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The characteristics and prognostic predictors of unplanned hospital admission within 72 hours after ED discharge
American Journal of Emergency Medicine 31 (2013) 1490–1494
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Original Contribution
The characteristics and prognostic predictors of unplanned hospital admission within 72 hours after ED discharge☆,☆☆ Shih-Yu Cheng, MD a, 1, Hui-Ting Wang, MD a, Chi-Wei Lee, MD b, Tsung-Cheng Tsai, MD a, Chi-Wei Hung, MD a, Kuan-Han Wu, MD a,⁎ a b
Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung County 833, Taiwan Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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Article history: Received 24 June 2013 Received in revised form 28 July 2013 Accepted 3 August 2013
a b s t r a c t Objectives: The aims of this study were (1) to identify the characteristics of patients who return to the emergency department (ED) within 72 hours and are admitted to the hospital and (2) to identify the characteristics and predictors of in-hospital mortality subgroup. Methods: This study was conducted in a tertiary teaching hospital to identify characteristics of adult nontraumatic revisit-admission patients from January 1 to December 31, 2011. Demographic data, cause of revisit, and the underlying diseases as well as the in-hospital complications were reviewed. Results: Of the 72 188 ED discharged patients, 690 revisit-admission patients were enrolled. The top 3 disease classifications were infection (38.7%), neurology (11.3%), and gastroenterology (11.2%). The etiology of the revisit included recurrent symptoms (72%), disease complications (15.8%), and inadequate diagnosis (12.1%). A total of 150 patients (21.7%) had complications, including receiving operation (17.2%), intensive care unit admission (4.2%), and cardiovascular conditions (2.5%). Forty-nine patients (7.1%) died during hospitalization owing to sepsis (57.1%), malignancy (34.7%), cardiogenic diseases (4.1%), and cerebrovascular conditions (4.1%). The nonsurvival group was older (64.1 ± 15.3 vs 55.7 ± 17.8; P b .001), had more patients with a diagnosis of moderate to severe liver disease (18.4% vs 4.8%; P b .001), malignancy (69.3% vs 20.1%; P b .001), and metastatic solid tumor (38.8% vs 6.2%; P b .001). Conclusions: Age and diagnosis with malignancy, metastatic tumors, or moderate-to-severe liver disease were predictors of in-hospital mortality among 72-hour revisit-admission patients. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Unscheduled 72-hour emergency department (ED) return visit is a widely reviewed quality assurance tool [1-6] and is an important component of an indicator used by the Taiwan Joint Commission on Hospital Accreditation. It is also used for continuous quality monitoring, and further investigation of the underlying causes should be conducted if the return rates exceed a baseline level because a high rate of return visits may reflect potential ED dysfunction [7,8]. The risk of early return visits in the overall ED population has been reported to be approximately 3% in most studies, ranging from 1.9% to 5.47% [2-6]. These patients are considered to be at a higher risk for complications and mortality and are considered worthy of further investigation to avoid possible medical errors [1,2]. The proportion of avoidable ☆ Prior presentations: The abstract of this manuscript has been presented as a poster in the International Society for Quality in Healthcare 29th International Conference, October 21 to 24, 2012, Geneva, Switzerland. ☆☆ Funding sources/disclosures: No. ⁎ Corresponding author. Kaohsiung County 833, Taiwan (R.O.C.). Tel.: +886 0988 593 592; fax: +886 07 7317123 8415. E-mail address: [email protected] (K.-H. Wu). 1 Cofirst author (equal contribution): Shih-Yu Cheng and Hui-Ting Wang. 0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajem.2013.08.004
unscheduled ED revisits was reported to be between 8.2% [4] and 32.3% [2]. The causes of revisits, chief complaints, and characteristics of the general population who return to the ED within 72 hours have been analyzed in various time frames and hospital settings [6,7,9,10]. Compared with those who revisit and are discharged, patients who revisit and are admitted within 72 hours from the first ED visit (“revisit-admission”) tend to be at a higher risk for inappropriate management or even medical errors. The overall ward admission rate among patients with unscheduled 72-hour revisits has been reported to be 22% to 35.7% [9,11-13]. However, to our knowledge, only a few studies have further examined this specific high-risk group. MartinGill and Reiser [14] performed an analysis to identify risk factors for revisit-admission patients within 72 hours after ED discharge. According to this study, patients who were older, had insurance for the elderly (Medicare), and arrived by ambulance were at a higher risk for revisit admission. The highest risks at initial diagnosis were mental disorders, genitourinary diseases, and symptom-based diagnoses. Another study reported that dehydration was the most common diagnosis (prevalence, 25%) in the return-admit populations [12]. In 1 previous report [11], the mortality of patients who visited the ED within 72 hours was 1%, whereas another study observed an
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overall 10% mortality rate in revisit-admission patients [13]. However, detail information about the outcomes and etiology of revisit admissions in these patients is still insufficient. 2. Aim The primary objective of this study was to determine the rates, causes, characteristics, and outcomes of revisit-admission patients. The second objective was to identify characteristics of in-hospital mortality subgroup. 3. Methods 3.1. Study design A retrospective study was performed to identify the characteristics of adult nontrauma patients with unscheduled 72-hour ED revisitadmission patients. 3.2. Study setting and population This study was conducted in a 3000-bed, tertiary teaching hospital in southern Taiwan that annually receives 72 000 adult nontrauma ED visits. The sample consisted of all patients with 72-hour ED return visits from January 1 to December 31, 2011. Electronic charts were extracted from our ED administrative database. Patients who revisited the ED for nonrelated medical problems were excluded. To analyze revisit-admission populations related to medical decision only, we also excluded patient-associated revisits, which were defined as revisits by patients who were discharged against medical advice or who were discharged owing to patient's personal reasons, mostly socioeconomic problems, such as poor compliance, a preference for outpatient treatment, or family care problems. 3.3. Study protocol and measurements The patients' clinical characteristics including underlying disease, triage level according to Taiwan triage and acuity scale, diagnosis, disease classifications, management in the first ED visit (eg, the examinations performed), disposition, and ED length of stay (LOS) were documented. Major underlying disease, which is included in the validated prognosis forecasting score, Charlson Comorbidity Index [15], was recorded. Included diseases were myocardial infarction, congestive heart failure, peripheral vascular disease, dementia, cerebrovascular disease, chronic lung disease, connective tissue disease, ulcer, chronic liver disease, hemiplegia, moderate or severe kidney disease, diabetes, diabetes with complications, tumor, leukemia/lymphoma, moderate or severe liver disease, malignant tumor, metastasis, and AIDS. Moderate or severe liver disease was defined as patient who had Child-Pugh score B or C. The type of examinations including blood or urine laboratory tests, electrocardiography, echo studies, plain radiological plain images, computed tomography, or other specific image studies were also documented. Diseases were grouped into the following 16 medical categories: cardiovascular (CV) conditions, gastroenterology, chest, nephrology, infection, general medicine, neurology, oncology, hematology, rheumatology, endocrinology, surgery, gynecology and obstetrics, otolaryngology, ophthalmology, and psychiatry diseases. All febrile diseases such as pneumonia or urinary tract infection were all categorized into infection group except patients who might need surgery intervention. For example, if a patient who presented with abdominal pain and fever and later returned with appendicitis, he would be categorized into surgery group. The survival and complications of revisit admission and the etiology of the revisits were reviewed. Complications were defined as mortality; intensive care unit (ICU) hospitalization; receiving an operation; and cardiogenic complications,
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including myocardial infarction, receiving a cardiac catheterization, and ventricular arrhythmia. The patients included in the study were reviewed and categorized into 3 groups according to the etiologies of the return visit: recurrent symptoms, disease complications, and “inadequate diagnosis.” For the first 2 classifications, the diagnosis related to the disease entity was similar between the first ED visit and the revisit; the reason for the revisit was categorized as “disease related.” Patients who had a different diagnosis in the course of the revisit were categorized into the inadequate diagnosis group. Recurrent symptoms were defined as the recurrence of the same symptoms, such as fever or abdominal pain, attributed to the patient in the first ED diagnosis. In these cases, no new evidence of disease progression or complications was presented. Disease complications were defined as new symptoms or evidence of reasonable and unavoidable disease progression. Inadequate diagnosis was considered to have potentially resulted from an inappropriate or inadequate assessment of the patient's condition, atypical disease patterns or limited evidence in the early disease course, disease that was not immediately life threatening (eg, malignancy), and true misdiagnosis. Patients were further divided into survival and nonsurvival groups for further comparison to identify risks of mortality. All the electronic medical records of every revisit patient were reviewed independently by 2 experienced emergency physicians (EPs) for determining patient inclusion and identifying the etiology of the revisit. If inconsistency occurred between the 2 authors, the final decision was made after a consensus meeting with a third author. The study was approved by the institutional review board in the study institution. 3.4. Data analysis Data were expressed as mean ± SD or percentage (%). Continuous variables were analyzed by the independent t test, and categorical variables were analyzed by the χ 2 test. We used SPSS statistical software for Windows version 13 (SPSS for Windows, version 13; SPSS, Inc, Chicago, IL). A 2-tailed P value of less than .05 was considered statistically significant. 4. Results During the 1-year study period, 72 188 nontraumatic adult patients visited the ED and were discharged. Of these, 2275 patients revisited the ED within 72 hours (3.15%). Among these revisiting patients, 1103 (48%) were admitted to the hospital, resulting in an overall 72-hour revisit-admission rate of 1.5%. We then excluded patients who made unrelated revisits (n = 137) or patient-related revisits including those against medical advice (n = 87) and those who made visits for personal reasons (n = 187). Consequently, 690 patients who revisited under the same diagnosis as the first ED visit were enrolled in the study. The baseline clinical characteristics are listed in Table 1. The mean age of the study group was 56.0 ± 17.7 years, and most patients (74.8%) were categorized into triage level III in the first ED visit. Moreover, 45.2% of the population returned in the first 24 hours. In addition, 534 patients (77.4%) received laboratory tests, and 376 patients (54.5%) underwent radiologic studies, so that overall 609 patients (87.8%) received at least 1 or more examinations in the first visit. Furthermore, 39.9% of these patients were temporarily kept in the ED observation room for treatment or further examination. The average ED LOS was 39.40 hours. The most common chief complaints among our study population were fever (28.1%), abdominal pain (23.2%), and dizziness/vertigo (12.5%). The top 3 disease categories were febrile (38.7%), neurologic (11.3%), and gastroenterological (11.2%) diseases. The distribution of the etiology for revisits is presented in Table 2. In particular, 72% of the
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Table 1 Demographic factors and characteristics of patients who returned to the ED within 72 hours and were admitted to the hospital (n = 690) Variables
Patient number (%)
Age Male Triage distribution in the first visit Level I Level II Level III Level IV Level V First ED visit disposition Discharge from ED Discharge from observation room First ED visit LOS (h) Disease categories Infection Neurology Gastroenterology
56.34 ± 17.7 353 (51.2%) 2 (0.3%) 150 (21.7%) 516 (74.8%) 22 (3.2%) 0
Table 3 Complications and mortality among revisit-admission patients (n = 690) Total complications Surgery ICU hospitalization Cardiogenic complicationsa Total death Cardiogenic origin Sepsis Cerebrovascular origin Malignancy
150 (21.7%) 119 (17.2%) 29 (4.2%) 17 (2.5%) 49 (7.1%) 2 (0.3%) 28 (4.1%) 2 (0.3%) 17 (2.5%)
a Cardiogenic complications including myocardial infarction, receiving cardiac catheterization, and ventricular arrhythmia.
415 (60.1%) 275 (39.9%) 39.40
underlying disease showed no statistically significant difference in both group.
(38.7%) (11.3%) (11.2%)
5. Discussion study group revisited the ED because of recurrent symptoms without obvious complications. Patient revisiting with new symptoms related to the complications of disease progression accounted for 15.8% of the study group. The overall inadequate diagnosis rate was 12.1%. The top 3 disease categories were infectious (29.8%), surgical (25%), and neurologic (11.2%) diseases. As shown in Table 3, 49 (7.1%) of the revisit-admission patients died during hospitalization. Of them, the etiology for mortality was owing to sepsis (57.1%), malignancy (34.7%), cardiogenic conditions (4.1%), and cerebrovascular conditions (4.1%). A total of 150 patients (21.7%) had complications: 119 patients (17.2%) underwent an operation during the revisit; 29 (4.2%) were indicated for ICU admission; and 17 (2.5%) had CV complications, including myocardial infarction, receiving cardiac catheterization, or ventricular arrhythmia. Among the patients who received an operation in the revisit admission, the 3 most common diagnoses were acute appendicitis (14.3%); malignancy-related complications (12.6%), including bleeding or intestinal tract obstruction; and cholecystitis (10.9%). For identifying the characteristics of in-hospital mortality subgroup, patients were divided into the nonsurvival group and the survival group for further comparisons (Table 4). A notably higher mortality was observed in older patients (64.1 ± 15.3 vs 55.7 ± 17.8 years; P b .001). The management in the first visit included observation and examination, and the overall LOS in the ED showed no statistical significance difference between the 2 groups. The most common disease categories of the mortality group were oncologic (42.9%) and infectious (38.8%) diseases. Meanwhile, the top 3 disease categories in the survival group were febrile (38.7%), gastroenterological (11.9%), and neurologic (11.7%) diseases. No significant differences were observed between the 2 groups in terms of disease categories and the etiology of the return visits. As for the underlying disease, the nonsurvival group had more patients with a diagnosis of moderate or severe liver disease (18.4% vs 4.8%; P b .001), malignancy such as leukemia (69.3% vs 20.1%; P b .001), and metastatic solid tumor (38.8% vs 6.2%: P b .001) in univariate analysis. Other
Table 2 Etiologies of return visit patients and the disease categories of inadequate diagnosis group Disease-related etiologies Recurrent symptoms Disease complications Inadequate diagnosis Infection Surgery Neurology
497 109 84 25 21 12
(72.0%) (15.8%) (12.2%) (29.8%) (25%) (14.3%)
The unscheduled 72-hour ED return is a well-known quality indicator in terms of the quality of care and patient safety. However, as a quality indicator, it has 2 major issues that have the potential to affect regular auditing and result in the ineffective application of administrative resources. First, patients may return to the ED for a variety of reasons unrelated to a medical error. One of the most common patient-related causes of return visits has been substance abuse among chronic users and addicts [14]. Some frequent ED users return to the ED with similar complaints because of chronic psychiatric/personality problems [14]. Patients may revisit ED as a source of primary care out of selfconvenience, social-fiscal problems, or poor compliance. These socalled patient-related causes may influence the effectiveness of chart review and may require more time and manpower for the regular audit. Pham et al [16] found that patients who return to the ED within 72 hours do not use more resources, are not more severely ill, and do not have a higher hospital admission rate than those who had not been previously seen. In their opinion, a more refined subgroup such as 72-hour revisit admission may have more value as a quality indicator [16]. Therefore, we enrolled a more solid study population by choosing patient with revisit admission and excluded patients who made unrelated revisits or patient-related revisits and those who made visits for personal reasons. Second, the overall mortality of patients who revisit within 72 hours has been reported to be as low as 0% to 1% [7,11]. Hospital
Table 4 The characteristics of mortality in the return visit after hospitalization
Age Male sex Observation during first visit First length of stay (min) First examination (%)a Etiologies of return visit Recurrent symptoms Disease complications Inadequate diagnosis Disease categories Infection Neurology Gastroenterology Oncology Moderate or severe liver disease Any malignancy Metastasis a
Nonsurvival (n = 49)
Survival (n = 641)
P
64.1 ± 15.3 25 (51.0%) 25 (51.0%) 628.6 ± 1178.6 45 (91.8%)
55.7 ± 17.8 328(51.2%) 390 (60.8%) 531.6 ± 967.1 561 (87.5%)
.001 1.000 .176 .506 .498 .985
36 (73.5%) 7 (14.3%) 6 (12.2%)
461(71.9%) 102 (15.9%) 78 (12.2%)
19 (38.8%) 2 (4.1%) 2 (4.1%) 22 (44.9%) 9 (18.4%) 34 (69.3%) 19 (38.8%)
248 (38.7%) 76 (11.9%) 75 (11.7%) 38 (5.9%) 31 (4.8%) 129 (20.1%) 40 (6.2%)
Examination performed in the first ED visit.
b.001
b.001 b.001 b.001
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admission has been identified as a critical indicator of the severity of disease, and these patients could represent the highest risk subset of early returns [11,14]. In the present study, we found an overall 7.1% in-hospital mortality and a high complication rate of up to 21.7%. In consideration of the growing restraint on medical resources and the relatively low prevalence of complications among 72-hour revisit patients, it is reasonable for ED directors to review 72-hour revisitadmission patients for risk management and serving as a nice educational tool for young ED physician, especially those patients who had complications. A number of studies have investigated patients who revisited the ED within 72 hours; however, very few have studied the attributes of revisit-admission patients. This study aimed to clarify the characteristics and outcome of this high-risk subgroup. Three major features of these patients are worth noting. First, the most common chief complaints among our study population were fever (28.1%), abdominal pain (23.2%), and dizziness/vertigo (12.5%). Meanwhile, the top 3 disease categories according to the final primary diagnoses were febrile (38.7%), neurologic (11.3%), and gastroenterological (11.2%) diseases. In the study by Keith et al [2], infectious and gastroenterological diseases were 2 of the top 3 diagnosis groups in nontrauma patients who made unscheduled revisits. The results of our study were also similar with those of a previous study that analyzed the 72-hour revisit group [6]. In this previous study, the most common initial ED presentations were for abdominal pain (12.9%), fever (12.6%), vertigo (4.5%), headache (2.1), and upper respiratory infection (2.1%). The presentation of patients with fever, abdominal pain, and dizziness/vertigo are a continual challenge in emergency care. For abdominal pain and headaches, 57% and 59% of patients were discharged with a symptomatic diagnosis, respectively, rather than a definite pathologic diagnosis [17]. Patients with abdominal pain represented 6.5% of all ED visitors, but they were diagnosed with an undifferentiated etiology [18]. In terms of fever, ED-managed patients with a febrile illness frequently show no particular localizing symptom or sign to suggest a fever source. This ill-defined but rather common clinical manifestation has been called unexplained fever [19]. Gur et al [19] reported that the etiology of unexplained fever in the admission and discharge groups combined was still unknown in 71.22% (99/139) of cases after 30-day follow-up. Although obtaining a definitive diagnosis for these patients is often difficult, patients with fever, abdominal pain, and dizziness/vertigo should be carefully examined because they account for 61.2% of all revisit-admission groups. Second, patients were grouped according to the objectively documented diagnosis rather than by retrospective judgments in our study. It is because differentiating between the natural course of a disease, inadequate patient instruction, suboptimal therapy, and true medical errors is often difficult in retrospective chart reviews. In taking this approach, we found that disease-related revisits accounted for mostly (87.8%) of the study group. In terms of inadequate diagnosis group, some EPs would argue that obtaining a definitive diagnosis is often neither possible nor necessary for all cases in the ED setting. For example, patients who visit the ED because of constipation may have occult rectum malignancy, and the EPs may not perform subsequent examination if the condition is relieved by medication. Understandably, in these types of scenarios, judging the diagnosis as “misdiagnosis” is questionable. Therefore, we simply categorized these patients as inadequate diagnosis; these patients accounted for 12.2% (84/690) of the study group. Of them, the most frequent diagnosis was fever (25/84 [29.8%]) without specific focus, and the final diagnosis of these patients included dengue fever (4), infective spondylitis (3), atypical infection (3), cellulitis (3), septic arthritis (2), left axillary abscess (1), liver abscess (1), occult sepsis (2), viral meningitis (1), urinary tract infection (3), pneumonia (1), and malignancy (1). Most of the patients in this category presented initially with fever and nonspecific symptoms, such as myalgia or
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general malaise, and they were treated with supportive care during the first visit. The subsequent most frequent diagnoses were surgical diseases (21/84 [25%]), which comprised 8 cases of appendicitis, 7 cases of ileus, and 6 cases of cholecystitis. These patients initially presented with only nonspecific pain, vomiting or nausea, and gastrointestinal upset. Patients with infectious or gastrointestinal disease often present with atypical or trivial manifestations that may result in inadequate diagnosis in the ED. Although inaccurate diagnoses at the early stage is understandable, it is mandatory for EPs to accumulate sufficient clinical experience through case conferences for the early detection of underlying clinical problems and to provide adequate patient education before ED discharges to avoid medico-legal disputes. Third, the most notable finding of our study was the high mortality (7.1%) and morbidity of these revisit-admission patients. In terms of mortality for 72-hour ED revisit-admission patients, only 1 other report has been published on this subject. In a retrospective analysis of revisit-admission patients, Wang et al [13] found an overall mortality rate of 10%. However, this previous report had limited power resulting from the 1-month period of the study and the small sample group (n = 60). The cause of death in this previous study was related to sepsis (57.1%), malignancy (34.7%), CV disease (4.1%), and cardiogenic conditions (4.1%). In our study, the initial chief complaint of “fever” was found to be a major potential pitfall in the ED diagnoses. The complication rate of the current patient group was up to 21.7%. The leading major source of complications was in regard to receiving an operation, and the leading 3 diagnoses were acute appendicitis (17/119, 14.3%), malignancy-related diseases (15/119, 12.6%) (such as colon cancer presenting with ileus, recurrent tumor bleeding, dysphagia related to esophageal cancer), and cholecystitis (13/119, 10.9%). In a previous study focusing on 72-hour revisit-admission and subsequent operations, Yen et al [20] found that urolithiasis and biliary tract disease were the most frequent diagnoses of their study group after comparisons with the control group. These specific diseases should be kept in mind to prevent unnecessary revisitadmission complications. To survey the characteristics for in-hospital mortality subgroup, we further analyzed the patients' underlying diseases and found a notably higher mortality in patients who were older, previously diagnosed with any malignancy (eg, leukemia), and had moderate or severe liver disease or a metastatic solid tumor. Our findings are consistent with those of Martin-Gill and Reiser [14], in which older patients, especially those older than 65 years and patients with insurance for the elderly (Medicare) were at higher risk for revisit admission. Another work published by Fan et al [21] showed that an age of 65 years or older was a risk factor for unexpected ICU admission within 3 days after discharge from the ED. As such, an age of 65 years or older was a risk factor of revisit admission in both of these previous studies and was one of the independent predictors of mortality in the revisit ICU admission group. Our findings are compatible with these previous results and further showed that age was a risk factor of inhospital death among revisit-admission groups. In the present study, we also noticed that the in-hospital mortality was not correlated with the LOS in the ED during the initial ED visit, the amount of medical examinations performed, or the cause of the ED revisits. The in-hospital mortality was only correlated with the underlying medical conditions of the revisiting patients. Our results imply that the patient's underlying condition, including age and comorbidities, are the major predictors of in-hospital mortality among 72-hour revisit-admission patients. Further research is needed to validate and corroborate this finding. The revisit-admission rate was 48% in the current study and was higher than that of previous reports (22%-35.7%) [9,11-13]. This phenomenon could be partially explained by overcrowding and the shortage of in-hospital beds. Of the patients, 87.8% received at least 1 examination (eg, computed tomographic scan). Overall, 39.9% of
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patients were briefly managed in the ED observation room, with an average LOS of 39.4 hours. The long LOS as well as the high proportion of those who underwent exams and observation reflected relatively complicated disease entities. Combined with the 87.8% diseaserelated revisits, the premature discharge with possible inadequate treatment or observation during the first visit was likely. In our ED, we have 150 observation beds with a high occupancy rate of 92.68%. Patients who should have been admitted to the in-hospital ward were treated in the observation room instead. Emergency department physician tends to discharge patients for relieving overcrowding, and patients did not favor staying in the observation room if the symptoms were improved after partial treatment. Revisiting for inhospital bed waiting and admission were mostly suggested in the discharge plan. A higher revisit-admission rate could be expected under such conditions. 6. Limitations This retrospective study had several limitations. First, because the study was carried out in only 1 hospital, the results may not be generalizable to other settings. Second, ED patients may have revisited the EDs of other hospitals. However, our hospital is one of the largest medical centers in southern Taiwan, and its ED deals with most ED patients in the local region. Therefore, the number of patients revisiting other EDs was considered to be negligible. Third, a lack of consensus is present among EPs about the criteria for hospitalizing ED patients. Patients were admitted primarily based on the clinical judgments of treating EPs in a busy and crowded ED, which might have influenced the composition of the study group. Finally, this study was studied in an extremely overcrowding ED, as previously described. Thence, the severity and overall revisitadmission rate of study population tend to be higher than other hospital. The higher proportion of inadequate diagnosis related to premature discharge was also likely. Further large-scale, multicenter, prospective studies should be performed for further investigations of this group of patients. 7. Conclusion A relatively high occurrence of high morbidity and mortality rate was observed among revisit-admission patients. It might be helpful by establishing a policy of chart audits to review these patients for risk management and standard discharge plan development. Patients with tumors, leukemia, metastatic tumors, and moderate-to-severe liver disease and who are elderly represent the most high-risk population
for in-hospital mortality. Further efforts to identify prospective methods of preventing 72-hour admissions are warranted. References [1] Lerman B, Kobernick MS. Return visits to the emergency department. J Emerg Med 1987;5:359–62. [2] Keith KD, Bocka JJ, Kobernick MS, Krome RL, Ross MA. Emergency department revisits. Ann Emerg Med 1989;18:964–8. [3] Pierce JM, Kellerman AL, Oster C. “Bounces”: an analysis of short-term return visits to a public hospital emergency department. Ann Emerg Med 1990;19:752–7. [4] Hu SC. Analysis of patient revisits to the emergency department. Am J Emerg Med 1992;10:366–70. [5] Wilkins PS, Beckett MW. Audit of unexpected return visits to an accident and emergency department. Arch Emerg Med 1992;9:352–6. [6] Wu CL, Wang FT, Chiang YC, Chiu YF, Lin TG, Fu LF, et al. Unplanned emergency department revisits within 72 hours to a secondary teaching referral hospital in Taiwan. J Emerg Med 2010;38:512–7. [7] Kelly AM, Chirnside AM, Curry CH. An analysis of unscheduled return visits to an urban emergency department. N Z Med J 1993;106:334–6. [8] Schenkel S. Promoting patient safety and preventing medical error in emergency departments. Acad Emerg Med 2001;7:1201–22. [9] Chung CH, Ng CP. An analysis of unscheduled return visits to the accident and emergency department of a general public hospital. J Emerg Med 2003;10: 153–61. [10] White DKL, Eddy L. Characteristics of patients who return to the emergency department within 72 hours in one community hospital. Adv Emerg Nurs J 2011;33(4):344–53. [11] Nunez S, Hexdall A, Aguirre-Jaime A. Unscheduled returns to the emergency department: an outcome of medical errors? Qual Saf Health Care 2006;15:102–8. [12] Gordon JA, An LC, Hayward RA, Williams BC. Initial emergency department diagnosis and return visits: risk versus perception. Ann Emerg Med 1998;32: 569–73. [13] Wang HY, Chew G, Kung CT, Chung KJ, Lee WE. The use of Charlson comorbidity index for patients revisiting the emergency department within 72 hours. Chang Gung Med J 2007;30:437–44. [14] Martin-Gill C, Reiser RC. Risk factors for 72-hour admission to the ED. Am J Emerg Med 2004;22:448–53. [15] Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–83. [16] Pham JC, Kirsch TD, Hill PM, DeRuggerio K, Hoffmann B. Seventy-two-hour returns may not be a good indicator of safety in the emergency department: a national study. Acad Emerg Med 2011;18:390–7. [17] Wen LS, Kosowsky JM, Gurrola ER, Camargo Jr CA. The provision of diagnosis at emergency department discharge: a pilot study. Emerg Med J. 2002. http://dx.doi. org/10.1136/emermed-2012-201749. [18] Hastings RS, Powers RD. Abdominal pain in the ED: a 35 year retrospective. Am J Emerg Med 2011;29:711–6. [19] Gur H, Aviram R, Or J, Sidi Y. Unexplained fever in the ED: analysis of 139 patients. Am J Emerg Med 2003;21:230–5. [20] Yen P-C, Wu K-H, Cheng H-H, Cheng F-J, Gung C-T, Lee W-H. 72-hour revisit, hospitalization, and operations performed among patients originally discharged from the emergency department. J Taiwan Emerg Med 2009;11:117–22. [21] Fan JS, Kao WF, Yen DH, Wang LM, Huang CI, Lee CH. Risk factors and prognostic predictors of unexpected intensive care unit admission within 3 days after ED discharge. Am J Emerg Med 2007;25:1009–14.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Original Contribution
The characteristics and prognostic predictors of unplanned hospital admission within 72 hours after ED discharge☆,☆☆ Shih-Yu Cheng, MD a, 1, Hui-Ting Wang, MD a, Chi-Wei Lee, MD b, Tsung-Cheng Tsai, MD a, Chi-Wei Hung, MD a, Kuan-Han Wu, MD a,⁎ a b
Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung County 833, Taiwan Department of Emergency Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
a r t i c l e
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Article history: Received 24 June 2013 Received in revised form 28 July 2013 Accepted 3 August 2013
a b s t r a c t Objectives: The aims of this study were (1) to identify the characteristics of patients who return to the emergency department (ED) within 72 hours and are admitted to the hospital and (2) to identify the characteristics and predictors of in-hospital mortality subgroup. Methods: This study was conducted in a tertiary teaching hospital to identify characteristics of adult nontraumatic revisit-admission patients from January 1 to December 31, 2011. Demographic data, cause of revisit, and the underlying diseases as well as the in-hospital complications were reviewed. Results: Of the 72 188 ED discharged patients, 690 revisit-admission patients were enrolled. The top 3 disease classifications were infection (38.7%), neurology (11.3%), and gastroenterology (11.2%). The etiology of the revisit included recurrent symptoms (72%), disease complications (15.8%), and inadequate diagnosis (12.1%). A total of 150 patients (21.7%) had complications, including receiving operation (17.2%), intensive care unit admission (4.2%), and cardiovascular conditions (2.5%). Forty-nine patients (7.1%) died during hospitalization owing to sepsis (57.1%), malignancy (34.7%), cardiogenic diseases (4.1%), and cerebrovascular conditions (4.1%). The nonsurvival group was older (64.1 ± 15.3 vs 55.7 ± 17.8; P b .001), had more patients with a diagnosis of moderate to severe liver disease (18.4% vs 4.8%; P b .001), malignancy (69.3% vs 20.1%; P b .001), and metastatic solid tumor (38.8% vs 6.2%; P b .001). Conclusions: Age and diagnosis with malignancy, metastatic tumors, or moderate-to-severe liver disease were predictors of in-hospital mortality among 72-hour revisit-admission patients. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Unscheduled 72-hour emergency department (ED) return visit is a widely reviewed quality assurance tool [1-6] and is an important component of an indicator used by the Taiwan Joint Commission on Hospital Accreditation. It is also used for continuous quality monitoring, and further investigation of the underlying causes should be conducted if the return rates exceed a baseline level because a high rate of return visits may reflect potential ED dysfunction [7,8]. The risk of early return visits in the overall ED population has been reported to be approximately 3% in most studies, ranging from 1.9% to 5.47% [2-6]. These patients are considered to be at a higher risk for complications and mortality and are considered worthy of further investigation to avoid possible medical errors [1,2]. The proportion of avoidable ☆ Prior presentations: The abstract of this manuscript has been presented as a poster in the International Society for Quality in Healthcare 29th International Conference, October 21 to 24, 2012, Geneva, Switzerland. ☆☆ Funding sources/disclosures: No. ⁎ Corresponding author. Kaohsiung County 833, Taiwan (R.O.C.). Tel.: +886 0988 593 592; fax: +886 07 7317123 8415. E-mail address: [email protected] (K.-H. Wu). 1 Cofirst author (equal contribution): Shih-Yu Cheng and Hui-Ting Wang. 0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajem.2013.08.004
unscheduled ED revisits was reported to be between 8.2% [4] and 32.3% [2]. The causes of revisits, chief complaints, and characteristics of the general population who return to the ED within 72 hours have been analyzed in various time frames and hospital settings [6,7,9,10]. Compared with those who revisit and are discharged, patients who revisit and are admitted within 72 hours from the first ED visit (“revisit-admission”) tend to be at a higher risk for inappropriate management or even medical errors. The overall ward admission rate among patients with unscheduled 72-hour revisits has been reported to be 22% to 35.7% [9,11-13]. However, to our knowledge, only a few studies have further examined this specific high-risk group. MartinGill and Reiser [14] performed an analysis to identify risk factors for revisit-admission patients within 72 hours after ED discharge. According to this study, patients who were older, had insurance for the elderly (Medicare), and arrived by ambulance were at a higher risk for revisit admission. The highest risks at initial diagnosis were mental disorders, genitourinary diseases, and symptom-based diagnoses. Another study reported that dehydration was the most common diagnosis (prevalence, 25%) in the return-admit populations [12]. In 1 previous report [11], the mortality of patients who visited the ED within 72 hours was 1%, whereas another study observed an
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overall 10% mortality rate in revisit-admission patients [13]. However, detail information about the outcomes and etiology of revisit admissions in these patients is still insufficient. 2. Aim The primary objective of this study was to determine the rates, causes, characteristics, and outcomes of revisit-admission patients. The second objective was to identify characteristics of in-hospital mortality subgroup. 3. Methods 3.1. Study design A retrospective study was performed to identify the characteristics of adult nontrauma patients with unscheduled 72-hour ED revisitadmission patients. 3.2. Study setting and population This study was conducted in a 3000-bed, tertiary teaching hospital in southern Taiwan that annually receives 72 000 adult nontrauma ED visits. The sample consisted of all patients with 72-hour ED return visits from January 1 to December 31, 2011. Electronic charts were extracted from our ED administrative database. Patients who revisited the ED for nonrelated medical problems were excluded. To analyze revisit-admission populations related to medical decision only, we also excluded patient-associated revisits, which were defined as revisits by patients who were discharged against medical advice or who were discharged owing to patient's personal reasons, mostly socioeconomic problems, such as poor compliance, a preference for outpatient treatment, or family care problems. 3.3. Study protocol and measurements The patients' clinical characteristics including underlying disease, triage level according to Taiwan triage and acuity scale, diagnosis, disease classifications, management in the first ED visit (eg, the examinations performed), disposition, and ED length of stay (LOS) were documented. Major underlying disease, which is included in the validated prognosis forecasting score, Charlson Comorbidity Index [15], was recorded. Included diseases were myocardial infarction, congestive heart failure, peripheral vascular disease, dementia, cerebrovascular disease, chronic lung disease, connective tissue disease, ulcer, chronic liver disease, hemiplegia, moderate or severe kidney disease, diabetes, diabetes with complications, tumor, leukemia/lymphoma, moderate or severe liver disease, malignant tumor, metastasis, and AIDS. Moderate or severe liver disease was defined as patient who had Child-Pugh score B or C. The type of examinations including blood or urine laboratory tests, electrocardiography, echo studies, plain radiological plain images, computed tomography, or other specific image studies were also documented. Diseases were grouped into the following 16 medical categories: cardiovascular (CV) conditions, gastroenterology, chest, nephrology, infection, general medicine, neurology, oncology, hematology, rheumatology, endocrinology, surgery, gynecology and obstetrics, otolaryngology, ophthalmology, and psychiatry diseases. All febrile diseases such as pneumonia or urinary tract infection were all categorized into infection group except patients who might need surgery intervention. For example, if a patient who presented with abdominal pain and fever and later returned with appendicitis, he would be categorized into surgery group. The survival and complications of revisit admission and the etiology of the revisits were reviewed. Complications were defined as mortality; intensive care unit (ICU) hospitalization; receiving an operation; and cardiogenic complications,
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including myocardial infarction, receiving a cardiac catheterization, and ventricular arrhythmia. The patients included in the study were reviewed and categorized into 3 groups according to the etiologies of the return visit: recurrent symptoms, disease complications, and “inadequate diagnosis.” For the first 2 classifications, the diagnosis related to the disease entity was similar between the first ED visit and the revisit; the reason for the revisit was categorized as “disease related.” Patients who had a different diagnosis in the course of the revisit were categorized into the inadequate diagnosis group. Recurrent symptoms were defined as the recurrence of the same symptoms, such as fever or abdominal pain, attributed to the patient in the first ED diagnosis. In these cases, no new evidence of disease progression or complications was presented. Disease complications were defined as new symptoms or evidence of reasonable and unavoidable disease progression. Inadequate diagnosis was considered to have potentially resulted from an inappropriate or inadequate assessment of the patient's condition, atypical disease patterns or limited evidence in the early disease course, disease that was not immediately life threatening (eg, malignancy), and true misdiagnosis. Patients were further divided into survival and nonsurvival groups for further comparison to identify risks of mortality. All the electronic medical records of every revisit patient were reviewed independently by 2 experienced emergency physicians (EPs) for determining patient inclusion and identifying the etiology of the revisit. If inconsistency occurred between the 2 authors, the final decision was made after a consensus meeting with a third author. The study was approved by the institutional review board in the study institution. 3.4. Data analysis Data were expressed as mean ± SD or percentage (%). Continuous variables were analyzed by the independent t test, and categorical variables were analyzed by the χ 2 test. We used SPSS statistical software for Windows version 13 (SPSS for Windows, version 13; SPSS, Inc, Chicago, IL). A 2-tailed P value of less than .05 was considered statistically significant. 4. Results During the 1-year study period, 72 188 nontraumatic adult patients visited the ED and were discharged. Of these, 2275 patients revisited the ED within 72 hours (3.15%). Among these revisiting patients, 1103 (48%) were admitted to the hospital, resulting in an overall 72-hour revisit-admission rate of 1.5%. We then excluded patients who made unrelated revisits (n = 137) or patient-related revisits including those against medical advice (n = 87) and those who made visits for personal reasons (n = 187). Consequently, 690 patients who revisited under the same diagnosis as the first ED visit were enrolled in the study. The baseline clinical characteristics are listed in Table 1. The mean age of the study group was 56.0 ± 17.7 years, and most patients (74.8%) were categorized into triage level III in the first ED visit. Moreover, 45.2% of the population returned in the first 24 hours. In addition, 534 patients (77.4%) received laboratory tests, and 376 patients (54.5%) underwent radiologic studies, so that overall 609 patients (87.8%) received at least 1 or more examinations in the first visit. Furthermore, 39.9% of these patients were temporarily kept in the ED observation room for treatment or further examination. The average ED LOS was 39.40 hours. The most common chief complaints among our study population were fever (28.1%), abdominal pain (23.2%), and dizziness/vertigo (12.5%). The top 3 disease categories were febrile (38.7%), neurologic (11.3%), and gastroenterological (11.2%) diseases. The distribution of the etiology for revisits is presented in Table 2. In particular, 72% of the
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Table 1 Demographic factors and characteristics of patients who returned to the ED within 72 hours and were admitted to the hospital (n = 690) Variables
Patient number (%)
Age Male Triage distribution in the first visit Level I Level II Level III Level IV Level V First ED visit disposition Discharge from ED Discharge from observation room First ED visit LOS (h) Disease categories Infection Neurology Gastroenterology
56.34 ± 17.7 353 (51.2%) 2 (0.3%) 150 (21.7%) 516 (74.8%) 22 (3.2%) 0
Table 3 Complications and mortality among revisit-admission patients (n = 690) Total complications Surgery ICU hospitalization Cardiogenic complicationsa Total death Cardiogenic origin Sepsis Cerebrovascular origin Malignancy
150 (21.7%) 119 (17.2%) 29 (4.2%) 17 (2.5%) 49 (7.1%) 2 (0.3%) 28 (4.1%) 2 (0.3%) 17 (2.5%)
a Cardiogenic complications including myocardial infarction, receiving cardiac catheterization, and ventricular arrhythmia.
415 (60.1%) 275 (39.9%) 39.40
underlying disease showed no statistically significant difference in both group.
(38.7%) (11.3%) (11.2%)
5. Discussion study group revisited the ED because of recurrent symptoms without obvious complications. Patient revisiting with new symptoms related to the complications of disease progression accounted for 15.8% of the study group. The overall inadequate diagnosis rate was 12.1%. The top 3 disease categories were infectious (29.8%), surgical (25%), and neurologic (11.2%) diseases. As shown in Table 3, 49 (7.1%) of the revisit-admission patients died during hospitalization. Of them, the etiology for mortality was owing to sepsis (57.1%), malignancy (34.7%), cardiogenic conditions (4.1%), and cerebrovascular conditions (4.1%). A total of 150 patients (21.7%) had complications: 119 patients (17.2%) underwent an operation during the revisit; 29 (4.2%) were indicated for ICU admission; and 17 (2.5%) had CV complications, including myocardial infarction, receiving cardiac catheterization, or ventricular arrhythmia. Among the patients who received an operation in the revisit admission, the 3 most common diagnoses were acute appendicitis (14.3%); malignancy-related complications (12.6%), including bleeding or intestinal tract obstruction; and cholecystitis (10.9%). For identifying the characteristics of in-hospital mortality subgroup, patients were divided into the nonsurvival group and the survival group for further comparisons (Table 4). A notably higher mortality was observed in older patients (64.1 ± 15.3 vs 55.7 ± 17.8 years; P b .001). The management in the first visit included observation and examination, and the overall LOS in the ED showed no statistical significance difference between the 2 groups. The most common disease categories of the mortality group were oncologic (42.9%) and infectious (38.8%) diseases. Meanwhile, the top 3 disease categories in the survival group were febrile (38.7%), gastroenterological (11.9%), and neurologic (11.7%) diseases. No significant differences were observed between the 2 groups in terms of disease categories and the etiology of the return visits. As for the underlying disease, the nonsurvival group had more patients with a diagnosis of moderate or severe liver disease (18.4% vs 4.8%; P b .001), malignancy such as leukemia (69.3% vs 20.1%; P b .001), and metastatic solid tumor (38.8% vs 6.2%: P b .001) in univariate analysis. Other
Table 2 Etiologies of return visit patients and the disease categories of inadequate diagnosis group Disease-related etiologies Recurrent symptoms Disease complications Inadequate diagnosis Infection Surgery Neurology
497 109 84 25 21 12
(72.0%) (15.8%) (12.2%) (29.8%) (25%) (14.3%)
The unscheduled 72-hour ED return is a well-known quality indicator in terms of the quality of care and patient safety. However, as a quality indicator, it has 2 major issues that have the potential to affect regular auditing and result in the ineffective application of administrative resources. First, patients may return to the ED for a variety of reasons unrelated to a medical error. One of the most common patient-related causes of return visits has been substance abuse among chronic users and addicts [14]. Some frequent ED users return to the ED with similar complaints because of chronic psychiatric/personality problems [14]. Patients may revisit ED as a source of primary care out of selfconvenience, social-fiscal problems, or poor compliance. These socalled patient-related causes may influence the effectiveness of chart review and may require more time and manpower for the regular audit. Pham et al [16] found that patients who return to the ED within 72 hours do not use more resources, are not more severely ill, and do not have a higher hospital admission rate than those who had not been previously seen. In their opinion, a more refined subgroup such as 72-hour revisit admission may have more value as a quality indicator [16]. Therefore, we enrolled a more solid study population by choosing patient with revisit admission and excluded patients who made unrelated revisits or patient-related revisits and those who made visits for personal reasons. Second, the overall mortality of patients who revisit within 72 hours has been reported to be as low as 0% to 1% [7,11]. Hospital
Table 4 The characteristics of mortality in the return visit after hospitalization
Age Male sex Observation during first visit First length of stay (min) First examination (%)a Etiologies of return visit Recurrent symptoms Disease complications Inadequate diagnosis Disease categories Infection Neurology Gastroenterology Oncology Moderate or severe liver disease Any malignancy Metastasis a
Nonsurvival (n = 49)
Survival (n = 641)
P
64.1 ± 15.3 25 (51.0%) 25 (51.0%) 628.6 ± 1178.6 45 (91.8%)
55.7 ± 17.8 328(51.2%) 390 (60.8%) 531.6 ± 967.1 561 (87.5%)
.001 1.000 .176 .506 .498 .985
36 (73.5%) 7 (14.3%) 6 (12.2%)
461(71.9%) 102 (15.9%) 78 (12.2%)
19 (38.8%) 2 (4.1%) 2 (4.1%) 22 (44.9%) 9 (18.4%) 34 (69.3%) 19 (38.8%)
248 (38.7%) 76 (11.9%) 75 (11.7%) 38 (5.9%) 31 (4.8%) 129 (20.1%) 40 (6.2%)
Examination performed in the first ED visit.
b.001
b.001 b.001 b.001
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admission has been identified as a critical indicator of the severity of disease, and these patients could represent the highest risk subset of early returns [11,14]. In the present study, we found an overall 7.1% in-hospital mortality and a high complication rate of up to 21.7%. In consideration of the growing restraint on medical resources and the relatively low prevalence of complications among 72-hour revisit patients, it is reasonable for ED directors to review 72-hour revisitadmission patients for risk management and serving as a nice educational tool for young ED physician, especially those patients who had complications. A number of studies have investigated patients who revisited the ED within 72 hours; however, very few have studied the attributes of revisit-admission patients. This study aimed to clarify the characteristics and outcome of this high-risk subgroup. Three major features of these patients are worth noting. First, the most common chief complaints among our study population were fever (28.1%), abdominal pain (23.2%), and dizziness/vertigo (12.5%). Meanwhile, the top 3 disease categories according to the final primary diagnoses were febrile (38.7%), neurologic (11.3%), and gastroenterological (11.2%) diseases. In the study by Keith et al [2], infectious and gastroenterological diseases were 2 of the top 3 diagnosis groups in nontrauma patients who made unscheduled revisits. The results of our study were also similar with those of a previous study that analyzed the 72-hour revisit group [6]. In this previous study, the most common initial ED presentations were for abdominal pain (12.9%), fever (12.6%), vertigo (4.5%), headache (2.1), and upper respiratory infection (2.1%). The presentation of patients with fever, abdominal pain, and dizziness/vertigo are a continual challenge in emergency care. For abdominal pain and headaches, 57% and 59% of patients were discharged with a symptomatic diagnosis, respectively, rather than a definite pathologic diagnosis [17]. Patients with abdominal pain represented 6.5% of all ED visitors, but they were diagnosed with an undifferentiated etiology [18]. In terms of fever, ED-managed patients with a febrile illness frequently show no particular localizing symptom or sign to suggest a fever source. This ill-defined but rather common clinical manifestation has been called unexplained fever [19]. Gur et al [19] reported that the etiology of unexplained fever in the admission and discharge groups combined was still unknown in 71.22% (99/139) of cases after 30-day follow-up. Although obtaining a definitive diagnosis for these patients is often difficult, patients with fever, abdominal pain, and dizziness/vertigo should be carefully examined because they account for 61.2% of all revisit-admission groups. Second, patients were grouped according to the objectively documented diagnosis rather than by retrospective judgments in our study. It is because differentiating between the natural course of a disease, inadequate patient instruction, suboptimal therapy, and true medical errors is often difficult in retrospective chart reviews. In taking this approach, we found that disease-related revisits accounted for mostly (87.8%) of the study group. In terms of inadequate diagnosis group, some EPs would argue that obtaining a definitive diagnosis is often neither possible nor necessary for all cases in the ED setting. For example, patients who visit the ED because of constipation may have occult rectum malignancy, and the EPs may not perform subsequent examination if the condition is relieved by medication. Understandably, in these types of scenarios, judging the diagnosis as “misdiagnosis” is questionable. Therefore, we simply categorized these patients as inadequate diagnosis; these patients accounted for 12.2% (84/690) of the study group. Of them, the most frequent diagnosis was fever (25/84 [29.8%]) without specific focus, and the final diagnosis of these patients included dengue fever (4), infective spondylitis (3), atypical infection (3), cellulitis (3), septic arthritis (2), left axillary abscess (1), liver abscess (1), occult sepsis (2), viral meningitis (1), urinary tract infection (3), pneumonia (1), and malignancy (1). Most of the patients in this category presented initially with fever and nonspecific symptoms, such as myalgia or
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general malaise, and they were treated with supportive care during the first visit. The subsequent most frequent diagnoses were surgical diseases (21/84 [25%]), which comprised 8 cases of appendicitis, 7 cases of ileus, and 6 cases of cholecystitis. These patients initially presented with only nonspecific pain, vomiting or nausea, and gastrointestinal upset. Patients with infectious or gastrointestinal disease often present with atypical or trivial manifestations that may result in inadequate diagnosis in the ED. Although inaccurate diagnoses at the early stage is understandable, it is mandatory for EPs to accumulate sufficient clinical experience through case conferences for the early detection of underlying clinical problems and to provide adequate patient education before ED discharges to avoid medico-legal disputes. Third, the most notable finding of our study was the high mortality (7.1%) and morbidity of these revisit-admission patients. In terms of mortality for 72-hour ED revisit-admission patients, only 1 other report has been published on this subject. In a retrospective analysis of revisit-admission patients, Wang et al [13] found an overall mortality rate of 10%. However, this previous report had limited power resulting from the 1-month period of the study and the small sample group (n = 60). The cause of death in this previous study was related to sepsis (57.1%), malignancy (34.7%), CV disease (4.1%), and cardiogenic conditions (4.1%). In our study, the initial chief complaint of “fever” was found to be a major potential pitfall in the ED diagnoses. The complication rate of the current patient group was up to 21.7%. The leading major source of complications was in regard to receiving an operation, and the leading 3 diagnoses were acute appendicitis (17/119, 14.3%), malignancy-related diseases (15/119, 12.6%) (such as colon cancer presenting with ileus, recurrent tumor bleeding, dysphagia related to esophageal cancer), and cholecystitis (13/119, 10.9%). In a previous study focusing on 72-hour revisit-admission and subsequent operations, Yen et al [20] found that urolithiasis and biliary tract disease were the most frequent diagnoses of their study group after comparisons with the control group. These specific diseases should be kept in mind to prevent unnecessary revisitadmission complications. To survey the characteristics for in-hospital mortality subgroup, we further analyzed the patients' underlying diseases and found a notably higher mortality in patients who were older, previously diagnosed with any malignancy (eg, leukemia), and had moderate or severe liver disease or a metastatic solid tumor. Our findings are consistent with those of Martin-Gill and Reiser [14], in which older patients, especially those older than 65 years and patients with insurance for the elderly (Medicare) were at higher risk for revisit admission. Another work published by Fan et al [21] showed that an age of 65 years or older was a risk factor for unexpected ICU admission within 3 days after discharge from the ED. As such, an age of 65 years or older was a risk factor of revisit admission in both of these previous studies and was one of the independent predictors of mortality in the revisit ICU admission group. Our findings are compatible with these previous results and further showed that age was a risk factor of inhospital death among revisit-admission groups. In the present study, we also noticed that the in-hospital mortality was not correlated with the LOS in the ED during the initial ED visit, the amount of medical examinations performed, or the cause of the ED revisits. The in-hospital mortality was only correlated with the underlying medical conditions of the revisiting patients. Our results imply that the patient's underlying condition, including age and comorbidities, are the major predictors of in-hospital mortality among 72-hour revisit-admission patients. Further research is needed to validate and corroborate this finding. The revisit-admission rate was 48% in the current study and was higher than that of previous reports (22%-35.7%) [9,11-13]. This phenomenon could be partially explained by overcrowding and the shortage of in-hospital beds. Of the patients, 87.8% received at least 1 examination (eg, computed tomographic scan). Overall, 39.9% of
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patients were briefly managed in the ED observation room, with an average LOS of 39.4 hours. The long LOS as well as the high proportion of those who underwent exams and observation reflected relatively complicated disease entities. Combined with the 87.8% diseaserelated revisits, the premature discharge with possible inadequate treatment or observation during the first visit was likely. In our ED, we have 150 observation beds with a high occupancy rate of 92.68%. Patients who should have been admitted to the in-hospital ward were treated in the observation room instead. Emergency department physician tends to discharge patients for relieving overcrowding, and patients did not favor staying in the observation room if the symptoms were improved after partial treatment. Revisiting for inhospital bed waiting and admission were mostly suggested in the discharge plan. A higher revisit-admission rate could be expected under such conditions. 6. Limitations This retrospective study had several limitations. First, because the study was carried out in only 1 hospital, the results may not be generalizable to other settings. Second, ED patients may have revisited the EDs of other hospitals. However, our hospital is one of the largest medical centers in southern Taiwan, and its ED deals with most ED patients in the local region. Therefore, the number of patients revisiting other EDs was considered to be negligible. Third, a lack of consensus is present among EPs about the criteria for hospitalizing ED patients. Patients were admitted primarily based on the clinical judgments of treating EPs in a busy and crowded ED, which might have influenced the composition of the study group. Finally, this study was studied in an extremely overcrowding ED, as previously described. Thence, the severity and overall revisitadmission rate of study population tend to be higher than other hospital. The higher proportion of inadequate diagnosis related to premature discharge was also likely. Further large-scale, multicenter, prospective studies should be performed for further investigations of this group of patients. 7. Conclusion A relatively high occurrence of high morbidity and mortality rate was observed among revisit-admission patients. It might be helpful by establishing a policy of chart audits to review these patients for risk management and standard discharge plan development. Patients with tumors, leukemia, metastatic tumors, and moderate-to-severe liver disease and who are elderly represent the most high-risk population
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