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ORIGINAL RESEARCH Early emergency department representations Kent Robinson 1,2 and Bonnie Lam 2 1 Department of Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia and 2 The University of New South Wales, Sydney, New South Wales, Australia Abstract Objective: The present study aims to describe early ED representation rates and identify the causes for this commonly seen problem. Methods: This was a retrospective chart review of all patients that represented within 72 h of discharge from a tertiary level ED in Sydney, Australia, over a 2 month period between 1 May 2010 and 30 June 2010. Presentations were categorised according to their diagnosis and cause for representation. Each representation was then classified as being avoidable or unavoidable. Results: There were 10 141 presentations to the ED during the study period, with 497 patients (4.9%, 95% confidence interval [CI] 4.5–5.3) representing within 72 h of discharge. Disease- related causes of representation were seen in 55.1% (95% CI 50.7–59.5), with 39% (95% CI 34.8–43.4) of these caused by disease progression and 12.3% (95% CI 9.6–15.5) for sched- uled review. Patient-related causes were seen in 32.2% (95% CI 28.2–36.4) of representa- tions with 20.9% (95% CI 17.6–24.7) of these for patients who did not wait or left against medical advice. Physician-related causes were seen in 3.2% (95% CI 2.0–5.2) of represen- tations. Furthermore, 23.7% (95% CI 20.2–27.7) of patients who represented to the ED required hospital admission. A total of 37.0% (95% CI 32.9–41.4) of representations were assessed as being preventable. Conclusion: Early ED representations are a common problem. The majority of preventable represen- tations are patient related, and interventions to target these areas might be of benefit in reducing this problem. Key words: emergency department, representations, return visits. Introduction The unscheduled representation of patients recently dis- charged from the ED is a common problem. A signifi- cant proportion of these representations are considered to be preventable with this problem placing an extra burden on the health system and contributing to ED overcrowding. 1 There are many different factors that contribute to the problem, which can be generally grouped into illness-, patient-, physician- and system- related factors. Up to one-third of these representations are potentially avoidable. 2,3 There have been several studies on ED representa- tion that have described the problem and identified risk factors. 3–6 Representations have also been used as a quality assurance tool to measure the performance of an Correspondence: Dr Kent Robinson, Emergency Department, Liverpool Hospital, Elizabeth Street, Liverpool, NSW 2170, Australia. Email: [email protected] Kent Robinson, MBChB, FACEM, Senior Staff Specialist, Conjoint Senior Lecturer; Bonnie Lam, Medical Student. doi: 10.1111/1742-6723.12048 Emergency Medicine Australasia (2013) 25, 140–146 © 2013 The Authors EMA © 2013 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

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Page 1: Early emergency department representations

ORIGINAL RESEARCH

Early emergency department representationsKent Robinson1,2 and Bonnie Lam2

1Department of Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia and2The University of New South Wales, Sydney, New South Wales, Australia

Abstract

Objective: The present study aims to describe early ED representation rates and identify the causesfor this commonly seen problem.

Methods: This was a retrospective chart review of all patients that represented within 72 h ofdischarge from a tertiary level ED in Sydney, Australia, over a 2 month period between 1May 2010 and 30 June 2010. Presentations were categorised according to their diagnosisand cause for representation. Each representation was then classified as being avoidable orunavoidable.

Results: There were 10 141 presentations to the ED during the study period, with 497 patients(4.9%, 95% confidence interval [CI] 4.5–5.3) representing within 72 h of discharge. Disease-related causes of representation were seen in 55.1% (95% CI 50.7–59.5), with 39% (95% CI34.8–43.4) of these caused by disease progression and 12.3% (95% CI 9.6–15.5) for sched-uled review. Patient-related causes were seen in 32.2% (95% CI 28.2–36.4) of representa-tions with 20.9% (95% CI 17.6–24.7) of these for patients who did not wait or left againstmedical advice. Physician-related causes were seen in 3.2% (95% CI 2.0–5.2) of represen-tations. Furthermore, 23.7% (95% CI 20.2–27.7) of patients who represented to the EDrequired hospital admission. A total of 37.0% (95% CI 32.9–41.4) of representations wereassessed as being preventable.

Conclusion: Early ED representations are a common problem. The majority of preventable represen-tations are patient related, and interventions to target these areas might be of benefit inreducing this problem.

Key words: emergency department, representations, return visits.

Introduction

The unscheduled representation of patients recently dis-charged from the ED is a common problem. A signifi-cant proportion of these representations are consideredto be preventable with this problem placing an extraburden on the health system and contributing to EDovercrowding.1 There are many different factors that

contribute to the problem, which can be generallygrouped into illness-, patient-, physician- and system-related factors. Up to one-third of these representationsare potentially avoidable.2,3

There have been several studies on ED representa-tion that have described the problem and identified riskfactors.3–6 Representations have also been used as aquality assurance tool to measure the performance of an

Correspondence: Dr Kent Robinson, Emergency Department, Liverpool Hospital, Elizabeth Street, Liverpool, NSW 2170, Australia.Email: [email protected]

Kent Robinson, MBChB, FACEM, Senior Staff Specialist, Conjoint Senior Lecturer; Bonnie Lam, Medical Student.

doi: 10.1111/1742-6723.12048Emergency Medicine Australasia (2013) 25, 140–146

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© 2013 The AuthorsEMA © 2013 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

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ED and to improve patient care by attempting to detectinadequate management and identifying high-riskpatient groups.7–9

To our knowledge, there have been no studies pub-lished in Australasia in the recent literature on the issueof ED representation. This study describes the rate ofED representation in an Australian setting. It describesthe types of medical problems seen and reasons forrepresentation.

Methods

This was a retrospective chart review conducted at Liv-erpool Hospital, a large tertiary referral hospital in thesouthwest of Sydney with an annual ED attendanceof 61 800 patients. It sees both adult and paediatricpatients. The study was conducted during a 2 monthperiod between 1 May 2010 and 30 June 2010. Approvalto complete the study was granted by the hospital’sethics committee.

Patients were eligible for inclusion if they representedto the ED within 72 h of their first visit. Both adult andpaediatric patients were included in the study. Patientswho were admitted on their first presentation wereexcluded as these were failed inpatient discharges andwere not the focus of this study. Patients who attendedanother medical facility after their initial ED assessmentwere also excluded, as we had no access to their clinicalrecord at the other hospitals.

The hospital’s electronic medical record systemFIRSTNET was used to generate a report of all patientsrepresenting to the ED within 72 h of their initialdischarge time. For each episode, the second authorreviewed the electronic and paper record, and the firstauthor to ensure concordance of the results independ-ently reviewed a random selection of data sets. A totalof 50 (10.1%) of the records were selected using arandom number table for independent review by thefirst author. Data were independently collected and thencompared. A kappa score of 0.91 was calculated forthe comparison. Data collected included age, gender,primary language spoken, multiple presentationswithin the study period and diagnoses. Diagnoses weregrouped using the International Classification of Dis-eases, 10th revision diagnostic code classifications.10

ED representations were then categorised into fivegroups: illness related, patient related, physician related,system related and unrelated. These categories were inkeeping with previous studies on the topic. Box 1describes the five main categories of representation.

Although we felt that psychiatric presentations were anillness-related problem, they were included in patient-related causes to keep in line with other studies.

Each representation was further categorised as beingavoidable or unavoidable. Avoidable representationswere those in the patient-related, physician-related andsystem-related categories. They also included scheduledreturn for review in the illness-related category. Thesewere presentations where the authors felt that anintervention might have prevented the representation.Unavoidable representations were for factors suchas disease progression and psychiatric problems, andthese were for presentations where the authors felt thatthe representation would have occurred despite anyinterventions. The classifications of avoidable and una-voidable presentations were based on examples fromsimilar studies.

The study data was analysed descriptively with 95%confidence intervals (CIs) fitted around percentage pointestimates using the SPSS version 19 (IBM Corporation,Armonk, NY, USA) software package.

Results

Over the 2 month study period, there were 10 141patient visits to the ED. There were 708 representations

Box 1. Categories of ED representations

Illness-related representations• Progression of disease despite adequate treatment• Complications of initial treatment• Scheduled returns to the ED for clinical reviewPatient-related representations• Patients who did not wait on initial presentation• Patients who left against medical advice on initial

presentation• Psychiatric presentationsPhysician-related representations• Misdiagnosis• Missed radiological findings• Procedural complicationsSystem-related representations• Representations for booked admissions• Re-referral to the ED from private hospitals because

of insurance status of patientsUnrelated representations• Representations for a different medical problem to

the initial complaint

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identified, with 211 patients meeting exclusion criteria.The 497 representations (4.9%, 95% CI 4.5–5.3) wereseen in 402 individual patients.

One hundred and fifty-five (31.2%) of the representa-tions were by patients who presented to the ED morethan once in the study period. Seventeen patients madethree or more separate representations to the ED, andone patient represented a total of 17 separate times.There were 209 female and 288 male presentations inthe ED representations. Four hundred patients (80.5%)spoke English as their primary language, and 97(19.5%) spoke another primary language. Eighty-two(16.5%) of the representations were under 16 years ofage, 352 (70.8%) of patients were in the age group 17–65years and 63 (12.7%) were over the age of 65.

Table 1 shows the disposition of the initial ED visitand the representation. The majority of patients weredischarged on their representation; however, 21.7%required admission to hospital.

Table 2 describes the diagnostic categories of theinitial ED presentations. Forty-two (8.5%) revisits wereunrelated to the initial presenting problem. For theprimary presentation, the top three most common prob-lems were trauma, gastrointestinal complaints andinfectious diseases.

Table 3 shows the causes for representations to theED. The highest cause for representation was fromillness-related problems (55.1%, 95% CI 50.7–59.5).These representations were mainly for disease progres-sion and scheduled reviews.

Patient-related causes were seen in 160 (32.2%, 95%CI 28.2–36.4) of the ED representations. The mostcommon causes in this group were not waiting to beseen (DNW) and leaving against medical advice (AMA).Inappropriate use of the ED was for requests for medi-cations prescribed on initial consult and attempts to fasttrack into outpatient clinics for non-urgent problems.

Table 3. Categories of causes for representation

Causes N (%, 95% CI)

Illness relatedDisease progression 196 (39.4, 35.2–43.8)Scheduled return 61 (12.3, 9.6–15.5)Return with radiographyReturn for procedure

11 (2.2, 1.2–3.9)6 (1.2, 0.6–2.6)

Patient relatedDNW 82 (16.5, 13.5–20.0)Psychiatric disorder 39 (7.9, 5.8–10.6)Left AMA 22 (4.4, 2.9–6.6)Drug and alcohol abuse 7 (1.4, 0.7–2.9)Inappropriate use of ED 7 (1.4, 0.7–2.9)Anxiety 3 (0.6, 0.2–1.8)

Physician relatedMisdiagnosis 9 (1.8, 1.0–3.5)Missed radiology 5 (1.0, 0.4–2.3)Treatment error 1 (0.2, 0.0–1.1)Incomplete work-up 1 (0.2, 0.0–1.1)

System relatedFor admission 2 (0.4, 0.1–1.5)Private hospital† 1 (0.2, 0.0–1.1)

Unrelated 42 (8.5, 6.3–11.2)Unknown 2 (0.4, 0.1–1.5)Total 497

†Discharged and transferred to private hospital – refusedadmission and represented.

Table 1. Disposition of initial and repeat ED visits

Disposition Initial visit, n(%, 95% CI)

Return visit, n(%, 95% CI)

Discharge 322 (64.8, 60.5–68.9) 303 (61.0, 56.6–65.2)Did not wait 86 (17.3, 14.2–20.9) 24 (4.8, 3.2–7.1)Admit ED short

stay unit24 (4.8, 3.2–7.1) 5 (1.0, 0.0–2.3)

Left AMA 23 (4.6, 3.1–6.9) 3 (1.0, 0.0–1.8)Hospital

admission108 (21.7, 18.3–25.6)

Incomplete data 42 54Total 497 497

Table 2. ED representations – diagnostic categories

Diagnosis Number Percentage

TraumaInjuries 82 16.5Environmental 5 1.0

Gastrointestinal 68 13.7Infectious 54 10.9Psychiatric 46 9.3Unrelated illness 42 8.5Drug and alcohol toxicology 34 6.8Cardiovascular 28 5.6Genitourinary 27 5.4Obstetric/gynaecology 22 4.4Respiratory 18 3.6Musculoskeletal 14 2.8Ophthalmology 13 2.6ENT 12 2.4Dermatology 11 2.2Neurological 11 2.2Miscellaneous 10 2.0Total 497 100

Miscellaneous = haematology, oncology, metabolic, endocrine,not elsewhere classified in ICD-10, unclassified because of missingdocumentation

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Physician-related causes were seen in 16 (3.2%, 95%CI 2.0–5.2) of representations. Misdiagnosis was themost common cause, and seven of the nine cases werefor patients with gastrointestinal symptoms. The treat-ment error was because of complication of a urinarycatheter, and the incomplete work-up was becauseof failure to order an indicated X-ray and missing afracture.

There were only three cases of system-related revis-its. Two of these revisits were from patients presentingto the ED for a booked admission, and the other casewas a patient who was transferred to a private hospitaland was refused admission because of their insurancestatus and was sent back to the ED for public inpatientadmission.

Representations were assessed as being avoidable in184 (37.0%, 95% CI 32.9–41.4) cases. Table 4 shows theavoidable and unavoidable rates of representationaccording to causes category. The majority of avoidablerepresentations were for patient-related factors andscheduled returns to ED, and unavoidable representa-tions were mostly for disease progression and unrelatedcauses.

The admission rate for patients with early re-presentation was 23.7%. The admission rate for the agegroup 0–16 years was 20.0%, 24.0% for the age range17–65 and 24.7% for patients older than 65 years.

Discussion

In the general medical literature, early representationsrange from 0.4% to 5.5% in the adult population,2,11 andfrom 3.3% to 13.4% in the paediatric population.1,12–14

Our representation rate of 4.9% was higher than manyof the other studies conducted. Comparisons with thesestudies are difficult as there were significant differencesin the study designs (Table 5). The other confoundingvariables were that our ED representation rate includedscheduled ED reviews and representations for problemsunrelated to the original presentation. Another contrib-uting factor to our higher return rate might have been

Table 4. Avoidable versus unavoidable representationsaccording to causes categories

Avoidable Unavoidable

Illness related 61 213Patient related 104 56Physician related 16 0System related 3 0Unrelated 0 42Unknown 0 2Total 184 313

Table 5. Related return visits in the literature

Author Year ofpublication

Country Revisittime period

Related returnvisits (n)

Percent Notes

Pierce et al.4 1990 USA 48 h 509/17 214 3.0 Includes scheduled andunscheduled return visits

Wong and Lam7 1994 Hong Kong 48 h 616/90 154 0.7 Excludes scheduled returnsGordon et al.15 1998 USA 72 h 1422/52 553 2.7 Includes scheduled and

unscheduled return visitsKeith et al.3 1989 USA 72 h 297/13 261 2.2 Excludes scheduled returnsKuan and Mahadevan.16 2009 Singapore 72 h 842/38 414 2.2 Excludes scheduled returnsLerman and Kobernick2 1987 USA 72 h 255/64 336 0.4 Includes scheduled and

unscheduled return visitsLiaw et al.17 1999 Taiwan 72 h 1.9Martin-Gill and Reiser9 2004 USA 72 h 609/104 584* 0.58 *Number of people admitted

on returnMiró et al.18 1999 Spain 72 h 406/29 000 1.4 Did not indicate if scheduled

visits were includedWu et al.11 2008 Taiwan 72 h 1899/34 714 5.5 Includes scheduled and

unscheduled return visitsHu19 1992 Taiwan 7 days – 4.9Kelly et al.20 1993 New Zealand 7 days 206/9258 2.2 Excludes scheduled returnsO’Dwyer and Bodiwala21 1991 England 1 month 235/8036 2.9 Excludes scheduled returns

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the convenience and availability of the public healthservice in Australia, which provides free treatment to allpatients.

Patients who make early representations after dis-charge from the ED are considered to be at high risk forincreased morbidity and mortality, and the need forhospital admission is generally thought to be a signifi-cant indicator of the severity of a patient’s condition.22

Hospital admission rates for patients who represent aregenerally higher than the admission rate for the generalED population.8 In our study, 23.7% of the patientsrequired admission on representation, which is less thanthe general admission rate of 36.0%. Previous studieshave demonstrated that geriatric and paediatric groupsboth generally have higher admission rates on represen-tation to the ED.1,6,12–14 This is thought to be because ofmultiple medical comorbidities in the geriatric group,and in the paediatric group, patients that represent tendto be more acutely unwell than in the adult group.14,23

Surprisingly in our data set, this was not reflected, withthe admission rate being similar across all age groups.

The disease-related rate for representation was 55.1%in our study, with the majority of these presentationsbeing related to disease progression (39.0%). The reportedrange in the medical literature varies from 23.4% to82.0%.4,5,7,11,21 Although the majority of these representa-tions were considered to be appropriate and unavoidable,some of these presentations might have been becauseof inadequate patient education, patient compliance orfailure to comply with recommended follow up. Keijzersand Del Mar24 have studied the use of a formalised check-list and discharge pathway for all patients who are dis-charged from the ED for improving quality of care andpatient satisfaction. This is a process that might poten-tially reduce these types of representation. The othersignificant cause for disease-related returns was for sched-uled representations, which occurred in 12.3%. Thesewere mostly for subspecialty review, and this is a problemthat could be relieved by organising appropriate review ofthese patients in an outpatient clinic setting.

In our study, 32.2% of representations had patient-related factors as the main cause for their return visit.Rates in the general medical literature range from 9.1%to 52.8%.4,5,7,11,17,20 A high proportion of these represen-tations are for patients who DNW or left AMA duringtheir first presentation.

Admission rates for these groups of patients havebeen shown to be double that of the general ED popu-lation.5 Reducing the waiting time in the ED has beenshown to reduce the number of patients who DNW.20 Inour study, patients who DNW or left AMA made up

24.4% of all ED representations making this a largegroup of preventable returns.

Habitual users of the ED are a small but costly group,and have high incidences of psychiatric disorders anddrug and alcohol issues.25 In our study, those who pre-sented with psychiatric problems and drug or alcoholissues had a representation rate of 9.3% and often hadmultiple ED representations during the study period.They were less likely to be admitted on subsequentpresentations, and frequently had avoidable representa-tions. One of the ways of reducing this problem hasbeen to use a frequent presenters plan that provides thetreating physician with clear instructions on how to bestmanage these patients when they present to the ED.

In the reported literature, the rates of physician-related returns varied from 5.0% to 18.0%,4,7,20,26 andin our study, the rate was 3.2% of representations.Common causes for this problem were from prematureor inappropriate discharge, drug reactions and misdiag-nosis.7,11 Misdiagnosis was associated with abdominalpain as the initial presenting problem in up to 55.7% ofcases.11 Patients who are misdiagnosed and representhave twice the admission rate of the general ED popu-lation, with some of these patients requiring intensivecare therapy.4 In the group attribute to misdiagnosis(1.8%), three-quarters of these presentations initiallypresented with gastrointestinal symptoms. The reasonfor this is often because of inconclusive physical exami-nation findings, the evolving nature of the disease andthe often ambiguous location leading to perceptionof pain distant to the original site of the disease.11

Physicians should be aware of this high-risk group andconsider admission to a short stay unit for observation,or short term follow up with the patients primary carephysician within 8–12 h of discharge.27

System-related returns do not appear to be a largecause of ED representation both in our study and in thereported literature.7,20

Limitations

This study has the limitation of being a retrospectivechart review. It was subject to incomplete, missing andin some cases illegible records. These problems wereonly seen in a small number of the charts reviewed andare unlikely to alter the conclusions of the study.

There was also the bias of unblinded review injudging the care retrospectively, and this bias waslimited by having two reviewers independently exam-ining the case records. Analysis of the data for avoid-

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ability was subjective, and as a result, it was likely to beaffected by measurement bias.

This study was only based on representations to thesame ED, and did not take into account presentationsmade to other distant hospital EDs, so this might nottruly represent the ED representation rate.

Conclusion

Early ED representations are a common problemaccounting for 4.9% of all emergency presentations.Most of these representations are related to disease-related factors, and specific interventions to target theseproblems such as formalised discharge checklists, spe-cific patient discharge plans and redirection of sched-uled ED revisits to outpatient facilities might reducethis problem. Patients who do not wait or leave againstmedical advice also significantly contribute to therepresentation rate and interventions to stream andreduce wait times in the ED might reduce this problem.Patients with psychiatric or drug and alcohol problemsare high risk for representation and the use of frequentpresenter plans might reduce this problem.

Acknowledgements

The authors thank Associate Professor Anna Holdgatefor critically reviewing the manuscript.

Author contributions

KR conceived the study. BL conducted the literaturereview. BL and KR extracted the data and performedthe analysis. BL prepared the initial draft of the manu-script. KR was responsible for editing and the final draftof the manuscript. KR assumes overall responsibility forthe paper.

Competing interests

None declared.

Accepted 9 December 2012

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