return for visit

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Documenting Patient Return Visits and Following Up on Missed Appointments

• December 1, 2018
• CAP Risk Management Department

As every patient visit concludes with a documented office visit encounter, the visit note should include when the patient is advised to return. The suggested return visit (i.e. f/u in 2 weeks, 1 month) should be documented in the Action or Plan portion of the progress notes and the patient instructed to make a follow-up appointment before leaving the office. At the end of each visit, the physician should confirm that the patient understands the rationale for the recommended return visit or treatments, the presumptive diagnosis, next steps for follow up, and signs or symptoms to watch for.

Following up with a patient is important and should be tailored to the patient’s symptoms and the progression of the disease. Following up gives the practitioner an opportunity to address unresolved concerns, respond to symptoms that have worsened or have not improved with treatment, or formulate a differential diagnosis through appropriate testing. Clinical conditions can be difficult to diagnose during a single patient encounter. There may not be enough time to address multiple problems during a visit. Providing return visits and following up may potentially identify a serious unsuspected medical condition.

Continuity of care can be compromised when more than one provider is involved in a patient’s care. This underlines the importance of clear communication between providers and across settings. A patient injury resulting from the patient’s own failure to return for a follow-up appointment could help defend against a claim of negligence or delay in treatment or diagnosis. When no specific follow-up is required, a “return if any problems” (specific problems can be noted if needed) or just f/u PRN in the note means the doctor gave the patient the responsibility to decide when to return.

Going a step further, the office should have a system in place to follow-up on patients that do not schedule their next appointment before leaving the office such as a simple tickler file that reminds staff to call the patient in the next day or two to schedule the next patient visit.

Staff also should document no-shows and/or canceled appointments in the medical record of patients who consistently miss or frequently cancel appointments. It is a good practice to develop a system to notify the provider of these instances so the provider can decide whether a follow-up phone call to reschedule should be made.

Many factors can contribute to non-adherence such as communication issues, a patient’s level of comfort with their treatment plan, or their ability to afford a treatment. It may take an additional effort on your part to address unresolved health complaints by non-adherent patients to address serious conditions.

Having this information documented in the patient medical record will show the provider is managing the patient's care and will undoubtedly help forego unnecessary medical liability claims. Careful history-taking and documentation are crucial.

Learn more about how the Cooperative of American Physicians, Inc. (CAP) can support your practice by downloading our free guide The Physician's Action Guide to Reducing Risk and Improving Business , which includes resources and tips to help physicians and medical staff solve common practice problems associated with seemingly routine tasks

This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.

Return ED Visits: Poor Performance or Flawed Metric?

As part of the triple aim, there is a very concerted effort to develop markers of high-quality care in all of American health care. The Centers for Medicare and Medicaid Services has developed reporting and payment targets for physicians and for hospitals, and a significant amount of reimbursement will be based on performance measures.

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For more than 20 years, emergency physicians have been faced with hospital programs that report ED return visits, usually in a 72-hour window. Multiple studies have characterized the return visit rate as a poor marker of quality. Definitions have been unclear, and strategies to address associated factors have been very nonspecific.

One study of return visits focused on the patient-driven factors. 1 Emergency medicine is a specialty driven by timeliness of care and perceived patient need. Research has found that patients used the emergency department based on their perception of good value. Patients returned due to perceived inability to access timely follow-up care, needed care that was not available, and concern about the progression of the original medical problem. The majority of patients had a primary care physician but felt that resources needed for completion of care would be accessed in a more timely manner by returning to the emergency department.

Patient-driven factors for return visits are highlighted in the book Quality Matters: Solutions for a Safe and Efficient Emergency Department by Shari Welch, MD. Her suggestion is that emergency departments should intentionally and systematically return high-risk patients to ensure the best patient outcomes.

From a quantitative basis, the Centers for Disease Control and Prevention National Hospital Ambulatory Medical Care Survey data in this area have always been enlightening. The latest data are from the 2014 reporting year:

• About 5.7 percent of ED visits were made by patients who had been seen in the same emergency department in the preceding 72 hours.
• About 4.8 percent of ED visits were for “follow-up.”
• In about 3 percent of ED visits resulting in hospital admission, the patient had been seen in the same emergency department within the prior 72 hours.

This is a very important baseline history. Other studies have found return rates to any emergency department in a particular region average 7.55 percent over a five-year period. 2,3 These authors reflect on the utility of regional health information exchanges to further track and improve the care of patients having return visits and further improve the value of the emergency department in providing care for patients with ongoing medical issues that did not result in inpatient care on the initial visit.

Pages: 1 2 3 | Single Page

Topics: Data Emergency Department Emergency Department Benchmarking Alliance Emergency Medicine Emergency Physicians Performance Measures Practice Trends Return Visit Survey Triple Aim

A Sobering Year for Emergency Departments and Their Patients

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Current issue.

ACEP Now: Vol 43 – No 05 – May 2024

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About the Author

James J. Augustine, MD, FACEP

James J. Augustine, MD, FACEP, is national director of prehospital strategy for US Acute Care Solutions in Canton, Ohio; clinical professor of emergency medicine at Wright State University in Dayton, Ohio; and vice president of the Emergency Department Benchmarking Alliance.

View this author's posts »

3 Responses to “Return ED Visits: Poor Performance or Flawed Metric?”

March 25, 2018

In the same manner in which you outline why return visits to ED is a poor marker of ED quality, we need to do away with using total length of stay (LOS) for discharged patients as a marker for ED quality. The CMS website notes that shorter LOS for discharged ED patients is “better” without qualifying this. The implication is that an efficient ED will be able to process all its discharged patients quickly and without delay, and that getting “in and out” quickly is better than staying in the ED for an extended period of time. What CMS (and developers/proponents of this specific measure) fail to understand is: – we have an aging population, in which multiple comorbidities, long drug lists, poorer communication skills, means an ED physician has to spend more time sifting through these confounders, which adds to LOS. Trying to skip review of these confounders in order to decrease LOS would be foolish. – similar to above point, an 80 y/o cancer patient with CHF, DM, CAD, PVD who presents with fever and sore throat is a much different workup than the 8 y/o child with ST who is otherwise healthy. Increasing age & increased complexities of patients makes for increased LOS in order to appropriately address the chief complaint. – PCPs recognize the above issues, and will preferentially send such patients to the ED rather than direct-admit them, or work them up in office/outpatient setting. These patients get extensive workups, including advanced imaging such as CT, and yet many are discharged – they received outstanding yet temporally-long comprehensive assessment that CMS does not value as “better”. This practice by PCPs also adds to crowded waiting rooms, further increasing LOS (even with the best-intentioned PI to optimize flow). – EDs are being pressured into holding patients within the ED, to complete workups that might otherwise be undertaken by the admitting physician, or to avoid “inappropriately admitting another drunk”, or to bypass inpatient psychiatric ward policies about holding a psychiatric patient in the ED rather than admit until placement can be arranged, often days of ED LOS. – Probably most importantly, many patients benefit from prolonged ED treatment, such as IVF, breathing treatments or other repeat medications, monitoring for clinical improvement, that may not ultimately result in an admission. These patients can be in ED for several hours receiving necessary treatment, which may be entirely appropriate, but adds to LOS, which again is defined by CMS as not “better”. – Even the argument that these patients can be placed into an observation unit does not help the LOS issue because CMS lumps the “observation stay” population with “discharged patient” population. This CMS measure should not include observation patients. Quality should be measured by improved efficiencies, improved outcomes, lower costs, but should not be measured by shorter turnaround times. There is more to an ED visit than just getting getting them out faster, and oftentimes a longer LOS is actually better quality of care.

April 9, 2018

I agree that the over all frequency of return visits within 48 or 72 hours is not a very useful metric of overall ED care. In fact there maybe too many to actually review in a timely fashion. However, a review of the reason for the return visit (especially if resulting in admission) may help to identify issues with misdiagnosis, a leading cause of malpractice actions. Identifying errors in clinical reasoning is a very difficult piece of information to obtain for the ED. By tracking errors in diagnosis, perhaps we can identify interventions to reduce their occurrence.

April 13, 2018

Thank you Dr. Wolford, for your suggestion and use of ED return visits as an important QI tool. The reason for the return visit may help to identify issues in care, communication, risk management, and needs for follow-up resources. Tracking errors in diagnosis is clearly an opportunity to educate the providers in the ED, and improve future care. Appreciate the clarification

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Return visits to the emergency department: the patient perspective

Affiliations.

• 1 Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA. Electronic address: [email protected].
• 2 University of California San Francisco School of Medicine, San Francisco, CA.
• 3 Department of Internal Medicine, San Francisco, CA.
• 4 Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA.
• 5 Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA.
• 6 Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
• PMID: 25193597
• DOI: 10.1016/j.annemergmed.2014.07.015

Study objective: Reasons for recurrent emergency department (ED) visits have been examined primarily through administrative data review. Inclusion of patients' perspectives of reasons for ED return may help inform future initiatives aimed at reducing recurrent utilization. The objective of this study is to describe the personal experiences and challenges faced by patients transitioning home after an ED discharge.

Methods: We performed semistructured qualitative interviews of adult patients with an unscheduled return to the ED within 9 days of an index ED discharge. Questions focused on problems with the initial discharge process, medications, outpatient care access, social support, and health care decisionmaking. Themes were identified with a modified grounded theory approach.

Results: Sixty interviews were performed. Most patients were satisfied with the discharge process at the index discharge, but many had complaints about the clinical care delivered, including insufficient evaluation and treatment. The primary reason for returning to the ED was fear or uncertainty about their condition. Most patients had a primary care physician, but they rarely visited a physician before returning to the ED. Patients cited convenience and more expedited evaluations as primary reasons for seeking care in the ED versus the clinic.

Conclusion: Postdischarge factors, including perceived inability to access timely follow-up care and uncertainty and fear about disease progression, are primary motivators for return to the ED. Many patients prefer hospital-based care because of increased convenience and timely results. Further work is needed to develop alternative pathways for patients to ask questions and seek guidance when and where they want.

Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Publication types

• Research Support, Non-U.S. Gov't
• Emergency Service, Hospital / statistics & numerical data*
• Interviews as Topic
• Middle Aged
• Patient Discharge
• Patient Satisfaction
• Patients / psychology
• Patients / statistics & numerical data
• Qualitative Research
• Time Factors
• Young Adult

• Cambridge Dictionary +Plus

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(Definition of return and visit from the Cambridge English Dictionary © Cambridge University Press)

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• Entering and staying in the UK
• Visas and entry clearance
• Visit and transit visas
• Visit visa: guide to supporting documents
• UK Visas and Immigration

Visiting the UK: guide to supporting documents

Updated 1 February 2024

© Crown copyright 2024

This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] .

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This publication is available at https://www.gov.uk/government/publications/visitor-visa-guide-to-supporting-documents/guide-to-supporting-documents-visiting-the-uk

To visit the UK, you need to show that you’re a genuine visitor.

You can do this by providing evidence that:

• you’re coming to do a permitted activity – see Appendix Visitor: Permitted Activities
• you’ll leave the UK at the end of your visit
• you’re able to support yourself and any dependants for the duration of your trip
• you’re able to pay for your return or onward journey and any other costs relating to your visit

Wherever possible, digital images should be taken of original documents, not copies.

If you submit a document that is not in English or Welsh, it must be accompanied by a full translation that can be independently verified by the Home Office. Each translation must contain:

• confirmation from the translator that it is an accurate translation of the original document
• the date of translation
• the translator’s full name and signature
• the translator’s contact details

You do not need to provide multiple copies of the same documents if you’re applying as a family or group at the same time.

If you’re applying to visit the UK as part of a Chinese tour group, you should read the specific guidance for ADS visitors .

Further information about coming to the UK as a visitor can be found in Appendix V: Visitor of the Immigration Rules and in the Visitor Guidance .

Submitting or presenting any of the documents listed below does not guarantee that your application for a visit visa or entry at the border will be successful. You should bear this in mind when making any bookings, particularly if you need to apply for a visitor visa before you travel to the UK.

1. Travel document (passport)

You must provide a valid passport or other travel document with all applications and when travelling to the UK. Your passport must have at least 1 page blank if you use it to apply for a visa.

Some passport holders may need to provide alternative evidence of their identity and nationality.

2. Demonstrating personal circumstances

If you are intending to visit the UK you will need to show that you are a genuine visitor who is coming to the UK to undertake a permitted activity, that you will leave at the end of your visit and that you have sufficient funds for yourself and any dependants to cover all reasonable costs in relation to your visit.

It is recommended that you provide information about your circumstances in your home country and details of the activity that you will be doing in the UK.

The following provides information about the types of documents that you might want to provide to help us consider your application against the Immigration Rules for Visitors ( Appendix V: Visitor ). This list is not exhaustive.

• what you will be doing in the UK, the reason for your visit and whether any costs are being met, including any letters from inviting or sending organisations
• a letter from your employer on company headed paper, detailing your role, salary and length of employment
• a letter from your education provider, on headed paper, confirming your enrolment and leave of absence
• business registration documents or recent invoices that confirm on-going self-employment
• copies of previous passports showing evidence of travel to other countries
• confirmation of legal residence, if you are not a national of the country in which you are applying or your right to reside there is not included in your passport
• bank statements which detail the origin of the funds held
• building society books which detail the origin of the funds held
• proof of earnings, such as a letter from your employer confirming employment details (start date of employment, salary, role, company contact details)

3. If you have a sponsor

If someone else (your sponsor) is providing your travel, maintenance or accommodation you should provide evidence showing:

• what support is being provided and whether it extends to any dependent family
• how this support is being provided

the person supporting you has enough funds to adequately support themselves and their dependents

the relationship between you and the sponsor, for example if they’re your family member or your employer

• the person supporting you is legally in the UK (if applicable), for example if they have a British passport or residence document

4. If you’re a child (under 18)

You should show a legal document showing the relationship between you and at least 1 of your parents or guardians, for example a birth certificate or adoption papers.

You should show a copy of the photo page of at least 1 parent’s or guardian’s passport, including their signature and passport number, if they’re not also applying for a visa.

If you have a different family name to your parent/guardian, you may be asked to provide evidence of your relationship. Evidence you can provide may include:

a birth or adoption certificate showing your relationship to your parent or guardian

a divorce or marriage certificate for your parent or guardian

4.1 If you’re not travelling with your parent or guardian

You should provide additional documents to show that your parent or guardian is aware of your travel plans and that they give you permission to enter the UK. Your application may be refused if you don’t.

You should provide a signed letter from your parent or guardian confirming your travel arrangements, including:

• your parent or guardian’s consent for you to travel to the UK
• who’s travelling with you – you’ll need to provide their passport number if they’re an adult
• who’ll look after you while you’re in the UK
• how you’ll travel to the UK
• If your parent or guardian does not have a passport, you should provide another official document that includes their signature

5. Visiting for business purposes

• the relationship between you and the sponsor, for example if they’re your family member or your employer)

6. Attendees of business-related events or conferences

If you are attending a business event or conference, you should provide a letter of invitation from the organiser of the event you are attending.

7. Intra-corporate visits

If you are visiting the UK to work with your UK based colleagues you should provide a letter from your employer confirming this, and if this will involve working with clients, your employer should confirm that this is not the main purpose of your visit.

8. Wet lease arrangements

If you are a pilot or cabin crew member travelling to the UK to work temporarily under a wet lease agreement, you should provide a letter from your employer confirming that you are employed by them and that a wet lease agreement is in place.

9. Visiting for training, research or paid engagements

9.1 academics coming to undertake research (12-month visa).

You should show that you’re highly qualified and working in your field at an academic or higher education institution. For example, you could provide:

• a letter from your employer outlining the research to be undertaken
• a letter from the UK host organisation confirming the arrangements for your research or exchange

You should check if you need a TB test .

You should check if your family members need a TB test if you’re bringing them to the UK with you.

9.2 Performers at one or more permit-free festivals

You may want to provide a letter of invitation from the organisers of each event, including the dates of your performances and details of any payments you’ll receive.

9.3 Professional and Linguistic Assessment Board (PLAB) test and Objective Structured Clinical Examination (OSCE) test

You’ll need to provide a letter from the General Medical Council or Nursing and Midwifery Council confirming your test.

9.4 Work-related training – unpaid clinical attachments and dental observer posts

You’ll need to provide confirmation of your offer to undertake a clinical attachment or dental observer post, that it involves no treatment of patients and that you’ve not previously undertaken this activity in the UK.

You should provide an acceptance letter from your course provider confirming the details of the course.

9.6 Study – medical electives 

You must provide written confirmation from your UK Higher Education provider confirming you have been accepted to undertake an elective relevant to your course of study overseas.

9.7 Study – research placements  

You must provide confirmation from your overseas course provider that the research or research tuition is part of, or relevant to, the course you’re doing overseas.

9.8 Permitted Paid Engagements

You’ll need to provide an invitation letter showing why you’re carrying out the engagement and how long it’s for from a relevant UK-based organisation, such as:

• a Higher Education institution
• an organisation in the creative arts or entertainment industries
• a sports organisation, agent or broadcaster
• a research organisation
• an aviation training organisation regulated by the United Kingdom Civil Aviation Authority
• a client, if you are a lawyer
• the organiser of a conference or seminar confirming your invitation to speak at their event

You should provide evidence of professional status in your home country or expertise, depending on the engagement.

9.9 Lecturers or examiners

You can provide:

• the names or details of your publications in your field of expertise
• dates and times of lectures you’ve given in that field
• a letter from your employer confirming where you work and your area of expertise

9.10 Entertainers/artists/sports people

• dates and times of performances, screenings, concerts, talks, readings and exhibitions
• details of any awards you’ve received
• proof of recent performances

9.11 Air pilot examiners

You should provide evidence showing you’ve been invited by an approved training organisation. They must be based in the UK and regulated by the UK Civil Aviation Authority .

9.12 Lawyers

You’ll need to provide evidence that you’re a qualified lawyer, for example a practising certificate or equivalent document.

You should also show you’ve been invited to represent a client in the UK court, for example confirmation of your right to audience, or ‘temporary call’ (where required).

10. Visiting for private medical treatment

If you’re applying to visit the UK as an S2 Healthcare Visitor, you should read the specific guidance for S2 Healthcare Visitors

10.1 Private Medical Treatment

You’ll need to provide a letter written by a doctor or consultant , that includes:

• details of the condition requiring consultation or treatment
• estimated cost and likely duration of any treatment
• details of where the consultation or treatment will take place.

If you are coming to the UK to receive medical treatment as part of a reciprocal healthcare arrangement between your country and the UK, you must provide an authorisation form from that country.

You should check if you need a TB test if you’re applying for an 11 month visa.

If you’re applying to extend your stay in the UK to receive private medical treatment you must show:

• a letter explaining your medical condition from a registered medical practitioner
• you’ve met the costs of the treatment you’ve already received

If you’re applying to extend your stay in the UK to continue receiving medical treatment as part of a reciprocal healthcare arrangement between your country and the UK, you must provide an authorisation form from that country which authorises further treatment.

10.2 Organ donors

You’ll need to provide a letter from either the lead nurse of the transplant team or a GMC-registered specialist , dated no more than 3 months before you intend to arrive in the UK, confirming:

• you’re a confirmed match to the recipient with whom you have a genetic or close personal relationship, or you’re being tested to determine whether you are a potential donor
• when and where the transplant or tests will take place

You should show the intended recipient is legally resident in the UK, such as a copy of their British passport or residence permit. You should provide the intended recipient’s name, nationality and date of birth if they are not legally resident in the UK and are applying for a visa at the same time.

11. Visiting for your marriage or civil partnership

You must apply for a marriage or civil partnership visitor visa to enter the UK to marry, form a civil partnership, or give notice of this.

You should provide evidence that you intend to give notice, marry or form a civil partnership during your stay, for example an appointment confirmation with a registrar or booking confirmation for your reception. If you’ve been married or in a civil partnership before, you should provide documents to show that you are free to marry or form a civil partnership.

You must be over 18.

12. Passing through the UK in transit

You should provide evidence that:

• your outward journey from the UK has been confirmed and is within 48 hours of arrival, for example travel booking confirmation
• you can enter the country you’re travelling to, for example a valid visa or residence permit

Further information can be found on the Visitor in Transit visa pages or in the Transit Guidance .

13. Documents you should not use as evidence

Some types of documents are less useful as evidence in visit applications. These include:

• bank statements or letters issued more than 1 year before the date of application
• credit card statements
• driving licence
• educational certificates that are not listed as required for your visa
• evidence of car ownership
• personal photographs
• notarial certificates
• business cards
• hotel bookings
• flight bookings (unless transiting)
• photocopies of bank cards
• certificates relating to leisure activities, for example sports trophies
• travel insurance
• sponsor’s utility bills
• sponsor’s council tax bills

You may be asked to provide additional information by a decision maker.

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Definition of return visit noun from the Oxford Advanced Learner's Dictionary

return visit

• This hotel is worth a return visit.
• The US president is making a return visit to Moscow.
• They came here last week, and we'll pay them a return visit in the summer.

Want to learn more?

Find out which words work together and produce more natural-sounding English with the Oxford Collocations Dictionary app. Try it for free as part of the Oxford Advanced Learner’s Dictionary app.

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Return Visitors

The difference between returning and new visitors, why is the return visitors metric useful, .css-uphcpb{position:absolute;left:0;top:-87px;} what are return visitors, definition of return visitors.

The metric of return visitors is a useful way of analyzing and segmenting the audience of your website. On a very basic level, return visitors are users who have been to your site before.

Every visitor to a website generates a unique random number, and a first timestamp, which combines to create their User ID, and allows their visits to the site to be tracked. For returning visitors, the timestamp allows analytics software to determine their status.

How To Use Customer Feedback for Business Growth

New visitors are defined as people visiting your site for the first time on a single device — so each first visit on your laptop, smartphone, and tablet counts as a separate new visit. 

Returning visitors have a time limit of two years, so if a single visitor waits more than two years to return to a website, they will be counted as a new visitor again.

A single website visit rarely converts a visitor into a customer, so return visitors are crucial for commercial success.

Understanding your visitors — why they come back, what attracts them, which page brings in the most visitors, etc. — is key to the performance of your website. If you can increase the number of return visitors, you are far more likely to be able to convert them into customers or deliver the information you intend to.

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Definition of 'return visit'

• return visit

return visit in British English

Examples of 'return visit' in a sentence return visit

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The return visit, outcome and predicting factors of return visit among suspected COVID-19 outpatients

Atousa akhgar.

1 Emergency Medicine Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran

Arash Safaei

2 Emergency Medicine Department, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran

Ali Mahdavi

3 Radiology Department, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Nafiseh Esmaeili Taheri

Hamideh akbari, mohammad jalili.

Rate of return visit, predicting factors of return visit and occurrence of adverse events in suspected to be or likely cases of COVID-19 patients who received outpatient treatment. This is a retrospective observational cohort study on patients (> 16 years), suspected to be or likely cases of COVID-19 who were visited in a respiratory emergency department and subsequently discharged home. Patients’ baseline characteristics were extracted from medical charts. All patients were followed-up for 7 days after their first visit. Patients’ outcomes during the7-day follow-up, as well as the severity of pulmonary involvement based on imaging were recorded. A total number of 601 patients (350 men and 251 women) were recruited. The rate of return visit was 27.74% (144 patients) with 6.74% (34 patients) experiencing a poor outcome. Six factors with a significant odds ratio were predictors of poor outcome in patients who received outpatient treatment, namely, older age [odds ratio = 3.278, 95% confidence interval: 1.115–9.632], days from onset of symptoms [1.068, 1.003–1.137], and history of diabetes [6.373, 2.271–17.883]). Predictors of favorable outcome were female gender [0.376, 0.158–0.894], oxygen saturation > 93% [0.862, 0.733–1.014], smoking habit [0.204, 0.045–0.934]. The findings of this study demonstrate that the rate of return visit with poor outcome in patients who received outpatient treatment was reasonably low. Age, male sex, diabetes mellitus and pulmonary disease are predicting factors of poor outcome in these COVID-19 patients who received outpatient management.

Introduction:

Since the first report of Coronavirus 2019 (COVID-19) in December 2019, this acute contagious infectious disease has spread throughout the globe, infecting more than 164 million people as of May 19, 2021. While about 20% of infected patients develop severe and critical form of the disease, the majority are asymptomatic or have mild-to-moderate symptoms. Although some countries such as China [ 1 ] admit all patients, including mild and asymptomatic confirmed cases, to be isolated, monitored and treated in designated hospitals, limited capacity of in-hospital beds, especially at the time of pandemics, makes it practically impossible to admit all symptomatic cases of COVID-19. In many countries, the response capacity of healthcare systems has already been overwhelmed by the influx of patients with signs and symptoms of COVID-19. According to the Centers of Disease Control and Prevention (CDC) and World Health Organization (WHO) guidelines, asymptomatic patients and patients with mild symptoms in the absence of viral pneumonia and hypoxia can be isolated in outpatient settings to receive home care [ 2 , 3 ]. Some countries such as Iran, United States of America (USA) and England consider outpatient management even for patients with moderate infections if clinically appropriate according to national guidelines [ 4 ]. This approach helps them decrease the pressure on the hospitals and create surge capacity for medical centers to focus on severe and critically ill patients. However, concerns have been raised regarding this approach, stating that these patients may return to the hospital with worsened symptoms requiring admission.

During this pandemic, prediction models have focused mostly on the risk of critical illness among admitted patients. Few studies mentioned the incidence of return hospital admission and the associated patient characteristics [ 5 ]. Therefore, in this cohort study, we evaluated the outcome of COVID-19 patients who were assessed in the emergency department and discharged home. We specifically focused on the rate of return visit and the occurrence of adverse events in order to disclose their predictors.

Materials and methods

Study design.

We carried out this retrospective observational cohort study to assess the rate of return visit and the adverse events in patients who were examined in the “Respiratory ED” (ResED) and discharged to receive only home treatment. The study protocol was approved by the university ethics committee (IR.TUMS.VCR.REC.1399.074).

Study setting

This study was conducted at a large university-affiliated tertiary care hospital, during March 2020 to April 2020. Following COVID-19 pandemic, a ResED was set up for patients with signs and symptoms suggestive of COVID-19. It is staffed 24/7 by board-certified specialists from the departments of emergency medicine and infectious diseases and had an average daily census of about 500 patients during the study period. The national protocol for management of COVID-19 patients is (Table ​ (Table1) 1 ) not mandatory, such that patients are admitted or discharged at the discretion of the physicians.

Outpatient management criteria for COVID-19 according to the Iranian National flowchart

a Diabetic mellitus

b Body mass index

c Hypertension

d Ischemic heart disease

e Respiratory rate

f O2 saturation

Participants

All patients (older than 16 years), suspected to be or likely cases of COVID-19 according to WHO definition [ 6 ], who were evaluated and subsequently discharged home from our ResED were eligible for this study. Based on the hospital guideline and at the discretion of the treating physician, these patients were discharged either on conservative treatments or antiviral/antibacterial treatment plus conservative management. Exclusion criteria included pregnancy and a known history of pulmonary disease independent from a hospital admission during the previous month.

Study protocol and measurements

One of the researchers (E.N.) extracted the list of all consecutive patients older than 16 who had been discharged from our ResED between March 2020 and April 2020. The researcher then screened the charts of the patients for inclusion and exclusion criteria. All data were recorded, including age, gender, primary vital signs, severity of primary illness, past medical history (including diabetes mellitus [DM], hypertension [HTN], ischemic heart disease [IHD], respiratory disease, and immune deficiency), medication history in the data collection sheet.

The severity of pulmonary involvement in chest CT scan of the patients who had undergone imaging was assessed by a board-certified radiologist who was blinded to the outcomes.

Then, one of the researchers (A.A.) compared the discharge criteria followed by the treating physician to those of the Iranian national flowchart, adding these results to the checklist. The same researcher also checked the hospital registration system to find any return visit of patients during the 7 days that followed the index examination. If no data were found, the patient was contacted to assess the outcome. If the first call failed, the researcher made follow-up phone calls for 3 consecutive days. Respondents were enquired regarding re-admission or the occurrence of adverse outcomes during the follow-up period.

Definitions

The diagnosis of Human Immunodeficiency Viruses (HIV) infection, of malignancy, any history of chemotherapy and transplantation, prednisone treatment > 12.5 mg/ day for > 2 weeks were considered as immunodeficiency.

The severity of COVID-19 was classified into four categories according to the Guidelines for the Diagnosis and Treatment of New Coronavirus Pneumonia [ 7 ]: (1) mild type: no complaints to mild clinical symptoms without any chest CT involvement; (2) moderate type: patients with fever and signs of respiratory infections with chest CT scan involvement; (3) severe type: any of these criteria: (a) a respiratory distress, respiratory rate ≥ 30/min; (b) finger oxygen saturation ≤ 93% in resting condition; (c) arterial partial pressure of oxygen (PaO2)/oxygen concentration (FiO2) ≤ 300, (4) critical type: any of these criteria: respiratory failure, needing Intensive Care Unit (ICU) admission, shock.

The severity of pulmonary involvement on chest CT scan was assessed by a semi-quantitative 0 to 5 scoring system [ 8 ] for each of the 5 lung lobes. The scoring system was based on the percentage lung involvement: Score 1, 1–5%; Score 2, 6–25%; Score 3, 26–50%; Score 4, 51–75%; Score 5, 76–100%. The sum of individual lobar scores was assumed as total CT scores and ranged from 0 (no involvement) to 25 (maximum involvement).

For the purpose of this study, patient outcomes were divided into poor or good. Patients were considered to have a good outcome if they did not return for an unscheduled visit during the first 7 days of follow-up period, if admission was not deemed necessary at the hospital examination during the same period. Poor outcome was defined as any hospital admission either to ward or to ICU, intubation or any cause of death during these 7 days.

The primary outcome in our study was return visit to our hospital or any other medical center and occurrence of adverse events including admission to ward, ICU, intubation, or all-cause mortality.

Sample size required for the present study was calculated to be 600 cases, considering 10% relative error, d  = 0.04 with confidence interval of 95% and α  = 0.05.

Statistical analysis

Analyses were done using IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, N.Y., USA). We used either chi-square or Fisher’s exact test for categorical variables. Shapiro–Wilk test was used to evaluate the normality of the scale distributions of the variables and we tested these variables with the Mann–Whitney U test. We performed binomial logistic regression to measure the relationship between dependent variables and the outcome of the patients (odds ratios).

During the study period, 601 patients, suspected or probable cases of COVID-19, were assessed and discharged from our ResED. We did not succeed in reaching 82 cases and, therefore, completed the follow-up for 519 patients. Participants’ flow in the study is demonstrated in Fig.  1 .

Participants’ flowchart

Among 519 patients for whom the 7-day follow-up was completed, 484 (93.26%) patients had good outcome: 375 (77.48%) had no return visit and 109 (22.52%) had a return visit but admission was not deemed necessary. Only 35 (6.74%) patients experienced poor outcome; 27 (77.14%) were admitted to the ward, 2 (5.71%) required ICU admissions, 1 (2.86%) underwent intubation, and 5 patients (14.30%) died.

Demographic and baseline characteristics of all patients as well as those experiencing good or poor outcome are shown in Table ​ Table2 2 .

Baseline characteristics and demographics of patients with coronavirus disease-2019

a Standard deviation

c Pulse rate

d Respiratory rate

e Hypertension

f Diabetic mellitus

Forty-seven patients (9.96%) were 65 years of age or older, 9 (19.15%) of them had poor outcome. On the other hand, among 472 patients (90.94%) younger than 65, only 26 (5.51%) had poor outcome ( P -value = 0.002).

As can be seen in Table ​ Table2, 2 , there is a significant difference between the two groups of patients (those with poor and those with good outcome) regarding their age, sex, days from symptoms onset, oxygen saturation on room air, body temperature, past history of IHD and DM, as well as severity of the disease. Although oxygen saturation and body temperature showed a statistically significant difference between the two groups, we do not consider this of importance in treating these patients.

Based on the available data from patients’ charts and the Hospital Information System (HIS), we managed to determine the adherence to our national protocol for disposition in 484 patients. We noted that in 397 cases (82.02%), discharge was in accordance with the national protocol, while in 87 cases (17.98%) the decision of outpatient management basis was made at the discretion of the treating physician, but not in strict compliance with the national protocol. Among the former group, 20 patients (5.04%) experienced poor outcome, while in the latter group, 12 (13.79%) had poor outcome. ( P value = 0.007). The analysis of the patients who were discharged home based on national protocol revealed that poor outcome was seen more likely in patients aged 65 or older ( P value = 0.040) and those who had pulmonary disease ( P value = 0.044).

When logistic regression model was applied to obtain odds ratios, several factors were found to be related to poor outcome. Odds ratios based on final output model are presented in Table ​ Table3. 3 . As noted in the table, from 14 factors entered into the model, only 6 had a significant odds ratio (namely, age [odds ratio = 3.278, 95% confidence interval: 1.115–9.632], gender [0.376, 0.158–0.894], oxygen saturation [0.862, 0.733–1.014], number of days from onset of symptoms [1.068, 1.003–1.137], smoking [0.204, 0.045–0.934], and history of DM [6.373, 2.271–17.883]).

Predicting factors of poor outcome in patients with coronavirus disease-2019

a Pulse rate

b O2 saturation

c Respiratory rate

d Temperature

The result of this retrospective observational cohort study revealed that the overall rate of return visit in patients who were visited in our ResED and received outpatient treatment was about 27.74% (144 patients) with 6.74% (35 patients) experiencing adverse events. There were factors which predicted poor outcome in patients who received outpatient management.

As in almost any other hospital, our ED was flooded by many patients who experienced signs or symptoms suggestive of COVID-19. A national protocol was in place to help clinicians identify those patients who did not require admission. We noted that the protocol worked fairly well in our setting. Only about 5 percent of patients who had been discharged based on the national protocol experienced a poor outcome during 7-day follow-up. Therefore, our national protocol seems to be successful in selecting patients for outpatient treatment.

We reviewed the predicting factors of poor outcome in those patients who had been treated on outpatient basis. Age (older than 65 years), male sex, past medical history of DM, and days from symptom onset were all independent predictors of poor outcome during the 7-day follow-up. Furthermore, predicting factors of poor outcome in a subset of patients for whom discharge disposition was in compliance with the national protocol were also assessed. Age (older than 65 years), pulmonary disease, DM and immune deficiency were found to predict poor outcome in these patients. Revising the national protocol by incorporating these predictors may lower the rate of poor outcome even further.

To the best of our knowledge, no prior study has evaluated the prognostic factors specifically in COVID-19 cases in outpatient setting. However, most of the factors identified in our study to predict a poor outcome were comparable to those reported in other COVID-19 populations and settings (including inpatients [ 9 ]).

In several studies [ 1 , 8 – 12 ], age was mentioned as a predicting factor for death and respiratory failure in hospitalized patients with COVID-19.

Male sex was a predicting factor for poor outcome in our patients. In other studies [ 8 , 12 , 13 ], male sex was shown to be a predicting factor for respiratory failure or death in COVID-19 patients admitted to the hospital. In a single study [ 11 ], gender was not considered a predicting factor.

In our study, patients' vital signs at first presentation to ResED did not independently predict poor outcome during the 7-day follow-up. In a study by Yang and his colleagues [ 11 ], respiratory rate in patients with severe COVID-19 was significantly higher than that of the patients in the mild group, while the blood oxygen saturation was significantly lower in the former group. We had the same result in our study, but in the regression model, these were not found to independently predict poor outcome, although there was a trend for oxygen saturation being lower in those with poor outcomes ( P value = 0.074). In the study by Yang et al., days from symptom onset to visit was also a predictive factor in the group with severe disease, which was similar to the results of our study.

One of the unexpected findings of our study was the higher rate of smokers (19% vs 5.70%) in patients with good outcome. In fact, based on our findings, being nonsmoker was a predicting factor of poor outcome in our patients (OR = 0.2, P value = 0.041). Although some anecdotal reports and initial studies on COVID-19 patients admitted to the hospital in China [ 14 ], England [ 13 ] and France [ 15 ] with COVID-19 revealed that the proportion of smokers was smaller in these patients, another study [ 16 ] which reviewed 8 meta-analysis or systematic reviews, supported the WHO [ 17 ] position on smoking which considered smoking as an important factor in increasing the risk of mortality and morbidity in hospitalized COVID-19 patients. The pathophysiology of the effect of smoking on this virus is not well described. Some scholars pointed out that smoking and nicotine could reduce the amount of Angiotensin-Converting Enzyme-2 (ACE2) receptors, which are used by coronavirus to enter the cells and mitigate the cytokine storm, while some other studies mentioned the upregulation of ACE2 inhibitors in smokers [ 18 ]. On the other hand smokers have destroyed ciliary apparatus and their survival is linked to coughing, caused by the irritation of the airways; therefore, by coughing they manage to clear their bronchial secretion somehow and avoid pneumonia. If COVID-19 impairs the ciliary system (as Influenza virus does) then smokers might still be able to clear their secretions, limiting the access of the virus to the small airways. In our study, only 98 patients (18.50%) were smokers; therefore, our study might be underpowered for finding any correlation between smoking and the prevalence or severity of COVID-19.

Severe underlying disease was the predictor of mortality and respiratory failure of COVID-19 patients especially, DM and severe pulmonary disease based on a large cohort study on 17 million COVID-19 patients in the United Kingdom [ 8 , 13 ]. According to Chinese CDC reports IHD, HTN, DM, respiratory disease, and cancer were also associated with high mortality in these patients [ 19 ]. Also in a retrospective cohort study in Iran [ 11 ] on 62,955 COVID-19 patients who were admitted to the hospital, patients with a history of cardiovascular disease, DM, pulmonary disease, active cancer or chronic liver disease had a higher rate of mortality compared to others. In our study, pulmonary disease, DM and immunodeficiency were predictors for poor outcome in patients who were discharged based on national protocol. The number of patients with immunodeficiency was very low in the study population, therefore, we should be cautious when considering this as predicting factors of poor outcome.

In several studies, higher severity score of lung involvement in chest CT scan was found to be associated with severe and critical forms of the disease [ 11 , 20 ]. We also reported the severity score in our patients. The mean radiological severity score was low (2.0 ± 3.7). A significant difference was not found between the severity score of the two groups of patients (poor vs good outcome), although there was a trend toward higher score in patients with poor outcome (4.7 ± 6.2 vs 1.9 ± 3.4, P -value = 0.065).

Limitations

This study faces several limitations. First, our study was a single-center low population study, conducted in a tertiary care hospital. Thus, reproducing it on larger sample will improve its generalizability. Secondly, our relatively high proportion of patients lost to follow-up might underestimate the result of poor outcomes. Third, admitted patients were not included in our study; therefore, we cannot calculate the sensitivity of our national protocol for detection of patients eligible for outpatient management. Actually, our guideline for admission was breached in a large proportion of patients due to capacity concerns in the hospitals, hence the discharge/admit guideline was not tested adequately for sensitivity and specificity. Our patients received different treatment regiments and their adherence to treatment was variable; this could have also affected the results. Limited availability of real-time PCR kit in our country made health care providers to perform the test only on admitted patients. However, considering the clinical, radiological and epidemiological factors the cases were very likely to be COVID-19.

The rate of return visit with poor outcome in patients who received outpatient treatment was reasonably low, especially in those who had been discharged in adherence to the national protocol. Age, male sex, DM, pulmonary disease and immunodeficiency are predicting factors of poor outcome in these COVID-19 patients who received outpatient management. We might consider age and pulmonary disease in our national protocol discharge criteria. There are a number of gaps in our study; therefore, further research should be considered to elaborate discharge predicting score for ED patients with COVID-19.

Acknowledgements

This study has been supported by Tehran University of Medical Sciences (TUMS). Authors would like to appreciate the support and constructive comments of methodologist research development office, Imam Khomeini Hospital Complex, Tehran, Iran.

This study was supported by the Tehran University of Medical Sciences research center [Grant no. 47304].

Declarations

The study protocol was approved by the university ethics committee (IR.TUMS.VCR.REC.1399.074).

Informed consent was obtained from all individual participants included in the study.

The author(s) declare that they have no conflict of interest.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Former Gamecock Commit Zavion Hardy Sets Official Visit

Fisher brewer | 1 minute ago.

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Zavion Hardy is poised to make a notable return, scheduling an official visit with the Gamecocks.

Former Gamecock commit and four-star defensive lineman Zavion Hardy is gearing up for an official visit to South Carolina this month.

Hardy, a standout from Macon, GA, committed to the Gamecocks in the class of 2023, choosing them over offers from prominent programs such as Southern California, Georgia, Florida, Auburn, Florida State, Miami, Michigan, and Ole Miss. His commitment made waves at the time, with South Carolina's early offer and consistent pursuit standing out. In high school, Hardy showcased his versatility as a two-way player for Tattnall Square Academy, primarily excelling on the defensive line while also contributing at tight end. He racked up an impressive 56 tackles and 7 sacks during his junior year, earning All-Region 1A-Private honors.

Despite his initial commitment, Hardy's journey took a detour when he opted to attend East Mississippi C.C., a renowned junior college. During his freshman year, he crossed paths with former Gamecock defensive back Anthony Rose. Hardy remained steadfast in his commitment to ultimately play under the lights at Williams-Brice Stadium.

Recently, Hardy's silence regarding his status with the Gamecocks left fans curious, especially as he garnered attention as one of the nation's top JUCO players, receiving offers from powerhouses like Georgia, Arkansas, Alabama, Auburn, Florida, and Ole Miss. However, Hardy confirmed in an exclusive interview with Gamecocks Digest that he plans to visit South Carolina from June 21st to the 23rd, marking his first return home in nearly two years.

This official visit presents a significant opportunity for the Gamecocks to welcome back a talented player with valuable experience. The anticipation surrounding Hardy's potential return underscores the excitement generated by his commitment to the Gamecocks two classes ago.

Gamecock class of 2025:

Four-Star CB Shamari Earls

Four-Star DL Caleb Williams

Four-Star WR Brian Rowe

Three-Star WR Jayden Sellers

Three-Star DL Anthony Addison

Three-Star S Damarcus Leach

Three-Star DL Kobby Sakyi-Prah

You Might Also Like:

• South Carolina Baseball Set to Begin CWS Run; How to Watch Raleigh Regional
• Get To Know Jayden Sellers, The Longest Standing South Carolina Gamecocks Commit
• Gamecock DB Commit Demarcus Leach Soars to Four-Star Status

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FISHER BREWER

Fisher has been covering the Gamecocks for 5 years as a freelancer under the name of USCTalk, a popular page in the Carolina community that led to his first reporting job for Rivals.com. He left to go back to being a freelancer and then, a year later, joined the Sports Illustrated family in January 2023.

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Blinken returns to Middle East in high-stakes push for Gaza cease-fire

​​WASHINGTON — US Secretary of State Antony Blinken returned to the Middle East on Monday, stopping first in Egypt and Israel on the heels of a dramatic Israeli rescue operation that freed four hostages but killed scores of Palestinians in the Gaza Strip. 

Blinken’s trip to the region — his eighth since Oct. 7 — comes more than a week after President Joe Biden outlined a three-phase proposal to end the war between Israel and Hamas, neither of which have explicitly endorsed the deal. Following his meeting in Cairo with Egyptian President Abdel Fattah al-Sisi, whose country has been a key mediator in the cease-fire talks, Blinken described the Palestinian militant group as the only obstacle to a deal. 

“My message to governments throughout the region, to people throughout the region, is if you want a cease-fire, press Hamas to say yes," Blinken said before departing for Tel Aviv. 

Blinken traveled to Israel to secure support for the proposed cease-fire during meetings with Israeli Prime Minister Benjamin Netanyahu and Defense Minister Yoav Gallant. Later in the week, Blinken will also visit Jordan to attend a humanitarian conference on Gaza and Qatar, which is helping mediate a potential cease-fire agreement. 

The deal on the table begins with a six-week pause in the fighting and release of women, wounded and elderly hostages in return for Palestinian prisoners. The second and third phases call for the release of male hostages, the full withdrawal of Israeli troops and the reconstruction of the devastated Palestinian territory. 

Hamas has yet to formally respond to what Biden described as an Israeli proposal and has long demanded an end to the war as part of any hostage release.  

Senior Hamas official Sami Abu Zuhri told Reuters on Monday that the militant group is “ready to deal positively with any initiative that secures an end to the war.” He also called on the Biden administration to put pressure on Israel. 

A deal could threaten Netanyahu’s political survival, with right-wing members of his coalition vowing to bring down his government should Israel accept cease-fire terms that do not ensure Hamas’ total defeat. The domestic pressure on Netanyahu deepened Sunday when centrist members of the emergency government Benny Gantz and Gadi Eisenkot announced their resignations.   

Blinken arrived in Israel hours before the UN Security Council was expected to vote on a US-led resolution that envisions a “full and immediate” cease-fire and the release of hostages. The text “urges both parties to fully implement its terms without delay and without condition." 

Even if it’s adopted by the 15-member council, there is no indication the US-sponsored resolution would have an immediate impact on the ground in Gaza. The UN body also passed a cease-fire resolution in March that did not halt the fighting. 

The US diplomatic push comes two days after Israel’s military carried out a daytime raid on the Nuseirat refugee camp in central Gaza that freed four hostages including Noa Argamani, whose abduction from the Nova musical festival on Oct. 7 was captured on video that went viral. 

The Health Ministry in the Hamas-run territory said that at least 270 people were killed and another 700 wounded in the Israeli operation in Nuseirat. An officer from Israel’s elite Yamam counterterrorism unit was also fatally shot during the rescue mission. 

UN special rapporteur Francesca Albanese said in a statement that she was “relieved that four hostages have been released," but that “it should not have come at the expense of Palestinians.”  

Israel’s eight-month military campaign has killed more than 37,000 Palestinians, a majority of them women and children, according to Gaza's Health Ministry. 

The militants on Oct. 7 killed roughly 1,200 people and took some 250 others hostage, according to Israeli estimates. Following Saturday’s rescue operation, Israel says 116 hostages remain in Gaza, at least 41 of whom are believed dead. 

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The Israel-Hamas War: Live Q&A with Amb. David Satterfield (Part 2)

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Around Town: Street closures announced for Trump’s Newport Beach visit Saturday

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One of the stops on former president Trump’s campaign visit to the Southland is a fundraiser at a private home in Newport Beach on Saturday, June 8. Multimillionaire tech entrepreneur Palmer Luckey is among the hosts, according to the L.A. Times.

He is expected to arrive in the early afternoon, according to city officials. Some roads will be closed from 7 a.m. to approximately 3 p.m.

Bayside Drive from Jamboree Road to Coast Highway will be closed to all motor vehicle traffic starting at 7 a.m., with only local residents allowed to enter with proof of residency such as a photo identification, passport or some other proof of address, according to the notice issued Friday from City Hall.

Residents of the Harbor Island community, Beacon Bay, Promontory Bay and Promontory Point communities will be able to access their homes during the event via Coast Highway and Bayside.

The Linda Isle community will not be directly impacted, as it is a gated community, but its access will be limited to Coast Highway and Bayside Drive.

The city asks residents to “be flexible as this will be a dynamic situation.” For more information contact Special Events Sgt. Sabrina Fabbri at (949) 644-3743.

Baroque Music Festival returns to Newport Beach

The 44th annual Baroque Music Festival will return to Newport Beach, with the first of its concerts scheduled for June 16 at St. Mark’s Presbyterian Church.

Tickets are now on sale for the festival at $45 to $55 for general admission, depending on the concert. Festival subscriptions are $325 and include a private, catered dinner at the end of the finale on June 23. Rush tickets for students between 12 and 29 are $10 with a valid student ID, though availability may vary.

To purchase tickets, visit bmf-cdm.org/tickets . For more information on the concerts and events, visit bmf-cdm.org/2024-programs .

Applications open for Art in the Park

The Newport Beach Arts Foundation has begun receiving applications for Art in the Park , scheduled for Sept. 14. Proceeds from the event go toward support for school tours, acquisition of art for the city and its arts and cultural programming.

For more information or to participate, contact [email protected] or visit newportbeachartsfoundation.org .

Free car show for Father’s Day at Balboa Bay Resort

The Balboa Bay Resort is hosting its 17th annual Father’s Day Car show from 11 a.m. to 2 p.m. on Sunday, June 16. A collection of cars, music and food will be available in the upper resort parking deck.

Tickets are not required for attendance, though organizers advise attendees to rideshare as parking is expected to be limited. For more information, visit balboabayresort.com/event/fathers-day .

OC Coastkeeper accepting grant applications

Orange County Coastkeeper is accepting applications for the Beach and Coast Accessibility Program. Grants can be up to $30,000 for tribes, nonprofit organizations and public entities to deploy accessibility equipment such as beach wheelchairs, walkers and mats.

Applications will be reviewed on a rolling basis and applicants are advised to speak with Coastkeeper staff about their projects. For more information, visit coastkeeper.org/bcap .

Newport Beach Film Festival launches automotive short film competition

The Newport Beach Film Festival announced Thursday its automotive short film competition, which is being organized in collaboration with Ant Anstead.

Filmmakers are encouraged to submit their films under the theme of “For the Love of Driving.” Films can be documentary-style or scripted and shot on film or phone. Films must be at least one minute and a maximum of six minutes long. For more information, visit newportbeachfilmfest.com/automotive .

Deadline for submissions is July 14 and submission fees are $25.

Flag Day celebration at Newport Beach City Hall

Mayor Will O’Neill announced Thursday he will host a Flag Day celebration at the Newport Beach Civic Center, with 249 flags to honor the 249th birthday of the U.S. Army.

The event will begin at 1 p.m. on June 14 and will be led by Cmdr. Brian Fleming of Newport Harbor American Legion Post 291 for the changing of the colors and flag-folding ceremony. Installation of the flags will take place on June 12 at 10 a.m.

‘Barbie’ to be screened June 15 at Costa Mesa’s Movie in the Park

Costa Mesa’s Balearic Park will be transformed into BarbieLand for one night only on Saturday, June 15, as one of the city’s seasonal Movie in the Park experiences. Barbie or Ken attire is encouraged.

The movie “Barbie” starts at sunset, around 8:30 p.m. Beginning at 6 p.m. the public can enjoy mocktails and food while earning raffle tickets at “Ken’s Mojo Dojo Casa House of Games,” the “Beach Obstacle Course” and more.

The park is located at 1975 Balearic Drive. For more information, call (714) 754-5300.

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Diana Ross, Eminem and Jack White perform for thousands as former Detroit eyesore returns to life

DETROIT — A myriad of Detroit’s greatest musical exports, including Diana Ross, Eminem and Jack White, took to the stage Thursday night in a pulsating sonic spectacle held on the eve of the historic reopening of an 18-story structure that long had symbolized their hometown’s decline.

The 90-plus-minute “Live From Detroit: The Concert at Michigan Central” celebrated the city’s refurbished train station, which opens to the public on Friday, six years after Ford Motor Co. took control of the building and more than three decades since the last train pulled out.

The vacant Michigan Central Station fell into disrepair and became emblematic of the Motor City’s decay. That is until 2018, when  Ford announced it was buying the building  and adjacent structures as part of the carmaker’s plans for a campus focusing on autonomous vehicles.

“Six years ago, we gathered here, and we dreamt of what was possible. We dared to dream that this station, which had become a symbol of a broken city, could once again shine as the symbol of the Motor City,” Bill Ford, his namesake company’s executive chairman, told the crowd before Ross, the Motown superstar, opened the festivities with “I’m Coming Out.”

The sold-out, ticketed, outdoor event that streamed live on Peacock also featured performances by Big Sean, the Clark Sisters, Common, Fantasia, Melissa Etheridge and the Detroit Symphony Orchestra. Presenters included Detroit Lions legend Barry Sanders, current Lions stars Jared Goff and Amon-Ra St. Brown and actors Taylor Lautner and Sophia Bush. Organizers said 20,000 people attended the event. And more than 60,000 are to tour the train station over the next 10 days.

“For most of my life, it was just a big eyesore,” Big Sean said of the train station. “It’s an oasis in the middle of the city. It’s a metaphor for us all: It’s our time right now.”

The concert was executive-produced by Eminem and his longtime manager, Paul Rosenberg. Eminem was not scheduled to perform, but surprised those in attendance by closing the show with a rousing set that included his new single, “Houdini,” “Not Afraid” and the most appropriate “Welcome 2 Detroit.”

Eminem’s appearance may have been the highlight of the night for attendees, but White’s performance wasn’t far behind.

Announcing he and his band were “going to play a couple songs tonight that were written a few blocks away from right here,” White was met with a thunderous response when he strummed the opening chords of the anthemic, “Seven Nation Army,” which he recorded while a member of The White Stripes. White, who grew up not far from MCS, held his guitar high above his head with one hand as pyrotechnics lit up the station behind him.

The hulking structure for years was ravaged by scavengers and urban explorers and rose high above Detroit’s Corktown neighborhood. The station now will serve as an anchor for a sprawling 30-acre (12-hectare) mobility innovation district and a resurgent Corktown. The project is expected to bring thousands of tech-related jobs. Restaurants, new hotels and other service-industry businesses already are moving into and near Corktown.

The reopening of the train station also comes as Detroit enjoys a bit of a renaissance.

A decade since exiting its painful bankruptcy, the city has stabilized its finances, staunched population losses and made inroads in cleaning up blight across its 139 square miles (360 square kilometers). In April, Detroit set  an attendance record for the NFL draft  when more than 775,000 fans poured into downtown over three days.

“I just love seeing everybody in our city happy,” Bill Ford said.

The Associated Press

NASA puts $10M down on Mars sample return proposals from Blue Origin, SpaceX and others

It turns out the space industry has a lot of ideas on how to improve NASA’s $11 billion, 15-year plan to collect and return samples from Mars . Seven of these proposals have caught the agency’s attention. 

Announced today , NASA has awarded $1.5 million contracts to seven companies to further develop their plans for the revamped Mars Sample Return mission. The awardees, and the title of their proposals, are as follows: 

• Lockheed Martin: “Lockheed Martin Rapid Mission Design Studies for Mars Sample Return”
• SpaceX: “Enabling Mars Sample Return With Starship”
• Aerojet Rocketdyne: “A High-Performance Liquid Mars Ascent Vehicle, Using Highly Reliable and Mature Propulsion Technologies, to Improve Program Affordability and Schedule”
• Blue Origin: “Leveraging Artemis for Mars Sample Return”
• Quantum Space: “Quantum Anchor Leg Mars Sample Return Study”
• Northrop Grumman: “High TRL MAV Propulsion Trades and Concept Design for MSR Rapid Mission Design”
• Whittinghill Aerospace: “A Rapid Design Study for the MSR Single Stage Mars Ascent Vehicle”

A total of 10 studies — including two NASA centers and the agency’s Jet Propulsion Laboratory and Applied Physics Laboratory — were selected to produce studies. These were selected after the agency put out a request for proposals in April. 

The titles don’t really say very much at all about the respective proposals — for example, it’s no surprise that SpaceX is offering up Starship for a mission to Mars, but how exactly the vehicle will be enabled to collect and return samples is still unclear. That’s the whole point of the study period: to help NASA understand whether there are viable alternative mission designs or mission elements to bring Martian samples home safely. 

According to the request for proposal, studies could be for complete overhauls of the mission design, or for designs that include elements of NASA’s MSR mission or NASA’s Artemis program. 

NASA turned to private industry after finally admitting that its architecture for MSR is incredibly complicated. In fact, it’s a bit of a misnomer to even call it a single mission, given that the plan involved the Perseverance rover, a novel sample retrieval lander, a rocket called a Mars Ascent Vehicle, and an Earth return orbiter. These vehicles would need to work in perfect synchronicity to collect and transport the samples. 

Last year, an independent review board recommended that NASA revisit the mission design given the concerns about the technical features and the high costs. So the agency is doing just that : In documents related to the RFP, NASA said it’s looking for a less complex mission design and one that would reduce the total costs to the agency. The agency also said it was looking for the earliest possible return date. 

Companies will start work in July and complete their studies in October.  

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Here’s everything Apple announced at the WWDC 2024 keynote, including Apple Intelligence, Siri makeover

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Apple confirms plans to work with Google’s Gemini ‘in the future’

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Watch the Apple Intelligence reveal, and the rest of WWDC 2024 right here

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Apple brings its GenAI ‘Apple Intelligence’ to developers, will let Siri control apps

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Apple Intelligence features will be available on iPhone 15 Pro and devices with M1 or newer chips

Older iPhones or iPhone 15 users won’t be able to use these features.

Apple brings ChatGPT to its apps, including Siri

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Apple debuts AI-generated … Bitmoji

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Apple TV+ introduces InSight, a new feature similar to Amazon’s X-Ray, at WWDC 2024

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Apple gives Siri an AI makeover

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Apple Intelligence is the company’s new generative AI offering

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Apple is launching its own password manager app

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Smart Script in iPadOS 18 will clean up your handwriting when using an Apple Pencil

With Smart Script, Apple says it’s making handwriting your notes even smoother and straighter.

Calculator for iPad does the math for you

iOS’ perennial tips calculating app is finally coming to the larger screen.

With macOS Sequoia, you can mirror your iPhone on your Mac

The new OS, announced at WWDC 2024, will allow users to mirror their iPhone screen directly on their Mac and even control it.

Apple unveils macOS Sequoia

At Apple’s WWDC 2024, the company announced MacOS Sequoia.

iPhones will soon text via satellite

“Messages via Satellite,” announced at Apple’s WWDC 2024 keynote, works much like the SOS feature does.

Apple revamps its Photos app for iOS 18

Apple says the new design will lead to less time searching for photos.

iOS 18 will let you hide and lock apps

Users will be able to lock an app when they hand over their phone.

Tap to Cash lets you pay by touching iPhones

Apple’s WWDC 2024 keynote was packed, including a number of key new updates for iOS 18. One of the more interesting additions is Tap to Cash, which is more or…

iOS 18 will finally let you customize your icons and unlock them from the grid

In iOS 18, Apple will now support long-requested functionality, like the ability to set app icons and widgets wherever you want.

Apple unveils iOS 18 with tons of AI-powered features

As expected, this is a pivotal moment for the mobile platform as iOS 18 is going to focus on artificial intelligence.

visionOS can now make spatial photos out of 3D images

Apple today kicked off what it promised would be a packed WWDC 2024 with a handful of visionOS announcements. At the top of the list is the ability to turn…

Apple to release Vision Pro in international markets

The Apple Vision Pro is now available in eight new countries.

Apple debuts visionOS 2 at WWDC 2024

VisionOS 2 will come to Vision Pro as a free update later this year.

Mandiant says hackers stole a ‘significant volume of data’ from Snowflake customers

The security firm said the attacks targeting Snowflake customers is “ongoing,” suggesting the number of affected companies may rise.

Kelvin wants to help save the planet by applying AI to home energy audits

French startup Kelvin, which uses computer vision and machine learning to make it easier to audit homes for energy efficiency, has raised $5.1M.