Abstract
BackgroundUnplanned re-attendance at the Emergency Department (ED) is often monitored as a quality indicator of the care accorded to patients during their index ED visit. High bed occupancy rate (BOR) has been considered as a matter of reduced patient comfort and privacy. Most hospitals in Singapore operate under BORs above 85 %. This study aims to explore factors associated with the unplanned 3-day ED re-attendance rate and, in particular, if higher BOR is associated with higher 3-day unplanned ED re-attendance rate.MethodsThis was a multicenter retrospective study using time series data. Three acute tertiary hospitals were selected from all six adult public hospitals in Singapore based on data availability. Daily data from year 2008 to 2013 were collected from the study hospitals’ information systems. These included: ED visit date, day of week, month, year, public holiday, daily hospital BOR, daily bed waiting time (BWT) at ED (both median and 95th percentile), daily ED admission rate, and 3-day ED re-attendance rate. The primary outcome of the study was unplanned 3-day ED re-attendance rate from all reasons. Both univariate analysis and generalized linear regression were respectively applied to study the crude and adjusted association between the unplanned 3-day ED re-attendance rate and its potential associated factors. All analyses were conducted using SPSS 18 (PASW 18, IBM).ResultsThe average age of patients who visited ED was 35 years old (SD = 2), 37 years old (SD = 2), and 40 years old (SD = 2) in hospitals A, B, and C respectively. The average 3-day unplanned ED re-attendance rate was 4.9 % (SE = 0.47 %) in hospital A, 3.9 % (SE = 0.35 %) in hospital B, and 4.4 % (SE = 0.30 %) in hospital C. After controlling for other covariates, the unplanned 3-day ED re-attendance rates were significantly associated with hospital, time trend, day of week, daily average BOR, and ED admission rate. Strong day-of-week effect on early ED re-attendance rate was first explored in this study. Thursday had the lowest re-attendance rate, while Sunday has the highest re-attendance rate. The patients who visited at ED on the dates with higher BOR were more likely to re-attend the ED within 3 days for hospitals A and B. There was no significant association between BOR and ED re-attendance rate in hospital C.ConclusionsA study using time series data has been conducted to explore the factors associated with the unplanned 3-day ED re-attendance rate. Strong day-of-week effect was first reported. The association between BOR and the ED re-attendance rate varied with hospital.
Highlights
Unplanned re-attendance at the Emergency Department (ED) is often monitored as a quality indicator of the care accorded to patients during their index ED visit
This study aims to determine (1) the daily factors associated with the 3-day ED re-attendance rate and especially (2) if higher bed occupancy rate (BOR) is associated with higher 3-day unplanned ED re-attendance rate
The highest re-attendance rate was observed for the patients who visited on Sunday, while lowest re-attendance rate was for the patients who visited on Thursday (p < 0.001)
Summary
Patients who return to ED fall into patient-related factors (gender, age, socioeconomic status, insurance status, inability to understand or comply with discharge planning, and misuse of emergency services), illness-related factors (worsening of an existing condition, acute exacerbation of a chronic condition, complications arising from disease, and new health problems), health-care staff or hospital-related factors (misdiagnosis, malpractice, inadequate communication between health-care providers and patients, and lack of subsequent referral services or continuity of care were identified as major issues), and many other reasons [7,8,9,10] It is of great interest for hospital administrators to know how daily operational factors (like bed occupancy rate (BOR), patients’ BWT, admission rate, etc.) affect the unplanned 3-day ED re-attendance rate to help them monitor and improve hospital operations [11, 12]. High BOR may cause delayed patient flow from ED to inpatient wards, resulting in overcrowding and resource constraints in ED [22, 23] as more ED resources would be allocated to take care of those patients waiting at ED
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