a b s t r a c t

Aim: The increased number of emergency clinic patients causes the length of stay in the emergency department, Low patient satisfaction and dismiss of real emergency patients. In this study, we aimed to determine the predic- tion levels of emergency clinicians according to working year on the outcome of the Ambulance patients and out- patients presented to the emergency department (ED).

Materials & methods: This prospective study included patients over 18 years old. The triage of outpatients was made by a senior nurse and patients were divided into three triage categories such as green, yellow and red. Then these patients were evaluated by the emergency physician at the examination areas. Ambulance patients were directly evaluated by the emergency physician. These ambulance patients were noted as yellow or red ac- cording to triage categories. The main complaints, triage category, presentation method, vital signs, predicted outcome noted by the clinicians.

Results: The correct prediction levels of hospitalisation (clinic/intensive care unit) were higher in clinicians whose working year is between 6 and 10 years (p b 0.05). There was no significant difference between 6-10 year and N10 year group according to prediction level (p N 0.05). Prediction of dischargement was higher in 0-5 year group than 6-10 year (p b 0.05) and N10 year (p b 0.05) group.

Conclusion: Experienced clinicians can make much more accurate prediction on length of stay and the prognosis of the emergency patients so crowded follow-up areas of the emergency room can be planned much more effectively.

(C) 2020

Introduction

Emergency service presentation ratios are arising each day and this situation cause much more crowded emergency rooms and length of stay. Because of this crowdedness appropriate triage, initial evaluation, diagnosis, treatment and follow-up steps should be arranged carefully [1]. Besides, emergency clinics are wide areas which are 24 h open, and easy accessible [2].

Some simple cases may wait for examination dependent on the con- sistence if the capacity level exceeded. The most important thing at this point is to determine the medical requirements of the patients and give priority to real emergency patients. An appropriate triage and initial evaluation of patients are the first steps of this procedure. The triage helps to determine the real urgency and emergency patients, direct them to the appropriate areas [3]. An effective triage and the initial eval- uation should aim to shorten the length of stay of the patients. Better area planning consequently patient/doctor satisfaction can be provided

? All authors declare that they have no conflict of interest.

* Corresponding author at: Adana Sehir Egitim Arastirma Hastanesi Acil Klinigi, Adana, Turkey.

E-mail address: [email protected] (S. Yolcu).

via convenient initial evaluation. Shortness of length of stay is known as one of the most important factor of patient satisfaction [4-8].

In this study, we aimed to determine the prediction levels of emer- gency clinicians according to working year on the outcome of the ambu- lance patients and outpatients presented to the emergency department.

Materials & methods

In this prospective study we enrolled 806 adult patients between 1 and 10 September 2019 after the ethics committee approval.

Ambulance patients were evaluated directly by the emergency phy- sician and divided into two categories (yellow/red). The outpatients’ tri- age was made by a senior nurse/paramedic and patients were examined according to their triage category (green, yellow, red). The main com- plaints, triage category, presentation method, vital signs, predicted out- come (discharges/admits to inpatient clinic/admits to ICU) and real outcome noted by the clinicians. The study form also included the work- ing year at the emergency service information (0-5 year, 6-10 year, N10 year) of the doctor that examined the patient first. The prediction of the clinicians and the real outcome results were compared for each group according to working year and presentation method.

https://doi.org/10.1016/j.ajem.2020.02.050

0735-6757/(C) 2020

1464 M. Calis et al. / American Journal of Emergency Medicine 38 (2020) 1463–1465

Patients under 18 years old, cardiopulmonary arrest patients and green zone patients. The green triage category patients do not wait longer than half an hour in our emergency department be- cause there are two examinations rooms for these patients. And there green area patients are almost discharged and we didn’t in- clude these patients for not to allow affecting the results of our study.

Statistical analyses

Statistical Package for the Social Sciences (SPSS) 23.0 package program for statistical analyses. Kolgomogrow-Smirnow and Shapiro-Wilk tests were used for normal distribution. For compar- ing parameters without normal distribution Student t-test, for pa- rameters with normal distribution Mann Whitney U Test was used. Chi-Square test was used for comparing the categorical variables. Significance level was 0.05.

Results

We included 466 females (57.8%) and 340 (42.18%) males totally 806 patients. Mean age of the study group was 52,49 +- 19,61 (min: 18, max: 99) years. Four hundred fifty six (56.5%) patients were brought by the ambulance and 350 (43.4%) patients were outpatients. There was 713 (88.5%) patients were in the yellow and 93 (11.5%) patients were in the red triage category.

The emergency clinicians working year ratios those examined the patients first were 34.4% for 0-5 years, 41.2% for 5-10 years, and 24.4% for N10 years.

The highest real dischargement ratio of the patients according to working year was determined in the 0-5 year group and this difference was statistical significant (p b 0.05).

Dischargement, admission into inpatient clinic and admission into ICU prediction ratios of the clinicians were 387 (48%), 271 (33.6%) and 148 (18.4%) respectively. According to the real out- comes there ratios were 535 (%66,4%), 111 (13,8%), and 157

(19,5%) respectively.

The correct outcome prediction ratio of our study was 70.6% (n:569). When we considered the outcome prediction according to working year 0-5 year group’s correct prediction ratio was lower when compared 5-10 year and N10 year group (p b 0.05). There was no significant difference between 5-10 year and N10 year groups (p N 0.05) (Table 1).

The correct and wrong prediction ratios were significantly dif- ferent between 0-5 and 6-10 year groups (p b 0.05), similarly 0-5 and N10 year groups (p b 0.05). But we couldn’t find a signifi- cant difference between 6-10 year and N10 year group (p N 0.05) (Table 2).

The prediction levels of the patients didn’t significantly differ ac- cording to presentation way (ambulance/outpatient) (p N 0,05). The

Table 1

The outcome prediction ratios of the groups according to working year.

Groups	Predictiona					p
	Inpatient clinic		ICU		Discharge
	n (%)		n (%)		n (%)
0-5 year (n: 277)	87 (41,2)		9 (9,8)		181 (59,2)	0,000?
6-10 year (n: 332)	124 (58,8)		83 (90,2)		125 (40,8)
0-5 year (n: 277)	87 (59,2)	60 (40,8)		181 (69,1)		0,000?
10 yil ve uzeri (n: 197)	60 (40,8)	56 (86,2)		81 (30,9)
6-10 year (n: 332)	124 (67,4)	83 (59,7)		125 (60,7)		0,269
N10 year (n: 197)	60 (32,6)	56 (40,3)		81 (39,3)

ICU: Intensive care unit.

* p b 0,05.

^a Pearson’s Chi-squared test.

Table 2

Correct and wrong prediction ratios of the groups according to working year.

Groups	Real outcomea		p
	Correct	Wrong
	n (%)	n (%)
0-5 year (n: 277)	217 (50,0)	60 (34,3)	0,000?
6-10 year (n: 332) 0-5 year (n: 277)	217 (50,0) 217 (61,6)	115 (65,7) 60 (49,2)	0,011?
N10 year (n: 197)	135 (38,4)	62 (50,8)
6-10 year (n: 332)	217 (61,6)	115 (65,0)	0,258
N10 year (n: 197)	135 (38,4)	62 (35,0)
* p b 0,05.
a Pearson’s Chi-squared test.

correct prediction ratio for ambulance patients was 70.4%, for outpa- tients 70.9%, and totally 70.6%.

Discussion

The crowdedness of emergency services is a global health problem. Unnecessary presentations, lack of healthcare givers and empty bed problems are the most important case of this problem An appropriate triage and an initial evaluation are the most important parts of the pa- tients evaluation for planning the emergency clinic areas and the circu- lation of the clinic.

In this study we tried to evaluate the emergency clinicians whether they could estimate the severity level of the patients at first presentation. Most of the patients were presented with ambu- lance with a ratio of 56.5% because of exclusion of green triage level patients from the study. The majority of the patients were fe- males. And the mean age 52.49. In a Japanese data the mean age for ambulance presentation was 70 [9]. The red triage level ratio was 11.5% and almost brought by the ambulance and similar results have been suggested in literature [10]. Lower percentages have also been reported [2].

Similar to the other jobs, experience is important also for Emergency doctors for making immediate decisions. 65.6% of the doctors of our study were experienced in the emergency clinics for minimally 5 years. The working year of emergency clinicians have been researched [11].

When we considered the correct dischargement, admission into inpatient clinic and admission into ICU prediction ratio of the clini- cians was 70.6%. The outcome prediction according to working year 0-5 year group’s correct prediction ratio was lower and the 5-10 year and N10 year groups didn’t differ. The prediction levels of the patients didn’t significantly differ according to presentation way (ambulance/outpatient) and the total correct prediction ratio was about 70%.

An Australia based study has reported that the correct prediction ratio for disposition as 82.7% in their study they included physicians, and other health care givers (registrars, hospital medical officers, in- terns and nurse practitioners) and 301 patients. The most of the correct prediction ratio for dischargement was among the emergency physi- cians with 95.8%. Totally accurate admission prediction ratio was 79.7%. As a result, the physicians made the most accurate predictions ac- cording to this data. But they didn’t address the seniority of the doctors [12].

In Vlodaver’s study, the emergency physicians made a correct pre- diction with 88.6%. In this prospective study they enrolled totally 35 emergency physicians and 398 patients were included. The doctors pre- dicted that 78 patients admit and 320 patients discharges. The correct prediction ratio of admission was 51.8% and 89.1% for dischargement. The prediction level of the clinicians for admission into the clinic or ICU was insufficient. These results could be detailed whether the au- thors had evaluated the working year degree of the doctors [13].

M. Calis et al. / American Journal of Emergency Medicine 38 (2020) 1463–1465 1465

Conclusion

Minimally 5 years experienced emergency clinicians can make much more accurate predictions for the outcome of the emergency service pa- tients. Initial evaluation by an experienced doctor method may help making correct immediate decisions for the patients, consequently the area and bed planning. It also may help to shorten the length of stay in the emergency room and fasten the circulation. Further comprehen- sive prospective studies are required for solving the crowdedness prob- lem of the emergency departments.

Limitations

In our study, we didn’t want those green area patients to affect our results. It’s almost related with our government’s healthcare politics and we have two examination rooms and two doctors just examine these green area patients for 24 h and they almost (nearly 95%) are discharged. And this study was held in Autumn, at the end of summer. The data may change according to seasonal diseases such as pneumonia but our hospitalisation ratios are usually similar but it would be better to see the results in all seasons.

CRediT authorship contribution statement

Mustafa Calis:Conceptualization, Methodology, Formal analysis. Kemal Sener:Data curation, Formal analysis.Adem Kaya:Conceptuali- zation, Methodology, Data curation.Sezai Sari:Data curation, Formal analysis.Mustafa Polat:Data curation.Sadiye Yolcu:Conceptualization, Methodology, Writing – review & editing.

Acknowledgements

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

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