Unscheduled return visits to the emergency department: consequences for triage

The objective was to conduct a survey of unscheduled revisits (URs) to the emergency department (ED) within 8 days of a prior visit, to test the hypothesis that patients making these URs are disproportionately likely to suffer short-term mortality or manifest a need for any admission to the hospital (adverse events [AEs]) at the time of the UR, compared to patients triaged at the same level who did not have an unscheduled ED revisit within 8 days.

This was a 1-year retrospective study of patients with an UR to the ED of an urban, 1,600-bed tertiary care center and teaching hospital. The criteria for inclusion as an UR were: 1) making an emergency visit to our adult ED during 2008, without being admitted to our hospital nor being transferred to another hospital; and 2) subsequently making an UR to the same ED within 8 days following the first one. Patients who were contacted by members of our staff and specifically asked to make return visits to our ED (such as those who returned for wound care follow-up visits), and those who made more than five visits to our ED during 2008, were excluded. AEs were defined as death or hospitalization within 8 days of the second visit.

During 2008, there were 946 patients with URs (2% of patients treated and released after the first ED visit), and 931 were analyzed (n = 15 missing values). Associated with the second visit, an AE was noted for 276 (30%) patients. Eight variables were significantly associated with AE: age ≥ 65 years, previously diagnosed cancer, previously diagnosed cardiac disease, previously diagnosed psychiatric disease, presence of a relative at the time of the UR, arrival with a letter from a general practitioner at the time of the UR, a higher level of severity assigned at triage for the UR than for the first ED visit, and having had blood sample analysis performed during the first visit. The median triage score for the UR was not significantly different from that group's median triage score for the first ED visit, whereas the proportion of admissions to the hospital (29%) or to the intensive care unit (ICU; 2%) was greater overall in the UR group than in the patients making their first ED visit.

The authors observed that 2% of patients had an UR. This UR population was at greater risk of AE at the time of their URs compared to their initial visits, but the median triage nurse score was not significantly different between the first visit and the UR. This suggests that the triage score should be systematically upgraded for UR patients.