Assessing the rate and factors associated with unscheduled return visits to a medical paediatric emergency department in a resource-limited setting

Scheepers, Lynn (2018-12)

Thesis (MMed)--Stellenbosch University, 2018.

Thesis

ENGLISH ABSTRACT: Background: An unscheduled return visit is defined as a patient presenting to the emergency department (ED) within 72 hours after being discharged, with the same primary complaint. It is commonly assumed that patients who returned shortly after discharge were misdiagnosed or mismanaged. Unscheduled return visits are used as an indicator of quality of care in the ED’s. Studies to determine rates of unscheduled return visits in paediatric EDs have been conducted in developed countries with well-resourced health care systems; unexpected return visit rates varied between 2-5.2% in these studies. No such study has been conducted in South Africa. Objective: The purpose of this study was to determine the rate of returning patients to a paediatric emergency department within 72 hours after discharge, the factors associated with unexpected return visits and the outcome of these patients. The following factors were hypothesised to be potentially affecting return visits rate: age of patient, nutritional status, HIV status, triage category, predisposing medical condition, time of day of initial visit, income level of parents/caregiver and diagnosis at initial visit. Time of year was also noted to identify seasonal influences on patient returns. Method: This was a retrospective case control study. This study was done in a paediatric emergency department within an academic hospital in a resource limited setting, observing the rate of returning paediatric patients within 72 hours of discharge over a period of one year. Cases for the study were obtained from the hospitals data base system (Clinicom). Cases were defined as patients who returned unscheduled to the emergency department within 72 hours of being discharged. Scheduled returning patients, patients participating in research studies and those with surgical conditions were excluded from the study. Controls were selected using a simple random sampling excel tool and were matched for month of presentation only. All patient information was accessed from medical files which are stored on a web database system. All data was then entered onto a Microsoft excel spread sheet and analysed with assistance of a biostatistician. Results: The rate of returning patients in our setting was 1.07%. One-hundred fifty-eight patients out of a total of 14827 patients seen in our ED department returned unscheduled. We found that returning patients were of a younger age than controls and with every 1-month increase in age, there was a 0.6% decrease in the odds of returning. Weight-for-age within normal limits was found in >80% in both groups. Being underweight-for-age was associated with an increased risk of returning (p=0.003), as was having a predisposing medical condition (p= 0.027). There was no difference found in gender, HIV status or income category of parents. Day of week and time of day did not contribute as a factor for returning. The grade of doctor seeing the patient did impact the risk of returning as more patients who returned were seen by inexperienced doctors (interns). Returning patients had a higher percentage of orange vs green triage categories. No specific diagnoses were found to be associated with returning patients. Seven percent of the returning patients were associated with an adverse event. Conclusion: The rate of returns in our setting is lower than rates found in countries with well-resourced health care settings. This may be influenced by the short stay unit which is linked to our emergency department and the possibility of patients returning to another health care facility. Poor nutritional status, having a predisposing medical condition, being referred from a general practitioner, having a triage category of orange (vs green) and being seen by an inexperienced doctor, are associated with increased risk of return.

Agtergrond: ‘n Ongeskeduleerde terugkoms word gedefinieer as ‘n pasiënt wat binne 72 uur na ontslag vanuit die Noodeenheid met dieselfde probleem na die noodeenheid terugkeer. Dit word algemeen aanvaar dat pasiënte wat kort na ontslag terugkeer waarskynlik verkeerd gediagnoseer of verkeerd behandel is. Ongeskeduleerde terugkomste word as n aanwyser van die kwaliteit van sorg in die noodeenheid gebruik. Verskeie studies is in ontwikkelde lande met goed toegeruste gesondheidsorg gedoen om die persentasie ongeskeduleerde terugkomste in pediatriese noodeenhede te bepaal. Die persentasie ongeskeduleerde terugkomste het gewissel tussen 2 – 5.2% in hierdie studies. Daar is nog nie voorheen sulke studies in Suid-Afrika gedoen nie. Doel: Die doel van hierdie studie was om die aantal ongeskeduleerde terugkomste binne 72 uur na ontslag vanuit ons pediatriese noodeenheid, die faktore geassosieer met hierdie ongeskeduleerde terugkomste en die uitkomste van hierdie pasiënte te bepaal. Die volgende faktore word gehipotetiseer om die aantal ongeskeduleerde terugkomste te beinvloed: ouderdom van die pasiënt, voedingtoestand van die pasiënt, HIV status, triage (sorterings)-telling, die aanwesigheid van ‘n vorige mediese probleem, die tyd van die dag en dag van die week van die oorsponklike besoek, die inkomste van die ouers of die oppasser en die diagnose tydens die oorspronklike besoek. Die tyd van die jaar is ook in ag geneem om die seisoensinvloed op terugkomste te bepaal. Metode: Hierdie retrospektiewe gevalskontrole studie is in die pediatriese noodeenheid van ‘n akademiese hospitaal in ‘n hulpbron-beperkte omgewing uitgevoer. Ondersoek is ingestel na die aantal pediatriese pasiënte wat binne 72 uur na ontslag na die pediatriese noodeenheid terugkeer oor ‘n tydperk van een jaar. ‘n Geval is beskryf as ‘n pasiënt wat binne 72 uur na ontslag ongeskeduleerd terugkeer na die pediatriese noodeenheid. Pasiënte wat geskeduleer was om terug te kom, pasiënte wat deelgeneem het aan navorsingstudies en pasiënte met chirurgiese probleme was van hierdie studie uitgesluit. Die kontrolegroep was ewekansig geselekteer deur ‘n eenvoudige Excel ewekansige steekproefprogram wat kontrole pasiënte identifiseer het volgens die maand van presentering. Alle pasiëntinligting is uit die mediese lêers verkry wat op ‘n web-gebaseerde databasis gestoor word. Alle pasiëntinligting wat verkry is, is op ‘n Microsoft Excel sigblad gelaai en daarna met die hulp van ‘n biostatikus geanaliseer. Resultate Die persentasie ongeskeduleerde terugkomste in ons pediatriese noodeenheid was 1.07%. Eenhonderd-ag-en-vyftig uit n totaal van 14872 pasiënte het ongeskeduleerd terugekom. Ons bevindinge dui daarop dat pasiënte wat terugkom jonger was as die kontroles en dat met elke maand wat ‘n pasiënt ouer raak, was daar 0.6% minder kans dat die pasiënt sou terugkom. Wangevoede pasiënte (p=0.003) en pasiënte met vorige mediese probleme (p=0.027) het ‘n hoër risiko van terugkomste gehad. Daar was geen verskil tussen gevalle en kontroles met betrekking tot geslag, HIV status of inkomste van die ouers/oppasser nie. Die dag van die week of tyd van die dag het ook nie ‘n verskil aan die ongeskeduleerde terugkomste gemaak nie. Die ervaring van die dokters deur wie die pasiënte gesien is, het wel ‘n verskil gemaak aan die terugkomste; pasiënte wat gesien is deur n onervare dokter (intern) het ‘n hoër risiko gehad om terug te kom. Met betrekking tot triage/sortering-telling het pasiënte met ‘n sortering van oranje meer dikwels teruggekom as pasiënte wat as groen gesorteer was. Daar was geen spesiefieke diagnoses wat met terugkomste geassosieer was nie. Sewe persent van die ongeskeduleerde terugkomste was as gevolg van ‘n nadelige gebeurtenis. Samevatting: Die hoeveelheid terugkomste in ons omgewing is laer as wat gerapporteer is in ander (ontwikkeldende) lande. Moontlike redes hiervoor is die beskikbaarheid van ‘n oornag waarnemingseenheid wat gekoppel is aan die pediatriese noodeenheid, die beperkte geografiese gebied van die studie en die moontlikheid dat pasiënte terugkeer na ‘n ander gesondheidsfasiliteit. Wanvoeding, die teenwordigheid van n vorige mediese probleem, pasiënte wat verwys is deur ‘n algemene praktisyn, ‘n sorteringstelling van oranje (eerder as groen) en pasiënte wat gesien is deur onervare dokters, was faktore geassosieer met ‘n hoër waarskynlikheid van ongeskeduleerde terugkomste.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/105130
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