ORIGINAL CONTRIBUTIONS

Received: September 19^th 2014

Accepted: October 14^th 2014

Perception of medical emergencies in a private pediatric hospital

Ramón Antonio González-López,^a José Iglesias-Leboreiro,^b Maria Isabel Bernárdez-Zapata,^b Manuel Testas-Hermo,^b Mario Enrique Rendón-Macías^a

^aUniversidad La Salle, Facultad Mexicana de Medicina, División de Postgrado, Distrito Federal, México

^bDepartamento de Pediatría Urgencias, Hospital Español de

México, Distrito Federal, México

Communication with: Mario Enrique Rendón-Macías

Email: drmariorendon@gmail.com

 

Background: The aim of this study was to determine if the care of child patients on admission, coincides with perception of real urgency on the part of parents with that of the doctor and not because of perceived worry in the family (perceived emergencies).

Methods: All the care given in the emergency department, from January 1^st 2009 to December 31^st 2010, was analyzed. A real urgency was determined by consensus on the conditions of the child. Sociodemographic of real urgency conditions were compared against those perceived.

Results: 8,888 consultations were given, of which 2,024 (22.7 %) met criteria for real urgency. The main causes of real urgency were infectious diseases were followed by accidents and poisoning. Of real emergencies 17 (1 %) eventually required intensive management. Factors associated with real urgency were age, non-infectious disease, occurring between Monday to Friday, during the morning shift and in the winter months.

Conclusions: The frequency of care for real urgency was low compared to that reported in other pediatric centers. Restructuring of pre-consultation services for the implementation of optimal patient classification before going to emergency helps greatly to optimize the use of the emergency department,  deriving the patients in true need sooner.

Keywords: Emergency medical services, Pediatric hospitals, Pediatrics.

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Emergency medical attention for children is a priority to maintain their health, since some diseases, even short term, can cause dire consequences if the emergency worsens. Emergency is ordinarily understood as medical care of a clinical problem that threatens the life or integrity of an organ or function, accelerating the need for care when it occurs in children;¹ it is therefore desirable for emergency medical services to always be available.

However, as Fiorentino¹ says from an operational point of view, an emergency is defined primarily by the child's needs and the perception of severity of their families, who decide to go to an emergency room for care for the infant. When this decision is based on an unjustified fear, that is, when the child is stable and shows no signs that may endanger their life or the integrity or functionality of an organ, this is considered a "felt emergency." Under this condition, going to an emergency room can contribute to saturating the capacity of the health care service, which can cause errors in the medical care of children and even in medical prescription,^2,3 or impact correct treatment.^4-6 On the other hand, a real medical emergency is defined as threatening the child's life or the functionality of an organ. Along this line of thinking, we decided to investigate real or perceived emergencies in the emergency department, from January 1^st, 2009 until December 31^st, 2010, gathering information about the causes perceived by parents.

Methods

Information from children’s records was collected regarding: age, diagnosis, and time and date of admission to the emergency department. Based on the clinical condition of the child upon review at admission, their diagnosis of illness, and in some cases the follow-up of their treatment in the hospital room or in intensive care, it was decided by consensus whether the care of these children was a real or felt emergency.

Table I classifies children into 5 categories according to their age (under one year, 1-5 years, 6-11 years, 12-15 years, and 16-18 years). Diagnoses were classified according to the system or apparatus involved, except infections, which were analyzed together, given their high frequency of occurrence.

Other factors analyzed were: day of the week of attention (summarized as "weekday" or attention from Monday to Friday, and "weekend" or attention during Saturday and Sunday), shift of attention (morning or 8:00 to 14:00, afternoon or 14:01 to 21:00, and night or 21:01 to 7:59), season (spring, summer, autumn, and winter) and the year. 

Finally, the exit status of children was recorded as: discharged home, hospitalization in room, intensive care hospitalization, death, or voluntary discharge.

Statistical analysis was performed among patients seen for a real emergency versus a felt emergency. The frequency of real emergencies was estimated in percentage with a 95% confidence interval, in the group in general and for each variable considered, and, given that it was a study of all cases, no statistical comparison was made (high possibility of making a statistical error). Just to establish associated factors we proceeded to perform a binary logistic regression with the previously mentioned predictors and emergency type as the dependent variable. The analysis was made using backward conditional selection strategy with SPSS version 20. Odds ratios and their confidence intervals were obtained with beta exponents. 

Results

During the analysis period a total of 8888 children were attended, in whom real emergency was determined in 2024 (22.7%) (95% CI 21.8-23.6%) and 77.2% determined as felt emergency (95% CI 76.3-78.1%). As shown in Table I, there were more cases of real emergency in the extreme ages (under one year and over 15), on weekdays, and during the morning shift. More real emergencies were also presented during the winter and fewer in the spring (p < 0.0001). There were no statistically significant differences with respect to sex and year.

Infectious processes in the presence of fever were the main reason for requesting attention, with an overall percentage of 42.7%. Second was conditions associated with poisonings in conjunction with injuries (25%), and thirdly gastrointestinal diseases (11%). The most frequent infectious processes (n = 3797) were upper respiratory infections (48.9%), followed by gastrointestinal (20.1%) and lower respiratory (18%).

When analyzing the proportion of real emergencies as the condition that caused attendance (Table II), it was found that the highest proportion of real versus felt emergency was in patients with cardiovascular disease, although the sample was very small. The proportion of real emergency in non-infectious diseases was also higher than in infectious diseases; in the first, the average percentage was 55%, while it was 20% for infectious. The lowest frequencies of real emergency occurred in dermatological conditions, some orthopedic conditions associated with muscle pain, and non-infectious external otitis evaluated in the otolaryngology department. It is important to note that there were 65 patients in whom no disease was found (healthy), who were admitted for general care questions, which happened particularly in children under one year of age.

With regard to the conditions of discharge, 6983 children (78.5%) were discharged to home with treatment recommendations, 6.8% of whom (n = 449) had gone for real emergencies meriting immediate treatment, 75% of which were associated with a trauma or poisoning that was resolved in the emergency room in a period not exceeding 24 hours. Hospitalization was indicated in 1870 patients (21%), of whom 170 (30.1%) were hospitalized for felt emergencies and 69.9% for real emergencies. A total of 17 of the 1700 (1%) real emergencies merited intensive management. Two patients died in the emergency room (one seven-year-old girl from acute abdomen, and another two years old with septic shock). It is worth noting that there were 14 voluntary discharges, of which only two cases were for real emergencies (both for bone fractures). Finally, two patients who had come with real emergencies (one for neurological disease, and the other for suspected neoplasia) were transferred to other hospital centers.

Table III shows that, in the multivariate analysis of the factors studied, those most associated with real emergency were as follows: for age, there was less chance of real emergency in the age groups from 1 to 15; there was greater chance of real emergency in organic diseases, as well as in attention to cases seen on weekdays and mornings. And finally, events seen in the winter.

Discussion

With our work it is clear that there are fewer real emergencies at the private level, since parents tend to use the emergency room when children present simple symptoms that could be handled in the office, unlike other hospitals that people turn to when it really is vital.

As it expected, we see that the kinds of emergency were highest when it came to children under one year and older than 16. It is possible that for the first, the level of concern generated is greater, so they go to emergency services much more frequently. On the other hand, for adolescents, going to a center is often less desirable and, therefore, they only request it when they feel really bad or really have life-threatening injuries.

As reported, the emergencies most observed are usually secondary to injuries, poisonings, or intoxications. Though all worthy of immediate management, not all cases threaten life or function, and they do not always need to be treated in a hospital. In many countries, telephone communication systems and now the Internet can help parents solve some non-serious cases in their homes. Through education we can achieve options so that assessment by parents and physicians of children who really need care can be more successful, so that in the end those who are at real risk are taken to an emergency room. For example, training in first aid measures to minimize damage and thus provide better hospital care.⁷

In relation to the diseases that led to immediate emergency care, infectious cases, it was obvious to find more real emergencies in conditions of chronic diseases or associated with previous malformations.

As for the conditions of care, as discussed previously, there were more real emergencies on weekdays and in the morning shift. This can be explained because the parents of children treated in our hospital work at these times and are therefore likely to make a better analysis of the conditions of their children so as not to miss work. Moreover, it is likely that analysis made during the work day is made by caregivers of children in daycares or schools, who tend to be more objective in identifying risks.

Finally, we note that in the winter there were more real emergencies, which were associated with more severe respiratory infectious diseases. This is expected due to the presence of virus outbreaks associated with these diseases and worsened conditions in at-risk children (asthma, bronchopulmonary dysplasia, heart disease, patients with neurological disability, among others). These seasonal changes have been reported in other studies.⁸

The main strength of this study is the large number of cases analyzed and the two years of study, as well as the proper classification of cases as real or felt, and the availability to follow up from intake to discharge.

Analyzing the types of emergencies in hospitals allows for action strategies to provide better quality of care. A key aspect is preventing over-utilization of these services, which occurs in situations where the chief complaint could be resolved in other places such as a doctor’s office.⁹ Although our frequency of real emergency is in the lower limit reported in other studies,¹⁰ it is still within the acceptable range. We had a high percentage of felt care associated with parents’ anguish before an unresolved disease, and there may have been a lack of information about the behavior of different disease entities, especially those of infectious origin.¹¹ Mainly, persistent fever was the most frequent reason for these consultations.

We find that the main limitation of the study is the hospital’s recognition bias, since, although it is an open hospital, care does not cover the entire representative population of our city. The characteristics of families, both in terms of socio-economics and education, could explain different behaviors in the request for emergency care. In the request for emergency care, the perception of children or their parents has great influence. 

Conclusions

The frequency of real emergency care was 24%, which is considered low for that reported in other pediatric centers. Restructuring of pre-consultation services for the implementation of optimal patient classification before going to the emergency room would help greatly to optimize the emergency department, allowing the admission of patients who actually warrant it sooner.

In addition, for the pediatric team, standardization in health education for parents in the management of symptoms and signs that warrant treatment of children with mild symptoms and signs, can reduce the rate of visits for felt emergencies.

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