Predictors and outcomes of patients that return unplanned to the Emergency Department and require critical care admission: A multicenter study

Abstract

ObjectiveTo determine the incidence, characteristics (including timeframe) and predictors of patients discharged from the Emergency Department (ED) that later return and require admission. MethodsA retrospective cross-sectional study examining all return visits to three EDs in Sydney, Australia, over a 12-month period. Patients returning within 28 days from ED discharge with the same or similar complaint were classified as a return visit to ensure capture of all return visits. Descriptive and inferential statistics were used to analyse the data and logistic regression was performed to predict factors associated with return visits with general admission, and return visits admitted to critical care. ResultsThere were 1,798 (30%) return visits which resulted in admission, mostly to a non-critical care area (1,679, 93%). The current NSW 48 -h time frame used to define a return visit in NSW captured half of all admitted returns (49.5%) and just over half (59.2%) of critical care admissions. Variables associated with an admission to critical care were age (OR 1.02, 95% CI 1.01, 1.03), initial presentation (index visit) made to a lower level ED (OR 3.76 95% CI 2.06, 6.86), Triage Category 2 (OR 3.67 95% CI 2.04, 6.60) and a cardiac diagnosis (OR 5.76, 95% CI 3.01, 11.01). This model had adequate discriminant ability with AUROC = 0.825. ConclusionA small number of return visits result in admission, especially to critical care. These patients are at risk of poor outcomes. As such, clinicians should have increased index of suspicion for patients who return that are older, present with cardiac problems, or have previously presented to a lower level ED. Revision of the current timeframe that defines a return visit ought to be considered by policy makers to improve the accuracy of this widely used key performance indicator.