Factor Associated with Return Visits by Elders within 72 Hours of Discharge from the Emergency Department

1. Introduction

The return visits to the emergency department (ED) is a global indicator of monitoring the quality of emergency care. The ED return visit rate among adults aged 65 years and above is higher than other populations [1]. Return visits to the ED are associated with adverse events [2,3], additional medical expenditures [4] and a 3–10% increase in mortality rate [5]. Return visits also reflect premature discharge, leading to a high risk for negative health outcomes, an impact on patient safety, medical disputes [2,3], a heavy workload on ED healthcare providers, and an increased financial burden on society [6]. It is crucial to identify the factors associated with return ED visits by elders to improve ED care and reduce the number of unnecessary return visits to the ED.

The definition of ED return visit can range from 48 hour to 90 days, commonly used for 72 hours of discharge, with reported rates from 0.92-27% [7,8,9]. A below 5% of ED return visit rate often use to indicate the quality of care in Taiwan and other countries [10,11]. The management of the elders in EDs is difficult due to physical deterioration, cognitive decline, multimorbidity and atypical presentation [12], which increase the risk of return visits by elders to the ED. The increasing aging population has a significant impact on the demand for ED services and presents a global challenge to emergency care. In Taiwan, the elders aged 65 and above comprised approximately 17.56% of the total population in 2022 [13]. Elders Taiwanese are the main users of emergency care, accounting for 24.92–28.5% of all ED visits by adults [14,15] and 40.8% of ED medical expenses among adults in Taiwan [16]. Identifying the factors that predict elders return visits can increase early recognition by ED staff of high-risk patients and reduce return visits by elders.

ED return visits by elders cause negative physical, psychological and social impacts on patients and family caregivers [1,17]. Studies have shown that ED return visits are avoidable [9,18,19]. An early study conducted in the US found that 32.5% of return visits within 72 hours after discharge were avoidable [9]. Another study reported that 17% of patients and 23–25% of doctors felt that return visits were unnecessary [19]. To reduce the risk of return visits by elders, ED healthcare providers need to be aware of the risk factors for return visits in the elders. Previous studies have explored the risk factors for ED return visits by elders [2,3,20,21] but have not identified clear early risk factors for return visits within different amounts of time following discharge. Identifying the factors associated with return visits to the ED within different amounts of time following discharge will help prevent elders return visits. The purpose of this study was to determine the factors associated with return visits to the ED by elders within 72 hours after discharge and to predict the risk factors in return visits within different amounts of time after discharge.

2. Materials and Methods

2.1. Study design and setting

This is a retrospective review study. The medical charts of elders who return visits to the ED from January to December 2017 were analyzed. The participating hospital is a regional hospital in Taiwan, with approximately 75,000 to 80,000 patients presenting annually to the ED.

2.2. Participants

Patients who met the following criteria were included in the study: 1) ≥65 years of age and 2) returned to the ED within 72 hours after discharge.

2.3. Risk-screening tool

The study investigators retrieved the medical charts of eligible patients and recorded demographic information, including age and sex, as well as triage, time of discharge, time and reason for the return visit after discharge, and outcome after the last ED visit. The risk factors identified by the Triage Risk Screening Tool (TRST) were applied in the study. The TRST is a simplified version of the Identification of Seniors at Risk (ISAR) measurement tool, developed to identify risks and predict early ED return visit rates by elders. First modified by Meldon et al. to stratify the risk of ED return visits and hospitalization in the elders [22]. The TRST assesses the following factors: history or evidence of cognitive impairment, difficulty walking, recent falls, polypharmacy (use of ≥ 5 medications), a visit to the ED in the previous 30 days, hospitalization in the past 120 days, whether the patient lives alone with no family caregiver, and professional evaluation by ED healthcare professionals. The presence of risk factors listed in the TRST was assessed by answers of ‘yes’ or ‘no’, and in cases where two ‘yes’ answers were recorded, the patient was deemed to be at high risk for an ED return visit. The area under the receiver operating characteristic (ROC) curve for TRST in predicting ED return visits and hospitalization within 30 and 120 days was 0.65, 0.72 and 0.65, respectively. This indicates that the performance of the TRST was acceptable.

2.4. Data analysis

Data were analyzed using IBM SPSS 20.0. The continuous variables are presented as the mean and standard deviation, and the categorical variables are presented as percentages. For subgroup analysis, data were stratified by age (65–74, 75–84 or ≥ 85 years), return visit time (within 24, 24–48 or 48–72 hours after discharge), and triage level (1 and 2, emergent, ≥3, urgent). Differences in demographic and medical data were analyzed using the chi-square test. The potential predictors of return visits were tested by logistic regression. The association between risk factors and return visits after different amounts of time is expressed as the odds ratio (OR) and 95% confidence interval (CI). A p value <0.05 was considered statistically significant in all tests.

3. Results

3.1. Characteristics of return visits by elders

The total number of participants in the study was 1187, representing 27.17% of all ED visits. A total of 4.71% of all adult patients made return visits to the ED within 72 hours following discharge, while 8.64% of all elders discharged from the ED return visits within 72 hours. The rate of return visits by elders male and female patients was similar. The majority of return visits were made by patients aged 65–74 (39.46%) and 75–84 years of age (38.62%), non-trauma patients, and patients at level 3 of triage on the Taiwan Triage and Acuity Scale, and most return visits were made within 24 hours (Table 1).

The primary reasons for a return visit within 72 hours were new medical conditions (51.8%) or conditions pertaining to a previous illness or treatment (48.2%). The destination after return visits included discharge from the ED (66.3%) and hospitalization (29.2%). The top three TRST risk factors were a history of chronic disease (93.9%), living alone without a family caregiver (69.5%) and a previous ED visit in the past 30 days (49.9%) (Table 1). In a total of 24.5% of return visits, the patient was assessed by ED nurses as being in need of discharge care. The top two needs in discharge care were tubing care (49.0%) and wound care (24.5%) (Figure 1).

3.2. Return visit reason and time

For elders who made return visits due to conditions pertaining to a previous disease or treatment, a total of 53.8% of return visits were made within 24 hours after discharge, 29.5% of return visits were made within 24–48 hours and 16.5% of return visits were made within 48–72 hours. For elders who made return visits due to new medical conditions, the distribution of the three time-points were similar. The results of an analysis of the reason and amount of time before the return visit demonstrated that the number of patients with conditions pertaining to a previous illness or treatment who returned to the ED within 24 hours of discharge was higher than the number of patients who returned within 24 hours of discharge with new medical conditions (OR, 2.57; 95% CI, 2.06–3.21; p < 0.0001). Comparing these two groups of elders with those who returned for different reasons, the patients who had conditions pertaining to a previous problem were less likely to return to the ED within 24–48 hours of discharge (OR, 0.68; 95% CI, 0.54–0.85; p=0.0008) or within 48–72 hours after discharge (OR, 0.45; 95% CI, 0.35–0.58; p < 0.0001). An analysis of the destination of patients following return visits showed that the proportion of patients who ended up hospitalized decreased with the amount of time that lapsed between discharge and the return visit (Table 2).

By analyzing the time characteristics of the attributes of return visits within 72 hours, the results demonstrated the return visit rate gradually decreased with time at different ages. The highest portion was return visit within 24 hours after discharge from ED. This accounted for 44.4% of return visits in aged 65–74 years, 42.1% of those aged 75–84 years, and 37.9% of those aged ≥85 years. There was no statistical significance among the age subgroups and return visit time as well as no differences in gender. Analysis of follow-up outcomes of the ED return visit showed that the proportion of patients who ended up hospitalized decreased with time.

3.3. Factors associated with return visits by elders

The results of an analysis of the distribution of TRST risk factors in elders who made return ED visits according to time point showed that almost half of elders with cognitive impairment returned within 24 hours after discharge from the ED. Elders with cognitive impairment had a higher rate of return visits within 24–48 hours after discharge (OR, 0.62; 95% CI, 0.43–0.91; p=0.013). The proportion of elders who were deemed to have care needs after discharge and who made return visits differed significantly among the time points, with 40.4% making a return visit within 24 hours, 30.2% making a return visit within 24–48 hours and 22.3% making a return visit within 48–72 hours. The elders who had care needs post-discharge had a significantly higher rate of returning within 24 hours after discharge (OR, 1.33; 95% CI, 1.02–1.74; p=0.035). Elders with difficult walking, polypharmacy, a return visit to the ED in the previous 30 days, hospitalization in the previous 120 days, and who were living alone without a family caregiver showed no statistically significant difference between the two time points (Table 2).

3.4. Distribution of risk factors for return visits by elders

The TRST risk factors were further investigated by multivariate regression analysis. Only six patients in this study lived alone. This factor was excluded from the multivariate analysis. The results showed that difficulty walking and care needs after discharge were statistically associated with a risk of a return visit to the ED within 24 hours. Elders with difficulty walking had a significantly increased risk of a return visit to the ED within 24 hours (adjusted OR [aOR], 1.76; 95% CI, 1.23–2.50; p=0.002) compared to those without difficulty walking. Elders who had care needs after discharge had a decreased risk of returning within the first 24 hours (aOR, 0.66; 95% CI, 0.48–0.91; p=0.012) compared to those who did not have care needs. The presence of cognitive impairment (aOR, 1.7; 95% CI, 1.06–2.72; p=0.027) and polypharmacy (aOR, 1.4; 95% CI, 1.07–1.83; p=0.015) significantly increased the risk of a return visit to the ED within 24–48 hours after discharge. Multivariate analysis showed that the TRST factors significantly associated with a return visit to the ED within 48–72 hours after discharge included difficult walking, hospitalization during the previous 120 days, and the need for nursing care post-discharge. Elders with difficulty walking showed a decreased risk of making a return visit to the ED within 48–72 hours after discharge (aOR, 0.57, 95% CI, 0.39–0.82, p=0.003) compared to those without difficulty walking. Patients who had been hospitalized in the previous 120 days had an increased risk of making a return visit within 48–72 hours after discharge (aOR, 1.52; 95% CI, 1.07–2.16; p=0.019) compared to those without such a history. Elders assessed as needing nursing care post-discharge had an increased risk of making a return visit within 48–72 hours (aOR, 1.62; 95% CI, 1.1–2.37; p=0.014) compared to those without this need (Table 3).

By analyzing the time characteristics of the attributes of return visits within 72 hours, the results demonstrated the return visit rate gradually decreased with time at different ages. The highest portion was return visit within 24 hours after discharge from ED. This accounted for 44.4% of return visits in aged 65–74 years, 42.1% of those aged 75–84 years, and 37.9% of those aged ≥85 years. There was no statistical significance among the age subgroups and return visit time as well as no differences in gender. Analysis of follow-up outcomes of the ED return visit showed that the proportion of patients who ended up hospitalized decreased with time.

4. Discussion

This retrospective review study analyses the factors associated with ED return visits by elders in Taiwan. Difficulty walking, post-discharge care needs, cognitive impairment, polypharmacy and hospitalization in the previous 120 days were associated with return visits to the ED by elders. Elders in whom these factors were present were at greater risk of making a return visit to the ED within 72 hours of discharge. The findings of this study are consistent with those of previous studies showing that difficulty walking and falls [23], cognitive impairment [2], polypharmacy [2,3] and post-discharge care needs [3,21] led to increased ED return visits. Recent hospitalization is also a predictor of return visits. Previous studies have emphasized that elders with a history of a recent ED return visit [6 Tsai] and those who have been hospitalized in the previous six months [24] should be managed more cautiously in the ED. Elders are subject to deterioration due to functional decline, cognitive impairment, frailty, malnutrition and polypharmacy [25]. Geriatric assessment and recognition of the risk factors affecting elders are critical in the ED.

5. Conclusions

The results of this study may help to reduce ED return visits by elders. Based on the findings of this study, it is recommended that hospital administrators strengthen the ability of ED staff to perform comprehensive geriatric assessments. ED in-service training related to geriatric care should be regularly provided to ED staff to enhance their ability to recognize and assess high-risk elders. ED care should include effective discharge planning for elders with post-discharge needs. Identifying the risk factors for return visits by elders will help prevent return visits and improve both the quality of care and the health outcomes of these patients.