Original article

Patient influx to emergency departments at two Norwegian university hospitals from 2012–21

Norwegian

Målfrid Asheim Nummedal, Dagfinn Lunde Markussen, Lars Eide Næss, Lars Erik Laugsand, Lars Petter Bjørnsen

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Målfrid Asheim Nummedal

malfrid.a.nummedal@ntnu.no

Author contribution: analysis and interpretation of data, draft and revision of manuscript, and approval of submitted version.

Målfrid Asheim Nummedal, student on the Medical Student Research Programme at the Norwegian University of Science and Technology (NTNU).

The author has completed the ICMJE form and declares no conflicts of interest.

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Dagfinn Lunde Markussen

Author contribution: project design and formulation of research question, collection, analysis and interpretation of data from Haukeland University Hospital, revision of manuscript and approval of submitted version.

Dagfinn Lunde Markussen, specialist in internal medicine, infectious diseases and emergency medicine, senior consultant at the Department of Emergency Medicine, Haukeland University Hospital and PhD research fellow at the University of Bergen.

The author has completed the ICMJE form and declares no conflicts of interest.

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Lars Eide Næss

Author contribution: collection, analysis and interpretation of data from St Olav's Hospital, revision of manuscript and approval of submitted version.

Lars Eide Næss, MSc in clinical health sciences, data analyst at the Emergency Medical Communication Centre, St Olav's Hospital, Trondheim University Hospital, and PhD research fellow at the Norwegian Air Ambulance Foundation, Norwegian University of Science and Technology (NTNU).

The author has completed the ICMJE form and declares no conflicts of interest.

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Lars Erik Laugsand

Author contribution: project design and formulation of research question, revision of manuscript and approval of submitted version.

Lars Erik Laugsand, PhD, specialist in emergency medicine, senior consultant and assistant clinic director at the Clinic of Emergency Medicine and Prehospital Care, St Olav's Hospital, Trondheim University Hospital, and associate professor at the Norwegian University of Science and Technology (NTNU).

The author has completed the ICMJE form and declares no conflicts of interest.

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Lars Petter Bjørnsen

Author contribution: concept, project design and formulation of research question, revision of manuscript and approval of submitted version.

Lars Petter Bjørnsen, specialist in emergency medicine, senior consultant at the Clinic of Emergency Medicine and Prehospital Care, St Olav's Hospital, Trondheim University Hospital, and associate professor at the Norwegian University of Science and Technology (NTNU).

The author has completed the ICMJE form and declares no conflicts of interest.

Abstract

Background

Background

The increased patient visits to emergency departments is a global challenge. We aimed to map the patient influx and population at two Norwegian university hospitals over time.

Material and method

Material and method

A retrospective, descriptive study of patient visits (patients ≥ 16 years of age) to the emergency departments of Haukeland University Hospital, Bergen, and St Olav's Hospital, Trondheim University Hospital in the period 2012–21. Data were retrieved from electronic patient records and the patient administration system.

Result

Result

A total of 585 780 patient visits were included. The number of patient visits in the emergency departments was 30 696 in 2012 and 40 396 in 2021 at Haukeland University Hospital, and 18 967 in 2012 and 28 822 in 2021 at St Olav's Hospital. The largest increase during the study period appeared to be in the age group 67–79 years, with an increase of 57 % (from 6 190 to 9 691) at Haukeland University Hospital, and 77 % (from 3 849 to 6 817) at St Olav's Hospital. The proportion of hospital admissions was 82 % in 2012 and 74 % in 2021 at Haukeland University Hospital, and 87 % in 2012 and 61 % in 2021 at St Olav's Hospital. Of the patients that were admitted, the median age was 65 years, while the median age of those who were discharged from the emergency department was 48 years at Haukeland University Hospital and 52 years at St Olav's Hospital.

Interpretation

Interpretation

The study showed an increase in patient influx at the emergency departments at Haukeland University Hospital and St Olav's Hospital over ten years. The number of older adults in the population will continue to increase in the years ahead, and the need for emergency care will increase correspondingly. It is important that healthcare services are aware of changes in the patient influx and population in order to ensure patient safety and the working environment at emergency departments in the future.

Article

Introduction

Increased patient influx to emergency departments (EDs) is a global challenge to patient management (1). Capacity overload can create challenges for patient flow and have adverse consequences for patients and staff (1, 2). Demographics and trends in patient influx have been examined (3–6), but there is a lack of up-to-date studies.

Efficiency and patient safety in EDs have long been central themes in the Norwegian health service. In 2007, a nationwide inspection uncovered serious shortcomings in EDs within the somatic specialist health service (7). Concerns were found in over half of the EDs in relation to the professional adequacy of clinical assessments and diagnoses, with high patient influx and long waiting times identified as risk factors. This led to calls for more systematic and targeted management. The first national clinical guidelines for EDs, which were introduced in 2014 and revised in 2022 (8), emphasised the need for continuous monitoring of the activity. The Norwegian Institute of Public Health's report on EDs and the risk zone for patient safety also highlighted the importance of regular data collection for effective management and planning (9).

In this study, we evaluated patient visits over a ten-year period in the EDs at Haukeland University Hospital, Bergen, and St Olav's Hospital, Trondheim University Hospital. The aim was to update the knowledge on patient influx to aid the planning of future emergency services.

Some of the data from St Olav's Hospital used in this study has been published previously, including data on patient influx in the period 6 January to 22 March 2020 (3), data on patient influx and length of stay in the EDs for the entire study period, and hospital admissions (6). This study presents additional data for the same period from St Olav's Hospital, along with previously unpublished data from Haukeland University Hospital.

Material and method

Material and method

This is a retrospective observational study of patient visits to the EDs at Haukeland University Hospital, Bergen, and St Olav's Hospital, Trondheim University Hospital in the period 1 January 2012 to 31 December 2021.

Hospital setting

Hospital setting

St Olav's Hospital serves as the local and regional hospital for 327 000 and 730 000 people respectively, and is Trondheim municipality's only ED (10). The ED primarily treats patients over the age of 16 and all patients requiring treatment by a team (i.e. medical emergency team, stroke team and trauma team). Patients who typically bypass the ED are those with ear, nose and throat (ENT), gynaecological and eye conditions, as well as those on the fast-track pathway for a coronary intervention or with hip fractures.

Several hospitals in the Bergen area provide emergency medical care for patients in the specialist health service. Haukeland University Hospital serves as the local hospital for 290 000 people with medical complaints, 433 000 people with other conditions, and as the regional hospital for

1 000 000 people (11). The ED deals with all acute conditions for all age groups, but children with non-surgical medical issues, pregnant women, women in need of gynaecological care and fast-track patients with hip fractures often bypass the ED.

Data collection

Data collection

Data on patients visits were retrieved from the EDs' patient record systems (Akuttdatabasen, Helse-Vest IKT, version 1.5.5, Stavanger, and Meona, Mesalvo Freiburg, Germany). These records were linked to the hospitals' patient administration system (Nimes, Logex AS, Oslo, Norway and the Norwegian Population Register) for information on patient pathways.

In 2017, Haukeland University Hospital replaced the electronic patient record (EPR) software Akuttdatabasen with Meona. After this change, all data for 2018 (and a brief period in November 2015), except for the number of patient visits, were missing. The data on date/time of death and the patients' gender were also missing for the period 2019–21.

The number of patient visits with incomplete data was registered, and those lacking individual variables were excluded from the calculation of percentages.

Length of stay was calculated as the time from ED admission up until discharge. Where this was registered as < 5 min or > 2 days, the length of stay for the patient visit was recorded as not available.

Mortality rates after 24 hours, 7 days and 30 days were calculated based on date/time of arrival at the ED and date/time of death, and reported per 1 000 patient visits.

Chief complaints and medical specialty involved were examined for 2021, and for Haukeland University Hospital these were based on referral diagnoses and for St Olav's Hospital on Emergency Signs and Symptoms (ESS) codes.

In the ED at Haukeland University Hospital, the triage level was assessed using the South African Triage Scale (SATS) Norway (12), while St Olav's Hospital used the Rapid Emergency Triage and Treatment System (RETTS) (13). Patient visits reported as admission to a ward, surgical department, observation unit or intensive care unit were grouped together as 'hospital admission'.

Patient visit was defined as a patient registered and evaluated in the ED. This means that the same patient could be represented by more than one patient visit. Patient visits for patients < 16 years of age were excluded. Age categories were 16–66 years, 67–79 years and ≥ 80 years. For some results, the study period was divided into two five-year periods: 2012–16 and 2017–21.

Data were analysed using R (R Core Team, version 4.3.0, 2023) and RStudio (RStudio Team, version 2023.06.0 + 421, 2023) and presented as a mean and a standard deviation (SD) or 95 % confidence interval (CI), number (n) and percentage (%). Median and interquartile range were used for data with a non-normal distribution.

Ethics

Ethics

Use of data from St Olav's Hospital was approved by the hospital's data protection officer (ESA no. 16/9114), and the study was considered a quality improvement project, and did not therefore require submission to the Regional Committee for Medical and Health Research Ethics (REK Central, 2016/1813). Use of data from Haukeland University Hospital for the years 2012–17 was approved by the hospital's data protection officer and REK West (2018/2128). For the period 2018–21, only aggregated data were used, which did not require REK approval.

Results

Results

A total of 602 653 patient visits were registered in the two EDs for the study period 2012–21. Of these, 15 255 at Haukeland University Hospital and 1 618 at St Olav's Hospital were excluded due to age < 16 years. Thus, the study included 349 884 and 235 896 patient visits, respectively.

Of the total 585 780 patient visits at Haukeland University Hospital and St Olav's Hospital, data were missing for age in 43 980 and 4 956 patient visits, for gender in 154 492 and

4 958 patients, for length of stay in 65 578 and 494, for triage levels in 46 159 and 532, and for treatment levels in 41 721 and 96, respectively. At Haukeland University Hospital, data on admission date/time were missing for 40 630 and date/time of death for 154 485. The high numbers for gender and date/time of death at Haukeland University Hospital were due to missing data after the year 2017.

The median age was 62 years (Table 1). At Haukeland University Hospital, in the age groups < 80 years, 46 % were women, compared to 57 % among those aged ≥ 80 years. The corresponding figures for St Olav's Hospital were 49 % and 57 %, respectively.

Table 1

Age, gender and length of stay for patient visits in the EDs at Haukeland University Hospital and St Olav's Hospital in the period 2012–21.

	Haukeland University Hospital N=349 884	St Olav's Hospital N=235 896
Age (years), median (interquartile range)	62 (41–77)	62 (41–76)
Gender (female), number (%)1	93 397 (48)	116 128 (50)
Length of stay (hours, minutes), median (interquartile range)	2 h 27 mins (1 h 34 mins–3 h 37 mins)	3 h (1 h 44 mins–4 h)

¹Patient visits with incomplete data were not included in the calculation of percentages (%)

Abdominal pain (13 % and 16 %) and chest pain (11 % and 10 %) were the most common reasons for contact at both EDs (Table 2), and the majority of patient visits were medical (44 % and 53 %) or surgical (24 % and 25 %) (Table 2).

Table 2

Chief complaints and assigned medical specialty for patient visits in the EDs at Haukeland University Hospital and St Olav's Hospital in 2021

		Haukeland University Hospital N=40 396	St Olav's Hospital N=28 822
Chief complaints¹, number (%)²
	Abdominal pain	5 222 (13)	4 592 (16)
	Chest pain	4 358 (11)	3 008 (10)
	Suspected stroke	2 041 (5)	2 210 (8)
	Dyspnoea	1 713 (4)	1 551 (5)
	Other	27 062 (67)	14 333 (50)
Assigned medical specialty¹, number (%)²
	Internal medicine including oncology	17 964 (44)	15 197 (53)
	Surgery	9 679 (24)	7 075 (25)
	Neurology	4 399 (11)	1 795 (6)
	Orthopaedics	3 093 (8)	2 218 (8)
	Neurosurgery	2 220 (5)	501 (1.7)
	Other³	2 759 (7)	2 036 (7)

¹Based on Emergency Signs and Symptoms codes (St Olav's Hospital) and admission diagnoses (Haukeland University Hospital)

²Patient visits with incomplete data were not included in the calculation of percentages (%)

³Includes dermatology, gynaecology and obstetrics, ophthalmology, otolaryngology, and emergency medicine

The ED at Haukeland University Hospital had a mean of 3.8 (SD 2.2) new patient visits per hour, and the corresponding figure at St Olav's Hospital was 2.5 (SD 1.6) (Figure 1). For new patient visits with the highest triage level, the mean per hour at Haukeland University Hospital was 0.4 (SD 0.2), compared to 0.3 (SD 0.1) at St Olav's Hospital.

The ED at Haukeland University Hospital had a median (interquartile range) annual increase of 856 (362–1 350) patient visits, from 30 696 in 2012 to 40 396 in 2021; representing a total increase of 32 %. At St Olav's Hospital, the median annual increase was 1 040 (762–1 318), from 18 967 in 2012 to 28 822 in 2021; representing a total increase of 52 % (Figure 2). The corresponding total increases distributed by age groups 16–66 years, 67–79 years and ≥ 80 years were 25 % (from

17 908 to 22 348), 57 % (from 6 190 to 9 691) and 27 % (from 6 598 to 8 356), respectively, at Haukeland University Hospital. At St Olav's Hospital, the changes in the respective age groups were 57 % (from 10 308 to 16 156), 77 % (from 3 848 to 6 817) and 48 % (from 3 726 to 5 531) (Figure 3). The proportion of elderly (≥ 67 years) was 41 % (2012–16) and 44 % (2017–21) for both EDs combined.

The proportion of patient visits at Haukeland University Hospital that resulted in admission was 82 % in 2012 and 74 % in 2021, while at St Olav's Hospital the corresponding proportions were 87 % in 2012 and 61 % in 2021, respectively (Figure 4). The median age (interquartile range) for patient visits resulting in admission to the hospital versus those discharged directly from the ED was 65 years (46–78) and 48 years (30–68), respectively, at Haukeland University Hospital and 65 years (44–78) and 52 years (33–71) at St Olav's Hospital.

The median length of stay (interquartile range) in the ED for patients admitted to the hospital and discharged from the ED at Haukeland University Hospital was 2 h and 24 mins (1 h and 34 mins–

3 h and 31 mins) and 2 h and 53 mins (1 h and 50 mins–4 h and 13 mins), respectively. At St Olav's hospital, the corresponding durations were 2 h and 33 mins (1 h and 41 mins–3 h and 47 mins) and 3 h and 12 mins (2 h and 4 mins–4 h and 45 mins), respectively.

The ED at Haukeland University Hospital (2012–17) and St Olav's Hospital had 0–1 and 0–3 deaths per year, respectively. Mortality per 1 000 patients in the ED at Haukeland University Hospital (2012–17) was 3 after 24 hours, 6 after 7 days and 11 after 30 days. The corresponding figures for St Olav's Hospital were 5, 8 and 18.

Discussion

Discussion

This retrospective review of patient influx at two Norwegian EDs demonstrates a considerable increase in patient visits in the period 2012–21; 32 % at Haukeland University Hospital and 52 % at St Olav's Hospital. This increase appeared to be steady, apart from a temporary small decrease in 2020, which likely reflects the COVID-19 pandemic. There was no obvious difference in the distribution of age, gender, chief complaints and mortality between the two EDs.

The most common chief complaints were abdominal pain, chest pain, dyspnoea and suspected cerebral stroke. These collectively accounted for approximately one-third of the patient visits at the two EDs. Medical patients made up about half (53 %) of the total at St Olav's Hospital, with a slightly smaller proportion at Haukeland University Hospital (44 %). This difference can be attributed to the larger patient catchment area for surgical conditions compared to internal medicine, as well as the existence of medical departments at Haraldsplass Diaconal Hospital in Bergen. Additionally, patients with stroke symptoms were assigned to neurology at Haukeland University Hospital, while St Olav's Hospital assigned these patients to internal medicine.

On weekdays, a clear peak in patient influx was observed around lunchtime, while patients with the highest triage level seemed to be more evenly distributed throughout the day. The higher number of patient visits during the day without an increase in high triage level visits was an expected finding. This is because patients with less acute conditions are less likely to seek medical attention in the evening or at night, and because the primary care service mainly sees patients during the day (14). The general increase in patient visits in afternoons and evenings can pose a challenge for EDs but can potentially be reduced by giving patients with non-urgent conditions appointments for the following morning.

The population growth in Bergen municipality (8 %) and Trondheim municipality (14 %) in 2012–21 was lower than the increase in patient influx (15), which may indicate that the increase cannot be solely attributed to population growth. The age group with the greatest increase appeared to be 67–79 years, with a 57 % increase at Haukeland University Hospital and 77 % at St Olav's Hospital. The proportion of older patients (≥ 67 years) was found to be 41 % in the first part of the study period and 44 % in the second. An earlier study from St Olav's Hospital reported a similar increase in patient influx to the ED in 1992–2011 (4), and global studies show a similar trend (2).

A decreasing trend in the proportion of patient visits resulting in hospital admission has previously been demonstrated at St Olav's Hospital (4, 6) and may be related to the introduction of specialists in emergency medicine whose competence and presence makes it more likely that the patient is dealt with efficiently in the ED without the need for consultation (6). The organisational structures of the two hospitals differ slightly, and St Olav's Hospital has a provision for outpatient treatment, which partly explains the more pronounced decrease observed at this hospital. The length of stay was also likely to be slightly longer at St Olav's Hospital than at Haukeland University Hospital.

With the projected significant increase in the population (16), particularly in the older age groups, it is reasonable to expect a continued increase in the patient influx to EDs. The fact that older patients are hospitalised more often than younger patients means that EDs will not only have to prepare for a higher patient influx but will also be faced with a patient population that requires other types of care. In 2023, the Health Personnel Commission confirmed that the specialist health service will have lower or no staff growth, with resources being directed to the primary care service instead (17). This means that EDs may face a higher demand without a corresponding increase in the supply of personnel. To prepare EDs for this future challenge, robust professional expertise and decision-making support are needed. The Norwegian Directorate of Health's guidelines for somatic EDs (8) recommend placing doctors who specialise in emergency medicine in EDs. We also argue that close collaboration with the primary care service is essential for ensuring appropriate and optimal patient pathways. Cooperation should be strengthened through uniform guidelines in primary care and the specialist health service for when and how patients should be referred to EDs and hospitals, emergency beds in the primary care service, outpatient appointments with specialists or other healthcare services. This could help ensure that patients with minor ailments receive the necessary care without hospitalisation, while enabling prompt hospital treatment for those requiring emergency care.

One of the strengths of our study was the inclusion of data from two different EDs, but data access and registration practices varied, and the introduction of a new computer system at Haukeland University Hospital during the study period may have affected data quality. In future studies, it would be helpful to distinguish between patient visits and unique patients.

This study showed changes in patient influx and population at the EDs at Haukeland University Hospital and St Olav's Hospital over a ten-year period. The age group 67–79 years appears to have had the highest annual percentage increase in patient visits. The proportion of patient visits that resulted in hospitalisation appeared to decrease. The findings of this study are significant for the planning of future emergency services.

The article has been peer-reviewed.

References

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Comments ( 1 )

Dette kommentarfeltet modereres, men kommentarer blir ikke redaksjonelt behandlet ut over å sikre at de følger retningslinjer for vårt kommentarfelt.

24.07.2024:

I artikkelen skriver Nummedal og medarbeidere: "I 2023 stadfesta Helsepersonellkommisjonen at spesialisthelsetenesta vil få lågare eller ingen personalvekst til fordel mot kommunale tenester."

Jeg vil minne om at det er laget en motmelding til Helsepersonellkommisjonen som i stor grad tilbakeviser at antallet helsepersonell ikke kan øke (1). Dette er et spørsmål som det også må være opp til hele den norske befolkningen å avgjøre, all den tid det handler om hva og hvor mye vi ønsker at velferdsstaten vår skal håndtere. Dersom sykehusene med sine akuttmottak bemannes for skrint med påfølgende lavere kvalitet, vil dette høyst sannsynlig gjøre sykehusene til mindre attraktive arbeidsplasser og økt grobunn for private tjenester. Vi risikerer at private tilbydere støvsuger Norge for helsepersonell og tilbyr tjenester til alle som kan betale. Dette reduserer ikke antallet helsepersonell, bare flytter de fra offentlige til private helsetjenester.

I motmeldingen som ligger på Oslo legeforenings nettside finner du mer informasjon (1). Jeg håper leserne og artikkelforfatterne tar seg tid til å sjekke denne kilden!

1. https://www.legeforeningen.no/contentassets/276d3938493d4d25bdfc0da4639afd67/motmelding_helsepersonellkommisjonen_skjerm_230811.pdf

This article was published more than 12 months ago and we have therefore closed it for new comments.

Published: 24 June 2024

Tidsskr Nor Legeforen 24 June 2024 Vol. 144.

doi:

10.4045/tidsskr.23.0669

Received 3.10.2023, first revision submitted 16.2.2024, accepted 5.5.2024.

Open access CC-BY-ND
Copyright: The author(s)

Published: 24 June 2024

Tidsskr Nor Legeforen 2024 Vol. 144.

doi: 10.4045/tidsskr.23.0669

Received 3.10.2023, first revision submitted 16.2.2024, accepted 5.5.2024.

Open access CC-BY-ND
Copyright: The author(s)

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