- Email: [email protected]
Pediatric use of emergency departments
Pediatric Use of . Emergency Departments Robin
Weir,
PhD,
RN, Elizabeth Joan Crook,
Rideout, MSc, MSc, RN
.
MHSc,
RN, and
This cross-sectional survey examined the use of emergency services by children, from birth to 16 years of age, in two urban teaching hospitals. A retrospective chart survey design was used to obtain data on the prevalence of types of patient problems; the pattern of use, including time of day and day of week; and decisions regarding patient disposition. A random sample of 10% of the average monthly pediatric emergency visits was obtained for a l&month period and relevant data were extracted by trained research assistants. Variation in the presenting health care problems by age group, season of the year, and by time of day and day of the week was found. Approximately 50% of visits involved such primary health care problems as soft tissue injuries, and respiratory and digestive tract infections. Possible reasons for this use of emergency departments for primary care needs are discussed and strategies are suggested for the provision of a better “fit” between consumer demand and health care services. I PEDIATR HEALTH CARE. (1989). 3, 204-210.
L
arge numbers of children, from birth to 16 years of age, are known to receive medical care through emergency departments. Questions are often raised by clinicians, as well as researchers, concerning the appropriateness of the choice of the emergency department for the kinds of problems presented there (Davison, Hildrey, & Floyer, 1983; Habenstriet, 1986), the factors that affect the choice of health service (Bowling, Issacs, Armston, Roberts, & Elliot, 1987), and the effects of the absence of follow-up care in a system in which continuity of care is claimed to be valued (Hidtech, 1980). Studies of the use of emergency services for the pediatric population have addressed these questions from various perspectives, including the nature of the problem presented and the accessibility of services. Although it is estimated that one half to two thirds of emergency visits are of the “non-urgent type” and
Robin Weir is Associate Professor, School of Nursing, Sciences, McMaster University, and Clinical Associate versity Medical Center, Ontario, Canada. Elizabeth Rideout is Associate Professor, Health Sciences, McMaster University.
School
Faculty of Health at McMaster Uni-
of Nursing,
Faculty
of
Joan Crook is Professor, School of Nursing, Faculty of Health Sciences, McMaster University, and Clinical Associate at McMaster University Medical Center. Funded
by Summer
Canada Works,
Project
No. 3404 B13.
Reprint requests: Robin Weir, PhD, RN, School of Nursing, Room 3N28, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 325, Canada.
204
hence inappropriate for emergency care, there is no standard definition of non-urgent problem across studies (Guterman, Franaszek, Murdy, & Gifford, 1985; Habenstriet, 1986; Hilker, 1978). Similarly, studies that address the selection of this health care service are inconclusive and have conflicting results. Nelson, Nelson, Shank, and Thompson (1979) documented higher use of the emergency department for non-urgent problems by welfare than non-welfare patients. While these patients may account for a higher percentage of use, it is clear that patients from more privileged economic groups also choose the emergency department for care (Feldman & Cullum, 1984). Physical accessibility also appears to be an important variable in choosing emergency care. Hidtech (1980) and Ullman, Block, Boatright, and Stratmann (1978) demonstrated a decrease in emergency department use when family physicians were made more available through extended hours of service and hospital-based practice settings. However, the increased availability of family physicians did not lead to a complete shift in behavior, since the emergency service continued to be used. For example, Levy, Bonnano, Schwartz, and Sanofsky (1979) reported that people who used neighborhood health centers for their primary care also used the emergency department for the treatment of non-urgent problems. Other studies have suggested that the use of emergency services for non-urgent problems is largely the JOURNAL
OF PEDIATRIC
HEALTH
CARE
Journal of Pediatric Health Care
result of different views of urgency by patients (and their parents) and health care personnel. In a household survey conducted by Ullman et al. (1978), 95% of respondents chose the emergency department because they believed their problem to be an urgent one. Guterman et al. (1985) found that 60% of their sample judged their illness to be an emergency; in only 3 1% of cases did physicians agree. These studies demonstrate the difference in perception between professionals and parents, and may explain the continuing conflict between user and providers’ judgment about appropriateness. Questions of why and on what criteria parents base the assessment of severity have not been addressed. To date, little work has been published on pediatric use of emergency departments in Canada, where universal health care coverage provides open access to all health services, including choice of physician. Utilization studies within this context are a more true reflection of patient choice because financial barriers to services are not a factor in the decision. The previously reported studies by Hidtech (1980), completed in Toronto, Ontario, examined physician availability as a variable in emergency department use, whereas Feldman and Cullum (1984) examined the impact on emergency use of a pediatric walk-in clinic. A study is needed to describe in detail the use of emergency care by pediatric patients, to determine if problems exist in the delivery of services when there are no financial barriers to access. 9 PURPOSE OF THE STUDY
The purpose of the present study was to determine the variables associated with the use of emergency departments by children (from birth to 16 years of age) in two urban teaching hospitals in a mediumsized center in southern Ontario. It was thought that particular variables would emerge to explain the expected proportionately high presentation of nonurgent medical problems. m METHOD
A retrospective cross-sectional survey design was used to study the emergency room records of a random sample of pediatric charts in two universityaffiliated teaching hospitals. Because these hospitals are the sites for all pediatric inpatient services in the city and the location of all pediatric physician residency programs, it was assumed that these sites would be representative of pediatric use. A random sample of 10% of the average monthly pediatric emergency visits in each of the study hospitals was
Pediatric
Use of Emergency
Departments
205
obtained for a 12-month period. Data were abstracted by two trained researchers using a pretested form that was demonstrated to show high reliability. The chart extraction form focused on three categories of variables: (a) sociode~~rapbic chamctektics, including age and sex of child, method of payment, and name and location of family physician; (b) detaiZ of the presenting complaint, including triage status (emergent, urgent, deferrable, or elective), patient/parent statement of the presenting complaint, its duration, and previous treatment for the same problem; and (c) diagmsk and dirposition, including discharge diagnosis, discharge disposition (home or admitted), and plan for follow-up care. The retrospective nature of the survey did not allow for an exploration of the parent’s perception of the urgency of their child’s problem or their rationale for choosing the emergency department for care.
4
uestions of why and on what criteria parents base the assessment of severity have not been addressed.
n
RESULTS
For the purpose of this report, data are reported from the combined sample from both hospitals. The sample comprised 1726 patient files. This represented 96% of the 1796 files (10% of total visits) selected randomly for inclusion in the study. Missing files were randomly spread across months within each of the study settings. Sample Characteristics Age and gender of sample. Of the children presenting to the emergency setting, 12% were infants (0 to 1 year), 22% were toddlers (1 to 2 years), 20% were preschoolers (3 to 5 years), 31% were school age (6 to 12 years), and 15% were adolescents (13 to 16 years). Males presented proportionately more than females (58% vs. 42%). On admission to both emergency departments, patients and/or family were routinely asked whether they had a family physician. The overwhelming majority of the sample (98.65%) reported having a family physician. Triage Status
The majority (93%) of users were ambulatory in their presentation to the emergency departments. Only 6% of the sample arrived by ambulance.
206
Weir, Rideout,
Volume 3, Number 4 July-August 1989
& Crook
(N-591
)
28% (N-490)
21% (N-362)
13% (N=218)
3% (N&O)
08001259
13001759 The
n
23000359
18002259
FIGURE 1 Frequency
of
..I_ EL04000759
-
N-1721
day
of use of services by time of day.
While patients presenting to both hospitals were “triaged” at admission by the emergency nurse according to a regionally approved categorization of presenting signs and symptoms, only Hospital “B” recorded this categorization on the emergency rec-
T
he overwhelming majority of the sample (98.65%) reported having a family physician.
ord. The triage categories assigned at entry to the emergency department are defmed as follows: Emergent. Requires immediate medical attention; disorder is acute and potentially threatens life or function; delay is harmful to patient. Urgent. Requires medical attention within a few hours; disorder is acute, but not necessarily severe; patient is in danger if not attended. Deferrable. Does not require resources of an emergency service; disorder is minor or nonacute. Elective. Planned in advance; usually booked procedure. From Hospital “B” only, and using this regional
categorization, 79% of the sample were judged by the triage nurse at admission to be in need of the resources offered by the emergency service (10% emergent + 69% urgent). The remainder of the sample were judged to be deferrable (19%) and elective (2.5%). Use of Services Time of visit. The frequency of use of services, by the time of day and day of the week, are displayed in Figures 1 and 2, respectively. There was a gradual increase in frequency of visits between 8:00 AM and 11:00 PM, with the highest frequency (34%) occurring between 6:00 PM and 11:00 PM. Approximately 33% of all visits occurred on Saturdays and Sundays combined, with the remaining visits spread relatively evenly across the remaining days of the week. Of the children using the emergency services, in total 50% presented in the evenings, on weekends, or early mornings. These are times when private physicians are not usually in their offices. This suggests that nonavailability of family physicians may be a contributing factor to the decision to use emergency services. Types of presenting problems. The emergency record in both study settings was the same and con-
Journal of Pediatric Health Care
Pediatric
Use of Emergency
Departments
207
20 16.5% (N=284) 15 -
13% (N=226)
12.6%
14% (~=248) -.F
Mon.
Tues.
Wed.
13% (N=227)
Thurs.
16.4% (~=282)
13.7% N=235)
10 -
5-
0 -
__- Nzl719 Fri.
Sat.
Sun.
Days of week n
FIGURE 2 Frequency
of use of services by day of week.
tained an area for recording the “presenting complaint” and the “discharge diagnosis.” Because only one or the other category was completed in a substantial number of records, a small subanalysis was conducted to determine the percent of agreement between the recorded “presenting complaint” and the “discharge diagnosis.” A random sample of 95 abstraction forms was selected by two of the authors and independent judgments were made regarding the congruency between the symptoms (presenting complaint) and discharge diagnosis. There was a high agreement (100%) between the two categories and it was judged appropriate to use the “presenting complaint” when the discharge diagnosis was absent. Diagnosis/presenting complaint was post-coded into categories for purposes of analyses. The types and frequencies of presenting problems /diagnoses are presented in Table 1. Trauma, respiratory, and gastrointestinal problems accounted for 76% of the visits in the combined study settings. The remaining 24% included a wide variety of problems with a low frequency of occurrence. The frequency of types of problems by age group and season of the year are displayed in Tables 2 and 3, respectively. Children with respiratory problems were more likely to be toddlers, whereas gas-
trointestinal and trauma problems occurred more frequently in school age children. There was a significant relationship (x2[6] = 13.03,~ s 0.05) between season ofthe year and type of presenting problem, with proportionately more respiratory problems appearing in the winter months, whereas gastrointestinal problems occurred most frequently in the spring, and trauma problems in the summer. In the combined sample, trauma had the highest frequency and probability of occurrence in any season of the year.
T
rauma, respiratory, and gastrointestinal problems accounted for 76% of the visits in the combined study settings.
Management of the problem. Approximately 86% of the total sample were discharged home. A further analysis of Hospital B’s data was conducted to examine the disposition decision according to the triage category assigned at presentation to the emergency. Of the v i si ts judged to be emergent, 5 1% were discharged home, and of the visits judged to be ur-
208
Weir, Rideout,
TABLE 1 Frequency emergency settings
n
Volume 3, Number 4 July-August 1989
& Crook
of types of conditions
in
TofALS CATEGCXIES OF CUN~toNS Trauma/accidents Soft tissue injury Laceration Head injury Fracture Burn Multiple injury Respiratory problems URI (pharyngifis, laryngitis, Eonsillitis, croup, rhinitis) O.M. (earache) LRJ (pneumonia, bronchitis, shortness of breath) Asthma Gastrointestinal problems Castroenteritis (vomiting, diarrhea, nausea) Abdominal pain Influenza Miscellaneous Skin conditions Ingestion (overdcise, poisoning, substance abuse) Pyrexia Elective Eye problems Communicable diseases (mumps, chicken poxI measles) GU problems fUTI, va$inaf b!wding, sexual assault) Seizures Not otherwise classified Missing data
N
%
669 289 230 66 74 9 1 412 192
(39) (17) (13) (4) (4) (0.5) (0.1) (24) (11)
125 65
(7) (4)
30 215 119
(21 (13) (7)
59 37 260 67 46
(3)
(2) (16) (41 (3)
43 26 25 23
(2) (2)
16
(1)
14 147 170
(1) @I ~10)
(3)
(1)
gent, 88% were discharged home. In total, 78.8% of patient visits were judged to be emergent or urgent at the time of admission. Of this total group, 83.5% of patients were discharged home. n
DISCUSSION
The purposes of this retrospective chart survey of pediatric use of emergency services were (1) to identify the frequency of types of problems with which children presented, and (2) to determine the variables related to the use of this health service. Charts were randomly selected from each month of the study year at each study setting to achieve a 10% sample and to control for seasonal variation.
Approximately 50% of this sample had diagnoses that reflected primary health care problems, as defined by Dershewitz (1988). These included-in descending order of frequency-soft tissue injuries ( 17%)) upper respiratory infections ( 11% ) , otitis media (7%), gastroenteritis (7%), lower respiratory infections (4%), and skin conditions (4%). This list of diagnoses is remarkably similar to any list of presenting complaints from such primary care facilities as community health centers or family practices. Why then was the emergency department chosen for care? Several reasons have been advanced for the choice of emergency care, including the perceived urgency and/or severity of the problem (Halperin, Myers, & Alpert, 1979); accessibility (Bowling et al., 1987; Habenstriet, 1986); quality of available technical and specialist support (Levy et al., 1979); and the perceived need for a second opinion concerning the problem (Hilker, 1978). Although this study design precluded any discussion with the patient/parent about their choice of the emergency department for care, the data suggest that perception of urgency and accessibility were important factors of the decision.
I n total,
78.8% of patient visits were judged to be emergent or urgent at the time of admission.
In the study setting in which triage data were recorded, only 21% of the visits were judged at admission to be non-urgent. It could be argued that patients’ (parents’) perceptions of distress, which initiated the help-seeking process, were for the most part (79%) congruent with the perceptions of the health professional. Whether this degree of agreement regarding urgency and, hence, appropriateness of use remained constant after a more thorough assessment is unknown. In both study settings combined, 86% of patients were discharged home. Within Hospital B, where triage data were available, 50% of patients categorized as emergent and 88% of urgent patients were discharged to their homes. While the discharge status of patients may suggest less agreement after patient assessment was completed, the decision to admit or discharge is influenced by a variety of clinical and situational variables and may not be a reliable indicator of urgency of the problem. In addition, there is considerable reluctance to hospitalize children unless absolutely necessary. Also, these data may reflect the types of urgent conditions that can be stabilized in the emergency de-
Journal of Pediatric Health Care
n
TABLE
2 Frequency*
Pediatric
of types of problems
in various age groups in combined
RESPIRATORY
Infant Toddler Preschool In school Adolescent Totals *Represents
n
TABLE
Departments
209
study settings
CASTROINTESTlNAL
TRAUMA
N
%
N
%
N
%
64 141 109 84 14 412
(16) (34) (27)
27 50 42 73 23 215
(13) (23) (20) (34) (11)
35 105 113 251 164 668
(5) (16) (17) (38)
(20) (3)
(25)
75% of total visits.
3 Combined
frequency*
of types of problems RESPIRATORY
Winter (Dee-Feb) Spring (Mar-May) Summer (June-Aug) Fal I (Sept-Nov) Totals *Represents
Use of Emergency
by season of the year in both study settings GASTROiNTESTlNAL
TRAUMA
N
%
N
%
N
%
125 103 72 106 406
(36.3) (30.2) (26.9) (31.5)
46 71 41 55 213
(13.3) (20.8) (15.3) (16.4)
173 167 154 175 669
(50.2) (48.9) (57.7) (52.1)
TOTAL N 344 341 267 337 iEF
75% of total visits.
partment. It is, however, reasonable to conclude from these data that the patients required health care services. The question remains whether the resources of the emergency department were not only necessary but sufficient for the types of presenting health care problems. The data lend considerable support to the irnportance of accessibility in the decision to use emergency services. Approximately one third of the study visits occurred in evening hours (6:00 PM to 11:OO PM) and one third of all visits per week took place on weekends. That the number of visits increased when physicians were not in their offices and when parents are not usually at work suggests it is becoming increasingly more difficult for working people to see a physician during traditional office hours. Although the overwhelming majority (98%) of children were patients of physicians in private practice, there were no data to suggest the family physician was contacted before the decision to use the emergency service. It seems that accessibility to the family health care provider is a key factor in choosing emergency care. Continuity of care, careful follow-up, and patient/parent education are all valued in primary care settings and tend not to be part of emergency department care. Given this orientation and the poten-
tial for establishing more personalized care, it seems preferable that primary health care problems be assessedand managed in community health centers and family physician offices. If health professionals are to be successful in influencing patients to use family practices rather than emergency services, some of the following changes seem indicated. First, extended hours of practice into evenings and on weekends would enhance accessibility. Second, patient education programs that address preventable illnesses and accidents are warranted, as are programs directed at early detection of health problems. Similarly, patients’/parents’ ability to differentiate urgent from deferrable problems demands knowledge and confidence, both gained through programs of education within an open and supportive relationship with a health care professional. Third, parents need to understand the expected course of their child’s illness, including the anticipated result of any therapy. For example, the parent whose child has been diagnosed with otitis media needs information concerning the nature of the problem, the expected effect of prescribed treatment, and the signs and symptoms indicative of a worsening condition. As well, they need to be informed of actions to intitiate should their child not respond to therapy. There is considerable evidence
210
Weir, Rideout,
Volume 3, Number 4 July-August 1989
& Crook
that the quality of the relationship between the health care professional and patient is critical to the success of such programs (Meichenbaum & Turk, 1987). The pediatric nurse practitioner can institute such education on a consistent basis while providing continuity in the care process. Despite the best efforts and actions of primary health care personnel, some individuals will continue to use hospital emergency services (Levy et al., 1979; Maynard & Dodge, 1983). Therefore, adaptation of pediatric emergency services to provide optimal quality care is also warranted. Because emergency departments are presently intended to serve patients with severe trauma or other serious disease, conflicting expectations result between user and provider about inappropriateness of this health service for non-urgent problems. Efforts should be made to educate the providers of emergency care about the reasons patients seek such care. The provision of on-site primary care pediatric services is also suggested. Such a service should use the strengths of pediatric nurse practitioners and primary care physicians. Hospital-based group practices (Halperin, Myers, & Alpert, 1979) or pediatric walkin clinics (Feldman & Cullum, 1984) represent such alternatives to community care. In such settings, communication links could be established between the on-site caregivers and community clinicians to facilitate appropriate follow-up. Patient and parent education by skilled educators would enhance the service traditionally associated with emergency care.
T
here was a definite pattern of use of services by hours of the day and days of the week.
In summary, this survey has identified the wide variety of health care problems in children who were brought to the emergency department. There was clear variation in the types of problems that occurred in various age groups and seasonal variation among conditions. There was a definite pattern of use of services by hours of the day and days of the week. Parents’ judgment about the urgency of the problem seemed to be congruent with the initial triage decision made by the emergency nurse. However, the preponderance of primary health care problems and the apparent demand for care outside of regular office hours suggest a disparity between user and provider expectation for health care services.
On the basis of our data, it appears that the emergency department will continue to be viewed as an alternate source of primary care for pediatric health problems. Rather than pursue the debate regarding the use and misuse of the emergency department for non-urgent problems, we should shift our attention to the provision of optimal care, regardless of setting. Nurse practitioners are especially well prepared for important roles in both community- and hospitalbased pediatric practices. n REFERENCES Bowling, A., Issacs, D., Armston, J., Roberts, J. E., & Elliot, E. J. ( 1987). Patientuseof pediatrichospitalcasualty department in the east end of London. Journal of Family l%uti~e, 4, 8590. Davison, A. G., Hildrey, C. C., & Floyer, A. (1983). Use and misuse of an accident and emergency department in the east end of London. Journal of the Rqval Socieg ofMedicine, 76, 3740. Dershewitz, R. A. (Ed.). (1988). Ambulatory pediatric care. Philadelphia: J.B. Lippincott. Feldman, W., & Cullum, C. (1984). The pediatric walk-in clinic: Competition for the private practitioner. Canadian Medical Association Journal, 130, 1003. Guterman, J., Franaszek, J. B., Murdy, D., & Gifford, M. (1985). The 1980 patient urgent study: Further analyses of the data. Annals ofEmegencyMedicine, 14, 1191-1198. Habenstriet, M. A. (1986). Health care patterns of non-urgent patients in an inner city emergency room. New Ywk State Journ& of Medicine. 86, 5 17. Halperin, R., Myers, A., & Alpert, J. (1979). Utilization of pediatric emergency services: A critical review. Pediatric Clinirs of North America, 26, 747-757. Hidtech, J. R. (1980). Changes in emergency deparnnent use associated with increased family physician availability. Journal of Farnib Practice, 11, 9 1. Hilker, T. (1978). Non-emergency visits to a pediatric emergency deparunent. Journal of American College of Emeuenq l’bysicians, 7(9). Levy, J. C., Bonnano, R. A., Schwartz, C. G., & Sanofsky, P. A. (1979). Primary care: Patterns of use of pediatric medical facilities. Medical Care, 9, 88 1. Maynard, E. J. & Dodge, J. S. (1983). Introducing a community health center in Mosgiel, New Zealand: Effects on use of the hospital accident and emergency department. Medical Care, 21, 379-388. Meichenbaum, D., & Turk, D. (1987). Facihtatin5 treatment adherence. New York: Plenum. Nelson, D. A. F., Nelson, M. A., Shank, H. C., & Thompson, F. (1979). Emergency room misuse by medical assistance patients in a family practice residency. Journal of Family Practice, 8, 341. Parker, S. (1983). Pediah care: A &de fm patient education. Norfolk, Corm.: Appleton-Century-Crofts. Uliman, R., Block, J. A., Boatright, N., & Stratmann, W. (1978). Impact of a primary care group practice on emergency room utilization at a community hospital. Medical Care, 16, 723.
Weir,
PhD,
RN, Elizabeth Joan Crook,
Rideout, MSc, MSc, RN
.
MHSc,
RN, and
This cross-sectional survey examined the use of emergency services by children, from birth to 16 years of age, in two urban teaching hospitals. A retrospective chart survey design was used to obtain data on the prevalence of types of patient problems; the pattern of use, including time of day and day of week; and decisions regarding patient disposition. A random sample of 10% of the average monthly pediatric emergency visits was obtained for a l&month period and relevant data were extracted by trained research assistants. Variation in the presenting health care problems by age group, season of the year, and by time of day and day of the week was found. Approximately 50% of visits involved such primary health care problems as soft tissue injuries, and respiratory and digestive tract infections. Possible reasons for this use of emergency departments for primary care needs are discussed and strategies are suggested for the provision of a better “fit” between consumer demand and health care services. I PEDIATR HEALTH CARE. (1989). 3, 204-210.
L
arge numbers of children, from birth to 16 years of age, are known to receive medical care through emergency departments. Questions are often raised by clinicians, as well as researchers, concerning the appropriateness of the choice of the emergency department for the kinds of problems presented there (Davison, Hildrey, & Floyer, 1983; Habenstriet, 1986), the factors that affect the choice of health service (Bowling, Issacs, Armston, Roberts, & Elliot, 1987), and the effects of the absence of follow-up care in a system in which continuity of care is claimed to be valued (Hidtech, 1980). Studies of the use of emergency services for the pediatric population have addressed these questions from various perspectives, including the nature of the problem presented and the accessibility of services. Although it is estimated that one half to two thirds of emergency visits are of the “non-urgent type” and
Robin Weir is Associate Professor, School of Nursing, Sciences, McMaster University, and Clinical Associate versity Medical Center, Ontario, Canada. Elizabeth Rideout is Associate Professor, Health Sciences, McMaster University.
School
Faculty of Health at McMaster Uni-
of Nursing,
Faculty
of
Joan Crook is Professor, School of Nursing, Faculty of Health Sciences, McMaster University, and Clinical Associate at McMaster University Medical Center. Funded
by Summer
Canada Works,
Project
No. 3404 B13.
Reprint requests: Robin Weir, PhD, RN, School of Nursing, Room 3N28, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 325, Canada.
204
hence inappropriate for emergency care, there is no standard definition of non-urgent problem across studies (Guterman, Franaszek, Murdy, & Gifford, 1985; Habenstriet, 1986; Hilker, 1978). Similarly, studies that address the selection of this health care service are inconclusive and have conflicting results. Nelson, Nelson, Shank, and Thompson (1979) documented higher use of the emergency department for non-urgent problems by welfare than non-welfare patients. While these patients may account for a higher percentage of use, it is clear that patients from more privileged economic groups also choose the emergency department for care (Feldman & Cullum, 1984). Physical accessibility also appears to be an important variable in choosing emergency care. Hidtech (1980) and Ullman, Block, Boatright, and Stratmann (1978) demonstrated a decrease in emergency department use when family physicians were made more available through extended hours of service and hospital-based practice settings. However, the increased availability of family physicians did not lead to a complete shift in behavior, since the emergency service continued to be used. For example, Levy, Bonnano, Schwartz, and Sanofsky (1979) reported that people who used neighborhood health centers for their primary care also used the emergency department for the treatment of non-urgent problems. Other studies have suggested that the use of emergency services for non-urgent problems is largely the JOURNAL
OF PEDIATRIC
HEALTH
CARE
Journal of Pediatric Health Care
result of different views of urgency by patients (and their parents) and health care personnel. In a household survey conducted by Ullman et al. (1978), 95% of respondents chose the emergency department because they believed their problem to be an urgent one. Guterman et al. (1985) found that 60% of their sample judged their illness to be an emergency; in only 3 1% of cases did physicians agree. These studies demonstrate the difference in perception between professionals and parents, and may explain the continuing conflict between user and providers’ judgment about appropriateness. Questions of why and on what criteria parents base the assessment of severity have not been addressed. To date, little work has been published on pediatric use of emergency departments in Canada, where universal health care coverage provides open access to all health services, including choice of physician. Utilization studies within this context are a more true reflection of patient choice because financial barriers to services are not a factor in the decision. The previously reported studies by Hidtech (1980), completed in Toronto, Ontario, examined physician availability as a variable in emergency department use, whereas Feldman and Cullum (1984) examined the impact on emergency use of a pediatric walk-in clinic. A study is needed to describe in detail the use of emergency care by pediatric patients, to determine if problems exist in the delivery of services when there are no financial barriers to access. 9 PURPOSE OF THE STUDY
The purpose of the present study was to determine the variables associated with the use of emergency departments by children (from birth to 16 years of age) in two urban teaching hospitals in a mediumsized center in southern Ontario. It was thought that particular variables would emerge to explain the expected proportionately high presentation of nonurgent medical problems. m METHOD
A retrospective cross-sectional survey design was used to study the emergency room records of a random sample of pediatric charts in two universityaffiliated teaching hospitals. Because these hospitals are the sites for all pediatric inpatient services in the city and the location of all pediatric physician residency programs, it was assumed that these sites would be representative of pediatric use. A random sample of 10% of the average monthly pediatric emergency visits in each of the study hospitals was
Pediatric
Use of Emergency
Departments
205
obtained for a 12-month period. Data were abstracted by two trained researchers using a pretested form that was demonstrated to show high reliability. The chart extraction form focused on three categories of variables: (a) sociode~~rapbic chamctektics, including age and sex of child, method of payment, and name and location of family physician; (b) detaiZ of the presenting complaint, including triage status (emergent, urgent, deferrable, or elective), patient/parent statement of the presenting complaint, its duration, and previous treatment for the same problem; and (c) diagmsk and dirposition, including discharge diagnosis, discharge disposition (home or admitted), and plan for follow-up care. The retrospective nature of the survey did not allow for an exploration of the parent’s perception of the urgency of their child’s problem or their rationale for choosing the emergency department for care.
4
uestions of why and on what criteria parents base the assessment of severity have not been addressed.
n
RESULTS
For the purpose of this report, data are reported from the combined sample from both hospitals. The sample comprised 1726 patient files. This represented 96% of the 1796 files (10% of total visits) selected randomly for inclusion in the study. Missing files were randomly spread across months within each of the study settings. Sample Characteristics Age and gender of sample. Of the children presenting to the emergency setting, 12% were infants (0 to 1 year), 22% were toddlers (1 to 2 years), 20% were preschoolers (3 to 5 years), 31% were school age (6 to 12 years), and 15% were adolescents (13 to 16 years). Males presented proportionately more than females (58% vs. 42%). On admission to both emergency departments, patients and/or family were routinely asked whether they had a family physician. The overwhelming majority of the sample (98.65%) reported having a family physician. Triage Status
The majority (93%) of users were ambulatory in their presentation to the emergency departments. Only 6% of the sample arrived by ambulance.
206
Weir, Rideout,
Volume 3, Number 4 July-August 1989
& Crook
(N-591
)
28% (N-490)
21% (N-362)
13% (N=218)
3% (N&O)
08001259
13001759 The
n
23000359
18002259
FIGURE 1 Frequency
of
..I_ EL04000759
-
N-1721
day
of use of services by time of day.
While patients presenting to both hospitals were “triaged” at admission by the emergency nurse according to a regionally approved categorization of presenting signs and symptoms, only Hospital “B” recorded this categorization on the emergency rec-
T
he overwhelming majority of the sample (98.65%) reported having a family physician.
ord. The triage categories assigned at entry to the emergency department are defmed as follows: Emergent. Requires immediate medical attention; disorder is acute and potentially threatens life or function; delay is harmful to patient. Urgent. Requires medical attention within a few hours; disorder is acute, but not necessarily severe; patient is in danger if not attended. Deferrable. Does not require resources of an emergency service; disorder is minor or nonacute. Elective. Planned in advance; usually booked procedure. From Hospital “B” only, and using this regional
categorization, 79% of the sample were judged by the triage nurse at admission to be in need of the resources offered by the emergency service (10% emergent + 69% urgent). The remainder of the sample were judged to be deferrable (19%) and elective (2.5%). Use of Services Time of visit. The frequency of use of services, by the time of day and day of the week, are displayed in Figures 1 and 2, respectively. There was a gradual increase in frequency of visits between 8:00 AM and 11:00 PM, with the highest frequency (34%) occurring between 6:00 PM and 11:00 PM. Approximately 33% of all visits occurred on Saturdays and Sundays combined, with the remaining visits spread relatively evenly across the remaining days of the week. Of the children using the emergency services, in total 50% presented in the evenings, on weekends, or early mornings. These are times when private physicians are not usually in their offices. This suggests that nonavailability of family physicians may be a contributing factor to the decision to use emergency services. Types of presenting problems. The emergency record in both study settings was the same and con-
Journal of Pediatric Health Care
Pediatric
Use of Emergency
Departments
207
20 16.5% (N=284) 15 -
13% (N=226)
12.6%
14% (~=248) -.F
Mon.
Tues.
Wed.
13% (N=227)
Thurs.
16.4% (~=282)
13.7% N=235)
10 -
5-
0 -
__- Nzl719 Fri.
Sat.
Sun.
Days of week n
FIGURE 2 Frequency
of use of services by day of week.
tained an area for recording the “presenting complaint” and the “discharge diagnosis.” Because only one or the other category was completed in a substantial number of records, a small subanalysis was conducted to determine the percent of agreement between the recorded “presenting complaint” and the “discharge diagnosis.” A random sample of 95 abstraction forms was selected by two of the authors and independent judgments were made regarding the congruency between the symptoms (presenting complaint) and discharge diagnosis. There was a high agreement (100%) between the two categories and it was judged appropriate to use the “presenting complaint” when the discharge diagnosis was absent. Diagnosis/presenting complaint was post-coded into categories for purposes of analyses. The types and frequencies of presenting problems /diagnoses are presented in Table 1. Trauma, respiratory, and gastrointestinal problems accounted for 76% of the visits in the combined study settings. The remaining 24% included a wide variety of problems with a low frequency of occurrence. The frequency of types of problems by age group and season of the year are displayed in Tables 2 and 3, respectively. Children with respiratory problems were more likely to be toddlers, whereas gas-
trointestinal and trauma problems occurred more frequently in school age children. There was a significant relationship (x2[6] = 13.03,~ s 0.05) between season ofthe year and type of presenting problem, with proportionately more respiratory problems appearing in the winter months, whereas gastrointestinal problems occurred most frequently in the spring, and trauma problems in the summer. In the combined sample, trauma had the highest frequency and probability of occurrence in any season of the year.
T
rauma, respiratory, and gastrointestinal problems accounted for 76% of the visits in the combined study settings.
Management of the problem. Approximately 86% of the total sample were discharged home. A further analysis of Hospital B’s data was conducted to examine the disposition decision according to the triage category assigned at presentation to the emergency. Of the v i si ts judged to be emergent, 5 1% were discharged home, and of the visits judged to be ur-
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TABLE 1 Frequency emergency settings
n
Volume 3, Number 4 July-August 1989
& Crook
of types of conditions
in
TofALS CATEGCXIES OF CUN~toNS Trauma/accidents Soft tissue injury Laceration Head injury Fracture Burn Multiple injury Respiratory problems URI (pharyngifis, laryngitis, Eonsillitis, croup, rhinitis) O.M. (earache) LRJ (pneumonia, bronchitis, shortness of breath) Asthma Gastrointestinal problems Castroenteritis (vomiting, diarrhea, nausea) Abdominal pain Influenza Miscellaneous Skin conditions Ingestion (overdcise, poisoning, substance abuse) Pyrexia Elective Eye problems Communicable diseases (mumps, chicken poxI measles) GU problems fUTI, va$inaf b!wding, sexual assault) Seizures Not otherwise classified Missing data
N
%
669 289 230 66 74 9 1 412 192
(39) (17) (13) (4) (4) (0.5) (0.1) (24) (11)
125 65
(7) (4)
30 215 119
(21 (13) (7)
59 37 260 67 46
(3)
(2) (16) (41 (3)
43 26 25 23
(2) (2)
16
(1)
14 147 170
(1) @I ~10)
(3)
(1)
gent, 88% were discharged home. In total, 78.8% of patient visits were judged to be emergent or urgent at the time of admission. Of this total group, 83.5% of patients were discharged home. n
DISCUSSION
The purposes of this retrospective chart survey of pediatric use of emergency services were (1) to identify the frequency of types of problems with which children presented, and (2) to determine the variables related to the use of this health service. Charts were randomly selected from each month of the study year at each study setting to achieve a 10% sample and to control for seasonal variation.
Approximately 50% of this sample had diagnoses that reflected primary health care problems, as defined by Dershewitz (1988). These included-in descending order of frequency-soft tissue injuries ( 17%)) upper respiratory infections ( 11% ) , otitis media (7%), gastroenteritis (7%), lower respiratory infections (4%), and skin conditions (4%). This list of diagnoses is remarkably similar to any list of presenting complaints from such primary care facilities as community health centers or family practices. Why then was the emergency department chosen for care? Several reasons have been advanced for the choice of emergency care, including the perceived urgency and/or severity of the problem (Halperin, Myers, & Alpert, 1979); accessibility (Bowling et al., 1987; Habenstriet, 1986); quality of available technical and specialist support (Levy et al., 1979); and the perceived need for a second opinion concerning the problem (Hilker, 1978). Although this study design precluded any discussion with the patient/parent about their choice of the emergency department for care, the data suggest that perception of urgency and accessibility were important factors of the decision.
I n total,
78.8% of patient visits were judged to be emergent or urgent at the time of admission.
In the study setting in which triage data were recorded, only 21% of the visits were judged at admission to be non-urgent. It could be argued that patients’ (parents’) perceptions of distress, which initiated the help-seeking process, were for the most part (79%) congruent with the perceptions of the health professional. Whether this degree of agreement regarding urgency and, hence, appropriateness of use remained constant after a more thorough assessment is unknown. In both study settings combined, 86% of patients were discharged home. Within Hospital B, where triage data were available, 50% of patients categorized as emergent and 88% of urgent patients were discharged to their homes. While the discharge status of patients may suggest less agreement after patient assessment was completed, the decision to admit or discharge is influenced by a variety of clinical and situational variables and may not be a reliable indicator of urgency of the problem. In addition, there is considerable reluctance to hospitalize children unless absolutely necessary. Also, these data may reflect the types of urgent conditions that can be stabilized in the emergency de-
Journal of Pediatric Health Care
n
TABLE
2 Frequency*
Pediatric
of types of problems
in various age groups in combined
RESPIRATORY
Infant Toddler Preschool In school Adolescent Totals *Represents
n
TABLE
Departments
209
study settings
CASTROINTESTlNAL
TRAUMA
N
%
N
%
N
%
64 141 109 84 14 412
(16) (34) (27)
27 50 42 73 23 215
(13) (23) (20) (34) (11)
35 105 113 251 164 668
(5) (16) (17) (38)
(20) (3)
(25)
75% of total visits.
3 Combined
frequency*
of types of problems RESPIRATORY
Winter (Dee-Feb) Spring (Mar-May) Summer (June-Aug) Fal I (Sept-Nov) Totals *Represents
Use of Emergency
by season of the year in both study settings GASTROiNTESTlNAL
TRAUMA
N
%
N
%
N
%
125 103 72 106 406
(36.3) (30.2) (26.9) (31.5)
46 71 41 55 213
(13.3) (20.8) (15.3) (16.4)
173 167 154 175 669
(50.2) (48.9) (57.7) (52.1)
TOTAL N 344 341 267 337 iEF
75% of total visits.
partment. It is, however, reasonable to conclude from these data that the patients required health care services. The question remains whether the resources of the emergency department were not only necessary but sufficient for the types of presenting health care problems. The data lend considerable support to the irnportance of accessibility in the decision to use emergency services. Approximately one third of the study visits occurred in evening hours (6:00 PM to 11:OO PM) and one third of all visits per week took place on weekends. That the number of visits increased when physicians were not in their offices and when parents are not usually at work suggests it is becoming increasingly more difficult for working people to see a physician during traditional office hours. Although the overwhelming majority (98%) of children were patients of physicians in private practice, there were no data to suggest the family physician was contacted before the decision to use the emergency service. It seems that accessibility to the family health care provider is a key factor in choosing emergency care. Continuity of care, careful follow-up, and patient/parent education are all valued in primary care settings and tend not to be part of emergency department care. Given this orientation and the poten-
tial for establishing more personalized care, it seems preferable that primary health care problems be assessedand managed in community health centers and family physician offices. If health professionals are to be successful in influencing patients to use family practices rather than emergency services, some of the following changes seem indicated. First, extended hours of practice into evenings and on weekends would enhance accessibility. Second, patient education programs that address preventable illnesses and accidents are warranted, as are programs directed at early detection of health problems. Similarly, patients’/parents’ ability to differentiate urgent from deferrable problems demands knowledge and confidence, both gained through programs of education within an open and supportive relationship with a health care professional. Third, parents need to understand the expected course of their child’s illness, including the anticipated result of any therapy. For example, the parent whose child has been diagnosed with otitis media needs information concerning the nature of the problem, the expected effect of prescribed treatment, and the signs and symptoms indicative of a worsening condition. As well, they need to be informed of actions to intitiate should their child not respond to therapy. There is considerable evidence
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that the quality of the relationship between the health care professional and patient is critical to the success of such programs (Meichenbaum & Turk, 1987). The pediatric nurse practitioner can institute such education on a consistent basis while providing continuity in the care process. Despite the best efforts and actions of primary health care personnel, some individuals will continue to use hospital emergency services (Levy et al., 1979; Maynard & Dodge, 1983). Therefore, adaptation of pediatric emergency services to provide optimal quality care is also warranted. Because emergency departments are presently intended to serve patients with severe trauma or other serious disease, conflicting expectations result between user and provider about inappropriateness of this health service for non-urgent problems. Efforts should be made to educate the providers of emergency care about the reasons patients seek such care. The provision of on-site primary care pediatric services is also suggested. Such a service should use the strengths of pediatric nurse practitioners and primary care physicians. Hospital-based group practices (Halperin, Myers, & Alpert, 1979) or pediatric walkin clinics (Feldman & Cullum, 1984) represent such alternatives to community care. In such settings, communication links could be established between the on-site caregivers and community clinicians to facilitate appropriate follow-up. Patient and parent education by skilled educators would enhance the service traditionally associated with emergency care.
T
here was a definite pattern of use of services by hours of the day and days of the week.
In summary, this survey has identified the wide variety of health care problems in children who were brought to the emergency department. There was clear variation in the types of problems that occurred in various age groups and seasonal variation among conditions. There was a definite pattern of use of services by hours of the day and days of the week. Parents’ judgment about the urgency of the problem seemed to be congruent with the initial triage decision made by the emergency nurse. However, the preponderance of primary health care problems and the apparent demand for care outside of regular office hours suggest a disparity between user and provider expectation for health care services.
On the basis of our data, it appears that the emergency department will continue to be viewed as an alternate source of primary care for pediatric health problems. Rather than pursue the debate regarding the use and misuse of the emergency department for non-urgent problems, we should shift our attention to the provision of optimal care, regardless of setting. Nurse practitioners are especially well prepared for important roles in both community- and hospitalbased pediatric practices. n REFERENCES Bowling, A., Issacs, D., Armston, J., Roberts, J. E., & Elliot, E. J. ( 1987). Patientuseof pediatrichospitalcasualty department in the east end of London. Journal of Family l%uti~e, 4, 8590. Davison, A. G., Hildrey, C. C., & Floyer, A. (1983). Use and misuse of an accident and emergency department in the east end of London. Journal of the Rqval Socieg ofMedicine, 76, 3740. Dershewitz, R. A. (Ed.). (1988). Ambulatory pediatric care. Philadelphia: J.B. Lippincott. Feldman, W., & Cullum, C. (1984). The pediatric walk-in clinic: Competition for the private practitioner. Canadian Medical Association Journal, 130, 1003. Guterman, J., Franaszek, J. B., Murdy, D., & Gifford, M. (1985). The 1980 patient urgent study: Further analyses of the data. Annals ofEmegencyMedicine, 14, 1191-1198. Habenstriet, M. A. (1986). Health care patterns of non-urgent patients in an inner city emergency room. New Ywk State Journ& of Medicine. 86, 5 17. Halperin, R., Myers, A., & Alpert, J. (1979). Utilization of pediatric emergency services: A critical review. Pediatric Clinirs of North America, 26, 747-757. Hidtech, J. R. (1980). Changes in emergency deparnnent use associated with increased family physician availability. Journal of Farnib Practice, 11, 9 1. Hilker, T. (1978). Non-emergency visits to a pediatric emergency deparunent. Journal of American College of Emeuenq l’bysicians, 7(9). Levy, J. C., Bonnano, R. A., Schwartz, C. G., & Sanofsky, P. A. (1979). Primary care: Patterns of use of pediatric medical facilities. Medical Care, 9, 88 1. Maynard, E. J. & Dodge, J. S. (1983). Introducing a community health center in Mosgiel, New Zealand: Effects on use of the hospital accident and emergency department. Medical Care, 21, 379-388. Meichenbaum, D., & Turk, D. (1987). Facihtatin5 treatment adherence. New York: Plenum. Nelson, D. A. F., Nelson, M. A., Shank, H. C., & Thompson, F. (1979). Emergency room misuse by medical assistance patients in a family practice residency. Journal of Family Practice, 8, 341. Parker, S. (1983). Pediah care: A &de fm patient education. Norfolk, Corm.: Appleton-Century-Crofts. Uliman, R., Block, J. A., Boatright, N., & Stratmann, W. (1978). Impact of a primary care group practice on emergency room utilization at a community hospital. Medical Care, 16, 723.