Admissions to emergency department may be classified into specific complaint categories

In recent years, several new emergency departments (ED) have been established in Denmark with a more heterogeneous mix of patients than in the specialised departments. Many previous studies on ED patients have focused on the incidence of certain diseases or specific traumas. However, patients admitted to the EDs are referred with a complaint rather than a specific diagnosis. Only few studies have described the incidence of different presenting complaints in the ED [1-5], and so far no such studies on Danish EDs have been published.

Since the ED patients present with a multitude of complaints, an aggregation into major categories is mandatory. The preferred level of aggregated information should be sufficient to cover the vast majority of patients without becoming too comprehensive to be practical [2].

The number of categories necessary to cover the main complaints will depend on the type of ED. Today, no international standard exists for such an aggregation [1, 2]. In 2001, a 54-category classification was proposed [5].The Canadian Emergency Department Information

System (CEDIS) initiative developed a complaint classification based on ED compilations of complaints combined with elements from the Manchester Emergency triage. This resulted in 165 complaints grouped according to organ systems covering in-patients and out-patients [2]. Since triage of acute patients is often linked to an ABCDE (airways, breathing, circulation, disability, environment) and pain assessment of the patient, it would be of interest to evaluate if the categories of complaints fit into this approach rather than being organised according to organ system. Some triage systems assume this [6, 7], but evidence of how the chosen complaints were identified is often lacking. The aim of the present study was to establish a suitable and limited number of categories of presenting complaints based on the ABCDE and pain approach. The categories should cover the majority of all admissions in a Danish ED. A second aim was to quantify the volume of patients in each category.

MATERIAL AND METHODS

We performed a cross-sectional study of all patients admitted to the ED of Kolding Hospital between 1 January and 31 December 2010.

The study group consisted of two physicians in their internship and one specialist in internal medicine, all employed at the ED.

The ED was divided into two sections. In the emergency room, self-referred patients and patients from 112 calls were administratively handled as out-patients, and the hospital received 29,622 such cases in 2010. If an admission was decided, the patient was transferred to the admission area registration system. The admission area of the ED received acute patients referred for admission from general practitioners within the specialties of internal medicine including cardiology, general surgery, orthopaedic surgery and vascular surgery. Unless they were severely ill, the following patients were not admitted via the ED: Patients with symptoms of stroke or acute coronary syndrome, paediatric medical patients and gynaecological/obstetrical patients, patients with chronic obstructive pulmonary disease (COPD) or chronic renal failure. Orthopaedic patients with a known in-hospital stay of more than 48 hours were admitted directly to the orthopaedic department (e.g. hip fractures or major traumas).

All patients who came to the admission area of the ED were included in the study, even if they were sent home after the initial examination.

Information about the presenting complaint or referring diagnosis was collected from the electronic interactive screens where the ED nurses wrote a few sentences about the complaints according to the information provided by the referring doctor or the patient on arrival. This information was used as a description of the reason for admission. The authors had no access to the patients’ discharge diagnoses or their files.

Based on a list of complaints from Canada [2] and the ABCDE pain approach, the authors first produced a list of complaint categories for patients referred for ED admission. Then, all three authors evaluated the same 200 patients using the list to obtain consensus on how to categorise their complaints. The three authors divided the next 1,500 admissions among them and independently categorised 500 admissions each. The admissions for which an author was in doubt as to which category was to be used were discussed, and minor revisions and clarifications were made to the list. This led to 13 main categories and 77 subcategories of complaints (Figure 1 and Table 1). The remaining patients were then divided between the three authors. Agreement on categorisation was ensured through continual discussions between the authors when doubt arose as to which category would be the most appropriate. The patients’ complaints could be divided into two main categories (e.g. pain or bleeding) and 2 subcategories (e.g. pain in upper stomach or bleeding per rectum). When a patient was referred with a presumptive diagnosis rather than a complaint, the diagnosis was kept and placed under the most appropriate category of complaints (e.g. “rule out appendicitis” to “abdominal pain”). All specific fractures were grouped under complaints (e.g. Colle’s fracture under “trauma to upper extremity”). If a patient presented with more than two complaints, the two most serious ones were chosen according to the authors’ judgement.

Based on the resulting list of complaint frequencies and presumptive diagnoses, the data were then further aggregated into fewer groups. In this process, the patients with a presumptive diagnosis were grouped under a relevant complaint (e.g. appendicitis under abdominal pain), many of the subcategories were reduced to fewer (e.g. pain in the different quadrants of the abdomen to pain in the abdomen). If the frequency of a complaint was below 1%, it was included into another group unless it was of clinical importance to keep it, either due to the acuity of the complaint (e.g. neurological dysfunction), if the complaint involved specialists not normally present in the ED (e.g. psychiatric complaints) or if admission was most likely not necessary (e.g. high blood pressure).

All results were presented as numbers and percentages of the total. For all continuous data, medians and interquartile ranges (IQR) were calculated.

The study was based on existing data from the interactive screen boards with no contacts to the patients or their files. Thus no ethical approval was required for the study. The study was registered by the Danish Data Protection Agency (2008-58-0035).

Trial registration: NCT01747434.

RESULTS

In 2010, a total of 8,294 patients were referred for admission 10,070 times (median 1 time, range 1-21 times) and registered at the electronic screens.

Of these, seven patients were excluded due to lack of their personal registration number, nine patients because they belonged to other specialties than the above-mentioned and 191 patients did not have sufficient information to establish a complaint. Among the remain- ing 9,863 (98%), there were 48% men and 52% women with a median age of 59 years (interquartile range 39-76 years), and 49% were admitted as medical patients, 31% as surgical patients, 15 % as orthopaedic patients and 5% as vascular surgical patients.

Among these referrals, 1,075 were sent home after their initial examination, the remaining were admitted. Whereas 35% of the patients were referred with a presumptive diagnosis, the remaining 65% had a complaint.

A total of 11,031 complaints were allocated to 13 main categories, 77 subcategories and 44 presumptive diagnoses. This aggregation resulted in 134 different groups with 99 groups of less than 1% (Table 1).

In Table 2, the data from Table 1 have been aggregated into 31 larger categories. According to this categorisation, it was possible to place 93.2% of the complaints into the 31 categories. Among these complaints, abdominal pain accounted for 19.9%, followed by dyspnoea, fever, trauma to extremity, non-traumatic pain in extremity, chest pain, all representing 5-7% of the complaints. Of the 746 complaints (6.8%) that were not covered, the largest groups were patients admitted for postoperative complications and procedures or examination for various diseases (572 (5.2%)).

DISCUSSION

In this study, we have allocated 9,863 patients’ complaints or presumptive diagnoses into 31 different categories of complaints. Among these categories, abdominal pain, dyspnoea, fever, trauma to extremity, non-traumatic pain in extremity and chest pain covered more than 50% of the complaints.

Few other EDs have attempted to categorise their patients according to complaints. The first proposals published in 2001 included 54 categories [5], the Canadian Emergency Department Triage and Acuity Scale included 61 complaints [2, 8]. In the Nordic countries, a Swedish study divided 12,995 medical ED admissions into 33 categories [4]. Their categories were generally smaller and more detailed than ours. The Medical Emergency Triage and Treatment System (METTS) included 43 categories [7], in the Swedish Adaptive Process Triage (ADAPT), 74 complaint were defined [9], whereas the Danish Hilleroed Adaptive Process Triage (HAPT) had 27 categories [6], but none of these systems reported how they identified the categories.

In 2012, a study from Finland approached the problem in the same manner as we did, analysing around 40,000 ED visit free texts, and they categorised the visits using the International Classification for Primary Care (ICPC-2) which includes 687 codes. They found that a list with 89 complaints including outpatient visits was reasonable and well-accepted.

Currently, a national initiative from the Danish Regions includes a proposal for a simple triage model based on the ABCDE principles, including approx. 15 complaints with a high acuity, such as bleeding or chest pain. The complaints are divided into degrees of severity, e.g. strong, moderate or slight pain (personal information). While this approach will secure an early response to the most urgent complaints, it will not cover the majority of ED patient complaints.

The 31 categories this study has produced are quite similar to the METTS and HAPT categories. The number of categories is always a trade-off between the manageability and the precision of the categories. Fewer but larger categories result in some degree of information loss compared to many, smaller categories, but few larger categories are more easily applied to everyday clinical practice.

The results of the relative distribution of complaints in the present study are difficult to compare with those of other studies where out-patients were included [2] (Finland; Canada). For the METTS, ADAPT and HAPT triage systems, no data on the relative distributions of complaints have been published.

The strengths of the present study are that it covers a whole year, data are unbiased by the patients’ discharge diagnoses, as the authors had no knowledge of these, and the case-mix of presenting complaints is generally broad and unselected, with some exceptions.

The study is, however, weakened by other factors. It is retrospective and based on information from the communication between a referring doctor and a nurse which had been reduced to few lines of text on a screen. This is not believed to be of major importance as the nurses were trained in receiving this kind of information and wrote directly on the screen before any diagnostic approach to the patient. Furthermore, sorting the complaints into different categories posed some challenges in the cases in which complaints could be placed in several categories. After the final agreement on the classification list which was based on the first 1,700 admissions, no further inter-observation variation study was performed. This weakens the validity of the study. The authors agreed on coding a maximum of two complaints. In a limited number of cases, they would have been able to code more, but no significant information has been lost on this account.

The author group consisted of two physicians in their internship and one specialist in internal medicine. The group thus represented a limited field of experience and specialisation. While most of the work categorising the complaints was straightforward, it is possible that a more specialised and experienced author group might have ended up with results different to the ones we obtained.

Many patients were referred with a text such as “rule out peptic ulcer” by their general practitioner. These presumptive diagnoses were changed into categories of assumed complaints without knowing if the patient complaint was actually covered by this assumption.

For the generalizability, it is important to notice that only admitted patients were included. Since EDs differ in terms of local admission agreements and case-mix, the relative frequencies of complaints will vary between hospitals. For comparison of different EDs, it is important to develop a grouping of the complaints according to the specialties to which the patients belong. We believe, however, that the admission pattern seen in the study ED resembles the situation in many other EDs for the major groups of categories.

For the future management of patient flow in the ED, it is important to know at an aggregated level why the patients are referred. Such knowledge will underpin the planning of staff allocation and the development of diagnostic packages in the ED. Furthermore, for comparison of the different EDs, a certain consistency in the usage of categories of complaints is warranted. We have presented a first proposal. However, the categorisation has not been evaluated in other Danish EDs yet, and further studies from other EDs are requested. Based on the experiences from our study, we suggest that future studies include EDs where other patient groups are admitted, including, among others, children or pregnant women, and EDs with more experienced and specialised ED health staff in the study group. We also recommend using a prospective, structured collection of complaints from in- as well as outpatients in the ED and to evaluate the inter-observer variation. A standardised list of complaints is of interest for health professionals as well as health planners and needs continuous improvements, a task that may be best undertaken by a centralised national stakeholder.

Correspondence: Christian Backer Mogensen, Fælles Akutmodtagelse, Akutcentret, Sygehus Sønderjylland, Aabenraa, Kresten Philipsens Vej 15, 6200 Aabenraa, Denmark. E-mail: christian.backer.mogensen@shs.regionsyddanmark.dk

Accepted: 17 January 2014.

Conflicts of interest:Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk