Evaluation of Patients ’ Referral Causes to the Emergency Department

Background and Objectives: Proper management of resources and patients in emergency departments (ED) is the main priority of the hospitals. By investigating patient referrals to our ED during 5 years, we tried to help making policies about development and management of ED. Methods: In this cross-sectional descriptive study, data pertaining to etiology of admission and final discharge of patients were collected through medical record review (HIS) from 2011 to 2015, and analyzed utilizing SPSS software. Results: 444552 patients were referred to our ED among whom 22.37% were outpatients. The most common indications for admission were trauma (37.97%), abdominal pain (20.63%), headache (10.59%) and CVA impression (3.59%). 25.92% of patients had personal consent to leave the ED without being visited (Left Without Being Visited: LWBV) by a physician. Mortality rate was 0.76% in five years. Trauma was the most common cause of death in first three years (25.87%, 20.90% and 20.07%, respectively); and decreasing level of consciousness was the most common cause of death in last two years (22.89% and 30.40%, respectively). Conclusion: Considering safety and patient’s satisfaction as two factors determining quality of emergency care, these findings reveal the need for reducing LWBS (by improving communication skills and quality of care) and lowering the incidence of mortality and morbidities (by improving diagnostic and therapeutic skills).


INTRODUCTION
Healthcare systems of all countries have complicated and expanded structures, consisted of hospitals, clinics, diagnostic departments, doctors, nurses, pharmacists, statistical systems and health care information of each country (4,5).Nowadays Emergency department is defined as the mainstay of health care system and its promotion and improvement is the main goal of health care system in all countries (6).About 25% of referrals and hospital admissions are done in the emergency department with 40% of patients being admitted into the clinical wards after referring to the emergency department (3).Appropriate approach on the right time can reduce rate of mortality and morbidity of the patients (7).Quality of service providing and behavior with patients in the emergency department is the symbol of overall services in the hospital.This important concept has a tight relationship with choosing the qualified management, health care workers, and facilities in emergency departments (8).Way of providing services to the patients and its quality is one of the most remarkable factors of patient's satisfaction who refer to emergency departments.(9).Managers of emergency departments with high Tabriz University of Medical Sciences during recent 5 years from 2010 till 2015 were studied and investigated.Factors of entering to this study included all patients referring to Imam Reza Hospital of Tabriz University of Medical Sciences in recent 5 years, and all data were extracted from HIS system of hospital.
Design: According to the type of study and investigating all patients referring to the emergency department, defaced data in HIS system were went out from our study.Information of patients referring to emergency of Imam Reza hospital in recent 5 years was consisted of the reason of admitting (illness or trauma) and discharge from emergency which were noted.Due to sampling, population of data were consisted of all patients referring to emergency department of Imam Reza hospital was 444552 during 2010 to 2015 who were studied.
Statistical analysis: All data were analyzed by SPSS version 22 software, and then were reported as descriptive statistics (mean, percent).

RESULT
Total admitted patients in emergency department of Imam Reza hospital in recent 5 years were 444552 (the average: 88910.4patients) (Table 1 Many of the patients who were admitted in the emergency of Imam Reza hospital from 2010 to 2015 were discharged after primary cares (66.985%, 62.37%, 56.37%, 62.07%, 63.45%).About a quarter of them (25.92%)left the emergency with personal consent.Maximum frequency of admission was in 2012 (31.79%), whereas the minimum was in 2010 (20.78%).Prevalence of mortality in emergency room of Imam Reza hospital in recent 5 years was 0.76%, although it had been increasing from 2010 to 2015 (0.59%, 0.60%, 0.70%, 0.84%, 1.16%).(Table 3) The most common reason of mortality in the patients who has been admitted in the Imam Reza hospital in recent 5 years was related to trauma (16.94%).The most common reason of mortality in 2010, 2011, 2012 was trauma (25.78%, 20.90%, 20.07%), whereas in 2013 and 2014 loss of consciousness as a medical reason (22.895, 30.40%) was the most common reason of mortality.The other reasons of mortality in recent 5 years were pulmonary embolism and CVA (11.75%, 6.74%).(Table 4)

DISCUSSION
The total number of admitted patients in emergency department of Imam Reza hospital was 444552 in recent 5 years   (15).In conclusion, considering safety and patient's satisfaction as two factors determining quality of emergency cares, reveal the need for reducing LWBS (by improving communication skills and quality of cares) and lowering the incidence of mortality and morbidities (by improving diagnostic and therapeutic skills).

Table 1 .
Emergency department reception during five years, Imam Reza Hospital, Tabriz

Table 2 .
Etiologies of admission in emergency department during five years, Imam Reza Hospital, Tabriz (11,14)geable patients to other wards lead to lower rate of discharge, quick decision making, and discharging high risk patients makes number of discharges high.Trauma, abdominal pain, and headache are the most common causes of admitting in the emergency room of Imam Reza hospital in recent 5 years (37.97%,20.63%,10.59%respectively).Evaluation of demographic features, age and sex distribution of patients tio of doctors to the patients, medical errors, lack of control on medical residents' management are associated with high mortality rate(11,14).The most common causes of mortality rate in emergency department of Imam Reza hospital in recent 5 years was trauma (16.94%).The most common cause of mortality in 2010, 2011, 2012 were trauma with the frequency of 25.87%, 20, 90%, 20.07%respectively, whereas

Table 3 .
Final disposition of patients in emergency department during five years, Imam Reza Hospital, Tabriz

Table 4 .
Etiologies of inpatients' mortality in emergency department during five years, Imam Reza Hospital, Tabriz

Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent
(14) et al study in 2014 showed that rate of acute injuries is increasing with age and a quarter of elderly traumatized patients are admitted through emergency room(7).Shams et al study in 2013 indicates rate of satisfaction is not related to sex and health insurance, whereas it is correlated with education level and frequency of hospital admission.Public satisfaction from health care services is increasing by age, although there are decreased satisfaction from hospital facilities and space(8).Soleimanpoor et al. study in 2012 about public satisfaction in emergency of Imam Khomeini hospital of Tabriz, demonstrated that less waiting time, helping patients to understand the meaning of "waiting "in emergency room and cleanliness and hygiene of the emergency department may increase rate of patient satisfaction(9).Cassidy Smith et al study in 2007 investigating throughput time, expectation and public satisfaction, found out that by increasing through put time more than expectation, patients' satisfaction is reducing(10).Malek Makan et al. study in 2010 demonstrated ED cleanness, respecting patients' physical space and continuous monitoring lead to high public satisfaction(11).Reid et al study in 1999 investigated hospital admission in London.According to this study 45% of admitting was related to emergency room.Reason of admitting had a significant difference related to each area(13).In a study by Jarman et al. in1999 mortality rate of 4 years after discharging from hospital in England has been increased from 3.4% to 13.6% (the average: 8.5%).The most important reason in mortality rate was emergency room admission(14).In Mcdonald et al. study from 1993 to 2004 about admitting patients with atrial fibrillation showed that admitting patients with AF diagnosis has increased in recent 10 years