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Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 23-27

Emergency department revisits within 72 hours to a tertiary care referral hospital in South India

Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission27-Nov-2019
Date of Decision22-Dec-2019
Date of Acceptance31-Dec-2019
Date of Web Publication03-Feb-2020

Correspondence Address:
Dr. Joshua J Vijay
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmi.cmi_65_19

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Introduction: Emergency department (ED) revisits are an important indication of health-care quality provided by a hospital. In the West, ED revisits rate range from 2.9% to 4.9%. However, data from India are lacking, and hence. this study was done.
Methodology: This retrospective observational study was done in a 45-bedded ED of a teaching hospital in South India. All the patients who revisited the ED within 72 hours over a 1-year period were considered. The revisit was categorized as unavoidable if the patient was diagnosed correctly and managed appropriately during the first visit or if the patient presented with an unrelated illness within 72 hours.
Results: The ED revisit rate was 0.8% (549/65,900). The monthly revisit rates ranged from 0.50% to 1.91%. About 57.9% were initially categorized as priority 3, 33.9% as priority 2, and 8.3% as priority 1 patients. During the revisit, 41.6% were priority 3 patients, 44.3% were priority 2 patients, and 13.7% were priority 1 patients. Gastrointestinal symptoms such as abdominal pain, vomiting, diarrhea, and constipation were the most common initial presenting complaints seen in 36% of the patients followed by fever (15.3%). A majority (75%) of these patients were initially discharged by the ED registrars. More than half (55.2%) of the revisits were avoidable. During the second visit, 58% were discharged in a stable condition, 31.7% were admitted to the hospital, and 4.8% died in the ED.
Conclusion: ED revisits are associated with significant distress to the patients and more than half of them can be avoided.

Keywords: 72 hours, emergency department revisits, emergency department triage, revisit rate

How to cite this article:
Mathew N, Guttikonda A, Mitra S, Vijay JJ, Abhilash KP. Emergency department revisits within 72 hours to a tertiary care referral hospital in South India. Curr Med Issues 2020;18:23-7

How to cite this URL:
Mathew N, Guttikonda A, Mitra S, Vijay JJ, Abhilash KP. Emergency department revisits within 72 hours to a tertiary care referral hospital in South India. Curr Med Issues [serial online] 2020 [cited 2023 Jun 6];18:23-7. Available from: https://www.cmijournal.org/text.asp?2020/18/1/23/277533

*Shubhanker Mitra - Deceased 03 January 2016

  Introduction Top

Emergency medicine (EM) in India remains an area that is largely underdeveloped and overlooked. It has remained a nascent specialty and is practiced by inadequately trained clinicians in poorly equipped emergency departments (EDs).[1] The four parameters that assess the quality of medical care provided by an ED are mortality rate, revisit rate, patient waiting time, and the number of patients who left the ED without being seen by a doctor.[2] An ED revisit, in this study, is defined as a patient who makes an unscheduled visit within 72 hours of the initial visit. Unscheduled revisits increase the workload of ED staff, utilize more resources of the hospital and the patient, and also result in increased patient wait time.[3] Studying the revisits will help to devise strategies to overcome such challenges and minimize revisits, and therefore, similar studies have been undertaken around the world. Data from countries such as Canada,[3] Australia,[4] USA,[5] Spain,[6] the Netherlands,[7] and Taiwan[8] showed that the revisit rates ranged from 0.8% to 5.8%. A study done in the USA[5] reviewed each revisit case and classified them as avoidable and unavoidable. They found that 32.3% of the unscheduled related return visits were avoidable. A literature review revealed that no such study has ever been done before in India. In India, under the public health system, tertiary care service is provided by a limited number of medical colleges and advanced medical research institutes. There exists a tremendous burden on tertiary care centers due to referrals from the primary and secondary level hospitals. The rationale behind this study is to evaluate current emergency medical care standards and further to design effective prevention and comprehensive management strategies. In our study, we aim to ascertain the number, rate, and proportion of revisits to assess the quality of emergency medical care. We also seek to review each case to see whether the revisits were avoidable or unavoidable.

  Methodology Top

Study setting

The Christian Medical College and Hospital is a tertiary care teaching hospital located in Vellore, in North Tamil Nadu. Its 50-bedded adult ED provides 24-h emergency medical care to an average of 200–250 patients a day. The department caters to all adult emergency cases (> 15 years) as well pediatric trauma cases. All other pediatric emergency cases are taken care of by the pediatric ED.

Study design

We undertook a retrospective observational study in the ED of the Christian Medical College, Vellore. All patients who revisited the adult ED within 72 hours of their initial visit between March 1, 2014, and February 28, 2015, were included in the study. The patients were identified using the 72-h revisit register maintained at triage of the ED. A retrospective chart review was performed on all the above-said patients using the hospital's electronic medical database.

For patients who revisited the ED more than once in the 3-day time frame, the initial visit and the last revisit were considered for study purposes Triage assessment sheets and charts were studied individually for each eligible patient, and the patients' demographic details, triage priorities, presenting complaints, and admitting diagnoses were obtained for each visit. In addition to these details, details about the discharge deposition were also obtained for the initial visit and the revisit. Triage priorities were determined using the following criteria:

  1. Triage priority 1 – Patients with an acute medical condition with airway, breathing, or circulation compromise
  2. Triage priority 2 – Patients with an acute medical condition with stable airway, breathing, and circulation but requiring admission
  3. Triage priority 3 – Patients with acute or chronic medical conditions, who are in a hemodynamically stable condition and ambulant.

Outcome variables

The details were analyzed, and rates and reasons for revisit were deduced. Finally, revisits were categorized subjectively as avoidable or unavoidable. A revisit was categorized as unavoidable if the patient was diagnosed correctly and managed appropriately during the first visit or if the patient presented with an unrelated illness within 72 hours. Patients with incomplete documentation were excluded from the analysis.

Statistical methods

Statistical analysis was performed using SPSS Software (SPSS Inc., SPSS for Windows, version 16.0, Chicago, IL, USA). The mean (standard deviation) were calculated for the continuous variables and t-test or Mann–Whitney test was used to test the significance. Background characteristics were obtained, and all descriptive data were expressed as a mean and standard deviation. The categorical variables were expressed in proportion, and Chi-square test or Fisher exact test was used to compare dichotomous variables. For all tests, a two-sided P = 0.05 or less was considered statistically significant.

Ethical considerations

This study was approved by the Institutional Review Board prior to the commencement of the study (IRB Min. No. 9045 dated January 22, 2015). Patient confidentiality was maintained using unique identifiers and password-protected data entry software with restricted users.

  Results Top

The ED was attended by 65,900 patients in the 12-month study. The revisit rate was 0.8% (549/65,900) [Figure 1]. The mean age of the revisit patients was 42 (±17) years. A majority of them (59.2%) were male. More than half of them were from Tamil Nadu (54.9%), 9.9% were from Andhra Pradesh, and the remaining were from other states of India, such as West Bengal and Jharkhand. The most prevalent comorbidities were diabetes mellitus (20.2%), hypertension (19.9%), and cancer (13.6%). The proportion of revisits as compared to the total number of visits per month was highest in March at 1.9%. Weekday revisit rates were 1.6/day and weekend revisit rates were 1.5/day. Nearly 84% of the patients presented with acute conditions (<14 days) and the rest of the patients (15.6%) presented with chronic complaints. The median symptom duration was 2 days. Patients who returned with the same complaints accounted for 83.1%, while the rest revisited with unrelated complaints.
Figure 1: Flowchart of patients revisiting the emergency department

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Abdominal symptoms such as pain, vomiting, and diarrhea (36%) were the most common symptoms at the index visit, constituting more than one-third of the complaints. Fever (13.6%) and dyspnea (7.8%) constituted the second and the third most common complaints [Figure 2]. A majority of the patients were initially categorized as priority 3 (57.9%), while 33.9% were categorized as priority 2, and 8.3% were priority 1 patients [Table 1]. At the second visit, however, 41.6% of the patients presented as priority 3, 44.3% were priority 2 patients, and 13.7% were priority 1 patients. In the first visit, a majority of the patients (82.3%) were discharged in a stable condition and 17.7% required admission in the ward for surgical intervention or conservative management. Of all the patients discharged stable, 70.5% were discharged by ED registrars. Other departments that discharged patients from the ED were hematology (4.2%), medicine (3.8%), and neurology (3.8%). At the end of the second visit, 58% of the patients were discharged stable. Nearly a third of the patients (31.7%) were admitted for further intervention and 4.8% of the patients died. More patients (55.8%) tended to return on the same day as the first visit as opposed to those who returned to the ED (44.2%) after more than 24 h. Almost all the patients (93.7%) revisited the ED only once and a small proportion revisited more than once. Less than half of the return patients classed under triage priorities 1 and 2 had avoidable revisits (32% and 49%, respectively) [Figure 3].
Figure 2: Presenting complaints at the first and second visits

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Table 1: Triage priority at the first visit and outcome

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Figure 3: Triage priority at the first visit and avoidability of revisit

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  Discussion Top

The primary objective of our study was to assess the rate of revisits to the ED. We found that the return rate in our setting was 0.8%, which was comparable to or less than those in some other countries where similar studies were undertaken.[3],[4],[5],[6],[7],[8] This revisit rate indicated a satisfactory level of emergency care. One of the factors which led to the low revisit rate could have been the triage system, which was the first of its kind in the country. The triage system helps in the efficient prioritization of patients and ensures that each patient gets the adequate level of care. Other factors contributing to the low revisit rate include the efficient follow-up system in the outpatient department and the multiple higher specialties, such as plastic surgery, cardiothoracic surgery, hand surgery, and neurology, which are involved in patient care at the ED itself.

The mean age of revisit patients was 42 ± 17 years and the age distribution correlated with the normal age distribution of the Indian population. In a study done by van der Linden et al. in the Netherlands, the mean age of revisit patients was 39.3 ± 20.2 years.[7] Thus, both in our study and in the study in the Netherlands, people from the middle age groups tend to revisit the ED more. On the contrary, another study done by Aminzadeh and Dalziel in Canada[9] found that old people tend to utilize ED services more and thus tend to have more revisits. This could be because of the different population-age distributions in different countries. Overall, abdominal symptoms (abdominal pain, vomiting, and diarrhea) constituted the most common presenting complaints, especially among triage priority 2 and 3 patients. An explanation for this could be that abdominal symptoms are the most common complaints at the initial visit and are, therefore, also the most common complaints at revisit. This may also be a reason why these symptoms tend to be underestimated. Furthermore, abdominal pain (67.4%), which forms a significant proportion of abdominal symptoms, is often not easy to evaluate and diagnose. It requires an in-depth workup to deduce the etiology and is most often referred to the outpatient department for follow-up. This result is akin to that of a similar study done in Taiwan where the most frequent presenting complaints were abdominal pain (12.9%) and fever (12.6%).[8]

In our study, 37.7% of the revisit patients presented initially with chronic conditions. Similarly, in a study done by the White et al. in the Netherlands,[10] more than one-third of the return visit patients presented to the ED with chronic conditions. We speculate that the reason for a large number of chronic conditions is the fact that patients use the ED as a source of primary care instead of going to the outpatient department for management.

In our study, we attempted to examine the allotment of triage priorities and assessed whether there was any correlation between the acuity of illness and triage priority. However, we found that there was no correlation between chronic illnesses and lower triage priorities (P = 1.77).

Almost a quarter of the studied patients returned to the ED with a worsening of symptoms, demonstrated by a change in their triage priority. Nearly three-fourth (70.5%) of the patients who revisited the ED had been discharged previously by ED registrars (P< 0.001). On the surface, this might point toward lapses in medical management, but on deeper analysis, we found that ED registrars grapple with a huge patient load every day. Most of the staff in the ED are composed of junior doctors, and since it is a new specialty, protocols and training are in a nascent phase. More efficient training is required to equip the doctors in the ED to handle the footfall. Another finding that further reiterates this fact is the monthly revisit rate. Monthly revisit rates are highest in March (1.9%) when the ED is least staffed because of a turnover in fellowship students. Our hospital staff in the ED consists of a fluctuating base of junior medical doctors, which is least in March during our study period. That, along with patient load, may have contributed to inappropriate discharge.

Less than half of the return patients classed under triage priorities 1 and 2 had avoidable revisits (32% and 49%, respectively). However, 63% of the patients classed under triage priority 3 had avoidable revisits. This may be because priority 3 patients appear stable and less ill, and thus, their complaints are not taken as seriously as those of the other priorities. These patients are usually not evaluated in detail in the ED and are referred to the outpatient department for further investigation. Therefore, there is a need to focus on such patients to minimize unnecessary revisits. ED revisits are a significant source of distress to patients, and at the end of the study, we observed that more than half of them are avoidable (55%). In a study done by Keith et al. in the USA, only 32.3% of the unscheduled return visits to the ED were found to be avoidable.[11] A possible intervention to reduce this disparity would be improved patient education. Wilkins and Beckett defined patient education as an explanation of duration of symptoms, reassurance regarding illness and its symptoms, and explanation of ongoing management of the disease.[12]

Some other studies have attempted to evaluate standards of the existing emergency medical care by assessing revisits and the expenses incurred by the hospital and the patient.[11],[12] This study, however, uses revisit rates and their avoidability to do the same. Revisit rates can thus be used as a yardstick for ED care, especially in younger EDs that are still formulating standards for medical management.

Our hospital is a tertiary care multispecialty hospital situated in a town flanked by many districts. Being the only tertiary center catering to about 190 plus villages means that many cases that come to ED are not actually “referred cases.” These cases that could, otherwise, have been managed effectively at the primary and secondary health care level serve to unnecessarily congest the ED and shift the focus from seriously ill patients who actually require specialized health care. The primary health care infrastructure (primary health centers and sub-centers) provides the first level of contact between the population and health care providers whereas the secondary health-care infrastructure (community health centers and district hospitals) serves as the first referral level. It is at this level that health care will be most effective within the context of the area's needs and limitations. Realizing their importance in the delivery of health services to the population and equipping them to deal with a larger spectrum of medical complaints will reduce the burden on tertiary care centers, which should serve only as the second referral center providing specialized health care.

About 58% of the patients were discharged stable at the second visit. These could be cases that could be managed at a different health-care setting because they did not require admission for care or investigations. A possible remedy to reduce the burden on EDs could be to identify and manage appropriate cases at a primary or secondary health-care level. This would have the benefit of helping the tertiary care centers to focus on patients who require immediate expert care from the various medical specialties they hold. This would also consolidate the position of primary health-care centers as the first tier of medical service to the community.

Retrospective nature of the study was a major limitation we faced. Our study is limited by sources of error common to all retrospective chart reviews, such as incomplete transfer of data into the electronic medical records system, missing chart information, and difficulty in interpreting documentation. Another limitation was the subjective nature of the evaluation of the avoidability of revisits. Thus, further prospective studies need to be done to assess revisits.

  Conclusion Top

Our study demonstrates a 72-h revisit rate of 0.8%, which is lower than those many of other countries. Of these, 55% were avoidable, and hence, ED doctors need to be more vigilant, especially in the case of priority 3 patients. The most common complaints that revisited were abdominal symptoms. Thus, this symptom has a high risk for a revisit, and protocols must be implemented to ensure that these conditions are not taken lightly. Equipping primary and secondary healthcare settings to handle emergency cases that do not require admission or specialized care could help to reduce the burden on the EDs of tertiary care centers.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is IRB Min. No. 9045 dated 22.01.2015. We also certify that we have not plagiarized the contents in this submission and have done a Plagiarism Check.

  References Top

David SS, Vasnaik M, Ramakrishnan TV. Emergency medicine in India: Why are we unable to 'walk the talk'? Emerg Med Australas 2007;19:289-95.   Back to cited text no. 1
Miró O, Sánchez M, Espinosa G, Millá J. Quality and effectiveness of an emergency department during weekends. Emerg Med J 2004;21:573-4.  Back to cited text no. 2
Foran A, Wuerth-Sarvis B, Milne WK. Bounce-back visits in a rural emergency department. Can J Rural Med 2010;15:108-12.  Back to cited text no. 3
Robinson K, Lam B. Early emergency department representations. Emerg Med Australas 2013;25:140-6.  Back to cited text no. 4
Gordon JA, An LC, Hayward RA, Williams BC. Initial emergency department diagnosis and return visits: Risk versus perception. Ann Emerg Med 1998;32:569-73.  Back to cited text no. 5
Nuñez S, Hexdall A, Aguirre-Jaime A. Unscheduled returns to the emergency department: An outcome of medical errors? Qual Saf Health Care 2006;15:102-8.  Back to cited text no. 6
van der Linden MC, Lindeboom R, de Haan R, van der Linden N, de Deckere ER, Lucas C, et al. Unscheduled return visits to a Dutch inner-city emergency department. Int J Emerg Med 2014;7:23.  Back to cited text no. 7
Wu CL, Wang FT, Chiang YC, Chiu YF, Lin TG, Fu LF, et al. Unplanned emergency department revisits within 72 hours to a secondary teaching referral hospital in Taiwan. J Emerg Med 2010;38:512-7.  Back to cited text no. 8
Aminzadeh F, Dalziel WB. Older adults in the emergency department: A systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med 2002;39:238-47.  Back to cited text no. 9
White D, Kaplan L, Eddy L. Characteristics of patients who return to the emergency department within 72 hours in one community hospital. Adv Emerg Nurs J 2011;33:344-53.  Back to cited text no. 10
Keith KD, Bocka JJ, Kobernick MS, Krome RL, Ross MA. Emergency department revisits. Ann Emerg Med 1989;18:964-8.  Back to cited text no. 11
Wilkins PS, Beckett MW. Audit of unexpected return visits to an accident and emergency department. Arch Emerg Med 1992;9:352-6.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]

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