Director’s Corner: Thinking Outside the Box part 2

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Last time, we looked at individual techniques to reduce medical errors and also some EMR solutions that can help.   Today, we’ll look at it from a quality improvement perspective.

When you are looking to improve care at your site, many lessons can be learned by reviewing individual cases.  Cases come to the attention of a director in many ways– ED providers might give you a “heads up” about a challenging case, a patient might lodge a complaint, another non-ED provider may bring a case to your attention, or a case may be referred to the ED by the hospital quality team.  A director needs to review all these cases obviously.  However, to really move the needle regarding the quality of care provided in your department, you should be reviewing the “bounce backs.”

Reviewing bounce backs


ED bounce backs are patients that have an unscheduled return to an ED for the same or similar issue within a short timeframe.  These cases have long been known to be a “good pond to fish” when looking for opportunities to improve care.

Most of the time in the ED literature, the timeframe for a “bounce back” return visit is defined 72 hours.  This timeframe is considered to represent a bit of a sweet spot in that it is long enough to capture a significant portion of revisits related to the initial visit but short enough to avoid capturing return visits that are not preventable or unrelated to the initial visit.  Although it varies per ED, the rate of 72-hour return visits is typically about 3-4%.  Return visits to the ED that result in admission on the second visit is typically reported as 0.5-1.0%.

There is general agreement that return visit percentage is NOT a good way to compare the quality of care at one department versus another.  Obviously, EDs vary in the populations of patients they serve, the availability of follow up care, and the use of the ED for scheduled follow up visits (wound checks, BHCG checks, or even abdominal re-exams).  However, looking at the individual cases involving bounce backs makes lots of sense.


When developing a bounce back chart audit program, most EDs begin by looking at all 72-hour revisits that result in admission on the second visit.  You might consider extending this out to 7 days for certain select diagnosis (e.g. MI, SAH, stroke).  If possible, you should consider including 72-hour admissions at other hospitals other than you own site.  Studies have shown that depending on your geography, 10-35% of your 72-hour return admissions may occur at a hospital other than your own hospital. A report listing your 72-hour return visits can typically be generated by your EMR, your quality department, or your billing company.  Getting this data monthly is preferred so that you can review cases close to when they occurred.

Doing the actual chart audits takes time and while the ED director may do some of these reviews, it is best to get other site providers involved in doing these reviews.  It gets them in involved in the QA process and there are lessons learned in simply performing the audits.  If there are too many charts to review each month, consider prioritizing certain cases (e.g., those admitted to the ICU or those with certain diagnoses).

It’s a good idea to create an audit form which allows for more consistent reviews and allows you to detect trends.  Consider including fields such as diagnosis/condition, whether a quality concern was identified, and severity of patient harm if a quality concern was identified. When looking at 72-hour revisits, the published literature suggests that quality concerns are typically found in 5-25% of patients admitted on the second visit.

While each site has its nuances, there are common themes involving 72-hour revisits that result in admission.  First, certain patient complaints are at higher risk for a return visit than others – in particular, patients with abdominal pain, shortness of breath, fever, dizziness, and weakness.  Second, discharge tachycardia is a real concern.


You will almost certainly identify bad outcomes (especially in patients with suspected infection) that could have been avoided if the patient with persistent tachycardia was admitted on the first visit.  Lastly, cognitive errors are real.  You’ll see the impact of cognitive shortcuts and all sorts of cognitive biases.  You may see critical lab or radiology findings that were simply not noticed by the provider.

Providing Feedback

Once the chart audit program is in place, the next step is to figure out how to best use the information gained through these reviews.  A good start is to make sure that each of your providers is aware of their cases – especially if a quality concern was identified.  You can likely build reports in your EMR that allows each provider to search for their own patients that triggered a quality review.

Of course, this means providers need to be interested enough to check this on a regular basis and review the chart.  Alternatively, you can provide a copy of the spreadsheet to each doc in your group.  Remember to maintain HIPPA compliance, which at the very least requires a password protected spreadsheet and/or strictly using your hospital or employers email servers to maintain security.

The next step in the quality project is to identify common causes of avoidable 72-hour revisits that result in admission.  The goal is to identify opportunities for quality improvement initiatives that will solve the issues for your patients at your site.

As you decide on the key issues, like the febrile diabetic cellulitis patients we had years ago, present these themes with case examples to your group. There is also value in presenting a subset of the high risk, low occurrence cases that have complexity in management or are time sensitive.  Cases include STEMI, Stroke, and Sepsis fallouts so everyone can learn from the issues that occurred.


Funny enough, I think the new CMS billing documentation guidelines while complicated, and probably designed to lower the level each chart gets billed, actually will push all of us to review the data more carefully and think outside the box more often, just because we have to spend more time documenting a differential diagnosis.  Be aware of your own cognitive biases and take a second to reflect on individual patients and whether your own bias impacted your decision making. With a pause before discharge to provide a final review of the chart, including the data, and concentrating on the being a STAR, we can reduce some of the individual mistakes.

Of course, solutions to your site’s issues can take many forms – education, clinical pathways for higher risk complaints, checklists, EMR solutions and other systems fixes.   There are and always will be opportunities to improve.  By reviewing the 72-hour return admissions at your site, you’ll have a good sense of your local quality “hotspots” where you can make a difference.

Improving our situation awareness, combined with a focused quality improvement program, should lead to an improvement in patient outcomes.


Doherty T, Carroll A. Believing in Overcoming Cognitive Biases.  AMA J Ethics. 2020;22(9):E773-778. doi: 10.1001/amajethics.2020.773.

Weinstock MB, Longstreth R, Henry G.  Bouncebacks! Emergency Department Cases: ED Returns.  2nd ed.  2007.  Anadem Publishing.  Columbus, Ohio.

Chartier LB, Ovens H, Hayes E, et al.  Improving Quality of Care Through a Mandatory Provincial Audit Program:  Ontario’s Emergency Department Return Visit Quality Program.  Ann Emerg Med.  2021; 77:193-202.

Shy BD, Shapiro JS, Shearer PL, et al. A conceptual framework for improved analyses of 72-hour return cases. Am J Emerg Med. 2015;33:104-107.

Shy BD, Loo GT, Lowry T, et al. Bouncing back elsewhere: multilevel analysis of return visits to the same or a different hospital after initial emergency department presentation. Ann Emerg Med. 2018;71:555-563.e1.

Hartigan S, Brooks M, Hartley S, et al.  Review of Cognitive Error in Emergency Medicine:  Still No Easy Answers.  West J Emerg Med. 2022 No; 21 (6z): 125-131.


EXECUTIVE EDITOR Dr. Silverman is Chair of Emergency Medicine at VHC Health. He also taught a leadership development course for over a decade. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

Dr Sverha is a Regional Quality Director for US Acute Care Solutions and Vice-Chair of the Emergency Department at VHC Health in Arlington, VA.

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