Rates and Causes of Emergency Department Revisits within 48 Hours

Transcription

1 Original Article Rates and Causes of Emergency Department Revisits within 48 Hours Chiu-Lung Wu *, Fa-Tsai Wang, Yao-Chiu Chiang, Yuan-Fa Chiu, Teong-Giap Lin, Lian-Fong Fu, and Tsung-Lung Tsai Department of Emergency Medicine, Kuang Tien General Hospital, Taichung Abstract Objective: The purpose of this study was to determine the rates and causes of revisits to the emergency department (ED) of a 710-bed secondary teaching referral hospital (Kuang Tien General Hospital), to identify areas for improvement, and to find out the initial ED presentations that affect such revisits. Materials and methods: There were patients were seen and discharged in the ED, and 1486 patients returned within 48 hours, from 1 January 2006 to 31 December 2006, and monthly revisit rates were calculated. The cases that revisited the ED within 48 hours were retrospectively identified by the authors, and examined all charted revisits to determine the causes of the revisits. Results: One thousand four hundred and eighty-six cases (4.28%) were found have revisited the ED within 48 hours after their initial visit. The monthly revisit rate ranged from 1.82% to 5.13% (average, 4.28%). The rates of revisits related to factors of illness, patients, and doctors accounted for 79.9%, 10.8%, and 9.3%, respectively. Among the factor of the doctors, 4.4% (66 cases) were due to misdiagnosis and abdominal pain was the most common presentation (56.1%, 37/66). The most common initial ED presentations are abdominal pain (15.5%), fever (15.1%), vertigo (4.2%), headache (2.0), and URI (2.0%). Conclusions: Differentiation between the natural course of a disease, suboptimal therapy, over anxious reaction, and medical errors is difficult. Good communication skills and good patient-physician relationship are much more important than revisits rate in the quality assurance of emergency care. While this study indicates that most revisits are illness-related, further prospective studies are needed to evaluate the most common and serious causes of revisits to see if improvements can be made. Key Words: Revisit, Emergency, Department, Misdiagnosis. *Corresponding author Received:30 Jan 2008;Accepted:10 Mar

2 Chiu-Lung Wu, et al. Introduction When patients return to the emergency department (ED) shortly after being seen, it is generally assumed that their initial evaluation or treatment was inadequate (1). However, the circumstances surrounding these repeat visits are poorly understood. Previous researchers have demonstrated different results under different time frames. In 1990, Pierce presented a rate of 3.0% in the revisits within 2 days (2). Hu revealed a rate of 4.9% in the revisits within 7 days (3). Keith et al revealed a rate of 3.4% in the revisits within 72 hours (4). In addition, Liaw et al reported a rate of 1.9% in the revisits within 3 days (5). The quality of the emergency care 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 quality assurance activities. Liaw et al suggested setting a baseline for monthly ED revisits at 2% for future computer programming audit filters in their ED (5). Many short-term return visits may be medically unnecessary because it is known that substantial numbers of patients use Eds for nonemergency problems (6-9). Patients revisiting the ED should not be regarded as patients who are abusing or misusing emergency service. The revisiting patients who do not turn to another hospital because of faith in previous practice are essentially giving the ED and the emergency physicians (Eps) a second chance to solve their problems (10). Special examinations, laboratory studies, physical examination, and detailed history taking should be provided without prejudice. A common disease may run an atypical course or have uncommon presentations that show the initial diagnosis may be wrong. 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 (11-15). 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 (2,4,16). The purpose of our study was to identify common and serious causes of ED revisits within 48 hours, and to find out the initial ED presentations that affect such revisits. Material and Methods The study was conducted in a 710-bed, secondary teaching hospital that receives approximately emergency visits per year in middle Taiwan. Emergency patients that visited and revisited the ED within 48 hours from 1 January 2006 to 31 December 2006 were collected as study subjects. The medical records of every revisit were reviewed by one of the authors. Data collected included information about age, sex, arrival and discharge time, ED diagnosis, disposition, final prognosis and diagnosis after discharge. All records of revisits were categorized into one of the following classification under the judgment of two of the authors independently. If the classifications of the two reviewers were inconsistent, the record of the revisit was reviewed again by the leader author and reassigned to 10

3 Revisits to ED a category. If the revisits had illness-related and doctor-related causes, illness-related and patient-related, or patient-related and doctor-related causes at the same time, it was judged to the later cause. The causes of revisits were classified as follows: (1) illness-related, defined as reasonable expectation of symptoms to recur, fail to improve, or worsen, or adverse effects from the treatment that could be reasonably expected (new problems, progression of diseases or recurrent disease process); (2) patient-related, defined as patients who left against the advice of the doctor, had psychosocial problems such as drug abuse, or came to the ED with nonemergency complaints (substance abuse, habitual use, noncompliant patient, drugs, dressing, catheter changes, needs for certificates or other needs for legal purposes, needs to care for the patients aroused from families, or subjective needs of the patients and bypass the OPD arrangement); and (3) doctor-related, defined as the physician was primarily responsible for the patient returning to the ED including a) treatment error defined as the original physician made the right diagnosis but made an error in treatment (drug reaction, no analgesics, or inadequate treatment); and b) misdiagnosis defined as chart review reveals a diagnosis or problem missed by the physician who saw the patient on the first visit (presented with abdominal pain, chest pain, dizziness, fever, shortness of breath, flank pain or nausea and vomiting). Results There were patient visits to the Kuang Tien General Hopital ED from 1 January 2006 to 31 December Of these visits, 1486 (4.28%) represented return visits to the ED within 48 hours, and monthly revisit rates ranged from 1.82% to 5.13% (average, 4.28%) (Table 1). 11

4 Chiu-Lung Wu, et al. Included were 749 males and 737 females with a mean age of 45 years. The final disposition (second visit) for patients to revisit the ED was discharged 1070 patients (72.0%), ward admission 340 patients (22.9%), ICU admission 11 patients (0.7%), discharged against medical advice 55 patients (3.7%), and escaped 10 patients (0.7%). The most common reason for patients to revisit the ED was determined to be due to disease factors (79.9%), with patient factors (10.8%), and doctor related factors (9.3%) considered much less frequent causes (Table 2). Among patients for whom revisits were judged to be due to misdiagnosis (Table 3), 48 (72.8%) were admitted at the time of their revisit, 16 (24.2%) were discharged, and two (3.0%) were discharged against medical advice. The overall admission rate for revisit patients was 23.6%, almost the same as the total ED admission rate of 22.9%. The most common complaints and diagnoses at the first visit are abdominal pain (15.5%), fever (15.1%), vertigo (4.2%), headache (2.0%), and URI (2.0%) (Table 4). 12

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6 Chiu-Lung Wu, et al. Discussion The incidence of 4.28% of ED revisits was high compared with most studies. Included were 749 males and 737 females with a mean age of 45 years. While patients returning to the ED shortly after been seen are commonly regarded as high-risk patients, little is known about this group (1). Lerman et al reviewed the charts of 255 patients returning to the William Beaumont Hospital ED within 72 hours of being seen (16). Almost one third were felt to be avoidable with better patient education and medical care. Less than 18% were thought to represent cases of medical error (16). Keith et al studied a larger series of cases from this same institution and reported that almost one third of unscheduled returns within 72 hours were avoidable (4). Almost 40% of these avoidable visits were felt to be due to deficiencies in medical care. Of note, 85% of all avoidable visits and 92% of cases involving medical deficiencies returned within 48 hours, suggesting that the narrower time frame can effective screen for problem cases with little loss in sensitivity. Pierce et al revealed that about 3% patients returned within two days of initial registration in emergency department (2). Disease-related factors accounted for 79.9% of the revisits, higher than the data from the report by Liaw et al, and Hung et al (15,17). Hung et al revealed that recurrent disease processes alone accounted for over half of the revisits (60.4%). Common problems included acute exacerbation of asthma, chronic pancreatitis, headache, vertigo, cancer pain, and recurrent flank pain in urolithiasis (17). Hu reported that the five leading causes of disease-related revisits were chronic obstructive pulmonary disease, benigh prostatic hypertrophy, urolithiasis, bronchial asthma, and coronary artery disease (3). Liaw et al revealed that most common causes of disease related revisits were abdominal pain, fever, shortness of breath, nausea, vomiting, flank pain, gastroenteritis, cancer, URI, urolithiasis, liver cirrhosis, and hepatitis (5). For visits outside normal office hours, patients must seek treatment from the ED. The terminal cancer patients for cancer pain must rely on the ED for their chronic pain control. This may be one of the reasons for the high revisit rate to the ED. Patient-related revisits accounted for 10.8% of the overall revisits. The results of Liaw et al (5) were 9.1%, and Hung et al (17) were 14.2%. Common problems included substance abuse, habitual use, noncompliant patient, anxiety, needs for certificates or other needs for legal purposes, needs to care for the patients aroused from families, or subjective needs of the patients and bypass the OPD arrangement. The results of Pierce et al were different (2). He found that patient-related factors were responsible for a majority of repeat visits (53%). Primary factors accounting for patient-related return visits were left the ED against medical advice or left before being instructed to do so, left without being seen by a physician, anxiety, chronic psychiatric, substance abuse, habitual use, noncompliant patient, malingering, and social problems. Patients may want to bypass the outpatient clinics since the ED is convenient and running 24 hours a day and their medical needs are met instantaneously. Patients may come to the ED for medication to chronic hypertension or diabetes mellitus. To solve the problems of overcrowding in the ED, this category of revisits should be reduced as much as possible. Since 9.3% of the revisits were due to 14

7 Revisits to ED doctor-related factors, the major doctor-related revisits in our study partly resulted from premature discharge of patients. Patients were discharged early after initially relieving the symptom or sign. Communication and the relationship between physicians and patients are especially important to avoid revisits and reduce the dissatisfaction of patients. When the outcome of a patient is poor during the revisit, litigation is likely to occur if the patient perceived a poor outcome which could have been avoided if the physician had diagnosed and treated the condition early. In fact, differentiating between the natural course of a disease, suboptimal therapy, overanxious reaction, and medical errors is difficult. A study by Pierce et al found that although only 18% of all early returns were the result of physician-related factors, these patients were more than twice as likely to require admission, thus indicating that returns requiring admission could represent a greater proportion of returns resulting from physician-related factors. Premature discharge from the ED was associated with 12% of readmissions. It is likely that many of these short-term treatment failures and disease recurrences may have been anticipated if these patients could have been monitored for longer periods before discharge (2). Lerman et al (16) concluded that 15% of their revisits could have been avoided by better patient education. Keith et al (4) concluded that 32.3% of their revisits were avoidable. Of these avoidable visits, 38 (39.6%) had medical management deficiencies, 14 (14.6%) had inappropriate prescribed follow-up, 20 (20.8%) had not been given proper education, and 35 (36.5%) were due to patient noncompliance. Among 66 revisits due to misdiagnosis, abdomen pain accounted for 37 patients (56.1%). The most common chief complaint of misdiagnosed abdominal pain was epigastralgia. Most of them were taken as gastritis or gastroenteritis, however, appendicitis, hollow organ perforation, duodenal ulcer, biliary tract diseases, or ileus was the final diagnosis. The presentation of patients with abdominal pain is a continual challenge in emergency care. It is one of the most common complaints in ED. Results of the physical examination is often not helpful (18-20). As the disease evolves, the examination results can change over time. Pain perception may be far away from the site of disease. For emergency physicians who compete against time, this is a problem as seemingly routine symptoms and signs may stem from life-threatening problems. Emergency physicians are taught to reevaluate non-specific abdominal pain at 8 to 12 hours after discharge (21). This may result in a return visit to the ED or an appointment scheduled with a primary care physician. The admission rate of doctor-related revisits was higher than the illness-related and patient-related revisits. All of the misdiagnosed cases and 48 cases (72.8%) of treatment error were admitted to the hospital. This might imply that the emergency physician tended to under-diagnosed and sub-optimal management to patient with illness of non-obvious presentation or atypical course. The rate of revisits caused by misdiagnosis varies from study to study. The results of Liaw et al (15) were 7.8% and Hung et al (17) were 9.0%. It is interesting to note that the admission rate among misdiagnosis subgroup (72.8%) was much higher than the overall revisit admission rate (23.6%). This suggests that these 15

8 Chiu-Lung Wu, et al. patients were sicker than originally thought or that the doctors recognized that the initial management approach was in error. From the perspectives of the physicians and patients, revisits are a safeguard to misdiagnoses and insecurities. Physicians have the burden to improve their knowledge and skills so as to reduce medical errors. Optimal treatment must be given wisely to avoid suboptimal and excess management (22-23). Communication, education, and assurance must be adequately provided to avoid overanxious reactions of the patients. Statistical data from Graff et al and Rusnak et al revealed that a senior physician could provide better service in the ED and lessen the chance of patient revisits (24-25). Not just the knowledge and techniques improved with seniority, the senior physicians also had better interpersonal skills which is essential to the maintenance of the patient-doctor relationship. Communication skills and relationship building skills are now priority in many primary care specialties and medical schools (26). For the purpose of quality improvement in emergency care, training in communication skills is at least as important as cognitive ability and technical skills (17). 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 (27-28). It is generally blamed on poor quality of service when patients return to the ED shortly after being treated (1). Establishing a policy of chart audits to review return-visit patients emergency records to find and correct medical deficiencies is becoming more popular with ED directors (2,4). In conclusion, taking the rate of revisits as an index to gauge the performance of the ED is far from ideal. Many of the revisits are purposely encouraged by the current practice of emergency medicine. Revisits should be named as follow-up since only the ED service is available outside of office hours. Revisits, either to the ED or to outpatient clinics, should be used as a tool to address many of the risk problems of emergency medicine. Differentiation between the natural course of a disease, suboptimal therapy, over anxious reaction, and medical errors is difficult. Good communication skills and good patient-physician relationship are much more important than revisits rate in the quality assurance of emergency care. While this study indicates that most revisits are illness-related, further prospective studies are needed to evaluate the most common and serious causes of revisits to see if improvements can be made. Limitations This study has several important limitations. The data presented were all collected from a single emergency department, and may not be generalizable in other regions. This retrospective study has the limitations of that methodology, in addition to those inherent to documentation and changing practice in a busy teaching hospital ED. All records of revisits were categorized into one of the classification under the judgment of two of the authors independently. If the classifications of the two reviewers were inconsistent, the record of the revisit was reviewed again by the leader author and reassigned to a category. The independent variable of this study was the treating physician s behavior, which is difficult to control. One of the major limitations of 16

9 Revisits to ED this study is that we did not identify how many of our ED patients visited other hospital EDs rather than revisit this hospital within 48 hours of their previous discharge. Additionally, differentiating between the natural course of a disease, inadequate patient communication, suboptimal therapy, and an overanxious patient is difficult by retrospective chart review. Conclusion Differentiation between the natural course of a disease, suboptimal therapy, over anxious reaction, and medical errors is difficult. Good communication skills and good patient-physician relationship are much more important than revisits rate in the quality assurance of emergency care. While this study indicates that most revisits are illness-related, further prospective studies are needed to evaluate the most common and serious causes of revisits to see if improvements can be made. References 1. Rogers JT: Risk Management in Emrgency Medicine. Dallas, TX, American College of Emergency Physicians, 1985; 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: Hu SC. Analysis of patients revisits to the emergency department. Am J Emerg Med 1992; 10: Keith KD, Bocka JJ, Kobernick MS, Krome RL, Ross MA. Emergency department revisits. Ann Emerg Med 1989;18: 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: Elliott MJ, Vayda E. Characteristics of emergency department users. Can J Public Health 1978;69: Wood TCA, Cliff KS. Accident and emergency department Why people attend with minor injuries and aliments. Public Health 1986;100: Buesching DP, Jablonowski A, Vesta E, et al. Inappropriate emergency department visits. Ann Emerg Med 1985;14: H a d d y R I, S c h m a l e r M E, E p t i n g R J. Non-emergency emergency room use in patients with and without primary care physicians. J Fam Pract 1987;24: Gregory LH: Specific high-risk medicolegal i s s u e s. I n : E m e rg e n c y M e d i c i n e R i s k Management: A comprehensive review. Dallas: American College of Emergency Physicians, 1991: Tr e s c h D D. A t y p i c a l p r e s e n t a t i o n s o f cardiovascular disorders in the elderly. Geriatrics 1987;42: Fox Ra. Atypical presentation of geriatric infections. Geriatrics 1988;43: O dell C. Atypical presentations of neurological illness in the elderly. Geriatrics 1988;43: Gambert SR, Escher JE. Atypical presentation of endocrine disorders in the elderly. Geriatrics 1988;43: Gupta KL, Dworkin B, Gambert SR. Common nutritional disorders in the elderly: Atypical manifestations. Geriatrics 1988;43:

10 Chiu-Lung Wu, et al. 16. Lerman B, Kobernick MS. Return visits to the emergency department. J Emerg Med 1987;5: Hung SC, Chew G, Kong CT, Hsiao CT, Liaw SJ. Unplanned emergency department revisits within 72 hours. J Taiwan Emerg Med 2004;6: Brewer RJ, Golden GT, Hitch DC, Rudolf LE, Wangensteen SL. Abdominal pain. An analysis of 1,000 consecutive cases in a university hospital emergency room. Am J Surg 1976;131: Holt S, Diaz MC, Eckhauser ML, et al. Acute acalculous cholecystitis. Int Med 1986;7: Freund HR, Rubinstein E. Appendicitis in the elderly. Am Surg 1984;50: American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with a chief complaint of nontraumatic abdominal pain. Ann Emerg Med 1994;23: Stair TO. Quality assurance. Emerg Med Clin North Am 1987;5: Kellermann AL. Clinical emergency medicine, t o d a y a n d t o m o r r o w. A n n E m e rg M e d 1995;25: Graff L, Mucci D, Radford MJ. Decision to hospitalize: Objective diagnosis-related group criteria versus clinical judgment. Ann Emerg Med 1988;17: 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: Waitzkin H. Doctor-patient communication: Clinical implications of social scientific research. JAMA 1984;252: Flint LS, Hammett WH, Martens K. Quality assurance in the emergency department. Ann Emerg Med 1985;14: Whitcomb JE, Stueven H, Tonsfeldt D, Kastenson G. Quality assurance in the emergency department. Ann Emerg Med 1985;14:

11 原著研究 病患非計畫性 48 小時內急診回診之因素分析 * 吳九龍王發財江耀玖邱源發林長業傅連鳳蔡崇隆光田醫療社團法人光田綜合醫院急診醫學科 摘要目的 : 本研究在界定出非計畫性急診回診的因素分析及急診醫師應有的醫療行為, 藉以增進急診醫師的醫療品質 方法 : 本研究地點是在中部一家約 710 床區域教學醫院, 於民國 95 年 1 月至 12 月之 人次之急診處置中, 有 1486 位 48 小時內回診案例 (4.28%) 結果 : 於這些回診案例中, 與疾病相關者計 79.9% 病患個人因素計 10.8% 醫師醫療相關者有 9.3%; 醫師醫療相關因素中被判定為誤診者共 4.4%, 其中腹痛是最常見之主訴 (56.1%) 回診案例中最常見的主訴及診斷為腹痛 (15.5%), 發燒 (15.1%), 眩暈 (4.2%), 頭痛 (2.0%) 及上呼吸道感染 (2.0%) 結論 : 於疾病之自然病程 未適當之處置或治療 病患之過度焦慮及醫療疏失之間作出鑑別及歸因是很困難的 本研究指出急診醫師應該具備良好的溝通技巧及建構醫病關係之能力, 且與疾病相關原因佔最多數, 預先評估非計畫性返診原因, 可作為改善急診品質的方法之一 關鍵字 : 急診回診, 誤診, 醫療品質 * 通訊作者收件日期 :2008 年 1 月 30 日 ; 接受日期 :2008 年 3 月 10 日 19

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