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Introduction
The recruitment rate of pediatric residents in Korea has declined from 71.0% in 2020 to 27.5% in 2022 and 25.5% in 2023 (1-3). As of March 2023, only 22.5% of the 409 emergency medical centers nationwide were able to provide a 24/7 pediatric emergency care (PEC) (3). Additionally, 23.7% of the 93 pediatrician-training hospitals in the country were planning further service reduction by August 2023, posing a crucial threat to the accessibility of PEC. Although PEC hours are expected to continue to decrease, there has been insufficient evidence on the impact of this reduction on emergency department (ED) utilization. Therefore, the purpose of this study was to analyze the changes in ED utilization patterns of pediatric patients in response to the reduced PEC hours.
Methods
1. Study design
This study was approved by the institutional review board of Konyang University Hospital, which is located in Daejeon (Korea), a provincial metropolitan city, and was exempted from obtaining informed consent from the participants (IRB no. 2024-08-001). The ED of the hospital has served as a regional emergency medical center where also has provided PEC. The Department of Pediatrics handled diseaserelated cases, whereas the Department of Emergency Medicine handled injury-related cases, referring to other specialties as needed.
Previously, PEC at the ED was available on a 24/7 basis by in-house pediatric residents, primarily by a junior resident. On September 27, 2022, PEC for disease-related cases started to be provided by the pediatric residents or specialists during 08:00-24:00, as the number of pediatric residents decreased from 7 to 3. We analyzed the impact of this reduction on pediatric ED utilization by defining the period from March 27, 2022 through September 26, 2022 as the “control period,”and that from September 27, 2022 through March 26, 2023 as the“ reduction period.”Throughout the periods, the division of care between the Department of Pediatrics and the Department of Emergency Medicine remained unchanged, and thus, 24/7 care for injuries was maintained.
2. Study setting and participants
The “all-aged patients”were defined as individuals of any age, including adults, who visited the ED. The “child patients”were defined as individuals aged 14 years or younger who visited the ED. Of the child patients, “pediatric patients”were defined as who visited the ED for disease-related cases and underwent the pediatricians’practices in the ED during the periods.
We analyzed the following variables: the numbers of patients (all-aged, child, and pediatric); and for pediatric patients, age with age group (< 1, 1-2, 3-4, 5-11, and 12-14 years), sex, visits via ambulances, severity by the Korean Triage and Acuity Scale (KTAS) with high acuity (a KTAS level 1-2) (4,5), disease-related visits, time of visit (1-hour unit in the 24-hour system [e.g., 00-01]), ED length of stay (EDLOS; time from registration to discharge at the ED), and ED disposition. To reflect the reduction in pediatric practice in the ED, 00:00-07:59 was termed as the“ reduced treatment hours.”The ED disposition included overall and intensive care unit hospitalization, transfer, discharge, and inhospital mortality. Additionally, for pediatric patients, we documented their chief complaints and primary discharge diagnoses according to the eighth edition of the Korean Standard Classification of Diseases (6).
3. Statistical analysis
Continuous variables were presented as medians and interquartile ranges, while categorical variables were done as numbers and percentages. Normality tests were conducted on the continuous variables to determine their distributions. Based on whether the variables were continuous, we employed either t-tests or Mann-Whitney U-tests, chi-square tests or Fisher’s exact tests. All analyses were performed using IBM SPSS Statistics ver. 22.0 (IBM Corp.), with significance set at a P value < 0.05.
Results
During the study period, the numbers of all-aged, child, and pediatric patients decreased by 2.8%, 27.3%, and 41.9%, respectively (Fig. 1, Table 1). Among the child patients, the proportion of visits via ambulances increased during the reduction period compared to the control period, while the proportion of high-acuity cases and overall hospitalization, and median EDLOS decreased. The percentage of disease-related cases decreased by 41.9%.
Among the pediatric patients, the median age increased during the reduction period, with a more prominent decrease in the proportion of those aged 4 years or younger. Additionally, the proportion of high-acuity cases did not differ, and the median EDLOS and overall hospitalization decreased, while the use of ambulances increased (Table 2).
Among the pediatric patients who visited during the control period, 758 patients visited during 00:00-07:59 (Table 3). Proportions of the patients aged 4 years or younger were higher in those who visited during 00:00-07:59 (68.3%) than those who visited during 08:00-24:00 (61.0%). We noted a higher proportion of highacuity cases and longer EDLOS, but a lower rate of overall hospitalization in those who visited during 00:00-07:59. The largest decrease in the number of visits by the pediatric patients between 08:00 and 24:00 occurred between 23:00 and 24:00, with a 61.0% reduction (Fig. 2).
The chief complaints remained consistent over both periods, with fever being most common (Table 4). Comparison of the discharge diagnoses showed differences between the 2 periods, with “gastroenteritis and colitis of unspecified origin,”“other acute upper respiratory infections of multiple sites,” “coronavirus disease 2019, virus identified,”“acute bronchitis, unspecified,”“acute bronchiolitis, unspecified,” and “sepsis, unspecified”less common in the reduction period (Table 5).
Discussion
The reduction in PEC hours particularly affected the pediatric patients aged 4 years or younger given the increase in the median age and the corresponding decrease in the proportion of the age groups during the reduction period. It is suggested that pediatricians, compared to other specialists, are particularly well-suited to treat patients under the age of 4 years, as they provide care grounded in a comprehensive understanding of developmental stages and pediatric physiology. Additionally, their expertise in communicating effectively with the parents highlights the critical need for pediatricians in ED. These factors demonstrate the necessity of having pediatricians in EDs.
The reduction in EDLOS and hospitalization during the reduction period was likely due to a shorter waiting time in the ED due to fewer patients and stricter-than-before hospitalization criteria by the pediatricians. Conversely, despite the lack of difference in the proportion of the high-acuity cases, we speculate that the increase in intensive care unit hospitalization during the reduction period stemmed from a rise in severe respiratory diseases, which were probably more prevalent in the reduction period (i.e., fall and winter) than the control period. This also suggests that the KTAS for children may not fully reflect the severity of conditions as judged by clinicians in real-world practice, as reported in a previous study by Noh et al. (7).
The decrease in the pediatric patient volume (n = 947) during the reduction period was larger than the number of pediatric patients who visited in 00:00-07:59 during the control period (n = 758). In addition, the most notable decrease during the reduction period was observed in visits before the end of time for PEC for disease-related cases. This finding suggests that from a healthcare providers’ perspective, EDs may limit the registration of pediatric patients earlier than the official closing time to allow sufficient time for essential practices or tests, such as blood tests or radiographs. Patients with low-acuity cases may have opted to seek care at primary care facilities with night-time services or chose to visit outpatient clinics during regular hours, which may explain the observed increase in the ambulance use.
The lower frequency of infection-related diagnoses during the reduction period suggests a weakened ability to manage infection-related cases by reduced PEC hours. This change in the ED policy also led to an 11.6% decrease in the number of injury-related visits (from 2,068 [47.8%] to 1,834 [58.2%]). This indicates that the reduction in PEC affected not only disease-related visits but also injury-related visits. It is likely that clinicians in other departments felt burdened by managing children without support of the pediatricians.
Previous studies investigating the general characteristics of patients in Korea have reported that a notable proportion of pediatric emergency center visits for illness occur during night hours. For instance, Song et al. (8) reported that 52.4% of these visits occurred during 22:00-08:00 on weekdays, whereas Choi et al. (9) and Shin et al. (10) respectively reported that 76.7% and 88.6% of patients visited during 21:00-09:00 on weekdays and Saturdays. Since many disease-related patients seek PEC during night hours, the reduction in nocturnal PEC hours in the ED could greatly impact the accessibility and reliability of PEC. Compared to the relevant studies, this present study provides a more detailed analysis of disease-related visits to the ED based on the time of visit, offering a more nuanced understanding of the importance of PEC during these critical hours.
This study had the following limitations: First, the analysis of changes in ED utilization focused solely on the reduction in ED operating hours. In addition, to exclude potential factors such as the coronavirus disease 2019 pandemic, the study period was set at 6 months before and after the reduction in PEC hours. However, this approach might rather fail to reflect other factors such as seasonality, indicating the need for further research over the same period. Second, while changes in ED utilization may vary depending on hospital location, size, and the time of day when ED care is restricted, this study was conducted in a single provincial metropolitan ED and focused on a fixed reduction in hours of care from midnight to 8 a.m. Therefore, it may not be possible to extrapolate the findings to overall pediatric ED utilization, and further studies in other regions and with EDs of different sizes are warranted.
In summary, the reduction in PEC hours in the ED led to a decrease in the number of visits for both diseases and injuries. Notably, in the pediatric patients’visits, there was a more pronounced decrease in patients aged 4 years or younger. While there were no remarkable changes in the highacuity cases, there were reductions in both EDLOS and overall hospitalization. The results of this study indicate that PEC resources must be redistributed to ensure access for those aged 4 years or younger, even with the reduction of PEC hours due to a shortage of pediatricians. Similarly, patients with low-acuity cases should be diverted to primary care clinics or outpatient services during regular hours, thus allowing for more efficient care of those with high-acuity cases. Furthermore, it is necessary to consider additional measures, such as expanding the use of pediatric specialist-centered emergency practice (11). The findings of this study may provide strategies for the efficient allocation and optimization of PEC resources, which are expected to become increasingly limited.
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