Most EDs track return visits — cases in which patients come back with new or worsening symptoms. But what if that patient goes to a different ED? Investigators recently examined this question.1
“Our research group undertook this study to better understand how patients moved between different hospitals after an initial ED discharge,” says Bradley Shy, MD, the study’s lead author. Researchers analyzed more than 12 million return visits (sometimes called “bouncebacks”) occurring within 72 hours of initial presentation at 31 EDs over a five-year period. These included 841,259 same-site visits and 107,713 different-site return visits.
“This work may raise important malpractice implications for the second ED involved in a two-hospital bounceback,” says Shy, associate medical director and director of quality assurance and process improvement in the department of emergency medicine at Mount Sinai School of Medicine in New York City.
The data showed “a huge variability” in how frequently patients from any particular ED will return to a different hospital within 72 hours, Shy says. The ED most likely to have patients return to another site saw a 52% increase in the number of 72-hour returns identified when other hospitals were included in this analysis.
“This work highlights the perils of using 72-hour return frequency as a surrogate measure for quality of care,” Shy notes.
Health information exchanges could allow ED physicians to learn in real time the nature of a patient’s recent visit to an outside hospital. “There are countless examples — access to blood culture results, avoiding redundant CT scans, knowledge about patients’ allergic drug reaction history — of how this technology can be potentially life-saving,” Shy says.
As health information exchanges grow, ED physicians could conceivably be liable for not reviewing data from outside hospitals. “If EDs have access to these records from outside hospitals and do not access these, these physicians and hospitals could be taking on significant risk,” Shy warns.
Shy stresses that EPs should look for ways that this can improve their patient care. “It is very likely health information exchanges will become substantially larger and more robust over the next decade.”
The traditional understanding of a 72-hour bounceback was based on identifying patients who had returned to the same facility. “But it is logical to consider the possibility that if the initial visit resulted in a return, the patient may want their repeat evaluation to be done by a different center,” says Michael B. Weinstock, MD, co-author of Bouncebacks! Emergency Department Cases: ED Returns.
Investigators did not seek to determine if there was a medical error resulting in the return. “In fact, there are some patients who will have a progression of their disease or new symptoms. We want these patients to return,” says Weinstock, associate program director of Adena Emergency Medicine Residency and director of medical education and research at Adena Health System.
Factors that increased the likelihood that the patient would return to the same ED included age of 65 years or older, and the existence of an emergency medicine residency program at the hospital.
“Risk management factors to consider when discharging a patient are to anticipate patients who may have progression of disease and to ensure they understand the importance of returning for a recheck,” Weinstock says, noting that patients should know they are welcome to return to the ED any time. “But going to the closest ED, even if a different ED, should not be discouraged.”
The need to return to the ED is not always clear to patients. “A patient’s presentation is a question that sometimes only we understand — for example, a thunderclap headache or left lower quadrant pain in an amenorrheic woman,” Weinstock offers. It is important that both the ED provider and the patient understand the question that needs answering. “This will help with encouraging the patient to return if their symptoms progress or change,” Weinstock notes.
When seeing a bounceback patient, there is a risk EPs will fall into “diagnosis momentum,” according to Weinstock. “One of the biggest impediments to making an accurate current diagnosis is to attribute undue importance on the previous diagnosis,” he says.
When a patient returns to a different ED, Weinstock says, “the previous ED visit should be explored for complaints not explored, lab abnormalities not acted on, and abnormal vital signs not recognized.”
Some EPs may be inclined to blame the initial doctor for a misdiagnosis. “This may prompt the patient to initiate a lawsuit,” Weinstock warns.
The presentation may seem obvious on the return visit, but the diagnosis may have not been so clear at the time of the first ED visit. A common example is a patient presenting with the earliest symptoms of appendicitis (mild nonfocal abdominal pain and nausea). If the patient feels better with conservative treatment, exhibits good vital signs, and shows improvement during a follow-up physical exam, discharge may be indicated, provided that good ED return precautions are understood by the patient.
“Although appendicitis would be possible at this point, other diagnoses, such as gastritis, may be more likely,” Shy says. On a return visit to the same or different ED, symptoms may be more severe and consistent with appendicitis. “At this point, this diagnosis can be readily made,” Shy adds.
EPs should keep in mind that the previous ED evaluation and management might have been entirely appropriate based on the information available at the time. “We should never cast blame on a previous provider,” Weinstock advises.
For example, a patient with complaint of headache may have told the initial provider that it was identical to past headaches. But with the additional information of unintentional weight loss given to an EP at the second ED, now primary or metastatic malignancy moves up on the differential.
“Keep the encounter focused on the patient’s symptoms and making a diagnosis and management plan,” Weinstock offers. “Leave litigation for someone else.”
1. Shy BD, Loo GT, Lowry T, et al. Bouncing back elsewhere: Multilevel analysis of return visits to the same or a different hospital after initial emergency department presentation. Ann Emerg Med 2018;71:555-563.
• Bradley Shy, MD, Associate Medical Director/Director of Quality Assurance and Process Improvement, Department of Emergency Medicine, Mount Sinai School of Medicine, New York. Phone: (646) 537-8703. Email: email@example.com.
• Michael B. Weinstock, MD, Associate Program Director, Adena Emergency Medicine Residency; Director, Medical Education and Research, Adena Health System; Professor, Emergency Medicine, Department of Emergency Medicine, Wexner Medical Center, The Ohio State University, Columbus. Phone: (614) 507-6111. Email: firstname.lastname@example.org.