One of the critical roles of the emergency department is to provide unscheduled care to all persons, regardless of age or presenting problem. Additionally, the emergency department has a growing role as the diagnostic center for the medical community. As 69 percent of inpatients are processed through the emergency department, emergency physicians are responsible for the evaluation and diagnostic testing that allow those patients to be treated expeditiously and moved to the surgical, interventional, or inpatient units that meet their needs. Emergency physicians are also responsible for the management of patients who do not require inpatient services.

To plan for services for patients across this wide range, emergency physicians must plan ahead for likely arrival patterns, evaluation methodologies, treatment modalities, and disposition that are needed for safe and high-quality care. One of the important planning considerations is the age mix of patients.

The data that can be used for this analysis are reported by the Emergency Department Benchmarking Alliance (EDBA), which uses a voluntary data submission process for emergency departments and has been collecting and reporting these data since 2004. For 2017, there were 1,812 emergency departments that reported data on more than 75 million ED visits.

Defining “Pediatric ED”

One area of interest from ED leaders is the differences in serving pediatric patients compared with adults in the emergency department. A vexing problem was how to define “pediatric.” Beginning with the ED Performance Measures Summit in 2006, a uniform definition of pediatric was adopted. The EDBA data survey defined patient groups that are “under age 2” and “pediatric” (under the age of 18) and reported them as a percentage of the entire volume of patients seen in the emergency department.

An emergency department that sees more than 50 percent of patients in the pediatric age group is classified as a pediatric emergency department in the EDBA reports, and an emergency department that sees less than 5 percent of patients under age 18 years is classified as an adult emergency department. These ED groupings allow an analysis of patient parameters that are useful for ED planning.

Within the EDBA data survey, 22.5 percent of patients in 2004 were pediatric patients, and this dropped to 19.6 percent in 2017.¹ This is a trend also seen in the Centers for Disease Control and Prevention National Hospital Ambulatory Medical Care Survey data. The definition of pediatric in this survey is under age 15. In their survey of ED visits, patients under 15 years of age represented 25.1 percent of the patient mix in 1992, and in 2015, it had decreased to 19.8 percent.² There are significant differences between adult and pediatric ED patients in their arrival patterns, diagnostic test utilization, and disposition. This is important, as some emergency departments are developing service lines to accommodate higher percentages of geriatric patients, with appropriate diagnostic testing capability.

Plan for Your Patient Mix

The data in Table 1 reflect the real differences in the characteristics of pediatric and adult patients. Adult patients are generally higher acuity, arrive much more frequently by ambulance, require more diagnostic testing (and subsequently more time in the emergency department), and get admitted at a much higher rate.

(click for larger image) Table 1: EDBA 2017 Data Survey of Adult vs. Pediatric ED Characteristics

Diagnostic test utilization is particularly important for ED planning. EDBA reports on ED utilization of diagnostic imaging, measured in the number of procedures performed per 100 patients seen. So a patient having multiple imaging procedures done (eg, a hip X-ray and a chest X-ray) would have two procedures in the EDBA reporting system. Utilization of CT scans appears to have peaked in the EDBA data survey. However, utilization remains higher in emergency departments that are high-level trauma centers and see more adult patients. Pediatric emergency departments only use CT imaging about four times per 100 patients seen. There are smaller differences in adult and pediatric utilization of ultrasound and MRIs.

The analysis shows that emergency departments that see adult patient populations generally have higher acuity, more EMS arrivals, higher admission rates, and longer processing times. The use of ECGs as a diagnostic modality is at least 10 times higher in adult patients.

It is critical that emergency physicians and ED leaders appreciate and plan for the patients who will be seen. This includes an appreciation of the differences in patient characteristics between pediatric and adult patients. The planning process is most important in community emergency departments that serve all age groups but are likely seeing an increasing percentage of older patients with higher acuity needs.

References

1. The Emergency Department Benchmarking Alliance data report for 2017. EDBA website. Accessed Jan. 11, 2019.
2. National Hospital Ambulatory Medical Care Survey: 2015 emergency department summary tables. CDC website. Accessed Jan. 11, 2019.