Children taken to A&E with 'routine complaints'

A study has found that the number of “under-15s attending casualty with routine medical complaints has increased by 42% over past decade,” reported The Guardian. It said that “‘patchy’ out-of-hours services were to blame and parents felt they had no choice but to take their child to the local A&E unit”.

This review examined the common medical complaints (for example, non-surgical or trauma-related admissions) for which children attended an accident and emergency (A&E) department in 2007-2008, compared with 10 years earlier. It found a 42% increase in the number of such presentations. Of the 14,724 admissions of this type in 2007, 85% were among the top 10 common problems (such as breathing difficulties, fever and diarrhoea).

There are important considerations given below that need to be taken into account when interpreting these findings, which are not simply due to a lack of availability of out-of-hours GPs.

This question of why such an increase has occurred needs much further study. The data from a single hospital’s A&E ward may not reflect the situation elsewhere, which cannot be known without a review of other hospital admissions data nationwide. Further hospital data collection is needed to inform how practice and care provision may be improved.

Where did the story come from?

The study was carried out by researchers from Nottingham Children’s Hospital, and the University of Nottingham Medical School. No sources of funding were reported for this research. It was published in the peer-reviewed British Medical Journal .

The figures reported in the newspapers and the general reporting of the 42% increase in medical presentations are correct. Many newspapers said that the increase in the numbers of children presenting to A&E with common illnesses is thought to be due to a difficulty in accessing out-of-hours GPs. However, the study did not look into the reasons behind why the numbers have risen, and this is only one theory.

What kind of research was this?

The main aim of this research was to examine the common medical complaints for which children attended an accident and emergency (A&E) department, compared with 10 years earlier.

The researchers reviewed electronic medical records from child and adolescent A&E attendances over a one-year period between February 2007 and February 2008, at a single university hospital. These records were then compared with those from 10 years earlier.

What did the research involve?

The study was conducted at the A&E department of Queens Medical Centre, Nottingham, a busy hospital that covers a population of 592,000 people in Nottingham and the surrounding localities. This catchment area includes about 108,000 children and adolescents aged under 15.

The electronic patient record and clinical information system (EDIS iSOFT) was used to identify paediatric attendances at the hospital in 2007-2008. Information was available on:

demographics
time and source of referral (for example, self-referral or those who had been advised to attend A&E by a GP or other health practitioner)
the presenting problem
diagnosis
management

The researchers were only interested in medical problems, and excluded presentations of trauma (accidental injury), surgical, obstetric or gynaecological problems. They then removed from their analyses the cases that had been referred directly by their GP to the paediatric admission teams, leaving only those that had been ‘self-referred’.

Children were grouped by age, referral source (self, parent, guardian or other health practitioner) and the presenting medical problem. The 2007-2008 admissions were compared with a similar cohort between 1997-1998, that had collected data using the electronic patient administration system (PAS) and paper records.

What were the basic results?

In 2007-2008, a total of 39,394 children and adolescents (57% boys) were seen in A&E, compared with 38,982 10 years in 1997-1998. After the admissions due to trauma, surgical, obstetric or gynaecological problems were excluded, there were 14,724 medical attendances compared with 10,369 10 years before, an increase of 42%.

After excluding the 15.8% of cases who had been directly referred from the GP to the paediatric admitting teams, the researchers were left with 12,389 medical attendances in 2007-08 without GP referral (the number of 1997-98 medical attendances with or without a direct referral from their GP is not given for comparison). The majority of these self presentations (69.8%) were in the 0-4 age group.

Of these 12,389 attendances, 71.5% were self-, parent- or guardian-referred, while 14.5% had been seen or advised by a health practitioner prior to deciding to attend A&E. Of the 10.6% who came to A&E by ambulance, it was unclear whether they had received any advice prior to calling the ambulance. These proportions are, again, not provided for the study years 1997-98.

When the researchers ranked the 2007-2008 medical presentations according to their frequency, they found that 85% of attendances were for the following top 10 common presenting problems:

breathing difficulty (2,494; 20.1%)
feverish illness (1,752; 14.1%)
diarrhoea with or without vomiting (1,731; 14.0%)
rash (1,066; 8.6%)
cough (835; 6.7%)
abdominal pain (not with a cause needing surgery) (810; 6.5%)
seizure (781; 6.3%)
other (644; 5.2%)
ingestion (presumably of substance) (509; 4.1%)
headache (272; 2.2%)

When they compared these proportions with those from 1997-98 there was a consistency between both years, though breathing problems accounted for 31% of attendances a decade earlier, compared with 20.1% in 2007-08.

How did the researchers interpret the results?

The researchers conclude that over a 10-year period, there has been a rise in the number of people attending A&E with medical conditions, and there are 10 common presentations that account for 85% of these medical attendances.

They say their results suggest that the increasing use of A&E for common presenting problems should prompt further study exploring the reasons for A&E attendance and how and why they choose to seek medical advice. These findings are needed for the planning of paediatric emergency and urgent care services.

Conclusion

This study found an overall 42% increase in paediatric medical presentations to this A&E department between 1997-98 and 2007-08. There are important considerations that need to be taken into account when interpreting these findings, and they cannot be assumed to be due to a lack of availability of out-of-hours GPs. Some important considerations include:

The overall number of A&E presentations in this age group did not change over this 10-year period, though medical presentations did increase. However, the 42% increase in medical presentations (14,724 versus 10,369, 10 years earlier) includes both children that self-referred and those that were GP referred. Exclusions of GP referrals left 12,389 children going to A&E in 2007-08, 71.5% of whom had received no advice from a health professional. The number of 1997-98 medical attendances with a direct referral from their GP is not given for comparison, so it is not possible to see whether there has been a change in the rate of self-presentations and GP referrals.
This information may help to shed light on the question of whether parents are bypassing their GP and directly attending hospital now compared to 10 years ago. However, even if it is the case that there are fewer GP referrals now than previously, without further study it still cannot tell us why this is (for example, whether it is parent choice, or, as the papers suggest, it is due to poorer availability of GPs).
This is data from a single university hospital, and though it may reflect the situation elsewhere, this would have to be verified by a review of other hospital admissions data nationwide. It would also be beneficial to examine other years.
To examine whether GP availability had any effect on the number of presentations to A&E, the factors influencing the decision would need to be examined in more detail. For example, the number of presentations at the weekend or late evening could be compared with weekday daytime presentations when GP surgeries are open. Parents or guardians could be surveyed as to whether they were aware of any GP out-of-hours service in their locality, and if this had been more openly accessible they would have chosen to go to the GP rather than direct to A&E.
Of note, despite an increase in presentations, the reasons for attending A&E show little change over 10 years. When looking at the presenting problems, 85% of attendances in 2007-08 fell into the top 10 common problems (with breathing difficulties, fever and diarrhoea having the highest ranking), and this ranking had not changed in 10 years, though there has been a reduction in the number of children presenting with breathing difficulties. The reasons for this are unclear.

Further data collection related to paediatric emergency attendances nationwide is needed. As the researchers say, better understanding of frequent presenting problems can inform commissioning and pathway provision, development of guidelines, and medical training.