Why come back? 72 hours Revisits in a Tertiary care Emergency Department in Saudi Arabia

Why come back? 72 hours Revisits in a Tertiary care Emergency Department in Saudi Arabia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Why come back? 72 hours Revisits in a Tertiary care Emergency Department in Saudi Arabia Maan Jamjoom, Baraa Badr Milibari, Bsaim Abdulsalam Altirkistani, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6195483/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction : The number of emergency department (ED) visits has increased locally and internationally, however, not all these visits require immediate treatment. The increased rate of ED visits has led to ED crowding, which has negative effects on patients, healthcare providers, and the healthcare system. One of the contributing factors of ED crowding is ED revisits. An ED revisit is defined as a patient presenting to the ED within 72 hours after discharge from the previous ED visit. This study aimed to provide insights into the patterns and characteristics of emergency department revisits. Methods : This is a retrospective study investigated pattern of revisits to the ED at King Abdulaziz Medical City, Jeddah, Saudi Arabia. A consecutive sampling technique was employed, utilizing the hospital's Electronic Medical Record database. Results: A total of 461 patients were included in this study, out of which 261 (56.5%) were females. At the 1 st ED visit, 415 (90%) of patients were discharged directly from ED and only 25 (5.4%) required admission and were then discharged. However, the same patients visited the ED within the 72 hours, 313 (67.9%) of patients discharged from ED directly without the need of admission or transfer in the 2 nd ED visit and 134 (29.1%) of patient required admission and were discharged after their hospitalization. Conclusion: It is crucial to be aware about ED revisits in which it can affect several aspects such as hospital resource usage, healthcare worker exhaustion/burnout, or patient level of satisfaction with the delivered care. Figures Figure 1 Background Emergency department is defined as a department that provides assessment, diagnosis, and treatment for any patient at any given time [1]. The number of emergency department visits has increased locally and internationally, yet not all these visits require immediate treatment [2][3]. The increased rate of ED visits has led to ED crowding, which has negative effects on patients, healthcare providers, and the healthcare system [4]. Unfortunately, the information about ED frequent visits and patients’ characteristics in the Middle East and especially in Saudi Arabia are limited [2]. One of the contributors of ED crowding is ED revisits. An ED revisit is defined as a patient presenting to the ED within 72 hours after discharge from the previous ED visits [5,6]. Moreover, ED revisits rate is used as a quality indicator of provided care [7]. There are many causative factors for ED revisits, for instance, suboptimal assessment or management of the patient in the first visit, course of the disease, and patient-related factors such as over-anxious response of the patient [8,9,10]. Since ED revisits could cause crowding, this might lead to delay of treatment of other urgent cases waiting in the ED [5]. ED revisits could also increase the health costs [7]. A study was done in the United States to assess the number of revisits between 2006 and 2010, and the results showed that the number or revisits was 8.2% [11]. Another study done in Saudi Arabia among children with chronic diseases found that the revisit rate was 11% [12]. Therefore, this study aims to provide insights into the patterns and characteristics of emergency department revisits, contributing to improved patient care and resource management in King Abdulaziz Medical City, Jeddah. Materials and Methods This is a retrospective study of all patients older than 14 years of age who visited the Emergency Department in King Abdulaziz Medical City, Jeddah, Saudi Arabia, and had revisits within 72 hours of their previous visit. The included duration was from 1st of January 2022–31st of December 2022, while those returning beyond 72 hours were excluded. Ethical approval was granted by the Institutional Review Board at King Abdullah International Medical Research Centre (KAIMRC), Jeddah, Saudi Arabia via IRB number NRJ23J/118/04. A consecutive sampling technique was employed, utilizing the hospital's Electronic Medical Record. The study collected data on demographics, medical history, revisit timing, chief complaints, pain scores, vital signs, ED length of stay, hospitalization status, and outcomes. Data was organized and analyzed using Excel. Statistical Analysis: The data was collected and checked for completeness before being entered and analyzed using IMB’s Statistical Package for the Social Sciences (SPSS) v23. Categorical variables were presented as frequency (%), while continuous variables were reported as mean and standard deviation. Results A total of 461 patients were included in this study, out of which 261 (56.5%) were females. The mean age was 46.6 (± 20.5). The number of patients who were medically and surgically free was 151 (32.8%). While hypertension and diabetes constituted most of co-morbidities in the study population, 150 (32.5%) and 134 (29.1%), respectively, Table 1. Table 1. Bio-demographic characteristics Bio-demographic data Frequency (%), Mean (±SD) (n=461) Age in years 46.6 (±20.5) Gender Male 200 (43.4%) Female 261 (56.5%) Co-morbidities Medically & surgically free 151 (32.8%) Hypertension 150 (32.5%) Diabetes Mellitus 134 (29.1%) Oncology 62 (13.4%) Dyslipidemia 58 (12.6%) Cardiac Disease 50 (10.8%) Bronchial asthma 37 (8%) Hypothyroidism 31 (6.7%) Psychiatric disorder 28 (6.1%) Benign Prostatic Hyperplasia 25 (5.4%) Chronic Kidney Disease 23 (5%) Gastroesophageal reflux Disease 13 (2.8%) Stroke 13 (2.8%) End Stage Renal Disease 11 (2.4%) Sickle Cell Disease 11 (2.4%) Epilepsy/Seizure disorder 11 (2.4%) Biliary cholelithiasis 11 (2.4%) Osteoporosis 11 (2.4%) Liver Disease 9 (2%) Migraine 9 (2%) Multiple Sclerosis 7 (1.5%) Deep Venous Thrombosis 4 (0.9%) Recurrent SVT 4 (0.9%) Parkinson’s disease 2 (0.4%) Chronic Obstructive Pulmonary Disease 1 (0.2%) Table 2: Chief complaints Complaint Frequency (%) Abdominal pain 151 (32.8%) Nausea 66 (14.3%) Vomiting 58 (12.6%) Fever 54 (11.7%) Shortness of breath 40 (8.7%) Cough 39 (8.5%) Chest pain 34 (7.4%) Dizziness 33 (7.2%) Headache 32 (6.9%) Body pain 32 (6.9%) Back pain 23 (5%) Trauma 20 (4.3%) Moreover, 151 (32.8%) of patients presented with abdominal pain, 66 (14.3%) had nausea, and 58 (12.6%) had vomiting. While only 34 (7.4%) had chest pain complaints upon ED presentations, table 2. At the 1st ED visit, 415 (90%) of patients were discharged directly from ED and 25 (5.4%) required admission and were then discharged home. However, the same patients visited the ED within 72 hours, 313 (67.9%) of patients discharged from ED directly without the need of admission or transfer in the 2nd ED visit and 134 (29.1%) of patients required admission and were discharged after their hospitalization, Table 3. The major reason for revisits was recurrence of same complaint 199 (43.2%), followed by no improvement of condition 72 (15.6%). While those who revisited ED for different issue/complain constituted 88 (19.1%) of patients, Fig. 1. Table 3 1st and 2nd Visit Data: Outcome, Admission, Admission under which specialty 1st visit 2nd visit Outcomes Frequency (%) Frequency (%) Discharged from ER 415 (90%) 313 (67.9%) Discharged after admission 25 (5.4%) 134 (29.1%) Discharged against medical advice 20 (4.3%) 5 (1.1%) Transfer to other hospital for admission 1 (0.2%) 0 (0%) Deceased 0 (0%) 7 (1.5%) Still admitted 0 (0%) 2 (0.4%) Admission: Any department 25 (5.4%) 142 (30.8%) Obstetrics & Gynecology 6 (21.4%) 40 (28.2%) Internal Medicine 6 (21.4%) 33 (23.2%) Cardiology 2 (7.1%) 2 (1.4%) Nephrology 2 (7.1%) 2 (1.4%) Hematology 2 (7.1%) 4 (2.8%) Medical oncology 2 (7.1%) 16 (11.3) Vascular surgery 1 (3.6%) 3 (2.1%) General surgery 1 (3.6%) 20 (14%) Gastroenterology 1 (3.6%) 3 (2.1%) Orthopedics 1 (3.6%) 0 (0%) Adult neurology 1 (3.6%) 9 (6.3%) ENT 0 (0%) 2 (1.4%) Pulmonology 0 (0%) 1 (0.7%) Oral & maxillofacial surgery 0 (0%) 1 (0.7%) Discussion Out of the 461 patients who were included in this study, the majority of which were 261 females (56.5%) with a mean age of 46.6 years. These data are consistent with findings in a similar study which was done in a tertiary care hospital in Saudi Arabia. The study collected data on all ED visits that happened over a one-year period, which showed that more than half of the frequent ED visitors were female (60.12%) [2]. Almost one third of the patients (32.8%) were medically and surgically free, However, the remaining two thirds suffer from variable comorbidities. Hypertension (32.5%) and diabetes (29.1%) were the most common among them which aligns with a nationwide study done in Saudi Arabia. The study examined a total of 12,436 critically ill COVID-19 patients aged 18 and above. Their results demonstrated that the most prevalent comorbidities found in these patients were diabetes (48.2%) followed by hypertension (44.2%) [14], Table 1 . In regard to patients’ chief complaints, a lot of which were gastrointestinal in nature. The most frequently reported symptom was abdominal pain (32.8%), followed by nausea and vomiting, (14.3%) and (12.6%) respectively. These findings are similar to two studies where abdominal pain complaints were more prevalent in ED visits when compared to other chief complaints. Moreover, dyspnea (8.7%) and chest pain (7.4%) were similar when compared to a multi-centered cohort study that analyzed 223,612 ED visits. The study revealed that out of the total populations, abdominal pain complaints (16.3%) were higher than dyspnea (11.8%) and chest pain (7.7%) [15, 17], Table 2. The causes of revisits to the ED were classified into different categories according to what was documented in the patients’ electronic medical records upon revisiting the ED. The major reason for revisits was the recurrence of the same complaint (43.2%) after its resolution in the initial visit, as well as lack of improvement in the patient’s condition (15.6%) since the first visit. These two collectively account for nearly 60% of all revisits. The findings in previous studies do align with this and show that ED revisits were predominantly due to illness-related factors [5,16]. Moreover, revisits for a different issue accounted for (19.1%) of cases, indicating that a subgroup of patients have returned for different health concerns that are unrelated to their initial ED visit. This demonstrates that some revisits are inevitable and do not always reflect whether the care given during the initial visit was deficient or not. System-related causes of patients’ revisits such as being called for abnormal results (5.6%), follow up appointments (4.3%) could be attributed to delays happened during the diagnostic work-up or a further need of management that cannot be executed outside the ED setting. This uncovers areas, for example, where telemedicine and follow-up clinics could be integrated to reduce such revisits. Other minor causes included revisits for admission (2.6%) and medication refills (1.5%). Even though these numbers are relatively small, they do suggest that areas such as outpatient medication management and triage systems that could recognize patients who need admission in their initial visit, can prevent unnecessary ED revisit. Furthermore, this data revealed that (6.3%) of revisits were related to complications of underlying diseases that already have been diagnosed in those patients. For example, patients presenting in the second visit due to asthma exacerbation. Such cases are influenced by the natural course of the disease, or challenges to reach appropriate follow-up care facilities outside the ED setting. Furthermore, complications of treatment constituted (1.7%) of the overall revisits. Although this is a small percentage of cases, it is an important finding since it reflects possible iatrogenic factors that led to patient morbidity, like adverse drug reactions and inappropriate therapeutic interventions. Adhering to evidence-based guidelines along with carefully assessing the risks and benefits of treatments given in the ED could help mitigate treatment related complications thus reducing ED revisits. This study followed the outcomes of each patient in both the first and the second visits which shows a marked difference between them. The data demonstrated that a significant proportion of patients in the first visit were discharged from the ED (90%). The percentage drops to (67.9%) in the second ED visit. Similar results were depicted in a study that was conducted in a tertiary care hospital in Dubai in which the majority of patients were discharged from the ED [16]. The number of patients discharged following admission to the hospital rose substantially from (5.4%) at the first visit to (29.1%) at the second visit. One possible reason for the increased rate of admission in the second visit, is the need for more observation and further investigations since one of the major causes of revisits in this study was recurrence of same complaint. The percentage of patients discharged against medical advice (AMA) decreased between the first and second visits, from (4.3%) at the first visit to (1.1%) at the second visit. This reduction in AMA could be due to worsening patients’ condition in the second ED visit, and it could be greatly reduced by enhancing patient-physician communication. The worst outcome was present in the second ED visit. Out of the 461 revisit patients included in this study, seven (1.5%) patients died. Another outcome was transfer to another hospital for admission, which included only one patient in the first visit and none in the second visit due to the need of psychiatric ward admission which is not available in this study’s setting. The last outcome included only two patients who were still admitted after their second visit at the time of collecting the data. Conclusion This study provides valuable insights into the patterns of ED revisits. The most common cause of ED revisits was due to illness-related factors such as recurrence of the same complaint by and lack of improvement in the patient’s condition. It is crucial to be aware about the root causes of ED revisits in which it can affect several aspects such as resource usage, healthcare worker exhaustion or burnout, or patient satisfaction with the delivered care. Limitations and recommendations One limitation of this study is its retrospective design, which depends on the documentation written by the emergency physicians in the patients’ electronic medical record. These documents at times lacked the satisfactory details to clearly explain the patients’ revisits. Additionally, the study was conducted at a single center, limiting the generalizability of the findings. Future multi-centered studies are required to explore the reasons to why these revisits happen in an emergency setting. Furthermore, investigating effective strategies of patient care would help in improving patient outcomes and reducing emergency revisits in the future. Declarations Consent for publication: Not applicable. Availability of Data and Materials: The datasets used and/or analyzed in the current study is available from the corresponding author upon reasonable request. Competing interests : The authors declare that they have no competing interests. Funding : This study did not receive any specific grants from funding agencies in public, commercial, or non-profit sectors. Author Contributions: This study was conducted in accordance with the Declaration of Helsinki. conducted the study. BM, BA, AA, FS, AA, HA, and KA were responsible for data collection. FB provided statistical advice and study design and analyzed the data. BM, BA, AA, FS, AA, HA, and KA drafted the manuscript. ZB edited the manuscript and wrote the title page and the cover page along with being corresponding author. MJ took responsibility and supervised the study. All authors reviewed the study. All the authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work. Acknowledgments : Not applicable Ethical approval: Ethical approval was granted by the Institutional Review Board at King Abdullah International Medical Research Centre (KAIMRC), Jeddah, Saudi Arabia via IRB number NRJ23J/118/04. 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Revisit rates and associated costs after an emergency department encounter: a multistate analysis. Ann Intern Med. 2015;162(11):750-756. Doi:10.7326/M14-1616 Ahmed, Anwar E et al. “Emergency department 72-hour revisits among children with chronic diseases: a Saudi Arabian study.” BMC pediatrics vol. 18,1 205. 26 Jun. 2018, doi:10.1186/s12887-018-1186-8 Yoo S, Lee KH, Lee HJ, Ha K, Lim C, Chin HJ, Yun J, Cho EY, Chung E, Baek RM, Chung CY. Seoul National University Bundang Hospital's electronic system for total care. Healthcare Inform Res. 2012;18(2):145-52. Al-Otaiby M, Almutairi KM, Vinluan JM, Al Seraihi A, Alonazi WB, Qahtani MH, et al. Demographic characteristics, comorbidities, and length of stay of COVID-19 patients admitted into intensive care units in Saudi Arabia: A nationwide retrospective study. Front Med (Lausanne) [Internet]. 2022;9:893954. Available from: http://dx.doi.org/10.3389/fmed.2022.893954 Arvig M, Mogensen C, Skjøt-Arkil H, Johansen I, Rosenvinge F, Lassen A. Chief complaints, underlying diagnoses, and mortality in adult, non-trauma emergency department visits: A population-based, multicenter cohort study. West J Emerg Med [Internet]. 2022 [cited 2024 Nov 28];23(6). Available from: https://escholarship.org/uc/item/5f0497zg Al Ali M, Alfalasi MR, Taimour HA, Ahmed AM, Muhammed Noori OQ. ED revisits within 72 hours to a tertiary health care facility in Dubai: A descriptive study. Cureus [Internet]. 2023 [cited 2024 Nov 29];15(3). Available from: https://www.cureus.com/articles/133876-ed-revisits-within-72-hours-to-a-tertiary-health-care-facility-in-dubai-a-descriptive-study#!/ Soeno S, Hara K, Fujimori R, et al. Initial assessment in emergency departments by chief complaint and respiratory rate. J Gen Fam Med . 2021;22(4):202-208. Published 2021 Feb 22. doi:10.1002/jgf2.423 Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8245737 Additional Declarations No competing interests reported. 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08:23:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":670728,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6195483/v1/67395beb-68c5-4590-aa43-1238038b5df6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Why come back? 72 hours Revisits in a Tertiary care Emergency Department in Saudi Arabia","fulltext":[{"header":"Background","content":"\u003cp\u003eEmergency department is defined as a department that provides assessment, diagnosis, and treatment for any patient at any given time [1]. The number of emergency department visits has increased locally and internationally, yet not all these visits require immediate treatment [2][3]. The increased rate of ED visits has led to ED crowding, which has negative effects on patients, healthcare providers, and the healthcare system [4]. Unfortunately, the information about ED frequent visits and patients\u0026rsquo; characteristics in the Middle East and especially in Saudi Arabia are limited [2]. One of the contributors of ED crowding is ED revisits. An ED revisit is defined as a patient presenting to the ED within 72 hours after discharge from the previous ED visits [5,6]. Moreover, ED revisits rate is used as a quality indicator of provided care [7]. There are many causative factors for ED revisits, for instance, suboptimal assessment or management of the patient in the first visit, course of the disease, and patient-related factors such as over-anxious response of the patient [8,9,10]. Since ED revisits could cause crowding, this might lead to delay of treatment of other urgent cases waiting in the ED [5]. ED revisits could also increase the health costs [7]. A study was done in the United States to assess the number of revisits between 2006 and 2010, and the results showed that the number or revisits was 8.2% [11]. Another study done in Saudi Arabia among children with chronic diseases found that the revisit rate was 11% [12]. Therefore, this study aims to provide insights into the patterns and characteristics of emergency department revisits, contributing to improved patient care and resource management in King Abdulaziz Medical City, Jeddah.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis is a retrospective study of all patients older than 14 years of age who visited the Emergency Department in King Abdulaziz Medical City, Jeddah, Saudi Arabia, and had revisits within 72 hours of their previous visit. The included duration was from 1st of January 2022\u0026ndash;31st of December 2022, while those returning beyond 72 hours were excluded. Ethical approval was granted by the Institutional Review Board at King Abdullah International Medical Research Centre (KAIMRC), Jeddah, Saudi Arabia via IRB number NRJ23J/118/04. A consecutive sampling technique was employed, utilizing the hospital's Electronic Medical Record. The study collected data on demographics, medical history, revisit timing, chief complaints, pain scores, vital signs, ED length of stay, hospitalization status, and outcomes. Data was organized and analyzed using Excel.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis:\u003c/h2\u003e \u003cp\u003eThe data was collected and checked for completeness before being entered and analyzed using IMB\u0026rsquo;s Statistical Package for the Social Sciences (SPSS) v23. Categorical variables were presented as frequency (%), while continuous variables were reported as mean and standard deviation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 461 patients were included in this study, out of which 261 (56.5%) were females. The mean age was 46.6 (± 20.5). The number of patients who were medically and surgically free was 151 (32.8%). While hypertension and diabetes constituted most of co-morbidities in the study population, 150 (32.5%) and 134 (29.1%), respectively, Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1. Bio-demographic characteristics\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBio-demographic data\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (%), Mean (±SD) (n=461)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAge in years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46.6 (±20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGender\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Male\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003e200 (43.4%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Female\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003e261 (56.5%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCo-morbidities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eMedically \u0026amp; surgically free\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e151 (32.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eHypertension\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e150 (32.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eDiabetes Mellitus\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e134 (29.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eOncology\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62 (13.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eDyslipidemia\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58 (12.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCardiac Disease\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50 (10.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eBronchial asthma\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eHypothyroidism\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ePsychiatric disorder\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28 (6.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eBenign Prostatic Hyperplasia\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25 (5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eChronic Kidney Disease\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eGastroesophageal reflux Disease\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eStroke\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eEnd Stage Renal Disease\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eSickle Cell Disease\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eEpilepsy/Seizure disorder\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eBiliary cholelithiasis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eOsteoporosis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eLiver Disease\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eMigraine\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eMultiple Sclerosis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (1.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eDeep Venous Thrombosis\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (0.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eRecurrent SVT\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (0.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eParkinson’s disease\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eChronic Obstructive Pulmonary Disease\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cdiv align=\"left\"\u003e\u003cstrong\u003eTable 2: Chief complaints\u003c/strong\u003e\u003c/div\u003e\n\u003c/div\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eComplaint\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eAbdominal pain\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e151 (32.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eNausea\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e66 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eVomiting\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58 (12.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eFever\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54 (11.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eShortness of breath\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40 (8.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCough\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39 (8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eChest pain\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34 (7.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eDizziness\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33 (7.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eHeadache\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32 (6.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eBody pain\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32 (6.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eBack pain\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eTrauma\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMoreover, 151 (32.8%) of patients presented with abdominal pain, 66 (14.3%) had nausea, and 58 (12.6%) had vomiting. While only 34 (7.4%) had chest pain complaints upon ED presentations, table 2.\u003c/p\u003e\n\u003cp\u003eAt the 1st ED visit, 415 (90%) of patients were discharged directly from ED and 25 (5.4%) required admission and were then discharged home. However, the same patients visited the ED within 72 hours, 313 (67.9%) of patients discharged from ED directly without the need of admission or transfer in the 2nd ED visit and 134 (29.1%) of patients required admission and were discharged after their hospitalization, Table 3. The major reason for revisits was recurrence of same complaint 199 (43.2%), followed by no improvement of condition 72 (15.6%). While those who revisited ED for different issue/complain constituted 88 (19.1%) of patients, Fig.\u0026nbsp;1.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003e1st and 2nd Visit Data: Outcome, Admission, Admission under which specialty\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1st visit\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2nd visit\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eOutcomes\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eDischarged from ER\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e415 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e313 (67.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eDischarged after admission\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e134 (29.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eDischarged against medical advice\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eTransfer to other hospital for admission\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eDeceased\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (1.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eStill admitted\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdmission: Any department\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e142 (30.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eObstetrics \u0026amp; Gynecology\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (28.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eInternal Medicine\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (23.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eCardiology\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eNephrology\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eHematology\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMedical oncology\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eVascular surgery\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eGeneral surgery\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eGastroenterology\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eOrthopedics\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eAdult neurology\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eENT\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePulmonology\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eOral \u0026amp; maxillofacial surgery\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (0.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOut of the 461 patients who were included in this study, the majority of which were 261 females (56.5%) with a mean age of 46.6 years. These data are consistent with findings in a similar study which was done in a tertiary care hospital in Saudi Arabia. The study collected data on all ED visits that happened over a one-year period, which showed that more than half of the frequent ED visitors were female (60.12%) [2]. Almost one third of the patients (32.8%) were medically and surgically free, However, the remaining two thirds suffer from variable comorbidities. Hypertension (32.5%) and diabetes (29.1%) were the most common among them which aligns with a nationwide study done in Saudi Arabia. The study examined a total of 12,436 critically ill COVID-19 patients aged 18 and above. Their results demonstrated that the most prevalent comorbidities found in these patients were diabetes (48.2%) followed by hypertension (44.2%) [14], Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eIn regard to patients\u0026rsquo; chief complaints, a lot of which were gastrointestinal in nature. The most frequently reported symptom was abdominal pain (32.8%), followed by nausea and vomiting, (14.3%) and (12.6%) respectively. These findings are similar to two studies where abdominal pain complaints were more prevalent in ED visits when compared to other chief complaints. Moreover, dyspnea (8.7%) and chest pain (7.4%) were similar when compared to a multi-centered cohort study that analyzed 223,612 ED visits. The study revealed that out of the total populations, abdominal pain complaints (16.3%) were higher than dyspnea (11.8%) and chest pain (7.7%) [15, 17], Table\u0026nbsp;2.\u003c/p\u003e \u003cp\u003eThe causes of revisits to the ED were classified into different categories according to what was documented in the patients\u0026rsquo; electronic medical records upon revisiting the ED. The major reason for revisits was the recurrence of the same complaint (43.2%) after its resolution in the initial visit, as well as lack of improvement in the patient\u0026rsquo;s condition (15.6%) since the first visit. These two collectively account for nearly 60% of all revisits. The findings in previous studies do align with this and show that ED revisits were predominantly due to illness-related factors [5,16]. Moreover, revisits for a different issue accounted for (19.1%) of cases, indicating that a subgroup of patients have returned for different health concerns that are unrelated to their initial ED visit. This demonstrates that some revisits are inevitable and do not always reflect whether the care given during the initial visit was deficient or not. System-related causes of patients\u0026rsquo; revisits such as being called for abnormal results (5.6%), follow up appointments (4.3%) could be attributed to delays happened during the diagnostic work-up or a further need of management that cannot be executed outside the ED setting. This uncovers areas, for example, where telemedicine and follow-up clinics could be integrated to reduce such revisits. Other minor causes included revisits for admission (2.6%) and medication refills (1.5%). Even though these numbers are relatively small, they do suggest that areas such as outpatient medication management and triage systems that could recognize patients who need admission in their initial visit, can prevent unnecessary ED revisit. Furthermore, this data revealed that (6.3%) of revisits were related to complications of underlying diseases that already have been diagnosed in those patients. For example, patients presenting in the second visit due to asthma exacerbation. Such cases are influenced by the natural course of the disease, or challenges to reach appropriate follow-up care facilities outside the ED setting. Furthermore, complications of treatment constituted (1.7%) of the overall revisits. Although this is a small percentage of cases, it is an important finding since it reflects possible iatrogenic factors that led to patient morbidity, like adverse drug reactions and inappropriate therapeutic interventions. Adhering to evidence-based guidelines along with carefully assessing the risks and benefits of treatments given in the ED could help mitigate treatment related complications thus reducing ED revisits.\u003c/p\u003e \u003cp\u003eThis study followed the outcomes of each patient in both the first and the second visits which shows a marked difference between them. The data demonstrated that a significant proportion of patients in the first visit were discharged from the ED (90%). The percentage drops to (67.9%) in the second ED visit. Similar results were depicted in a study that was conducted in a tertiary care hospital in Dubai in which the majority of patients were discharged from the ED [16]. The number of patients discharged following admission to the hospital rose substantially from (5.4%) at the first visit to (29.1%) at the second visit. One possible reason for the increased rate of admission in the second visit, is the need for more observation and further investigations since one of the major causes of revisits in this study was recurrence of same complaint. The percentage of patients discharged against medical advice (AMA) decreased between the first and second visits, from (4.3%) at the first visit to (1.1%) at the second visit. This reduction in AMA could be due to worsening patients\u0026rsquo; condition in the second ED visit, and it could be greatly reduced by enhancing patient-physician communication.\u003c/p\u003e \u003cp\u003eThe worst outcome was present in the second ED visit. Out of the 461 revisit patients included in this study, seven (1.5%) patients died. Another outcome was transfer to another hospital for admission, which included only one patient in the first visit and none in the second visit due to the need of psychiatric ward admission which is not available in this study\u0026rsquo;s setting. The last outcome included only two patients who were still admitted after their second visit at the time of collecting the data.\u003c/p\u003e"},{"header":"Conclusion","content":" \u003cp\u003eThis study provides valuable insights into the patterns of ED revisits. The most common cause of ED revisits was due to illness-related factors such as recurrence of the same complaint by and lack of improvement in the patient\u0026rsquo;s condition. It is crucial to be aware about the root causes of ED revisits in which it can affect several aspects such as resource usage, healthcare worker exhaustion or burnout, or patient satisfaction with the delivered care.\u003c/p\u003e"},{"header":"Limitations and recommendations","content":"\u003cp\u003eOne limitation of this study is its retrospective design, which depends on the documentation written by the emergency physicians in the patients\u0026rsquo; electronic medical record. These documents at times lacked the satisfactory details to clearly explain the patients\u0026rsquo; revisits. Additionally, the study was conducted at a single center, limiting the generalizability of the findings. Future multi-centered studies are required to explore the reasons to why these revisits happen in an emergency setting. Furthermore, investigating effective strategies of patient care would help in improving patient outcomes and reducing emergency revisits in the future.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed in the current study is available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This study did not receive any specific grants from funding agencies in public, commercial, or non-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003eThis study was conducted in accordance with the Declaration of Helsinki. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; conducted the study. \u0026nbsp;BM, BA, AA, FS, AA, HA, and KA were responsible for data collection. FB provided statistical advice and study design and analyzed the data. \u0026nbsp;BM, BA, AA, FS, AA, HA, and KA drafted the manuscript. ZB edited the manuscript and wrote the title page and the cover page along with being corresponding author. MJ took responsibility and supervised the study. All authors reviewed the study. All the authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval:\u003c/strong\u003e Ethical approval was granted by the Institutional Review Board at King Abdullah International Medical Research Centre (KAIMRC), Jeddah, Saudi Arabia via IRB number NRJ23J/118/04.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMedford-Davis L, Marcozzi D, Agrawal S, Carr BG, Carrier E. Value-Based Approaches for Emergency Care in a New Era. Ann Emerg Med. 2017;69(6):675-683. Doi:10.1016/j.annemergmed.2016.10.031\u003c/li\u003e\n\u003cli\u003eAl-Surimi, Khaled et al. \u0026ldquo;Epidemiology of Frequent Visits to the Emergency Department at a Tertiary Care Hospital in Saudi Arabia: Rate, Visitors\u0026apos; Characteristics, and Associated Factors.\u0026rdquo; International journal of general medicine vol. 14 909-921. 17 Mar. 2021, doi:10.2147/IJGM.S299531\u003c/li\u003e\n\u003cli\u003eScherer, Martin et al. \u0026ldquo;Patients Attending Emergency Departments.\u0026rdquo; Deutsches Arzteblatt international vol. 114,39 (2017): 645-652. Doi:10.3238/arztebl.2017.0645 4.\u003c/li\u003e\n\u003cli\u003eRasouli, Hamid Reza et al. \u0026ldquo;Outcomes of Crowding in Emergency Departments; a Systematic Review.\u0026rdquo; Archives of academic emergency medicine vol. 7,1 e52. 28 Aug. 2019\u003c/li\u003e\n\u003cli\u003eSah, Rajesh et al. \u0026ldquo;Characteristics of an Unscheduled Emergency Department Revisit Within 72 hours of Discharge.\u0026rdquo; Cureus vol. 14,4 e23975. 9 Apr. 2022, doi:10.7759/cureus.23975\u003c/li\u003e\n\u003cli\u003eNu\u0026ntilde;ez S, Hexdall A, Aguirre-Jaime A. Unscheduled returns to the emergency department: an outcome of medical errors?. Qual Saf Health Care. 2006;15(2):102-108. doi:10.1136/qshc.2005.016618\u003c/li\u003e\n\u003cli\u003eNamgung, Myeong et al. \u0026ldquo;A Comparison of Emergency Department Revisit Rates of Pediatric Patients between Pre-COVID-19 and COVID-19 Periods.\u0026rdquo; Children (Basel, Switzerland) vol. 9,7 1003. 4 Jul. 2022, doi:10.3390/children9071003\u003c/li\u003e\n\u003cli\u003eTangkulpanich, Panvilai et al. \u0026ldquo;Clinical Predictors of Emergency Department Revisits within 48 Hours of Discharge; a Case Control Study.\u0026rdquo; Archives of academic emergency medicine vol. 9,1 e1. 5 Nov. 2020, doi:10.22037/aaem.v9i1.891\u003c/li\u003e\n\u003cli\u003eGuo, Di-You et al. \u0026ldquo;The Association Between Emergency Department Revisit and Elderly Patients.\u0026rdquo; Journal of acute medicine vol. 10,1 (2020): 20-26. Doi:10.6705/j.jacme.202003_10(1).0003\u003c/li\u003e\n\u003cli\u003eWu CL, Wang FT, Chiang YC, et al. Unplanned emergency department revisits within 72 hours to a secondary teaching referral hospital in Taiwan. J Emerg Med. 2010;38(4):512-517. Doi:10.1016/j.jemermed.2008.03.039\u003c/li\u003e\n\u003cli\u003eDuseja R, Bardach NS, Lin GA, et al. Revisit rates and associated costs after an emergency department encounter: a multistate analysis. Ann Intern Med. 2015;162(11):750-756. Doi:10.7326/M14-1616\u003c/li\u003e\n\u003cli\u003eAhmed, Anwar E et al. \u0026ldquo;Emergency department 72-hour revisits among children with chronic diseases: a Saudi Arabian study.\u0026rdquo; BMC pediatrics vol. 18,1 205. 26 Jun. 2018, doi:10.1186/s12887-018-1186-8\u003c/li\u003e\n\u003cli\u003eYoo S, Lee KH, Lee HJ, Ha K, Lim C, Chin HJ, Yun J, Cho EY, Chung E, Baek RM, Chung CY. Seoul National University Bundang Hospital\u0026apos;s electronic system for total care. Healthcare Inform Res. 2012;18(2):145-52.\u003c/li\u003e\n\u003cli\u003eAl-Otaiby M, Almutairi KM, Vinluan JM, Al Seraihi A, Alonazi WB, Qahtani MH, et al. Demographic characteristics, comorbidities, and length of stay of COVID-19 patients admitted into intensive care units in Saudi Arabia: A nationwide retrospective study. Front Med (Lausanne) [Internet]. 2022;9:893954. Available from: http://dx.doi.org/10.3389/fmed.2022.893954\u003c/li\u003e\n\u003cli\u003eArvig M, Mogensen C, Skj\u0026oslash;t-Arkil H, Johansen I, Rosenvinge F, Lassen A. Chief complaints, underlying diagnoses, and mortality in adult, non-trauma emergency department visits: A population-based, multicenter cohort study. West J Emerg Med [Internet]. 2022 [cited 2024 Nov 28];23(6). Available from: https://escholarship.org/uc/item/5f0497zg\u003c/li\u003e\n\u003cli\u003eAl Ali M, Alfalasi MR, Taimour HA, Ahmed AM, Muhammed Noori OQ. ED revisits within 72 hours to a tertiary health care facility in Dubai: A descriptive study. Cureus [Internet]. 2023 [cited 2024 Nov 29];15(3). Available from: https://www.cureus.com/articles/133876-ed-revisits-within-72-hours-to-a-tertiary-health-care-facility-in-dubai-a-descriptive-study#!/\u003c/li\u003e\n\u003cli\u003eSoeno S, Hara K, Fujimori R, et al. Initial assessment in emergency departments by chief complaint and respiratory rate. \u003cem\u003eJ Gen Fam Med\u003c/em\u003e. 2021;22(4):202-208. Published 2021 Feb 22. doi:10.1002/jgf2.423 Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8245737\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6195483/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6195483/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e : The number of emergency department (ED) visits has increased locally and internationally, however, not all these visits require immediate treatment. The increased rate of ED visits has led to ED crowding, which has negative effects on patients, healthcare providers, and the healthcare system. One of the contributing factors of ED crowding is ED revisits. An ED revisit is defined as a patient presenting to the ED within 72 hours after discharge from the previous ED visit. This study aimed to provide insights into the patterns and characteristics of emergency department revisits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This is a retrospective study investigated pattern of revisits to the ED at King Abdulaziz Medical City, Jeddah, Saudi Arabia. A consecutive sampling technique was employed, utilizing the hospital's Electronic Medical Record database.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 461 patients were included in this study, out of which 261 (56.5%) were females. At the 1\u003csup\u003est\u003c/sup\u003e ED visit, 415 (90%) of patients were discharged directly from ED and only 25 (5.4%) required admission and were then discharged. However, the same patients visited the ED within the 72 hours, 313 (67.9%) of patients discharged from ED directly without the need of admission or transfer in the 2\u003csup\u003end\u003c/sup\u003e ED visit and 134 (29.1%) of patient required admission and were discharged after their hospitalization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIt is crucial to be aware about ED revisits in which it can affect several aspects such as hospital resource usage, healthcare worker exhaustion/burnout, or patient level of satisfaction with the delivered care.\u003c/p\u003e","manuscriptTitle":"Why come back? 72 hours Revisits in a Tertiary care Emergency Department in Saudi Arabia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-17 16:16:24","doi":"10.21203/rs.3.rs-6195483/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"250ad529-5532-4e44-bc62-1f6c25b7b428","owner":[],"postedDate":"March 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-07T08:23:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-17 16:16:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6195483","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6195483","identity":"rs-6195483","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}