In many countries the number of consultations in hospital emergency departments increased over the past decade. Possible explanations are the ageing of the population, increased levels of social deprivation, higher expectations from urban populations, or artefacts in admissions data.1–3 Implications for healthcare planners are far reaching; an understanding of how much of this trend is attributable to an increase in less severe cases is crucial.4 Studies of administrative data may aid such understanding.
Methods and results
I analysed administrative data collected from 1993 to 1999 for consultations in the emergency department of the Centre Hospitalier Universitaire Vaudois, the public general hospital serving 286 000 inhabitants in the Lausanne area. Over this period, the number of consultations increased by 7421 from 30 822 to 38 243. This was a mean annual increase of 1.5% between 1993 and 1996 and 5.9% between 1996 and 1999 while the resident population remained stable (it increased by only 0.5%).
The three measures of the severity of emergencies that I used were the proportion of patients that (a) was transported by ambulance or helicopter; (b) stayed in the emergency department for at least six hours (not attributable to understaffing in this setting); and (c) died or were transferred to another acute care department. From 1998 the triage nurse assigned a National Advisory Committee for Aeronautics admission category.5 The proportion to which at least one measure of severity applied increased steadily with age (17% of children younger than 10 years old and 86% of people aged 80 years and older). Although the number of consultations grew, the proportion to which at least one of the three measures of severity applied remained stable; it ranged from 44.3% to 46.1% (table).
Further analysis suggested two explanations for the stability of the proportion of consultations to which a measure of severity applied. The number of consultations with people 80 years and older more than doubled between 1993 and 1999 (1603 v 3510), and proportionately more measures of severity applied.
On the other hand, there was an increase of 3471 (55%) consultations with patients of “other nationalities,” to which fewer measures of severity applied. Foreign nationals with a long tradition of migration to Switzerland showed an increase similar to Swiss nationals. The “other nationalities” subgroup is nationalities other than Swiss, French, German, Italian, or Spanish.
Comment
The increased use of the emergency department was not associated with a change in the proportion of severe cases being seen. More than 70% ((3471+1907)/7421) of the increase in emergency department use over the seven year period is accounted for by an ageing population and immigration.
The ageing of the population increased the number of consultations due to immediate medical needs. Also, the changing structure of younger age groups due to immigration led to increased demand that could be treated in settings other than the emergency department. The different social and cultural backgrounds of recent immigrants may explain the difficulty in diverting less severe cases away from emergency departments. Hospital emergency departments have to be able to respond to this demand.
Supplementary Material
Table.
Emergency consultations in which given measures of severity applied at Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland, 1993-9
| Year |
Measure of severity
|
|||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Length of stay ⩾6 hours
|
Dead or hospitalised
|
Ambulance or helicopter
|
At least one criterion fulfilled
|
|||||||||
| N | n | % | N | n | % | N | n | % | N | n | % | |
| 1993 | 30 818 | 7766 | 25.20 | 30 800 | 10 149 | 32.95 | 29 532 | 7066 | 23.93 | 30 882 | 14 199 | 46.07 |
| 1994 | 31 937 | 7717 | 24.16 | 31 929 | 9842 | 30.82 | 31 057 | 7416 | 23.88 | 31 937 | 14 255 | 44.63 |
| 1995 | 33 100 | 7812 | 23.60 | 32 931 | 10 153 | 30.83 | 32 262 | 7453 | 23.10 | 33 101 | 14 732 | 44.51 |
| 1996 | 32 242 | 7574 | 23.49 | 32 049 | 9798 | 30.57 | 30 056 | 7153 | 23.80 | 32 243 | 14 308 | 44.38 |
| 1997 | 34 300 | 7887 | 22.99 | 34 115 | 10 176 | 29.83 | 32 573 | 7891 | 24.23 | 34 301 | 15 326 | 44.68 |
| 1998 | 36 382 | 8622 | 23.70 | 36 376 | 10 666 | 29.32 | 34 809 | 8410 | 24.16 | 36 384 | 16 155 | 44.40 |
| 1999 | 38 242 | 9325 | 24.38 | 38 235 | 11 137 | 29.13 | 36 359 | 8874 | 24.29 | 38 243 | 16 950 | 44.32 |
N=number of valid cases for analysis.
n=number of cases with measure of severity.
Footnotes
Funding: Health Services Research Unit of the Institute of Social and Preventive Medicine, University of Lausanne.
Competing interests: None declared.
Background information about emergency care in Switzerland appears on bmj.com
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