1 in 20 pediatric patients returns to ED days after first visit

As many as 20% of pediatric patients revisit an emergency department (ED) within 1 week of their initial visit, according to a new report.

This statistic reveals that past estimates of pediatric revisits were underestimated because they didn’t take into account patients who went to another hospital after their first visit, the report notes.

The study, published in Pediatrics, reveals that patients who first visited EDs that see fewer pediatric patients were most likely to go to another ED with higher volumes of pediatric patients.¹

Lead author Kenneth Michelson, MD, MPH, of the Boston Children’s Hospital Division of Emergency Medicine, Boston, Massachusetts, says providers have to take note of this number in light of the increasing focus on revisits in quality assessment and repayment measures.

“I think this study confirms what emergency physicians and pediatricians already suspected, which is that families try and make the best decisions they can for their child’s care, often switching EDs or hospitals if they believe it will better serve them,” Michelson says. “Pediatricians should consider counseling families about the benefits and downsides of switching hospitals. For instance, a downside of switching is often that 1 hospital does not have ready access to the records of another, but an upside may be that a resource unavailable at 1 hospital is available at another.”

The study evaluated discharge data for pediatric patients at 261 hospitals in New York and Maryland in an attempt to uncover data on discharges and revisits. Revisits within 1 week occurred in 1 in 20 pediatric ED patients, according to the report, and 1 in 5 of those visits involved a patient returning to an ED at a different hospital for the second visit. The overall revisit rate was 5.9% of a total of 4.3 million discharges, according to the data. The study also examined cases in which a child was brought to the ED for a third visit, which occurred an average of 8 days after the second revisit.

The most common diagnoses associated with additional ED visits were fever, upper respiratory tract infections, and unspecified viral infections, according to the researchers.

Michelson says he was surprised at the variability of the decision to switch hospitals and seek care elsewhere. “At some hospitals, families chose to seek care elsewhere upward of half the time they made a decision to return to an ED. At some, they nearly always chose to return to the same facility. Children tended to return to the same place at EDs that see many more children each year,” he says.

Michelson says he hopes the study will motivate pediatricians and emergency care providers to open the discussion about where to seek care with parents. “I also think that, as a system, when we measure return visits to our hospital, we need to work harder to find out how often patients decide not to come back to our same hospital,” he says. “We should talk with those families and find out why they chose to change, as it may improve our own practice.”

Michelson says parents should be reminded that their child’s regular pediatrician is probably their best resource, but not dissuaded from seeking emergency care when needed.

“I often tell the families I see that if they are worried about their child, their child is getting worse, or something is just not right, that we as pediatricians want to see them, and that they should seek care,” Michelson says. “The primary care pediatrician frequently knows a child best since [he/she has] a long-standing relationship. If parents or guardians do not think the child has an emergency, I encourage speaking with a pediatrician first, as pediatricians can help gauge whether emergency services are needed. But as an emergency medicine doctor for kids, I think if a family believes an emergency exists, they should come to an ED.”

References:

1. Michelson KA, Lyons TW, Bachur RG, Monoteaux MC, Finkelstein JA. Timing and location of emergency department revisits. Pediatrics. April 12, 2018. Epub ahead of print.