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Journal of the Academy of Hospital Administration

A STUDY OF SICKNESS & ADMISSION PATTERN OF PATIENTS ATTENDING AN EMERGENCY DEPARTMENT IN A TERTIARY CARE HOSPITAL

Author(s): A. Chattoraj, S. Satpathy

Vol. 18, No. 1 (2006-01 - 2006-12)

A. Chattoraj(1), S. Satpathy(2)

Key Words: Emergency, Emergency Department (ED), Casualty, co morbidities, disciplines, admissions

ABSTRACT

Emergency Medicine is yet to be considered as a specialty and the emergency care needs of the patients are catered through the “casually” department in most hospitals in India. However, the workload on this department and the emerging needs of the department as well as patients, play a very crucial role in providing quality services and operational profitability in hospitals. A study was undertaken to analyze the sickness pattern of patients coming to the Emergency Department (ED) and their subsequent pattern of admission vis-a-vis the type of sickness they reported to the Casualty. This apex tertiary care hospital Casualty, which receives approximately 500-600 patients every day, accounts for 11% of the admissions to the hospital. On an average, 20-25 patients are admitted daily from the Casualty. Findings showed that the majority of the patients are admitted under General Medicine; of which, respiratory disorders accounted for the maximum number.

Co morbidities in the form of Diabetes Mellitus and Hypertension were found to be common. It was also found out that once patients were admitted to the ward of the concerned specialty, the rest got accommodated in the emergency wards. A very small percentage of the patients were admitted to private wards from the Casualty. Interestingly, most of the admissions took place in the afternoon shift. While disciplines like Neurosurgery, Cardiology and Gastroenterology had bulk of the admissions, Dental surgery, Dermatology and Psychiatry accounted for the least number of admissions.

INTRODUCTION

“Emergency” is defined as a condition determined clinically, or considered by the patient or his relative as requiring urgent medical, dental or allied service, failing which it would result in loss of life or limb. “Medical Emergency” is defined as a situation when the patient requires urgent and high quality medical care to prevent loss of life or limb and initiate action for the restoration of normal healthy life. Emergency Medicine is not a specialty in India as yet and hence, very few hospitals in our country currently have Emergency Medicine Department (EMD). However, most hospitals have an area designated as “Casualty”, which is most often staffed by junior doctors and is inadequately equipped to effectively handle emergencies.1

Emergency Care should be of high quality, cost effective and compassionate. The Accident & Emergency services are one of the mainstays in the chain of medical care offered by the present day hospitals. The need for effective emergency healthcare delivery through an Emergency Department (ED) is well recognized and all hospitals must be able to provide basic life support through their Emergency Services to the patients in need. With emergency department admissions accounting for about 40 percent of all hospital admissions in most countries, managing and improving processes in the ED is crucial to both care quality and operational profitability2. In 1961, Platt Committee (UK) recommended the name Accident & Emergency Department (A & E Dept.) for “casualty” services. In India, the Central Council of Health in 1963 urged all State Governments to set up Emergency Medical Services in all major towns & cities3. Common denominators of any successful Emergency Care are4:

  • Availability of adequate physical facilities, equipments and supply of all life saving drugs and surgical items.
  • Immediate professional attention after arrival in the hospital ED (Emergency Department)
  • Continued and contant medical support till the patient is in the ED.
  • Speedy diagnosis and resuscitation so as to make it possible for integrating a patient into an existing system of patient care services in the institution.

AIM & OBJECTIVES

The aim of the present study was to analyze the illness profile of patients attending the Emergency Department (Casualty) at the tertiary care hospital; and their subsequent admission pattern.

The key objectives were to:

  • Determine the workload of the hospital Emergency Department (Casualty) and find out trends over a specified period of time (3 months) in terms of number of patients as well as available emergency beds.
  • Ascertain the category of patients (attending Casualty) based on the type of illness they are diagnosed to have during the specified period of time.
  • Analyze the admission patterns under various medical and surgical disciplines during the specified time period with the type of sicknesses the patients reported with.
  • Elicit the correlation between the pattern of admission and illness profile.

METHODOLOGY

A retrospective record based study was carried out of the patients who had reported to the Emergency Department (casualty) of the tertiary care hospital over a period of three months (June to August 2003). Data was collected from secondary sources, (e.g. hospital statistics, bed census etc.); and focus group discussions were held with the doctors and nurses at the Emergency Department (casualty) to get insight into various illnesses for categorisation of patients. Descriptive statistics was used and findings were discussed with suitable explanations. Study design was cross sectional and study population included all patients attending Emergency Department during three months study period.

To study the type of sicknesses vis-a-vis the pattern of admission among the patients reporting to the Casualty, a detailed study was carried out of the patients admitted to the AIIMS Hospital from the Emergency over a period of three months during the period June 2003 to August 2003.

Variables studied were:

  1. Increase in number of patients and emergency beds (till 2003).
  2. Average daily admission and its ratio to total admissions.
  3. Distribution of patients across specialties during these 3 months.

RESULTS

• Workload on ED (Casualty):

The study revealed that during the last 3-4 years there has been a steady rise in the Emergency Department attendance, both in absolute terms as well as daily averages.

Table-1: Average daily attendance in the ED (Casualty)

Year ED Attendance Average Daily Attendance
2000-01 123145 337
2001-02 117561 322
2002-03 134052 667
2003-04
(April 2003-December 2003)
119530 434

However, it was also evident that the Casualty (ED) attendance as a percentage of total attendance has remained more or less constant at around 9% during this period (Table 2).

Table 2: Casualty attendance as a percentage of total OPD attendance during the last three years

Year Total OPD
Attendance
Total Emergency
OPD Attendance
% COPD / OPD
Attendance
2000-01 1309278 123145 9.4
2001-02 1377201 117561 8.5
2002-03 1444587 134052 9.3

Results revealed that the availability of emergency beds in the tertiary care hospital (as a % of bed complement) showed a gradual rise from 5.60% in 70-71 to 13.6% in 2003 October onwards (Table 3).

Table 3: Emergency beds as a % of hospital bed complement

Year Bed Complement Emergency Ward
Beds
Emergency beds as a % of
bed complement
1970-71 750 42 5.60
1974-75 775 50 6.45
1978-79 795 65 8.17
1979-80 810 70 8.64
1989-90 866 75 8.66
1999-00 866 75 8.66
2003
October
onwards
986 135 13.6

Table 4: Average daily emergency admission during the last three years

Year Total Emergency
Admission
Average daily Emergency
Admission
2001-02 7789 21.34
2002-03 8314 22.78
2003-04
(April 2003-December 2003)
5694 20.71

It is seen that on an average about 20-25 patients are admitted daily from the Casualty. Existing policy of the hospital does not allow admission more than the bed complement. Table 1 above shows that the COPD attendance has been increasing steadily. However, Emergency admission figures have remained more or less static, seeming to suggest that Emergency admissions have reached saturation point.

Table 5: Total admission, emergency admissions and their percentage

Year Total
Admissions
Admission in
emergency wards
Percentage
2000-01 68443 7941 11.6
2001-02 70826 7789 10.99
2002-03 74856 8314 11.1

Emergency admissions, as a percentage of total admissions to the hospital has remained static at around 11%.

Admissions from Casualty

Patients admitted from ED during the study period (n-1782) were studied and categorised into various medical and surgical specialties and super specialties. The following observations were made:

Table 6: Distribution of patients specialty wise admitted from Casualty

Specialty Actual no
of patients
(n = 1782)
% of total
emergency
admissions
Medicine 286 16.04
Neuro Surgery 210 11.38
Gastro Enterology 186 10.43
Cardiology 179 10.04
Paediatric Medicine 176 9.76
Surgery 145 8.1
Orthopaedics 136 7.63
Neurology 115 6.45
Nephrology 61 3.32
Paediatric Surgery 51 2.86
Haematology 49 2.75
Obstetrics & Gynaecology 40 2.24
Urology 27 1.5
ENT 33 1.35
Radiotherapy 23 1.29
Medical Oncology 23 1.29
Cardio Thoracic & Vascular
Surgery (CTVS)
21 1.17
Endocrinology 16 0.89
Gastro Instestinal Surgery 14 0.78
Psychiatry 7 0.39
Dermatology 5 0.28
Dental Surgery 1 0.056

Table 7: Distribution of patients admitted in various areas thorough Emergency

Area June 2003 July 2003 Aug 2003 Total %
Emergency Wards 287 240 277 784 43.99%
Specialty Wards 254 198 202 654 36.7%
Specialty ICUs 94 95 98 287 16.11%
Pvt Ward 6 2 3 11 0.62%
Peripheral bed (vacant beds in unrelated speciality wards) 13 20 13 46 2.36%

About half (43.99%) of the patients admitted through ED are admitted in Emergency wards and about one third (36.7%) in speciality wards. One seventh of the admissions (16.11%) are in ICU; 2.36% in peripheral beds and less than 1% in Private Wards.

Fig 1: 1% Distribution of patients admitted through Emergency OPD

It is evident that about two thirds (63.13) of the patients were admitted under medical disciplines (specialties & super specialties) with Medicine, Gastroenterology and Cardiology being the top three disciplines which account for about half of the patients. Similarly, more than one third (36.87%) patients were admitted under surgical disciplines, with Neurosurgery, General surgery and Orthopaedics accounting for one fourth of surgical patients.

The following findings were observed during the study:

  • Total Emergency admissions have increased by 10% during last three years.
  • OPD patients are at times admitted in the emergency ward on the pretext of non availability of bed in respective speciality even if the cases are non emergent.
  • Emergency wards receive 44% of COPD admissions while 54% cases are admitted directly in concerned specialty ward from casualty complex.
  • Of those patients who go directly to specialty wards, 17% are admitted directly in ICUs.
  • A negligible number of patients (0.62%) are admitted directly to Private wards (Payment wards) from the casualty.
  • Sometimes the Emergency ward beds are exhausted and the patients are admitted on peripheral beds (vacant beds in non related speciality wards identified from the evening census) made available through the Hospital Administration (2% cases). Distribution of patients across specialities and illness profile
  • The bulk of the patients admitted from the Emergency are admitted under the discipline of Medicine (17%). About 45% of these patients are found to be suffering from respiratory disorders, the top two ailments being Chronic Obstructive Airways Disease (COAD) and Tuberculosis. The other frequent cause of admission under Medicine is poisoning from various substances including snake venom.
  • Paediatric patients comprise nearly 13% of the admissions from the COPD under the disciplines of Paediatric Medicine (10%) and Paediatric Surgery (3%).
  • General surgery discipline and Orthopaedics accounted for about 8% of the admissions each.
  • Least number of admissions took place under Dental Surgery (0.056%) followed by Dermatology (0.28%) and Psychiatry (0.39%).
  • One tenth (10%) of the admissions are for patients who are 70 years of age or older.
  • The other disciplines under whom large number of admissions take place from the emergency are Neurosurgery (11%), Cardiology (10%) and Gastroenterology (10%). Head injuries from road traffic accidents resulting in intracranial bleed is the commonest neurosurgical problem. Coronary Artery Disease (CAD) accounts from the majority of the admissions under Cardiology and Cirrhosis of Liver with either upper GI or lower GI bleed is the commonest cause for admission under Gastroenterology.
  • It was seen that 42% of the admissions were made in the afternoon shift, 38% in the night shift and only 16% of the admissions took place in the morning shift.

In the United States of America studies have revealed that5:

  • Most admissions are routine admissions to the hospital—not through the Emergency Department.
  • However, over a third of all hospital admissions are through the Emergency Department.
  • Five of the top 10 conditions for which people are admitted through the Emergency are heart problems, like heart attack.
  • Two of the top 10 conditions are infections: pneumonia and blood infection (septicemia).
  • Nearly 55 percent of hospital stays for the very old (80 years and older) start in the Emergency Department, compared with 45 percent for younger age groups.
  • Over half of all hospitalized patients have at least one co morbidity. Co morbidities are coexisting conditions that are not the main reason for the hospital stay. About a third of patients have two or more. High blood pressure (hypertension) is the most common co morbidity. Other common co morbidities are lung disease and diabetes.

DISCUSSION

Emergency Services are a vital component of the hospital and has become the round the clock physician of the community. The ED (Casualty), of the tertiary care hospital which receives approximately 500&600 patients every day, accounts for 11% of the admissions to the hospital. On an average 20-25 patients are admitted daily. During the study, it was found out that most of the admissions took place in the afternoon shift (1 pm to 9 pm) and least admissions were made in the morning shift. The possible explanation for this could be that during morning shift OPD is open and most patients prefer to go there, where as during later half of afternoon shift only Emergency Deptt. is accessible for patient care. The limited beds available get filled up during this shift, leaving very few beds for patients attending ED during night shift. Majority of the patients were admitted under the discipline of General Medicine. Of these, respiratory disorders accounted for the maximum number of admissions. Co morbidities in the form of Diabetes Mellitus and Hypertension are common. The other disciplines under whom bulk of the admissions take place are Neurosurgery, Cardiology and Gastroenterology. Dental surgery, Dermatology and Psychiatry accounted for the least number of admissions. Nearly 13% of the admissions awere of the paediatric age group and 10% admissions were in the 70 plus age group. Most of the patients were admitted to the ward of the concerned speciality. Rest were accommodated in the emergency wards. A very small percentage of the patients were admitted to private wards from the casualty. Ideally provision of all diagnostic and therapeutic facilities for the emergency should be made in the emergency department itself so that the Emergency dept is not dependent at all on other areas of the main hospital. The study helps us to focus and plan on the specific areas of manpower and infrastructure needed to increase the efficiency and effectiveness of the Emergency Department. Data on average and peak daily emergency department admissions helps predict the demand and allows for planning for the capacity needed and system adjustments to meet the demand. For example, ED staff can be rescheduled from low-demand to highdemand periods6. A multidisciplinary care coordination team perhaps would improve emergency department practice7.

CONCLUSION

The ED of modern hospital are considered as “minihospitals” today and form an important part in the chain of medical care. The ED of tertiary care public sector hospital catering to about 500 patients, admits about 20-25 patients daily. The study was undertaken to determine workload trends over 3 months and analyse the sickness pattern vis-a-vis. admission of patients in various disciplines. Results showed that majority of patients are admitted under medicine disciplines; and co-morbidities like DM & HT were most common.

REFERENCES

  1. Vasnaik M. Emergency Medicine Department – operational essentials for effective implementation in: Gupta S, Parmar NK, Kant S. Editors, Emergency Medical Services & Disaster Management – A Holistic Approach. 1st ed. New Delhi Jaypee Publishers; 2001. p 38-48.
  2. Cerner, Clinical Solutions: Emergency Medicine. Cerner Corporation, 2004
  3. Satpathy S. Emergency Medical Technicians in the new millennium. Journal of Academy of Hospital Administration 1999; 11 (2): 21-7.
  4. Medical Communication Network, Hospital Administration Section. URL: http://www.mcindia.com/hospadmn
  5. Elixhauser A, Yu K, Steiner C, Bierman AS. Hospitalization in the United States, HCUP Fact Book No. 1, 1997.
  6. Midelfort L. A resource from the Institute for Healthcare Improvement, Mayo Health System, Eau Claire, Wisconsin, USA.
  7. Moss JE, Flower CL, Houghton LM, Moss DL, Nielsen DA, Taylor MD. Med J Aust 2002; 177. URL: http://www.mja.com.auhealthcare, 21/10/02

(1) A. Chattoraj is Research Pool Officer, Office of the Director General Armed Forces Medical Services, New Delhi
(2) S. Satpathy is Additional Professor, Deptt. of Hospital Administration, AIIMS, New Delhi
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