oa A Prospective Study Regarding Factors Related to Unscheduled Revisit Within 72 Hours in Adult Emergency Department. Al Khor Hospital, State of Qatar

Background

Crowding in hospital Emergency Departments (EDs) is a commonly observed problem in all over the world. Although the reasons and mechanisms are different, the major factors are increasing volume of patients seeking medical care in ED services, lack of inpatient beds, and care for non-urgent conditions for patients who identify the ED as their easiest and usual site of care, notwithstanding the typical treatment of patients with serious illnesses or injuries, non availability and accessibility of other medical services in the community.

Objective

To identify the factors related to patients unscheduled revisit in ED, to find out average length of stay in different priority patients and to identify the reason for more than 6 hours stay in ED.

Methods

The alkhor hospital has 110 bed capacities in the north part of Qatar with an annual ED patient volume of 158000.

A prospective study conducted during two months periods from 15/09/2014 to 14/11/2014 in ED. The census sample of patients who had revisit within 72 hours of discharge from the ED was recruited in the Study. CERNER system utilized to collect all revisit patients data including demographic and first visit information. Two experts from ED consultants reviewed the data independently. Further data include average length of stay and reason for more than 6 hours stays in ED were collected by the research team and all the data was analyzed by the author. The factors were categorized in to four types includes: physician related: missed diagnosis, not prescribed medications, treatment error/ patient related: perception of not improved/illness related: complications of disease process, prognosis of disease process/system related: not availability of health care, not availability of health center locally.

Results

During study period 24933 patients visited in ED, 849 were revisited within 72 hours of their discharge which accounts 3.4%. 165 were excluded from the study which includes LWBS,DAMA and absconded patients. The characteristic of revisited patients, more likely young adults between 20–40 years of age (59.79%). Mostly males (78.94%) expatriate (69.73%) 30.27% patient had three visit in ED while 69.73% twice visited. The most of the patients (538) were self-reported in ED during their second visit. The vast majority of patients (542) agreed that they received discharge instructions.

Physician related Factors includes: this includes missed diagnosis (1.6%), adverse drug reaction ((1.3%) and discharged without home medication (8.4%)

Patient related: The 60.26% (331) of the patients perceived that they were not improved with initial treatment. However, among these patients only 8 were admitted in Alkhor hospital and one transferred to another health care facility for expert management. The vast majority of the patients 97.2% patients were discharge from the ED.

Illness related: This was the most common reason for revisit in ED, 52.9% (362) return with same complaints while 21.3% (146) with related complaints in which 97.6% patients were discharged and 1.3% (7) admitted in hospital 22.8% (156) patients reported in ED with new complaint.

System related: The 23.49% revisited patient's living in Alkhor or nearby area, with their primary health center facility 70 km away from their residential area. 30% patients have no health center facility for further follow up. This cause high financial burden for low income workers

During the study period 718 patients found stayed more than 6 hours in ED, which accounts 2.87% of the total ED patients, mean age of 35.43 years. Most of the patients were males (93.3%). The vast majority of patients were priority 3 and 4 which accounts 26.6% and 63.6 % respectively. The mean times for triage and physician assessment were 2.538 hours and 2.571 hrs accordingly and length of stay in ED was 8.365 hrs. The top 5 reasons for delay the patient in ED was waited for assessment by physician (26.3%), waiting for reassessment by physician (20.2%) observation (11.3%) waited for triage by nurse (8.6%) and repeat lab works (8.2%).

The revisited patients distributed unequally in the three shift duty hours. The morning (7 am–15 pm) and evening (15 pm–23 pm) shifts received the highest proportion 43.12% (295) and 38.45(263) compared to night shift (23 pm–7 am) 15.05% (103). Whereas on daily basis of revisited patients maintained almost equal distribution.

In general the average length of stay of priority 2 patients was 2 hours 14 mts, priority 3 was 2 hrs 17 mts where as priority 4 and 5 was 2 hrs 27 mts and 1 hour 54 mts respectively

Conclusion

The patients decision to revisit in ED is complex, it include several factors like poor quality of service, missed diagnosis, financial factors, disease process etc. From our study we found majority of revisit due to illness or system related factors like their perception of disease progress, lack of local health center facility for workers, financial burden etc. Effective educational program and initiation of tele nursing service for discharged patients can avoid unnecessary ED visits.