Is there anything more disconcerting to an emergency physician reporting for a shift than being approached by a colleague who says, “Do you remember that patient you saw?”
Of the more than 120 million visits to emergency departments each year in the United States, approximately three percent of these patients return within 72 hours. (Ann Emerg Med 1990: 19:752.) One in four of these bouncebacks require admission (Ann Emerg Med 1998;32:569), and in up to 30 percent of these cases, the return visit is related to a possible medical error or mismanagement during the first visit. This number is difficult to get a handle on because EDs increasingly are tasked with providing follow-up care for patients who have nowhere else to go. The pressure to manage patients as outpatients is particularly acute in the emergency department.
Return visits are highest for patients with headache, back pain, and abdominal pain and lowest for chest pain. (Ann Emerg Med 2010 Mar 17 [Epub].) Painful conditions have the highest rates of recidivism. In one study from Singapore, abdominal pain accounted for a quarter of unscheduled return visits, and more than half were admitted. (Singapore Med J 2009;50:1068.) Advanced age and dyspnea also were associated with unscheduled returns to the ED that required admission. Patients over 65 had a greater risk of admission after an unscheduled return (Am J Emerg Med 2004;22:448), and patients with an initial diagnosis of dehydration had the highest rate of return and the greatest risk of hospital admission. (Ann Emerg Med 1998; 32:569.)
A 10-year retrospective study from the University of Arizona studied deaths within seven days of an ED visit. (Ann Emerg Med 2007;49:735.) The researchers made a number of important findings, including that 60 percent of the deaths were due to a possible medical error. Fifty percent died from a condition related to the initial visit, and the death was unexpected half the time. Frequent chief complaints of those who died included CNS symptoms, chest pain, shortness of breath, abdominal pain, and weakness.
Michael Weinstock, MD, and Ryan Longstreth, MD, in their book Bouncebacks! Emergency Department Cases: ED Returns, advocate a process they call “the two-step approach.” The first step involves using the literature to identify prospectively the patients at highest risk for return visits. Then they ask that the physician take a “second look” at the workup and disposition of the patient, focusing on those with life- or limb-threatening illness leaving without a definitive diagnosis, and the following checklist could identify those at high risk:
- Atypical presentations or unusual problems.
- Decompensation of chronic conditions.
- Abnormal vital signs.
- Mental disability.
- Advanced age.
- Language barriers.
- Unmet expectations, upset patients.
- Diagnosis of dehydration.
The authors recommend making certain that all complaints are addressed and that the history is accurate. They advise physicians to consider and mentally address the most serious diagnostic possibilities, ensure timely follow-up, and provide specific instructions.
Why not take this strategy a step further and consider the three-step approach? After identifying high-risk patients, particularly elderly patients with diagnostic uncertainty, devise a call back-come back process. Depending on your department's demographics, one approach, or perhaps a hybrid approach, would make sense. The staff keeps a list of contact information for high-risk patients who they will call for a telephone recheck. Particularly high-risk patients are instructed to come back in a prescribed time period for a recheck of their condition. These follow-up patients should be instructed to return during low census times of the day, and paperwork and processes can be streamlined. They might be placed in an area with recliners for a recheck by the physician, with a different and more streamlined chart to expedite flow.
Both call back and come back processes are great for patient satisfaction, can be used as service recovery strategies for disappointed patients, and are a great risk-management strategy. In these days when EPs are pressured to keep patients out of the hospital, this is a strategy physicians grow to like. The patient who was a worry leaving the emergency department has a planned repeat visit to safeguard against something being missed. Most departments do this to a degree, at least at the individual level. This call back-come back strategy involves formalizing and standardizing the mechanism for better results. In these days of profound health care access issues, this plan may make sense on many levels. So try this: Deliberately bounceback the patient. Turn the patient into a scheduled follow-up!