Steps to cut unscheduled visits include more docs on late shift, doubling of emergency dept beds

A STUDY by National University Hospital (NUH) doctors has found that patients treated by medical officers at its emergency department were twice as likely than those seen by specialists to make unscheduled return visits for more treatment.

But the percentage of these medical officers’ patients returning for additional or corrective treatment for the same complaint is small – 489 out of 22,529 patients, or a return rate of 2.17 per cent.

In contrast, the return rate among patients seen by its specialists was less than 1 per cent.

Corresponding figures for the other hospitals were unavailable.

The return rate for the entire emergency department is also small – just 842 patients, or 2.2 per cent, of the 38,414 patients handled.

The hospital has nonetheless acted to bring down the figure.

Dr Malcolm Mahadevan, a senior consultant in NUH’s emergency department, said the difference in return rates may be because those seen by specialists tend to be more serious cases and likely to already be in-patients.

The study he did in 2005 with a colleague, Dr W.S. Kuan, was published recently in the Singapore Medical Journal.

It also unearthed other patterns among NUH’s return patients: One was that patients who sought emergency treatment in the wee hours of the morning were the most likely to return for more treatment – a return rate of 3.4 per cent.

The authors of the study concluded that the higher return rate between midnight and 8am was the result of fewer doctors being on duty, fatigue among those who were working, and less supervision by senior doctors.

Another trend was that the return rate among patients of doctors from “non-traditional sources”, such as the Philippines or India, was higher than that of the medical officers, at 2.54 per cent.

Doctors trained in the United States, Europe or Australia are deemed as having been drawn from “traditional” sources.

Dr Mahadevan said NUH’s overall return rate of 2.2 per cent was comparable to published rates in hospitals elsewhere.

The overall return rate at Singapore General Hospital (SGH) is between 1 per cent and 1.5 per cent; the rate has been less than 2 per cent at KK Women’s and Children’s Hospital (KKH) since 2007.

Changi General Hospital (CGH) does not differentiate between scheduled and unscheduled returns.

Although none of NUH’s return patients in the study died, several had serious illnesses and 307 had to be admitted.

Dr Mahadevan said: “It is not possible to totally eliminate re-attendances because of the progression of certain diseases.”

To lower its return rate, NUH has doubled the number of beds in its emergency department, so patients – those with abdominal pains, which are harder to diagnose, for example – can be observed for a longer period to ensure they do not need hospitalisation.

It has also begun giving patients intravenous fluids to forestall dehydration, which has been identified as one reason for unscheduled return visits following discharge.

The hospital has since also increased the number of doctors on duty on the midnight shift.

Other hospitals have also done this to lower their return rates.

Dr Fatimah Lateef, an emergency medicine specialist at SGH, said the dip in SGH’s rate over the years was partly due to the hospital deploying senior doctors to vet cases.

SGH’s emergency medicine head, Dr Mark Leong, added that a senior doctor is on duty 24 hours a day all year round.

This has been so for the last 10 years. KKH also has a senior doctor on duty at all times, while CGH has between two and four on duty round-the-clock.

CGH’s emergency department head, Dr Mohan Tiru, said that since last October, patients have been given a number to call for advice if they notice a change in their condition while they are at home, so they will know what to do to prevent their condition from getting worse.

Dr Mahadevan’s study recommended that proper discharge advice be given to patients at NUH as well.

He said: “Despite a year-on-year increase in our A&E patient volume, the unscheduled return rate has remained stable over the last five years. I think this showed that our initiatives have worked.”