|Year : 2017 | Volume
| Issue : 3 | Page : 142-147
Paediatric emergency department during the holidays: Findings from a 10-year analysis of visit rates and trauma patterns
Faisal Ahmed M Alhusain1, Nada Faris A Alhassan1, Wijdan Abdullah A Aljohi1, Fahd Issa Alrumaih2, Nawfal Abdullah Al Jerian3, Nesrin Abdurhman Alharthy4
1 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Department of Emergency Medicine, King Abdullaziz Medical City, Riyadh, Saudi Arabia
4 Department of Emergency Medicine, King Abdullah Specialist Children Hospital, Riyadh, Saudi Arabia
|Date of Web Publication||12-Jul-2017|
Faisal Ahmed M Alhusain
College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh
Context: It has been observed that emergency department (ED) visits have been continuously increasing globally and that certain days might affect ED visits and trauma patterns. In previous literature, there is controversy regarding the correlation between paediatric ED (PED) visits and holidays.
Aims: To identify the impact of holidays on overall PED visits, trauma rates and characteristics.
Settings and Design: This is a retrospective time-series analysis of PED visits and paediatric trauma from 2004 to 2013 conducted in King Abdul-Aziz Medical City, Riyadh, Saudi Arabia.
Subjects and Methods: We extracted all ED visits during the 10-year period and included all trauma-related visits recorded in the paediatric trauma registry. The days were marked as holidays or non-holidays.
Statistical Analysis Used: SAS Ver. 9.3 was used for analysis. Chi-square test and negative binomial regression were used. Significance was declared at P< 0.05.
Results: Holidays were associated with decreased PED visits by 13% compared to non-holidays. Paediatric trauma increased during the holidays by 30%. The highest decrease of PED visits was observed during the summer by 32%. By contrast, during the summer, there was a 56% increase in trauma rates. In Eid A-Fitr, all PED visits decreased by 28%, whereas paediatric trauma increased by 70%. Time of trauma arrival, mechanism of injury, Injury Severity Score and Glasgow coma scale changed significantly during the holidays.
Conclusions: Holidays appear to be associated with higher rates of paediatric trauma and fewer overall PED visits. Future work could focus on exploring the reasons behind this change and potential counter measures.
Keywords: Emergency, holidays, paediatric, trauma
|How to cite this article:|
Alhusain FA, Alhassan NF, Aljohi WA, Alrumaih FI, Al Jerian NA, Alharthy NA. Paediatric emergency department during the holidays: Findings from a 10-year analysis of visit rates and trauma patterns. J Health Spec 2017;5:142-7
|How to cite this URL:|
Alhusain FA, Alhassan NF, Aljohi WA, Alrumaih FI, Al Jerian NA, Alharthy NA. Paediatric emergency department during the holidays: Findings from a 10-year analysis of visit rates and trauma patterns. J Health Spec [serial online] 2017 [cited 2018 Apr 22];5:142-7. Available from: http://www.thejhs.org/text.asp?2017/5/3/142/210435
Faisal Ahmed M. Alhusain, Nada Faris A. Alhassan these authors contributed to this work equally
| Introduction|| |
Knowledge of the distribution and spectrum of emergency department (ED) visits during previous years is an important factor which impacts quality of care, patient satisfaction and satisfaction of the emergency healthcare provider. With recent years, it has been observed that the volume of ED visits has been continuously increasing globally. ED visits in the United States increased by 28% between 1992 and 2005, with an annual visit rate of 35.7 visits per 100 persons in 1992 and 39.6 visits per 100 persons in 2005. In Saudi Arabia, from 2003 to 2005, the number of ED visits rate has increased by 29.4%. Trauma is considered to be one of the main causes of mortality globally and in Saudi Arabia. In the United States, firearm injuries account for the majority of trauma and trauma-related deaths, followed by traffic accidents and falls., According to King Abdul-Aziz Medical City (KAMC) trauma registry, the most common mechanisms of injury in paediatrics were road traffic related injuries with 52%, followed by falls with 23.4%. However, the traumas were not correlated with a specific time of the year such as holidays, weekends or festival days. These days have an atypical routine, including changes in sleeping patterns, psychological factors, eating habits and road traffic dynamics.
Multiple studies have explored the trends of ED visits over the years and tried to link them to different possible factors, such as the weather, time of year and holidays., One study conducted in New South Wales demonstrated an increase of weekly visits to the ED over the Christmas and New year holiday period. However, the additional visits were mostly attributed to general practitioner-type visits. In addition, a growing body of evidence demonstrates that traumatic injuries might also be affected by several factors. Association has been well established between weekends and paediatric road traffic accidents. Moreover, victims of road traffic accidents in the weekends suffered more severe injuries than on weekdays. According to previous literature, holidays have been consistently linked to an increased rate of trauma. Specific types of injuries such as burns and firework injuries were reported during Easter festivities, Christmas and around the major national holidays.,, One study conducted in Turkey showed an increase in the number of patients visiting EDs during the holiday period. In Saudi Arabia, there was a significant seasonal variation effect on the number of road traffic accidents which were higher during the hot summer months; September, August and October. In addition, another study compared between Ramadan, a holy month, and non-Ramadan months showing no significant differences in paediatric trauma admissions to the ED.
Few studies on the effect of special days on the paediatric ED (PED) visits were published globally. Despite its importance, especially in our region which has a high prevalence of trauma, studies on the effects of holidays on the incidence of paediatric trauma visits in the EDs are scarce and have given variable and inconclusive results. To the limit of our knowledge, no studies have explored the effect of holidays on trauma among children in Saudi Arabia. Holidays in Saudi Arabia include the summer vacation, weekends, Eid Al-Fitr, Eid Al-Adha, and the National Day. Our purpose of this study, therefore, is to determine the impact of the aforementioned holidays on overall PED visits, trauma characteristics and rates among children in the PED, in KAMC, Riyadh, Saudi Arabia.
| Subjects and Methods|| |
This study was conducted in KAMC in Riyadh, Saudi Arabia which is a tertiary care hospital with a bed capacity of 1501 and a level I trauma centre. The Emergency Care Centre is located close to the Riyadh-Dammam highway and receives plenty of cases with acute injuries. In addition, King Abdullah Specialist Children Hospital, is considered a part of KAMC, containing 600 beds, with 60 beds for paediatric emergency and trauma. On an average, 50,000 – 60,000 paediatric visits occur annually to ED., This study was a retrospective time-series analysis of PED visits to KAMC from January 1, 2004 through December 31, 2013, targeting paediatric population, which is between the ages of 0 - 14 years, according to the hospital system.
Rates: To achieve our aim, data was obtained from two different sources. First, daily counts of ED visits during the 10-year period were obtained from the Clinical Information Management Systems and Information Systems and Informatics Division. After cleaning the data, we included only PED visits, which were 296,346 out of 1,862,397 overall ED visits. This dataset contains date of birth and date of ED visit on a daily basis. In addition, we extracted paediatric trauma data during the same period from the paediatric trauma registry in KAMC, which is a database that records all trauma patients presenting to KAMC, with a total of 3560 paediatric trauma-related visits. To demonstrate the rates of trauma, we matched the dates of paediatric trauma-related visits with overall PED visits as the denominator. Trauma characteristics: To describe the characteristic differences in trauma, we used the KAMC trauma registry, which contains both clinical and non-clinical information, such as date of visit, demographic data, mode of transport, time of arrival, injury type, mechanism of injury, patient condition, hospital disposition, Injury Severity Score (ISS) and Glasgow coma scale (GCS). We applied our inclusion criteria on all data and included only paediatric age group and excluded missing data. Holidays: We marked the days and classified data as holiday or non-holiday based on a calendar set for each year. Holidays were defined as summer vacations, weekends, Eid Al-Fitr, Eid Al-Adha, and Saudi National Day. Eid Al-Fitr is a fast-breaking festival celebrated by Muslims worldwide and in Saudi Arabia, people usually have a 2-week holiday in accordance with it. Eid Al-Adha is a festival of the sacrifice and the second of two Muslim holidays celebrated worldwide each year. It is worth mentioning that these Islamic holidays are marked by the lunar Hijri calendar which is shorter than the solar Gregorian calendar. With each year, the Hijri calendar shifts about 11 days earlier than the Gregorian calendar. We were aware of this fact and adjusted the dates accordingly when coding the data. We have also considered the change in weekend days in Saudi Arabia from Thursday and Friday to Friday and Saturday, which was made in July 2013. Ethical approval was granted from King Abdullah International Medical Research Centre. Our institution did not require consent from individual subjects as we used only aggregated data in this study, not any individualised data.
Demographic characteristics including age and gender were summarised and reported in terms of frequencies and proportions and compared between holidays and non-holidays using Chi-square test. Clinical characteristics of paediatric trauma including transportation, time of arrival, injury type, mechanism of injury, hospital disposition, and condition were summarised and reported in terms of frequency and proportions and were compared across holidays and non-holidays using Chi-square test. ISS and GCS were summarised in terms of mean and standard deviation (SD) and compared between holidays and non-holidays using t-test.
Rates of trauma-related PED visits were compared between holidays and non-holidays using negative binomial regression. The dependent variable was the count of trauma visits encountered on each day of the year. The independent variable was a categorical variable indicating the type of the day (holiday or non-holiday). To account for variations in the volume of PED visits between days, an offset variable was included in the model accounting for the log of the overall PED visits during that day. Several models have been developed to compare trauma visits between different types of holidays (summer, weekends, Eid Al-Fitr, Eid Al-Adha, national day). All results were reported using rate ratio and 95% confidence interval (CI). Significance was declared at the value of P< 0.05. SAS Ver. 9.3 (SAS Institute Inc., Cary, NC, USA) was used for analysis.
| Results|| |
Our study included all PED visits (296,346 cases) for a period of 10 years (2004–2013). Out of which, 3560 cases were trauma patients. [Figure 1] shows the impact of holidays on all PED visits and trauma. Combining all different types of holidays was shown to account for a 13% decrease in all PED visits (95% CI: 7%–19%; P< 0.0001), with a 30% increase in trauma rates (95% CI: 18%–42%; P< 0.0001). The highest percentage of change was observed during the summer, where there is a 32% decrease of all PED visits (95% CI: 26%–37%; P< 0.0001). In contrast, during the summer, there was a 56% increase in trauma rates (95% CI: 40%–73%; P< 0.0001). The weekends had a contrasting effect, with an 8% increase in all PED visits (95% CI: 0.3%–17%; P = 0.0428) and a 7% decrease in trauma (95% CI: 0%–16%; P = 0.1571). In Eid Al-Fitr, all PED visits decreased by 28% (95% CI: 15%–40%; P = 0.0001), whereas paediatric trauma increased by 70% (95% CI: 38%–209%; P< 0.0001). During Eid Al-Adha, an increase in both all PED visits by 7% (95% CI: 0%–26%; P = 0.455) and trauma rates by 3% (95% CI: 0%–18%; P = 0.8274) was observed. During the National Day, all PED visits decreased by 29% (95% CI: 0%–33%; P = 0.2789), whereas trauma increased by 29% (95% CI: 0%–43%; P = 0.5411). [Table 1] shows the demographics of paediatric trauma presenting to the PED. [Table 1] also clarifies the difference between non-holiday visits (1718 cases) and all holiday visits (1842 cases). Males accounted for more paediatric trauma compared with females (68.2% vs. 31.7%) with no considerable difference between holidays and non-holidays (P = 0.524). The proportion between age categories (0 – 2 years, 3 – 5 years, 6–9 years, and 10–14 years) was almost equal without any significant differences (P = 0.807). [Table 2] demonstrates the descriptive analysis which was used to describe the basic features of the variables among paediatric trauma visits. 25.9% of the patients were brought to PED by non-private transport (advanced life support/basic life support ambulance, helicopter or police) whereas the rest by private transport with a P = 0.238. When comparing shifts during holidays and non-holidays, there was a significant decrease in shift A (8:00–15:59) during holidays with a percentage of 21.9% compared with 36.4% during non-holidays. Increase in shift C (12:00–7:59) during holidays was 21% compared with 8.4% during non-holidays (P = 0.000). Majority of the injuries were blunt (73.5%) followed by burn/scald (16.4%) with no statistical difference between holidays and non-holidays (P = 0.674). The most common mechanism of injury during holidays and non-holidays was falls, with a percentage of 30% on non-holidays and 29.4% on holidays (P = 0.000). Most patients arrived to the PED alert during both holidays and non-holidays (84.9%) with no statistical difference between holidays and non-holidays (P = 0.759). Majority of the patients were discharged home in both groups (94.65%) with no significant difference between holidays and non-holidays (P = 0.608). The mean of ISS was found to be higher during holidays (8.44, SD ± 14.36) compared with non-holiday (7.67, SD ± 12.54) with a P = 0.004. The mean of GCS was higher during non-holiday (13.66, SD ± 3.23) compared with holidays (13.54 SD ± 3.45) with a significant P = 0.043.
|Figure 1: Impact of holidays on overall paediatric emergency department visits and trauma|
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|Table 1: Demographics of paediatric trauma between holidays and non-holida|
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|Table 2: Characteristics of paediatric trauma between holidays and non-holidays|
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| Discussion|| |
The purpose of this study was to explore the effect of holidays on PED visits, trauma rates and trauma characteristics. Our results suggest that the compound effect of all holidays showed a decrease in overall PED visits, whereas all holidays were associated with an increase in paediatric trauma. Analysis of paediatric trauma characteristics showed a significant difference between holidays and non-holidays in regards to time of arrival, mechanism of injury, ISS and GCS. In this study, we considered ages below 14 as paediatric according to our hospital policy in defining age limits which will be seen in the PED. Other hospitals might have a different system and guidelines, which is reflected by the age inclusion criteria in other studies.,, While multiple studies have examined the effect of summer season on the ED, we were more interested in studying the summer vacation because of the paediatric age group targeted in our study.
Overall emergency department visits
Previous literature regarding ED visits during the holidays shows inconsistent results. One study reported that Christmas and New Year holiday period was the busiest time of the year for the ED, with an increase of 9% during the holidays. On the other hand, Faryar in Montgomery County, Ohio showed that there was a decrease in the number of ED visits on federal holidays. D'Ippolito et al. conducted a study to observe the PED over eight common holidays in the United States and reported that holidays were associated with an insignificant decline of PED visits. Our results suggest that holidays were associated with decreased overall visits to the PED by 13%. The greatest decrease was attributed to summer vacation by 32%. This could be due to the fact that families living in Saudi Arabia tend to prefer to travel and leave the country during the summer vacation  and thereby decreasing the workload on PEDs. This finding appears to agree with a previous study conducted reporting that summer as a season has the fewest ED visits. Travelling may also account for the decreased PED visits by 28% during Eid Al-Fitr, which was significant in our study. After Ramadan, people might leave the capital city of Riyadh to visit their relatives outside the city in neighbouring areas, which is considered as one of the most valued rituals in celebrating Eid Al-Fitr. Another possibility is that Eid Al-Fitr is one of the most celebrated holidays, and therefore; people tend to be busier than usual preparing for the holiday, which might reduce non-urgent visits to the PED. Interestingly, our results show that PED visits increased during the weekends by 8%, which is consistent with another study carried out in the US showing a 32% increase in ED visits during the weekends. One possibility is that people are busier in the weekdays with work and school more than weekends, and therefore, non-urgent visits are pushed to the weekends where primary care centres are not available and these visits end up in the PED. In Eid Al-Adha, the 7% increase in PED visits was not statistically significant, which is inconsistent with a Turkish study reporting that Eid Al-Adha was associated with a 10% increase of ED visits. We did not find an explanation for the difference in these results, and further research is needed.
D'Ippolito et al. also reported that the highest number of paediatric injuries was during Labour Day followed by Memorial Day, Fourth of July, and Halloween. Whereas Christmas was associated with the least paediatric injuries. Our results demonstrated that all holidays were associated with a 30% increase in paediatric trauma rates. The greatest increase was during Eid Al-Fitr with a 70% rise in paediatric trauma rates. The increase in paediatric trauma may be related to the celebrations of Eid Al-Fitr, including fireworks and other outdoor festivities that might increase the risk of injuries. Summer vacation was also found to be associated with a remarkable increase of paediatric trauma by 56%. During the long summer vacation, children tend to engage more in outdoor physical activities rather than being confined indoors, which puts them at a higher risk of injuries. Swimming, which might be the reason behind the increased drowning-related injuries from 3.6% in non-holidays to 5.2% in the holidays, is one of the outdoor physical activities children are involved in during the summer where it might make them more prone to injuries, especially without parental supervision.
Our results were also consistent with D'Ippolito et al. when comparing different aspects and characteristics of paediatric trauma during the holidays and non-holidays. We also found that paediatric trauma was distributed across age groups quite evenly and boys sustained more injuries than girls. They also reported that the most common diagnoses were lacerations, contusion/abrasions, fractures and sprain/strains. However, in contrast with their results, we found that the most common injuries during the holidays were falls, followed by motor vehicle accident, pedestrian, and scald\burn by liquid. We were not able to identify a plausible explanation for this difference. We did not find previous research studying the impact of holidays on the time of paediatric trauma arrival to the PED. Our results show that during the holidays, less paediatric trauma arrived to the PED during shift A (8:00–15:59) whereas shift C (12:00–7:59) was linked with a higher number of paediatric trauma arriving to the PED during the holidays, with 8.4% during non-holidays to 21% during the holidays. This might be explained by the change of sleep patterns that is observed during the holidays. Children, especially, tend to stay up late hours of the night during the holidays, and spend most of the afternoon sleeping.
As with most studies, our study had limitations, keeping in consideration that this is the first study to look at the impact of Saudi holidays on the PED over a duration of 10 years. One of the limitations is the retrospective and observational nature of the study, which might introduce potential unmeasured confounders and increase bias. Another limitation is that it included only the patients of a single institute in the region of Riyadh. Because the Saudi national day is a 1-day holiday, a multi-centre study can provide enough data to accurately examine its effect on the PED.
| Conclusions\recommendations|| |
Holidays appear to be associated with higher rates of paediatric trauma and fewer overall PED visits. Future work could focus on exploring the reasons behind this change that was found in the PED, as well as determining the cost effectiveness of special training, alternative services, and resource allocation as some of the counter measures, which might be needed during the holidays. Awareness in the community about the injuries that were found to be associated with certain behaviours and activities during the holidays may also help in preventing such trauma.
We would like to thank Dr. Mohamed Hussein for his assistance with statistical analysis. We also wish to express our gratitude to Ms. Roa Faiz and Mr. Salem Alenezi for helping us with data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]