A Retrospective Investigation of Emergency Department Revisits in Turkish Older Patients

Although 72-hour emergency department (ED) revisits are increasingly used as a hospital metric, there is no known empirical basis for this 72-hour threshold. The objective of this study was to determine the timing of ED revisits for adult patients within 30 days of ED discharge. This was a retrospective cohort study of all nonfederal ED discharges in Florida and Nebraska from April 1, 2010, to March 31, 2011, using data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP). ED discharges were followed forward to identify ED revisits occurring at any hospital within the same state within 30 days. The cumulative hazard of an ED revisit was plotted. Parametric and nonparametric modeling was performed to characterize the rate of ED revisits. There were 4,782,045 ED discharges, with 7.5% (95% confidence interval [CI] = 7.4% to 7.5%) associated with 3-day revisits, and 22.4% (95% CI = 22.3% to 22.4%) associated with 30-day revisits, inclusive of the 3-day revisits. A double-exponential model fit the data best (p < 0.0001), and a single hinge point at 9 days (multivariate adaptive regression splines [MARS] model) yielded the best linear fit to the data, suggesting 9 days as the most reasonable cutoff for identification of acute ED revisits. Multiple stratified and subgroup analyses produced similar results. Future work should focus on identifying primary reasons for potentially avoidable return ED visits instead of on the revisit occurrence itself, thus more directly measuring potential lapses in delivery of high-quality care. Almost one-quarter of ED discharges are linked to 30-day ED revisits, and the current 72-hour ED metric misses close to 70% of these patients. Our findings support 9 days as a more inclusive cutoff for studies of ED revisits.

The “Identification of Seniors at Risk” (ISAR) screening is a tool to identify seniors at risk of adverse outcomes. We investigated whether seniors with a positive ISAR screening have an increased risk of Emergency Department (ED) re-visits and health-service costs. In a pilot project, we enrolled 96 ED patients (≥70 years) who received an ISAR screening in the ED. We compared the rate of ED re-visits and in-hospital costs between ISAR positive (≥2 pts) and ISAR negative (<2 pts) patients. In some patients, a geriatrician performed a single Geriatric Consultation (GC) during the ED stay to assess older patients’ needs.32% of the study population had an unplanned ED re-visit (31 of 96). Fifty patients were ISAR positive (52%) and showed an increased risk of ED re-visits compared with ISAR negative patients (dds ratio (OR) 6.8, 95% confidence interval (CI) 2.2–21.0, p = 0.001). The positive ISAR screening tool fairly predicted ED re-visits in seniors (area under the curve (AUC) 0.711). A single GC during the ED stay did not reduce the risk of unplanned ED re-visits in ISAR positive patients (p = 0.80) ISAR positive patients with GC did not have higher in-hospital costs than ISAR negative patients without GC. Based on these findings, we aim to establish a comprehensive outpatient geriatric assessment program to identify relevant risk factors for ED re-visits and to recommend preventive strategies in ISAR positive ED seniors.

IntroductionOlder patients currently represent up to 12%−24% of all emergency department (ED) visits. While increasing in number, they are also at high risk of revisits once discharged. The rate of ED revisits within 72 h is a key indicator of the quality of care in emergency medicine and varies between 1% and 15%. The reasons for ED revisits are natural course of illness, misdiagnosis, lack of homecare, and self-discharge against medical advice. However, the risk factors for ED revisits have not been fully investigated. Therefore, this study aimed to analyze the incidence of ED revisits and identify the risk factors for ED revisits within 72 h after ED discharge.MethodsIn this retrospective study, older patients (≥70 years) were consecutively enrolled if they presented with an Emergency Severity Index of 2 or 3 in a tertiary care ED in 2019, with discharge after the ED visit. The primary endpoint was the frequency of unplanned ED revisits within 72 h after ED discharge. The secondary endpoints were the reasons and potential risk factors for ED revisits. Univariate and multivariate logistic regression models were used.ResultsA total of 592 older patients were enrolled, of whom 30 (5.1%) revisited the ED within 72 h. Gastrointestinal diagnosis [odds ratio (OR), 2.9; 95% confidence interval [CI], 1.04–8.2; p = 0.043) and nausea in particular (OR, 3.5; 95% CI, 1.3–9.4; p = 0.016) were significant risk factors for ED revisits. Furthermore, discharge against medical advice (OR, 5.6; 95% CI, 1.7–18.1; p = 0.004) and ED presentation during the night (OR, 2.7; 95% CI, 1.2–6.1; p = 0.014) were significant risk factors for ED revisits within 72 h after discharge, respectively.ConclusionAlthough the frequency of ED revisits among older patients at 72 h after discharge tends to be low and most revisits were illness-related, all older patients need to be assessed for risk factors for ED revisits. Discharge should be carefully evaluated to improve patient safety and provide the best healthcare to this frail population.

Identifying older emergency department (ED) patients with clinical features associated with adverse postdischarge outcomes may lead to improved clinical reasoning and better targeting for preventative interventions. Previous studies have used single-country samples to identify limited sets of determinants for a limited number of proxy outcomes. The objective of this study was to identify and compare geriatric syndromes that influence the probability of postdischarge outcomes among older ED patients from a multinational context. A multinational prospective cohort study of ED patients aged 75 years or older was conducted. A total of 13 ED sites from Australia, Belgium, Canada, Germany, Iceland, India, and Sweden participated. Patients who were expected to die within 24 hours or did not speak the native language were excluded. Of the 2,475 patients approached for inclusion, 2,282 (92.2%) were enrolled. Patients were assessed at ED admission with the interRAI ED Contact Assessment, a geriatric ED assessment. Outcomes were examined for patients admitted to a hospital ward (62.9%, n=1,436) or discharged to a community setting (34.0%, n=775) after an ED visit. Overall, 3% of patients were lost to follow-up. Hospital length of stay (LOS) and discharge to higher level of care was recorded for patients admitted to a hospital ward. Any ED or hospital use within 28 days of discharge was recorded for patients discharged to a community setting. Unadjusted and adjusted odds ratios (ORs) were used to describe determinants using standard and multilevel logistic regression. A multi-country model including living alone (OR=1.78, p≤0.01), informal caregiver distress (OR=1.69, p=0.02), deficits in ambulation (OR=1.94, p≤0.01), poor self-report (OR = 1.84, p≤0.01), and traumatic injury (OR=2.18, p≤0.01) best described older patients at risk of longer hospital lengths of stay. A model including recent ED visits (OR=2.10, p≤0.01), baseline functional impairment (OR=1.68, p≤0.01), and anhedonia (OR=1.73, p≤0.01) best described older patients at risk of proximate repeat hospital use. A sufficiently accurate and generalizable model to describe the risk of discharge to higher levels of care among admitted patients was not achieved. Despite markedly different health care systems, the probability of long hospital lengths of stay and repeat hospital use among older ED patients is detectable at the multinational level with moderate accuracy. This study demonstrates the potential utility of incorporating common geriatric clinical features in routine clinical examination and disposition planning for older patients in EDs.

128 In-Hospital Outcomes After Emergency Department Revisit in Taiwan: A Nationwide Analysis

Revisit, Subsequent Hospitalization, Recurrent Fall, and Death Within 6 Months After a Fall Among Elderly Emergency Department Patients

Heart failure (HF) is a prevalent cause of emergency department (ED) visits among adults. However, there is limited understanding of the characteristics of patients with HF who frequently utilize the ED for symptom management. Aim: To describe factors associated with ED revisits among symptomatic patients with chronic HF. Methods: We identified 1,472,083 adults (age ≥ 18 years) with HF who had no history of left ventricular assist device or heart transplantation between January 2010 and March 2020 from the TriNetX Research Network, which included 47 US healthcare organizations. In this retrospective observational study, 24,070 patients presenting with dyspnea and receiving intravenous (IV) Furosemide at the ED were followed up for 1 year from the index ED visit. ED revisits related to the treatment of dyspnea with IV diuretics were tracked. Factors associated with these ED revisits were identified using multivariate Cox regression analysis. Results: A total of 3,574 ED revisits were observed from 2,559 patients (10.6% of the sample, mean age 63 years, 51% men, 39% White, 62% Non-Hispanic). The ED revisit rates were 52, 96, 125, and 148 visits per 1,000 persons within 1, 3, 6, and 12 months, respectively. The median time to the first ED revisit for symptom management with IV diuretics was 65 days (range 2-364 days). In the Cox model, younger patients (&lt; 65 years) had a higher risk of ED revisits compared to older patients (HR 1.65, 95% CI 1.50-1.82, p&lt;0.001). Men had a higher risk of ED revisits compared to women (HR 1.12, 95% CI 1.02-1.23, p=0.02). Black patients had a higher risk of ED revisits compared to other races (HR 1.36, 95% CI 1.20-1.53, p&lt;0.001). Patients with HFrEF (e.g., ICD-10 I50.2) had a higher risk of ED revisits compared to those with congestive HF (e.g., ICD-10 I50 without HF type information) (HR 1.25, 95% CI 1.12-1.40, p &lt; 0.001). Patients diagnosed with HF more than 1 year prior to the index ED visit had a higher risk of ED revisits compared to those diagnosed within 1 year (HR 1.31, 95% CI 1.19-1.44, p &lt; 0.001). Conclusions: Younger age, male gender, Black race, HFrEF classification, and longer duration of HF were associated with ED revisits among symptomatic adults with HF. To reduce repeated ED visits, targeted interventions for high-risk patients are essential.

People with sickle cell disease (SCD) often have emergency department (ED) revisits. The characteristics of people with SCD with ED revisits were assessed in this study using Medicaid administrative claims data from California and Georgia, representing 2794 and 3641 individuals with SCD, respectively. In both states, those with 6+ primary care provider (PCP) encounters had the highest percentage of ED revisits. In California, those with 6+ hematology encounters had the lowest percentage of individuals with an ED revisit; in Georgia, those with 1-2 hematology encounters. Increasing access to hematologic care may reduce ED revisits among people with SCD.

Frequency of ED revisits and death among older adults after a fall

ObjectiveThe identification of older patients at risk of repeated emergency department (ED) visits is crucial for managing preventable adverse outcomes. This study aims to identify risk factors associated with ED revisits and to develop and validate a nomogram for predicting risk of geriatric ED revisits.MethodsThis was a cohort study comprising 553 older patients, who attended the two tertiary hospitals EDs in China from August 2018 to February 2019 and were prospectively followed for any unplanned revisit within 1 year after discharge. Patients were randomly assigned to a training or validation set at a ratio of 2:1. Stepwise selection procedure was applied to select factors associated with ED revisits for inclusion in a multivariable logistic model from which a nomogram was elaborated. Discrimination, calibration and clinical utility of the nomogram were assessed using C-statistic, calibration plot, Hosmer-Lemeshow test, and decision curve analysis (DCA).ResultsThe final nomogram included four predictors for ED revisits: age, BMI, frailty and polypharmacy. Older patients having revisits were more likely to be frail (OR = 1.17, p = 0.031), have polypharmacy (OR = 1.69, p = 0.049) or BMI <18.5 kg/m2 (OR = 2.45, p = 0.025), and were less likely to be older than 90 years (OR = 0.21, p = 0.002). The nomogram demonstrated acceptable discrimination ability in the training (C-index = 0.661) and validation sets (C-index = 0.651), satisfactory calibration (p > 0.05), and good clinical applicability.ConclusionA nomogram incorporating four obtainable variables was constructed to individualize ED readmission risk in older patients. These patients may benefit from early triage and better-targeted care if considering the nomogram as a clinical decision aid.

IntroductionGeriatric syndrome (GS) increases risk of disability and mortality in older adults. Sarcopenia is a predominant illness of GS and accelerate its progression. This study aimed to investigate associations between mortality, emergency department (ED) re-visits and GS-related illnesses among older adults who visited the ED.MethodThis retrospective observational study enrolled elderly patients who visited the ED in our hospital between January 2018 and October 2020. Patients were evaluated for potential sarcopenia, which was defined by both low handgrip strength and calf circumference. Follow-up was at least 6 months. Data of age, gender, mortality, ED re-visits, and GS-related illnesses were collected and analyzed for associations.ResultsA total of 273 older adults aged 74 years or older were included, of whom 194 were diagnosed with possible sarcopenia. Older adults with possible sarcopenia also had significantly lower body mass index (BMI); a higher proportion needed assistance with daily activities; more had malnutrition, frailty, and history of falls (all p < 0.001) and acute decline in activities of daily living (p = 0.027). Multivariate analysis showed that possible sarcopenia [adjusted hazard ratio, aHR): 9.89, 95% confidence interval (CI): 1.17–83.81, p = 0.036], living in residential institutions (aHR: 2.85, 95% CI: 1.08–7.50, p = 0.034), and frailty (aHR: 7.30, 95% CI: 1.20–44.62, p = 0.031) were associated with mortality. Aged over 85 years (adjusted odds ratio: 2.44, 95% CI: 1.25–4.80, p = 0.02) was associated with ED re-visits.ConclusionSarcopenia is associated with mortality among older adults who visit ED. Initial screening for sarcopenia and relevant risk factors among older adults in the ED may help with early intervention for those at high-risk and may improve their prognosis.

Urology Consultation and Emergency Department Revisits for Children with Urinary Stone Disease

Emergency department (ED) revisits are used as a measure of care quality. Many EDs measure only revisits to the same facility, underestimating true rates. We sought to determine the frequency, location, and predictors of ED revisits to the same or a different ED. We studied ED discharges for children <18 years old in Maryland and New York in the statewide ED and inpatient databases. Revisits were defined as ED visits within 7 days of an index visit. Our primary outcome was the proportion of revisits that were different-hospital revisits (DHRs). We measured the underestimation of total revisits when only same-hospital revisits were measured. We determined the risk of DHR by quartile of annual ED pediatric volume, adjusting for case mix, insurance, state, and urban location. Revisits across 261 EDs occurred after 5.9% of 4.3 million discharges. A per-ED median 21.9% of revisits were DHRs (interquartile range 14.2%-34.6%). Measuring only same-hospital revisits underestimated total revisits by 17.4%. The proportions of revisits that were DHRs by increasing volume quartile were 28.1%, 25.5%, 22.6%, and 14.5%. The adjusted risk of DHR was lower for increasing quartiles of pediatric volume (adjusted odds ratio for highest versus lowest quartile 0.27; 95% confidence interval, 0.19-0.36). Measuring ED revisits only at the index ED significantly underestimates total revisits. Lower pediatric volume is associated with higher DHRs as a proportion of revisits. When using revisits as a measure of emergency care quality, effort should be made to assess revisits to different EDs.

Introduction: Pulse oximetry is a standard component of Emergency Department (ED) patient monitoring. Pulse oximetry measures peripheral capillary oxygen saturation (SpO2) levels and can be used to monitor cardiorespiratory conditions. The normal SpO2 level for adults is approximately 96%. Oxygen saturations of &amp;lt;92% are considered problematic and levels &amp;lt;90% may indicate cardiorespiratory disease. However, low oxygen saturations are often seen in elderly patients with comorbidities. This research investigated the significance of hypoxia in asymptomatic older ED patients with no apparent acute illness. Methods: ED patients &amp;gt;75 years with a documented room air pulse oximetry reading &amp;lt;92% were eligible. Exclusion criteria included dyspnea, chest pain, SBP &amp;lt;100mmHg, HR &amp;gt;120 or &amp;lt;50; sustained tachypnea (RR &amp;gt; 20); acute cardiopulmonary conditions, delirium or acutely altered mentation. Eligible patients were separated into two groups: 1) Sustained hypoxia: two or more SpO2 readings &amp;lt;92% 2) Unsustained hypoxia: one SpO2 reading &amp;lt;92%. 30-day adverse events were tracked using a Sunrise Emergency Care record review. Adverse outcomes investigated included death, MI, CHF, PE, cardioversion, ICU admission, intubation, ED revisit or re-hospitalization. Patient characteristics studied were age, sex, arrival mode, triage complaint, CTAS level, pulse, BP, RR, weight, residence (independent, assisted living, facility), comorbidities, PHN, referral, disposition, and test results (CXR, troponin, ECG, CT). Follow-up phone calls were completed after 30 days to assess patient status and confirm ED revisit. Results: A total of 876 ED patients &amp;gt;75 years were screened and 30-day follow-up data was analyzed for 34 enrolled patients. The sustained hypoxia group (n = 23) showed higher rates of 30-day adverse outcomes of death, ED re-visitation, MI, CHF, a severe episode of COPD, PE and ICU stays compared to the unsustained hypoxia group (n = 11). Administrative data of 31,095 patients &amp;gt;75 years from four Calgary EDs in 2017 was also analyzed and 7,771 (20%) were hypoxic at triage (SpO2 &amp;lt;92%). Adverse outcomes and mortality were significant in discharged hypoxic patients (especially if SpO2 &amp;lt;90%). Conclusion: ED re-visits, cardiorespiratory complications, and mortality were significant in discharged sustained hypoxic patients, especially if O2 sat &amp;lt;90%. Pulse oximetry assessment of oxygen saturation in seniors’ care facilities and physicians’ offices may be important in screening for future adverse health outcomes in elderly patients.

ObjectiveSuboptimal transitional care (ie, needs assessment and coordination of follow-up care) in the emergency department (ED) is an important cause of ED revisits and hospital admissions and may potentially harm...