Return Visits to the Emergency Department
There is no sufficient information concerning patients seeking care after a short time. Ever since the introduction of discouragement of readmissions based on financial implications, medical institutions emphasized on a 30-day reduction of readmissions through several initiatives and interventions. According to Rinsing et al., “approximately a third of acute care visits and half of the hospital admissions come from the emergency department in the US” (Rising et al., 2015). It is not clear concerning the way continued Emergency Department (ED) use fits in the debate around readmissions. There are emerging measures seeking to minimize the number of readmissions to the Emergency Department. Policymakers and relevant stakeholders who want to reduce costs, improve outcomes, and promote improved patient experience regard safe transition as an essential goal. The hospital readmissions are regarded as tools that capture the transition of care deficits in hospital settings (Cheng et al., 2016). It is now a measure of quality that is now linked to penalties for poor-performing medical institutions. For over 20 years, physicians in the ED are under programs that report the visits back to the ED within 72 hours. Several studies group the return visit rate as poor in marking quality. A study concerning return visits emphasized on patient-driven aspects. The study also revealed that patients utilize the ED according to their perception of value. They returned because of the alleged inability to access follow- upcare, their concerns on the medical problem, and its progression. Most patients had physicians but still felt that the required resources for completing care would get accessed timely through their return to the ED. Quantitatively, the CDC data offered insights on this issue. For instance, in 2014, close to 5.7% of the ED visits involved patients who were previously in the ED in the last three days. Approximately 4.8% of the visits were due to follow-up. Also, close to 3% of the ED visits were previously there 72 hours before.
The revisiting of the ED is now a measure of the adequacy of Emergency Department discharge practices. The short return to the Emergency Department closely gets monitored. This metric also reflects the emergency care quality, especially in cases where patients need hospitalization in their return to the ED. However, there are faults to adopting return visits as measures of quality since it is uncertain and linked with unintended consequences. ED offers care for a mixture of the patient population. Many of the patients get discharged home after treatment. This investigation identified the issue associated with the adult population in Florida state. This analysis identifies the gap that is to search for solutions that address the challenges associated with ED return visits. ED physicians must know how to balance expected hospitalization benefits against costs associated with a hospital stay and clinical uncertaintywhen making decisions concerning patient hospitalization. This project also examines clinical outcomes as well as the utilization of resources by patients who revisited the ED and the hospitalized patients in the state of Florida who never returned to the ED. There is a need for other quality measures in determining the quality of ED care and also intervention efforts to the Florida state. Therefore, the study involves answering the PICOT question: Can the adult population in Florida reduce the visits back to Emergency Departments through use of appropriate measures that identify ED care quality so that the medical institution’s get incentivized in ways that benefit patients compared to physicians practicing due diligence and sharing decision-making with patients in reducing inpatients costs, time taken for hospitalization, admission into the ICU, and mortalityrate in the hospital in 30 days.
Role of DNP prepared Nurse
DNP produces leaders who can achieve and oversee the demand and high- quality care while developing a meaningful change in the country’s healthcare system. DNP prepared nurses to have unique roles in clinical practice. These professionals act as leaders, change agents, and developers of programs. DNP does not change the scope of practice for nurse practitioners. DNP nurses make significant impacts on the efficiency and effectiveness of care systems by making contributions in advocacy, implementation of evidence-based practices, and nursing education. DNP prepared nurses can also impact this case by acting as change agents. For instance, nurses can spearhead healthcare policy. They are well-informed, ready, and can support healthcare policy development. These nurses take part in policy intervention as well as creation. As catalysts for change, the nurse can develop policy agendas and get support from legislators to help develop and pass policies that will reduce the ED return visits. They can use their knowledge and apply it in clinical practice. They possess skills that can assist in implementing practice changes, evaluating impacts of outcomes on the patients as well as their families. The DNP prepared nurses can use their leadership skills to focus on quality improvement. The nurses can help address the problem by using their ability to impacting every area of the healthcare system. They can advise and come up with better ways of addressing the return visits issue.
The Florida state is populous, which makes it a perfect place to develop and implement intervention strategies. ED data in this state is robust, and it is easy to track return visits. There are several reasons accorded to the return visits to the emergency departments. Some of the reasons include the desire for reassurance, repeat treatment, complications from treatment,worsening of original medical issues, scheduled revisit, among others. If a patient goes to another ED, some of the factors can be causative. It can show movement to high care levels or initial unsatisfactory encounter by a patient that ended up with an issue that was not addressed (Lowry et al., 2018). Based on these factors, it is likely that the number of returns may not accurately be representative of quality. The return visit case is not a vital quality measure.Sabbatini (2016) revealed that patients experiencing ED visits who got admitted shortly after discharge reported low costs and reduced in-hospital mortality. Contrastingly, patients returning back to Emergency Department got linked with high ICU admission and mortality rates.The patients that revisited the ED because of medical errors previously indicated signs of having high hospital admission rates compared to the general ED population. Additionally, they are at great risk of poor clinical outcome. The rates of return to ED are perceived as a failure in patient management and representative of medical error. This has significant policy implications in healthcare systems that are value-driven. Changes witnessed in healthcare financing like physician profiling, including pay for performance incentives, piled pressure on hospitals, and to the physicians in reducing unnecessary admissions. Despite there being a value in tracking return visits to indicate the assurance process, focusing on hospital performance based on the returns, they can create unintended consequences. An instance is the encouragement of unnecessary hospitalizations if ED physicians attempt to guarding clinical uncertainty and seek favorable revisit measures.
A major intervention effort that will help address the problem is to choose appropriate measures that will identify ED care quality will help the hospitals, as well as physicians, get incentivized in a manner that benefits patients. Return visits that lead to hospital admission should not get perceived as poor care (Cheng et al., 2016). The visits can become fruitful and offer a platform for quality improvement activities. There is a suggestion that high-quality care occurs if patients are in the ED, get tested, and offered treatment released since they do not meet the criteria for admission. Clinicians can also discharge patients depending on the patient’s preferences. Also, the patient’s ability to manage the condition as an outpatient. These two reasons impact revisit rates (Dean et al., 2015). An instance involves providing anticipatory guidance for the time that a patient should return to the emergency department. This is a vital aspect of ED discharge. The patient perspective is a critical element in explaining the recurrent ED visits. Understanding the risk factors can improve patient experience in times of ED visit and after the visit. This will reduce ED revisits. Patients face emotional and physical issues during discharge from the ED. Most of them revisit the ED due to uncertainty for their medical conditions. They also show distrust in the system to respond to their needs. Such revelations are vital in creating solutions to address increased ED revisits. It involves actively engaging patients in acute care episodes to define their problems in staying healthy. Therefore, the DNP nurses, physicians, and other relevant caregivers should offer patients reassurance in and after the episodes of care more so in the period where no clear explanation exists to define the cause of the symptoms. Emergency providers shouldproactively get concerned with addressing patient concerns before they get discharged. It can include communicating test results, verbalizing clinical thinking, and dealing with the uncertainty that patients feel due to no clear diagnoses. Another reason that helps inform measures that should get taken involvespatients not having accessibility to essential advice from the time they schedule visits and when staying in the hospitals. It is partly due to US medicine “reactive nature”(Rising et al., 2015).Experts started focusing on ways of inserting critical thinking about healthy choices in waking hours yearly spent away from the physician’s office. It directly links with the policy initiatives that emphasize healthcare delivery’s increasing value. Several factors contribute towards providers’ and patients’ divide such as fee-for-service-models, home visits failure, especially to patients that have mobility challenges, referral of a patient to ED, and other changes in delivery. Despite patients’ knowledge during discharge from the ED, they will still have questions that will arise after getting to their home environment. There should be an established andreliable way of contacting providers after the discharge period via telemedicine. Such methods can assist patients in managing their concerns without the need to return to the hospital. Another intervention effort involved physicians exercising due diligence and sharing the process of decision-making with patients. This would make the patients feel at ease and get informed, thereby reducing concerns. Overall, patients go back to the ED due to anxiety caused by symptoms, being unsure about what action to take, and losing faith in the healthcare system. Reducing ED revisits would, therefore, involve meeting patient needs. Attention should focus on the development and facilitation of pathways that patients can get to ask questions and guidance. Technology can also facilitate connections and improve access to help that patients need.
Nurses have a chance of playing a key role in transforming care. Nurses can offer detailed explanations concerning patient discharge to the patients. It will entail the factors that will arise while the patient will be at home, and how to approach situations that may compel them to go back to the ED. This will help prevent the patients from going to the ED again. Another short-term solution involves the physicians discussing detailed information about the illness involved with their patients. The physicians can also properly address concerns that their patients may have to reduce uncertainty from them. In the long run, the physicians and nurses should ensure they create an ED-based care program that will integrate the care teams in the ED. The program should offer more trainings on handling patients at the ED including the aspects of discharge to prevent the return cases. Intensive training should aim towards enhancing the nurses and physician role that includes patient engagement. Physicians can serve as a liaison to other colleagues who practice by assisting them find the patients appropriately. Physicians should also work closely with identified pharmacists allied to the hospital, to offer medication counselling. This will foster patient self-management education and reduce uncertainty from patients.
Cheng, J., Shroff, A., Khan, N., & Jain, S. (2016). Emergency department return visits resulting in admission: do they reflect quality of care?. American Journal of Medical Quality, 31(6), 541-551.
Duseja, R., Bardach, N. S., Lin, G. A., Yazdany, J., Dean, M. L., Clay, T. H., … & Dudley, R. A. (2015). Revisit rates and associated costs after an emergency department encounter: a multistate analysis. Annals of internal medicine, 162(11), 750-756.
Rising, K. L., Padrez, K. A., O’Brien, M., Hollander, J. E., Carr, B. G., & Shea, J. A. (2015). Return visits to the emergency department: the patient perspective. Annals of emergency medicine, 65(4), 377-386.
Sabbatini, A. K., Kocher, K. E., Basu, A., & Hsia, R. Y. (2016). In-hospital outcomes and costs among patients hospitalized during a return visit to the emergency department. Jama, 315(7), 663-671.
Shy, B. D., Loo, G. T., Lowry, T., Kim, E. Y., Hwang, U., Richardson, L. D., & Shapiro, J. S. (2018). Bouncing Back Elsewhere: Multilevel Analysis of Return Visits to the Same or a Different Hospital After Initial Emergency Department Presentation. Annals of emergency medicine, 71(5), 555-563.