Simon Harold K, Hirsh Daniel A, Rogers Alexander J, Massey Robert, Deguzman Michael A
Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.
J Emerg Med. 2009 Apr;36(3):311-6. doi: 10.1016/j.jemermed.2007.10.090. Epub 2008 Jul 26.
The objective of this study was to utilize the electronic medical record system to identify frequent lower acuity patients presenting to the Pediatric Emergency Department and to evaluate their impact on Pediatric Emergency Department overcrowding and resource utilization. The electronic medical records (EMR) of two pediatric emergency centers were reviewed from August 2002 to November 2004. Pediatric Emergency Department encounters that met any of the following criteria were classified as Visits Necessitating Pediatric Emergency Department care (VNEC): Disposition of admission, transfer or deceased; Intravenous fluids (IVF) or medications (excluding single antipyretic or antihistamine); Radiology or laboratory tests (excluding Rapid Strep); Fractures, dislocations, and febrile seizures. All other visits were classified as non-VNEC. ICD-9 (International Classification of Diseases, Ninth Revision) codes from the Pediatric Emergency Department encounters were defined as representing chronic or non-chronic conditions. Patients were then evaluated for utilization patterns, frequency of Emergency Department (ED) visits, chronic illness, and VNEC status. There were 153,390 patients identified, representing 255,496 visits (1.7 visits/patient, range 1-49). Overall, 189,998 visits (74%) required defined ED services and were categorized as VNEC, with the remaining 65,498 visits (26%) categorized as non-VNEC. With increasing visits, a steady decline in those requiring ED services was observed, with a plateau by visit six (VNEC 77% @ one visit, 64% @ six visits, p < 0.001). There were 141,765 patients seen fewer than four times, representing 92% of the patients and 74% of all visits (1.3 visits/patient, 225 visits/day). In contrast, 2664 patients disproportionately utilized the ED more than six times (maximum 49), representing 1.7% of patients and 9.8% of visits (9.4 visit/patient, 30 visits/day, p < 0.001). Excluding patients with chronic illness, 1074 patients also disproportionately utilized the ED more than six times (maximum 28), representing 0.7% of patients and 3.6% of visits (8.6 visit/patient, 11 visits/day, p < 0.001). While representing < 2% of patients, frequent lower acuity utilizers of ED services accounted for nearly 10% of all visits (30/day). Low acuity patients may require only limited additional marginal resources for their individual care. However, in aggregate, inefficiencies occur, especially when systems reach capacity constraints, at which point these patients utilize limited resources (manpower and space) that could more effectively be directed toward the more acutely ill and injured patients. Therefore, identification of these patients utilizing the electronic medical record will allow for targeted interventions of this subgroup to improve future resource allocation.
本研究的目的是利用电子病历系统识别经常前往儿科急诊科的低急症患者，并评估他们对儿科急诊科过度拥挤和资源利用的影响。回顾了2002年8月至2004年11月两个儿科急诊中心的电子病历（EMR）。符合以下任何一项标准的儿科急诊科就诊被分类为需要儿科急诊科护理的就诊（VNEC）：住院、转院或死亡处置；静脉输液（IVF）或药物治疗（不包括单一退烧药或抗组胺药）；放射学或实验室检查（不包括快速链球菌检测）；骨折、脱位和热性惊厥。所有其他就诊被分类为非VNEC。儿科急诊科就诊的ICD - 9（国际疾病分类，第九版）编码被定义为代表慢性或非慢性疾病。然后对患者的使用模式、急诊科（ED）就诊频率、慢性病和VNEC状态进行评估。共识别出153,390名患者，代表255,496次就诊（平均每人1.7次就诊，范围为1 - 49次）。总体而言，189,998次就诊（74%）需要明确的急诊服务并被分类为VNEC，其余65,498次就诊（26%）被分类为非VNEC。随着就诊次数增加，需要急诊服务的患者比例稳步下降，到第六次就诊时趋于平稳（首次就诊时VNEC为77%，第六次就诊时为64%，p < 0.001）。有141,765名患者就诊次数少于4次，占患者总数的92%和所有就诊次数的74%（平均每人1.3次就诊，每天225次就诊）。相比之下，2664名患者就诊次数超过6次（最多49次），占患者总数的1.7%和就诊次数的9.8%（平均每人9.4次就诊，每天30次就诊，p < 0.001）。排除患有慢性病的患者后，1074名患者就诊次数也超过6次（最多28次），占患者总数的0.7%和就诊次数的3.6%（平均每人8.6次就诊，每天11次就诊，p < 0.001）。虽然这些频繁的低急症急诊服务使用者占患者总数不到2%，但却占所有就诊次数的近10%（每天30次）。低急症患者个体护理可能仅需要有限的额外边际资源。然而，总体而言，会出现效率低下的情况，尤其是当系统达到容量限制时，此时这些患者会占用有限的资源（人力和空间），而这些资源本可更有效地用于病情更危急的患者。因此，利用电子病历识别这些患者将有助于针对该亚组进行干预，以改善未来的资源分配。
