72-Hour ED Revisits by Tom Scaletta, MD

Tom Scaletta, MDEmergency department directors often monitor the rate patients that return to the ED for unscheduled revisits within 72-hours.  Special attention is appropriately placed on those cases that result in admission.  In my view, this particular subset is a reasonable screening tool for physician judgment errors though these are a very small fraction of all 72-hour revisits.  Indeed, it is untrue that that overall rate of unscheduled revisits is inversely proportional to care quality.

Unscheduled returns that result in admission are worthy of analysis, specifically for appropriateness of the initial diagnosis and disposition.  Similarly, floor admissions that upgrade to ICU with 72-hours deserve review.  For both metrics, this can be as straightforward as a physician leader reviewing a regularly generated list of initial and subsequent diagnoses to help determine if the care requires further review.  For instance, when a patient sent home with calf strain returns a couple days later with a pulmonary embolism, opportunities for improvement are sought.  The overwhelming majority of revisits simply relate to natural disease progression or patient noncompliance with what would have otherwise been an effective plan.

If we were mandated to base appropriate disposition decisions purely upon evidence-based medicine, then many patients would never leave the ED as there is very little hard evidence of exactly where to draw the line.  Some tools are available.  For instance, a pneumonia severity index above 90 suggests admission is the appropriate disposition (http://pda.ahrq.gov/clinic/psi/psicalc.asp).  However, most of our disposition acumen comes from practice experience and formal training in EM.

Measuring 72-hour revisits that do not result in admission has no real utility because the right correct rate is unknown.  Overly conservative physicians certainly waste limited resources. A well-trained, experienced physician that understands the risk/benefit of the disposition options, that makes careful discharge plans, that carefully educates the patient, can safely send home a lot more patients.

In an era where PCPs and payers push hard to send patients home, we need strategies to closely monitor discharged patients and make sure they remain safe.  Callback programs exist to fulfill that purpose.  A clerk can make sure the patient is doing well, has follow-up, and understands the aftercare plan.  Clinical issues are referred to the charge nurse for resolution and, whenever an on-call specialist tries to block a necessary follow-up visit, the hospital leadership can intervene.

If you are interested in a data collection tool to categorize 72-hour revisits that result in admission, just shoot me an email (tom@emergencyexcellence.com) and I will forward it to you.

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