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The Factors Affecting Neonatal Presentations to the Pediatric Emergency Department
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–6, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.12.031
Original Contributions
THE FACTORS AFFECTING NEONATAL PRESENTATIONS TO THE PEDIATRIC EMERGENCY DEPARTMENT Ezgi Deniz Batu, MD,* Serap Yeni, RN,† and Ozlem Teksam, MD† *Division of Rheumatology, Department of Pediatrics and †Division of Emergency Medicine, Department of Pediatrics, Hacettepe University Medical Faculty, Ankara, Turkey Reprint Address: Ezgi Deniz Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara 06100, Turkey
, Abstract—Background: A pediatric emergency department (PED) may be utilized by neonates for nonurgent complaints. Various factors, such as primiparity, maternal age, early postnatal discharge, race, income, and maternal and paternal educational levels, have been reported to affect the acuity of neonatal emergency department utilization. Objective: To determine the characteristics of PED visits by neonates (infants # 28 days of age) and to evaluate the factors affecting the acuity of these visits. Methods: We prospectively collected the data of neonates who were admitted to the PED of a tertiary university hospital within a 6-month period. Presenting problems were classified as acute if diagnostic tests were requested or the patient was hospitalized, unless the final diagnosis was ‘‘normal newborn.’’ Results: Over this period, 28,389 children (0–18 years of age) visited the PED, of which 531 were newborns (1.9%). The mean age was 14.1 ± 8.3 days, with a slight predominance of males (57.3%). The chief complaints were jaundice (23.4%), irritability (9.5%), and vomiting (7.1%), and the most common diagnoses were normal newborn (33.9%), indirect hyperbilirubinemia (13.2%), and colic (5.8%). Acute visits were 55.7% of the total visits. Premature infants, infants of multiparous mothers, infants of older mothers ($25 years), and physician-referred infants were more likely to present with acute problems (p values were 0.001, 0.013, 0.006, and <0.001, respectively). Conclusion: The results suggest that there may be a relationship between nonacute neonatal visits to a PED and insufficient knowledge of the caretaker on newborn care. Thus, more detailed education and early postnatal support programs regarding
newborn care may help to decrease nonacute PED visits by neonates. Ó 2015 Elsevier Inc. , Keywords—newborn; emergency department; acute visit; primiparity; prematurity
INTRODUCTION A pediatric emergency department (PED) may be utilized by neonates for nonurgent complaints. However, the arrival of a newborn to a busy emergency department (ED) is a concern for PED physicians. This concern grows out of several factors, such as crowded waiting and evaluation areas, which are inappropriate for newborns; high risk of acute deterioration; and similar response of newborns to variable types of stress, which makes it difficult to decide about the acuity of the condition (1). In addition, the differential diagnosis for each nonspecific symptom in the neonatal period is extensive (2). There has also been an increase in early discharges after birth in Turkey over the last few decades, as a result of changing psychosocial factors, health considerations, and financial constraints, which have been seen in other countries. Therefore, the management of early infant care has shifted from the newborn nursery to the PED. There are conflicting results of different studies about the effects of early neonatal discharge on the utilization of a PED
RECEIVED: 1 June 2014; FINAL SUBMISSION RECEIVED: 1 December 2014; ACCEPTED: 21 December 2014 1
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E. D. Batu et al.
(3–7). Previously, various factors, such as primiparity, maternal age, marital status, race, income, maternal and paternal educational levels, self-referral, and having a regular physician, have been reported to affect ED utilization (6,8–12). In our country, there have been increasing rates of newborns being discharged earlier and presenting to the PED with nonacute complaints, although there is no documentation about the increasing use of the PED or examining the urgency of presenting problems or demographic factors associated with ED use by families of newborn infants. In this prospective study, we determined the characteristics of PED visits by neonates and the demographic and perinatal factors associated with acute attendance at a PED of newborns within the first 28 days of life. MATERIALS AND METHODS This study was conducted prospectively in the PED of a large tertiary care hospital with more than 55,000 PED visits annually over a 6-month period from February through July 2011. Data were obtained on all newborns who attended the PED in the neonatal period (#28 days of age). All neonates visiting the PED were evaluated for neonatal presentations, maternal and neonatal characteristics, and the need for hospitalization and observation at the PED setting. A set of variables, including the age and gender of the patient, gestational week, birth weight, labor type, place of birth, time of discharge after birth, time of presentation to the ED and length of stay in the ED, method of referral (self or physician referred), presenting complaint(s), ED diagnosis, and maternal data (maternal age, parity, educational status) were recorded. We defined early discharge as a postnatal hospital stay of <48 h. The data were analyzed to determine the general characteristics of these patients and to identify the factors affecting the acuity of the visits. The visits were classified as acute if diagnostic tests were requested in the PED or if the patient was hospitalized, unless the final diagnosis was ‘‘normal newborn.’’ The triage code assigned by a triage nurse did not refer to an acute presentation because in our ED, all newborns are categorized as emergent or urgent for timely examination and treatment. For statistical analyses, we used SPSS 15.0 for Windows (IBM, Armonk, NY). Descriptive statistics were presented in the forms of percentages, medians, means, and standard deviations. We compared the groups by using cross tabs and chi-squared test; p < 0.05 was accepted as statistically significant. This study was approved by the research ethics committee of the study hospital.
RESULTS During the 6-month study period, a total of 28,389 patients visited our PED, of which 531 (1.9%) were neonates. Among those infants, the average age was 14.1 6 8.3 days, with a median age of 14 days. In total, 52% of infants were <14 days of age, and the remaining infants were ages 14 to 28 days. Males comprised 57.3% (n = 304) of the study group, with a male-to-female ratio of 1.34:1. Gestational age was <37 weeks in 71 infants (13.4%). Deliveries were performed at the hospital in a vast majority (99.6%) of the cases, and the labor type was cesarean section in half of the cases (51.8%). A total of 49 neonates (9.2%) had a birth weight < 2500 g. Additionally, 261 infants (49.2%) presented to the PED out of hours. Forty percent of patients spent <1 h in the PED, and 54% spent 1–6 h and 6% spent 6–24 h. Overall, 66.1% of infants were discharged within 48 h after birth, which was defined as an early postnatal discharge. The chief complaints of newborns presented to the PED were jaundice (23.4%), irritability (9.5%), and vomiting (7.1%), and the most common diagnoses were normal newborn (33.9%), indirect hyperbilirubinemia (13.2%), and colic (5.8%). Of all patients, 23.2% were hospitalized, and their most frequent diagnoses were indirect hyperbilirubinemia (17.9%) and pneumonia (10.6%). The admission rate in infants #7 days of age was found to be 31.8%, whereas it was 29% in infants #14 days of age. Of the PED visits by neonates, 55.7% (n = 296) were classified as acute presentations. A total of 20% of all infants were physician referred, and these infants were more likely to have acute complaints when they visited the PED, compared to self-referred ones (p < 0.001). Additionally, 34 (32%) of the 106 physician-referred infants were brought to the PED by ambulance. Acute presentations were more common among infants of multiparous mothers (p = 0.013) and mothers older than 25 years of age (p = 0.006). Premature infants were also more likely than mature infants to present with acute problems (p = 0.001). In addition, no significant difference was found in the acuity of the PED visits between early and late discharged infants in the postnatal period. There was no significant difference in the acuity of PED presentations between patients, with regard to the distance to PED. The other factors, such as age of the infant, maternal educational status, or birth weight, did not significantly affect the acuity of presentation (Table 1). When we examined the acutely presenting infants (n = 296), according to the hospital admission status, physician-referred infants and infants who were younger than 14 days of age were more likely to be admitted to the hospital (p < 0.001 and p = 0.004, respectively) (Table 2).
Neonates and the Emergency Department
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Table 1. Comparison of the Neonatal and Maternal Factors of Infants with Acute or Nonacute Presentations Neonatal and Maternal Factors Age <14 days 14–28 days Gestational week <37 weeks of gestation $37 weeks of gestation Birth weight <2500 g $2500 g Postnatal discharge time <48 h $48 h Maternal age <25 years $25 years Maternal parity Primipara Multipara Educational status of mother Less than high school High school and beyond Patient referral Self-referred Physician-referred
Acute n (%)
Nonacute n (%)
p Value
165 (59.8) 131 (51.4)
111 (40.2) 124 (48.6)
0.051
52 (73.2) 244 (53)
19 (26.8) 216 (47)
0.001
31 (63.3) 265 (55)
18 (36.7) 217 (45)
0.266
188 (53.6) 108 (60)
163 (46.4) 72 (40)
0.157
78 (47) 218 (59.7)
88 (53) 147 (40.3)
0.006
133 (50.4) 163 (61)
131 (49.6) 104 (39)
0.013
122 (59.2) 172 (52.9)
84 (40.8) 153 (47.1)
0.149
217 (51.1) 79 (74.5)
208 (48.9) 27 (25.5)
<0.001
DISCUSSION Our study demonstrated that 44.3% of PED visits by neonates were nonacute. Two previous studies by Kennedy et al. and Donovan et al. demonstrated nonacute neonatal visit rates of 70% and 49%, respectively (6,13). Furthermore, Lutfi et al. reported that approximately 90% of neonatal visits to the PED were seen by doctors and sent home immediately (7). The different ratios may be due to different definitions of acute visits and different inclusion criteria, especially with regard to the age of patients. In our study, we defined the visits as acute if the ED pediatrician required any assessment to rule out a serious problem or the patient was admitted to the hospital, unless the final diagnosis was normal newborn. The most frequent diagnoses were normal newborn, indirect hyperbilirubinemia, and infantile colic. Of 531 infants, 23.2% were admitted to the hospital in our study. Indirect hyperbilirubinemia, pneumonia, and sepsis accounted for 37.3% of our infant population who were admitted to hospital. Flanagan and Stewart reviewed 223 visits by neonates in the first 2 weeks of life, and feeding difficulties, respiratory tract infection, and jaundice were the most frequent diagnoses in their study population (14). Their admission rate was 24%, which was similar to ours (23.2%). Kennedy et al. showed that gastrointestinal system problems, minor infections, and well newborn were the most common diagnoses among infants <14 days of age (6).
Table 2. Comparison of the Neonatal and Maternal Factors of Acutely Presented Neonates, According to the Hospital Admission Status Neonatal and Maternal Factors (Acute Visits)
Hospitalized n (%)
Age <14 days 80 (48.5) 14–28 days 42 (32.1) Gestational week <37 weeks of 25 (48.1) gestation $37 weeks of 97 (39.8) gestation Birth weight <2500 g 15 (48.4) $2500 g 107 (40.4) Postnatal discharge time <48 h 70 (37.2) $48 h 52 (48.1) Maternal age <25 years 37 (47.4) $25 years 85 (39) Maternal parity Primipara 53 (39.8) Multipara 69 (42.3) Educational status of mother Less than high 52 (43.3) school High school and 65 (38.2) beyond Patient referral Self-referred 66 (30.4) Physician-referred 56 (70.9)
Nonhospitalized n (%)
p Value
85 (51.5) 89 (67.9)
0.004
27 (51.9)
0.268
147 (60.2) 27 (51.9) 158 (59.6)
0.391
118 (62.8) 56 (51.9)
0.066
41 (52.6) 133 (61)
0.193
80 (60.2) 94 (57.7)
0.666
68 (56.7)
0.383
105 (61.8) 151 (69.6) 23 (29.1)
<0.001
The admission rate of this study was 11%, which was lower than ours. In another study in infants #8 days of age, normal newborn, jaundice, and feeding problems were the most frequent diagnoses, and the hospital admission rate was 32.9% (15). Different admission rates are probably due to the differences between the study populations. On the other hand, the most frequent complaints and diagnoses for neonates visiting PEDs are usually similar. Therefore, emergency physicians should be familiar with the normal variations of physiology, jaundice, and feeding problems in newborns. In this study, we found that primiparity and a young maternal age (<25 years) were associated with a nonacute presentation (p = 0.013 and p = 0.006, respectively). This finding is consistent with the results of the study by Kennedy et al., which demonstrated that infants <14 days of age of primiparous mothers were more likely to utilize the ED with nonurgent complaints (6). Although the age of the infant does not seem to affect the acuity of the presentation to the PED in our study, infants younger than 14 days of age with an acute PED visit had higher hospital admission rates when compared to older neonates (p = 0.004). Prematurity status is an important measure of newborn risk (16). Our study revealed that premature infants were more likely to have acute
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problems when they visited the PED. This result is concordant with other studies (6,17,18). Reducing the length of postnatal hospital stays has given rise to some concerns about increasing re-admission rates. The effect of postnatal discharge time on the acuity of ED visits is still an area of debate in the literature (19). Some studies have demonstrated an association between earlier neonatal discharge and an increased rate of rehospitalization, whereas in several other studies, no difference was found between babies discharged early or late, with respect to the acuity of presentation to ED and admission rates (3–7,15,20,21). In our study, the postnatal discharge time was not associated with the acuity of PED visits by neonates. To decrease nonacute visits to the PED by neonates, providing parents a relevant and accurate education program on newborn care and a postdischarge followup within 48 h may be a better strategy than simply increasing the length of the postnatal hospital stay. PED physicians may identify specific groups of families, which may be targeted to receive a more detailed education and support for newborn care (6). The education regarding newborn care may take place in the perinatal period, which may minimize the effect of postnatal hospital stay on newborn health (22). Another goal should be facilitating the access of newborns and caretakers to medical care outside the PED to prevent the exposure of newborns to busy PEDs (17). Limitations The limitation of our study is that we did not have followup information for the nonacute neonates whom we sent home. There is a possibility that they were subsequently admitted to another hospital with acute problems that we missed. CONCLUSION Our study demonstrated associations between nonacute neonatal PED visits and maturity, primiparity, young maternal age (<25 years), and self-referral. There was no association between the timing of postnatal neonatal discharge and acuity of PED visits. Due to these results, it can be speculated that the nonacute PED visits in our study were mainly due to insufficient caretaker knowledge and information on newborn care. It is important to study these factors associated with the nature of PED visits to determine the groups of parents at risk and who probably need further education about newborn care and to minimize the nonurgent neonatal visits to the PED, which is costly and not an effective way of coordinating neonatal care. Being aware of these factors may also help PED physicians in deciding the acuity of the condition, which is also important
for proper triage. Future research should also focus on developing standard triage procedures and an evaluation of newborns in a busy PED by studying the factors affecting the nature of newborn PED visits. Acknowledgment—The authors would like to thank to all staff of _ Hacettepe University Ihsan Do gramacı Children’s Hospital Pediatric Emergency Department, including residents and nurses for their great support during the study.
REFERENCES 1. Perry AM, Caviness AC, Allen JY. Characteristics and diagnoses of neonates who revisit a pediatric emergency center. Pediatr Emerg Care 2013;29:58–62. 2. Brousseau T, Sharieff GQ. Newborn emergencies: the first 30 days of life. Pediatr Clin North Am 2006;53:69–84. vi. 3. Boulvain M, Perneger TV, Othenin-Girard V, Petrou S, Berner M, Irion O. Home-based versus hospital-based postnatal care: a randomised trial. BJOG 2004;111:807–13. 4. Danielsen B, Castles AG, Damberg CL, Gould JB. Newborn discharge timing and readmissions: California, 1992–1995. Pediatrics 2000;106:31–9. 5. Gupta P, Malhotra S, Singh DK, Dua T. Length of postnatal stay in healthy newborns and re-hospitalization following their early discharge. Indian J Pediatr 2006;73:897–900. 6. Kennedy TJ, Purcell LK, LeBlanc JC, Jangaard KA. Emergency department use by infants less than 14 days of age. Pediatr Emerg Care 2004;20:437–42. 7. Lutfi S, Al-Rifai H, Al-Ansari K. Neonatal visits to the pediatric emergency center and its implications on postnatal discharge practices in Qatar. J Clin Neonatol 2013;2:14–9. 8. Brown EM, Goel V. Factors related to emergency department use: results from the Ontario Health Survey 1990. Ann Emerg Med 1994;24:1083–91. 9. Feigelman S, Duggan AK, Bazell CM, Baumgardner RA, Mellits ED, DeAngelis C. Correlates of emergency room utilization in the first year of life. Clin Pediatr (Phila) 1990;29:698–705. 10. Kotagal UR, Atherton HD, Bragg E, Lippert C, Donovan EF, Perlstein PH. Use of hospital-based services in the first three months of life: impact of an early discharge program. J Pediatr 1997;130: 250–6. 11. Polivka BJ, Nickel JT, Salsberry PJ, Kuthy R, Shapiro N, Slack C. Hospital and emergency department use by young low-income children. Nurs Res 2000;49:253–61. 12. Woolfenden S, Ritchie J, Hanson R, Nossar V. Parental use of a paediatric emergency department as an ambulatory care service. Aust N Z J Public Health 2000;24:204–6. 13. Donovan EF, Perlstein PH, Atherton HD, Kotagal UR. Prenatal care and infant emergency department use. Pediatr Emerg Care 2000;16:156–9. 14. Flanagan CF, Stewart M. Factors associated with early neonatal attendance to a paediatric emergency department. Arch Dis Child 2014;99:239–43. 15. Millar KR, Gloor JE, Wellington N, Joubert GI. Early neonatal presentations to the pediatric emergency department. Pediatr Emerg Care 2000;16:145–50. 16. Jain S, Cheng J. Emergency department visits and rehospitalizations in late preterm infants. Clin Perinatol 2006;33:935–45. abstract xi. 17. Calado CS, Pereira AG, Santos VN, Castro MJ, Maio JF. What brings newborns to the emergency department?: a 1-year study. Pediatr Emerg Care 2009;25:244–8. 18. Escobar GJ, Greene JD, Hulac P, et al. Rehospitalisation after birth hospitalisation: patterns among infants of all gestations. Arch Dis Child 2005;90:125–31. 19. Bravo P, Uribe C, Contreras A. Early postnatal hospital discharge: the consequences of reducing length of
Neonates and the Emergency Department stay for women and newborns. Rev Esc Enferm USP 2011;45: 758–63. 20. Liu LL, Clemens CJ, Shay DK, Davis RL, Novack AH. The safety of newborn early discharge. The Washington State experience. JAMA 1997;278:293–8.
5 21. Lock M, Ray JG. Higher neonatal morbidity after routine early hospital discharge: are we sending newborns home too early? CMAJ 1999;161:249–53. 22. Standing TS, el-Sabagh N, Brooten D. Maternal education during the perinatal period. Clin Perinatol 1998;25:389–402.
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ARTICLE SUMMARY 1. Why is this topic important? By identifying the factors associated with nonacute neonatal visits to pediatric emergency departments (PEDs), we can determine the groups of parents who are at risk and probably need further education about newborn care. Accordingly, we can take precautions to minimize nonurgent neonatal visits, which are costly and not an effective way of coordinating neonatal care. 2. What does this study attempt to show? This study attempted to demonstrate the factors associated with nonacute neonatal visits to PEDs. 3. What are the key findings? Nonacute PED visits by neonates were shown to be associated with maturity, primiparity, young maternal age (<25 years), and self-referral. There was no association between timing of postnatal neonatal discharge and acuity of PED visits. 4. How is patient care impacted? From our results, we speculate that the reason for nonacute neonatal visits to the PED may be insufficient knowledge of the caretaker on newborn care. Thus, precautions to educate the groups of parents at risk in the prenatal period may be taken. Simply increasing the length of postnatal hospital stay does not seem to be an effective precaution.
http://dx.doi.org/10.1016/j.jemermed.2014.12.031
Original Contributions
THE FACTORS AFFECTING NEONATAL PRESENTATIONS TO THE PEDIATRIC EMERGENCY DEPARTMENT Ezgi Deniz Batu, MD,* Serap Yeni, RN,† and Ozlem Teksam, MD† *Division of Rheumatology, Department of Pediatrics and †Division of Emergency Medicine, Department of Pediatrics, Hacettepe University Medical Faculty, Ankara, Turkey Reprint Address: Ezgi Deniz Batu, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara 06100, Turkey
, Abstract—Background: A pediatric emergency department (PED) may be utilized by neonates for nonurgent complaints. Various factors, such as primiparity, maternal age, early postnatal discharge, race, income, and maternal and paternal educational levels, have been reported to affect the acuity of neonatal emergency department utilization. Objective: To determine the characteristics of PED visits by neonates (infants # 28 days of age) and to evaluate the factors affecting the acuity of these visits. Methods: We prospectively collected the data of neonates who were admitted to the PED of a tertiary university hospital within a 6-month period. Presenting problems were classified as acute if diagnostic tests were requested or the patient was hospitalized, unless the final diagnosis was ‘‘normal newborn.’’ Results: Over this period, 28,389 children (0–18 years of age) visited the PED, of which 531 were newborns (1.9%). The mean age was 14.1 ± 8.3 days, with a slight predominance of males (57.3%). The chief complaints were jaundice (23.4%), irritability (9.5%), and vomiting (7.1%), and the most common diagnoses were normal newborn (33.9%), indirect hyperbilirubinemia (13.2%), and colic (5.8%). Acute visits were 55.7% of the total visits. Premature infants, infants of multiparous mothers, infants of older mothers ($25 years), and physician-referred infants were more likely to present with acute problems (p values were 0.001, 0.013, 0.006, and <0.001, respectively). Conclusion: The results suggest that there may be a relationship between nonacute neonatal visits to a PED and insufficient knowledge of the caretaker on newborn care. Thus, more detailed education and early postnatal support programs regarding
newborn care may help to decrease nonacute PED visits by neonates. Ó 2015 Elsevier Inc. , Keywords—newborn; emergency department; acute visit; primiparity; prematurity
INTRODUCTION A pediatric emergency department (PED) may be utilized by neonates for nonurgent complaints. However, the arrival of a newborn to a busy emergency department (ED) is a concern for PED physicians. This concern grows out of several factors, such as crowded waiting and evaluation areas, which are inappropriate for newborns; high risk of acute deterioration; and similar response of newborns to variable types of stress, which makes it difficult to decide about the acuity of the condition (1). In addition, the differential diagnosis for each nonspecific symptom in the neonatal period is extensive (2). There has also been an increase in early discharges after birth in Turkey over the last few decades, as a result of changing psychosocial factors, health considerations, and financial constraints, which have been seen in other countries. Therefore, the management of early infant care has shifted from the newborn nursery to the PED. There are conflicting results of different studies about the effects of early neonatal discharge on the utilization of a PED
RECEIVED: 1 June 2014; FINAL SUBMISSION RECEIVED: 1 December 2014; ACCEPTED: 21 December 2014 1
2
E. D. Batu et al.
(3–7). Previously, various factors, such as primiparity, maternal age, marital status, race, income, maternal and paternal educational levels, self-referral, and having a regular physician, have been reported to affect ED utilization (6,8–12). In our country, there have been increasing rates of newborns being discharged earlier and presenting to the PED with nonacute complaints, although there is no documentation about the increasing use of the PED or examining the urgency of presenting problems or demographic factors associated with ED use by families of newborn infants. In this prospective study, we determined the characteristics of PED visits by neonates and the demographic and perinatal factors associated with acute attendance at a PED of newborns within the first 28 days of life. MATERIALS AND METHODS This study was conducted prospectively in the PED of a large tertiary care hospital with more than 55,000 PED visits annually over a 6-month period from February through July 2011. Data were obtained on all newborns who attended the PED in the neonatal period (#28 days of age). All neonates visiting the PED were evaluated for neonatal presentations, maternal and neonatal characteristics, and the need for hospitalization and observation at the PED setting. A set of variables, including the age and gender of the patient, gestational week, birth weight, labor type, place of birth, time of discharge after birth, time of presentation to the ED and length of stay in the ED, method of referral (self or physician referred), presenting complaint(s), ED diagnosis, and maternal data (maternal age, parity, educational status) were recorded. We defined early discharge as a postnatal hospital stay of <48 h. The data were analyzed to determine the general characteristics of these patients and to identify the factors affecting the acuity of the visits. The visits were classified as acute if diagnostic tests were requested in the PED or if the patient was hospitalized, unless the final diagnosis was ‘‘normal newborn.’’ The triage code assigned by a triage nurse did not refer to an acute presentation because in our ED, all newborns are categorized as emergent or urgent for timely examination and treatment. For statistical analyses, we used SPSS 15.0 for Windows (IBM, Armonk, NY). Descriptive statistics were presented in the forms of percentages, medians, means, and standard deviations. We compared the groups by using cross tabs and chi-squared test; p < 0.05 was accepted as statistically significant. This study was approved by the research ethics committee of the study hospital.
RESULTS During the 6-month study period, a total of 28,389 patients visited our PED, of which 531 (1.9%) were neonates. Among those infants, the average age was 14.1 6 8.3 days, with a median age of 14 days. In total, 52% of infants were <14 days of age, and the remaining infants were ages 14 to 28 days. Males comprised 57.3% (n = 304) of the study group, with a male-to-female ratio of 1.34:1. Gestational age was <37 weeks in 71 infants (13.4%). Deliveries were performed at the hospital in a vast majority (99.6%) of the cases, and the labor type was cesarean section in half of the cases (51.8%). A total of 49 neonates (9.2%) had a birth weight < 2500 g. Additionally, 261 infants (49.2%) presented to the PED out of hours. Forty percent of patients spent <1 h in the PED, and 54% spent 1–6 h and 6% spent 6–24 h. Overall, 66.1% of infants were discharged within 48 h after birth, which was defined as an early postnatal discharge. The chief complaints of newborns presented to the PED were jaundice (23.4%), irritability (9.5%), and vomiting (7.1%), and the most common diagnoses were normal newborn (33.9%), indirect hyperbilirubinemia (13.2%), and colic (5.8%). Of all patients, 23.2% were hospitalized, and their most frequent diagnoses were indirect hyperbilirubinemia (17.9%) and pneumonia (10.6%). The admission rate in infants #7 days of age was found to be 31.8%, whereas it was 29% in infants #14 days of age. Of the PED visits by neonates, 55.7% (n = 296) were classified as acute presentations. A total of 20% of all infants were physician referred, and these infants were more likely to have acute complaints when they visited the PED, compared to self-referred ones (p < 0.001). Additionally, 34 (32%) of the 106 physician-referred infants were brought to the PED by ambulance. Acute presentations were more common among infants of multiparous mothers (p = 0.013) and mothers older than 25 years of age (p = 0.006). Premature infants were also more likely than mature infants to present with acute problems (p = 0.001). In addition, no significant difference was found in the acuity of the PED visits between early and late discharged infants in the postnatal period. There was no significant difference in the acuity of PED presentations between patients, with regard to the distance to PED. The other factors, such as age of the infant, maternal educational status, or birth weight, did not significantly affect the acuity of presentation (Table 1). When we examined the acutely presenting infants (n = 296), according to the hospital admission status, physician-referred infants and infants who were younger than 14 days of age were more likely to be admitted to the hospital (p < 0.001 and p = 0.004, respectively) (Table 2).
Neonates and the Emergency Department
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Table 1. Comparison of the Neonatal and Maternal Factors of Infants with Acute or Nonacute Presentations Neonatal and Maternal Factors Age <14 days 14–28 days Gestational week <37 weeks of gestation $37 weeks of gestation Birth weight <2500 g $2500 g Postnatal discharge time <48 h $48 h Maternal age <25 years $25 years Maternal parity Primipara Multipara Educational status of mother Less than high school High school and beyond Patient referral Self-referred Physician-referred
Acute n (%)
Nonacute n (%)
p Value
165 (59.8) 131 (51.4)
111 (40.2) 124 (48.6)
0.051
52 (73.2) 244 (53)
19 (26.8) 216 (47)
0.001
31 (63.3) 265 (55)
18 (36.7) 217 (45)
0.266
188 (53.6) 108 (60)
163 (46.4) 72 (40)
0.157
78 (47) 218 (59.7)
88 (53) 147 (40.3)
0.006
133 (50.4) 163 (61)
131 (49.6) 104 (39)
0.013
122 (59.2) 172 (52.9)
84 (40.8) 153 (47.1)
0.149
217 (51.1) 79 (74.5)
208 (48.9) 27 (25.5)
<0.001
DISCUSSION Our study demonstrated that 44.3% of PED visits by neonates were nonacute. Two previous studies by Kennedy et al. and Donovan et al. demonstrated nonacute neonatal visit rates of 70% and 49%, respectively (6,13). Furthermore, Lutfi et al. reported that approximately 90% of neonatal visits to the PED were seen by doctors and sent home immediately (7). The different ratios may be due to different definitions of acute visits and different inclusion criteria, especially with regard to the age of patients. In our study, we defined the visits as acute if the ED pediatrician required any assessment to rule out a serious problem or the patient was admitted to the hospital, unless the final diagnosis was normal newborn. The most frequent diagnoses were normal newborn, indirect hyperbilirubinemia, and infantile colic. Of 531 infants, 23.2% were admitted to the hospital in our study. Indirect hyperbilirubinemia, pneumonia, and sepsis accounted for 37.3% of our infant population who were admitted to hospital. Flanagan and Stewart reviewed 223 visits by neonates in the first 2 weeks of life, and feeding difficulties, respiratory tract infection, and jaundice were the most frequent diagnoses in their study population (14). Their admission rate was 24%, which was similar to ours (23.2%). Kennedy et al. showed that gastrointestinal system problems, minor infections, and well newborn were the most common diagnoses among infants <14 days of age (6).
Table 2. Comparison of the Neonatal and Maternal Factors of Acutely Presented Neonates, According to the Hospital Admission Status Neonatal and Maternal Factors (Acute Visits)
Hospitalized n (%)
Age <14 days 80 (48.5) 14–28 days 42 (32.1) Gestational week <37 weeks of 25 (48.1) gestation $37 weeks of 97 (39.8) gestation Birth weight <2500 g 15 (48.4) $2500 g 107 (40.4) Postnatal discharge time <48 h 70 (37.2) $48 h 52 (48.1) Maternal age <25 years 37 (47.4) $25 years 85 (39) Maternal parity Primipara 53 (39.8) Multipara 69 (42.3) Educational status of mother Less than high 52 (43.3) school High school and 65 (38.2) beyond Patient referral Self-referred 66 (30.4) Physician-referred 56 (70.9)
Nonhospitalized n (%)
p Value
85 (51.5) 89 (67.9)
0.004
27 (51.9)
0.268
147 (60.2) 27 (51.9) 158 (59.6)
0.391
118 (62.8) 56 (51.9)
0.066
41 (52.6) 133 (61)
0.193
80 (60.2) 94 (57.7)
0.666
68 (56.7)
0.383
105 (61.8) 151 (69.6) 23 (29.1)
<0.001
The admission rate of this study was 11%, which was lower than ours. In another study in infants #8 days of age, normal newborn, jaundice, and feeding problems were the most frequent diagnoses, and the hospital admission rate was 32.9% (15). Different admission rates are probably due to the differences between the study populations. On the other hand, the most frequent complaints and diagnoses for neonates visiting PEDs are usually similar. Therefore, emergency physicians should be familiar with the normal variations of physiology, jaundice, and feeding problems in newborns. In this study, we found that primiparity and a young maternal age (<25 years) were associated with a nonacute presentation (p = 0.013 and p = 0.006, respectively). This finding is consistent with the results of the study by Kennedy et al., which demonstrated that infants <14 days of age of primiparous mothers were more likely to utilize the ED with nonurgent complaints (6). Although the age of the infant does not seem to affect the acuity of the presentation to the PED in our study, infants younger than 14 days of age with an acute PED visit had higher hospital admission rates when compared to older neonates (p = 0.004). Prematurity status is an important measure of newborn risk (16). Our study revealed that premature infants were more likely to have acute
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problems when they visited the PED. This result is concordant with other studies (6,17,18). Reducing the length of postnatal hospital stays has given rise to some concerns about increasing re-admission rates. The effect of postnatal discharge time on the acuity of ED visits is still an area of debate in the literature (19). Some studies have demonstrated an association between earlier neonatal discharge and an increased rate of rehospitalization, whereas in several other studies, no difference was found between babies discharged early or late, with respect to the acuity of presentation to ED and admission rates (3–7,15,20,21). In our study, the postnatal discharge time was not associated with the acuity of PED visits by neonates. To decrease nonacute visits to the PED by neonates, providing parents a relevant and accurate education program on newborn care and a postdischarge followup within 48 h may be a better strategy than simply increasing the length of the postnatal hospital stay. PED physicians may identify specific groups of families, which may be targeted to receive a more detailed education and support for newborn care (6). The education regarding newborn care may take place in the perinatal period, which may minimize the effect of postnatal hospital stay on newborn health (22). Another goal should be facilitating the access of newborns and caretakers to medical care outside the PED to prevent the exposure of newborns to busy PEDs (17). Limitations The limitation of our study is that we did not have followup information for the nonacute neonates whom we sent home. There is a possibility that they were subsequently admitted to another hospital with acute problems that we missed. CONCLUSION Our study demonstrated associations between nonacute neonatal PED visits and maturity, primiparity, young maternal age (<25 years), and self-referral. There was no association between the timing of postnatal neonatal discharge and acuity of PED visits. Due to these results, it can be speculated that the nonacute PED visits in our study were mainly due to insufficient caretaker knowledge and information on newborn care. It is important to study these factors associated with the nature of PED visits to determine the groups of parents at risk and who probably need further education about newborn care and to minimize the nonurgent neonatal visits to the PED, which is costly and not an effective way of coordinating neonatal care. Being aware of these factors may also help PED physicians in deciding the acuity of the condition, which is also important
for proper triage. Future research should also focus on developing standard triage procedures and an evaluation of newborns in a busy PED by studying the factors affecting the nature of newborn PED visits. Acknowledgment—The authors would like to thank to all staff of _ Hacettepe University Ihsan Do gramacı Children’s Hospital Pediatric Emergency Department, including residents and nurses for their great support during the study.
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5 21. Lock M, Ray JG. Higher neonatal morbidity after routine early hospital discharge: are we sending newborns home too early? CMAJ 1999;161:249–53. 22. Standing TS, el-Sabagh N, Brooten D. Maternal education during the perinatal period. Clin Perinatol 1998;25:389–402.
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ARTICLE SUMMARY 1. Why is this topic important? By identifying the factors associated with nonacute neonatal visits to pediatric emergency departments (PEDs), we can determine the groups of parents who are at risk and probably need further education about newborn care. Accordingly, we can take precautions to minimize nonurgent neonatal visits, which are costly and not an effective way of coordinating neonatal care. 2. What does this study attempt to show? This study attempted to demonstrate the factors associated with nonacute neonatal visits to PEDs. 3. What are the key findings? Nonacute PED visits by neonates were shown to be associated with maturity, primiparity, young maternal age (<25 years), and self-referral. There was no association between timing of postnatal neonatal discharge and acuity of PED visits. 4. How is patient care impacted? From our results, we speculate that the reason for nonacute neonatal visits to the PED may be insufficient knowledge of the caretaker on newborn care. Thus, precautions to educate the groups of parents at risk in the prenatal period may be taken. Simply increasing the length of postnatal hospital stay does not seem to be an effective precaution.