Characteristics of visits and predictors of admission from a paediatric emergency room in Saudi Arabia

Following ethical approval, we conducted this retrospective study at King Fahd Hospital of the Imam Abdulrahman Bin Faisal University in the Eastern Province of SA. The Paediatrics’ ER contains 7 observation beds, 2 examination rooms, 1 triage room, a waiting area, and a minor surgical room. Major trauma cases are treated in the resuscitation room (for both adults and paediatrics). Paediatric ER is supported by pharmacy, radiology services, and the ability to refer the patient for admission as needed. The ER staff is made up of six qualified paediatric emergency consultants, as well as eight paediatric specialists devoted to emergency coverage. This is in addition to rotating paediatric program residents in different levels, one each month. The initial triage in the registration area is done by a qualified nurse while the paediatric ER triage is done by the assigned paediatric nurse and the rotating residents. The ER staff work in three shifts to cover the 24 h, these are the morning shift (8:00 am-16:00 pm), the evening shift (pm 16:00–00:00 am), and the night shift (am 00:00–8:00 am). To cover the needs in the morning and night shifts, there are two to four physicians, and two to four nurses except for the evening shift where there is a minimum of three physicians. Some shifts also involve rotating interns and students for training and teaching.

The study included all patients presented to the paediatric ER, aged from 1 day to < 14 years old between the 1st of January 2018 and the 31st of December 2018. According to the hospital’s policy, the paediatric department is responsible for patients who fall within this age range.

A structured data collection sheet to collect data from the patient’s electronic medical records was used. Data included information about patient’s age, sex, season in which the patient presented in, chief complaint – as reported by the caregiver and categorised by the involved system, which shift received the patient, and whether admission to the hospital ward was ordered. These variables were chosen based on the study objectives as well as the literature and availability of the data.

The age groups were allocated as the following: neonates (< 29 days), infants (29 days–1 year), toddlers (> 1 year–3 years), pre-schoolers (> 3 years–6 years), schoolers (> 6 years–12 years) and adolescents (> 12 years–14 years). Nationality as: Saudis and non-Saudis. The time of visits was grouped based on the season; Winter (December, January, February), Spring (March, April, May), Summer (June, July, August), and Autumn (September, October, November). Shifts were divided into three groups: morning (8:00 am-16:00 pm), evening shift (pm 16:00–00:00 am), and night shift (am 00:00–8:00 am). The chief complaints were categorized according to the system involved. The triage categories were according to the CTAS implemented in the hospital, in which I is for resuscitation, II for emergent, III for urgent, IV for less urgent, and V for non-urgent [4]. Descriptive statistics were presented as frequencies and percentages. The main outcome was whether the patient was admitted to hospital or not. The Chi-squared test was performed to compute the P-values, and statistical significance was set at P < 0.05. The Bonferroni adjustment was used to adjust for multiple comparisons. Unadjusted and adjusted Odds ratios (ORs) were drawn through multivariable binary logistic regression, where the reference category was the most frequent. The final model was chosen based on appropriate model diagnostics. Statistical analysis was performed in Stata Software 15 Software [9].

Within this data, it was found that the most common paediatric age group was for toddlers aged between 1 < 3 years. Similar distributions have been found in other paediatric ERs in the US [10], Lebanon [11], and in another Saudi hospital located at the capital city of Riyadh [12]. Toddlerhood is a critical period where children start crawling, walking, learning to run, climbing, and jumping. Therefore, they may be prone to accidents or minor injuries. Moreover, the least common age group in our data were neonates, which is in sharp contrast to data from Pakistan which found that neonates had the highest rate of visits [13]. Cultural differences may have played a role where mothers attempt to treat theirs infants with herbal medicines or over the counter medications when they display certain symptoms such as infantile colic rather than presenting their child to a doctor [14].

Fever was the highest presenting complaint in our data. This is similar to other studies in Thailand and Lebanon [11, 15]. Fever is a general complaint and may be a sign of a wide spectrum of illnesses which may explain how it became the most common presenting complaint. Like the Thailand study [15], respiratory symptoms were the second most common complaint, which usually presents in the form of coughing, sneezing and difficulty in breathing. Such symptoms may be brought by air pollution, second-hand smoking or more strongly by changes in weather. Indeed, our findings show that weather has been found to play a role in the rates of ER visits. The highest number of visits were found to be during the winter, in November and December, but more specifically in January. Higher winter visits are mainly due to the common viral infections occurring in this period such as bronchitis, viral upper respiratory tract infections as well as complicated viral infections superimposed with bacterial infections. On the other hand, the summer season had the lowest number of visits. Prior to the COVID-19 epidemic, families tend to travel abroad during this season [16]. Other studies have also found similar patterns to that of our analysis both locally and internationally [12, 15]. Two Saudi studies, one based in Riyadh (1997) and the other in the Eastern region (2007), have found that non-urgent cases belonging to triage IV and V comprised between 35.9 and 59.5% of ER visits [6, 7]. Although, these two studies have been published a long time ago, the issue remains persistent and is worsening. Approximately two thirds of our patients were classified in Triage category IV, indicating they are non-urgent cases which may have been better dealt with in a primary care setting. To date, parents and patients in general in SA still prefer to seek medical services in the ER. Possible explanations may have to do with a lack of knowledge of a primary care centre near their home, long appointment hours in the primary care centre, dissatisfaction with the primary care physician, accessibility issues or even a perception that the condition is urgent and warrants medical attention straight away [5, 17, 18]. The management of such non-urgent cases in the ER increases the burden on the ER staff which may subsequently affect the quality of care that should be reserved for the high priority cases.

The admission rate of paediatric ER cases in this study was 2.45%. It is similar to the 3.3% rate of admission reported in the US [19], but much smaller than that reported in Lebanon, South Korea, and Pakistan, where the rates were reported to be 9.8, 14.3 and 45% respectively [11, 13, 20]. A systematic review by Obermeyer et al. (2015) assessed emergency care in low and middle-income countries and found that the median paediatric admission rate was 22% [21]. Comparing it with the admission rate from this study further emphasizes the role of primary care centres in accommodating the vast majority of patients presenting in the ER. Similar to the South Korean study [20], we found no significant differences in admission rates between males and females.

Unlike studies conducted in the US, Lebanon, Pakistan and Egypt, analyses here have shown that the neonate age group had the highest odds of admission, even though they were the smallest number with regards to ER visits [11, 13, 22, 23]. Differences in rates may be attributed to the different disease prevalence in these countries which may be affected by genetics, accessibility and the type of healthcare provided in hospitals. A further explanation to the higher odds of admission of neonates could be related to the hospital regulations and protocols to rule out neonatal sepsis [24].

Haematological conditions also had the highest odds of admissions. The Saudi population, especially those residing in the Eastern Province, which this data is derived from, are known to have a high prevalence of sickle cell disease (SCD) in children [25]. The prevalence of genetic haematological diseases in SA may be lowered by educating new prospective couples and enforcing recommendations by premarital counselling, as they are yet to be obligatory. Our data contrasts with that of Pakistan and Nigeria, where respiratory complaints had the highest rate of admissions [13, 26]. In Lebanon, complaints related to cardiology were the highest [11].

Furthermore, Triage I was associated with the highest odds of admission in these patients. Similar patterns were found in a US study, although the Emergency Severity Index level was used rather than CTAS [27]. Triage V was associated with lower odds of admission, which again highlights that the ER may suffer from overcrowding due to the presentation of non-urgent cases.

Neither the shift nor the season of the paediatric patients visiting the ER had any association with the rates of admission. It may be of notice that Spring, Autumn and Summer, despite their non-statistical significance, did show lower odds of admission when compared to Winter. In Australia, high and low temperatures were significantly associated with an increase in paediatric ER admissions [28], this was also noted in the UK [29]. Higher admission rates in low temperatures may be explained by children being more prone to cold weather viruses that could subsequently cause bronchiolitis in under 2 years olds and ultimately lead to an increased ER admission [30].

Several limitations with this study have been identified. The study is based on retrospective medical records drawn from a single healthcare institution, which may compromise the generalisability of the results. Also, despite the large number of data, some confidence estimates were wide which may be due to the extremely small number of cases within cells.