Relative Risk Analysis of Patient Return Within 72  Hours to Emergency Department

Naveen Kumar P

ISSN 0972-5997

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Mangalore, India

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OJHAS Vol. 21, Issue 3: (July-September 2022)

Original Article
Relative Risk Analysis of Patient Return Within 72 Hours to Emergency Department

Authors:
Aishwarya TR, Post graduate student,
Naveen Kumar P, Professor and Head,
Department of Hospital Administration, Kasturba Medical College, Manipal Academy of Higher Education, Manipal - 576104.

Address for Correspondence
Naveen Kumar P,
Department of Hospital Administration,
Kasturba Medical College,
Manipal Academy of Higher Education,
Manipal - 576104.
E-mail: naveen.kumar@manipal.edu.

Citation
Aishwarya TR, Naveen Kumar P. Relative Risk Analysis of Patient Return Within 72 Hours to Emergency Department. Online J Health Allied Scs. 2022;21(3):4. Available at URL: https://www.ojhas.org/issue83/2022-3-4.html

Submitted: May 8, 2022; Accepted: Jul 8, 2022; Published: Nov 15, 2022

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This work is licensed under a Creative Commons Attribution-No Derivative Works 2.5 India License

Abstract: Introduction: Transparency in patient care in an emergency department can be projected by capturing data from the medical records of patients. Policy makers envision that transparency in this data will allow the patient to choose the right hospital of his choice. Relative risk is a ratio of the probability of an event occurring in the exposed group versus the probability of the event occurring in the non-exposed group. It is usually used in the scenario of clinical events. In this study we have used it to analyse one of the key performance indicators used in Emergency Department, as per Emerald standards. The problem statement identified in the study is the returning of patients to the Emergency department of a private, tertiary care hospital within 72 hours after the initial visit. A revisit in this study is assumed as an unplanned visit done by the patient within 72 hours with similar presenting complaints. Methodology: A retrospective cohort study for all emergency visits between January to June 2021. People who returned to EMD within 72 hours were compared to other non-re attending patients based on medical diagnosis, patient demographics, mode of arrival, triage category and qualification of doctors in charge. Multivariate analysis using the generalized linear model was conducted on variables associated with 72-hour ED re-attendance. Result: Among 18,355 patients, 128 (0.69%) were in the 72-hour re-attendees’ group. Multivariate analysis showed female gender as more, above 60 years of age, arrival by ambulance, triaged as yellow. Among the ICD-10 diagnosis for the patients who returned, it was not possible to identify one specific condition. But abdominal pain was one reason for the re-visit of a few patients. There was also a significant difference in the seniority ranking of the doctor-in-charge between both groups. Conclusion: Identification of characteristics of patients lead to improved care by surgeons and gastroenterology.
Key Words: Returning patients, emergency medicine, re attendees, Abdominal pain, Gastroenterology, ICD-10

Introduction:

Transparency in healthcare as defined by Institute of Medicine (IOM) is provisioning of accurate data, in a reliable, understandable manner on the consumer experience of care provided in the hospital.[1] Hospital readmission is an important contributor to medical expenditure and is an emerging indicator of quality of care. A readmission is the subsequent admission of a patient as an acute admission within a defined period, as within 72 hours.[2] From 2010, a hospital Re-admission Reduction Program (HRRB) has been started in USA in hospitals where medicare insurance patients were accepted for treatment. This aims at monitoring hospitals with high rate of re-admission within 30 days of first admission to reduce the payments, as to questioning on why risk profiling of patient was not done and treatment was not provided in first visit of the patient.[3] They had identified six common ailments where re-admissions happen, for e.g. Acute myocardial infarction (AMI), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), coronary artery bypass grafting (CABG), elective total hip / knee replacement.[4,5] Penalties due to re-admission after initiating HRRB program amounted to USD 2 Billion. 72-hour emergency department (ED) re-attendance is a widely used quality indicator for quality of care and patient safety.

Patients who return within 72 hours of discharge from the ED are often perceived to have received inadequate treatment or evaluation.[2] The commonly held belief is that these patients represent premature discharges from the first ED visit, missed diagnoses, or some other failure of their treatment or discharge plan. If this is the case, then it is probable that these patients may re-present with higher acuity and have worse outcomes compared to patients with similar complaints who did not have a previous visit to the ED. In the emergency department (ED), other common indicators used to measure the quality of care include the rate that patients leave without being seen, ambulance diversion time, total length of stay, and the time from a patient’s arrival until he or she is seen by a provider.

In this exercise analysis of medical health records, we also aimed to identify possible factors that contributed to 72-hour EMD re-attendance. Literature published across the world also suggests considerable variation in probable causes of 72-hour Emergency department re attendances.

Methodology

Study setting: The hospital selected is one of South India's largest acute tertiary hospitals. Annually, the EMD sees about 90,000 patients, with 180 – 200 patient visits per day. The 40 bedded department is Level 1 research center, providing round the clock emergency care for all adult emergency cases(>15 years) as well as pediatric trauma cases. Pediatric emergencies are taken care of by pediatric emergency department.

Study Design: This was a retrospective cohort study analyzing variables extracted from the Medical Records Department manually. The study population included patients who visited the EMD between 1 January 2021 and 30 June 2021. All patients who were aged 21 years and above, and had visited the EMD were included. We excluded patients who left without being registered, who were discharged against medical advice (DAMA) or who were dead on arrival. The study population were divided into two groups for comparison: those who returned within 72 hours of discharge from ED (72-hour re-attendees’ group) and those who did not return within 72 hours (non-re-attendees’ group). The re-attendance window was defined as the time from the index visit discharge to registration at the second visit. The index visits for the 72-hour re-attendees group was defined as the first of two visits made by a patient who returned within 72 hours of discharge from the ED. The index visits for the non-re-attendee’s group were defined as the first visit made by the patient within the study period. We analyzed the following patient demographics and variables associated with the index visit: gender, mode of arrival, patient triage category (yellow, blue, or red), seniority ranking of doctor-in-charge and medical diagnosis. The patient’s medical diagnosis is coded in the MRD department according to the International Classification of Diseases, Tenth Revision (ICD-10) from the medical records department. The ICD-10 is designed to promote international comparability in the collection, processing, classification, and presentation of mortality statistics.[3,6]

Data analysis was performed using Microsoft Excel 2010 version. Two patient groups were compared by first identifying the variables that were significantly different using analysis of two-way tables (measures of association). Multivariate analysis using the generalized linear model (relative risk [RR]) was then conducted on variables associated with 72-hour ED reattendance. The level of statistical significance was set at p < 0.001.

Results:

The EMD was supervised by faculty of Emergency department. They had post-graduation courses being run under the department. The admission protocol mandates emergency department faculty stabilizing the patients and referring the patient to specific specialties. Any patient presenting to the department is seen at the Triage desk by a nurse who has received special training in Triaging. After assessing the patients’ complaints and vital signs, the patient is triaged by the Five level Emergency Severity Index (ESI) into any one of five triage categories. There are five state of art customized resuscitation Cubicle “ResCue” for immediate stabilization in the Resuscitation area (Blue Area) which receives patients with immediate threat to life (Priority 1) or cannot wait for Care (Priority 2). The Critical Care area (Red Area) is fully equipped with ventilators, advanced monitoring and Emergency Renal Replacement therapy where patients who require continued stabilization are admitted. Patients who are less acute but with multiple resource requirements are managed in the Yellow area (Priority 3). Patients who are requiring single or no resource are treated in the Green Area (Priority 4 and 5).

Total of 18,355 patients visited and got treated during the 6-month period. Of this number, 128 were re-attendees and 18,227 were non re-attendees. On an average per month, we can have 20 people returning. Out of the 128 patients, 75% of them survived following the readmission. Figure 1 shows the month-wise percentage of patients who returned to the Emergency department in the tertiary care center within 72 hours.

Figure 1: Percentage of patients who returned to EMD department within 72 hours during 6-month study period, January 2021 to June 2021

Table 1: Patient characteristics, mode of arrival, triage category, seniority of doctors attending the patient and top ICD 10 diagnosis for the re attendees.
Parameters		72 Hr.Re-attendees (N=128) n,%	Non- re-attendees (N=18227) n,%	P value
Gender	Male	39 (30.5%)	10556 (57.9%)	*<0.001
Gender	Female	89 (69.5%)	7671 (42.1%)	*<0.001
Age Group (Yrs.)	21-30	2 (1.6%)	1800 (9.9%)	*<0.001
	31-40	14 (10.9%)	4750 (26.1%)
	41-50	56 (43.8%)	7890 (43.3%)
	51-60	18 (14.1%)	3550 (19.5%)
	61-70	35 (27.3%)	167 (0.9%)
	71-80	2 (1.6%)	55 (0.3%)
	>80	1 (0.8%)	15 (0.1%)
Mode of Arrival	Ambulance	88 (68.8%)	9125 (50.1%)	*<0.001
Mode of Arrival	Non-Ambulance	40 (31.3%)	9102 (49.9%)	*<0.001
Triage Category	Green	15 (11.7%)	2739 (15%)	*<0.001
	Yellow	90 (70.3%)	5243 (28.8%)
	Blue/Red	23 (18%)	10245 (56.2%)
Seniority of the doctor who attended the Patient first	Consultant	28 (21.9%)	227 (1.2%)	*<0.001
Seniority of the doctor who attended the Patient first	Post graduate	100 (78.1%)	18000 (98.8%)	*<0.001
ICD Diagnosis	Abdominal Pain	14 (10.9%)	No data	Cannot compute
	RTA	10 (7.8%)
	Vomiting	7 (5.5%)
	Giddiness	4 (3.1%)
	Back Pain	10 (7.8%)
	Cellulitis	4 (3.1%)
	Multiple other causes	79 (61.7%)
*Significant

The graph shows linear increase correlating with the increase in number of patients visiting EMD in that month. Table 1 shows the variables associated with the visits of both groups. Chi square test have been used to find statistical significance. There was statistical significance (p<0.001) between 2 group of patients in their gender, age group, mode of arrival, triage category and seniority of doctors who saw the patient. The ICD 10 diagnosis done for the patients during this period revealed that among multiple other diagnosis, abdominal pain was the most frequent cause of re-attendances. The other reasons included RTA, vomiting, dizziness, back pain and cellulitis. Table 2 shows ICD codes of all the common reasons for re-attendances.

Table 2: ICD codes of all the common reasons for re-attendances.
	ICD 10 code
Unspecified Abdominal Pain	R10.9
Vomiting	R11.11,R11.0
Dizziness	R42
Back Pain	M54.50
Cellulitis	L03.90

Table 3 uses multivariate analysis to find out influencing factors for 72 hour re attendees. Regarding the gender, female population has higher chance of returning to EMD with symptoms within 72 hours. (Relative Risk - 3.140, p<0.001). The age group 61-70 years had a relatively higher risk of returning. Patients who arrived by ambulance had more chance of returning (Relative risk - 2.194, p<0.001) and patients triaged as yellow had more chance of returning to EMD.

There was significant difference in the seniority of doctors attending the patient first with consultants being the people who saw the patients who returned first (Relative Risk of 22.203, p<0.001)

Table 3: Multivariate analysis to find out influencing factors for 72 hour re attendees

Factors		Odds Ratio	95% C.I.		p value
Factors		Odds Ratio	Lower	Upper	p value
Gender	(Female/Male)	3.140	2.153	4.581	<0.001
Age (Ref.: Age:21-30yrs.)	31-40	0.377	0.086	1.660	0.197
	41-50	0.162	0.040	0.666	0.012
	51-60	0.197	0.046	0.845	0.029
	61-70	0.005	0.001	0.022	<0.001
	71-80	0.031	0.004	0.221	0.001
	>80	0.017	0.001	0.194	0.001
Mode of Arrival	Ambulance/Non-Ambulance	2.194	1.508	3.193	<0.001
Triage Category (Ref.:Blue/Red)	Green	0.410	0.214	0.787	0.007
Triage Category (Ref.:Blue/Red)	Yellow	0.131	0.083	0.207	<0.001
Seniority of the doctor who attended the Patient first	Consultant / Post graduate	22.203	14.313	34.441	<0.001

Logistic Regression has been done to estimate the influencing factors of 72 hr. re-attendees in emergency department. Each factor is assessed separately.

Discussion:

From the relative risk factor analysis some of the factors like gender, advanced age, arrival by ambulance, yellow area triaging status, diagnoses of abdominal pain and RTA had higher association of returning back and cases where senior doctors were attending.

In the analysis it was found that females had a higher risk of returning within 72 hours. The likely explanation for this finding could be that there were more females in the elderly age group as women outlive men.

It was found that the patient who came back were in yellow area triaging, were patients who were more sick. However, our analysis could not determine if their revisit was related to the preceding visit or the patient was of yellow triaging and above status in earlier visit; the latter could suggest inadequate treatment on their first visit. Following recommendations post study, the 72 hours re-visit register was expanded to include columns with initial triage category.

Having identified the three most common diagnoses that were the greatest risk factors in the 72-hour re-attendees group, namely abdominal pain, vomiting and RTA, we have to look in to the reasons for the initial presenting complaints and see if the condition was inadequately treated in the first visit which led to the re visit. After evaluation of the first major cause of return the Emergency, gastroenterology training courses were given for senior residents.

In future studies, we aim to look beyond the index visit and investigate if there was a significant difference in diagnosis and presentation status between the index and return ED visit. Our study showed that there was a significant difference in the signs and symptoms of patient who presented after 72 hours, which could be the reason they were missed in the first place. It would also be useful to examine admission outcomes of the revisit in the subgroup of 72-hour re-attendees whether it resulted in death or ICU stay. In our study death outcome was linked to only 25% of the cases. Studies have shown a readmission to Emergency Department within 72 hours is often linked with poor prognosis.

Another interesting aspect of the study was that patient seen by doctors of more seniority ranking was likely to return. But this could be explained by the fact that patients were having more serious presentations and hence were being seen by the senior faculty first. This was explained by the fact that senior doctors were attending to more serious cases when compared to the junior residents. The study helped to identify the target groups and specific areas to focus within the department.

The study findings lead to the formulation of a departmental operating standard that 72 hour returnees would be seen by senior consultants only and stricter triage protocols.

Return to the department factors can be classified into 3 headings- illness wise, doctor and patient related causes.(7) In illness related returns the patient has received appropriate emergency care but returned due to disease progression. In doctor related returns, it is the doctor's fault. In patient related causes, the return is initiated by the patient maybe due to natural course of disease or anxiety. In our study the causes of the return were found to be illness related in majority with patient factors weighing in on few cases.

Lastly, it would be interesting to study the reasons why patients who arrived by ambulance were more likely to return. This may be due to the fact that the patients may not have realised the urgency of their condition during the first visit and later had to resort to the use of ambulance. The reasons for the return should also be analysed.

In conclusion we found several patient and event related factors associated with increased risk of being a 72 hour reattenders’ study can be a basis for hypothesis generation and for more studies to find out the reason for the same and develop interventions to target high – risk groups.

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