role. After discharge from the hospital, ED patients may still experience physical discomfort requiring further examination and treatment. Through telephone follow-up, a hospital may improve provision of care to patients as a result of nursing follow-up and medical consultation where appropriate to treat people in an extramural environment. Care provided in a timely manner helps alleviate stress and provides safety and support. 29 Telephone follow-up can help discharged patients adapt to their surroundings, remind them of their return visits, and support their successful return to the community. These types of interventions are supported by evidence and are recommended as an effective way to reduce the number of revisits.
FOLLOW-UP AS CONTINUITY OF CARE AFTER ED PATIENT DISCHARGE
Discussion
Continuous follow-up on a patient’s condition after discharge may also result in improved quality of care, reduced revisit rates, and increased patient satisfaction. Failure to provide continuity of care to discharged patients is a likely contributor to early ED revisit or readmission, and subsequent problems could affect patients, family members, and the wider society. 48 For patients, these problems include increased levels of physical and mental stress, as well as financial burdens. For family members, the responsibilities of long-term care could affect their work performance and quality of life. In the broader social context, readmission and early ED revisits increase health care expenditure and impose a financial burden on families and taxpayers. Telephone follow-up has been tested as one way of tracking a patient’s condition after discharge from the
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The Formosa Medical Association suggests that the baseline rate for early ED revisits should be set at 2%, which could be used as an audit filter. 2 The authors of one study recommended that a target rate of below 1% is achievable for early ED revisits within 72 hours and should be adopted to monitor patient care in the emergency department. 2 However, these benchmarks have not been accepted worldwide. 2,3 When the early revisit rate exceeds a certain limit, this may indicate a dysfunctional emergency department. Further investigations are necessary to determine the reasons for an increase in early ED revisit rates within organizations and specific health care systems. Patient-centered care is one of the core goals of emergency care. In one study, ED patients’ and physicians’ views about ED revisits were compared. Research found only 31.4% consistency between physicians’ and patients’
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responses. 50 The current article has explored the rate and characteristics of early revisits. However, it is important to understand the phenomenon of early ED revisits from the patient’s point of view. Further investigation is needed to examine patient perceptions. Many patients with early ED revisits have short stays during the first visit to the emergency department, with 51.6% of these patients staying less than 2 hours. 29 Contact between ED health care staff and ED patients can be very brief. 18 ED staff collect limited information and make decisions under extreme pressure during a patient’s short stay in the emergency department, which results in inadequate preparation for discharge and the likelihood of unresolved health issues. A study found that ED nurses can sometimes perceive discharge planning as “getting rid” of patients or merely completing an administrative task. 51 However, without preparation for discharge and adequate planning for their care after the ED visit, ED patients may not have their discharge needs met and early revisit can occur. Research related to discharge planning has been conducted with hospitalized patients, but only a limited number of studies have investigated the implementation of discharge planning for ED patients, 29,32,35,43,47 and most of these studies focused on groups with high early revisit rates, such as elderly and pediatric patients. The authors suggest that further research is needed to investigate discharge planning programs for different types of problems and to evaluate the relationship between the specific programs and early ED revisit rates. Discharge planning can be an effective strategy that can help patients deal with problems after they return home. It is one of the main ways of ensuring continuity of care within the health care system after patient discharge and is a common means of reducing revisit and readmission rates. 41,42,48 Despite this evidence, discharge planning is not always provided as part of ED care. Emergency medical management focuses on dealing with acute problems. Nonacute issues, such as discharge planning, seem to be ignored by ED health care staff. 28 However, all patients should receive comprehensive discharge planning and follow-up. Research found that the emergency department was not able to provide patients with customized discharge planning, nor were there regulations governing discharge. 51 This apparent lack of coordination and policy may be affecting the ability of ED nursing staff to implement comprehensive care. The characteristics of an ED environment, patient anxiety and irritability, the expectation that problems will be dealt with as soon as possible, stressed staff, and pressure from organizations to reduce the time taken with patients and re-presentation rates have an impact on the effectiveness of comprehensive care. 51 Therefore, a follow-up service after discharge from the emergency department should be
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provided to help patients deal with problems encountered after discharge from the hospital. A follow-up service can not only be a supplement to discharge planning but may also help ensure continuity of care after a patient returns home.
Limitations
This review was based only on articles published in English and Chinese, which may have resulted in selection bias. The oldest article reviewed was published in 1987. Some publications prior to 1985 and unpublished articles may have contained material of relevance but were not included in the search. It is possible that publication bias exists within this area of research, but this did not seem to be a major concern because published studies showed a trend toward publishing all results, including negative and insignificant results.
Conclusion
The early ED revisit rate remains an important issue in emergency care. Reduction of the early ED revisit rate through discharge planning would not only allow health care staff to have more time to assess ED patients but would also provide patients with appropriate medical management and measures to ensure continuity of care at home after discharge. The care provided to the ED patient can be improved, 6,15,19,22 and medical and legal problems can be reduced. 2,3 Study authors further recommended that in-service training be conducted regularly to emphasize the importance of discharge planning and continuity of care in the emergency care area. Future studies could explore patients’ experiences in early ED revisits using qualitative approaches. It would also be helpful to investigate the medical care–seeking process and patient experiences, as well as to collect comparative data on perceptions of early ED revisits from physicians and nursing staff. Acknowledgments
Authors would like to thank the research funding provided by National Science Council (NSC99-2314-B-255-003-MY2) and Chang Gung Memorial Hospital, Linkou BMRPB93 and CMRPF190031). REFERENCES 1. Easter JS, Bachur B. Physicians’ assessment of pediatric returns to the emergency department. J Emerg Med. 2013;44:311–314. 2. Liaw SJ, Bullard MJ, Hu PM, Chen JC, Liao HC. Rates and causes of emergency department revisits within 72 hours. J Formos Med Assoc. 1999;98:422–425.
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3. Lerman B, Kobernick MS. Return visits to the emergency department. J Emerg Med. 1987;5:359–362.
23. van der Linden MC, Lindeboom R, de Haan R, et al. Unscheduled return visits to a Dutch inner-city emergency department. Int J Emerg Med. 2014;7:23.
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25. Wang HC, Wu KH, Kuo HC, Lee WH. Clinical characteristics of 72hour unscheduled revisits to the pediatric emergency department medical center. J Taiwan Emerg Med. 2007;9:S35–S41.
6. Nuñez S, Hexdall A, Aguirre-Jaime A. Unscheduled returns to the emergency department: an outcome of medical errors?. Qual Saf Health Care. 2006;15:102–108.
26. Wu CL, Wang FT, Chiang YC, et al. Unplanned emergency department revisits within 72 hours to a secondary teaching referral hospital in Taiwan. J Emerg Med. 2008;38:512–517.
7. Ministry of Health and Welfare. Health statistics. http://www.mohw. gov.tw/cht/DOS/Statistic.aspx?f_list_no=312&fod_list_no=4724. Accessed December 16, 2014.
27. Yen ZS, Shih FY, Tsai KC, Chen SC, Chen WJ. Revisits to the emergency department: analysis of risk factors and reasons. J Emerg Crit Care Med. 2003;14:93–98.
8. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52:546–553.
28. Kirby SE, Dennis SM, Jayasinghe UW, Harris MF. Unplanned return visits to emergency in a regional hospital. Aust Health Rev. 2012;36:336–341.
9. Fan JS, Kao WF, Yen DHT, Wang LM, Lee CH. An analysis of intensive care unit admission for patients revisiting emergency department within 3 days. J Taiwan Emerg Med. 2005;7:8–18.
29. Lin LL, Chen LC, Chang YM, Wang WP, Han CY. A project of decreasing unplanned emergency department revisit rate in a medical center. J Chang Gung Inst Technol. 2010;12:15–26.
10. Foran A, Wuerth-Sarvis B, Milne WK. Bounce-back visits in a rural emergency department. Can J Rural Med. 2010;15:108–112.
30. Law CK, Yip PSF. Acute care service utilization and the possible impacts of a user-fee policy in Hong Kong. Hong Kong Med J. 2002;8:348–353.
11. Friedmann PD, Jin L, Karrison TG, et al. Early revisit, hospitalization, or death among older persons discharged from the ED. Am J Emerg Med. 2001;19:125–129.
31. Lee A, Lau F, Hazelett CB, et al. Factors associated with non-urgent utilization of accident and emergency services: a case-control study in Hong Kong. Soc Sci Med. 2000;51:1075–1085.
12. Gordon JA, An LC, Hayward RA, Williams BC. Initial emergency department diagnosis and return visits: risk versus perception. Ann Emerg Med. 1998;32:569–573.
32. Baker MD, Monroe KW, King WD, Sorrentino A, Glaeser PW. Effectiveness of fever education in a pediatric emergency department. Pediatr Emerg Care. 2009;25:565–568.
13. Goldman RD, Ong M, Macpherson A. Unscheduled return visits to the pediatric emergency department—one-year experience. Pediatr Emerg Care. 2006;22:545–549.
33. Chern CH, How CK, Wang LM, Lee CH, Graff L. Decreasing clinically significant adverse events using feedback to emergency physicians of telephone follow-up outcomes. Ann Emerg Med. 2005;45:15–23.
14. Goldman RD, Kapoor A, Mehta S. Children admitted to the hospital after returning to the emergency department within 72 hours. Pediatr Emerg Care. 2011;27:808–811.
34. Hayes BD, Zaharna L, Winters ME, Feemster AA, Browne BJ, Hirshon J. To-go medications for decreasing ED return visits. Am J Emerg Med. 2012;2:2011–2014.
15. Hu SC. Analysis of patient revisits to the emergency department. Am J Emerg Med. 1992;10:366–370.
35. Hegney D, Buikstra E, Chamberlain C, March J, McKay M, Cope G. Nurse discharge planning in the emergency department: a Toowoomba study. J Clin Nurs. 2006;15:1033–1044.
16. Hu KW, Lu YH, Lin HJ, Guo HR, Foo NP. Unscheduled return visits with and without admission post emergency department discharge. J Emerg Med. 2012;43:1110–1118. 17. Hung SC, Chew G, Kong CT, Hsiao CT, Liaw SJ. Unplanned emergency department revisits within 72 hours. J Taiwan Emerg Med. 2004;6:230–238. 18. Imsuwan I. Characteristics of unscheduled emergency department return visit patients within 48 hours in Thammasat University Hospital. J Med Assoc Thai. 2011;94:S73–S80. 19. Keith KD, Bocka JJ, Kobernick MS, Krome RL, Ross MA. Emergency department revisits. Ann Emerg Med. 1989;18:964–968. 20. Kelly AM, Chirnside AM, Curry CH. An analysis of unscheduled return visits to an urban emergency department. N Z Med J. 1993;106:334–336.
36. McQuaid EL, Garro A, Seifer R, Hammond K, Borrelli B. Integrating asthma education and smoking cessation for parents: financial return on investment. Pediatr Pulmonol. 2012;47:950–955. 37. Sockrider MM, Abramson S, Brooks E, et al. Delivering tailored asthma family education in a pediatric emergency department setting: a pilot study. Pediatrics. 2006;117:S135–S144. 38. Tsai HC, Chen JH, Hu ST, Chen SC. Decreasing 72-hour revisiting rate for febrile pediatric patients in emergency room. New Taipei J Nurs. 2005;7:95–108. 39. Wong FKY, Chow S, Chang K, Lee A, Liu J. Effects of nurse follow-up on emergency room revisits: a randomized controlled trial. Soc Sci Med. 2004;59:2207–2218.
21. Martin-Gill C, Reiser RC. Risk factors for 72-hour admission to the ED. Am J Emerg Med. 2004;22:448–453.
40. Woods ER, Bhaumik U, Sommer SJ, et al. Community asthma initiative: evaluation of a quality improvement program for comprehensive asthma care. Pediatrics. 2012;129:465–473.
22. Pierce JM, Kellerman AL, Oster C. “Bounces”: an analysis of short-term return visits to a public hospital emergency department. Ann Emerg Med. 1990;19:51–56.
41. Foust JB. Discharge planning as part of daily nursing practice. Appl Nurs Res. 2007;20:72–77.
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42. Kumar S, Grimmer-Somers K. A synthesis of the secondary literature on effectiveness of hospital avoidance and discharge programs. Aust Health Rev. 2007;31:34–49.
47. Chande VT, Wyss N, Exum V. Educational interventions to alter pediatric emergency department utilization patterns. Arch Pediatr Adolesc Med. 1996;150:525–528.
43. Guttman A, Afilalo M, Guttman R, et al. An emergency departmentbased nurse discharge coordinator for elder patients: does it make a difference?. Acad Emerg Med. 2004;11:318–327.
48. Birmingham J. Discharge planning: a collaboration between provider and payer case managers using Medicare’s Condition of Participant. Lippincotts Case Manag. 2004;9:147–151.
44. Shen C. From TQIP to examine the unscheduled returns to the ED. Qual Indicator Pract Res. 2002;3:199–207.
49. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of followup telephone calls to patient after hospitalization. Am J Med. 2001;111:26S–30S.
45. Legrain S, Tubach F, Bonnet-Zamponi D, et al. A new multimodal geriatric discharge-planning intervention to prevent emergency visits and rehospitalization of elder adults: the optimization of medication in AGEd Multicenter randomized controlled trial. J Am Geriatr Soc. 2011;59:2017–2018. 46. Cardin S, Collet JP. Intervention to decrease emergency department crowding: does it have an effect on return visits and hospital readmissions?. Ann Emerg Med. 2003;41:173–185.
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50. Huang JA, Lai CS, Weng RH, Hu WH, Yang DY. Factors associated with unscheduled return visits: a study of the patient’s perspective. J Emerg Med. 2004;6:306–314. 51. Han CY, Barnard A, Chapman H. Emergency department nurses understanding and experiences of implementing discharge planning. J Adv Nurs. 2009;65:1283–1292.
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EARLY REVISIT TO THE EMERGENCY DEPARTMENT: AN INTEGRATIVE REVIEW Authors: Chin-Yen Han, PhD, MSN, RN, Li-Chin Chen, MSN, RN, Alan Barnard, PhD, MA, BA, RN, Chun-Chih Lin, PhD, RN, Ya-Chu Hsiao, EdD, RN, Hsueh-Erh Liu, PhD, RN, and Wen Chang, MSN, RN, Taiwan, Republic of China, Brisbane, Australia
n unscheduled repeat visit by a patient within a short period after discharge from the emergency department is known as an early revisit. The early ED revisit rate is regarded as a quality of care indicator and a tool for improving the quality of care provided to ED patients. 1–4 ED staff who care for patients who make an early revisit are responsible for managing patients’ problems with discretion. Patients who make early ED revisits have increased mortality 5 and are at high risk of medical and legal problems arising from medical errors or patient dissatisfaction. 2 Such problems are particularly likely to occur when the early revisit is the result of medical error, earlier unsatisfactory care, or a serious condition requiring admission to an ICU. 6 Staff need to be aware of the potential legal ramifications of these cases. 2,3 In recent years, the number of initial ED visits has increased in many countries but is heavily reliant on the health care system design and available resources within countries. For example, the number of ED visits in Taiwan was 3 million in 1992 and increased to 12 million in 2012. 7 Taiwan has a medical system that relies less on local medical
A
Chin-Yen Han is Assistant Professor, Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan, Republic of China. Li-Chin Chen is Deputy Director, Department of Nursing, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, Republic of China. Alan Barnard is Senior Lecturer, Queensland University of Technology, Brisbane, Australia. Chun-Chih Lin is Assistant Professor, Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan, Republic of China. Ya-Chu Hsiao is Associate Professor, Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan, Republic of China. Hsueh-Erh Liu is Professor, School of Nursing, Chang Gung University, Taoyuan, Taiwan, Republic of China. Wen Chang is Lecturer, Department of Nursing, Chang Gung University of Science and Technology, and Doctoral Student, Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taiwan, Republic of China. For correspondence, write: Wen Chang, MSN, RN, 261, Wen-hwa 1st Road, Kwei-Shan, Taoyuan, Taiwan, Republic of China, 33303; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.11.013
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practitioners in the community than on health care delivery through tertiary institutions. There is enormous pressure on ED departments in Taiwan, and fewer early ED revisits would reduce demand on resources and the associated national expenditure on health care. To date, relevant literature, which includes research findings on the rate and characteristics of early ED revisits and reports of intervention studies designed to reduce early ED revisits, remains widely dispersed. The aim of this integrative review was to provide a comprehensive understanding of this literature, thus providing ED staff with a unique resource for identifying and ameliorating the problems associated with early ED revisits. Methods SEARCH STRATEGY
This integrative review was conducted in accordance with the methodological strategies proposed by Whittemore and Knafl. 8 The search strategy involved using Medline, CINAHL, PubMed, Applied Social Sciences Index and Abstracts, The Cochrane Library, Cochrane Central Register of Controlled Trials, and the Chinese Periodicals Index database from 1987 to 2014. Multiple search terms were used to maximize the scope and depth of the investigation. The following search terms, linked with AND and OR, were used to search each of the databases: “unplanned revisit,” “unscheduled returns,” “return visits,” “early return,” “72-hour returns,” “48-hour returns,” “hospital,” “emergency department,” “emergency room,” and “emergency service.” According to Whittemore and Knafl, the inclusion of diverse data sources, including both empirical and theoretical studies, makes the process of data evaluation in an integrative review more complicated and may provide little value. 8 Therefore, both empirical and theoretical studies were included in the integrative review. All studies that met the inclusion criteria were handled in the same way in the present study. The “related articles” feature was used to search for additional sources. The article for each citation was reviewed manually for possible inclusion. Titles that were found to be unrelated to the literature review were excluded. When the citation could
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Records identified through database searching (n =104)
Additional records identified through other sources (n =59)
Records screened after duplicates removed (n =151)
Articles assessed for eligibility (n = 41)
Abstracts and poster-only articles excluded after search for full articles (n = 6)
All full articles included in synthesis (n = 35)
FIGURE The search strategy used to identify relevant articles relating to unplanned ED revisits (1987-2014).
not be excluded based on the title, the abstract was reviewed. Studies were reviewed in full when the abstract could not be excluded based on the content presented. STUDY SELECTION
The inclusion criteria were as follows: (1) studies that explored the rate and characteristics of early ED revisit; (2) outcomes measurement related to early ED revisit; (3) publications written in English or Chinese; and (4) articles retrieved in full text. Editorials, commentaries, guidelines, opinion pieces, and conference papers were excluded. Results SEARCH RESULTS
An initial search of the literature produced 151 articles for potential inclusion in the study. Of these 151 articles, 41 abstracts met the inclusion criteria. Full texts of 35 articles were retrieved for further evaluation in this review (Figure). In 23 reviewed articles, the rate and patient characteristics of unplanned ED revisits were discussed. The methods used to
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investigate the rate and characteristics of unplanned ED revisits were entered into the Retrospective Chart Review and Statistical Computer System for Emergency Medicine (Table 1). Additionally, 12 research articles were related to intervention studies aiming to reduce the rate of early ED revisits (Table 2). The studies covered in the 35 articles were conducted in Belgium, Canada, Hong Kong, New Zealand, Netherlands, Singapore, Spain, Thailand, Taiwan, and the United States. EARLY ED REVISIT RATE
Interestingly, consistency with regard to what constitutes an early revisit is lacking. Depending on the time frame within which the early revisit occurred (from 48 hours to 90 days) and the particular department involved, reported results ranged from 0.39% to 27%. 1–3,7,9–25 Worldwide, most surveys focused on early ED revisits that occurred within 48 to 72 hours. 2,3,6,9,10,12–14,16–19,21,22,24–27 Using this criterion, an early US study found that the rate of early ED revisit was 3.96%. 3 In New Zealand, the rate of early ED revisit within 7 days was 2%, 18 but in the Netherlands, the rate was based on 7 days and was 5.0%. 21 In Taiwan the
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rate of early ED revisit was calculated within 72 hours and was between 1.9% and 6.19%. 2,9,16,17,25–27 Elderly patients had higher revisit rates. A study found that 16% of elderly patients had an unplanned ED revisit, hospitalization, or death within 30 days, and this rate increased to 27% within 90 days. 11 Studies have also investigated the rate of unplanned revisits to pediatric emergency departments. The reported rates of unplanned pediatric revisits ranged from 1.1% to 6.19% 1,13,14,25 and also lacked consistency about an agreed-upon time frame, but of those revisiting pediatric patients, 60.4% of revisits were within 24 hours. CHARACTERISTICS OF EARLY ED REVISITS
Four categories of precipitating factors that influence early ED revisits were identified: patient-related, illness-related, health care system–related, and other factors. The patientrelated factors that were investigated included gender, age, race, socioeconomic status, insurance status, inability to understand or comply with discharge planning, and misuse of emergency services. Pediatric patients have higher revisit rates as a patient group, and children younger than 5 years were found to have higher rates. 1,13,14,25 Elderly patients with chronic diseases also had higher early revisit rates, with more than 80% being admitted to the ICU after their early revisits. 28 In some countries uninsured patients or those receiving public insurance had a higher incidence of ED repeated use. 28 Illness-related factors include the worsening of an existing condition, acute exacerbation of a chronic condition, complications arising from disease, and new health problems. Patients with respiratory, gastrointestinal, and infectious diseases have higher revisit rates. 10 Common complaints and symptoms exhibited by revisit patients on their first visit to the emergency department are fever, abdominal pain, or pain in other parts of the body. 26 Persistent diseases or symptoms and progressive conditions also contributed to early revisits. 29 Nontrauma patients had higher revisit rates and shorter stays at the first ED visit than did trauma patients. 27 Two types of health care system–related factors were identified: staff related and hospital related. Misdiagnosis, malpractice, inadequate communication between health care providers and patients, and lack of subsequent referral services or continuity of care were identified as major issues. 10,20,22,27 In terms of other factors, studies indicated that when the appropriateness of emergency service use was examined from the perspective of emergency care workers, many early revisits were seen to be unnecessary. A significant proportion of all early ED revisits (57% to 72%) were categorized as nonurgent. 30,31 Clearly many
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countries have a culture of use of the emergency department for nonurgent problems, or patients were unwilling to return to an outpatient department or their local health care provider. 10,20,22,27 ED DISCHARGE PLANNING TO REDUCE THE EARLY REVISIT RATE
Providing patients with comprehensive discharge planning helps reduce the number of early ED revisits and results in better health outcomes for patients. 29,32–40 The emergency department is a multidisciplinary environment, and patients present with multiple diseases. Studies demonstrate that effective discharge planning is a clinical pathway for effective continuing care and smooth transition from hospital to home. 41,42 In Australia, patients discharged from the emergency department are provided with risk screening and discharge planning by specialized community nurses. Their results show a decrease in early ED revisit rates from 21% to 5% and a decrease in the readmission rate from 10.2% to 4.7%. 35 A US study conducted among elderly ED patients who were provided with integrated discharge planning by hospital-based discharge coordinators reported a decrease in the risk of early ED revisits and an increase in patient satisfaction. 43 It would appear that integration of ED discharge education and provision of comprehensive discharge planning improves continuity of care. Patients return home and the early revisit rate is reduced. Studies indicate that one third of early ED revisits can be avoided by comprehensive discharge planning and appropriate medical intervention. 19,22 Twenty-five years ago, investigators found that 32.3% of early ED revisits occurring within 72 hours after discharge could be avoided. 19 Of the avoidable revisits, 40% were the result of some form of insufficient care. 19 Pierce et al 22 concurred, suggesting that ED revisits result from inadequate assessment and management at the first visit to the emergency department and a lack of postdischarge information from the emergency department. A more recent study added that illness-related factors are the number one cause of early ED revisits, accounting for 79.7% of these early revisits. 44 For these patients, early return to the emergency department as a result of unimproved symptoms and new problems emerging after discharge are the central reasons for their behavior. It is suggested that early ED revisit caused by inadequate medical management and misconceptions about the use of emergency resources could be avoided by improving ED discharge planning. 44 Other studies have demonstrated that effective discharge planning can result in fewer admissions and hospital revisits. 35,45 Therefore, early ED revisits could be avoided by improving discharge
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TABLE 1
Summary of the rate and characteristics of unplanned ED revisits by chart review or retrospective study
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Study
Time frame Sample
Sample size Results
Easter and Bachur, 2013 1
96 h
ED pediatric patients
97374
Fan et al, 2005 9
72 h
ED patients
152072
Foran et al, 2010 10
72 h 7d
ED patients
9935
Friedmann et al, 2001 11
30 d, 90 d ED patients aged 65+ y
463
Gordon et al, 1998 12 Goldman et al, 2006 13 Goldman et al, 2011 14
72 h
ED patients
52553
72 h
ED pediatric patients
37725
72 h
ED pediatric patients
47655
Hu, 1992 15 Hu et al, 2012 16
7d 72 h
ED patients ED patients aged N 14 y
22471 13361
Hung et al, 2004 17
72 h
Nontrauma, nonpediatric patients
5423
Imsuwan, 2011 18
48 h
ED patients
33370
Keith et al, 1989 19
72 h
ED patients
13264
1.1% (1091) returned to the emergency department and were admitted; 72% of those were due to progression of disease, 12% to potential deficiency, and 16% to other causes 3.3% revisit rate; 0.076% of those (116/152072) were admitted to the ICU after unplanned ED revisits (116/5064); 80% of those (93/116) were elderly patients 2.9% revisit rate for 72 hours; 4.5% revisit rate for 7 days; the most common CTAS score was CTASIV (45.3%); the most common diagnosis was unspecified abdominal pain (4%); most patients (88.6%) were discharged home 16% and 27% experienced ED revisit, hospitalization, or death within 30 days and 90 days, respectively 2.9% revisit rate; dehydration (15%) was the most common problem 5.2% revisit rate; a quarter of the children who returned were younger than 1 y 4.4% revisit rate; a quarter of the children who returned were younger than 1 y; progression of illness resulting in higher acuity 4.9% revisit rate; 8.2% of revisits were avoidable 3.1% revisit rate; of these patients, 36% were admitted and had a mortality rate of 4.1% 5.8% revisit rate; 14.2% had patient-related factors, 62.1% had illness-related factors, and 23.7% had health care system–related factors; 9.0% (21 cases) had experienced misdiagnosis; abdominal pain was the most common presentation (66.7%, 14/21) 0.92% revisit rate; 8.5% had patient-related factors, 60.6% had illness-related factors, and 28.3% had health care system–related factors 3.4% revisit rate; 32.3% of revisits were avoidable; 39.6% had medical management deficiencies, 14.6% had inappropriate prescribed follow-up, 20.8% had not been given proper education, and 36.5% were related to patient noncompliance continued
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Table 1 Continued Study
Kelly et al, 1993
Time frame Sample 20
7d
Sample size Results
ED patients
Lerman & Kobernick, 72 h 1987 3 72 h Liaw et al, 1999 2
ED patients
64336
ED patients
25526
Martin-Gill and Reiser, 2004 21
72 h
ED patients
104584
Nuñez et al, 2006 6
72 h
ED patients aged N 32523 14 y and nonobstetric gynecological emergencies
Pierce et al, 1990 22
48 h
ED patients
17214
van der Linden et al, 2014 23 Verelst et al, 2014 24
7d
ED patients
49341
72 h
ED patients N 16 y
44574
Wang et al, 2007 25
72 h
ED pediatric patients
9135
Wu et al, 2008 26
72 h
ED patients
34716
Yen et al, 2003 27
72 h
ED patients
5467
2% revisit rate; 27% had patient-related factors, 61% had illness-related factors, and 12% had health care system–related factors 0.39% revisit rate; 32.5% of returns were avoidable 1.9% revisit rate; 79% had illness-related factors, 9.1% had patient-related factors, and 10.5% had health care system–related factors; other 1.4% 0.47% revisit rate; highest risk diagnosis categories: mental disorder, genitourinary system, and symptom-based diagnosis No revisit rate given; the main factor associated with unscheduled returns was error in prognosis (OR 18.62, 95% CI 9.60-36.09); advanced age and a chief complaint of dyspnea were associated with unscheduled returns and admission to the hospital 3.0% revisit rate; 53% had patient-related factors, 25% had illness-related factors, and 22% had health care system–related factors; 19% were admitted 5.0% revisit rate; 49% had illness-related factors and 41% had patient-related factors 2.7% revisit rate; 85.1% of revisits were due to patients’ persistence, 12% to a wrong initial diagnosis, and 2.9% to an adverse event related to the treatment initially received 6.19% revisit rate; reasons for revisit: symptoms not relieved (71%); most common diagnoses were acute respiratory infection (46.9%) and fever (7.4%); admission rate after revisit was 64.1% 5.47% revisit rate; 10.9% had patient-related factors, 80.9% had illness-related factors, and 8.2% had health care system–related factors 3.8% revisit rate; 40.6% had patient-related factors, 30.9% had illness-related factors, and 28.5% had health care system–related factors
CI, Confidence interval; CTAS, Canadian Triage and Acuity Scale; OR, odds ratio.
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TABLE 2
Summary of studies to reduce unplanned ED revisits Study
Time frame
Patient characteristics
Sample size
Intervention
Results
Baker et al, 2009 32
—
Caregivers of children aged 3-36 mo whose chief complaint included fever and no obvious source of fever at triage (nonemergency)
280 (140 intervention group, 140 control group)
Intervention group watched an 11-minute video about home management of fever; control group watched a video about child safety
Cardin & Collet, 2003 46
7d
Patients discharged from the emergency department and from the hospital
Intervention group had significantly improved knowledge and attitudes about childhood fever; no statistical difference between intervention and control groups in return visits No difference in incidence of return visits between the periods before and after implementation of intervention (either emergency department or hospital)
Chande et al, 1996 47
6 mo
Chern et al, 2005 33
3d
Hayes et al, 2012 34
7d
Hegney et al, 2006 35
—
4701 Increased emergency (1935 emergency physician coverage, department, 2766 designation of physician hospital ward) coordinators, and new hospital policies regarding laboratory, consultation, and admission procedures by physicians ED pediatric patients 130 (69 Intervention group received intervention specialized educational group, 61 materials (10-minute control group) videotape on pediatric health care issues and an information booklet); control group received standard pediatric ED discharge instructions High-risk conditions 963 (556 before Feedback to physicians on (including neurologic, intervention, telephone follow-up cardiovascular, pulmonary, 397 after outcomes of ED discharged gastroenteric, infections, intervention) patients and resident intoxication, and abnormal training (about the uncertain laboratory data) presentation of serious diseases and the need to use additional evaluation on selected patients) Adult patients with 4257 (243 To-go medications provided cellulitis, UTI, and intervention (free, full-course antimicrobial dental infections group, 4014 therapy upon ED discharge) control group) N 70 y
2139
Risk-screened (face to face in the emergency department or via telephone) and given community services referrals when necessary by a specialist community nurse
No significant difference in returns to the pediatric emergency department within 6 mo
Decreased return visits from 10.1% to 4.9% and decreased clinically significant adverse events from 4.1% to 1.5%
50% reduction in ED return visits for patients who received to-go medications (2.5% vs 5.9%) ED re-presentation rate decreased 16%
continued
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Table 2 Continued Study
Time frame
Patient characteristics
Sample size
Intervention
Results
Lin et al, 2010 29
72 h
Adults with acute gastroenteritis
940
Unplanned ED revisit rate decreased from 5.38% to 3.3%
McQuaid et al, 2012 36
—
Smokers who were caregivers of a child with asthma
224
ED nurses provided discharge follow-up including telephone interview, patient’s medical condition follow-up, and discharge patient education Asthma education and smoking counseling (3 home visits) by a nurse
Sockrider et al, 2006 37
9 and Children with acute 12 mo asthma symptoms
464 (263 intervention group, 201 control group)
Tsai et al, 2005 38
72 h
Febrile pediatric patients
110
Wong et al, 2004 39
30 d
Patients with fever or a respiratory or gastrointestinal condition
395 intervention group, 400 control group
Woods et al, 2012 40
—
Children with asthma
283 (through ED visits or hospitalizations)
TEDAS pediatric asthma educational intervention used a computer-based resource, follow-up telephone call, and asthma education hotline to provide a customized asthma action plan and educational summary ED nurses provided health education about febrile pediatrics to children’s family, follow-up and consultation by telephone Planned telephone consultations by an experienced ED nurse
Nurse case management (face-to-face visits during hospitalization or through telephone contact) and home visits
12-mo data showed a significant reduction in mean annual ED visits Return ED visits were significantly lower in the intervention group; caregiver self-confidence and well-visit follow-up were significantly effective in the intervention group
Unplanned ED revisit rate decreased from 6.8% to 4.9%
Health outcome and 30-day ED revisits were significantly improved in the intervention group 12-mo data showed a significant decrease in any (≥1) asthma ED visits and hospitalizations
TEDAS, Texas Emergency Department Asthma Surveillance; UTI, urinary tract infection.
planning and providing better education in the emergency department. This knowledge is especially important given that in countries such as Taiwan, huge numbers of persons present to emergency departments on a daily basis. Although discharge planning is seen as an effective way to decrease patient revisits or readmissions, some nonpositive outcomes were also reported. A Canadian study evaluated the effect of interventions to decrease ED
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crowding on the incidence of return revisits to the emergency department or a hospital ward. Interventions included increased ED physician coverage, the designation of physician coordinators, and new hospital policies regarding laboratory, consultation, and admission procedures. 46 Their results showed no difference in the incidence of return visits between the periods before and after implementation of the intervention, either for patients
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discharged from the emergency department (all returns: 11.0% versus 12.4%; unscheduled-related returns: 6.5% versus 5.8%) or the hospital (all returns: 6.8% versus 6.6%; unscheduled-related returns: 4.2% versus 4.0%). The intervention to decrease crowding reduced the mean length of stay for patients discharged from the emergency department from 13.8 to 5.9 hours, without resulting in increased return visits to the emergency department or hospital readmission. 46 Two studies demonstrated that pediatric patients have higher rates of early ED revisits compared with adult patients. 26,38 In Taiwan, the implementation of an education program for pediatric fever management produced a decrease in the 72-hour revisit rate from 6.8% to 4.9%. 26 Another Taiwanese project focused on ED pediatric patients with fever by providing an educational program to the primary caregiver. After implementation of the project, the rate of ED revisits within 72 hours after discharge decreased from 6.81% to 4.9%. 38 It would appear that predischarge education delivered appropriately and at a timely moment can make a difference in revisit rates. However, it is important to note the reasons for use of ED resources. In the US, a prospective, randomized controlled trial involved one-time educational interventions targeting the primary care providers of ED pediatric patients. 47 The results showed no significant difference in returns to the pediatric emergency department within a 6-month period for both the intervention group (30%) and the control group (26%). The study suggested that one-time educational interventions may not alter long-term ED utilization habits because these have more to do with the health care system and the culture of use than with the ability of ED staff to address a patient’s health care concerns at any one time.
hospital. Studies show that telephone follow-up can reduce the revisit or readmission rate and increase patient satisfaction. 29 In Taiwan, for instance, the results of a telephone follow-up project are especially promising because patient re-presentation after discharge from the emergency department has shown a decrease in the revisit rate from 5.38% to 3.3% and an increase in patient satisfaction. 18 A similar study in Hong Kong reported that patients who were interviewed via telephone perceived an improvement in their health and had a lower revisit rate. 39 In the US, a study using pharmacists to make follow-up telephone calls to patients after discharge from the emergency department found that patients had higher satisfaction with discharge instructions and a lower ED revisit rate. During the course of the study, 15 of 756 patients were helped in solving problems associated with their medication. 49 In general, people like to receive attention from others and feel that someone is taking care of them. 29 Telephone follow-up on a patient’s condition after discharge could be a nursing role. After discharge from the hospital, ED patients may still experience physical discomfort requiring further examination and treatment. Through telephone follow-up, a hospital may improve provision of care to patients as a result of nursing follow-up and medical consultation where appropriate to treat people in an extramural environment. Care provided in a timely manner helps alleviate stress and provides safety and support. 29 Telephone follow-up can help discharged patients adapt to their surroundings, remind them of their return visits, and support their successful return to the community. These types of interventions are supported by evidence and are recommended as an effective way to reduce the number of revisits.
FOLLOW-UP AS CONTINUITY OF CARE AFTER ED PATIENT DISCHARGE
Discussion
Continuous follow-up on a patient’s condition after discharge may also result in improved quality of care, reduced revisit rates, and increased patient satisfaction. Failure to provide continuity of care to discharged patients is a likely contributor to early ED revisit or readmission, and subsequent problems could affect patients, family members, and the wider society. 48 For patients, these problems include increased levels of physical and mental stress, as well as financial burdens. For family members, the responsibilities of long-term care could affect their work performance and quality of life. In the broader social context, readmission and early ED revisits increase health care expenditure and impose a financial burden on families and taxpayers. Telephone follow-up has been tested as one way of tracking a patient’s condition after discharge from the
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The Formosa Medical Association suggests that the baseline rate for early ED revisits should be set at 2%, which could be used as an audit filter. 2 The authors of one study recommended that a target rate of below 1% is achievable for early ED revisits within 72 hours and should be adopted to monitor patient care in the emergency department. 2 However, these benchmarks have not been accepted worldwide. 2,3 When the early revisit rate exceeds a certain limit, this may indicate a dysfunctional emergency department. Further investigations are necessary to determine the reasons for an increase in early ED revisit rates within organizations and specific health care systems. Patient-centered care is one of the core goals of emergency care. In one study, ED patients’ and physicians’ views about ED revisits were compared. Research found only 31.4% consistency between physicians’ and patients’
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responses. 50 The current article has explored the rate and characteristics of early revisits. However, it is important to understand the phenomenon of early ED revisits from the patient’s point of view. Further investigation is needed to examine patient perceptions. Many patients with early ED revisits have short stays during the first visit to the emergency department, with 51.6% of these patients staying less than 2 hours. 29 Contact between ED health care staff and ED patients can be very brief. 18 ED staff collect limited information and make decisions under extreme pressure during a patient’s short stay in the emergency department, which results in inadequate preparation for discharge and the likelihood of unresolved health issues. A study found that ED nurses can sometimes perceive discharge planning as “getting rid” of patients or merely completing an administrative task. 51 However, without preparation for discharge and adequate planning for their care after the ED visit, ED patients may not have their discharge needs met and early revisit can occur. Research related to discharge planning has been conducted with hospitalized patients, but only a limited number of studies have investigated the implementation of discharge planning for ED patients, 29,32,35,43,47 and most of these studies focused on groups with high early revisit rates, such as elderly and pediatric patients. The authors suggest that further research is needed to investigate discharge planning programs for different types of problems and to evaluate the relationship between the specific programs and early ED revisit rates. Discharge planning can be an effective strategy that can help patients deal with problems after they return home. It is one of the main ways of ensuring continuity of care within the health care system after patient discharge and is a common means of reducing revisit and readmission rates. 41,42,48 Despite this evidence, discharge planning is not always provided as part of ED care. Emergency medical management focuses on dealing with acute problems. Nonacute issues, such as discharge planning, seem to be ignored by ED health care staff. 28 However, all patients should receive comprehensive discharge planning and follow-up. Research found that the emergency department was not able to provide patients with customized discharge planning, nor were there regulations governing discharge. 51 This apparent lack of coordination and policy may be affecting the ability of ED nursing staff to implement comprehensive care. The characteristics of an ED environment, patient anxiety and irritability, the expectation that problems will be dealt with as soon as possible, stressed staff, and pressure from organizations to reduce the time taken with patients and re-presentation rates have an impact on the effectiveness of comprehensive care. 51 Therefore, a follow-up service after discharge from the emergency department should be
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provided to help patients deal with problems encountered after discharge from the hospital. A follow-up service can not only be a supplement to discharge planning but may also help ensure continuity of care after a patient returns home.
Limitations
This review was based only on articles published in English and Chinese, which may have resulted in selection bias. The oldest article reviewed was published in 1987. Some publications prior to 1985 and unpublished articles may have contained material of relevance but were not included in the search. It is possible that publication bias exists within this area of research, but this did not seem to be a major concern because published studies showed a trend toward publishing all results, including negative and insignificant results.
Conclusion
The early ED revisit rate remains an important issue in emergency care. Reduction of the early ED revisit rate through discharge planning would not only allow health care staff to have more time to assess ED patients but would also provide patients with appropriate medical management and measures to ensure continuity of care at home after discharge. The care provided to the ED patient can be improved, 6,15,19,22 and medical and legal problems can be reduced. 2,3 Study authors further recommended that in-service training be conducted regularly to emphasize the importance of discharge planning and continuity of care in the emergency care area. Future studies could explore patients’ experiences in early ED revisits using qualitative approaches. It would also be helpful to investigate the medical care–seeking process and patient experiences, as well as to collect comparative data on perceptions of early ED revisits from physicians and nursing staff. Acknowledgments
Authors would like to thank the research funding provided by National Science Council (NSC99-2314-B-255-003-MY2) and Chang Gung Memorial Hospital, Linkou BMRPB93 and CMRPF190031). REFERENCES 1. Easter JS, Bachur B. Physicians’ assessment of pediatric returns to the emergency department. J Emerg Med. 2013;44:311–314. 2. Liaw SJ, Bullard MJ, Hu PM, Chen JC, Liao HC. Rates and causes of emergency department revisits within 72 hours. J Formos Med Assoc. 1999;98:422–425.
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