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BACKGROUND:High-risk unscheduled return visits (HRURVs), defined as return visits within 72 hours that require admission or die in the emergency department (ED) on representation, are a key quality metric in the ED. The objective of this study was to determine the incidence and describe the characteristics and predictors of HRURVs to the ED. METHODS:Case-control study, conducted between 1 November 2014 and 31 October 2015. Cases included all HRURVs over the age of 18 that presented to the ED. Controls were selected from patients who were discharged from the ED during the study period and did not return in the next 72 hours. Controls were matched to cases based on gender, age (±5 years) and date of presentation. RESULTS:Out of 38 886 ED visits during the study period, 271 are HRURVs, giving an incidence of HRURV of 0.70% (95% CI 0.62% to 0.78%). Our final analysis includes 270 HRURV cases and 270 controls, with an in-ED mortality rate of 0.7%, intensive care unit admission of 11.1% and need for surgical intervention of 22.2%. After adjusting for other factors, HRURV cases are more likely to be discharged with a diagnosis related to digestive system or infectious disease (OR 1.64, 95% CI 1.02 to 2.65 and OR 2.81, 95% CI 1.05 to 7.51, respectively). Furthermore, presentation to the ED during off-hours is a significant predictor of HRURV (OR 1.64, 95% CI 1.11 to 2.43) as is the presence of a handover during the patient visit (OR 1.68, 95% CI 1.02 to 2.75). CONCLUSION:HRURV is an important key quality outcome metric that reflects a subgroup of ED patients with specific characteristics and predictors. Efforts to reduce this HRURV rate should focus on interventions targeting patients discharged with digestive system, kidney and urinary tract and infectious diseases diagnosis as well as exploring the role of handover tools in reducing HRURVs.

Objectives: Lactate/albumin (L/A) ratio is a biomarker in sepsis that has been shown to outperform lactate. This prospective study aims to validate the superior prognostic value of the L/A ratio to lactate in sepsis and septic shock. Methods: Prospective cohort conducted from September 2018 till February 2021 on adult patients presenting to the Emergency Department (ED) at a tertiary care centre with sepsis or septic shock. The primary outcome was the prognostic value of the L/A ratio compared to lactate with regards to mortality. Results: A total of 939 septic patients were included throughout the study period. A total of 236 patients developed septic shock. The AUC value of the L/A ratio in septic patients was 0.65 (95% CI 0.61-0.70) and was higher than that of lactate alone 0.60 (95% CI 0.55-0.64) with a p<.0001. The optimal L/A ratio cut-off threshold that separated survivors from non-survivors was found to be 0.115 for all septic patients. The AUC of the L/A ratio was significantly higher for patients with a lactate ≦2 mmol/L: 0.69 (95% CI 0.64-0.74) versus 0.60 (95% CI 0.54-0.66) with a p<.0001 as well as for patients with an albumin level less than 30 g/L (AUC = 0.69 95% CI= 0.62-0.75 vs AUC= 0.66 95% CI= 0.59-0.73, p<.04). Among septic shock patients there was no statically significant difference in the AUC value of the L/A ratio compared to lactate (0.53 95% CI 0.45-0.61 vs 0.50 95% CI 0.43-0.58 respectively with a p-value=.11). Conclusions: The L/A ratio is a better predictor of in-patient mortality than lactate in sepsis patients. This superiority was not found in the septic shock subgroup. Our results encourage the use of the ratio early in the ED as a superior prognostic tool in sepsis patients. [ABSTRACT FROM AUTHOR]