Patients with a history of substance abuse or chronic pain were most likely to “bounce back” to the ED, according to the authors of a study.1

“Patient bounce-backs are a part of emergency medicine, and occur for many different reasons — system-related, patient-related, and disease-related,” says Janine E. Curcio, DO, the study’s lead author and an EMS fellow at OhioHealth Doctors Hospital in Columbus.

Curcio and colleagues analyzed 732 charts for ED visits from 2015 to 2017. They found 4.65% of patients returned within 72 hours. The authors expected training level (i.e., residents vs. attending physicians) might affect bounce-back rates, but this was not the case. “It’s important to look at bounce-backs as a second chance to look at the problem again and to help the patient. It’s when our bias starts creeping in that we open ourselves up to more liability risks,” Curcio offers.

Multiple visits to an ED “are always challenging in a lawsuit,” says Susan Martin, RN, JD, executive vice president of litigation management and loss control at AMS Management Group in Plano, TX.

Virtually everyone discharged from an ED receives instructions along the lines of “Return if there is no improvement, or if symptoms worsen.” When patients follow those instructions, though, it needs to be taken seriously.

“It should raise a red flag for physicians to consider that it may be a missed opportunity for a more definitive diagnosis, or an indication of a more serious medical emergency,” Martin says.

A recent malpractice case involved a young man who arrived in the ED after a car accident with a puncture wound on his lower arm. The patient reported the air bags deployed and glass broke, but denied sustaining any other injuries. The EP cleaned and dressed the wound and discharged the patient.

Two days later, the patient returned to the ED complaining the wound was painful. During the second ED visit, the EP did not review the record from the first visit. The second EP simply examined the wound and instructed the patient to change the dressings and keep the wound clean.

During the second ED visit, a dangerous (and incorrect) assumption was made. “The ED physician assumed the prior ED physician performed X-rays on the arm and examined the wound,” Martin says.

The patient was discharged again. Four days later, the man returned with an obviously infected wound. Upon exam, the third EP noted the wound was swollen with purulent material. The third EP ordered an X-ray, which showed a large foreign body in the deep tissue, likely a piece of glass. The patient started antibiotics, was admitted to the surgical floor, and eventually underwent surgery to retrieve the foreign body.

His arm eventually healed, but the patient sued the first EP and second EP for malpractice after incurring significant medical expenses and lost wages. The case was settled for an undisclosed amount. “The lesson is that you never assume what occurred on an earlier visit,” Martin says. Ideally, the EMR automatically flags return visits within a certain period of a previous ED visit, such as 48 or 72 hours. That should prompt the EP to scrutinize the original visit and the return visit to be sure nothing is missed.

“Such policies, and careful review and thoughtful re-examination, are in the best interest of the patient and may deter a lawsuit,” Martin says.

Patients who return to the ED after discharge within a day or two “represent a unique challenge from a patient safety standpoint,” says Andrew P. Garlisi, MD, MPH, MBA, VAQSF, EMS medical director at Cleveland-based University Hospitals EMS Training & Disaster Preparedness Institute.

One problem is ED providers sometimes look at return visits as annoying. “Emergency physicians and nurses should avoid the tendency to consider these patients an attention-seeking nuisance,” Garlisi cautions.

In reality, the return visit is a red-flag warning that something was missed or evolved since the first visit. “A careful review of the prior medical record should ensue,” Garlisi suggests.

ED providers should find out if the patient’s history or physical exam changed in any way since the first visit. Prior lab and imaging results also should be reviewed. “The team should approach the patient encounter with fresh eyes and a critical thinking process unencumbered by judgmental bias,” Garlisi says.

Frequently, abdominal pain complaints are encountered on repeat visits. “This is no surprise, as abdominal pain has a huge differential diagnosis,” Garlisi observes.

Often, the specific etiology of abdominal pain cannot be identified on the first (or even subsequent) visit. The patient’s immediate safety is ensured as long as the EP considers and rules out a surgical emergency (e.g., testicular or ovarian torsion, appendicitis, perforated bowel, bowel ischemia, or aortic aneurysm leak) or medical emergency (e.g., acute coronary syndrome, pancreatitis, GI bleed, or pyelonephritis).

EPs must decide whether to admit a bounce-back patient for observation, symptom management, further testing, or consultation. “Patients who continue to have abdominal pain despite multiple doses of pain medication, or persistent vomiting despite [ondansetron] and [prochlorperazine], should be hospitalized,” Garlisi says.

Discharging a bounce-back patient a second time in a short period “invites close scrutiny and increased risk of malpractice action if the patient dies or has serious negative health consequences,” Garlisi warns. This documentation helps the defense:

  • The EP considered various life-threatening conditions but believed these were unlikely.
  • The patient had improved/was stable.
  • Follow-up was not just recommended, but arranged, for the patient. For instance, ED staff can schedule next-day follow-up with the surgeon, a specialist (e.g., a cardiologist for chest pain), or the primary care physician.
  • The ED provider spoke directly to the doctor following up with the patient.

“Arranging a scheduled, short-term follow-up announces to the world that the emergency physician realizes that the patient’s condition could deteriorate,” Garlisi says.

It also is an opportunity for the consultant to make further recommendations for ancillary testing, which could be handled before the patient leaves the ED. “This strongly supports that the emergency physician did everything reasonably possible to ensure a positive clinical outcome,” Garlisi says.

Not all ED bounce-backs indicate a patient safety concern. EPs are “often in the position of using a reasonable amount of resources to explore a chief complaint, and then advising a patient who looks well enough to go home to return if symptoms worsen,” says Renée Bernard, JD, vice president of patient safety at The Mutual Risk Retention Group in Walnut Creek, CA.

If the patient returns per the ED discharge instructions, that is appropriate; it is how the system is intended to work. “There are nonmedical, social access reasons that EDs see the same patients multiple times. A lot of malpractice cases involve multiple ED visits and complex care issues,” Bernard explains.

The challenge becomes showing the standard of care was met, even though a patient experienced a bad outcome. “The actions of a provider on the second visit become a bit more critical than on the first,” Bernard notes.

The second EP must review the first visit and explore in detail with the patient what changed since then. “It’s very important to document a thorough exam and history on the chief complaint,” Bernard adds.

In retrospect, ED providers often wish they had addressed a lab result that was not quite normal. The second EP also must be clear on the timing of their own documentation about reassessments and differentiate that from prior exams. “That will help tell the story more clearly, as not all EMRs make it easy to track progression of symptoms or exams,” Bernard says.

The second EP also should take the trouble to document the bounce-back visit in real time as opposed to hours later. “Though this is not always practical, it is essential in a patient who is at higher medical risk,” Bernard adds.

REFERENCE

  1. Curcio J, Little A, Bolyard C, et al. Emergency department “bounce-back” rates as a function of emergency medicine training year. Cureus 2020;12:e10503.