Three steps to addressing, and possibly avoiding, return ED visits

Clear communication with patients is needed.


Lingering fear about their health, dissatisfaction with the care they received, and concerns about access to care are among the reasons patients return to the emergency department (ED) within days of being discharged from there, according to a 2013 study published in the Annals of Emergency Medicine.

For the study, 60 patients who were discharged from the ED and returned there, unscheduled, within 9 days were interviewed by a team led by Kristin L. Rising, MD, MS, director of acute care transitions in the Department of Emergency Medicine at Thomas Jefferson University in Philadelphia.

Photo by Thinkstock
Photo by Thinkstock.

The most common reason patients offered for returning was uncertainty about their health: They believed their conditions were getting worse and they didn't understand what was causing their symptoms. Others felt their needs weren't met, or they had wanted more tests or to be admitted, during their first visit to the ED. Still others felt that the ED was the most convenient or speediest place to get care. Of the 60 patients, 24 were admitted to the hospital upon their ED return visit.

The results of the study demonstrate the need for clear communication with patients, both to elicit and alleviate their concerns, said Dr. Rising.

“Sometimes patients do identify something that we missed. But more often they have unanswered questions or don't understand our reasoning for choosing certain tests or treatments and not others. All they hear is that we're going to do this but not that,” Dr. Rising said. “We need to explain our thinking so they understand it.”

Ask

The key to avoiding potentially unnecessary ED return visits is to address patients' concerns during their first visit, and the best way to do that is to find out what those concerns are and keep them in mind even if other issues arise, said Dr. Rising.

“Have a clear time at which you stop to ask patients if they have any questions or if there is something they are worried about that you haven't discussed. Sometimes if an issue or symptom that we identify appears more severe or immediate than the patient's primary complaint, we focus on that at the expense of what the patient actually came in for,” said Dr. Rising. For example, one patient came to the ED for pain in her stomach. She received medication for nausea, but not pain.

The patient may also have come in for reasons other than immediate symptoms, noted Stephen R. Pitts, MD, associate professor of medicine in the Department of Emergency Medicine at Emory University in Atlanta.

“We have a tendency to classify people by their chief complaint, but it might be sensible to visit other issues,” Dr. Pitts said. “Did their doctors refer them to the ED, or did their family members insist on taking them? What do they hope will happen in the ED?”

This line of questioning may be useful with inpatients, too, to avoid ED visits shortly after they're discharged, said Michelle Mourad, MD, director of quality and safety in the Division of Hospital Medicine and associate professor of medicine at the University of California, San Francisco Medical Center.

“Sometimes hospitalists become inured to the fact that hospitalization can be a life-changing event for a patient. Even though it's normal for us to be in this environment, it's not normal for them. So ask them what they are afraid of, what they hope to get out of being in the hospital, and what they hope will improve, so you can see if they have realistic expectations,” Dr. Mourad said.

Dr. Mourad added that it's best to have this conversation early in the hospitalization to build a rapport with the patient.

Dr. Rising's team used a semi-structured interview process, which they published in the paper. For example, the interview opens with, “Tell me the story of how/why you landed back here so soon” and asks questions such as, “What is your preferred place to get your health care? Why?” and “Were you referred to any physicians or clinics when you were discharged?”

Such guides can be helpful in getting to the patient's “story behind the story,” said Amy Boutwell, MD, MP, president of Collaborative Healthcare Strategies and a hospitalist at Newton-Wellesley Hospital and Massachusetts General Hospital in Boston.

Dr. Boutwell encourages all hospitalists, whether they work closely with ED staff or work mostly in the wards, to get experience with interviewing patients.

“I recommend doing 5 to 10 of these interviews for your own education to see exactly why patients come back to the hospital. There is insight from this study about patient fear and uncertainty that was heretofore undiscovered,” Dr. Boutwell said.

Explain

Patients often don't understand what the limitations of the ED are, and that can exacerbate their fears, so it's important to explain to them what they can expect, said Dr. Boutwell.

“They often don't understand that the ED is not meant to be a curative environment, and that it's really meant to diagnose, assess, and triage. Explain that it's to see if they are sick enough to be admitted or if they are well enough to go home and be treated elsewhere,” Dr. Boutwell said.

Explaining costs can help, too, said Dr. Pitts. “If they want to go to the observation unit, explain that while observation status is helpful and they could be out of there tomorrow, they might also leave with a $10,000 bill if their insurance doesn't cover it,” he said. “The same goes for tests that you feel they don't need. Patients do care about costs.”

If the patient will be discharged, explaining why some treatments or tests were not offered can go a long way, said Dr. Rising. “It can be as simple as saying, ‘These are the reasons I don't think you need antibiotics,’ or explaining to them the things you have ruled out by the tests you have already done.”

It's common for patients to feel that the hospital is the safest place to be when they are unwell, but that's because they are unaware of the risks. “It's tough for them to hear, but you need to explain the risk of infection or falls,” said Dr. Boutwell. Hospitalists should also discuss the risk of delirium to families who bring their elders to the ED, she added.

Other patients are lured back to the ED because they like knowing that there is a lot of fancy equipment nearby, even though that equipment is not necessarily relevant to their care, said Luke O. Hansen, MD, assistant professor at Northwestern University's Feinberg School of Medicine in Chicago.

“The hospital is perceived to be where the technology is, but the truth is that many treatments take more time than can be afforded during an ED visit or hospitalization. Long-term treatments are best addressed by their primary care providers,” Dr. Hansen said.

Follow up

Follow-up is the heart of post-ED and post-inpatient care, but waiting can be frustrating for patients, especially if they have a tough time scheduling appointments with their primary care clinicians.

To address this issue, hospitalists can work directly with primary care practices, said Dr. Mourad. “When we discharged patients, we set the bar at 2 weeks for a follow-up and partnered with PCP offices to get their commitment to ensure that they had open slots. We had to make sure the PCPs would prioritize discharge patients.”

But follow-up visits are only half the battle. “The other half is successful patient education so [patients] can recognize red flags, and getting the families involved to help the patient navigate the system,” Dr. Hansen said. “There should be multiple people describing what should be done, such as pharmacists explaining medications after physicians prescribe them, and nurses going over the instructions again at discharge.”

Most importantly, patients need to feel like they will get the care they need when they leave, Dr. Hansen said. “We're not going to be able to completely resolve everyone's symptoms or anxiety during an evaluation or hospitalization, so the patient needs support in knowing who to call next. They need to feel like once they leave the hospital, someone will be there to receive them.”