Emergency unscheduled returns: can we do better?

ABSTRACT 

Introduction This study serves to identify the reasons for unscheduled return visits to the emergency department (ED), paying particular attention to system, physician and patient factors. Its purpose is to highlight inadequacies and plan strategies to reduce re-attendance. 

Methods All patients returning to the ED within 72 hours of initial visit were identified between January 2005 and June 2005. 842 cases were reviewed to identify reasons for unscheduled returns. 

Results Unscheduled return visits accounted for two percent of patient encounters with the younger mobile group of patients contributing the largest number. Patients presenting with abdominal pain constituted a quarter of unscheduled returns, where more than half were admitted. Possible causes were lack of rehydration and lack of proper discharge advice to these patients. The assessment and disposition of abdominal pain patients with uncertain aetiology was a major category and 68.7 percent of missed diagnosis came from this group. There was a significant difference in the unscheduled return rates between the senior and junior doctors. There was minimal morbidity and no mortality among patients who returned to the ED for the second time. 

Conclusion A proposed strategy to reduce the number of unscheduled returns would be to target patients with abdominal pain with more liberal hydration strategies. Discharge advice with information about expected prognosis and specific signs and symptoms to look out for should be included. Educational sessions and better supervision of junior staff emphasising acute abdominal conditions should be actively incorporated to avoid associated morbidities with a missed diagnosis. 

Keywords: abdominal pain, emergency department, emergency re-attendance, emergency unscheduled returns 
Singapore Med J 2009; 50(11): 1068-1071