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Factors associated with emergency department visit within 30 days after discharge

Abstract

Background

Post-discharge care remains a challenge because continuity of care is often interrupted and adverse events frequently occur. Previous studies have focused on early readmission but few have investigated emergency department (ED) visit after discharge.

Methods

This retrospective observational study was conducted between April 2011 and March 2012 in a referral center in Taiwan. Patients discharged from the general medical wards during the study period were analyzed and their characteristics, hospital course, and associated factors were collected. An ED visit within 30 days of discharge was the primary outcome while readmission or death at home were secondary outcomes.

Results

There were 799 discharged patients analyzed, including 96 (12 %) with an ED visit of 12.4 days post-discharge and 111 (14 %) with readmissions at 13.3 days post-discharge. Sixty patients were admitted after their ED visit. Underlying chronic illnesses were associated with 72 % of ED visits. By multivariate analysis, Charlson score and the use of naso-gastric tube were independent risk factors for ED visit within 30 days after discharge.

Conclusions

Early ED visit after discharge is as high as 12 %. Patients with chronic illness and those requiring a naso-gastric tube or external biliary drain are at high risk for post-discharge ED visit.

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Background

Post-discharge care remains a challenge, especially for the elderly and those with underlying co-morbidities [13]. About 10 % of discharged patients have new or worsening symptoms within days to weeks [4] and the readmission rate is high, with a 30-day re-hospitalization rate of 15–20 % in literature [2, 57]. Factors associated with readmission include age, sex, race, and length of hospital stay, and number of previous hospitalizations [2]. Several possible reasons for readmission include instability of chronic disease and insufficient communication among physicians [8].

Aside from readmission, emergency department (ED) utilization is another adverse event after discharge, representing patient’s instability after discharge [7, 911]. There is a high proportion of hospitalization after ED visit, leading to higher costs [1214]. Thus, post-discharge transitional care such as phone-contact, home visits, and integrated strategy are needed to identify those at high-risk for ED visit after discharge [1518].

Although risk factors for early readmission are well evaluated, predictors of post-discharge ED visit by general medical patients have rarely been investigated. This retrospective study aimed to identify the causes, time course, and risk factors associated with ED visit after discharge from a general ward in a Taiwan hospital.

Methods

Study subjects

This retrospective observational study was conducted at the National Taiwan University Hospital, a tertiary-care referral center in Taiwan, from April 1, 2011 to March 31, 2012. All patients aged >20 years admitted to the general wards were screened. Index hospitalization was defined as the first admission during the study period. Those who were discharged alive were identified. Those who died during the index hospitalization, went home for anticipated dying, or were transferred to other departments or hospitals were excluded. The Institutional Review Board of the hospital’s Research Ethics Committee approved the study protocol. Written informed consent was waived.

Data collection

The patient characteristics, laboratory data, courses of index hospitalization, diagnoses, and dates of ED visits and readmissions were recorded using the hospital’s electronic medical records. Information on the date of death at home or living status was also acquired from records or from a routine survey of patients within 30 days after discharge. A unified recording form with a default option for selection to prevent ambiguous data coding was used.

The Charlson co-morbidity index and Barthel index were calculated as in previous studies [19, 20]. Underlying malignancy was defined as active cancer without mention of cure or remission. The primary care physician was defined as the doctor who was visited by the patient three or more times within one year prior to the index hospitalization [21]. A five-level triage system (1, resuscitation; 2, emergency; 3, urgent; 4, less urgent; and 5, not urgent) was used in the ED [22]. Artificial tube/catheter included naso-gastric tube, tracheostomy tube, draining tube, Foley catheter, and catheter for dialysis. Information was obtained from the medical records.

The clinical course and clinical diagnosis of each ED visit and readmission were reviewed. The cause of the ED visit was determined from the medical records. The causes of post-discharge adverse events were categorized by a nurse and a hospitalist, who independently decided if the causes were the same as those of the index hospitalization or if the causes were associated with chronic illness or malignancy. Any discrepancy was settled by consensus.

Outcome measurement and statistical analysis

The primary endpoint was the first ED visit within 30 days after discharge. The secondary endpoints included readmission and mortality within 30 days after discharge. Inter-group differences were compared using independent t test for numerical variables and chi-square test for categorical variables. After using the forward conditional selection method of all clinically relevant factors, multivariate Cox proportional hazard regression was used to identify factors associated with ED visit or adverse events within 30 days after discharge.

For multivariate models, patients were censored for endpoints of ED visit, readmission, or mortality. No one was lost to follow-up within 30 days. In terms of missing data (4 [0.5 %] in hemoglobin and 71 [8.9 %%] in discharge Barthel score), these were categorized as “unknown data” to avoid case loss in the multivariate model. Statistical significance was set at a two-sided p < 0.05. All analyses were performed using the SPSS (Version 15.0, Chicago, IL).

Results

Of the 1028 patients in the general medical wards who were screened, 1012 (98.4 %) were admitted from the ED. During the index hospitalization, 124 were transferred to other departments for further treatment, 13 were transferred to other hospitals, and 92 died before discharge or went home for the dying process. A total of 799 patients were included in the final analyses, including 753 (94 %) who returned home or those who were brought to a nursing home after discharge.

During the 30-day period after discharge, 96 (12 %) patients visited the ED, 111 (14 %) were readmitted, and two died at home (Fig. 1). The mean age (71.7 vs. 69.9 years) and sex (male: 45 % vs. 49 %) were similar between patients who visited the ED and those who did not (Table 1). The Charlson co-morbidity index scores were higher in patients with ED visit (age-unadjusted, 3.1 ± 2.5 vs. 2.4 ± 2.5; p = 0.013) and in those with readmission (age-unadjusted: 3.0 ± 2.5 vs. 2.4 ± 2.5, p = 0.023) within 30 days post-discharge. The age-adjusted Charlson score was only significantly higher in patients who visited the ED (5.8 ± 2.8 vs. 4.9 ± 3.0, p = 0.006).

Fig. 1
figure 1

Flow chart of patient enrollment

Table 1 Clinical characteristics of patients according to readmission or emergency department (ED) visit within 30 days post-discharge

The Barthel index for daily activity, proportion of primary care physician, and presence of wound requiring dressing were similar between patients who visited the ED and those who did not. Patients who visited the ED also had higher percentages of requiring naso-gastric tube or biliary tract drainage (26 % vs. 14 %; p = 0.003 and 3 % vs. 1 %; p = 0.048, respectively).

Regarding early (within 30 days) post-discharge adverse events, patients visited the ED around 12.4 days after discharge and were readmitted around 13.3 days after discharge (Table 2). There were 62 (64.5 %) and 65 (58.5 %) patients who visited their primary care physician before their ED visit and readmission, respectively. Thirty-three (34 %) visited the ED within one week after discharge. Among the patients with ED visits, the average triage level (±standard deviation [SD]) was 2.46 ± 0.64.

Table 2 Nature of readmission and emergency department visit within 30 days post-discharge

The cause of the index hospitalization was also the main cause in 69 % of ED visits and in 50 % of readmissions. Underlying chronic illnesses were associated with 72 % of ED visits and 62 % of readmissions, while underlying malignancy and organ failure accounted for 39 and 53 % of ED visits, respectively, and 45 and 47 % of readmissions, respectively (Fig. 2).

Fig. 2
figure 2

Category of chronic illnesses associated with emergency department (ED) visit post-discharge. CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease

Among patients with ED visits, 52 (54 %) were admitted from the ED while eight were discharged from the ED but returned and were admitted after the 2nd ED visit within the 30-day window. Those not admitted had a median ED stay of 8 h (inter-quartile range [IQR], 3.5–75.5 h).

In multivariate analysis (Table 3), the independent factors for ED visit within 30 days after discharge were non-adjusted Charlson co-morbidity score (Hazard Ratio [HR]: 1.108; 95 % confidence interval [CI]: 1.030–1.192), use of naso-gastric tube (HR: 2.081, 95 % CI: 1.315–3.293), and use of external biliary tract drain (HR, 4.191, 95 % CI, 1.298–13.261). Longer index hospitalization (HR, 1.014, 95 % CI, 1.02–1.026), age-adjusted Charlson co-morbidity index (HR, 1.067, 95 % CI, 1.012–1.124), and use of external biliary tract drain (HR, 4.158, 95 % CI, 1.679–10.296) were independent risk factors associated with adverse events, including ED re-visit, readmission, and death at home.

Table 3 Multivariate analysis of factors possibly associated with readmission or ED visit within 30 days post-discharge

Discussion

This retrospective study reviewed data of discharged patients and revealed that 12 % visited the ED in an average of 12.4 days after discharge, while 14 % were readmitted in 13.3 days. The same Illness during the index hospitalization was responsible for 69 % of ED visits and chronic illness correlated with 72 %. Malignancy and organ failure were the most common underlying co-morbidities. The Charlson co-morbidity index and use of naso-gastric tube or external biliary tract drain were independent predictors of ED visit within 30 days post-discharge. On the other hand, age-adjusted Charlson co-morbidity index, length of index hospitalization, and use of external biliary drain were associated with adverse events of ED visit, readmission, or death.

Early post-discharge ED visit was high (12 %) for patients with general medical illness and was similar to those of patients who underwent heart surgery (11.9 %) or colon resection for cancer (9.2 %) [23, 24]. Among patients on dialysis, ED visit was as high as 27 % within 30 days post-discharge [7].

The underlying co-morbidity may be one of the most important factors predicting post-discharge ED visit. A higher proportion of primary care physicians for readmitted patients also indicates that these patents have more chronic illness that require regular clinic visits before the index hospitalization. The high Charlson score is reasonable because it represents the complexity of the underlying disease and is important for readmission or other post-discharge adverse events [2527].

In this study, age is not associated with readmission and ED visit. This is similar to findings of a previous report for readmission [26]. However, age-adjusted Charlson score is still a predictor of readmission and is indicative that age alone is less influential. A possible reason is that many discharged patients are middle-aged but have underlying cancer or liver cirrhosis in the study referral center. Furthermore, the Charlson score, without age adjustment, is associated with ED visit. Thus, more attention should be given to a high Charlson score even in young patients.

In a previous study for readmission-associated illness, organ failure and cancer are the most common disease conditions [28]. Similarly, in the present study, organ failure is considered the leading problem. If all of the different kinds of organ failure are taken together, organ failure ranks higher than cancer.

Artificial catheter or tube that requires long-term care has several clinical meanings for a discharged patient. First, it indicates clinical dysfunction, like when a naso-gastric tube is required for swallowing dysfunction. Second, it is associated with chronic illness, like an external biliary drain that is used for cancer-related obstructive jaundice. Third, higher care skills are needed for patients who require tubes/catheters. The skills of caregivers are important in post-discharge transitional care, especially for patients without self-care ability [13, 17, 29, 30]. As such, the use of a tube/catheter may be a basis for requiring high level of care skills, especially when the associated chronic illness is severe. For example, an external biliary drain is usually associated with advanced liver cancer and biliary tract obstruction. For discharged patients with a high Charlson score and who require external naso-gastric tube or external biliary drain, education of care skills and monitoring of disease stability may be key points for reducing post-discharge adverse events.

In this study, by multivariate analysis, the Barthel index of a patient’s daily living activity does not correlate with ED visit. This is possible because the Barthel index on admission and on discharge may change with time, according to disease course [31]. The problem associated with low Barthel index is the key point, like an artificial tube/catheter. Moreover, complications of underlying diseases may not be predicted by the Barthel index (e.g., variceal bleeding in a cirrhotic patients leading to acute changes that do not correlate with daily activity). The causes of such adverse events are multi-factorial.

The present study has several limitations. First, because it was performed in a tertiary referral center, patients might be more severely ill, with a higher proportion of cancer cases. This is important for generalizing to regional or district hospitals or to non-hepatitis prevalent areas. Furthermore, as a retrospective study, discharge education and planning are not unified. Information of medication compliance were not been obtained. Third, the number of patients with external biliary drain was small, so the 95 % confidence interval of hazards ratio for this risk was wide. We should interpret the data carefully. Lastly, post-discharge adverse events might be biased in methods of phone contact and chart review.

Conclusions

Within 30 days after discharge, ED visit accounts for as high as 12 % in general medical patients. Patients with high Charlson co-morbidity score and those who use a naso-gastric tube or an external biliary drain are at high risk for post-discharge ED visit. Future studies for transitional care to minimize post-discharge adverse events are warranted.

Abbreviations

CI, confidence interval; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary diseaseED, emergency department; HR, hazard ratio

References

  1. Hasan O, Meltzer DO, Shaykevich SA, Bell CM, Kaboli PJ, Auerbach AD, Wetterneck TB, Arora VM, Zhang J, Schnipper JL. Hospital readmission in general medicine patients: a prediction model. J Gen Intern Med. 2010;25(3):211–9.

    Article  PubMed  Google Scholar 

  2. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–28.

    Article  CAS  PubMed  Google Scholar 

  3. McAlister FA, Youngson E, Bakal JA, Kaul P, Ezekowitz J, van Walraven C. Impact of physician continuity on death or urgent readmission after discharge among patients with heart failure. CMAJ. 2013;185(14):E681–9.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Epstein K, Juarez E, Loya K, Gorman MJ, Singer A. Frequency of new or worsening symptoms in the posthospitalization period. J Hosp Med. 2007;2(2):58–68.

    Article  PubMed  Google Scholar 

  5. Shu CC, Lin YF, Hsu NC, Ko WJ. Risk factors for 30-day Re-admission in general medical patients admitted from the emergency department: a single center study. Intern Med J. 2011;42(6):677–682.

  6. Shu CC, Hsu NC, Lin YF, Wang JY, Lin JW, Ko WJ. Integrated postdischarge transitional care in a hospitalist system to improve discharge outcome: an experimental study. BMC Med. 2011;9:96.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Harel Z, Wald R, McArthur E, Chertow GM, Harel S, Gruneir A, Fischer HD, Garg AX, Perl J, Nash DM, et al. Rehospitalizations and emergency department visits after hospital discharge in patients receiving maintenance hemodialysis. J Am Soc Nephrol. 2015.

  8. van Walraven C, Taljaard M, Bell CM, Etchells E, Stiell IG, Zarnke K, Forster AJ. A prospective cohort study found that provider and information continuity was low after patient discharge from hospital. J Clin Epidemiol. 2010;63(9):1000–10.

    Article  PubMed  Google Scholar 

  9. Hall RK, Toles M, Massing M, Jackson E, Peacock-Hinton S, O’Hare AM, Colon-Emeric C. Utilization of acute care among patients with ESRD discharged home from skilled nursing facilities. Clin J Am Soc Nephrol. 2015;10(3):428–34.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Dalal AA, Shah M, D’Souza AO, Mapel DW. COPD-related healthcare utilization and costs after discharge from a hospitalization or emergency department visit on a regimen of fluticasone propionate-salmeterol combination versus other maintenance therapies. Am J Manag Care. 2011;17(3):e55–65.

    PubMed  Google Scholar 

  11. Williams TP, Dimou FM, Adhikari D, Kimbrough TD, Riall TS. Hospital readmission after emergency room visit for cholelithiasis. J Surg Res. 2015;197(2):318–23.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Blecker S, Ladapo JA, Doran KM, Goldfeld KS, Katz S. Emergency department visits for heart failure and subsequent hospitalization or observation unit admission. Am Heart J. 2014;168(6):901–8. e901.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Ding ST, Wang CL, Huang YH, Shu CC, Tseng YT, Huang CT, Hsu NC, Lin YF, Tsai HB, Yang MC, et al. Demand and predictors for post-discharge medical counseling in home care patients: a prospective cohort study. PLoS One. 2013;8(5), e64274.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Hasegawa K, Tsugawa Y, Tsai CL, Brown DF, Camargo Jr CA. Frequent utilization of the emergency department for acute exacerbation of chronic obstructive pulmonary disease. Respir Res. 2014;15:40.

    Article  PubMed  PubMed Central  Google Scholar 

  15. van Walraven C, Mamdani M, Fang J, Austin PC. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004;19(6):624–31.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314–23.

    Article  PubMed  Google Scholar 

  17. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–8.

    Article  PubMed  Google Scholar 

  18. Scales Jr CD, Lin L, Saigal CS, Bennett CJ, Ponce NA, Mangione CM, Litwin MS, Project NUDiA. Emergency department revisits for patients with kidney stones in California. Acad Emerg Med Off J Soc Acad Emerg Med. 2015;22(4):468–74.

    Article  Google Scholar 

  19. Wang HY, Chew G, Kung CT, Chung KJ, Lee WH. The use of Charlson comorbidity index for patients revisiting the emergency department within 72 hours. Chang Gung Med J. 2007;30(5):437–44.

    PubMed  Google Scholar 

  20. Sainsbury A, Seebass G, Bansal A, Young JB. Reliability of the Barthel Index when used with older people. Age Ageing. 2005;34(3):228–32.

    Article  PubMed  Google Scholar 

  21. Sharma G, Fletcher KE, Zhang D, Kuo YF, Freeman JL, Goodwin JS. Continuity of outpatient and inpatient care by primary care physicians for hospitalized older adults. JAMA. 2009;301(16):1671–80.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Hung SC, Kung CT, Hung CW, Liu BM, Liu JW, Chew G, Chuang HY, Lee WH, Lee TC. Determining delayed admission to intensive care unit for mechanically ventilated patients in the emergency department. Crit Care. 2014;18(4):485.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Hansen DG, Fox JP, Gross CP, Bruun JS. Hospital readmissions and emergency department visits following laparoscopic and open colon resection for cancer. Dis Colon Rectum. 2013;56(9):1053–61.

    Article  PubMed  Google Scholar 

  24. Fox JP, Suter LG, Wang K, Wang Y, Krumholz HM, Ross JS. Hospital-based, acute care use among patients within 30 days of discharge after coronary artery bypass surgery. Ann Thorac Surg. 2013;96(1):96–104.

    Article  PubMed  PubMed Central  Google Scholar 

  25. van Walraven C, Dhalla IA, Bell C, Etchells E, Stiell IG, Zarnke K, Austin PC, Forster AJ. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. CMAJ. 2010;182(6):551–7.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Shu CC, Lin YF, Hsu NC, Ko WJ. Risk factors for 30-day readmission in general medical patients admitted from the emergency department: a single centre study. Intern Med J. 2012;42(6):677–82.

    Article  PubMed  Google Scholar 

  27. Capelastegui A, Espana Yandiola PP, Quintana JM, Bilbao A, Diez R, Pascual S, Pulido E, Egurrola M. Predictors of short-term rehospitalization following discharge of patients hospitalized with community-acquired pneumonia. Chest. 2009;136(4):1079–85.

    Article  PubMed  Google Scholar 

  28. Walsh B, Addington-Hall J, Roberts HC, Nicholls PG, Corner J. Outcomes after unplanned admission to hospital in older people: ill-defined conditions as potential indicators of the frailty trajectory. J Am Geriatr Soc. 2012;60(11):2104–9.

    PubMed  Google Scholar 

  29. Werth SL, Schutte DL, Stommel M. Bridging the gap: perceived educational needs in the inpatient to home care setting for the person with a new ostomy. J Wound Ostomy Continence Nurs. 2014;41(6):566–72.

    Article  PubMed  Google Scholar 

  30. Sandvik D, Bade P, Dunham A, Hendrickson S. A hospital-to-nursing home transfer process associated with low hospital readmission rates while targeting quality of care, patient safety, and convenience: a 20-year perspective. J Am Med Dir Assoc. 2013;14(5):367–74.

    Article  PubMed  Google Scholar 

  31. Shepperd S, Parkes J, McClaren J, Phillips C. Discharge planning from hospital to home. Cochrane Database Syst Rev. 2004;1, CD000313.

    Google Scholar 

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Acknowledgements

The authors thank the staff of the Multi-Disciplinary Integrated Ward, Information Technology office, and the Eighth Core Lab of the Department of Medical Research in National Taiwan University Hospital. The study was partial supported by the National Taiwan University Hospital (NTUH.104-N2836) and foundations of Department of Traumatology, National Taiwan University Hospital. The funders had no role in study design, data collection and analysis, decision to publish, and manuscript preparation.

Funding

Nil.

Availability of data and materials

All the data supporting our findings is contained within the manuscript.

Author contributions

SCC and WCL designed and performed the study. SCC, HMJ, HNC, LYF, DST, WCL, and CJS were involved in the manuscript writing and data analysis. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Written informed consent was waived due to retrospective study design.

Ethics approval and consent to participate

The Institutional Review Board of the National Taiwan University Hospital’s Research Ethics Committee approved the study protocol.

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Correspondence to Chin-Chung Shu.

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Wang, CL., Ding, ST., Hsieh, MJ. et al. Factors associated with emergency department visit within 30 days after discharge. BMC Health Serv Res 16, 190 (2016). https://doi.org/10.1186/s12913-016-1439-x

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