JEADV
DOI: 10.1111/jdv.12513
ORIGINAL ARTICLE
Dermatological conditions presenting at the Emergency Department in Siena University Hospital from 2006 to 2011 P. Rubegni,1,*† G. Cevenini,2,† A. Lamberti,1,† F. Bruni,3 R. Tiezzi,4 A. Verzuri,5 P. Barbini 2 P. Manzi,6 M. Fimiani1 1
Department of Medical, Surgical and Neurological Science, Dermatology Section, Siena University Hospital, Siena, Italy Department of Medical Surgery and Bioengineering, University of Siena, Siena, Italy 3 Department of Emergency Medicine, University of Siena, Siena, Italy 4 Department of Information and Communications Technology, ESTAV, University of Siena, Siena, Italy 5 Department of Molecular Medicine and Development, Hygiene and Preventive Medicine Section, University of Siena, Siena, Italy 6 Chief of Medical Management Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy *Correspondence: P. Rubegni. E-mail: [email protected] 2
Abstract Background Published studies on emergency dermatology consultations are few because there are few dermatology emergency units in the world. No study has yet described the Italian situation. Objectives To quantify and characterize patients evaluated in our dermatology emergency unit from 2006 to 2011. Methods We studied personal details, diagnosis, annual trend of cases, emergency level and hospitalization of dermatology cases over the 6-year period. Results A total of 12 226 patients were evaluated. The most numerous diagnostic group was infections (27.1%), followed by non-specific and descriptive diagnosis (22.5%), skin conditions caused by mechanical or physical agents (13.1%), eczematous diseases (10.5%), insect bites (9.5%) and urticaria/angio-oedema (8.8%). The most common indications for admission to hospital were skin conditions caused by mechanical or physical agents (33.3%), infections (27.5%), drug eruption (15.9%) and autoimmune or inflammatory disorders (7.4%). Emergency dermatology cases followed a variable annual trend, with more consultations in the summer months. Conclusion This is the first long-term retrospective analysis of a large series of dermatology emergency patients. It provides useful quantitative and qualitative information on cases for physicians and the national health system for the purposes of improving patient care and cost-effectiveness. Received: 23 November 2013; Accepted: 17 March 2014
Conflicts of interest None declared.
Funding sources None declared.
Introduction Although dermatology is often considered a largely outpatient specialization that treats diseases rarely classified as emergencies, urgent dermatological cases account for approximately 4–8% of all emergency department visits and may sometimes be life threatening.1–3 In recent years, Italy has followed the European trend of assigning outpatient status to medical specializations, creating a need for rational reorganization of available structural and human resources.4 Such changes imply a number of economic considerations. The Italian health system provides †
These authors equally contributed to this paper.
JEADV 2015, 29, 164–168
universal access to health care. Patients contribute to the cost through general taxation and also by paying a ‘ticket’ of €36 for specialist visits. The ticket is a regional incentive for health care and discourages unnecessary demands on the service. Until a few years ago, the ticket did not apply to emergency consultations. A recent financial law to limit state expenditure (Financial Law 2007; Law no. 296 of 27th December 2007, art. 1, para. 796) introduced a ticket for access to emergency departments for non-urgent cases. Since there are few reports on emergency dermatological consultations and none of them describe the Italian situation, we conducted a 6-year retrospective study (2006–2011) to evaluate
© 2014 European Academy of Dermatology and Venereology
Dermatological emergencies
Materials and methods We performed a retrospective review of all dermatology consultations in the Emergency Department of Siena University Hospital between 1st January 2006 and 31st December 2011. The province of Siena has an area of 3.821 km² and a population of 270.333. All data were obtained from computerized patient records compiled on admission and stored in a database. We entered the data in an Excel spreadsheet (Microsoft Corporation, Seattle, WA, USA). Our Dermatology Department consists of an inpatient unit (11 beds: two for patients with skin infections or parasites requiring isolation, two for burn patients requiring admission but not specialist care in a Burn Centre and seven for patients with skin diseases requiring hospitalization), a day hospital unit, nine outpatient consulting rooms and an outpatient dermatology emergency unit that works 24 h a day, 7 days a week, with a rotating dermatologist and resident. We reviewed 12 226 emergency unit consultations that produced 9475 definitive and 2751 inconclusive diagnoses. We considered personal details, medical history, complaint, diagnosis (conclusive or otherwise) and emergency level (five levels: white – minor problems, blue – can wait, green – critical but not life threatening, yellow – severe injury and altered vital function/s, red – life threatening). We also considered clinically determined diagnoses not requiring further investigation, such as culture, biopsy, etc., to be ‘definitive’, and diagnoses depending on a second examination and/or further tests to be ‘inconclusive’. The consultation team, comprising a rotating dermatology resident and an attending dermatologist, decided the final dermatological diagnosis. To handle the data more efficiently, all diagnoses were classified into 10 groups: (i) non-specific or descriptive diagnosis; (ii) eczematous diseases; (iii) infections; (iv) drug eruption; (v) urticaria/angiooedema; (vi) sexually transmitted diseases; (vii) autoimmune and inflammatory disorders; (viii) skin conditions caused by mechanical or physical agents; (ix) insect bites; and (x) tumours. This classification is based on a previous article on dermatology cases in the Emergency Department.11 Descriptive statistics, including frequency counts, histograms and tables, are reported, distinguishing by group of diseases, emergency level, age group and gender. We also specifically assessed cases hospitalized after emergency consultation, comparing diagnostic groups by two-tailed Fisher’s exact test or chi-squared test with a level of statistical significance equal to 0.05. Bonferroni’s correction for multiple comparisons was also performed.
JEADV 2015, 29, 164–168
Results In the study period, the total number of emergency consultations in our hospital was 281 093, 12 226 (4.35%) of which were dermatological. The latter were treated in the Dermatology Department. The population consisted of 46% males and 54% females. The number of cases by age group was as follows: paediatric (0–18 years) 2025 (16.6%), adult (19–60 years) 6583 (53.8%) and geriatric (>60 years) 3618 (29.6%) (Fig. 1). The most numerous diagnostic group was infections (n = 3315, 27.1%), followed by non-specific and descriptive diagnosis (n = 2751, 22.5%), skin conditions caused by mechanical or physical agents (n = 1607, 13.1%), eczematous diseases (n = 1286, 10.5%), insect bites (n = 1161, 9.5%), urticaria/ angio-oedema (n = 1070, 8.8%), autoimmune and inflammatory disorders (n = 555, 4.5%), drug eruption (n = 248, 2%), sexually transmitted diseases (n = 154, 1.3%) and tumours (n = 79, 0.6%) (Table 1). Analysing the annual trend of the 10 dermatological diagnostic groups, the most frequent in 2006 and 2007, in decreasing order, were infections, eczematous diseases, insect bites, urticaria/angio-oedema, autoimmune/inflammatory disorders, sexually transmitted diseases and tumours. Drug eruptions were the most frequent in 2008, non-specific and descriptive diagnosis in 2009 and conditions caused by mechanical and physical agents in 2011 (Fig. 2). An emergency level was assigned by an Hospital Emergency Department nurse after a first examination. The aim of examination was not diagnosis but to assign priority on the basis of
1600
Age group 0-18 years
1400
19-60 years
1200
Frequency
the reasons, nature and number of dermatological consultations seen in our emergency unit.5–14 The aim was to quantify and characterize cases to provide basic information for physicians and the national health system with a view to improving patient care and cost-effectiveness.
165
> 60 years
1000 800 600 400 200 0 2006
2007
2008
2009
2010
2011
Year Figure 1 Dermatological emergencies by age group. Patients were divided into three age groups: paediatric age group (0– 18 years, n = 2025; 16.6%); adult age group (19–60 years, n = 6583; 53.8%) and geriatric age group (>60 years, n = 3618; 29.6%). The adult group had always the highest frequency of cases.
© 2014 European Academy of Dermatology and Venereology
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Table 1 Annual frequencies (numerical and percentage) of cases in ten diagnostic groups Year
Diagnostic group NSD N
2006
(%) N
2007
(%) N
2008
(%) N
2009
(%) N
2010
(%) N
2011
(%) N
Total
(%)
505 20.7 367 20.5 413 21.7 575 27.6 482 24.7 409 19.8 2751 22.5
ED
Total I
240
DE 684
9.8 213
48
28.0
11.9
29.6
10.6
1.7
28.0
10.1
24.9
9.8
23.8
11.1 1286
28.4
10.5
9.8 8.9
248
27.1
154
8.8
171
11.9
3.9
9.5 157
14.0
8.3
261
4.5
194
12.5
95
9.3
280
4.9
169
14.4
100
8.7
305
4.8
161
14.8
555
1.3
12.7
267
94
1.5
1070
2.0
4.9
7.8
1607
4.5
T
309
213
74
1.6 30
IB
11.5
87
1.1 31
184
2.2
3315
281
4.3
0.8
7.8
46
105
22
191
1.8
586
36
1.1
9.2
36
MPA
15
162
1.8
464
230
8.3
2.7
AID
20
175
37
STD
1.5
149
51
518
191
8.6
30
532
211
209
2.0
531
201
U/A
1161
13.1
9.5
22 0.9 10 0.6 17 0.9 7 0.3 11 0.6 12 0.6 79 0.6
2439 100.0 1791 100.0 1902 100.0 2081 100.0 1950 100.0 2063 100.0 12226 100.0
AID, autoimmune/inflammatory diseases; ED, eczematous diseases; DE, drug eruption; NSD, non-specific or descriptive diagnosis; I, infections; IB, insect bites; MPA, skin conditions caused by mechanical or physical agents; T, tumours; STD, sexually transmitted diseases; U/A, urticaria/angio-oedema.
800 700
NSDD
I
UA
AID
IB
ED
DE
STD
MPA
T
1400 1200
Frequency
500 400
Yellow
Blue
Red
Green
1000
600
Frequency
Color White
800 600 400
300 200
200
0 2006
100 0
2007
2008
2009
2010
2011
Year 2006
2007
2008
2009
2010
2011
Year Figure 2 Frequency of cases in the different dermatological diagnostic groups by year. Infections (I), non-specific/descriptive diagnosis (NSDD) and conditions caused by mechanical and physical agents (MPA) showed the highest frequencies except in 2006, when the most frequent group was insect bites (IB). Although numerically less frequent, eczematous diseases (ED) were relatively constant over the 6 years of the study period. IB were frequent in 2006 and subsequently declined (T, tumour; AID, autoimmune and inflammatory diseases; STD, sexually transmitted disease; UA, urticaria/angio-oedema; DE, drug eruption).
specific algorithms for organizational purposes based on the evaluation of vital parameters and the presence of some semeiological signs and symptoms. Analysis of emergency levels showed
JEADV 2015, 29, 164–168
Figure 3 Emergency level colour codes of dermatological cases in the study period. According to Bonferroni’s correction, 2009 and 2010 were not significantly different (P > 0.0033), nor were 2007 and 2008 (P = 0.0032), unlike 2007–2008 and 2009–2010.
a slight increase in severe cases (yellow and green codes) in the study period. Blue and white codes (the least severe) decreased at first and then increased steadily. According to the Bonferroni’s correction, we considered P values < ac (ac = 0.0033) to be statistically significant. The years 2009 and 2010 were statistically indistinguishable (P > 0.0033), as were 2007 and 2008 (P = 0.0032). A statistically significant difference was found between 2007–2008 and 2009–2010 (Fig. 3), presumably due to extension of the ticket to emergency cases, which came into full effect in January 2008.
© 2014 European Academy of Dermatology and Venereology
Dermatological emergencies
167
2500
Hospitalization No Yes
3500
No hospitalization Hospitalization
3000
2000
Frequency
2500 2000
1500
1500
1000
1000 500
500
0 T
IB
PA M
D AI
2011
Year Figure 4 Hospitalization of dermatological emergencies in the 6year study period. A total of 258 patients were hospitalized (2.1% of the total number of cases treated by the dermatological emergency unit).
Emergency consultancy for dermatological complaints led to hospital admission of 258 patients (2.1%) in the 6-year study period (Fig. 4). Female patients predominated (145 females, 113 males) and were mostly (55.2%) in the geriatric age group. In descending order of frequency, the diagnostic groups were as follows: skin conditions caused by mechanical or physical agents (n = 86, 33.3%), infections (n = 71; 27.5%), drug eruption (n = 41, 15.9%), autoimmune or inflammatory disorders (n = 19, 7.4%), non-specific or descriptive diagnosis (n = 15, 5.8%), urticaria/angio-oedema (n = 11, 4.3%), eczematous diseases (n = 8, 3.1%), insect bites (n = 4, 1.6%) and sexually transmitted diseases (n = 3, 1.2%) (Fig. 5).
Discussion The aim of this study was to quantify and characterize cases to provide basic information for physicians and the national health system with a view to improving patient care and cost-effectiveness. Our retrospective analysis provided indications on the type of diseases presenting at the hospital emergency department The most common ‘urgent’ skin diseases were infectious (n = 3315, 27.1%), followed by skin conditions caused by mechanical or physical agents (n = 1607, 13.1%), eczematous diseases (n = 1286, 10.5%), insect bites (n = 1161, 9.5%) and urticaria/ angio-oedema (n = 1070, 8.8%). When we compared our results with data in the literature, we found differences that were probably due to different classification criteria.8,10,11,14 Another explanation for these differences could be different clinical organization. For example, we have two beds for burn patients and two for isolation cases. In other hospitals, these patients may be treated in plastic surgery and infectious diseases departments respectively.
JEADV 2015, 29, 164–168
D
2010
ST
2009
UA
2008
DE
2007
I
DD
2006
ED
NS
0
Figure 5 Hospitalization of dermatological emergency cases by diagnostic group (red columns): NSDD, non-specific or descriptive diagnosis; ED, eczematous diseases; I, infections; DE, drug eruption; UA, urticaria/angio-oedema; STD, sexually transmitted diseases; AID, autoimmune/inflammatory diseases; MPA, skin conditions caused by mechanical or physical agents.
However, although the authors of these studies used different diagnostic groupings, infections emerged as the most frequent diagnosis in emergency departments.5–14 The prevalence of skin diseases of infectious aetiology, especially erysipelas (data not shown), suggests the need for targeted diagnostic and therapeutic management protocols, possibly together with other specialists (infectologists etc.) and/or for optimization of peripheral healthcare structures (e.g. general practitioners).15–17 Such structures could ensure a faster and better approach to those patients, who by virtue of risk factors or frequency of relapse, need closer follow-up and should not have to face long waiting lists nor be forced to crowd the emergency department.18 Patients coming to our dermatological emergency unit for skin problems followed a variable annual trend. The mean monthly frequency of ‘urgent’ consultations showed higher values in summer months (June to August), implicating heat, humidity, outdoor activities and the higher frequency of insect bites.19,20 In summer, it is therefore advisable to maintain adequate staffing of hospitals and regional centres. It would also be worthwhile organizing training for general practitioners on certain aspects of dermatology to improve their diagnostic-therapeutic approach towards common skin disorders, including insect bites.21 When the data were normalized for the number of years in each of the three age groups, the adult group (19–60 years) proved responsible for the largest number of consultancies. This could be influenced by outpatient room working hours, which for adults are 8 am–5 pm. This precludes access to much of the working population, who would have to request time off work to be seen by a dermatologist. It is certainly easier and quicker to seek specialist advice at the Emergency Department, even for
© 2014 European Academy of Dermatology and Venereology
168
non-urgent problems. This indicates the need to extend outpatient activity to the late afternoon, allowing workers to make appointments for dermatological consultancy in the usual manner. Our analysis showed a slight increase in yellow and green codes (high severity) over the study period. White and blue codes (minor severity) showed a declining trend followed by an increasing trend. Introduction of the ticket for white and blue codes only initially influenced access to the Emergency Department for minor skin complaints not requiring urgent attention. In 2011, blue and white codes resumed their increasing trend, suggesting that easy access to an ‘urgent’ dermatological consultation outweighed the (low) cost of the ticket.22 These findings indicate that emergency department services are abused in Italy. The national health service will not be able to afford to give urgent attention to any patient who requests it for much longer. This practice subtracts resources from true emergencies. The percentage of patients requiring hospital admission was small (n = 258; 2.1%). Different percentages were found in the literature: Baibergenova & Shear 4%, Kim et al. 6.2% and Jack et al. 18%.1,8,11 The most common indications for admission were conditions caused by mechanical or physical agents (n = 86, 33.3%), infectious diseases (n = 71, 27.5%) and drug eruption (n = 41, 15.9%). In other studies we found different pathologies and percentages: Jack et al. mainly observed drug eruptions (erythema multiforme/Stevens–Johnson syndrome 22%, drug eruption 11%) and pemphigus vulgaris (14%); Kim at al., infections (n = 287, 55.7%), urticaria (n = 104, 20.2) and skin conditions caused by mechanical and physical agents (n = 33, 6.4%); Baibergenova & Shear, cellulitis (71.4%). These variations certainly depend on different guidelines for hospitalization of dermatology patients in the different countries.23 This is the first long-term retrospective analysis of a large series of dermatology emergency patients. It provides useful basic information on dermatological problems in the emergency department as a possible starting point for reorganization of available structural and human resources in the light of recent government health policy. In our opinion, studies like ours, combined with new technologies, will make it possible to optimize dermatological emergency units to the benefit of patients and state finance.24–26
References 1 Jack AR, Spence AA, Nichols BJ et al. Cutaneous conditions leading to dermatology consultations in the emergency department. West J Emerg Med. 2011; 12: 551–555. 2 Kirsner RS, Yang DG, Kerdel FA. Dermatologic disease accounts for a large number of hospital admissions annually. J Am Acad Dermatol 1999; 41: 970–973. 3 Cousen PJ. Dermatological Emergencies. Acute Med 2009; 8: 97–105. 4 Nardi R, Berti F, Fabbri LM et al. Toward a sustainable and wise healthcare approach: Potential contributions from hospital Internal Medicine Departments to reducing inappropriate medical spending. Italian J Med 2013; 7: 65–81.
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5 Mirkamali A, Ingen-Housz-Oro S, Valeyrie-Allanore L et al. Dermatological emergencies: a comparative study of activity in 2000 and 2010. J Eur Acad Dermatol Venereol 2013; 2: 916–918. 6 Hassan I, Rather PA. Emergency dermatology and need of dermatological intensive care unit (DICU). J Pak Assoc Derm 2013; 1: 71–82. 7 Lambert A, Delaporte E, Lok C et al. Skin diseases observed in the dermatology departments of three French university teaching hospitals. Ann Dermatol Veneorol 2006; 133: 657–662. 8 Baibergenova A, Shear NH. Skin conditions that bring patients to emergency departments. Arch Dermatol 2011; 147: 118–120. 9 Gupta S, Sandhu K, Kumar B. Evaluation of emergency dermatological consultations in a tertiary care centre in North India. J Eur Acad Dermatol Venereol 2003; 17: 303–305. 10 Martınez-Martınez ML, Escario-Travesedo E, Rodrıguez-Vazquez M et al. Consultas dermatol ogicas en el Servicio de Urgencias: situaci on previa a la instauraci on de guardias de la especialidad. Actas Dermosifiliogr 2011; 102: 39–47. 11 Kim JY, Cho HH, Hong JS et al. Skin conditions presenting in emergency room in Korea: an eight-year retrospective analysis. J Eur Acad Dermatol Venereol 2012; 27: 479–485. 12 Son BS, Sihn MS, Kwon HJ et al. A statistical analysis of dermatologic emergency patients visiting the emergency room over 10 years (1986– 1995). Korean J Dermatol 1997; 35: 223–227. 13 Wallet A, Sidhu S. Management pathway of skin conditions presenting to an Australian tertiary hospital emergency department. Australasian J Dermatol 2012; 53: 307–310. 14 Wang E, Lim BL, Than KY. Dermatological conditions presenting at an emergency department in Singapore. Singapore Med J 2009; 50: 881–884. 15 Perell o-Alzamora MR, Santos-Duran JC, Sanchez-Barba M, Ca~ nueto J, Marcos M, Unamuno P. Clinical and epidemiological characteristics of adult patients hospitalized for erysipelas and cellulitis. Eur J Clin Microbiol Infect Dis 2012; 31: 2147–2152. 16 Thomas K, Crook A, Foster K et al. Prophylactic antibiotics for the prevention of cellulitis (erysipelas) of the leg: results of the UK Dermatology Clinical Trials Network’s PATCH II trial. Br J Dermatol 2012; 166: 169– 178. 17 Lazzarini L, Pellizzer G. Erysipelas-cellulitis of the leg: impact of the application of a guideline in an infectious diseases unit. J Chemother 2011; 23: 378. 18 Durand AC, Palazzolo S, Tanti-Hardouin N et al. Non urgent patients in emergency departments: rational or irresponsible consumers? Perceptions of professionals and patients. BMC Res Notes 2012; 5: 525. 19 Carrieri M, Angelini P, Venturelli C, Maccagnani B, Bellini R. Aedes albopictus (Diptera: Culicidae) population size survey in the 2007 chikungunya outbreak area in Italy. II: Estimating epidemic thresholds. J Med Entomol 2012; 49: 388–399. 20 Romi R. Arthropod-borne diseases in Italy: from a neglected matter to an emerging health problem. Ann Ist Super Sanita 2010; 46: 436–443. 21 Lam TP, Yeung CK, Lam KF. What are the learning outcomes of a short postgraduate training course in dermatology for primary care doctors? BMC Med Educ 2011; 11: 20. 22 Smulowitz PB, Honigman L, Landon BE. A novel approach to identifying targets for cost reduction in the emergency department. Ann Emerg Med 2013; 61: 293–300. 23 Steptoe AP, Corel B, Sullivan AF, Camargo CA Jr. Characterizing emergency departments to improve understanding of emergency care systems. Int J Emerg Med 2011; 4: 42. 24 Muir J, Xu C, Paul S et al. Incorporating teledermatology into emergency medicine. Emerg Med Australas 2011; 23: 562–568. 25 Arnold JL, Dickinson G, Tsai M-C, Han D. A survey of emergency medicine in 36 countries. Canad J Emerg Med 2001; 3: 109–118. 26 Beniuk K, Boyle AA, Clarkson PJ. Emergency department crowding: Prioritising quantified crowding measures using a Delphi study. Emerg Med J 2012; 29: 868–871.
© 2014 European Academy of Dermatology and Venereology
DOI: 10.1111/jdv.12513
ORIGINAL ARTICLE
Dermatological conditions presenting at the Emergency Department in Siena University Hospital from 2006 to 2011 P. Rubegni,1,*† G. Cevenini,2,† A. Lamberti,1,† F. Bruni,3 R. Tiezzi,4 A. Verzuri,5 P. Barbini 2 P. Manzi,6 M. Fimiani1 1
Department of Medical, Surgical and Neurological Science, Dermatology Section, Siena University Hospital, Siena, Italy Department of Medical Surgery and Bioengineering, University of Siena, Siena, Italy 3 Department of Emergency Medicine, University of Siena, Siena, Italy 4 Department of Information and Communications Technology, ESTAV, University of Siena, Siena, Italy 5 Department of Molecular Medicine and Development, Hygiene and Preventive Medicine Section, University of Siena, Siena, Italy 6 Chief of Medical Management Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy *Correspondence: P. Rubegni. E-mail: [email protected] 2
Abstract Background Published studies on emergency dermatology consultations are few because there are few dermatology emergency units in the world. No study has yet described the Italian situation. Objectives To quantify and characterize patients evaluated in our dermatology emergency unit from 2006 to 2011. Methods We studied personal details, diagnosis, annual trend of cases, emergency level and hospitalization of dermatology cases over the 6-year period. Results A total of 12 226 patients were evaluated. The most numerous diagnostic group was infections (27.1%), followed by non-specific and descriptive diagnosis (22.5%), skin conditions caused by mechanical or physical agents (13.1%), eczematous diseases (10.5%), insect bites (9.5%) and urticaria/angio-oedema (8.8%). The most common indications for admission to hospital were skin conditions caused by mechanical or physical agents (33.3%), infections (27.5%), drug eruption (15.9%) and autoimmune or inflammatory disorders (7.4%). Emergency dermatology cases followed a variable annual trend, with more consultations in the summer months. Conclusion This is the first long-term retrospective analysis of a large series of dermatology emergency patients. It provides useful quantitative and qualitative information on cases for physicians and the national health system for the purposes of improving patient care and cost-effectiveness. Received: 23 November 2013; Accepted: 17 March 2014
Conflicts of interest None declared.
Funding sources None declared.
Introduction Although dermatology is often considered a largely outpatient specialization that treats diseases rarely classified as emergencies, urgent dermatological cases account for approximately 4–8% of all emergency department visits and may sometimes be life threatening.1–3 In recent years, Italy has followed the European trend of assigning outpatient status to medical specializations, creating a need for rational reorganization of available structural and human resources.4 Such changes imply a number of economic considerations. The Italian health system provides †
These authors equally contributed to this paper.
JEADV 2015, 29, 164–168
universal access to health care. Patients contribute to the cost through general taxation and also by paying a ‘ticket’ of €36 for specialist visits. The ticket is a regional incentive for health care and discourages unnecessary demands on the service. Until a few years ago, the ticket did not apply to emergency consultations. A recent financial law to limit state expenditure (Financial Law 2007; Law no. 296 of 27th December 2007, art. 1, para. 796) introduced a ticket for access to emergency departments for non-urgent cases. Since there are few reports on emergency dermatological consultations and none of them describe the Italian situation, we conducted a 6-year retrospective study (2006–2011) to evaluate
© 2014 European Academy of Dermatology and Venereology
Dermatological emergencies
Materials and methods We performed a retrospective review of all dermatology consultations in the Emergency Department of Siena University Hospital between 1st January 2006 and 31st December 2011. The province of Siena has an area of 3.821 km² and a population of 270.333. All data were obtained from computerized patient records compiled on admission and stored in a database. We entered the data in an Excel spreadsheet (Microsoft Corporation, Seattle, WA, USA). Our Dermatology Department consists of an inpatient unit (11 beds: two for patients with skin infections or parasites requiring isolation, two for burn patients requiring admission but not specialist care in a Burn Centre and seven for patients with skin diseases requiring hospitalization), a day hospital unit, nine outpatient consulting rooms and an outpatient dermatology emergency unit that works 24 h a day, 7 days a week, with a rotating dermatologist and resident. We reviewed 12 226 emergency unit consultations that produced 9475 definitive and 2751 inconclusive diagnoses. We considered personal details, medical history, complaint, diagnosis (conclusive or otherwise) and emergency level (five levels: white – minor problems, blue – can wait, green – critical but not life threatening, yellow – severe injury and altered vital function/s, red – life threatening). We also considered clinically determined diagnoses not requiring further investigation, such as culture, biopsy, etc., to be ‘definitive’, and diagnoses depending on a second examination and/or further tests to be ‘inconclusive’. The consultation team, comprising a rotating dermatology resident and an attending dermatologist, decided the final dermatological diagnosis. To handle the data more efficiently, all diagnoses were classified into 10 groups: (i) non-specific or descriptive diagnosis; (ii) eczematous diseases; (iii) infections; (iv) drug eruption; (v) urticaria/angiooedema; (vi) sexually transmitted diseases; (vii) autoimmune and inflammatory disorders; (viii) skin conditions caused by mechanical or physical agents; (ix) insect bites; and (x) tumours. This classification is based on a previous article on dermatology cases in the Emergency Department.11 Descriptive statistics, including frequency counts, histograms and tables, are reported, distinguishing by group of diseases, emergency level, age group and gender. We also specifically assessed cases hospitalized after emergency consultation, comparing diagnostic groups by two-tailed Fisher’s exact test or chi-squared test with a level of statistical significance equal to 0.05. Bonferroni’s correction for multiple comparisons was also performed.
JEADV 2015, 29, 164–168
Results In the study period, the total number of emergency consultations in our hospital was 281 093, 12 226 (4.35%) of which were dermatological. The latter were treated in the Dermatology Department. The population consisted of 46% males and 54% females. The number of cases by age group was as follows: paediatric (0–18 years) 2025 (16.6%), adult (19–60 years) 6583 (53.8%) and geriatric (>60 years) 3618 (29.6%) (Fig. 1). The most numerous diagnostic group was infections (n = 3315, 27.1%), followed by non-specific and descriptive diagnosis (n = 2751, 22.5%), skin conditions caused by mechanical or physical agents (n = 1607, 13.1%), eczematous diseases (n = 1286, 10.5%), insect bites (n = 1161, 9.5%), urticaria/ angio-oedema (n = 1070, 8.8%), autoimmune and inflammatory disorders (n = 555, 4.5%), drug eruption (n = 248, 2%), sexually transmitted diseases (n = 154, 1.3%) and tumours (n = 79, 0.6%) (Table 1). Analysing the annual trend of the 10 dermatological diagnostic groups, the most frequent in 2006 and 2007, in decreasing order, were infections, eczematous diseases, insect bites, urticaria/angio-oedema, autoimmune/inflammatory disorders, sexually transmitted diseases and tumours. Drug eruptions were the most frequent in 2008, non-specific and descriptive diagnosis in 2009 and conditions caused by mechanical and physical agents in 2011 (Fig. 2). An emergency level was assigned by an Hospital Emergency Department nurse after a first examination. The aim of examination was not diagnosis but to assign priority on the basis of
1600
Age group 0-18 years
1400
19-60 years
1200
Frequency
the reasons, nature and number of dermatological consultations seen in our emergency unit.5–14 The aim was to quantify and characterize cases to provide basic information for physicians and the national health system with a view to improving patient care and cost-effectiveness.
165
> 60 years
1000 800 600 400 200 0 2006
2007
2008
2009
2010
2011
Year Figure 1 Dermatological emergencies by age group. Patients were divided into three age groups: paediatric age group (0– 18 years, n = 2025; 16.6%); adult age group (19–60 years, n = 6583; 53.8%) and geriatric age group (>60 years, n = 3618; 29.6%). The adult group had always the highest frequency of cases.
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Table 1 Annual frequencies (numerical and percentage) of cases in ten diagnostic groups Year
Diagnostic group NSD N
2006
(%) N
2007
(%) N
2008
(%) N
2009
(%) N
2010
(%) N
2011
(%) N
Total
(%)
505 20.7 367 20.5 413 21.7 575 27.6 482 24.7 409 19.8 2751 22.5
ED
Total I
240
DE 684
9.8 213
48
28.0
11.9
29.6
10.6
1.7
28.0
10.1
24.9
9.8
23.8
11.1 1286
28.4
10.5
9.8 8.9
248
27.1
154
8.8
171
11.9
3.9
9.5 157
14.0
8.3
261
4.5
194
12.5
95
9.3
280
4.9
169
14.4
100
8.7
305
4.8
161
14.8
555
1.3
12.7
267
94
1.5
1070
2.0
4.9
7.8
1607
4.5
T
309
213
74
1.6 30
IB
11.5
87
1.1 31
184
2.2
3315
281
4.3
0.8
7.8
46
105
22
191
1.8
586
36
1.1
9.2
36
MPA
15
162
1.8
464
230
8.3
2.7
AID
20
175
37
STD
1.5
149
51
518
191
8.6
30
532
211
209
2.0
531
201
U/A
1161
13.1
9.5
22 0.9 10 0.6 17 0.9 7 0.3 11 0.6 12 0.6 79 0.6
2439 100.0 1791 100.0 1902 100.0 2081 100.0 1950 100.0 2063 100.0 12226 100.0
AID, autoimmune/inflammatory diseases; ED, eczematous diseases; DE, drug eruption; NSD, non-specific or descriptive diagnosis; I, infections; IB, insect bites; MPA, skin conditions caused by mechanical or physical agents; T, tumours; STD, sexually transmitted diseases; U/A, urticaria/angio-oedema.
800 700
NSDD
I
UA
AID
IB
ED
DE
STD
MPA
T
1400 1200
Frequency
500 400
Yellow
Blue
Red
Green
1000
600
Frequency
Color White
800 600 400
300 200
200
0 2006
100 0
2007
2008
2009
2010
2011
Year 2006
2007
2008
2009
2010
2011
Year Figure 2 Frequency of cases in the different dermatological diagnostic groups by year. Infections (I), non-specific/descriptive diagnosis (NSDD) and conditions caused by mechanical and physical agents (MPA) showed the highest frequencies except in 2006, when the most frequent group was insect bites (IB). Although numerically less frequent, eczematous diseases (ED) were relatively constant over the 6 years of the study period. IB were frequent in 2006 and subsequently declined (T, tumour; AID, autoimmune and inflammatory diseases; STD, sexually transmitted disease; UA, urticaria/angio-oedema; DE, drug eruption).
specific algorithms for organizational purposes based on the evaluation of vital parameters and the presence of some semeiological signs and symptoms. Analysis of emergency levels showed
JEADV 2015, 29, 164–168
Figure 3 Emergency level colour codes of dermatological cases in the study period. According to Bonferroni’s correction, 2009 and 2010 were not significantly different (P > 0.0033), nor were 2007 and 2008 (P = 0.0032), unlike 2007–2008 and 2009–2010.
a slight increase in severe cases (yellow and green codes) in the study period. Blue and white codes (the least severe) decreased at first and then increased steadily. According to the Bonferroni’s correction, we considered P values < ac (ac = 0.0033) to be statistically significant. The years 2009 and 2010 were statistically indistinguishable (P > 0.0033), as were 2007 and 2008 (P = 0.0032). A statistically significant difference was found between 2007–2008 and 2009–2010 (Fig. 3), presumably due to extension of the ticket to emergency cases, which came into full effect in January 2008.
© 2014 European Academy of Dermatology and Venereology
Dermatological emergencies
167
2500
Hospitalization No Yes
3500
No hospitalization Hospitalization
3000
2000
Frequency
2500 2000
1500
1500
1000
1000 500
500
0 T
IB
PA M
D AI
2011
Year Figure 4 Hospitalization of dermatological emergencies in the 6year study period. A total of 258 patients were hospitalized (2.1% of the total number of cases treated by the dermatological emergency unit).
Emergency consultancy for dermatological complaints led to hospital admission of 258 patients (2.1%) in the 6-year study period (Fig. 4). Female patients predominated (145 females, 113 males) and were mostly (55.2%) in the geriatric age group. In descending order of frequency, the diagnostic groups were as follows: skin conditions caused by mechanical or physical agents (n = 86, 33.3%), infections (n = 71; 27.5%), drug eruption (n = 41, 15.9%), autoimmune or inflammatory disorders (n = 19, 7.4%), non-specific or descriptive diagnosis (n = 15, 5.8%), urticaria/angio-oedema (n = 11, 4.3%), eczematous diseases (n = 8, 3.1%), insect bites (n = 4, 1.6%) and sexually transmitted diseases (n = 3, 1.2%) (Fig. 5).
Discussion The aim of this study was to quantify and characterize cases to provide basic information for physicians and the national health system with a view to improving patient care and cost-effectiveness. Our retrospective analysis provided indications on the type of diseases presenting at the hospital emergency department The most common ‘urgent’ skin diseases were infectious (n = 3315, 27.1%), followed by skin conditions caused by mechanical or physical agents (n = 1607, 13.1%), eczematous diseases (n = 1286, 10.5%), insect bites (n = 1161, 9.5%) and urticaria/ angio-oedema (n = 1070, 8.8%). When we compared our results with data in the literature, we found differences that were probably due to different classification criteria.8,10,11,14 Another explanation for these differences could be different clinical organization. For example, we have two beds for burn patients and two for isolation cases. In other hospitals, these patients may be treated in plastic surgery and infectious diseases departments respectively.
JEADV 2015, 29, 164–168
D
2010
ST
2009
UA
2008
DE
2007
I
DD
2006
ED
NS
0
Figure 5 Hospitalization of dermatological emergency cases by diagnostic group (red columns): NSDD, non-specific or descriptive diagnosis; ED, eczematous diseases; I, infections; DE, drug eruption; UA, urticaria/angio-oedema; STD, sexually transmitted diseases; AID, autoimmune/inflammatory diseases; MPA, skin conditions caused by mechanical or physical agents.
However, although the authors of these studies used different diagnostic groupings, infections emerged as the most frequent diagnosis in emergency departments.5–14 The prevalence of skin diseases of infectious aetiology, especially erysipelas (data not shown), suggests the need for targeted diagnostic and therapeutic management protocols, possibly together with other specialists (infectologists etc.) and/or for optimization of peripheral healthcare structures (e.g. general practitioners).15–17 Such structures could ensure a faster and better approach to those patients, who by virtue of risk factors or frequency of relapse, need closer follow-up and should not have to face long waiting lists nor be forced to crowd the emergency department.18 Patients coming to our dermatological emergency unit for skin problems followed a variable annual trend. The mean monthly frequency of ‘urgent’ consultations showed higher values in summer months (June to August), implicating heat, humidity, outdoor activities and the higher frequency of insect bites.19,20 In summer, it is therefore advisable to maintain adequate staffing of hospitals and regional centres. It would also be worthwhile organizing training for general practitioners on certain aspects of dermatology to improve their diagnostic-therapeutic approach towards common skin disorders, including insect bites.21 When the data were normalized for the number of years in each of the three age groups, the adult group (19–60 years) proved responsible for the largest number of consultancies. This could be influenced by outpatient room working hours, which for adults are 8 am–5 pm. This precludes access to much of the working population, who would have to request time off work to be seen by a dermatologist. It is certainly easier and quicker to seek specialist advice at the Emergency Department, even for
© 2014 European Academy of Dermatology and Venereology
168
non-urgent problems. This indicates the need to extend outpatient activity to the late afternoon, allowing workers to make appointments for dermatological consultancy in the usual manner. Our analysis showed a slight increase in yellow and green codes (high severity) over the study period. White and blue codes (minor severity) showed a declining trend followed by an increasing trend. Introduction of the ticket for white and blue codes only initially influenced access to the Emergency Department for minor skin complaints not requiring urgent attention. In 2011, blue and white codes resumed their increasing trend, suggesting that easy access to an ‘urgent’ dermatological consultation outweighed the (low) cost of the ticket.22 These findings indicate that emergency department services are abused in Italy. The national health service will not be able to afford to give urgent attention to any patient who requests it for much longer. This practice subtracts resources from true emergencies. The percentage of patients requiring hospital admission was small (n = 258; 2.1%). Different percentages were found in the literature: Baibergenova & Shear 4%, Kim et al. 6.2% and Jack et al. 18%.1,8,11 The most common indications for admission were conditions caused by mechanical or physical agents (n = 86, 33.3%), infectious diseases (n = 71, 27.5%) and drug eruption (n = 41, 15.9%). In other studies we found different pathologies and percentages: Jack et al. mainly observed drug eruptions (erythema multiforme/Stevens–Johnson syndrome 22%, drug eruption 11%) and pemphigus vulgaris (14%); Kim at al., infections (n = 287, 55.7%), urticaria (n = 104, 20.2) and skin conditions caused by mechanical and physical agents (n = 33, 6.4%); Baibergenova & Shear, cellulitis (71.4%). These variations certainly depend on different guidelines for hospitalization of dermatology patients in the different countries.23 This is the first long-term retrospective analysis of a large series of dermatology emergency patients. It provides useful basic information on dermatological problems in the emergency department as a possible starting point for reorganization of available structural and human resources in the light of recent government health policy. In our opinion, studies like ours, combined with new technologies, will make it possible to optimize dermatological emergency units to the benefit of patients and state finance.24–26
References 1 Jack AR, Spence AA, Nichols BJ et al. Cutaneous conditions leading to dermatology consultations in the emergency department. West J Emerg Med. 2011; 12: 551–555. 2 Kirsner RS, Yang DG, Kerdel FA. Dermatologic disease accounts for a large number of hospital admissions annually. J Am Acad Dermatol 1999; 41: 970–973. 3 Cousen PJ. Dermatological Emergencies. Acute Med 2009; 8: 97–105. 4 Nardi R, Berti F, Fabbri LM et al. Toward a sustainable and wise healthcare approach: Potential contributions from hospital Internal Medicine Departments to reducing inappropriate medical spending. Italian J Med 2013; 7: 65–81.
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5 Mirkamali A, Ingen-Housz-Oro S, Valeyrie-Allanore L et al. Dermatological emergencies: a comparative study of activity in 2000 and 2010. J Eur Acad Dermatol Venereol 2013; 2: 916–918. 6 Hassan I, Rather PA. Emergency dermatology and need of dermatological intensive care unit (DICU). J Pak Assoc Derm 2013; 1: 71–82. 7 Lambert A, Delaporte E, Lok C et al. Skin diseases observed in the dermatology departments of three French university teaching hospitals. Ann Dermatol Veneorol 2006; 133: 657–662. 8 Baibergenova A, Shear NH. Skin conditions that bring patients to emergency departments. Arch Dermatol 2011; 147: 118–120. 9 Gupta S, Sandhu K, Kumar B. Evaluation of emergency dermatological consultations in a tertiary care centre in North India. J Eur Acad Dermatol Venereol 2003; 17: 303–305. 10 Martınez-Martınez ML, Escario-Travesedo E, Rodrıguez-Vazquez M et al. Consultas dermatol ogicas en el Servicio de Urgencias: situaci on previa a la instauraci on de guardias de la especialidad. Actas Dermosifiliogr 2011; 102: 39–47. 11 Kim JY, Cho HH, Hong JS et al. Skin conditions presenting in emergency room in Korea: an eight-year retrospective analysis. J Eur Acad Dermatol Venereol 2012; 27: 479–485. 12 Son BS, Sihn MS, Kwon HJ et al. A statistical analysis of dermatologic emergency patients visiting the emergency room over 10 years (1986– 1995). Korean J Dermatol 1997; 35: 223–227. 13 Wallet A, Sidhu S. Management pathway of skin conditions presenting to an Australian tertiary hospital emergency department. Australasian J Dermatol 2012; 53: 307–310. 14 Wang E, Lim BL, Than KY. Dermatological conditions presenting at an emergency department in Singapore. Singapore Med J 2009; 50: 881–884. 15 Perell o-Alzamora MR, Santos-Duran JC, Sanchez-Barba M, Ca~ nueto J, Marcos M, Unamuno P. Clinical and epidemiological characteristics of adult patients hospitalized for erysipelas and cellulitis. Eur J Clin Microbiol Infect Dis 2012; 31: 2147–2152. 16 Thomas K, Crook A, Foster K et al. Prophylactic antibiotics for the prevention of cellulitis (erysipelas) of the leg: results of the UK Dermatology Clinical Trials Network’s PATCH II trial. Br J Dermatol 2012; 166: 169– 178. 17 Lazzarini L, Pellizzer G. Erysipelas-cellulitis of the leg: impact of the application of a guideline in an infectious diseases unit. J Chemother 2011; 23: 378. 18 Durand AC, Palazzolo S, Tanti-Hardouin N et al. Non urgent patients in emergency departments: rational or irresponsible consumers? Perceptions of professionals and patients. BMC Res Notes 2012; 5: 525. 19 Carrieri M, Angelini P, Venturelli C, Maccagnani B, Bellini R. Aedes albopictus (Diptera: Culicidae) population size survey in the 2007 chikungunya outbreak area in Italy. II: Estimating epidemic thresholds. J Med Entomol 2012; 49: 388–399. 20 Romi R. Arthropod-borne diseases in Italy: from a neglected matter to an emerging health problem. Ann Ist Super Sanita 2010; 46: 436–443. 21 Lam TP, Yeung CK, Lam KF. What are the learning outcomes of a short postgraduate training course in dermatology for primary care doctors? BMC Med Educ 2011; 11: 20. 22 Smulowitz PB, Honigman L, Landon BE. A novel approach to identifying targets for cost reduction in the emergency department. Ann Emerg Med 2013; 61: 293–300. 23 Steptoe AP, Corel B, Sullivan AF, Camargo CA Jr. Characterizing emergency departments to improve understanding of emergency care systems. Int J Emerg Med 2011; 4: 42. 24 Muir J, Xu C, Paul S et al. Incorporating teledermatology into emergency medicine. Emerg Med Australas 2011; 23: 562–568. 25 Arnold JL, Dickinson G, Tsai M-C, Han D. A survey of emergency medicine in 36 countries. Canad J Emerg Med 2001; 3: 109–118. 26 Beniuk K, Boyle AA, Clarkson PJ. Emergency department crowding: Prioritising quantified crowding measures using a Delphi study. Emerg Med J 2012; 29: 868–871.
© 2014 European Academy of Dermatology and Venereology
