ABSTRACT
Immigration increases physical, mental, and social health problems. Emergency departments constitute resources that refugees can easily access and where they frequently present. Physicians from every specialty (chest diseases, thoracic surgery, internal diseases, etc.) may be consulted if needed. We aimed to compare demographic data and clinical characteristics of Syrian refugees and Turkish citizens in our emergency department. This study was an observational cross-sectional study. It included patients who presented to the Adult Emergency Department between April 1 and July 1, 2018. The patients were grouped into Syrian refugee and Turkish citizen groups. Patient age, gender, International Statistical Classification of Disease and Related Health Problems (ICD-10) diagnostic codes, and judicial case status were recorded from physician–patient outpatient clinic data records. Disease diagnoses and judicial cases were statistically compared between the two groups. A total of 30,749 patients presented to the emergency department during the study period. Of these, 999 were Syrian refugees. The mean ages of the Syrian refugees and Turkish citizens were significantly different. There were also differences between the two groups in the top five diagnostic codes (M79–Soft tissue disorders, J39–Other disorders of the upper respiratory tract; R51–Headache; R10–Abdominal and pelvic pain; M54–Dorsalgia). A comparison of the judicial cases also revealed a difference in mean age between the groups. Fewer specific disease diagnoses were identified among Syrian refugees. This may be explained by difficulties related to language barriers between the refugees and healthcare personnel.
KEYWORDS: Syrian refugees, ICD diagnostic code, emergency department, judicial case
Introduction
In 2011, following the Arab Spring in the Middle East, a civil war broke out in Syria. Six million Syrians were displaced from their homes, and another 7 million had to seek refuge in foreign countries. Turkey has accepted the largest number of refugees, around 3.4 million people, of any country worldwide [1]. Istanbul hosts the largest number of refugees of any city, and Bursa, where this study was conducted, ranks seventh with 134,490 refugees [1].
Immigration causes physical, mental, and social health problems [2]. Difficulty with access to health facilities, poor nutritional status, bad living conditions, language problems, low educational levels, economic problems, and a lack of social security adversely affect the health of refugees [3]. Communicable diseases, vaccine-preventable diseases (measles, tuberculosis, hepatitis, etc.), and psychiatric disorders such as depression, anxiety disorders, burnout, sleep disorders, prolonged grief syndrome, and posttraumatic stress disorder are the most notable health disorders among refugees [4–6]. ‘Refugee health units’ providing refugees with primary care have been established in Turkey to offer preventive or curative services while providing healthcare and to facilitate access to healthcare. In total, 175 refugee health units in 86 refugee health centers serve Turkey’s 17 provinces [7]. Despite the establishment of these refugee health centers, the majority of Syrian refugees not granted Turkish citizenship are not registered in family practice centers [7]. Thus, the lack of family practice centers where refugees can be admitted on an outpatient basis for symptoms that are manageable increases the number of refugees requiring admittance to emergency departments.
Refugees benefit from free health services in Turkey, and translators are employed in hospitals to avoid communication problems. Although emergency departments provide uninterrupted service on a 24/7 basis, translation services may be unavailable outside daytime working hours, which may prevent refugees from expressing their complaints accurately and can adversely affect the diagnostic and therapeutic course. The resulting health problems lead to increases in need, demands, and costs and, ultimately, to a shortage of medical personnel and health facilities [8]. Syrian refugees reportedly caused a 10% extra financial burden on health expenditures in Jordan [9]. According to the Disaster and Emergency Management Center’s Temporary Sheltering Centers Report dated December 4, 2017, a total of 1,112,058 surgeries and 31,449,800 outpatient clinic visits were provided to Syrian refugees in Turkey between March 2011 and December 2017 [8]. A limited number of studies have addressed emergency admissions of Syrian refugees in Turkey. Sariaydın et al. examined refugees presenting to emergency departments within 2.5 years and reported that a total of 868 adult Syrian refugees with a mean age of 29.6 years, most of whom had upper respiratory infections (22%), followed by soft tissue injury (18%), were admitted to emergency departments [10].
In the present study, we aimed to compare the demographic data and clinical characteristics of Syrian refugees and Turkish citizens presenting to our emergency department, which ranks first in terms of patient visits in Turkey [11].
Materials and methods
Study design
This was an observational cross-sectional study. It included patients presenting to the Adult Emergency Department of Bursa Yuksek Ihtisas Education and Research Hospital (1350 beds; 2,083,195 total outpatient clinic admissions in 2017; 562,418 emergency department admissions over 10 months in 2017) between March 1, 2018, and July 1, 2018. The patients were grouped into Syrian refugee and Turkish citizen groups. Patients older than 18 years were enrolled. Patient age, gender, International Statistical Classification of Diseases and Related Health Problems (ICD-10) diagnostic codes, and judicial case status were recorded from physician–patient outpatient clinic data records. Patients with multiple admissions for the same diagnosis were enrolled only once. The study data were retrieved from the hospital’s electronic medical records registry. All patient encounters in the hospital are recorded using the International Statistical Classification of Diseases and Related Health Problems 10th version (ICD-10). We made a reference next to the code to the meaning. The primary study outcome was the presence of the ICD-10 codes pertinent to emergency diseases. The ICD-10 codes pertinent to emergency diseases were looked-up from the following web page: (https://icdcodelookup.com/icd-10/common-codes/emergency-dept).
Patients presenting with only drug injection were excluded. As the pediatrics and gynecology and obstetrics outpatient clinics were located in other buildings, physically separated from the emergency department, patients presenting to their emergency departments were excluded.
International classification of diseases-version 10 (ICD-10)
A specific ICD-10 code is assigned to each condition. This framework is very useful for both the management of health services and the conduct of epidemiological studies. In addition to administrative uses such as for patient follow-up, maintenance of and access to patient records and archives, and resource management, the system also offers an opportunity for making international health comparisons due to its international character.
ICD-10 codes use 25 of 26 available letters for initial care. No code starts with the letter ‘U’; codes between U00 and U49 are left blank for possible additions until the revision becomes definite or to use for temporary coding when national or international difficulties arise between revisions. Codes U50–U99 are for use in local research. We performed data analysis of the two groups based on the ICD-10 diagnostic codes.
Ethics
Ethics committee approval was received for this study from the Health Sciences University Bursa Yuksek Ihtisas Education and Research Hospital Ethics Committee (decision number 2011-KAEK-25 2018/05-26).
Statistical analysis
Normality of the distribution of age was examined using the Shapiro–Wilk test; as the distribution did not meet the criteria for normal distribution, these data are expressed as median (minimum–maximum) and (mean ± standard deviation). Age was compared using the Mann–Whitney U-test, while gender and the distribution of diseases were compared using the Chi-square and Fisher–Freeman–Halton tests. Statistical analyses were performed with the SPSS (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) software package. Values of p < 0.05 were considered statistically significant.
Results
The number of emergency department admissions during the study period came to 30,749; of these, 999 were Syrian refugees. (Table 1). The Turkish patients had a significantly higher median age than the Syrian refugees (p < 0.001), and the gender distribution differed significantly between the study groups (p < 0.001). A comparison of the most common diagnostic codes for patients older than 18 years presenting to the emergency department is shown in Figure 1.
Table 1.
Comparison of gender distribution between Turkish and Syrian patients
| Republic-of Turkey (n = 29,770) |
Syrian Arab Republic (n = 999) |
p-value | |
|---|---|---|---|
| Age | 39 (24) 42.27 ± 17.14 |
32 (19) 36 ± 13.89 |
<0.001a |
| Gender | |||
| Female | 14802 (49.72%) | 417 (41.74%) | <0.001b |
| Male | 14968 (50.28%) | 582 (58.26%) | |
The data were expressed as median (interquartile range), mean±standard deviation, and n (%).
a:Mann-Whitney U test, b:Chi-Square test
Figure 1.
The country-based distrubution of the most commonly diagnosed diseases among patients older than 18 years of age
Table 2, which shows the most common diagnostic codes among Turkish patients, also shows differences between the study groups. Subgroup analysis revealed the following findings. The disease encoded as M79 was significantly more common among the Syrian refugees (p = 0.001), whereas that encoded as R51 was significantly more common among the Turkish citizens (p = 0.029). Additionally, there were no significant differences between the patient groups with respect to the diseases encoded as J39, R10, and M54 (p = 0.098, p = 0.385, and p = 0.837, respectively).
Table 2.
Comparisons with Syrian refugees with respect to diseases commonly seen in Turkish citizens
| Diagnostic code | Republic-of Turkey (n = 29,770) |
Syrian-Arab Republic (n = 999) |
p-value |
|---|---|---|---|
| M79-Soft-tissue disorders | 7924(26.62%) | 312(31.23%) | 0.001 |
| J39-Upper-respiratory-tract disorders-other | 3073(10.32%) | 87(8.71%) | 0.098 |
| R51-Headache | 1601 (5.38%) | 38 (3.80%) | 0.029 |
| R10-Abdominal and pelvic pain | 1600 (5.37%) | 60 (6.01%) | 0.385 |
| M54-Dorsalgia | 1322 (4.44%) | 43(4.30%) | 0.837 |
| Others | 14250(47.87%) | 459(45.95%) |
The data were expressed as median (minimum-maximum), mean±standard deviation, and n (%).
aFisher Freeman Halton Test
The distribution of the most common diseases in Syrian refugees is shown in Table 3, which also includes the corresponding figures for Turkish patients. These findings revealed a significant difference between the countries in terms of the top five most common disorders (p = 0.001).
Table 3.
Comparison of the distribution of the diseases commonly seen in Syrian refugees
| Diagnostic code | Republic-of Turkey (n = 29770) |
Syrian-Arab Republic (n = 999) |
p-value |
|---|---|---|---|
| M79-Other-soft tissue-disorders | 7924 (26.62%) | 312 (31.23%) | 0.001 |
| J39-Upper respiratory rate tract disorders-other | 3073 (10.32%) | 87 (8.71%) | 0.098 |
| R10-Abdominal and pelvic pain | 1600 (5.37%) | 60 (6.01%) | 0.385 |
| R07-Throat and chest pain | 1304 (4.38%) | 48 (4.80%) | 0.520 |
| W19-Fall Undefined | 746 (2.51%) | 46 (4.60%) | 0.001 |
| Others | 15123 (50.80%) | 446 (44.64%) |
The data were expressed as n (%).
aChi-Square test
The subgroup analyses revealed the following findings:
▪ The rates of diseases with diagnostic codes M79 and W19 were greater in Syrian patients (both p = 0.001).
▪ The groups did not differ significantly in terms of diseases with the codes J39, R10, and R07 (p = 0.098, p = 0.385, and p = 0.520, respectively).
The comparison of judicial cases in the two groups revealed the following (Table 4);
Table 4.
Comparisons for judicial cases >18 years of age
| Republic-of Turkey (n = 29770) |
Syrian-Arab Republic (n = 999) |
p-value | |
|---|---|---|---|
| Age | 35 (22) 38.97 ± 16.50 |
28 (16) 31.66 ± 12.59 |
<0.001a |
| Gender | |||
| Female | 707 (31.73%) | 28 (28.57%) | 0.510b |
| Male | 1521 (68.27%) | 70(71.43%) | |
The data were expressed as median (interquartile range), mean±standard deviation, and n (%).
a:Mann-Whitney U test, b:Chi-Square test
• There was a significant difference in the mean ages of these groups, with Turkish patients having a higher median age (p < 0.001).
• There was no significant difference between the groups with respect to gender distribution (p = 0.510).
• Detailed explanations of ICD Codes of M54, M79, and R10. (Table 5)
Table 5.
Detailed explanations of ICD Codes of M54, M79 and R10
| M54.3 | Sacrococcygeal disorders, not elsewhere classified | M79.651 | Pain in right thigh |
|---|---|---|---|
| M54.5 | Low back pain | M79.652 | Pain in left thigh |
| M54.6 | Pain in thoracic spine | M79.659 | Pain in unspecified thigh |
| M54.89 | Other dorsalgia | M79.661 | Pain in right lower leg |
| M54.9 | Dorsalgia, unspecified | M79.662 | Pain in left lower leg |
| M79.601 | Pain in right arm | M79.669 | Pain in unspecified lower leg |
| M79.602 | Pain in left arm | M79.671 | Pain in right foot |
| M79.603 | Pain in arm, unspecified | M79.672 | Pain in left foot |
| M79.604 | Pain in right leg | M79.673 | Pain in unspecified foot |
| M79.605 | Pain in left leg | M79.674 | Pain in right toe(s) |
| M79.606 | Pain in leg, unspecified | M79.675 | Pain in left toe(s) |
| M79.609 | Pain in unspecified limb | M79.676 | Pain in unspecified toe(s) |
| M79.621 | Pain in right upper arm | R10.0 | Acute abdomen |
| M79.622 | Pain in left upper arm | R10.10 | Upper abdominal pain, unspecified |
| M79.629 | Pain in unspecified upper arm | R10.11 | Right upper quadrant pain |
| M79.631 | Pain in right forearm | R10.12 | Left upper quadrant pain |
| M79.632 | Pain in left forearm | R10.13 | Epigastric pain |
| M79.639 | Pain in unspecified forearm | R10.2 | Pelvic and perineal pain |
| M79.641 | Pain in right hand | R10.30 | Lower abdominal pain, unspecified |
| M79.642 | Pain in left hand | R10.31 | Right lower quadrant pain |
| M79.643 | Pain in unspecified hand | R10.32 | Left lower quadrant pain |
| M79.644 | Pain in right finger(s) | R10.33 | Periumbilical pain |
| M79.645 | Pain in left finger(s) | R10.84 | Generalized abdominal pain |
| M79.646 | Pain in unspecified finger(s) | R10.9 | Unspecified abdominal pain |
• When all records were examined, the rate of hospitalization was found 2.20% and 96% of them is Turkish and 4% is Syrian. No significant difference was found between the groups in terms of hospitalization (chi-square test, p = 0.567). (Table 6)
Table 6.
The rate of hospitalizations in each group
| Republic-of Turkey | Syrian-Arab Republic | Total | p-value | |
|---|---|---|---|---|
| Hospitalized | 649 (%2.16) | 27 (%2.72) | 676 (%2.19) | 0.567a |
| Discharged | 29121 (%97.84) | 963 (%97.28) | 30084 (%97.81) | |
| The data were expressed as n (%). a Chi-Square test | ||||
• Of the hospitalized patients 40.1% were female and 59.9% male and a significant difference was found in terms of hospitalization by gender (p < 0.01).The gender distribution by nationality in the hospitalized group is as follows: Turkish patients, 39.9% women, 60.1% men; Syrian patients, 44.5% female and 55.5% male. (p = 0.334) (Table 7)
Table 7.
The rate of hospitalizations in each group (Syrians/Turkish)
| Republic-of Turkey |
Syrian-Arab Republic |
P value | |
|---|---|---|---|
| Age | 54.88 ± 18.93 | 42.40 ± 16.98 | <0.05a |
| 57(32 (39–71)) | 38.5 (28 (28–56)) | ||
| Gender | |||
| Male | 390 (%60.1) | 15 (%55.5) | p = 0.334b |
| Female | 259 (%39.9) | 12 (%44.5) | |
The data were expressed as median (interquartile range), mean±standard deviation, and n (%).
a:Mann-Whitney U test, b:Chi-Square test
•The average age of all hospitalized patients was 56 ± 19.01; The median was measured at 56 (19–85; IQR 33 (38–71)). The average age of Syrian patients was 42.40 ± 16.98; median: 38.5 (19–85; 28 (28–56). The average age of patients nationality Turkey 54.88 ± 18.93, median 57 (18–85; 32 (39–71). Significant difference was found in age between the groups of hospitalized patients (p < 0.05).
• The rate of hospitalizations in Republic-of Turkey group per group of diagnoses and the differences between them (Table 8.) There was significant difference between the groups with respect to hospitalization with the codes G46, and R10 (p < 0.05) The groups did not differ significantly in terms of hospitalization with the codes M79, I67, W19 and others. (p < 0.05)
Table 8.
The rate of hospitalizations in Republic-of Turkey group per group of diagnoses and the differences between them
| Diagnostic code | Republic-of Turkey (n = 649) |
Syrian-Arab Republic (n = 27) |
p-value |
|---|---|---|---|
| G46 | 78 (12.01%) | 1 (3.70%) | <0.05 a |
| R10 – Abdominal and pelvic pain | 64 (9.86%) | 5 (18.51%) | <0.05 a |
| M79- Other-soft tissue-disorders | 63 (9.70%) | 3 (11.11%) >0.05 | |
| I67 | 32 (4.93%) | 1 (3.70%) >0.05 | |
| W19-Fall Undefined | 27 (4.31%) | 1 (3.70%) >0.05 | |
| Others | 384 (59.16%) | 16 (59.25%) |
The data were expressed as n (%).
aFisher Exact test
Others: Z04, R07, F29, R11, Z00, R42, K35, K92, R06, F41, K29, K52, N19, N39, D64, R51, R55, N23, I10, J18, J93, Y30, K81, J44, R50, T14, I46, K56, K85, W51, I62, J96, I60, J45, T30, X60, E13, G40, J39, I63, R04, W26, J98, R73, Y24, Y28, F20, F31, K80, M54, N18, N20, R05, E16, G30, K40, S00, E87, G93, I50, K21, K30, K74, K86, N63, R30, R31, T39, W14, X64, F92, J20, J22, K59, K76, N17, N42, Q67, R60, S20, S90, F44, F88, I21, I26, K83, L03, M73, R00, S09, T95, Z02, Z72, E14, E63, G35, I72, I73, I84, I95, K42, M16, M23, R17, R19, R47, R53, R58, S30, S32, S62, S70, T54, T60, X78, Y57, C18, C67, D13, D69, E03, E04, E07, E66, E78, F32, G03, G04, G47, G62, G81, G91, G95, H10, H16, H66, H91, I71, J06, J34, J38, J40, J81, J91, J94, K31, L02, L50, M17, M51, N32, N45, R52, S03, S10, S42, S50, S66, S72, S80, S83, T23, T51, T58, T62, T78, T81, V28, W10, X44, Y26, Z03, Z33
• The rate of hospitalizations in Syrian-Arab Republic group per group of diagnoses and the differences between them (Table 9.) There was significant difference between the groups with respect to hospitalization with the codes R10 and Z04 (p < 0.05) The groups did not differ significantly in terms of hospitalization with the codes M79, I67, W19, and others.
Table 9.
The rate of hospitalizations in Syrian-Arab Republic group per group of diagnoses and the differences between them
| Diagnostic code | Syrian-Arab Republic (n = 27) |
Republic of Turkey (n = 649) |
p-value |
|---|---|---|---|
| R10 – Abdominal and pelvic pain | 5 (18.51%) | 64 (9.86%) | <0.05 a |
| M79- Other-soft tissue-disorders | 3 (11.11%) | 63 (9.70%) | >0.05 |
| Z04 | 2 (7.40%) | 25 (3.85%) | <0.05 a |
| I67 | 1 (3.70%) | 24 (3.69%) >0.05 | |
| W19-Fall Undefined | 1 (3.70%) | 27 (4.16%) >0.05 | |
| Others | 15 (55.55%) | 446 (68.72%) |
The data were expressed as n (%).
aFisher-exact test
Others: Z00, F41, G46, J39, M73, N39, R11, I10, K35, K81, N23, R04, R42, R73, Z33, F29, G40, I67, I99, J91, J96, K42, K52, K74, K92, N19, R00, R06, R19, R51, R55, T39, T95, X60
Explanation of ICD-10-CM (Clinical Modification):
ICD-10-CM codes have between 3 and 7 characters and have the following characteristics: the first 3 characters of an ICD-10-CM code designate the diagnosis category.
Character 1 is alpha, characters 2 and 3 are numeric, characters 4–7 are alpha or numeric.
Decimal: Placed after the 3rd character.
Characters 1 through 3: Category; characters 4 through 6: Etiology, anatomic site, severity, or other clinical detail; character 7: Extension.
An example ICD-10-CM Code Detail:
S52 Fracture of the forearm.
S52.3 Fracture of the shaft of the radius.
S52.32 Transverse fracture of the shaft of the radius.
S52.321 Displaced transverse fracture of the shaft of the right radius.
S52.321A Displaced transverse fracture of the shaft of the right radius, initial encounter for closed fracture.
Discussion
This study detected significant differences between the Turkish citizens and Syrian refugees who presented to the emergency department. According to the data of 2019, the population catchment area of hospital’s ER (Yıldırım district) is 657.994. Of them 331.532 (50.38%) are men and 326.462 (49.61%) are women. As of July 2019, the number of Syrians registered with the Immigration Administration in Bursa was 173.832, while its ratio to the population is 5.81%.
(https://www.yenidonem.com.tr/yazarlar/h-gul-kolayli-55/bursa-daki-suriyelilerde-bir-yillik-artis-24-bin-11311.html-access date 31.10.2020) [12].
Syrian refugees presenting to the emergency department were significantly younger, and there was a male predominance in the refugee group. The most common reasons for emergency department admissions for all patients, in descending order, were soft tissue disorders (extremity pain, myalgia, rheumatism, etc.), upper respiratory tract disorders, headache, abdominal, and pelvic pain (acute abdomen, upper abdominal pain, abdominal pain, etc.), and dorsalgia (low back pain, sciatica, neck pain, back pain, etc.)
With respect to the refugees’ lower mean age, Guess et al. also found a lower mean age among refugees presenting to the emergency department [13]. With respect to gender, Karakuş et al. also reported that male Syrian refugees were admitted more frequently to the emergency department than were females [14]. Our results were similar to these previous findings. Most patients presenting to the emergency department were males in their third decade of life. These age and gender distributions are typical for refugees, as shown previously [15,16]. This may be due to several factors: young males have more endurance to make a dangerous trip to the accepting country; young men are more likely to seek asylum to provide shelter for their families; and/or women are not allowed to travel independently and alone due to religious and social rules.
An analysis of the most common diseases after emergency department admission revealed significant differences between Turkish citizens and Syrian refugees. Soft tissue disorders (ICD-10 diagnostic code M79) ranked first in frequency and were significantly more common among Syrian refugees. Similarly, a study reported from Switzerland found that musculoskeletal system disorders (ICD code M) ranked first among refugees fleeing regions of violent conflict. This may have been caused by Syrian refugees’ need to engage in heavy labor requiring more muscle power and long working hours to earn a living [17]. The frequency of headache also differed significantly between the two groups. Buhman et al. reported that some 36% of refugees complained of somatic problems. Among them, headache and gastrointestinal system problems ranked first [15]. By contrast, our study revealed a significantly lower rate of headache among Syrian refugees. A comparison of the most common conditions among Syrian refugees after emergency department admission with those of Turkish citizens also revealed significant differences between the two groups. Soft tissue disorders (ICD 10 diagnostic code M79) and falls (ICD 10 diagnostic code W19) were significantly more common among Syrian refugees than among Turkish citizens. Soft tissue disorders encompass the signs and symptoms of many disorders such as injuries, ankle strains, soft tissue infections, or inflammatory conditions. Previous studies have reported that some 20% of refugees suffer from musculoskeletal conditions such as myalgia and arthralgia, which usually result from falls. Likewise, our study demonstrated a two-fold higher rate of falls among Syrian refugees compared with Turkish citizens [18,19]. The reasons for such a high rate of falls may be the obligation to walk long distances for work or to meet daily needs due to the inability to afford commercial transport, the absence of commercial transport service where refugees live, or residing in areas with inadequate roads and environmental planning; it may also reflect the obligation to work in jobs where environmental safety measures are inadequate, resulting in accidents and falls. In a study, it was found that musculoskeletal system disorders (ICD code M) ranked first among refugees fleeing regions of violent conflict [20]. This may have forced the refugees to work at heavy duties requiring more muscle power and long working hours, leading to musculoskeletal problems. Soft tissue disorders cover the signs and symptoms of many disorders like injuries, ankle sprains, soft tissue infections, or inflammatory conditions [21].
Studies have reported that some 20% of refugees suffer musculoskeletal conditions such as myalgia and arthralgia, which usually result from falls [19,22].
Recent studies have found higher rates of involvement in judicial cases among males in their second and third decades who present to emergency departments [23–25]. Unlike data from previous studies, the age of involvement in judicial cases among Syrian refugees was concentrated in the second decade, significantly younger than Turkish citizens who are thus involved. This may indicate that teenagers or young adult males have to bear the burden of their families and therefore work in high-risk jobs with heavy duties.
Conclusions
The most common reasons for ED admissions for all patients, in descending order, were soft tissue disorders, upper respiratory tract disorders, headache, abdominal and pelvic pain, and dorsalgia. Syrian refugees presenting to the ED were significantly younger, and there was a male predominance in the refugee group. Soft tissue disorders and falls were significantly more common among Syrian refugees than among Turkish citizens.” The frequency of headache also differed significantly between the two groups.
Limitations
The most notable limitations of our study are that the analysis was limited to a 3-month period, the study was a single-center trial, and the study did not enroll pediatric and gynecological/obstetric patients because those emergency departments were in separate buildings.
Disclosure statement
No potential conflict of interest was reported by the authors.
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