Perspectives of older patients on the preventability of their unplanned emergency department return visit within 30 days in the Netherlands: a multicentre mixed methods study

Abstract

Objective

Older adults are prone to unplanned emergency department (ED) return visits (URVs). Knowledge about patient perspectives on the preventability and reasons for these URVs is limited and lacks a representable ED study population. This study aims to determine the proportion of URVs and to explore the preventability and underlying causes as perceived by a wide range of older adults and their caregivers.

Design

A multicentre mixed-methods study.

Setting

The ED of one academic and one regional hospital in the Netherlands.

Participants

Patients aged ≥70 years with a URV within 30 days after the index ED visit, consecutively sampled during a 6-week period.

Outcome measurements

Quantitative data regarding patient and clinical characteristics and perceived preventability of a URV were prospectively collected and analysed using descriptive statistics. Underlying causes of a URV were collected by semistructured interviews with patients and caregivers. Thematic content analysis was used to analyse the interview transcripts.

Results

Out of 1291 patients of 70 years and older, 151 patients had a URV (11.7%). In total, 64 patients were included after informed consent (42.4%). A total of 33 patients (51.5%) found their URV preventable. Perceived causes for a URV were categorised in six themes: (1) suboptimal treatment of health complaints, (2) premature hospital discharge, (3) poor assessment and arrangement of postdischarge needs, (4) patient and caregiver behaviour, (5) lack of advance care planning and insight in treatment options and (6) deficits in general practitioner care.

Conclusions

Our high rate of preventable URVs (51.5%) perceived by patients and caregivers underscores the importance to reduce URVs among older adults. Perceived causes in this study add other unexplored themes to the existing knowledge and create support for further research and interventional opportunities.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Instead of convenience sampling, this study has a robust and comprehensive sample size: 24/7 inclusion, from academic and teaching hospital study sites, and also including patients in supportive care facilities.

• This study was performed in one region in the Netherlands and findings may therefore not be representative for settings with a different sociodemographic and health system context.

• Findings may be influenced by selection bias as participation in this study may have been perceived as too burdensome for eligible cases with severe health problems and ongoing diagnostics and treatment.

Introduction

Emergency department (ED) crowding is a growing concern worldwide. ED crowding occurs when the need for emergency services exceeds the available resources for patient care in the ED.¹ Crowding can negatively impact the quality of care and the well-being of both patients and ED healthcare professionals, leading to prolonged ED stays, delays in the evaluation and treatment of patients, increased morbidity and mortality rates, increased healthcare costs, frequent readmissions, extended hospitalisation and reduced patient’s and ED healthcare professionals’ satisfaction.²,⁶ Several factors contribute to ED crowding, including the closing of EDs while patient volumes grow,^{7 8} staffing shortages^{9 10} and, most importantly, an ageing population with more and complex care needs.¹¹,¹³ Older patients aged>60 years represent 31% of all ED visits in 2021 in the Netherlands.⁸ Their comorbidities, polypharmacy, psychosocial problems, higher urgency classifications, atypical presentations and severe illnesses require more time from and involvement of ED healthcare professionals and more hospital admissions, compared with younger patients.¹⁴,¹⁶

Besides the increasing amount of older adults presenting to the ED with more complex care situations, they are also more prone to unplanned ED return visits (URVs) compared with younger patients.¹⁴¹⁷,¹⁹ These URVs attribute to more workload for ED staff and an increased risk of adverse patient outcomes, such as a decline of independency after ED discharge.²⁰,²² A reduction of URVs could contribute to lower ED care burden and, in turn, may contribute to safer ED care in general.

Perspectives of patients and healthcare professionals on preventability of URV could provide valuable insights to reduce these revisits. However, recent observational studies show that these perspectives on preventability may differ between patients, healthcare professionals and relatives.^{16 23 24} This study, however, consists of a convenience sample, due to inclusion of patients from an academic hospital only, inclusion during office hours and excluding patients living in an assisted living facility or nursing home. All previous studies suggest differing perspectives and interests between the parties involved around URVs. The amount of research on this topic is however scarce, and findings are limited by the lack of representative study populations due to absence of 24/7 sampling and the exclusion of patients residing in supportive care facilities. Studying a representative sample is essential to account for the increasing number of unplanned ED presentations of older adults. Therefore, the aim of this study was to determine the proportion of URVs and to explore the underlying causes as perceived by older adults and their caregivers.

Methods

Design and setting

A mixed-methods study was conducted. We used quantitative methods to assess the proportion of URVs perceived as preventable by patients and caregivers and held interviews to explore the underlying causes they address. Quantitative and qualitative data were collected prospectively in one academic (Radboudumc (RUMC), 22 000 annual ED visits of which 26% were older adults (70+)) and one regional teaching hospital (Canisius Wilhelmina Ziekenhuis (CWZ), 28 000 annual ED visits of which 30% were older adults (70+)) in the mid-east of the Netherlands during two periods from November 2022 to January 2023 and from August to September 2023. This qualitative part is conducted and reported in accordance with the Standards for Reporting Qualitative Research, while the quantitative part is conducted and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statement.

Study population and recruitment

All patients aged 70 years or older with a URV within 30 days after the index ED visit in one of the participating hospitals were eligible for inclusion. Patients who had an hospital admission before their ED revisit were included as well, as long as they had a previous index ED visit within 30 days. Exclusion criteria were: no acquired informed consent and the inability to speak or understand the Dutch language. Eligible patients or family members were approached during their URV by the main investigator (SvdB) or an ED clinician on duty and received oral and written information about the study purpose and methods. In each hospital, a medical graduate student (MR or OW) screened patients for eligibility on-site under the supervision of a local ED physician (SvdB, OS) and approached eligible persons for participation in the ED or by telephone in case they already had left the ED. Patients who returned to the ED during out-of-office hours were approached the next working day. Data collection started once written or audio-recorded consent by participants was obtained. Eligible patients who already participated in the study but visited the ED once again were included as a new case.

Data collection

Demographic and clinical data were collected via the electronic medical record to compare patients who deemed their URV as preventable with those who did not. Collected variables were: sex, age, presence of cognitive impairment, comorbidity (measured by the age-adjusted Charlson’s Comorbidity Index (CCI)), number of days between URV and index visit, moment of presentation categorised into office hours (08:00–18:00) and out-of-office hours (18:00–08:00), ED length of stay, urgency code, specialisms involved, the number of ED visits, hospital admissions and outpatient specialist visits in the previous 30 days and year, respectively.

Semistructured interviews took place with patients and/or caregivers within three working days following the ED presentation. The interviews were conducted via telephone (if the patient was discharged to the home setting) or face-to-face (in the ED or at the hospital ward). An interview guide (online supplemental file 1) was developed by the research team and designed to elicit perceived causes for the URV and the perceived preventability of the URV. First, the patient or caregiver was questioned about the reason of ED visit and if the visit could have been prevented (‘Do you think that this current ED visit could have been prevented by anyone or in any way?’). Answers were categorised into ‘yes’, ‘no’ or ‘don’t know’ and documented. In case of a yes answer, a semistructured interview was conducted to gain insight into the perceived root-cause(s). The interviews were held with a pilot-tested guide and lasted between 10 and 30 min. Furthermore, household activities and home care were asked to define a baseline level of self-care. The interviews were recorded and automatically transcribed using the artificial intelligence tool Good tape. Generated transcripts were then reviewed by the main researcher to ensure the accuracy of the text and to remove possible identifiable data.

Data analysis

Descriptive statistics were used to summarise and compare participant characteristics. Participants were stratified based on perceived preventability of the URV (yes/no/I don’t know). Data for continuous variables were analysed using independent sample t-tests (if data were normally distributed) or Mann-Whitney U tests. For categorical data, χ² or Fisher’s exact was used, based on expected cell counts. A p value of <0.05 was regarded as statistically significant. Data were analysed using SPSS V.25 for Windows.

The interview transcripts were systematically analysed according to the principles of thematic content analysis,²⁵ using Atlas.ti. The coding process was done independently by the three main investigators (SvdB, MR and OW), in which initial codes were generated by providing conceptual labels to relevant text passages. This resulted in the development of an initial codebook that, after being discussed and revised by SvdB and GH, acted as a blueprint for the coding of new data. After analysing new data, SvdB and MR critically examined the list of codes for relevance, uniqueness and formulation and made revisions when needed. Codes that referred to the same underlying concept were grouped into overarching themes.

Results

Study sample

During inclusion, 1291 patients of 70 years or older presented themselves at the ED of the CWZ (769 patients) and Radboudumc (522 patients) during the study period, of which 151 (11.7%) had a return visit within 30 days and were eligible for inclusion. Overall, 64 patients (42.4%) gave informed consent and were included. Four patients (6.3%) had two included revisits. Due to several reasons, such as severe patient illness or reduced availability of the participant, 13 (20.3%) interviews were not conducted within the intended timeframe of three working days. All interviews were done within 1 week of the ED revisit. A flowchart of the inclusion process can be seen in figure 1.

Figure 1. Flowcart of the inclusion process. CWZ, Canisius Wilhelmina Ziekenhuis; RUMC, Radboudumc.

Prevalence of preventable versus non-preventable URVs and their associative factors

A total of 33 patients deemed their ED revisit as preventable (51.5%), of which 22 (66.7%) presented at the CWZ and 11 (33.3%) at Radboudumc. One participant felt being unable to determine preventability.

Patient characteristics with stratification for perceived preventable versus non-preventable URVs are shown in table 1. Patients who deemed their revisit as preventable had a significant higher CCI Score at baseline (mean difference 1.18 95% CI 0.14 to 2.21; p=0.027). However, both groups did not differ significantly statistically on the estimated 10-year survival rate (mean difference −9.73 95% CI −24.72 to –5.26; p=0.20). No other associations were found.

Table 1. Characteristics of all included patients.

Characteristics*		Patients who found URV preventable (n=33)	Patient who found URV not preventable (n=30)	P value
Age, mean years (SD)		78.4 (5.43)	77.8 (6.51)	0.25
Sex	Male, %	45.5	60.0	0.33
	Female, %	54.5	40.0
Living situation	Independent, %	97.0	93.3	0.77
	Assisted living facility, %	3.0	6.7
Level of self-care	Independently, %	45.5	80	0.12
	Help from family member, %	39.4	16.7
	Professional help at home, %	12.1	0.0
	Care within facility, %	3.0	3.3
Cognitive impairment	No, %	78.8	100.0	0.29
	Dementia, %	3.0	0.0
	Other, %	15.2	0.0
	Unknown, %	3.0	0.0
Advanced care planning in place	Yes, %	51.5	56.7	0.52
	No, %	48.5	43.3
Charlson Comorbidity Index, mean score (SD)		5.58 (2.59)	4.40 (1.22)	0.027
Estimated 10-year survival rate, mean percentage (SD)		33.34 (33.6)	43.01 (24.7)	0.20
Hospital admissions, mean (SD)	<30 days	1.1 (1.0)	1.1 (1.2)	0.69
	<1 year	2.52 (3.89)	2.40 (4.39)	0.94
ED visit, mean (SD)	<30 days	2.18 (0.47)	2.20 (0.48)	0.78
	<1 year	2.85 (1.64)	3.23 (2.28)	0.22
Outpatient specialist visit, mean (SD)	<30 days	4.39 (5.98)	3.20 (5.65)	0.52
	<1 year	9.24 (11.74)	5.73 (6.84)	0.16
ED revisit day	Weekdays, %	100	83.3	0.39
	Weekend days, %	0.00	16.7
ED hour of presentation†	Office hours, %	78.8	56.7	0.13
	Out-of-office hours, %	21.2	43.4
ED referral	Self-referrer, %	9.1	16.7	0.83
	General practitioner, %	42.2	33.3
	Ambulance, %	12.1	6.7
	Outpatient specialist, %	36.4	40.0
	Nursing home specialist, %	0.0	3.3
Urgency classification‡	U1, %	0.0	0.0	0.55
	U2, %	15.6	20.0
	U3, %	37.5	43.4
	U4, %	46.3	25.7
	U5, %	0.0	10.0
ED length of stay, mean time in minutes (SD)		205.2 (71.4)	202.2 (114.6)	0.08
Number of consults in ED, mean (SD)		0.21 (0.49)	0.22 (0.52)	0.45
Discharge destination	Home, %	45.5	76.6	0.11
	Admitted to hospital ward, %	48.5	16.7
	Supportive care facility, %	6.1	6.7

^*One patient could not provide with an answer to the question around preventability, therefore total patients in this table is 63 instead of the included 64 patients.

^†Office hours where defined as between 08.:30 am and 17.:30 pm on weekdays.

^‡Urgency levels of the Netherlands Triage System (): levels 1 (Llife threatening), 2 (Eemergent), 3 (Uurgent), 4 (Nnon-urgent) and 5 (Aadvice).

EDemergency departmentURVunplanned emergency department return visit

Preventability of URVs

Six themes emerged from the data, each representing different causes for URVs being seen as preventable: (1) suboptimal treatment of health complaints during hospitalisation, (2) premature hospital discharge, (3) poor assessment and arrangement of post-discharge needs in the hospital, (4) patient and caregiver behaviour, (5) lack of advance care planning (ACP) and insight in treatment options and (6) deficits in general practicioners (GP) care. The findings are discussed in more detail below for each theme. Illustrative quotes per theme are summarised in table 2.

Table 2. Illustrative quotes per theme of perceived preventability URVs.

1. Suboptimal treatment of health complaints during hospitalisation
Quote 1.A	I assume that, if they immediately told me on the 22nd, […] you have to stay here, we will give you antibiotics through an IV because apparently oral is not working enough, then of course that second admission would have been prevented.—Patient in mid 70s with osteomyelitis
Quote 1.B	If you get a pneumonia four times within two or three months, and in the same place, then something is structurally wrong. Does this need to be investigated more in-depth?—Son of patient in early 80s
Quote 1.C	I came to pick her up, and she came out of the bathroom and then I immediately saw it. Oh, she said, I feel so bad again, I feel so sick. But well, you indicate this [to the staff], but the discharge papers are prepared, and you can go.—Daughter of patient in early 80s with pneumonia
2. Premature hospital discharge
Quote 2.A	Then I think afterwards, I think, oh dear, if only they had admitted me that second day and read about my operation again, then I wouldn’t have all those days… and I wouldn’t have lost 6.5 kilos.—Patient in early 70s with ileus
Quote 2.B	I think that people would rather, my mother in any case, maybe have been admitted two more days longer to recover better, and then go home.—Daughter of patient in early 80s with ileus
Quote 2.C	And then suddenly she could, after two days she could do everything again because she received drinks and food on time. […] So then they see a woman who has recovered and who can do it all, things like that. And now, we are back in the same position after two weeks.—Daughter of patient in mid 80s with an urinary tract infection
3. Poor assessment and arrangement of post-discharge needs in the hospital
Quote 3.A	Well, I think that in the discharge letter from the ED, the medical handover to the GP, […] someone had to put there, please perform follow-up of the CRP.—Daughter of patient in early 80s with pneumonia
Quote 3.B	But in the last months with a lot of help from us, because she still is not eligible for home care. There is no personnel available and she is too independent for that.—Son of patient in early 80s with a COVID-19 and influenza infection
4. Patient and carer behaviour
Quote 4	Well, I do think that my mother, as I said, she has always been resistant to care, but perhaps she should have admitted sooner that it just doesn’t work anymore, and that help is needed.—Daughter of patient in early 80s with hypoglycaemia
5. Lack of advanced care planning and insight in treatment options
Quote 5.A	Ultimately, we decided to have it treated with antibiotics and not to operate again. But I don’t know to what extent, it’s difficult for me to estimate, that decision could have been made in [supportive care facility], so to speak. If the options were discussed there, the admission might not have been necessary.—Daughter of patient in early 90s with a wound infection after a total hip prosthesis placement
Quote 5.B	My father is 91 years old, it is quite an operation to get him to the hospital. Sometimes I wonder if he shouldn’t go to the hospital anymore and just try to threat sickness at home.—Son of patient in early 90s with pneumonia
Quote 5.C	We don’t know how should have the responsibility to talk about advanced care planning. The GP? It would be good if these talks happened more often.—Daughters of patient in late 80s with pneumonia
6. Deficits in GP care
Quote 6	He should have referred me to the ED that second time. Yes, I think so. They would have immediately emptied the stomach through the nasal tube. […] Then I would have been home before I was admitted now.—Patient in early 70s with an ileus

GPgeneral practicionerURVsunplanned emergency department return visits

Theme 1: suboptimal treatment of health complaints during hospitalisation

Many patients deemed their revisit as preventable, because they felt that their initial treatment during their index ED visit or hospitalisation was insufficient, delayed or inappropriate (table 2, quote 1.A). For example, one participant attributed a decline in physical well-being to symptomatic anaemia, which could have been prevented with a timelier blood transfusion.

Several participants criticised the lack of a holistic view of their treating physician during their index visit or hospitalisation (table 2, quote 1.B). For example, in one case, the doctor seemed solely focused on the treatment of a suspected bladder infection while the patient also suspected a more comprehensive health problem, which turned out to be the case. Similarly, another participant advocated for a quicker correlation between complaints and medical history by the ED doctor. In his opinion, the risk for developing an ileus, rather than the misdiagnosis of constipation at the index visit, was not recognised.

Furthermore, several patients and caregivers also mentioned that they were not involved or poorly involved by the medical team in decisions regarding the diagnosis and treatment of the health problem they initially visited the hospital for. For example, decisions were made to discharge the patient home while patients or caregivers felt they were not well or safe enough to go home. Patients and caregivers felt not being heard, not to be participated in or were not informed around the decision to discharge. Overall, there was no shared decision-making around the discharge process (table 2, quote 1.C).

Theme 2: premature hospital discharge

Another perceived cause for preventability was the premature discharge from the ED or hospital at their index visit. These participants deemed the ED discharge inappropriate considering their physical state and felt that further hospital treatment would have prevented the URV (table 2, quote 2.A).

Also, the discharge from the ward was regarded as premature, providing insufficient opportunity for the patient to recover (table 2, quote 2.B). Some participants realised that the decision for discharge was based on a physical state that was unsustainable at home (table 2, quote 2.C). One participant cited that experience has shown that the patient (suffering from recurrent chronic obstructive pulmonary disease (COPD) exacerbations) showed great improvement while administered with prednisone during hospitalisation but would immediately relapse on returning home. Participants advocated for extended admission to facilitate recovery to health condition levels before admission.

Patients also regarded the poor assessment and arrangements of post-discharge care needs in the hospital as an important cause for experiencing a preventable URV (table 2, quote 3.A). For instance, insufficient information provision at discharge caused relatives to be unaware about when or where to alarm if patients deteriorated. One participant stated that the patient would have profited from a discharge consultation to discuss whether discharge was the wisest option at that time. Moreover, incomplete discharge papers resulted in negligent follow-up by the GP.

Concerns were also raised about the poor arrangement or inventory of post-discharge care (table 2, quote 6.B). This included ineligibility for home care or supportive care facilities, or if eligible when there was no capacity, resulting in patients being sent home. One participant recalled feeling overwhelmed with the time-consuming tasks as a caregiver. She argued that if this was properly assessed and noted at discharge during the initial visit, more home care could have been provided, thereby reducing the care burden and the exacerbation of complaints. Some participants with urinary catheters described the inadequate arrangement for necessary utilities, either due to deficient health insurance coverage or poorly arranged home care agreements, necessitating the patients to visit the ED again.

Theme 4: patient

Some participants cited that patient or caregiver related factors interfered with timely receiving of appropriate care (table 2, quote 4). Caregivers reflected that they could have alarmed or sought for help sooner when they realised the situation was deteriorating. For example, a participant stated that she misjudged the situation and should have asked for help earlier from their GP. Others described self-neglect or care-resistance as the cause of alarming too late.

Theme 5: lack of ACP and insight in treatment options

Some patients, but mostly caregivers, mentioned the lack of insight in treatment options as one of the reasons revisits were not preventable. They felt that if they were given better or more information around treatment options at home or in a supportive care facility, the ED revisit could have been prevented (table 2, quote 5A). Other reasons for perceived preventability were centred around ACP. Some caregivers mentioned that the revisit could have been prevented if such talks, for example, no more hospital visits or diagnostics, would have taken place before the ED visit (table 2, quote 5B). Others mentioned that insight and knowledge around ACP are limited and patients do not know who is responsible to initiate these talks (table 2, quote 5C). All participants argued that talking about and documenting preferences for future care should happen more often and could potentially prevent ED (re-)visits.

Theme 6: deficits in GP care

According to patients, some URVs could have been avoided if the GP would have handled the situation in another way (table 2, quote 6). Participants mentioned GPs misjudging or anticipating too late to specific care needs (eg, providing urinary catheter care), referring patients too late to hospital (outpatient) care, waiting times for GP consultations or minimally involved due to reduced confidence in the doctor–patient relationship and due to experiencing problems with reaching the GP in time (eg, during weekends and holiday periods).

Discussion

This study aimed to qualitatively assess the perceived preventability of URVs within 30 days at two Dutch hospital EDs for patients aged 70 years or older. This study is the first study to our knowledge that combines qualitative data and associative factors within a 24/7 inclusion setting for this population.

The study revealed a URV rate of 11.7% among older patients, which is slightly lower than the percentage suggested in previous literature.^{12 14 18 26} A higher CCI at baseline was significantly associated with increased patient perceived preventability. As a factor at baseline, the CCI had not previously been found as an associative factor for preventable ED revisits. However, prior research suggests that most ED revisits are disease related.¹⁶ With that insight, a higher CCI and thus a higher comorbidity seems a logical associative factor. These findings complete other studies identifying moderate cognitive impairment,¹²²⁶,²⁸ COPD,^{12 29} previous ED presentations^{12 26 30} hospitalisation,³⁰ polypharmacy^{26 27} and urgency level 4¹² as independent risk factors for URVs in both older and general populations.

Suboptimal treatment at the hospital of the index ED visit, premature hospital discharge, poor assessment and arrangement of post-discharge need and patient and caregiver behaviour have been previously recognised as perceived causes for URVs.^{1623 31},³⁴ This study adds factors around ACP and insight in treatment options as well as deficits in GP care as factors contributing to preventable URVs but also acknowledge perceived factors from previous studies. It seems that patients in this study predominantly viewed hospital and primary care as contributing factors for preventability, while, in other studies, participants most frequently blamed themselves.^{16 23} Earlier treatment adjustments were deemed necessary to prevent escalating health problems. The healthcare staff approach was perceived as narrow minded and a desire for a holistic view was expressed to prevent misdiagnosis and exclude concurrent disease. Alternatives for premature hospital discharge included admission to the ward instead of discharge home from ED, prolongation of hospital admission and conducting family consultations during admission to address concerns. Furthermore, open communication around ACP and insights in treatment options were stressed as important factors to reduce preventable URVs, while some participants acknowledged the fact that ACP should have a bigger role in current healthcare. Another opportunity to prevent URVs is improving the assessment and arrangement of post-discharge needs. This should be precisely executed, with attention to possible caregiver overload and complete information transfer to primary care. Hand-outs with discharge information and consultations for help in primary care were mentioned as possible interventions. Deficits in GP care were the last mentioned reasons for URVs, but these elements lie mostly beyond the control of hospital and ED care.

Notably, we reported a higher perceived preventable URV rate (59.5%), compared with the literature (9%–17%).¹⁶ Only one other study, reported a similar rate around 50%.³² Partially, this variance might be attributed to methodological differences. The 24/7 inclusion may have captured more perceived preventable URVs occurring during evening, night or weekend. Furthermore, a self-selection bias might have taken place due to eligible participants renouncing participation if they considered the URV as unpreventable. Seeing our reduced response rate when compared with similar qualitative studies, this could be the case (37.8% vs 53.8%–80.1%).^{24 27 30}

The study has several limitations. Despite intentions to conduct all interviews within three working days post ED presentation, unforeseen circumstances such as severe patient illness and participant unavailability led to prolongation of the timeframe to seven working days maximum, potentially increasing the degree of recall bias. The short timeframe between 0 and 3 days for most of the interviews likely helped to minimising this effect. A second limitation is that this study was performed in a single region in the Netherlands. This could impact the generalisability of our findings and warrants further research in different countries and cultures to validate these findings. Lastly, it was noticed that participation was seen as burdensome and thus renounced by some patients or family members, particularly in the case of severe sickness or ongoing diagnostic analyses into their illness or treatment options, resulting in possible selection bias. This issue is also encountered in similar studies with comparable inclusion rates, thus making the impact of this possible bias less relevant.²⁴ Regardless of these limitations, we believe our study sample provides a representative population by being the first study to include patients during a 24/7 time period and those living in supportive care facilities, giving a more representative patient population. This is something that was not previously presented in the literature, which consisted of a convenience sample only.^{16 23 24}

The findings in this study may have interesting implications for possible ED-based interventions and further research. Themes recognised in previous studies and acknowledged in this study could lead to interventions based around the components of these themes. Optimising the arrangement of post-discharge care, even from the ED, could reduce ED revisits. Moreover, ED-based interventions around ACP could provide another opportunity to reduce ED revisits as well. For example, an ED or hospital-wide intervention to increase knowledge around ACP in patients and caregivers or interventions to motivate patients and caregivers to think about ACP. However, literature studies on ED-based ACP interventions are limited and are mostly feasibility studies.³⁵,³⁷ Further research is needed to investigate if ACP interventions at the ED actually lead to a reduction of URVs to the ED.

To conclude, our established rate of preventable URVs perceived by participants underscores the urgency to reduce URVs among older adults. The causes for preventable elements of URVs detailed in this study create support for interventional opportunities. Future interventions should focus, for example, on engaging and acknowledging patients and their families with family consultations during hospitalisation and on treatment options or improving post-discharge care coordination to empower patient recovery at home.

Data availability statement

Data are available upon reasonable request.