Increasing use of the emergency department in a Swiss hospital: observational study based on measures of the severity of cases

Sir,

Brigitte Santos-Eggimann suggests that the increasing use of the
emergency
department in a Swiss hospital is mainly associated with an ageing
population and immigration.1 The emergency department she analysed serves
mainly adult patients. Her conclusions do not necessarily apply for
children.

We recently revealed the dramatic rise in the use of ten state-run
paediatric casualty department in the French-speaking part of Switzerland,
precisely the region where Santos-Eggimann¹s analysis was performed.2 This
increase (median 113 %, range 16 ­ 264 between 1990-1999) is obviously not
linked to a so called " ageing " population. Other causes have to be
considered. We report the dramatic increase in the use of our pediatric
emergency department, and offer an explanation for it.

Our district general hospital serves a total stable population of
110'000
(constant age structure, proportion of foreign nationals /refugees or
practising paediatricians) about 50 miles from Santos-Eggimann¹s
institution. Our paediatric department is the only out of hours emergency
unit to care for sick children in the region.

In late 1996, due to a regularly increasing out of hours work load of
the
residents (parental phone calls and number of consultations), we
implemented
a new system to evaluate children more efficiently in our paediatric
emergency department: (a) we organised a free nurse-led 24h/24h telephone
triage; (b) on week ends and bank holidays, we employed in the emergency
department local general paediatricians from the region¹s private
practices
to help assessing cases.

Between 1990 and 1996, the number of annual consultations increased
from
3186 to 3644 (a mean rise of 2.4%/y). Between 1996 and 2000, the number of
annual consultations increased from 3644 to 6840 (a mean annual rise of
21.9%/y). We seeked to assess the severity of emergencies by computing
from
the nurses's files the proportions of patients who were transferred from
the
emergency department to the paediatric ward. Available data are shown
underneath:

year                     1990   1991  1992  1993  1994  1995  1996  1997 1998  1999  2000
hospitalised patients (%) n.a    n.a   4.8   4.9   n.a.  3.9  5.5   4.2   3.5   3.1   3.4

The gradual drop in the proportion of paediatric patients being
transferred
from the emergency department to the acute care in-patient department
after
1996 suggests that the increased use of the emergency department was not
associated with an increase in the proportion of severe cases. Our data
suggest that a simple increase/improvement of health services to children
and their families in our region led to an increasing out of hours demand
in
acute care.

Hospital emergency departments have to be able to respond to the
population¹s demands.1 The latter, as in our case, could also be triggered
by hospitals' policies.

References

1 Santos-Eggimann B. Increasing use of the emergency department in a
Swiss
hospital: observational study based on measures of the severity of cases.
BMJ 2002; 324:1186-1187

2 Donatiello C, Laubscher B. Consultation pédiatriques " urgentes "
en
constante augmentation: un problème qui affecte toute la Suisse romande.
Rev
Med Suisse Romande 2001; 121(4):305-7