Return Visits to the Emergency Department: The Patient Perspective

doi:10.1016/j.annemergmed.2014.07.015

Annals of Emergency Medicine

Volume 65, Issue 4, April 2015, Pages 377-386.e3

Presented at the Society for Academic Emergency Annual Meeting, Dallas, TX, May 2014; and the Academy Health annual meeting, San Diego, CA, June 2014.

https://doi.org/10.1016/j.annemergmed.2014.07.015 Get rights and content

Study objective

Reasons for recurrent emergency department (ED) visits have been examined primarily through administrative data review. Inclusion of patients’ perspectives of reasons for ED return may help inform future initiatives aimed at reducing recurrent utilization. The objective of this study is to describe the personal experiences and challenges faced by patients transitioning home after an ED discharge.

Methods

We performed semistructured qualitative interviews of adult patients with an unscheduled return to the ED within 9 days of an index ED discharge. Questions focused on problems with the initial discharge process, medications, outpatient care access, social support, and health care decisionmaking. Themes were identified with a modified grounded theory approach.

Results

Sixty interviews were performed. Most patients were satisfied with the discharge process at the index discharge, but many had complaints about the clinical care delivered, including insufficient evaluation and treatment. The primary reason for returning to the ED was fear or uncertainty about their condition. Most patients had a primary care physician, but they rarely visited a physician before returning to the ED. Patients cited convenience and more expedited evaluations as primary reasons for seeking care in the ED versus the clinic.

Conclusion

Postdischarge factors, including perceived inability to access timely follow-up care and uncertainty and fear about disease progression, are primary motivators for return to the ED. Many patients prefer hospital-based care because of increased convenience and timely results. Further work is needed to develop alternative pathways for patients to ask questions and seek guidance when and where they want.

Introduction

Despite significant policy rhetoric about reducing “unnecessary” use of the hospital, very little is known about patients who repeatedly seek care within a short timeframe. Since the inception of financial disincentives for hospital readmissions, hospitals have focused on reducing 30-day readmissions with a number of interventions and initiatives.1, 2, 3 Almost one third (28%) of all acute care visits in the United States and half of hospital admissions originate in the emergency department (ED),⁴ but how repeated ED utilization fits into the overall conversation about hospital readmissions is not clear. Although limited, efforts to reduce the frequency of patients returning to the ED within a short period of ED discharge have emerged.

Editor’s Capsule Summary

What is already known on this topic

Factors associated with return emergency department (ED) visits have been studied with retrospective administrative data sets. Such analyses cannot reveal motivations for these visits.

What question this study addressed

Patients' perspectives on the medical and social factors that lead to return ED visits.

What this study adds to our knowledge

In this qualitative study of 60 patients returning to a single ED, patients' uncertainty was the primary reason for return visits.

How this is relevant to clinical practice

By gaining an understanding of why patients choose to return to the ED, we can begin to design and implement interventions designed to reduce the number of unnecessary return ED visits.

Coincident with this focus on reducing recurrent hospital use, implementation of the Patient Protection and Affordable Care Act and creation of the Patient-Centered Outcomes Research Institute have underscored the importance of including the patient voice in the design and delivery of health care. Reasons for patient returns to the ED and predictors of future return for both hospital readmissions and repeated ED visits have been investigated primarily through use of administrative data, and a number of factors associated with increased rate of ED return have been identified.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 These factors include patient descriptors such as older age, lack of family support, nonambulatory status, and arrival to the ED by ambulance. It is not clear, however, whether any of these factors are actually in the causal pathway of patient returns and to what extent they represent modifiable risk factors for intervention. To better understand this causal pathway and to build a model of patient-centered care, we must include the patient perspective.

Inclusion of the patient perspective may identify factors contributing to recurrent ED visits not previously identified in administrative data. An improved understanding of risk factors and best practices may ultimately improve the patient experience during and after an ED visit and decrease ED revisits.

The objective of this study is to describe the experiences of patients transitioning home after an ED discharge, with a focus on identifying medical and social challenges that patients perceive to have contributed to their return ED visit.

Section snippets

Study Design and Setting

This is a qualitative study using individual semistructured interviews with patients returning to the ED within 9 days of a previous ED treat-and-release visit (index visit). Nine days was selected on the basis of previous retrospective work in which we assessed the occurrence and timing of ED return visits after a previous ED discharge for approximately 5 million index ED discharges. In this work, we used advanced modeling techniques to characterize the timing of returns, with results

Results

We conducted a total of 60 interviews, 24 with patients who were admitted at their return ED visit (14 inpatient, 9 observation, and 1 transfer) and 36 with patients who were discharged from the return visit (1 against medical advice, 1 left without treatment complete, 34 routine discharge). The mean age of enrolled patients was 43 years (range 19 to 75 years), with 39 (65%) women. More than half of the patients (31/60) had only 1 or 2 previous ED visits in the year preceding their enrollment

Limitations

Our sample was limited to a convenience sample of 60 patients within a single health system, and thus the themes identified may not be generalizable to different patient populations. Although this was a heterogeneous sample, patients were not specifically enrolled by demographics, and thus we assumed no differences in response according to specific demographics.

Our sample intentionally has a key selection bias. Specifically, we did not enroll patients who had an ED visit and then had successful

Discussion

Our findings offer rich insight into both the physical and emotional challenges that patients have on discharge from the ED. In their narratives, most participants discussed their decision to return to the ED being driven largely by fear and uncertainty about their medical conditions, as well as a lack of trust in the system to be responsive to their needs. They perceived having no other option about where to go to obtain answers or further reassurance because of actual or anticipated

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Data about changes in the characteristics of ED return visits before and after the COVID-19 outbreak are limited. This study aimed to report the differences on utility in ED return visits after the COVID-19 outbreak.
This retrospective cohort study was conducted from 2019 to 2020. Adult patients with ED return visits were included in the analysis. Variables including demographic characteristics, pre-comorbidities, triage levels, vital signs, chief complaints, management, and diagnosis were recorded and confirmed via a manual assessment.
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When discussing lack of diagnosis, residents explained the evaluation revealed no cause for symptoms, noted concerning diagnoses that were excluded, and acknowledged both symptoms and patients’ feelings. Residents used explicit and implicit language to discuss diagnostic uncertainty with similar frequency. Almost half of the residents discussed the ED role as focused on emergent illness to give patients context for their uncertain diagnoses. However, 28% of residents in this study did not discuss diagnostic uncertainty in any form. All residents provided reassurance.
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Understanding contributing factors to patient returns is also necessary to guide future quality initiatives to address any performance or service delivery issues. Return visits can be patient-, clinical- or illness-related [8,35,37,38], or due to service gaps and limited access to primary care [39], therefore each factor warrants exploration before recommendations can be made. Further work is needed at the study sites to determine local contributing factors to enable targeted, evidence-based interventions to be developed that address the high admitted return visit rate.
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View all citing articles on Scopus

: Please see page 378 for the Editor’s Capsule Summary of this article.

: Supervising editor: Daniel A. Handel, MD, MPH

: Author contributions: KLR and BGC conceived of the study. KLR, JEH, BGC, and JAS designed the study. KAP and MO conducted the data collection. KLR, KAP, and MO analyzed and interpreted the data. KLR drafted the article, and all authors contributed substantially to its revision. KLR takes responsibility for the paper as a whole.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist and provided the following details: Supported by the 2013 Emergency Medicine Foundation/Emergency Nurses Association Foundation Directed Team Grant.

: A podcast for this article is available at www.annemergmed.com.

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Health policy/original researchReturn Visits to the Emergency Department: The Patient Perspective

Study objective

Methods

Results

Conclusion

Introduction

Editor’s Capsule Summary

Section snippets

Study Design and Setting

Results

Limitations

Discussion

Am J Emerg Med

J Emerg Med

Ann Emerg Med

Am J Emerg Med

Am J Emerg Med

J Emerg Nurs

Ann Emerg Med

Ann Emerg Med

J Emerg Nurs

A reengineered hospital discharge program to decrease rehospitalization: a randomized trial

Ann Intern Med

Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization

J Hosp Med

Where Americans get acute care: increasingly, it’s not at their doctor's office

Health Aff (Millwood)

Identifying patients at high risk of emergency hospital admissions: a logistic regression analysis

J R Soc Med

Case finding for patients at risk of readmission to hospital: development of algorithm to identify high risk patients

BMJ

Predicting the likelihood of emergency admission to hospital of older people: development and validation of the Emergency Admission Risk Likelihood Index (EARLI)

Fam Pract

Predicting hospital admission and returns to the emergency department for elderly patients

Acad Emerg Med

Adverse health outcomes after discharge from the emergency department—incidence and risk factors in a veteran population

J Gen Intern Med

A brief risk-stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department

Acad Emerg Med

Health policy/original research
Return Visits to the Emergency Department: The Patient Perspective