Thursday, March 20, 2008

Time, Ends

Time is the only effective cost. If doing must be directed to desired ends, time is best used determining ends rather than doing. That sounds stupid. I believe it is not. What are your thoughts?

Saturday, March 01, 2008



E. Hassen, R. Bhalla

There is a dearth of epidemiological research into paediatric attendances at Emergency Departments in the UK. Most Emergency Medicine research in the UK has looked at types of injuries although several have looked at all types of ED attendance. Only one study has looked at the epidemiology of ED attendances specifically. This latter study found that most attendances were due to injuries and that these varied by age and location and that the variations were not stable across sites. More information is needed from more sites for longer periods through the country in addition to the sentinel sites monitored by the DTI given the contingent and complex causes of ED attendances.

The lack of research in Emergency Medicine is due to the fact that this is a new speciality, that Emergency Medicine lacks political capital, that no dedicated funding exists for Emergency Medicine research, that no dedicated organisation is responsible for Emergency Medicine research, that Emergency Medicine practitioners have an action focus rather than a research focus and that Emergency Departments are under-resourced for service provision without the ability to do research. The Joint Statement on Children’s Attendances at Accident & Emergency Departments was published in 1999 with its most important references from 1985. The Care Group Workforce Team Recommendations 2003 Report did not deal with Emergency Medicine. The most recent numbers published for NHS Direct referrals to Emergency Departments were for 1999-2000, the first year that NHS Direct was operating.

Emergency Medicine is still an orphan speciality and needs research that proves the growing workload and the effectiveness (clinical, social and financial) of Emergency Departments. Towards that end we contribute this study.

This study looks at all types of ED attendance at one hospital to report on the use of the Emergency Department by children to see how these vary by age, sex and season.


Our hospital is a district general hospital in Wales serving a population of 250,000.

The Emergency Departments is fully computerised and records information on every attendance made. Data on all new ED attendances by children aged under 16 years of age were available for the period 1 January 2005 to 31 December 2005 (12,443 records).


In 2005 ED attendances peaked at age 2 and then decreased to a minimum at age 8 before rising again. For all attendances the peak was reached in week 28, which was also the week in which paediatric attendances peaked; however, as a proportion paediatric attendances peaked in week 27. For all ages males presented more frequently than females with the smallest difference at age 2 and the largest difference at age 12.

Figure 1 shows all ED attendances for the year for each week with trough at week 8 and peak at week 28.

Figure 2 shows all paediatric ED attendances for the year for each week with trough at week 7 and peak at week 28.

Figure 3 shows all paediatric ED attendances for the year for each age cohort.

Figure 4 shows all paediatric ED attendances for the year for each age cohort by sex as a percentage.


This study has looked exclusively at the numbers of children presenting to the ED. It has not looked at the presenting complaints, discharge diagnoses, discharge outcomes, process times and treatments initiated in the ED. These are all important and have all been reported by several investigators to the disadvantage of simple epidemiological information. Investigators have been interested in the effects of social class, ethnicity, learning disability, physical disability, injury types, injury sites, chronic medical conditions and acute medical conditions on attendance at Emergency Departments. Given that there will be more than 25 million ED attendances this year in the UK we know very little about how they will be distributed and how the distribution is changing over time.

Chronic medical conditions are uncommon in children including learning disabilities and physical disabilities and it is not these specifically that lead to ED attendances and yet it is the effects of these on ED attendances that have engaged the attentions of researchers. The factors responsible for ED attendances are many and varied and complex and not knowable. The recent Institute of Medicine Report on the future of Emergency Medical Services states explicitly that indicators should be developed and that these should include structure and process measures and that these should evolve towards outcome measures. To focus on outcome measures first is to put the cart before the horse considering that we do not have structure and process measures.

We have an advantage compared to the fragmented health services sector in America: most accidents and emergencies in the UK are dealt with by the NHS in the Accident & Emergency Department. Centralised data collection, analysis and dissemination are possible. We hope it happens; soon.