This article was downloaded by: [UQ Library] On: 23 November 2014, At: 12:21 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
College Students' Use of Emergency Medical Services Jack McKillip PhD Holly RN
a b
c
, Carol Lynn Courtney MA , Richard Locasso PhD , Patricia Eckert MA & Fran
a
Southern Illinois University , Carbondale, USA
b
Program Evaluation Center, Student Health Program , USA
c
School of Technical Careers , USA Published online: 09 Jul 2010.
To cite this article: Jack McKillip PhD , Carol Lynn Courtney MA , Richard Locasso PhD , Patricia Eckert MA & Fran Holly RN (1990) College Students' Use of Emergency Medical Services, Journal of American College Health, 38:6, 289-292 To link to this article: http://dx.doi.org/10.1080/07448481.1990.9936202
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
CLINICAL AND PROGRAM NOTES
College Students’ Use of Emergency Medical Sewices
Downloaded by [UQ Library] at 12:21 23 November 2014
JACK MCKILLIP, PhD, CAROL LYNN COURTNEY, MA, RICHARD LOCASSO, PhD, PATRICIA ECKERT, MA, and FRAN HOLLY, RN
Emergency medical care is an essential part of college health service. Because emergency service is expensive, it is important that health providers know more about how often the service is used, the nature of the problems students present, and whether the service i s being used appropriately. At Southern Illinois University at Carbondale (SIUC), the average cost of a student visit to the emergency room at the local hospital is almost three times that of a visit to the on-campus ambulatory care clinic. To discourage inappropriate and costly use of emergency services, SlUC has instituted a number of controls, including differential payments based on whether or not a visit is considered to be an emergency by the attending emergency room physician4 and use of an after-hours telephone service, called Dial-a-Nurse, to provide medical information. Baseline and descriptive information on students’ use of emergency medical services are important if planning for these services is to go beyond cost-containment This paper reports on a study of the use of emergency medical services by students at SlUC during the 5 semesters from fall 1982 through spring 1984. The study considered three questions: 1. What is the frequency, diagnosis, and appropriateness of student visits to the hospital emergency room? ~~
~
~
The authors are all at Southern Illinois University at Carbondale. Jack McKillip is a professor of psychology and coordinator of the Program Evaluation Center, Student Health Program, where Carol Lynn Courtney is a research assistant and Richard Locasso i s a consultant. Patricia Eckert is a visiting instructor with the School of Technical Careers, and Fran Holly is the infirmary supervisor.
V0138, MAY 1990
2. What is the frequency, diagnosis, and appropriateness of calls to Dial-a-Nurse? 3. How does the use of the emergency room compare with use of Dial-a-Nurse on these variables?
METHOD Student Population SIUC, which is located in a rural setting, is attended by 23,000 students. Approximately 60% of the student body are men and 40% are women. About 10% of the students are foreign nationals, 8% are black, and 82% are white. Eighty-five percent of the students are undergraduates, and 15% are graduate students. More than 75% of the students live within 5 miles of the on-campus clinic and the local hospital emergency room. Student Medical Services at SlUC Students on the SlUC campus are covered by a universal, comprehensive medical insurance program financed out of student fees. They are served by a fully staffed ambulatory care clinic that is open for 44 hours a week during regular school hours and on Saturday mornings. The clinic provides all normal medical care, with provisions for specialist referral and emergency services. An a p pointment system is used, along with provision for emergency appointments during regular clinic hours. At the time of the study, a $3 fee was assessed for each visit to the clinic; clinic use averaged 843.3 visits per 1,000 students per semester. Emergency room. If a student needs medical services when the on-campus clinic is not open, emergency
289
Downloaded by [UQ Library] at 12:21 23 November 2014
COLLEGE HEALTH medical services are provided by contract at the emergency room of the local hospital. Unless the visit falls into one of a small class of automatic admissions (7.8% of all visits during the study period), students receive only partial reimbursement for the cost of the emergency room visit. In addition to diagnosis, the emergency room physician makes a judgment of appropriateness of each visit. If the visit is judged to be an emergency, the student is assessed a fee of 10% of the cost of services (an average of $9). If the visit is judged to be a nonemergency, the student is assessed all costs in excess of $35 (an average of $55).
nurses at Dial-a-Nurse. A student health program physician and the head of Dial-a-Nurse reviewed the ICD-9 codes used during the study period. Each code was related to 1 of the 67 categories used to classify the emergency room visits; disagreements were resolved through discussion. The 17 major ICD-9 class headings provided the basis for analysis of diagnoses for both emergency room visits and Dial-a-Nurse calls.
Dial-a-Nurse. During the final 2 semesters of our survey (fall 1983 and spring 19841, a new emergency serviceDial-a-Nurse-was available when the clinic was not open. One of the purposes of this service was to increase the appropriateness of the use of the emergency room by providing information to students. During nonclinic hours, nursing personnel who staff the 8-bed on-campus infirmary were available by telephone to answer students' questions about medical problems and emergencies. In addition to answering questions, the nurse had the authority to refer a caller to the local hospital emergency room for treatment. In such cases, students were assessed only 10% of the actual medical fee, even if their cases were judged not to be emergencies by emergency room physicians. Nurses coded the time and date of all calls, the ICD-9 (International Classification of Diseases, version 9, of the World Health Organization) classification, and a judgment, on a 4point scale, of whether the caller's problem was an emergency: (1 = clear emergency; 2 = could go either way; 3 = probably not emergency; and 4 = not emergency). Categories 1 and 2 were classified as emergencies, and categories 3 and 4 were classified as nonemergencies. Because judgments were made over the telephone, they were probably less reliable than those provided by physicians at the time of admittance to the emergency room.
An analysis of the 3,420 emergency room visits during the study period is shown in Table 1. Diagnostic categories that reflected at least 2% of the visits are included. For the entire sample, 88% of the visits were judged to be emergencies; during the study period, SlUC students used the hospital emergency room at a rate of 41.73 per 1,OOO students per semester. Ninety percent of the emergency room visits were classified as Injury and Poisoning (17). These visits reflected trauma: contusions, sprains, lacerations, and fractures; 90% of them were judged to be emergencies; the visitation rate was 19 per 1,OOO students on campus. The second most frequently occurring disease category was Diseases of the Respiratory System (81, and the third was Diseases of the Digestive System (9). A much lower percentage of these visits were judged to be emergencies than those caused by Injury and Poisoning. Eighty percent of all classifiable visits to the emergency room during the study fell into these three categories. The frequency of emergency room visits by day of the week is shown in Table 2. Heaviest use was on weekends. Increased use did not indicate less appropriate use. In fact, the percentage of visits rated as emergencies on weekends (87%) was significantly higher than for ) p < .001). weekdays (83%, ~ ~ ( =1 12.54,
RESULTS Emergency Room Visits
Dial-a-Nurse Calls Study Period Use of the emergency room and Dial-a-Nurse was examined for 5 semester periods from fall 1982 (August 23, 1982) through spring 1984 (May 12, 1984), including summer 1983. Every day between the official beginning and ending of the semesters was included, except for 9-day break periods during the two fall and the two spring terms. These periods were chosen to reflect use during time when the full student body was on campus. We developed utilization rates with weighting by number of students enrolled and number of days covered for each of the 5 semesters included in the study. Semester rates were calculated for 108 calendar days.
Coordination of Diagnosis Systems The diagnostic category system used for the emergency room visits was coordinated with that used by the
290
Figures indicating the nature of the 1,134 calls to Diala-Nurse during the study period for the ICD-9 category that reflected at least 2% of the visits are shown in Table 3. Overall, 61 O/O of calls to Dial-a-Nursewere classified as emergencies, a much lower percentage than that for emergency room visits (shown in Table 1). Students called Dial-a-Nurseat a rate of 41.06 per 1,OOO students per semester, a rate as high as that for emergency room visits. The highest percentage of calls were classified as reflecting Diseases of the Respiratory System (8), which were almost equally divided between emergencies and nonemergencies. The second most frequently occurring disease classification was Injury and Poisoning (17), and Diseases of the Digestive System (9) was third. A much lower percentage of calls to Dial-a-Nurse in the Injury a'nd Poisoning category were emergencies than was the case for emergency room visits in that category. Sixty-nine percent of
IACH
EMERGENCY ROOM USE TABLE 1 Categorization of SlUC Students' Emergency Room Visits, September 1982 to May 1984
ICD-9 categories
Downloaded by [UQ Library] at 12:21 23 November 2014
6. Diseases of the nervous system and sense organs 8. Diseases of the respiratory system 9. Diseases of the digestive system 10. Diseases of the genitourinary system 16. Symptoms, signs, and ill-defined conditions 17. Injury and poisoning Other Unclassified TotalloveralI
of all visits (N = 3,420)
Percentage judged to be emergency visitst
Semester utilization rate per 1 ,OOO students*
4.6
90
1.93
14.7
74
6.15
8.3 3.9
70
80
3.45 1.64
2.7
63
1.15
45.5 5.6 15.5 100.85
90
19.00 5.15 4.70 41.73
77 84
88
tRated by emergency room physician at time of visit. Automatic admissions were excluded from calculations. *A semester 108 calendar days.
-
§Incidents could be coded into more than one category.
all classifiable calls to Dial-a-Nurse fell into ICD-9 categories 8, 17, and 9, revealing the same pattern as for emergency room visits. Figures in Table 2 show the percentage of emergency calls to Dial-a-Nurse. Weekend use was heavier than weekdays, but differences in the percentage of emergencies did not appear.
DISCUSSION
TABLE 2 SlUC Students' Use of Emergency Services by Day of the Week
Day
Emergency room visits M OIO t
Dial-a-Nurse calls M Ole*
Use of Emergency Medical Services College students in this study used the emergency room at a rate of 41.7 visits per 1,OOO students per semester, or 141 visits per 1,OOO students per day per calendar year. This rate is considerably lower than that found in other studies. The American public's emergency room use rate is about 300 visits per 1,OOO people per year,' and the 1986 National Health Interview Survey estimated emergency room use for those aged 18 to 24 at 252 visits per 1,OOO people per year." In addition, the appropriateness of emergency room use for this sample of college students was higher (88% of the visits were rated as emergencies) than for others. Research on the general population found that 67% of the visits to 24 hospital emergency rooms were judged by physicians to be emergencies that required treatment within 2 to 12 hours." In contrast to the results on frequency and appropriateness of emergency room use, visits by college students in this study fell into the same diagnostic categories and tended to occur in the same weekly,pattern as has been found for other populations. Injuries were the primary reason for visits to the emergency room in this study, and almost all of these visits were emergencies. Similar results have been reported for the general
V0138, MAY 1990
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
5.9 5.7 5.5 5.3 4.5 10.7 13.9
87 79 81 84
85 86 88
4.8 5.2 3.9 3.6 2.8 7.6 8.3
66 58 68 37 74 59 71
tPercentage of visits judged to be emergencies. *Percentage of calls judged to be emergencies.
populati~n.~,'~ Students' visits to the emergency room were heaviest during the weekend, and weekend visits were more likely to be classified as emergencies than weekday visits. Similar results have also been reported for the general p~b1ic.l~ The after-hours, Dial-a-Nurse program proved to be a very popular emergency service. During its second full semester of operation, it reached (and has continued to show) rates equal to that of the emergency room. The diagnostic categories for calls to Dial-a-Nurse were similar to those for visits to the emergency room, although more concentrated in categories that were rated as nonemergencies: Diseases of the Respiratory System and Diseases of the Digestive System. A recent telephone survey of
29 1
COLLEGE HEALTH TABLE 3 Categorization of SlUC Students’ Calls to Dial-a-Nurse, August 1983 to May 1984
of all calls (N = 1,134)
o/o
ICD-9 categories
6. Diseases of the nervous system
Downloaded by [UQ Library] at 12:21 23 November 2014
and sense organs 8. Diseases of the respiratory system 9. Diseases of the digestive system 10. Diseases of the genitourinary system 16. Symptoms, signs, and ill-defined conditions 17. Injury and poisoning Other Unclassified Total/overall
Percentage judged to be emergency callst
Semester utilization rate per 1,OOO students*
3.4
74
1.54
22.8
52
9.92
13.8 5.6
68 74
5.60 2.06
5.9
71
2.16
18.5 2.3 20.1 100.0
64 60 60 61
6.53 3.65 9.61 41.06
~
tCoded by nurse at time of call. *A semester = 108 calendar days.
callers found that 85% were satisfied with the ~ervice.’~ There is evidence that Dial-a-Nurse has affected student use of the emergency room. During the academic year from fall 1982 to spring 1983, 83% of student visits to the emergency room were judged to be emergencies. During the academic year after Dial-a-Nurse had been instituted, the percentage of visits judged to be emergencies rose to 95%, a percentage that has remained at that level. As a partial balance to this decrease in inappropriate use, the number of referrals of students to the emergency room by the student health program (almost all made by Dial-a-Nurse) increased from less than 1% to 8% of all visits. Because the number of visits judged to be emergencies did not change during this period, it appears that Dial-a-Nurse brought about a 6% drop in.the use of emergency room services by students. A number of factors can contribute to appropriate use of the emergency room by college students. These include easy availability of ambulatory care, differential cost to students of appropriate and inappropriate emergency room visits, and the effectiveness of programs that educate students about self-care and the use of emergency services. The Dial-a-Nurse after-hours phone service is one such program. Student use is concentrated in areas that tend to lead to inappropriate use of the emergency room. The service is available at the times when students are concerned and seeking information about the possibility of a medical emergency; it is flexible enough to handle a wide variety of emergency medical, self-care, and routine health service concerns. ACKNOWLEDGMENT The authors wish to thank Ellen Lewis and Pat Canevello for their help in data coding.
292
REFERENCES 1. Kolbe LJ, lverson DC. An assessment of student health needs: Implications for the planning and utilization of college health services. Am Coll Health Association 1978;26:263-267. 2. Kennedy DW, Kennedy SL. Using importance-petformance analysis for evaluating university health services. I Am Coll Health 1987;36:27-31. 3. Kraft DP. Dilemmas of voluntary versus mandatory coverage for campus health care. ] Am Coll Health 1987;36:158-164. 4. OGrady KF, Manning WG, Newhouse JP, Brook RA. The impact of cost sharing on emergency department use. N Engl ] Med 1985;313:484-490. 5. Shah CP, Egan TJ, Bain HW. An expanded emergency service: Role of telephone services in the emergency department. Ann Emerg Med 1980;9:617-623. 6. Kastiel DL. Reeling in health care data. Business Insurance 1985;March 18:3-6. 7. Demkovich LE. Health care costs at General Motors. Health Aff 1986;Fall:58-67. 8. jinkerson D. Lifestyle and Demographic Characteristics of College Emergency Room Users: lmplications for Prevention Programming. Carbondale, IL: Southern Illinois University at Carbondale; Dissertation. 1987. 9. American Hospital Association. The Hospital Emergency Department in Transition: Executive Summary. Chicago: AHA;
1986. 10. National Center for Health Statistics. Unpublished data from the National Health Interview Survey, 1986. 11. Gillford MJ, Franaszek JB, Gibson G. Emergency physicians and patients’ assessments: Urgency of need for medical care. Ann Emerg Med 1980;9:502-507. 12. Askenasi R, Rasquin C, Van Reeth 0, Ninane V, Todorov P. What is emergency: Analysis of a population presenting to an emergency room. Acta Anaesthesiol Belg 1984;1 :53-65. 13. Gibson G. Categorization of hospital emergency capabilities: Some empirical methods to evaluate appropriateness of emergency department utilization. ] Trauma 1978;18:94-101. 14. Moirs K, McKillip J. Health Service Satisfaction Survey, 7988. Carbondale, IL; Student Health Program, Southern Illinois University at Carbondale.
)ACH
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
College Students' Use of Emergency Medical Services Jack McKillip PhD Holly RN
a b
c
, Carol Lynn Courtney MA , Richard Locasso PhD , Patricia Eckert MA & Fran
a
Southern Illinois University , Carbondale, USA
b
Program Evaluation Center, Student Health Program , USA
c
School of Technical Careers , USA Published online: 09 Jul 2010.
To cite this article: Jack McKillip PhD , Carol Lynn Courtney MA , Richard Locasso PhD , Patricia Eckert MA & Fran Holly RN (1990) College Students' Use of Emergency Medical Services, Journal of American College Health, 38:6, 289-292 To link to this article: http://dx.doi.org/10.1080/07448481.1990.9936202
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
CLINICAL AND PROGRAM NOTES
College Students’ Use of Emergency Medical Sewices
Downloaded by [UQ Library] at 12:21 23 November 2014
JACK MCKILLIP, PhD, CAROL LYNN COURTNEY, MA, RICHARD LOCASSO, PhD, PATRICIA ECKERT, MA, and FRAN HOLLY, RN
Emergency medical care is an essential part of college health service. Because emergency service is expensive, it is important that health providers know more about how often the service is used, the nature of the problems students present, and whether the service i s being used appropriately. At Southern Illinois University at Carbondale (SIUC), the average cost of a student visit to the emergency room at the local hospital is almost three times that of a visit to the on-campus ambulatory care clinic. To discourage inappropriate and costly use of emergency services, SlUC has instituted a number of controls, including differential payments based on whether or not a visit is considered to be an emergency by the attending emergency room physician4 and use of an after-hours telephone service, called Dial-a-Nurse, to provide medical information. Baseline and descriptive information on students’ use of emergency medical services are important if planning for these services is to go beyond cost-containment This paper reports on a study of the use of emergency medical services by students at SlUC during the 5 semesters from fall 1982 through spring 1984. The study considered three questions: 1. What is the frequency, diagnosis, and appropriateness of student visits to the hospital emergency room? ~~
~
~
The authors are all at Southern Illinois University at Carbondale. Jack McKillip is a professor of psychology and coordinator of the Program Evaluation Center, Student Health Program, where Carol Lynn Courtney is a research assistant and Richard Locasso i s a consultant. Patricia Eckert is a visiting instructor with the School of Technical Careers, and Fran Holly is the infirmary supervisor.
V0138, MAY 1990
2. What is the frequency, diagnosis, and appropriateness of calls to Dial-a-Nurse? 3. How does the use of the emergency room compare with use of Dial-a-Nurse on these variables?
METHOD Student Population SIUC, which is located in a rural setting, is attended by 23,000 students. Approximately 60% of the student body are men and 40% are women. About 10% of the students are foreign nationals, 8% are black, and 82% are white. Eighty-five percent of the students are undergraduates, and 15% are graduate students. More than 75% of the students live within 5 miles of the on-campus clinic and the local hospital emergency room. Student Medical Services at SlUC Students on the SlUC campus are covered by a universal, comprehensive medical insurance program financed out of student fees. They are served by a fully staffed ambulatory care clinic that is open for 44 hours a week during regular school hours and on Saturday mornings. The clinic provides all normal medical care, with provisions for specialist referral and emergency services. An a p pointment system is used, along with provision for emergency appointments during regular clinic hours. At the time of the study, a $3 fee was assessed for each visit to the clinic; clinic use averaged 843.3 visits per 1,000 students per semester. Emergency room. If a student needs medical services when the on-campus clinic is not open, emergency
289
Downloaded by [UQ Library] at 12:21 23 November 2014
COLLEGE HEALTH medical services are provided by contract at the emergency room of the local hospital. Unless the visit falls into one of a small class of automatic admissions (7.8% of all visits during the study period), students receive only partial reimbursement for the cost of the emergency room visit. In addition to diagnosis, the emergency room physician makes a judgment of appropriateness of each visit. If the visit is judged to be an emergency, the student is assessed a fee of 10% of the cost of services (an average of $9). If the visit is judged to be a nonemergency, the student is assessed all costs in excess of $35 (an average of $55).
nurses at Dial-a-Nurse. A student health program physician and the head of Dial-a-Nurse reviewed the ICD-9 codes used during the study period. Each code was related to 1 of the 67 categories used to classify the emergency room visits; disagreements were resolved through discussion. The 17 major ICD-9 class headings provided the basis for analysis of diagnoses for both emergency room visits and Dial-a-Nurse calls.
Dial-a-Nurse. During the final 2 semesters of our survey (fall 1983 and spring 19841, a new emergency serviceDial-a-Nurse-was available when the clinic was not open. One of the purposes of this service was to increase the appropriateness of the use of the emergency room by providing information to students. During nonclinic hours, nursing personnel who staff the 8-bed on-campus infirmary were available by telephone to answer students' questions about medical problems and emergencies. In addition to answering questions, the nurse had the authority to refer a caller to the local hospital emergency room for treatment. In such cases, students were assessed only 10% of the actual medical fee, even if their cases were judged not to be emergencies by emergency room physicians. Nurses coded the time and date of all calls, the ICD-9 (International Classification of Diseases, version 9, of the World Health Organization) classification, and a judgment, on a 4point scale, of whether the caller's problem was an emergency: (1 = clear emergency; 2 = could go either way; 3 = probably not emergency; and 4 = not emergency). Categories 1 and 2 were classified as emergencies, and categories 3 and 4 were classified as nonemergencies. Because judgments were made over the telephone, they were probably less reliable than those provided by physicians at the time of admittance to the emergency room.
An analysis of the 3,420 emergency room visits during the study period is shown in Table 1. Diagnostic categories that reflected at least 2% of the visits are included. For the entire sample, 88% of the visits were judged to be emergencies; during the study period, SlUC students used the hospital emergency room at a rate of 41.73 per 1,OOO students per semester. Ninety percent of the emergency room visits were classified as Injury and Poisoning (17). These visits reflected trauma: contusions, sprains, lacerations, and fractures; 90% of them were judged to be emergencies; the visitation rate was 19 per 1,OOO students on campus. The second most frequently occurring disease category was Diseases of the Respiratory System (81, and the third was Diseases of the Digestive System (9). A much lower percentage of these visits were judged to be emergencies than those caused by Injury and Poisoning. Eighty percent of all classifiable visits to the emergency room during the study fell into these three categories. The frequency of emergency room visits by day of the week is shown in Table 2. Heaviest use was on weekends. Increased use did not indicate less appropriate use. In fact, the percentage of visits rated as emergencies on weekends (87%) was significantly higher than for ) p < .001). weekdays (83%, ~ ~ ( =1 12.54,
RESULTS Emergency Room Visits
Dial-a-Nurse Calls Study Period Use of the emergency room and Dial-a-Nurse was examined for 5 semester periods from fall 1982 (August 23, 1982) through spring 1984 (May 12, 1984), including summer 1983. Every day between the official beginning and ending of the semesters was included, except for 9-day break periods during the two fall and the two spring terms. These periods were chosen to reflect use during time when the full student body was on campus. We developed utilization rates with weighting by number of students enrolled and number of days covered for each of the 5 semesters included in the study. Semester rates were calculated for 108 calendar days.
Coordination of Diagnosis Systems The diagnostic category system used for the emergency room visits was coordinated with that used by the
290
Figures indicating the nature of the 1,134 calls to Diala-Nurse during the study period for the ICD-9 category that reflected at least 2% of the visits are shown in Table 3. Overall, 61 O/O of calls to Dial-a-Nursewere classified as emergencies, a much lower percentage than that for emergency room visits (shown in Table 1). Students called Dial-a-Nurseat a rate of 41.06 per 1,OOO students per semester, a rate as high as that for emergency room visits. The highest percentage of calls were classified as reflecting Diseases of the Respiratory System (8), which were almost equally divided between emergencies and nonemergencies. The second most frequently occurring disease classification was Injury and Poisoning (17), and Diseases of the Digestive System (9) was third. A much lower percentage of calls to Dial-a-Nurse in the Injury a'nd Poisoning category were emergencies than was the case for emergency room visits in that category. Sixty-nine percent of
IACH
EMERGENCY ROOM USE TABLE 1 Categorization of SlUC Students' Emergency Room Visits, September 1982 to May 1984
ICD-9 categories
Downloaded by [UQ Library] at 12:21 23 November 2014
6. Diseases of the nervous system and sense organs 8. Diseases of the respiratory system 9. Diseases of the digestive system 10. Diseases of the genitourinary system 16. Symptoms, signs, and ill-defined conditions 17. Injury and poisoning Other Unclassified TotalloveralI
of all visits (N = 3,420)
Percentage judged to be emergency visitst
Semester utilization rate per 1 ,OOO students*
4.6
90
1.93
14.7
74
6.15
8.3 3.9
70
80
3.45 1.64
2.7
63
1.15
45.5 5.6 15.5 100.85
90
19.00 5.15 4.70 41.73
77 84
88
tRated by emergency room physician at time of visit. Automatic admissions were excluded from calculations. *A semester 108 calendar days.
-
§Incidents could be coded into more than one category.
all classifiable calls to Dial-a-Nurse fell into ICD-9 categories 8, 17, and 9, revealing the same pattern as for emergency room visits. Figures in Table 2 show the percentage of emergency calls to Dial-a-Nurse. Weekend use was heavier than weekdays, but differences in the percentage of emergencies did not appear.
DISCUSSION
TABLE 2 SlUC Students' Use of Emergency Services by Day of the Week
Day
Emergency room visits M OIO t
Dial-a-Nurse calls M Ole*
Use of Emergency Medical Services College students in this study used the emergency room at a rate of 41.7 visits per 1,OOO students per semester, or 141 visits per 1,OOO students per day per calendar year. This rate is considerably lower than that found in other studies. The American public's emergency room use rate is about 300 visits per 1,OOO people per year,' and the 1986 National Health Interview Survey estimated emergency room use for those aged 18 to 24 at 252 visits per 1,OOO people per year." In addition, the appropriateness of emergency room use for this sample of college students was higher (88% of the visits were rated as emergencies) than for others. Research on the general population found that 67% of the visits to 24 hospital emergency rooms were judged by physicians to be emergencies that required treatment within 2 to 12 hours." In contrast to the results on frequency and appropriateness of emergency room use, visits by college students in this study fell into the same diagnostic categories and tended to occur in the same weekly,pattern as has been found for other populations. Injuries were the primary reason for visits to the emergency room in this study, and almost all of these visits were emergencies. Similar results have been reported for the general
V0138, MAY 1990
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
5.9 5.7 5.5 5.3 4.5 10.7 13.9
87 79 81 84
85 86 88
4.8 5.2 3.9 3.6 2.8 7.6 8.3
66 58 68 37 74 59 71
tPercentage of visits judged to be emergencies. *Percentage of calls judged to be emergencies.
populati~n.~,'~ Students' visits to the emergency room were heaviest during the weekend, and weekend visits were more likely to be classified as emergencies than weekday visits. Similar results have also been reported for the general p~b1ic.l~ The after-hours, Dial-a-Nurse program proved to be a very popular emergency service. During its second full semester of operation, it reached (and has continued to show) rates equal to that of the emergency room. The diagnostic categories for calls to Dial-a-Nurse were similar to those for visits to the emergency room, although more concentrated in categories that were rated as nonemergencies: Diseases of the Respiratory System and Diseases of the Digestive System. A recent telephone survey of
29 1
COLLEGE HEALTH TABLE 3 Categorization of SlUC Students’ Calls to Dial-a-Nurse, August 1983 to May 1984
of all calls (N = 1,134)
o/o
ICD-9 categories
6. Diseases of the nervous system
Downloaded by [UQ Library] at 12:21 23 November 2014
and sense organs 8. Diseases of the respiratory system 9. Diseases of the digestive system 10. Diseases of the genitourinary system 16. Symptoms, signs, and ill-defined conditions 17. Injury and poisoning Other Unclassified Total/overall
Percentage judged to be emergency callst
Semester utilization rate per 1,OOO students*
3.4
74
1.54
22.8
52
9.92
13.8 5.6
68 74
5.60 2.06
5.9
71
2.16
18.5 2.3 20.1 100.0
64 60 60 61
6.53 3.65 9.61 41.06
~
tCoded by nurse at time of call. *A semester = 108 calendar days.
callers found that 85% were satisfied with the ~ervice.’~ There is evidence that Dial-a-Nurse has affected student use of the emergency room. During the academic year from fall 1982 to spring 1983, 83% of student visits to the emergency room were judged to be emergencies. During the academic year after Dial-a-Nurse had been instituted, the percentage of visits judged to be emergencies rose to 95%, a percentage that has remained at that level. As a partial balance to this decrease in inappropriate use, the number of referrals of students to the emergency room by the student health program (almost all made by Dial-a-Nurse) increased from less than 1% to 8% of all visits. Because the number of visits judged to be emergencies did not change during this period, it appears that Dial-a-Nurse brought about a 6% drop in.the use of emergency room services by students. A number of factors can contribute to appropriate use of the emergency room by college students. These include easy availability of ambulatory care, differential cost to students of appropriate and inappropriate emergency room visits, and the effectiveness of programs that educate students about self-care and the use of emergency services. The Dial-a-Nurse after-hours phone service is one such program. Student use is concentrated in areas that tend to lead to inappropriate use of the emergency room. The service is available at the times when students are concerned and seeking information about the possibility of a medical emergency; it is flexible enough to handle a wide variety of emergency medical, self-care, and routine health service concerns. ACKNOWLEDGMENT The authors wish to thank Ellen Lewis and Pat Canevello for their help in data coding.
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