oRIGINAL CONTRIBUTION
Emergency Department Visits A Statewide Survey Henry C. Huntley, MD, MPH Jacksonville, Florida
In a r e v i e w b y q u e s t i o n n a i r e o f t h e e m e r g e n c y v i s i t s to 185 F l o r i d a h o s p i tals, t h e n u m b e r o f a n n u a l e s t i m a t e d v i s i t s a p p e a r s to e x c e e d n a t i o n a l estimates. In a d d i t i o n , t h e c o n c e p t t h a t in e x c e s s o f 75 % o f p a t i e n t s are n o t true e m e r g e n c i e s is n o t b o r n e out. In spite o f c h a n g e s in the e m e r g e n c y medical s e r v i c e s s y s t e m , o n l y 10 % o f p a t i e n t s c a m e b y a m b u l a n c e or rescue v e h i c l e . T h e s e p a t i e n t s w e r e m o r e l i k e l y to b e s e r i o u s l y ill as attested to b y the f a c t t h a t 50 % r e q u i r e d h o s p i t a l i z a t i o n . D e f i n i t i v e c a r e was p r o v i d e d for 80 % o f p a t i e n t s . S o m e 40 % o f F l o r i d a ' s e m e r g e n c y dep a r t m e n t s h a v e f u l l - t i m e e m e r g e n c y p h y s i c i a n s . A l t h o u g h n e a r l y 70 % o f the e m e r g e n c y p a t i e n t s w e r e s e e n b y t h e s e p h y s i c i a n s , 2.4 % w e r e s e e n b y interns o n l y , a n d a t o t a l o f 10 % w e r e s e e n b y h o u s e o f f i c e r s o n l y . T h e r e was a g r e a t v a r i e t y o f r e f e r r a l p a t t e r n s a m o n g t h e H e a l t h S e r v i c e A g e n cies.
Huntley HC: Emergency department visits - - a statewide survey. JACEP 6: 296-299, July, 1977. hospital emergency department, utilization, Florida. INTRODUCTION K n o w l e d g e of the c o m p o s i t i o n of the case loads of a state's h o s p i t a l emergency d e p a r t m e n t s can assist in planning for future needs as well as d e t e r m i n i n g e x i s t i n g m e d i c a l practices, A w a r e n e s s of the frequency of the various e m e r g e n c y problems and hospital admission, c o r r e l a t e d w i t h data from a m b u l a n c e t r i p r u n reports, will help d e t e r m i n e the adequacy of a state's emergency medical care system. In r e c o g n i t i o n of these premises, From the Emergency Services Section, State of Florida, Department of Health and Rehabilitative Services, Jacksonville, Florida. Address for reprints: Henry C. Huntley, MD, MPH, 4601 North Park Avenue, Suite 719, Chevy Chase, Maryland 20015. ~ )
6:7 (Jul) 1977
the F l o r i d a E m e r g e n c y Medical Service p r o g r a m c o n t r a c t e d w i t h t h e F l o r i d a H o s p i t a l Association to oht a i n this information.
METHODS The F l o r i d a H o s p i t a l A s s o c i a t i o n d e t e r m i n e d t h a t d a t a from all admiss i o n s for one w e e k in N o v e m b e r , 1975 and one w e e k in March, 1975 would be s t a t i s t i c a l l y significant for one state. There was a w e l l - p l a n n e d informational c a m p a i g n prior to sending out the q u e s t i o n n a i r e . This was p r i m a rily t h r o u g h publicity channels of the Hospital Association. However, staff of the s t a t e and regional e m e r g e n c y m e d i c a l s e r v i c e ~ ( E M S / offices also visited and discussed t h e questionn a i r e with most of the hospital administrators.
T h e r e w e r e s e p a r a t e m a i l i n g s of t h e q u e s t i o n n a i r e for t h e w e e k in N o v e m b e r and in March. These were sent to each hospital k n o w n to provide e m e r g e n c y services. There were a n u m b e r of calls and follow-up visits to clarify the questions and to urge completion of the questionnaire. The success of these efforts is a t t e s t e d to by the fact t h a t of the 186 hospitals p r o v i d i n g e m e r g e n c y s e r v i c e s in Florida, only one refused to complete the q u e s t i o n n a i r e . In r e v i e w i n g the data, however, it was discovered that the state's l a r g e s t e m e r g e n c y d e p a r t m e n t rep o r t e d for o n l y two d a y s of e a c h w e e k . T h e t o t a l n u m b e r of v i s i t s , therefore, is probably u n d e r - r e p o r t e d to the e x t e n t of 5% to 6%. This factor should not p r e v e n t the s t a t i s t i c a l validity of the following tables.
RESULTS AND DISCUSSION In s t u d y i n g emergency d e p a r t m e n t visits by day of week, t h e r e were no s i g n i f i c a n t differences (Table 11 alt h o u g h s l i g h t l y more p a t i e n t s came on F r i d a y and S a t u r d a y nights. In the only other report 1 on this question in the l i t e r a t u r e surveyed, New York Hospital had a high of 18c~ of t o t a l a d m i s s i o n s on S u n d a y and a low of 12~, on Wednesday. In Florida, a m b u l a n c e and rescue services provided t r a n s p o r t a t i o n for only 9.64~ of the p a t i e n t s a d m i t t e d to e m e r g e n c y services (Table 2). The 296/23
Table 1 E M E R G E N C Y DEPARTMENT VISITS BY DAY Day
Number
Percent
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Not specified
14,929 14,545 14,683 14,648 16,024 16,186 14,004
13.99 13.63 13.76 13.73 15.02 15.17 13.69
TOTAL
106,685
1,066
1.00 100.
Table 2 METHOD OF CONVEYANCE Number
Private car Not specified Ambulance Foot Public transportation Rescue vehicle TOTAL
Percent
81,599
76.57
8,940 8,932 3,830
8.39 8.38 3.59
1,920
1.81
1,344
1.26
106,565
100.
greatest majority of p a t i e n t s (76.57c2) came by private conveyance. No other statewide s u r v e y was found where s i m i l a r q u e s t i o n s of t r a n s p o r t a t i o n were answered. At St. Raphael's in New Haven, which served primarily a low income group, a study 2 on the use and misuse of a m b u l a n c e services indicated t h a t 20~ of t r a u m a patients arrived by ambulance. Our study did not break down the method of transportation for t r a u m a or n o n t r a u m a . We know from a m b u l a n c e trip reports t h a t 6 7 ~ of patients so transported Were ]lospitalized. Studies 3 of p h y s i c i a n - p a t i e n t contacts have u s u a l l y found a preponderance of female versus male patients. In the Florida emergency dep a r t m e n t s we found a slight excess of male over female p a t i e n t s (Table 3). This differs from reports from Bon Secours 4 in M a r y l a n d and New York' h o s p i t a l s w h e r e t h e n u m b e r of females a d m i t t e d was slightly h i g h e r . It may be t h a t the greater in-
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Table 3 E M E R G E N C Y DEPARTMENT VISITS (SEX) Number
Male Female Not specified
54,633 51,345
TOTAL
106,585
607
Percent
51.26 48.17 0.57 100.
cidence of injuries and cardiac malfunctions in males z accounts for the higher male admissions.
expected n u m b e r of visits from the over-65 age group may indicate that, because of Medicare, this group is more likely to visit a personal physician. With a 15~ n o n w h i t e population, we found t h a t 24~ of visits to emerg e n c y d e p a r t m e n t s w e r e by non_ whites (Table 5). This finding is not unexpected and m a y occur because of the g r e a t e r difficulties minority groups experience in finding medical care outside hospital settings. No o t h e r s t u d y r e v i e w e d con. trasted the visits of minority groups w i t h t h e p o p u l a t i o n s s e r v e d . As m i g h t be expected, the majority of patients at Bon Secours 4 and Maitl a n d 6 hospitals were from minority groups.
One of the unexpected findings is the lack of a n y excess of visits in the lower and upper age groups in proportion to the population (Table 4) although 20.95% were in the 14 and u n d e r age g r o u p . T h e New Y o r k Hospital study 1 showed the over-65 age group comprised 12% of the adm i s s i o n s w h i l e i n t h e s t u d y of a satellite clinic in ConnecticutG only 3% o f t h e patients admitted were 65 or over. In Florida, the lower t h a n
A critical issue is the percentage of e m e r g e n c y a d m i s s i o n s for which h o s p i t a l i z a t i o n was deemed necessary and the percent that required t r a n s f e r to o t h e r facilities directly from the emergency d e p a r t m e n t (Table 6). The 14.97% a d m i s s i o n rate
Table 4 E M E R G E N C Y DEPARTMENT VISITS (AGE)
Table 5 E M E R G E N C Y DEPARTMENT VISITS (RACE),
Number
Percent
0- 4 5-14 15 - 44 45 - 64 65 - 99 Not specified
9,375 12,949 48,274 17,881 15,513
8.8O 12.15 45.29 16.78 14.55
TOTAL
106,585
2,5.93
2.43 100.
White Black Spanish speaking Oriental Indian Not specified TOTAL
Number
Percent
76,061 21,373
71.36 20.05
3,546 157 64
3.33 0.14 0.06
5,390 106,585
5.06 100.
Table 6 PATIENT DISPOSITION
Treated and Released Hospitalized No T r e a t m e n t - - referred to another MD Hospitalized - - CCU Not specified Left, no treatment Transferred - - another hospital DOA DIE Transferred - - CCU TOTAL
Number
Percent
84,414 12,963 2,243 2,134 1,880 1,160 642 343 190 134
79.56 12.22 2.11 2.01 1.77 1.09 0.61 0.32 0.18 0.13
106,103
100.
6"7 (Jul)1977 J ~ P
;@resents 450,000 a d m i s s i o n s to hospital beds each year. In a conservative estimate (Florida Hospital Ass0ciation - - 1975 e s t i m a t e s ) these patients account for one third of the lotal hospital r e v e n u e in the state. 0~her studies have found a s i m i l a r r~e of hospital admissions. I n Connecticut in 1955, a survey of 90 hospitals7 showed a 17% admission rate from the e m e r g e n c y d e p a r t m e n t s . Virginia found a 15% admission rate s while i n d i v i d u a l hospitals have varying rates. Bon Secour 4 admitted 5% of emergency d e p a r t m e n t patients i n 1967 a n d New York H o s p i t a l 1 i n 1965 admitted 14%. In looking at the experiences of individual hospitals, we find t h a t i n n e r city hospitals, possibly t r y i n g to hold down bed case load, have a low rate of admissions while a few hospitals in overbuilt a r e a s have a d m i s s i o n rates of 25% to 40%. B r e a k i n g this down by regional patterns, we find that in t h e n i n e H e a l t h S e r v i c e s Agency (HSA) d i s t r i c t s i n F l o r i d a bed admissions r a n g e from a low of 12% in D i s t r i c t I I I ( J a c k s o n v i l l e area) to a high of 18% in HSA District IX (Miami area). Equally noteworthy is t h a t almost 80% of p a t i e n t s are treated and sent home. In 2.11% of cases, the p a t i e n t s were not t r e a t e d i n the e m e r g e n c y department b u t referred to t h e i r personal physician. The percentage of patients treated in emergency d e p a r t m e n t s with fulltime p h y s i c i a n s , i n c o n t r a s t w i t h visiting staff, h a s i n c r e a s e d i n Florida i n r e c e n t y e a r s as it h a s
Table 7 EMERGENCY DEPARTMENT PATIENTS' PHYSICIANS
Emergency physician Family physician Other Specialist Resident Not specified Intern TOTAL J~P
Number
Percent
73,217
68.69
10,563
9.91
9,503 8,040
8.92 7.54
2,704 2,558
2.54 2.40
106,585
6:7 (Jul) 1977
100.
Table 8 PATIENT C O M P L A I N T S Complaint
Laceration Fracture Bruise Musculoskeletal Cardiac Burn Psychiatric Drugs Alcohol Concussion Diabetes Poisoning Snakebite TOTAL
Actual Number
Percent
Annual Estimate
Percent
14,976 10,841 5,930 4,876 3,869 1,370 1,155 689 564 545 496 291 22
32.78 23.76 13.00 10.69 8.49 3.00 2.53 1.51 1.24 1.20 1,09 0.64 0.05
388,966 281,875 154,180 126,776 100,994 35,620 30,030 19,914 14,664 14,170 12,896 7,566 572
32.74 23.72 12.98 10.67 8.50 3.00 2.53 1.66 1.23 1.19 1.09 0.64 0.05
45,594
t h r o u g h o u t the n a t i o n 2 Only 10% of p a t i e n t s were seen by a visiting family physician (Table 7)_ Another 10% were seen by house officers. Nationally, a n i n c r e a s i n g n u m b e r of hospitals were t u r n i n g to full-time physicians to provide emergency care. A study of hospital emergency departm e n t s i n Florida in 1972 showed app r o x i m a t e l y 40% h a d f u l l - t i m e p h y s i c i a n s 3 Almost 70% (68.69%} of e m e r g e n c y p a t i e n t s were s e e n by e m e r g e n c y p h y s i c i a n s . A 1973 study TM in Detroit indicated t h a t 50% of e m e r g e n c y d e p a r t m e n t s w e r e staffed by full-time physicians. The belief has long been held that more a n d more frequently emergency d e p a r t m e n t s are serving as p r i m a r y care centers in lieu of family physiclans and t h a t the great majority of p a t i e n t s seen are nonemergencies. In actual fact, almost 74% of p a t i e n t s in our study had t r a u m a - r e l a t e d condit i o n s (bruises, b u r n s , c o n c u s s i o n s , f r a c t u r e s , l a c e r a t i o n s ) ( T a b l e 8). A l t h o u g h not all of this t r a u m a was life- or l i m b - t h r e a t e n i n g , all did require physician i n t e r v e n t i o n , either diagnostic or therapeutic, to definitely t r e a t or d e t e r m i n e the necessity for f u r t h e r therapy. In Virginia, s 59% of patients were classified as nonemergencies. In Baltimore, 4 49% of p a t i e n t s had surgical conditions, b u t 55% were considered nonemergencies.,-~, a r u r a l Connecticut clinic, 11 50% of p a t i e n t s seen were for t r a u m a related problems. I n Maitland, s t r a u m a admissions were
100.
1,188,213
100.
25% of the total; however, 32~7c of pat i e n t s were considered to be surgical p r o b l e m s . No c o n c l u s i o n s c a n be d r a w n w i t h certainty as to how m a n y patients seen have nonemergency problems. Perhaps the answer can be found only t h r o u g h a clearer unders t a n d i n g of terminology. Other pertinent questions may a r i s e from t h e c o m p o s i t i o n of the case load. For example, does the fact t h a t 500 to 600 persons are treated a n n u a l l y for snake bites with an average of only one death per year indicate t h a t t r e a t m e n t does not affect mortality, but that morbidity and possible disability is the only question? W i t h Florida legislation requiring medical t r e a t m e n t for alcoholics, why w(re only 15,000 seen in emergency d e p a r t m e n t s ? How m a n y of the 12,000 unsuccessful suicides and 10,000 a t t e m p t e d homicides were followed up by concerned agencies? S i x t y - e i g h t percent of e m e r g e n c y p a t i e n t s w i t h a cardiac d i a g n o s i s , 6.6% of t r a u m a patients a n d 6.4% of b u r n p a t i e n t s were hospitalized. Ann u a l l y , this would m e a n 2,280 b u r n p a t i e n t s a n d 62,850 v i c t i m s of t r a u m a were considered to have inj u r i e s of sufficient severity to be hosp i t a l i z e d . I n t h e s t u d y a t St. Raphael, 2 it was found t h a t 10% of t r a u m a p a t i e n t s required hospitalization. The p a t t e r n of referral and lack of referral to other facilities is of interest_ Statewide, 4.8% of all emergen298/25
cies r e q u i r i n g h o s p i t a l i z a t i o n were r e f e r r e d to some o t h e r facility, in m a n y instances, probably because of reasons other t h a n inability to provide q u a l i t y care. In referral p a t t e r n s of i n d i v i d u a l hospitals, some small h o s p i t a l s m a d e very few r e f e r r a l s w h i l e o t h e r s r e f e r r e d a large percentage of those r e q u i r i n g hospitalization. O n a regional basis, the percentage of r e f e r r a l s v a r i e d from a h i g h of 7.3% in HSA Region II (Gainesville) to a low of 2.8% in Region VIII (Ft. Lauderdale). This is not unexpected. For various reasons, the p a t t e r n s of referrals from smaller counties to the t e a c h i n g hospital at Gainesville has b e e n long e s t a b l i s h e d . In Broward County, we question the capabilities of every hospital to care for 97% of e m e r g e n c y p a t i e n t s r e q u i r i n g hospitalization. Few o t h e r - a t t e m p t s to provide answers to questions on emergency dep a r t m e n t visits on a statewide basis have been made in recent years. In 1967, Rudolf 9 a n d others mailed a q u e s t i o n n a i r e to all members of the Virginia Hospital Association. Fiftythree of the 79 were r e t u r n e d by hospitals with emergency departments. A n y other a t t e m p t s at statewide surveys are not available although there are n u m e r o u s a n a l y s e s of the case loads of isolated emergency departments. In 1967 B e a v e n et al 4 a n a l y z e d in-depth the emergency d e p a r t m e n t at Bon Secours in Baltimore. In addition, there is a report of the findings of cases admitted to New York Hospital, 1 which g e n e r a l l y serves a high economic level clientele. The effectiveness of a satellite clinic providing emergency care for a p r i m a r i l y r u r a l a r e a of C o n n e c t i c u t has been discussed elsewhere. 1' There is data on
26/299
the case c o m p o s i t i o n of the e m e r gency d e p a r t m e n t of a n i n n e r city h o s p i t a l i n N e w a r k , New J e r s e y . 7 N o t s u r p r i s i n g l y , t h e r e are b o t h s i m i l a r i t i e s and differences from our Florida study.
CONCLUSIONS The total case load seen in emergency d e p a r t m e n t s in Florida in two weeks (3,000,000) exceeds n a t i o n a l e s t i m a t e s of 60,000,000 visits per year 12 or 2,307,692 every two weeks. This could m e a n the n a t i o n a l estimates are inaccurate or t h a t Floridians depend more on emergency dep a r t m e n t s for p r i m a r y care. The s u p p o s i t i o n t h a t 75% of a n e m e r g e n c y d e p a r t m e n t case load consists of nonemergencies is probably not true. A more accurate statem e n t w o u l d be t h a t most are imm e d i a t e a n d p r e s s i n g problems for patients. A p p r o x i m a t e l y 50% of those pat i e n t s r e q u i r i n g hospitalization are b r o u g h t in by a m b u l a n c e or rescue vehicles, even though only 10% of all emergency p a t i e n t s are b r o u g h t by t h e s e v e h i c l e s . T h e r e are o v e r 300,000 emergency a m b u l a n c e r u n s annually. The very old or very y o u n g did not m a k e up the m a j o r p o r t i o n of the case load and only 25% consisted of b l a c k s or o t h e r d e f i n a b l e e t h n i c groups. The reasons for high hospitalization rates from some emergency services and low referral rates from some facilities m a y be e x a m i n e d by HSA s t u d y groups as m e d i c a l care patt e r n s w i t h i n r e s p e c t i v e H S A s are explored d u r i n g the next few years. It is i m p r o b a b l e t h a t all lifet h r e a t e n i n g emergencies are receiving the q u a l i t y of care necessary for
survival a n d the prevention of Pet, m a n e n t disability.
REFERENCES: 1. Reed JI, Reader GG: Qualitative sur. vey of New York Hospital emergeac~ room, 1965. N Y State Med 67:1335-134~ 1967. -'
2. Webb SB, Christoford J: Use and rais, use of ambulance services by the popula, tion using the emergency department at the Hospital of St. Raphael. Corm Med 37:195-8, 1974. 3. Current Estimates - - Health Inter. view Survey, United States, Table 20. US Department of Health, Education, and Welfare, 1975. 4. Beaven WE, Sordo JF, Wheltle I~: Emergency room problems of an 'inner core' city hospital: in-depth analysis of the emergency department, Bon Secour~ Hospital• MD State IViedJ 18:63-67, 1969, 5. Current Estimates - - Health Inter. view Survey, United States, Table 1. US Department of Health, Education, and Welfare, 1975. 6. Haycock CE, Rush Jr BF: Emergency department surgical experience in an inner city hospital. JACEP 3:18-22, 1973. 7. Shortliffe EC, Hamilton TS, Nordian EH: Emergency rooms and the changing pattern of medical care. N Engl J Med 258:20-25, 1958. 8. Rudolph LE, Kurzman RW, Brewster RC: Hospital emergency rooms in Virginia: statewide survey. Virginia Med Monthly 96:38-42, 1969. 9. Study of Emergency Departments. Florida Department of Health and Rehabilitation Services, 1972. 10. Krome RL, Schron S, Wilson RF: A study of emergency medical services in the Detroit metropolitan area. JACEP 2:177-82, 1973. 11. Pearson DA, Bernacki EJ, Miggs JW: Emergency medical care facility: program characteristics and patient attributes, JACEP 5:174-79, 1976. 12. University of Chicago - - Center for Health Administration Studies, University of Chicago Press, 1970, p 109, referred to in Hospital indicators. Hospitals 44:29. 1970.
6:7 (Jul)1977
~P
Emergency Department Visits A Statewide Survey Henry C. Huntley, MD, MPH Jacksonville, Florida
In a r e v i e w b y q u e s t i o n n a i r e o f t h e e m e r g e n c y v i s i t s to 185 F l o r i d a h o s p i tals, t h e n u m b e r o f a n n u a l e s t i m a t e d v i s i t s a p p e a r s to e x c e e d n a t i o n a l estimates. In a d d i t i o n , t h e c o n c e p t t h a t in e x c e s s o f 75 % o f p a t i e n t s are n o t true e m e r g e n c i e s is n o t b o r n e out. In spite o f c h a n g e s in the e m e r g e n c y medical s e r v i c e s s y s t e m , o n l y 10 % o f p a t i e n t s c a m e b y a m b u l a n c e or rescue v e h i c l e . T h e s e p a t i e n t s w e r e m o r e l i k e l y to b e s e r i o u s l y ill as attested to b y the f a c t t h a t 50 % r e q u i r e d h o s p i t a l i z a t i o n . D e f i n i t i v e c a r e was p r o v i d e d for 80 % o f p a t i e n t s . S o m e 40 % o f F l o r i d a ' s e m e r g e n c y dep a r t m e n t s h a v e f u l l - t i m e e m e r g e n c y p h y s i c i a n s . A l t h o u g h n e a r l y 70 % o f the e m e r g e n c y p a t i e n t s w e r e s e e n b y t h e s e p h y s i c i a n s , 2.4 % w e r e s e e n b y interns o n l y , a n d a t o t a l o f 10 % w e r e s e e n b y h o u s e o f f i c e r s o n l y . T h e r e was a g r e a t v a r i e t y o f r e f e r r a l p a t t e r n s a m o n g t h e H e a l t h S e r v i c e A g e n cies.
Huntley HC: Emergency department visits - - a statewide survey. JACEP 6: 296-299, July, 1977. hospital emergency department, utilization, Florida. INTRODUCTION K n o w l e d g e of the c o m p o s i t i o n of the case loads of a state's h o s p i t a l emergency d e p a r t m e n t s can assist in planning for future needs as well as d e t e r m i n i n g e x i s t i n g m e d i c a l practices, A w a r e n e s s of the frequency of the various e m e r g e n c y problems and hospital admission, c o r r e l a t e d w i t h data from a m b u l a n c e t r i p r u n reports, will help d e t e r m i n e the adequacy of a state's emergency medical care system. In r e c o g n i t i o n of these premises, From the Emergency Services Section, State of Florida, Department of Health and Rehabilitative Services, Jacksonville, Florida. Address for reprints: Henry C. Huntley, MD, MPH, 4601 North Park Avenue, Suite 719, Chevy Chase, Maryland 20015. ~ )
6:7 (Jul) 1977
the F l o r i d a E m e r g e n c y Medical Service p r o g r a m c o n t r a c t e d w i t h t h e F l o r i d a H o s p i t a l Association to oht a i n this information.
METHODS The F l o r i d a H o s p i t a l A s s o c i a t i o n d e t e r m i n e d t h a t d a t a from all admiss i o n s for one w e e k in N o v e m b e r , 1975 and one w e e k in March, 1975 would be s t a t i s t i c a l l y significant for one state. There was a w e l l - p l a n n e d informational c a m p a i g n prior to sending out the q u e s t i o n n a i r e . This was p r i m a rily t h r o u g h publicity channels of the Hospital Association. However, staff of the s t a t e and regional e m e r g e n c y m e d i c a l s e r v i c e ~ ( E M S / offices also visited and discussed t h e questionn a i r e with most of the hospital administrators.
T h e r e w e r e s e p a r a t e m a i l i n g s of t h e q u e s t i o n n a i r e for t h e w e e k in N o v e m b e r and in March. These were sent to each hospital k n o w n to provide e m e r g e n c y services. There were a n u m b e r of calls and follow-up visits to clarify the questions and to urge completion of the questionnaire. The success of these efforts is a t t e s t e d to by the fact t h a t of the 186 hospitals p r o v i d i n g e m e r g e n c y s e r v i c e s in Florida, only one refused to complete the q u e s t i o n n a i r e . In r e v i e w i n g the data, however, it was discovered that the state's l a r g e s t e m e r g e n c y d e p a r t m e n t rep o r t e d for o n l y two d a y s of e a c h w e e k . T h e t o t a l n u m b e r of v i s i t s , therefore, is probably u n d e r - r e p o r t e d to the e x t e n t of 5% to 6%. This factor should not p r e v e n t the s t a t i s t i c a l validity of the following tables.
RESULTS AND DISCUSSION In s t u d y i n g emergency d e p a r t m e n t visits by day of week, t h e r e were no s i g n i f i c a n t differences (Table 11 alt h o u g h s l i g h t l y more p a t i e n t s came on F r i d a y and S a t u r d a y nights. In the only other report 1 on this question in the l i t e r a t u r e surveyed, New York Hospital had a high of 18c~ of t o t a l a d m i s s i o n s on S u n d a y and a low of 12~, on Wednesday. In Florida, a m b u l a n c e and rescue services provided t r a n s p o r t a t i o n for only 9.64~ of the p a t i e n t s a d m i t t e d to e m e r g e n c y services (Table 2). The 296/23
Table 1 E M E R G E N C Y DEPARTMENT VISITS BY DAY Day
Number
Percent
Monday Tuesday Wednesday Thursday Friday Saturday Sunday Not specified
14,929 14,545 14,683 14,648 16,024 16,186 14,004
13.99 13.63 13.76 13.73 15.02 15.17 13.69
TOTAL
106,685
1,066
1.00 100.
Table 2 METHOD OF CONVEYANCE Number
Private car Not specified Ambulance Foot Public transportation Rescue vehicle TOTAL
Percent
81,599
76.57
8,940 8,932 3,830
8.39 8.38 3.59
1,920
1.81
1,344
1.26
106,565
100.
greatest majority of p a t i e n t s (76.57c2) came by private conveyance. No other statewide s u r v e y was found where s i m i l a r q u e s t i o n s of t r a n s p o r t a t i o n were answered. At St. Raphael's in New Haven, which served primarily a low income group, a study 2 on the use and misuse of a m b u l a n c e services indicated t h a t 20~ of t r a u m a patients arrived by ambulance. Our study did not break down the method of transportation for t r a u m a or n o n t r a u m a . We know from a m b u l a n c e trip reports t h a t 6 7 ~ of patients so transported Were ]lospitalized. Studies 3 of p h y s i c i a n - p a t i e n t contacts have u s u a l l y found a preponderance of female versus male patients. In the Florida emergency dep a r t m e n t s we found a slight excess of male over female p a t i e n t s (Table 3). This differs from reports from Bon Secours 4 in M a r y l a n d and New York' h o s p i t a l s w h e r e t h e n u m b e r of females a d m i t t e d was slightly h i g h e r . It may be t h a t the greater in-
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Table 3 E M E R G E N C Y DEPARTMENT VISITS (SEX) Number
Male Female Not specified
54,633 51,345
TOTAL
106,585
607
Percent
51.26 48.17 0.57 100.
cidence of injuries and cardiac malfunctions in males z accounts for the higher male admissions.
expected n u m b e r of visits from the over-65 age group may indicate that, because of Medicare, this group is more likely to visit a personal physician. With a 15~ n o n w h i t e population, we found t h a t 24~ of visits to emerg e n c y d e p a r t m e n t s w e r e by non_ whites (Table 5). This finding is not unexpected and m a y occur because of the g r e a t e r difficulties minority groups experience in finding medical care outside hospital settings. No o t h e r s t u d y r e v i e w e d con. trasted the visits of minority groups w i t h t h e p o p u l a t i o n s s e r v e d . As m i g h t be expected, the majority of patients at Bon Secours 4 and Maitl a n d 6 hospitals were from minority groups.
One of the unexpected findings is the lack of a n y excess of visits in the lower and upper age groups in proportion to the population (Table 4) although 20.95% were in the 14 and u n d e r age g r o u p . T h e New Y o r k Hospital study 1 showed the over-65 age group comprised 12% of the adm i s s i o n s w h i l e i n t h e s t u d y of a satellite clinic in ConnecticutG only 3% o f t h e patients admitted were 65 or over. In Florida, the lower t h a n
A critical issue is the percentage of e m e r g e n c y a d m i s s i o n s for which h o s p i t a l i z a t i o n was deemed necessary and the percent that required t r a n s f e r to o t h e r facilities directly from the emergency d e p a r t m e n t (Table 6). The 14.97% a d m i s s i o n rate
Table 4 E M E R G E N C Y DEPARTMENT VISITS (AGE)
Table 5 E M E R G E N C Y DEPARTMENT VISITS (RACE),
Number
Percent
0- 4 5-14 15 - 44 45 - 64 65 - 99 Not specified
9,375 12,949 48,274 17,881 15,513
8.8O 12.15 45.29 16.78 14.55
TOTAL
106,585
2,5.93
2.43 100.
White Black Spanish speaking Oriental Indian Not specified TOTAL
Number
Percent
76,061 21,373
71.36 20.05
3,546 157 64
3.33 0.14 0.06
5,390 106,585
5.06 100.
Table 6 PATIENT DISPOSITION
Treated and Released Hospitalized No T r e a t m e n t - - referred to another MD Hospitalized - - CCU Not specified Left, no treatment Transferred - - another hospital DOA DIE Transferred - - CCU TOTAL
Number
Percent
84,414 12,963 2,243 2,134 1,880 1,160 642 343 190 134
79.56 12.22 2.11 2.01 1.77 1.09 0.61 0.32 0.18 0.13
106,103
100.
6"7 (Jul)1977 J ~ P
;@resents 450,000 a d m i s s i o n s to hospital beds each year. In a conservative estimate (Florida Hospital Ass0ciation - - 1975 e s t i m a t e s ) these patients account for one third of the lotal hospital r e v e n u e in the state. 0~her studies have found a s i m i l a r r~e of hospital admissions. I n Connecticut in 1955, a survey of 90 hospitals7 showed a 17% admission rate from the e m e r g e n c y d e p a r t m e n t s . Virginia found a 15% admission rate s while i n d i v i d u a l hospitals have varying rates. Bon Secour 4 admitted 5% of emergency d e p a r t m e n t patients i n 1967 a n d New York H o s p i t a l 1 i n 1965 admitted 14%. In looking at the experiences of individual hospitals, we find t h a t i n n e r city hospitals, possibly t r y i n g to hold down bed case load, have a low rate of admissions while a few hospitals in overbuilt a r e a s have a d m i s s i o n rates of 25% to 40%. B r e a k i n g this down by regional patterns, we find that in t h e n i n e H e a l t h S e r v i c e s Agency (HSA) d i s t r i c t s i n F l o r i d a bed admissions r a n g e from a low of 12% in D i s t r i c t I I I ( J a c k s o n v i l l e area) to a high of 18% in HSA District IX (Miami area). Equally noteworthy is t h a t almost 80% of p a t i e n t s are treated and sent home. In 2.11% of cases, the p a t i e n t s were not t r e a t e d i n the e m e r g e n c y department b u t referred to t h e i r personal physician. The percentage of patients treated in emergency d e p a r t m e n t s with fulltime p h y s i c i a n s , i n c o n t r a s t w i t h visiting staff, h a s i n c r e a s e d i n Florida i n r e c e n t y e a r s as it h a s
Table 7 EMERGENCY DEPARTMENT PATIENTS' PHYSICIANS
Emergency physician Family physician Other Specialist Resident Not specified Intern TOTAL J~P
Number
Percent
73,217
68.69
10,563
9.91
9,503 8,040
8.92 7.54
2,704 2,558
2.54 2.40
106,585
6:7 (Jul) 1977
100.
Table 8 PATIENT C O M P L A I N T S Complaint
Laceration Fracture Bruise Musculoskeletal Cardiac Burn Psychiatric Drugs Alcohol Concussion Diabetes Poisoning Snakebite TOTAL
Actual Number
Percent
Annual Estimate
Percent
14,976 10,841 5,930 4,876 3,869 1,370 1,155 689 564 545 496 291 22
32.78 23.76 13.00 10.69 8.49 3.00 2.53 1.51 1.24 1.20 1,09 0.64 0.05
388,966 281,875 154,180 126,776 100,994 35,620 30,030 19,914 14,664 14,170 12,896 7,566 572
32.74 23.72 12.98 10.67 8.50 3.00 2.53 1.66 1.23 1.19 1.09 0.64 0.05
45,594
t h r o u g h o u t the n a t i o n 2 Only 10% of p a t i e n t s were seen by a visiting family physician (Table 7)_ Another 10% were seen by house officers. Nationally, a n i n c r e a s i n g n u m b e r of hospitals were t u r n i n g to full-time physicians to provide emergency care. A study of hospital emergency departm e n t s i n Florida in 1972 showed app r o x i m a t e l y 40% h a d f u l l - t i m e p h y s i c i a n s 3 Almost 70% (68.69%} of e m e r g e n c y p a t i e n t s were s e e n by e m e r g e n c y p h y s i c i a n s . A 1973 study TM in Detroit indicated t h a t 50% of e m e r g e n c y d e p a r t m e n t s w e r e staffed by full-time physicians. The belief has long been held that more a n d more frequently emergency d e p a r t m e n t s are serving as p r i m a r y care centers in lieu of family physiclans and t h a t the great majority of p a t i e n t s seen are nonemergencies. In actual fact, almost 74% of p a t i e n t s in our study had t r a u m a - r e l a t e d condit i o n s (bruises, b u r n s , c o n c u s s i o n s , f r a c t u r e s , l a c e r a t i o n s ) ( T a b l e 8). A l t h o u g h not all of this t r a u m a was life- or l i m b - t h r e a t e n i n g , all did require physician i n t e r v e n t i o n , either diagnostic or therapeutic, to definitely t r e a t or d e t e r m i n e the necessity for f u r t h e r therapy. In Virginia, s 59% of patients were classified as nonemergencies. In Baltimore, 4 49% of p a t i e n t s had surgical conditions, b u t 55% were considered nonemergencies.,-~, a r u r a l Connecticut clinic, 11 50% of p a t i e n t s seen were for t r a u m a related problems. I n Maitland, s t r a u m a admissions were
100.
1,188,213
100.
25% of the total; however, 32~7c of pat i e n t s were considered to be surgical p r o b l e m s . No c o n c l u s i o n s c a n be d r a w n w i t h certainty as to how m a n y patients seen have nonemergency problems. Perhaps the answer can be found only t h r o u g h a clearer unders t a n d i n g of terminology. Other pertinent questions may a r i s e from t h e c o m p o s i t i o n of the case load. For example, does the fact t h a t 500 to 600 persons are treated a n n u a l l y for snake bites with an average of only one death per year indicate t h a t t r e a t m e n t does not affect mortality, but that morbidity and possible disability is the only question? W i t h Florida legislation requiring medical t r e a t m e n t for alcoholics, why w(re only 15,000 seen in emergency d e p a r t m e n t s ? How m a n y of the 12,000 unsuccessful suicides and 10,000 a t t e m p t e d homicides were followed up by concerned agencies? S i x t y - e i g h t percent of e m e r g e n c y p a t i e n t s w i t h a cardiac d i a g n o s i s , 6.6% of t r a u m a patients a n d 6.4% of b u r n p a t i e n t s were hospitalized. Ann u a l l y , this would m e a n 2,280 b u r n p a t i e n t s a n d 62,850 v i c t i m s of t r a u m a were considered to have inj u r i e s of sufficient severity to be hosp i t a l i z e d . I n t h e s t u d y a t St. Raphael, 2 it was found t h a t 10% of t r a u m a p a t i e n t s required hospitalization. The p a t t e r n of referral and lack of referral to other facilities is of interest_ Statewide, 4.8% of all emergen298/25
cies r e q u i r i n g h o s p i t a l i z a t i o n were r e f e r r e d to some o t h e r facility, in m a n y instances, probably because of reasons other t h a n inability to provide q u a l i t y care. In referral p a t t e r n s of i n d i v i d u a l hospitals, some small h o s p i t a l s m a d e very few r e f e r r a l s w h i l e o t h e r s r e f e r r e d a large percentage of those r e q u i r i n g hospitalization. O n a regional basis, the percentage of r e f e r r a l s v a r i e d from a h i g h of 7.3% in HSA Region II (Gainesville) to a low of 2.8% in Region VIII (Ft. Lauderdale). This is not unexpected. For various reasons, the p a t t e r n s of referrals from smaller counties to the t e a c h i n g hospital at Gainesville has b e e n long e s t a b l i s h e d . In Broward County, we question the capabilities of every hospital to care for 97% of e m e r g e n c y p a t i e n t s r e q u i r i n g hospitalization. Few o t h e r - a t t e m p t s to provide answers to questions on emergency dep a r t m e n t visits on a statewide basis have been made in recent years. In 1967, Rudolf 9 a n d others mailed a q u e s t i o n n a i r e to all members of the Virginia Hospital Association. Fiftythree of the 79 were r e t u r n e d by hospitals with emergency departments. A n y other a t t e m p t s at statewide surveys are not available although there are n u m e r o u s a n a l y s e s of the case loads of isolated emergency departments. In 1967 B e a v e n et al 4 a n a l y z e d in-depth the emergency d e p a r t m e n t at Bon Secours in Baltimore. In addition, there is a report of the findings of cases admitted to New York Hospital, 1 which g e n e r a l l y serves a high economic level clientele. The effectiveness of a satellite clinic providing emergency care for a p r i m a r i l y r u r a l a r e a of C o n n e c t i c u t has been discussed elsewhere. 1' There is data on
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the case c o m p o s i t i o n of the e m e r gency d e p a r t m e n t of a n i n n e r city h o s p i t a l i n N e w a r k , New J e r s e y . 7 N o t s u r p r i s i n g l y , t h e r e are b o t h s i m i l a r i t i e s and differences from our Florida study.
CONCLUSIONS The total case load seen in emergency d e p a r t m e n t s in Florida in two weeks (3,000,000) exceeds n a t i o n a l e s t i m a t e s of 60,000,000 visits per year 12 or 2,307,692 every two weeks. This could m e a n the n a t i o n a l estimates are inaccurate or t h a t Floridians depend more on emergency dep a r t m e n t s for p r i m a r y care. The s u p p o s i t i o n t h a t 75% of a n e m e r g e n c y d e p a r t m e n t case load consists of nonemergencies is probably not true. A more accurate statem e n t w o u l d be t h a t most are imm e d i a t e a n d p r e s s i n g problems for patients. A p p r o x i m a t e l y 50% of those pat i e n t s r e q u i r i n g hospitalization are b r o u g h t in by a m b u l a n c e or rescue vehicles, even though only 10% of all emergency p a t i e n t s are b r o u g h t by t h e s e v e h i c l e s . T h e r e are o v e r 300,000 emergency a m b u l a n c e r u n s annually. The very old or very y o u n g did not m a k e up the m a j o r p o r t i o n of the case load and only 25% consisted of b l a c k s or o t h e r d e f i n a b l e e t h n i c groups. The reasons for high hospitalization rates from some emergency services and low referral rates from some facilities m a y be e x a m i n e d by HSA s t u d y groups as m e d i c a l care patt e r n s w i t h i n r e s p e c t i v e H S A s are explored d u r i n g the next few years. It is i m p r o b a b l e t h a t all lifet h r e a t e n i n g emergencies are receiving the q u a l i t y of care necessary for
survival a n d the prevention of Pet, m a n e n t disability.
REFERENCES: 1. Reed JI, Reader GG: Qualitative sur. vey of New York Hospital emergeac~ room, 1965. N Y State Med 67:1335-134~ 1967. -'
2. Webb SB, Christoford J: Use and rais, use of ambulance services by the popula, tion using the emergency department at the Hospital of St. Raphael. Corm Med 37:195-8, 1974. 3. Current Estimates - - Health Inter. view Survey, United States, Table 20. US Department of Health, Education, and Welfare, 1975. 4. Beaven WE, Sordo JF, Wheltle I~: Emergency room problems of an 'inner core' city hospital: in-depth analysis of the emergency department, Bon Secour~ Hospital• MD State IViedJ 18:63-67, 1969, 5. Current Estimates - - Health Inter. view Survey, United States, Table 1. US Department of Health, Education, and Welfare, 1975. 6. Haycock CE, Rush Jr BF: Emergency department surgical experience in an inner city hospital. JACEP 3:18-22, 1973. 7. Shortliffe EC, Hamilton TS, Nordian EH: Emergency rooms and the changing pattern of medical care. N Engl J Med 258:20-25, 1958. 8. Rudolph LE, Kurzman RW, Brewster RC: Hospital emergency rooms in Virginia: statewide survey. Virginia Med Monthly 96:38-42, 1969. 9. Study of Emergency Departments. Florida Department of Health and Rehabilitation Services, 1972. 10. Krome RL, Schron S, Wilson RF: A study of emergency medical services in the Detroit metropolitan area. JACEP 2:177-82, 1973. 11. Pearson DA, Bernacki EJ, Miggs JW: Emergency medical care facility: program characteristics and patient attributes, JACEP 5:174-79, 1976. 12. University of Chicago - - Center for Health Administration Studies, University of Chicago Press, 1970, p 109, referred to in Hospital indicators. Hospitals 44:29. 1970.
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