An Emergency Department or a Convenient Pediatric Walk in Clinic

Methods

This study was conducted at Princess Haya Hospital during the period between December 2006 and May 2007. This hospital is a general hospital that provides medical services for the whole population in Aqaba governorate in conjunction with two other small private hospitals and many primary care settings that provide medical services during day and night.

Participants were all children aged 14 years and below who attended the ED from 4:00pm until 8:30am the following morning. Children were examined   and   evaluated   by   pediatricians,   who

classified their cases as urgent or non-urgent. Variables regarding children and their caregivers thought to be most determining of non-urgent visits were recorded. These included age, sex, nature of complaints, residency, recent contact with primary care setting, family size, educational attainment of primary caregiver (usually the mother), employment status of parents, and health insurances type (public, private, none).

Results

Table I shows the demographic characteristic of children  and  their  caregivers  with urgent and non- urgent visits.

The  total number of children who attended the ED during the study period was 8,100 which represent 42% of total ED visits. About 5,751 (71%) of the cases were considered to be non-urgent. Children aged below six years represented 65% of our patients and males were more common than females in a ratio of 1.1:1.      

About 4,428 (77%) of non-urgent cases were medically insured by public health insurance, 1,093 (19%) had private insurance, and 230 (4%) were uninsured

History of contacting a primary health care setting was evident in 2,300 (40%). Families who lived within the city represented 4,946 (86%) of the sample, the rest were residents of villages and towns around Aqaba city, both groups used their own vehicles or public transportation to reach the hospital. Families in which both parents were employed represented 1,438 (25%) of the cases, while families with only one parent employed (usually father) numbered 3,451 (60%), resulting in 4,313 (75%) of the primary caregivers being unemployed. Of the total cases, 5,233 (91%) included caregivers/mothers who had attained a certain level of education (less than high school graduate, high school graduate, college or university) while 518 (9%) of them were illiterate mothers. Respiratory problems were the most frequent complaints, followed by gastrointestinal complaints, and dermatological lesions.  While minor surgical illnesses represented the least presenting complaints (Table II).

Truly urgent cases constituted 29% of the children, where 18% of them were admitted to the pediatrics ward for different reasons and 3% were admitted to the intensive care unit.  The most common chief complaint was respiratory problems (Table III).

Discussion

It is well known that the ED provides important public health services. Many children were more likely to receive emergency department services for problems and conditions which may have been cared for in the non-urgent clinic setting. The misuse of such services appeared to be a significant problem, and it is highlighted and discussed by this study.

The proportion of non-urgent visits in our sample reached 71% in rate, such a high figure is in concordance with most similar literature,^(2,5-6)  while few  authors  recorded  lower  rates.^(1,7) Some studies

showed that living relatively close to the hospital (distances were not mentioned) is associated with an increase in non-urgent visits,^(8,9-10) this finding was similar to our findings.  Also the fact that most patients with truly urgent cases originated from outside the city supports this finding.   We found that 40% of cases in our sample had  previous contact with a primary health care setting (mostly general practitioner working in Ministry of Health Medical Centers) and the majority of them were offered some form of treatment prior to their visit to our ED, again the finding of prior treatment was almost consistent with other studies.^(11,12)

An important variable is the status of health insurance. Our findings reported that 77% of non- urgent visitors were medically insured by public health insurance, such relatively high rate was inconsistent  and  even  contradicted  many studies,^(2,7-8) while only one study was in accordance with our findings.⁽⁵⁾  Inconsistent rates of different studies may be explained by the difference in health insurance systems in various countries.  Children aged less than six years constituted a large majority of the sample which is in agreement with the findings of another study.⁽¹⁾ One should note that all children below the age of six years enjoy free health insurance in Jordan.

Generally speaking, we found that slightly greater than half of the sample included primary caregivers educated past the high school level.  Of these, only 17% had a college or graduate degree.  These findings could suggest that the uneducated primary caregivers and those who have not finished high school, are less likely to come to the ED for non-urgent complaints.  In contrast, this same group were most likely to use the ED for a truly urgent case. Most studies gave divergent results in this aspect.^(5,11-13) Furthermore, three fourths of the primary caregivers who made non-urgent visits to the ED were unemployed which supports and contrasts similar studies.^(11,5)  Similarly, 68% of truly urgent cases were also made by unemployed primary caregivers. It was undetermined as to why the unemployed caregivers did not visit the outpatient clinic during normal working hours. A future study could explore this unknown.

We could not find a relationship between family size and rate of non-urgent visits in this study, while few studies claimed such a relationship.⁽¹²⁾ The most common presentations were respiratory complaints, probably due to the fact that the study was held mainly during Winter time.

Conclusion

This study clearly shows that there is a significant misuse of this ED which impacts negatively both on health workers and on the quality of services provided.

We believe that adoption of some measures and policies may be of value to tackle this dilemma.  For example the provision of mass media health education of the lay community, expansion and improvement of the primary health care centers and clinics, particularly in the vicinity of the ED, which can alleviate such undue pressures and lastly the establishment of a competent triage system in the ED, could be helpful.

Acknowledgment

I do cordially thank my dear colleague Dr. Nabil Al-Hmoud for his consistent encouragement, guidance, and support.

References                  

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