Anxieties about health, access to outpatient care drive patients back to ED after discharge

Patients who return to the ED shortly after discharge report that they do so out of fears for their health and because they can't access outpatient care quickly, a new study found.

Researchers performed semistructured qualitative interviews with 60 adult patients from 2 Philadelphia hospitals who returned to the ED within 9 days of a previous ED treat-and-release visit. The interviews comprised open-ended questions on clinical care, the discharge process, and prescriptions from the index visit; use of health care since the index visit; transportation availability/use; social support; activities of daily living; employment; health advice sources; factors influencing the decision to return to the ED; general use and beliefs about the health care system; and overall impressions of care in the ED. Results were published online Sept. 2 by Annals of Emergency Medicine.

Twenty-four of the 60 patients were admitted at their return visit, and 36 were discharged. Sixty-eight percent said they were satisfied with the discharge process from the initial visit. Those who expressed problems cited having difficulty understanding the written discharge papers, not receiving discharge papers before leaving the ED, or feeling rushed or unprepared for discharge. Forty percent of patients expressed concerns about the clinical care they received at the index visit, such as not having their chief symptom addressed and not getting certain diagnostic tests. Patients rarely reported problems with social resources, like transportation, access to food or housing, or child care.

Many patients reported they were not referred to an outpatient clinician when discharged from their index visit; just 20% of patients visited an outpatient clinic after discharge. One-third of patients contacted their outpatient clinicians to make a follow-up appointment but didn't attend it before returning to the ED. When asked why, the patients said they thought their symptoms were too severe to wait until their outpatient appointment or that their outpatient clinician told them to go to the ED. “Patients most frequently returned to the ED because of fear and uncertainty about their condition, with this fear driven by the belief that their condition was worsening or not improving in the timeframe they expected, as well as by a lack of explanation for what was causing their symptoms,” the authors wrote. Patients also spoke about “a lack of trust in the system to be responsive to their needs,” they added.

The findings suggest that clinicians need to be more proactive in ensuring that patient concerns have been addressed before discharge, which might include better explaining their clinical thinking, communicating test results, and addressing patient uncertainties about diagnoses. Also, the authors noted, the study highlights the issue that patients don't have ready access to advice from clinicians in between scheduled visits or hospital stays, which potentially could be remedied by using telemedicine in the postdischarge period.