Background and Objective: High-risk unscheduled return visits (HRURVs) are a key quality metric in the Emergency Department (ED). We, therefore, aimed to determine their incidence and clinical predictors in the pediatric ED. Design: This is a case control study. Setting: This study was conducted in the pediatric ED of an Eastern Mediterranean tertiary care hospital. Participants: Cases included HRURVs ≤18 years old that presented to the ED between November 1, 2014, and October 31, 2015. Controls included patients discharged from the ED during this period and who did not return within 72 hours. Controls were matched 1:1 based on age, gender and date of presentation (±7 days). Out of 14,805 Pediatric ED visits, 142 were HRURVs, with an incidence of 0.96% [95% confidence intervals (CI) 0.81 to 1.13]. Our final analysis included 139 HRURV cases and 139 controls. 3 were excluded because of incomplete charts. Main Outcome Measures: The outcome, HRURV was defined as an ED return visit within 72 hours that required admission or died in the ED. Results: Of the cases, 2.6% were admitted to the intensive care unit and 7.19% required surgical intervention. Cases were more likely to be hospitalised in the last 30 days [adjusted odds ratio (AOR) 19.53, 95% CI 2.45 to 155.44], have more laboratories ordered (AOR 3.74, 95% CI 2.15 to 6.48), present with a temperature > 38.5°C (AOR 2.63, 95% CI 1.26 to 5.48) and have a discharge diagnosis related to the digestive system (AOR 1.96, 95% CI 1.04 to 3.72). Receiving at least one medication at the index visit was a negative predictor (AOR 0.35, 95% CI 0.19 to 0.63). Conclusion: Efforts to reduce HRURVs should focus on the clinical predictors identified. Receiving medications in the ED appears to be protective requiring further research to identify medication categories driving this finding.

Keywords: Emergency Department, high risk unscheduled return visits, bounceback, Pediatrics