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Pediatric Emergency Medicine Journal > Volume 11(4); 2024 > Article
Hur, Choi, Oh, Park, and Lee: The impact of reduced pediatric emergency care hours on the patterns of emergency department utilization

Abstract

Purpose

: The declining recruitment rate of pediatric residents in Korea has led to a decrease in the number of emergency departments (EDs) offering a 24/7 pediatric emergency care (PEC). This study evaluated the impact of reduced PEC hours on the utilization patterns of a single ED.

Methods

: We reviewed medical records of pediatric patients who were defined as individuals aged 14 years or younger undergoing pediatricians’ practices in a tertiary hospital ED in Korea. Given the reduction of PEC hours from full-time to 08:00-24:00 on September 27, 2022, the patients were grouped as those who visited during March 27, 2022-September 26, 2022 (“control”), and those who visited during September 27, 2022-March 26, 2023 (“reduction”). The following variables were analyzed between the 2 periods: the number of patients, age, sex, visits via ambulances, severity by the Korean Triage and Acuity Scale with high acuity (a level 1-2 of the scale), disease-related visits, time of visit, ED length of stay (EDLOS), disposition, chief complaints, and diagnoses.

Results

: Among 3,577 pediatric patients, 1,315 visited the ED during the reduction period, down by 41.9% in numbers from the control period. From the control to reduction periods, we observed an increase in the median age (from 3.0 years [interquartile range, 1.0-7.0] to 4.0 years [1.0-8.0]; P = 0.005) and decreases in the median EDLOS (from 140.0 minutes [80.0-217.0] to 104.0 minutes [54.0-169.8]; P < 0.001) and proportion of hospitalization (from 22.1% to 12.6%; P < 0.001). No change was observed in the proportions of highacuity cases or chief complaints. We noted decreases in infection-related diagnoses during the reduction.

Conclusion

: Reducing PEC hours was associated with shorter EDLOS, fewer hospitalizations, and older age, with no difference in the severity. Even with reduced PEC hours, relevant resources should be redistributed to ensure the accessibility to PEC.

Introduction

The recruitment rate of pediatric residents in Korea has declined from 71.0% in 2020 to 27.5% in 2022 and 25.5% in 2023 (1-3). As of March 2023, only 22.5% of the 409 emergency medical centers nationwide were able to provide a 24/7 pediatric emergency care (PEC) (3). Additionally, 23.7% of the 93 pediatrician-training hospitals in the country were planning further service reduction by August 2023, posing a crucial threat to the accessibility of PEC. Although PEC hours are expected to continue to decrease, there has been insufficient evidence on the impact of this reduction on emergency department (ED) utilization. Therefore, the purpose of this study was to analyze the changes in ED utilization patterns of pediatric patients in response to the reduced PEC hours.

Methods

1. Study design

This study was approved by the institutional review board of Konyang University Hospital, which is located in Daejeon (Korea), a provincial metropolitan city, and was exempted from obtaining informed consent from the participants (IRB no. 2024-08-001). The ED of the hospital has served as a regional emergency medical center where also has provided PEC. The Department of Pediatrics handled diseaserelated cases, whereas the Department of Emergency Medicine handled injury-related cases, referring to other specialties as needed.
Previously, PEC at the ED was available on a 24/7 basis by in-house pediatric residents, primarily by a junior resident. On September 27, 2022, PEC for disease-related cases started to be provided by the pediatric residents or specialists during 08:00-24:00, as the number of pediatric residents decreased from 7 to 3. We analyzed the impact of this reduction on pediatric ED utilization by defining the period from March 27, 2022 through September 26, 2022 as the “control period,”and that from September 27, 2022 through March 26, 2023 as the“ reduction period.”Throughout the periods, the division of care between the Department of Pediatrics and the Department of Emergency Medicine remained unchanged, and thus, 24/7 care for injuries was maintained.

2. Study setting and participants

The “all-aged patients”were defined as individuals of any age, including adults, who visited the ED. The “child patients”were defined as individuals aged 14 years or younger who visited the ED. Of the child patients, “pediatric patients”were defined as who visited the ED for disease-related cases and underwent the pediatricians’practices in the ED during the periods.
We analyzed the following variables: the numbers of patients (all-aged, child, and pediatric); and for pediatric patients, age with age group (< 1, 1-2, 3-4, 5-11, and 12-14 years), sex, visits via ambulances, severity by the Korean Triage and Acuity Scale (KTAS) with high acuity (a KTAS level 1-2) (4,5), disease-related visits, time of visit (1-hour unit in the 24-hour system [e.g., 00-01]), ED length of stay (EDLOS; time from registration to discharge at the ED), and ED disposition. To reflect the reduction in pediatric practice in the ED, 00:00-07:59 was termed as the“ reduced treatment hours.”The ED disposition included overall and intensive care unit hospitalization, transfer, discharge, and inhospital mortality. Additionally, for pediatric patients, we documented their chief complaints and primary discharge diagnoses according to the eighth edition of the Korean Standard Classification of Diseases (6).

3. Statistical analysis

Continuous variables were presented as medians and interquartile ranges, while categorical variables were done as numbers and percentages. Normality tests were conducted on the continuous variables to determine their distributions. Based on whether the variables were continuous, we employed either t-tests or Mann-Whitney U-tests, chi-square tests or Fisher’s exact tests. All analyses were performed using IBM SPSS Statistics ver. 22.0 (IBM Corp.), with significance set at a P value < 0.05.

Results

During the study period, the numbers of all-aged, child, and pediatric patients decreased by 2.8%, 27.3%, and 41.9%, respectively (Fig. 1, Table 1). Among the child patients, the proportion of visits via ambulances increased during the reduction period compared to the control period, while the proportion of high-acuity cases and overall hospitalization, and median EDLOS decreased. The percentage of disease-related cases decreased by 41.9%.
Among the pediatric patients, the median age increased during the reduction period, with a more prominent decrease in the proportion of those aged 4 years or younger. Additionally, the proportion of high-acuity cases did not differ, and the median EDLOS and overall hospitalization decreased, while the use of ambulances increased (Table 2).
Among the pediatric patients who visited during the control period, 758 patients visited during 00:00-07:59 (Table 3). Proportions of the patients aged 4 years or younger were higher in those who visited during 00:00-07:59 (68.3%) than those who visited during 08:00-24:00 (61.0%). We noted a higher proportion of highacuity cases and longer EDLOS, but a lower rate of overall hospitalization in those who visited during 00:00-07:59. The largest decrease in the number of visits by the pediatric patients between 08:00 and 24:00 occurred between 23:00 and 24:00, with a 61.0% reduction (Fig. 2).
The chief complaints remained consistent over both periods, with fever being most common (Table 4). Comparison of the discharge diagnoses showed differences between the 2 periods, with “gastroenteritis and colitis of unspecified origin,”“other acute upper respiratory infections of multiple sites,” “coronavirus disease 2019, virus identified,”“acute bronchitis, unspecified,”“acute bronchiolitis, unspecified,” and “sepsis, unspecified”less common in the reduction period (Table 5).

Discussion

The reduction in PEC hours particularly affected the pediatric patients aged 4 years or younger given the increase in the median age and the corresponding decrease in the proportion of the age groups during the reduction period. It is suggested that pediatricians, compared to other specialists, are particularly well-suited to treat patients under the age of 4 years, as they provide care grounded in a comprehensive understanding of developmental stages and pediatric physiology. Additionally, their expertise in communicating effectively with the parents highlights the critical need for pediatricians in ED. These factors demonstrate the necessity of having pediatricians in EDs.
The reduction in EDLOS and hospitalization during the reduction period was likely due to a shorter waiting time in the ED due to fewer patients and stricter-than-before hospitalization criteria by the pediatricians. Conversely, despite the lack of difference in the proportion of the high-acuity cases, we speculate that the increase in intensive care unit hospitalization during the reduction period stemmed from a rise in severe respiratory diseases, which were probably more prevalent in the reduction period (i.e., fall and winter) than the control period. This also suggests that the KTAS for children may not fully reflect the severity of conditions as judged by clinicians in real-world practice, as reported in a previous study by Noh et al. (7).
The decrease in the pediatric patient volume (n = 947) during the reduction period was larger than the number of pediatric patients who visited in 00:00-07:59 during the control period (n = 758). In addition, the most notable decrease during the reduction period was observed in visits before the end of time for PEC for disease-related cases. This finding suggests that from a healthcare providers’ perspective, EDs may limit the registration of pediatric patients earlier than the official closing time to allow sufficient time for essential practices or tests, such as blood tests or radiographs. Patients with low-acuity cases may have opted to seek care at primary care facilities with night-time services or chose to visit outpatient clinics during regular hours, which may explain the observed increase in the ambulance use.
The lower frequency of infection-related diagnoses during the reduction period suggests a weakened ability to manage infection-related cases by reduced PEC hours. This change in the ED policy also led to an 11.6% decrease in the number of injury-related visits (from 2,068 [47.8%] to 1,834 [58.2%]). This indicates that the reduction in PEC affected not only disease-related visits but also injury-related visits. It is likely that clinicians in other departments felt burdened by managing children without support of the pediatricians.
Previous studies investigating the general characteristics of patients in Korea have reported that a notable proportion of pediatric emergency center visits for illness occur during night hours. For instance, Song et al. (8) reported that 52.4% of these visits occurred during 22:00-08:00 on weekdays, whereas Choi et al. (9) and Shin et al. (10) respectively reported that 76.7% and 88.6% of patients visited during 21:00-09:00 on weekdays and Saturdays. Since many disease-related patients seek PEC during night hours, the reduction in nocturnal PEC hours in the ED could greatly impact the accessibility and reliability of PEC. Compared to the relevant studies, this present study provides a more detailed analysis of disease-related visits to the ED based on the time of visit, offering a more nuanced understanding of the importance of PEC during these critical hours.
This study had the following limitations: First, the analysis of changes in ED utilization focused solely on the reduction in ED operating hours. In addition, to exclude potential factors such as the coronavirus disease 2019 pandemic, the study period was set at 6 months before and after the reduction in PEC hours. However, this approach might rather fail to reflect other factors such as seasonality, indicating the need for further research over the same period. Second, while changes in ED utilization may vary depending on hospital location, size, and the time of day when ED care is restricted, this study was conducted in a single provincial metropolitan ED and focused on a fixed reduction in hours of care from midnight to 8 a.m. Therefore, it may not be possible to extrapolate the findings to overall pediatric ED utilization, and further studies in other regions and with EDs of different sizes are warranted.
In summary, the reduction in PEC hours in the ED led to a decrease in the number of visits for both diseases and injuries. Notably, in the pediatric patients’visits, there was a more pronounced decrease in patients aged 4 years or younger. While there were no remarkable changes in the highacuity cases, there were reductions in both EDLOS and overall hospitalization. The results of this study indicate that PEC resources must be redistributed to ensure access for those aged 4 years or younger, even with the reduction of PEC hours due to a shortage of pediatricians. Similarly, patients with low-acuity cases should be diverted to primary care clinics or outpatient services during regular hours, thus allowing for more efficient care of those with high-acuity cases. Furthermore, it is necessary to consider additional measures, such as expanding the use of pediatric specialist-centered emergency practice (11). The findings of this study may provide strategies for the efficient allocation and optimization of PEC resources, which are expected to become increasingly limited.

Notes

Author contributions

Conceptualization, Formal analysis, Investigation, Methodology, and Visualization: SH Hur and HS Choi

Data curation and Resources: SH Hur

Project administration: HS Choi

Supervision and Validation: HS Choi and JS Oh

Writing-original draft: SH Hur and HS Choi

Writing-review and editing: HS Choi, JS Oh, SS Park, and JK Lee

All authors read and approved the final manuscript.

Conflicts of interest

No potential conflicts of interest relevant to this article were reported.

Funding sources

No funding source relevant to this article was reported.

Data availability

All data presented in this manuscript are available from the corresponding author upon reasonable request.

Fig. 1.
Flowchart for the selection of the study population.
pemj-2024-01095f1.jpg
Fig. 2.
Comparison of the number of pediatric patients in the control (dotted line) and reduction (solid line) periods according to the time of visit. The vertical line indicates 08:00, a starting point of reduced PEC hours during the latter period. Among the visits during 08:00-24:00, 66.5% (1,504/2,262) and 99.0% (1,302/1,315) occurred during the control and reduction periods, respectively. The decrease during the reduction period was most notable in the last-minute visits (arrow).
pemj-2024-01095f2.jpg
Table 1.
Change in ED visits for the all-aged patients (N = 48,224) and the child patients (N = 7,479) between the control and reduction periods
Variable Total Control Reduction % increase P value
All-aged patients 48,224 (100) 24,450 (100) 23,774 (100) -2.8
Child patients (≤ 14 y)* 7,479 (15.5) 4,330 (17.7) 3,149 (13.2) -27.3 < 0.001
Age, y 4.0 (2.0-8.0) 4.0 (1.0-8.0) 4.0 (2.0-8.0) 0.219
Age group, y 0.685
 < 1 794 (10.6) 469 (10.8) 325 (10.3) -30.7
 1-2 1,995 (26.7) 1,175 (27.1) 820 (26.0) -30.2
 3-4 1,306 (17.5) 755 (17.4) 551 (17.5) -27.0
 5-11 2,563 (34.3) 1,465 (33.8) 1,098 (34.9) -25.1
 12-14 821 (11.0) 466 (10.8) 355 (11.3) -23.8
Boys 4,446 (59.4) 2,606 (60.2) 1,840 (58.4) -29.4 0.127
Via ambulances 959 (12.8) 523 (12.1) 436 (13.8) -16.6 0.024
KTAS level < 0.001
 1 43 (0.6) 24 (0.6) 19 (0.6) -20.8
 2 517 (6.9) 344 (7.9) 173 (5.5) -49.7
 3 1,634 (21.8) 1,024 (23.6) 610 (19.4) -40.4
 4 4,506 (60.2) 2,494 (57.6) 2,012 (63.9) -19.3
 5 779 (10.4) 444 (10.3) 335 (10.6) -24.5
 High acuity 560 (7.5) 368 (8.5) 192 (6.1) -47.8 < 0.001
 Disease 3,577 (47.8) 2,262 (52.2) 1,315 (41.8) -41.9 < 0.001
EDLOS, min 98.0 (50.0-178.0) 106.0 (55.0-192.0) 98.0 (50.0-178.0) -7.5 < 0.001
ED disposition < 0.001
 Hospitalization, overall 785 (10.5) 574 (13.3) 211 (6.7) -63.2 < 0.001
Intensive care unit 40 (0.5) 17 (0.4) 23 (0.7) 35.3
 Transfer 12 (0.2) 8 (0.2) 4 (0.1) -50.0
 In-hospital mortality 3 (0.04) 1 (0.02) 2 (0.1) 100.0

Values are presented as numbers (%) or medians (interquartile ranges) unless otherwise stated.

* Below here, denominators are, in column order, 7,479, 4,330, and 3,149.

The sums of proportions are not equal to 100% due to rounding.

KTAS level 1-2.

ED: emergency department, KTAS: Korean Triage and Acuity Scale, EDLOS: emergency department length of stay.

Table 2.
Change in ED visits for pediatric patients between the control and reduction periods (N = 3,577)
Variable Total (N = 3,577) Control (N = 2,262) Reduction (N = 1,315) % increase P value
Pediatric/child patients, %* 47.8 52.2 41.8 -41.9 < 0.001
Age, y 3.0 (1.0-7.0) 3.0 (1.0-7.0) 4.0 (1.0-8.0) 0.005
Age group, y < 0.001
 < 1 537 (15.0) 349 (15.4) 188 (14.3) -46.1
 1-2 1,083 (30.3) 712 (31.5) 371 (28.2) -47.9
 3-4 559 (15.6) 374 (16.5) 185 (14.1) -50.5
 5-11 1,089 (30.4) 636 (28.1) 453 (34.4) -28.8
 12-14 309 (8.6) 191 (8.4) 118 (9.0) -38.2
Boys 2,027 (56.7) 1,306 (57.7) 721 (54.8) -44.8 0.091
Via ambulance 547 (15.3) 312 (13.8) 235 (17.9) -24.7 < 0.001
KTAS level 0.482
 1 42 (1.2) 24 (1.1) 18 (1.4) -25.0
 2 493 (13.8) 328 (14.5) 165 (12.5) -49.7
 3 1,287 (36.0) 803 (35.5) 484 (36.8) -39.7
 4 1,372 (38.4) 863 (38.2) 509 (38.7) -41.0
 5 383 (10.7) 244 (10.8) 139 (10.6) -43.0
 High acuity 535 (15.0) 352 (15.6) 183 (13.9) -48.0 0.183
EDLOS, min 125.0 (70.0-199.0) 140.0 (80.0-217.0) 104.0 (54.0-169.8) -25.7 < 0.001
ED disposition < 0.001
 Hospitalization, overall 667 (18.6) 501 (22.1) 166 (12.6) -66.9 < 0.001
Intensive care unit 33 (0.9) 13 (0.6) 20 (1.5) 53.8
 Transfer 9 (0.3) 6 (0.3) 3 (0.2) -50.0
 Discharge 2,898 (81.0) 1,754 (77.5) 1,144 (87.0) -34.8
 In-hospital mortality 3 (0.1) 1 (0.04) 2 (0.2) 100.0

Values are presented as percentages only, medians (interquartile ranges), or numbers (%) unless otherwise stated.

* See definitions in the methods section. The denominators are, in column order, 7,479, 4,330, and 3,149, which represent the number of ED visits for all patients aged 14 or younger.

The sums of proportions are not equal to 100% due to rounding.

ED: emergency department, KTAS: Korean Triage and Acuity Scale, EDLOS: emergency department length of stay.

Table 3.
Comparison of clinical characteristics for the pediatric patients in the control period (N = 2,262), divided into 2 groups based on the ED visit time (00:00-07:59 vs. 08:00-24:00)
Variable 00:00-07:59 (N = 758) 08:00-24:00 (N = 1,504) P value
Age, y 3.0 (1.0-7.0) 4.0 (1.0-8.0) 0.153
Age group, y 0.011
 < 1 122 (16.1)* 227 (15.1)
 1-2 268 (35.4)* 444 (29.5)
 3-4 127 (16.8)* 247 (16.4)
 5-11 187 (24.7)* 449 (29.9)
 12-14 54 (7.1)* 137 (9.1)
Boys 439 (57.9) 867 (57.6) 0.903
Via ambulance 95 (12.5) 217 (14.4) 0.217
KTAS 0.006
 1 1 (0.1) 23 (1.5)
 2 121 (16.0) 207 (13.8)
 3 283 (37.3) 520 (34.6)
 4 282 (37.2) 581 (38.6)
 5 71 (9.4) 173 (11.5)
High acuity 122 (16.1) 230 (15.3) 0.619
EDLOS, min 143.0 (91.0-235.0) 137.0 (74.0-209.0) < 0.001
ED disposition < 0.001
 Hospitalization, overall 98 (12.9) 403 (26.8) < 0.001
  Intensive care unit 1 (0.1) 12 (0.8)
 Transfer 1 (0.1) 5 (0.3)
 Discharge 658 (86.8) 1,096 (72.9)
 In-hospital mortality 1 (0.1) 0 (0)

Values are presented as medians (interquartile ranges) or numbers (%) unless otherwise stated.

* The sums of proportions are not equal to 100% due to rounding.

ED: emergency department, KTAS: Korean Triage and Acuity Scale, EDLOS: emergency department length of stay.

Table 4.
Top 10 chief complaints
Rank Control (N = 2,262) Reduction (N = 1,315)
1 Fever 981 (43.4) Fever 578 (44.0)
2 Abdominal pain 408 (18.0) Abdominal pain 315 (24.0)
3 Vomiting 279 (12.3) Vomiting 161 (12.2)
4 Seizure like motion 180 (8.0) Seizure like motion 145 (11.0)
5 Skin eruption 123 (5.4) Skin eruption 84 (6.4)
6 Cough 120 (5.3) Cough 70 (5.3)
7 Dyspnea 77 (3.4) Dyspnea 42 (3.2)
8 Headache 73 (3.2) Headache 33 (2.5)
9 Diarrhea 67 (3.0) Dizziness 26 (2.0)
10 Irritability 33 (1.5) Diarrhea 24 (1.8)

Values are presented as numbers (%).

Table 5.
Top 10 discharge diagnoses
Rank Control (N = 2,262) Reduction (N = 1,315)
1 Gastroenteritis and colitis of unspecified origin 560 (24.8) Gastroenteritis and colitis of unspecified origin 242 (18.4)
2 Other acute upper respiratory infections of multiple sites 313 (13.8) Other acute upper respiratory infections of multiple sites 143 (10.9)
3 COVID-19, virus identified 147 (6.5) Febrile convulsions 61 (4.6)
4 Urticaria, unspecified 75 (3.3) Pneumonia, unspecified 53 (4.0)
5 Pneumonia, unspecified 60 (2.7) Seasonal influenza virus identified influenza with other respiratory manifestations 49 (3.7)
6 Acute bronchitis, unspecified 60 (2.7) Allergic urticaria 39 (3.0)
7 Acute bronchiolitis, unspecified 52 (2.3) Acute bronchitis, unspecified 33 (2.5)
8 Sepsis, unspecified 48 (2.1) COVID-19, virus identified 29 (2.2)
9 Obstructive laryngitis, NOS 40 (1.8) Unspecified abdominal pain 25 (1.9)
10 Febrile convulsions 38 (1.7) Hyperpyrexia, NOS 24 (1.8)

Values are presented as numbers (%)

COVID-19: coronavirus disease 2019, NOS: not otherwise specified.

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