Every physician has had his share of bouncebacks, those patients who return to the ED soon after an initial visit, often with a more severe version of the problem that brought them there in the first place.
Some return patients are inevitable, but a new report even surprised researchers with rates that were higher than expected. They discovered that 8.2 percent of the patients had visited an emergency department again, 32 percent of those at a different hospital and 29 percent resulting in an admission, within three days of the initial ED visit. And the numbers just got worse from there.
Within 30 days of the index visit, 19.9 percent of patients had revisited an ED, with 28 percent at a different hospital. The cost for those revisits in Florida, the only state with complete cost data, was 118 percent greater than the total index costs of initial ED visits. Skin infections caused most of the revisits (23.1%), Florida had the highest revisit rates (24.8%), and Nebraska had the lowest (10.6%). (Ann Intern Med 2015;162:750.)
“Previous literature had showed people coming back at a lower rate. What this shows is that people are coming back more frequently, and one-third are going to another emergency department. There is a story here,” said Reena Duseja, MD, an assistant professor of emergency medicine at the University of California, San Francisco, and the lead author of the study.
The study was not set up to determine why people come back, Dr. Duseja said. “Either people are dissatisfied or are having trouble getting connected with the health care system, and are left going back to the emergency department for care.”
Higher than Expected
Ryan Radecki, MD, an assistant professor of emergency medicine at the University of Texas Health Science Center in Houston who blogs at EM Literature of Note, said he was most surprised by the 8.2 percent three-day bouncebacks. “That's much higher than people expected to see,” he said. He was less impressed by the cost estimates, however.
“Unless you are in a system providing a lot of structure, there is a lot of low-hanging fruit in the health care system for saving money. A lot of time, we find that the failure is not the emergency department, but the failure [is] of the rest of the system. Patients come back to the emergency department because they don't have support or they have a medication problem. It's not the quality of the emergency department but a measure of the health system's overall quality. It would be interesting to see what other countries' bounceback rates are like. Or what the rates were a decade ago.”
Michael Weinstock, MD, a clinical associate professor of emergency medicine at the Ohio State University College of Medicine who has written extensively about bouncebacks, pointed out that the problem is tricky. “The first step is to determine which patients you want to be worried about,” he said. Seventy-one percent of patients who are sent home and die within a week have unexplained tachycardia, for example.
One of his colleagues, David Sklar, MD, recommended revisiting these patients in the exam room to determine if they have progressed and to obtain all information on the patient. He also advised EPs to record a progress note to confirm their thought processes. “If you cannot convince yourself the patient is going to be OK, you can't convince a family member,” he said.
Dr. Sklar, a distinguished professor of emergency medicine at the University of New Mexico School of Medicine, said recruiting family members to monitor the patient is a good idea. “We tell them to come back if things get worse or persist,” he said. That may seem simple, but is not in the context of a busy emergency department.
Dr. Sklar also said Dr. Duseja's study importantly starts the process of finding out why patients bounceback and defines the extent of the issue. “They might not be bouncing back. They are just coming back. There is a way to address that,” he said.
The ED as a Symbol
Dr. Duseja has a federal five-year grant from the Agency for Healthcare Research and Quality to study these issues. “We want to know what emergency departments with lower rates are doing differently from those that have higher rates. Qualitative interviews of patients and providers might provide such answers,” she said.
Some literature has also shown that social reasons drive patients to return to the emergency department, Dr. Duseja said. Sometimes patients may not have transportation or they may have mental illness or substance abuse that deters them from seeking appropriate care.
“We need to develop interventions to stop this. The best care we can give to our patients does not mean coming back to a different provider every few days. The American College of Emergency Physicians studies show that people are using the emergency department more frequently, which drives up the rate of return visits,” she said, adding that the Affordable Care Act has not affected bouncebacks.
Yet something needs to change, she said. “Emergency departments are symbols of how well our health system is doing. If we are using it more, something is going wrong with outpatient systems.”
Los Angeles County is starting a health exchange where patient records are available everywhere. “It's a step in the right direction. If a provider can see what happened across town, he or she will not repeat tests or procedures,” Dr. Duseja said.
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