PEDIATRICS Vol. 111 No. 6 June 2003, pp. 1268-1272
Adult Patient Visits to Children’s Hospital Emergency Departments
Florence T. Bourgeois, MD* and
Michael W. Shannon, MD, MPH
* Department of Medicine
Division of Emergency Medicine, Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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ABSTRACT
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Background. Adults frequently seek medical services in children’s hospital emergency departments (CHEDs), and are required to be admitted to CHEDs under the provisions of the Emergency Medical Transfer and Active Labor Act (EMTALA), which requires medical evaluation and stabilization of every patient who presents to an emergency department. In recent years visits by adults to CHEDs appear to have increased.
Objective. There were 3 objectives to the current study: 1) to examine secular trends in the number of adult patients visiting CHEDs, 2) to determine if perceived increases are related to the implementation of EMTALA, and 3) to examine the characteristics, evaluation, and disposition of adult patients presenting for first-time visits to a CHED.
Methods. A database of all visits to an urban CHED between 1992 and 2002 was queried to collect information on adult patients (22 years or older). New adult patients were identified based on the assignment of new medical record numbers. The medical records of all adult patients presenting during the 1-year interval before and after the institution’s full implementation of EMTALA were reviewed and relevant data collected.
Results. Over the study period, there were 501 033 patient visits to the CHED. Of these, 5512 (1.1%) were by adult patients, which included 536 (9.7%) new adult patients. Using the 
2, test we found a significant increase in the total number of adult visits and the number of new adult visits, particularly after the implementation of EMTALA. The mean age of the new adult patients was 34.9 ± 11.9 years. Their most frequent chief complaints were injuries (24.4%), cardiac-related problems (7.6%), and syncope (6.7%). A total of 427 (79.7%) of the new adult patients were treated and released, 81 (15.1%) were transferred to an outside hospital for additional care, and 15 (2.8%) were admitted to our hospital. There were no significant differences between the new adult populations in 1997 and 1999. Comparing new and established adult populations in 1999, the population of new adults was significantly older (28.1 ± 6.8 vs 34.9 ± 11.9 years) and more likely to present with injuries or syncopal episodes. Among the total cohort of new adult patients in the study, chest pain also occurred at a significantly higher rate compared with established adults (6.7% vs 3.8%).
Conclusions. Adult visits to CHEDs appear to be increasing in frequency in association with the implementation of EMTALA regulations. It is therefore essential that physicians staffing CHEDs be properly trained in the stabilization of common adult medical emergencies. We recommend that the language of EMTALA be revised to allow adult patients with nonemergent problems to be directly referred to adult emergency departments, which are more appropriate than CHEDs.
Key Words: children’s hospital emergency departments • adult patients • EMTALA
Abbreviations: ED, emergency department • EMTALA, Emergency Medical Treatment and Active Labor Act • CHED, children’s hospital emergency department
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INTRODUCTION
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In the mid-1980s there was growing concern over the treatment of indigent patients in emergency departments (EDs). Several published studies at the time showed that uninsured patients were increasingly being denied treatment and transferred from private to public hospitals because of their inability to pay for the care rendered.1–3 In addition, patients were frequently transferred with unstable medical conditions and without their informed consent.1,2 In response to this escalating problem, the US government enacted the Emergency Medical Treatment and Active Labor Act (EMTALA).4 This statute mandates that every patient who presents to an emergency department and requests treatment must receive a medical screening examination to determine if an emergency medical condition exists. If such a condition exists, the patient must be appropriately treated until he is stabilized, and can only be transferred if certain provisions are met.
The Congressional Record confirms that the intent of Congress in enacting EMTALA was to prevent EDs from discriminating against patients unable to pay for their treatment.5 However, the law makes no specific reference to indigent or uninsured patients, and instead, refers to "any individual [who] comes... to the emergency department."4 This has significant implications for the EDs of freestanding children’s hospitals, which do not have designated facilities or staff for adult patients. There are currently an estimated 87 freestanding children’s hospitals in the United States (personal communication, American Hospital Association, October 2002). Under EMTALA, all adult patients who present to these children’s hospital emergency departments (CHEDs) must be examined and stabilized by the pediatric emergency medical staff.
The presentation of adult patients to pediatric EDs is a frequent event, which has been described in several hospitals.6,7 Our CHED has historically also treated a significant number of established adult patients.8 EMTALA was fully implemented in our CHED in 1998 when the US Department of Health and Human Services began strict enforcement of the law.9 Since then, there has been a perception that the number of new adult patients receiving treatment is increasing. We sought to further analyze this perception, characterize any temporal increase in the number of adult visits, and determine if changes in adult volume are related to the implementation of EMTALA. Secondary objectives were to analyze the chief complaint, evaluation, and outcome of adult patients presenting for first-time visits to the CHED.
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METHODS
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An electronic database of all patient visits to the Emergency Department of Children’s Hospital, Boston, between June 1, 1992, and May 31, 2002, was queried for this study. The database was used to identify all visits by adults, defined as patients 22 years of age or older. Information available in this database included patient name, age, medical record number, date and time of visit, chief complaint, and disposition. The chief complaint was entered at the time of registration as a numeric code. Adult patients never previously seen in our hospital were identified based on the assignment of new medical record numbers.
The medical records of all adult patients seen in calendar years 1997 and 1999 were reviewed in detail with data collected using a standard coding form. These 2 years were chosen to analyze the visits of new adult patients both before and after the implementation of EMTALA, which became fully implemented in our CHED in January 1998. Data abstracted included demographic information, mode of arrival, presenting problem, and past medical history, including encounter history at this hospital. We also recorded data for the diagnostic evaluation and interventions performed in the ED, diagnosis, and final disposition. As a control group, 100 pediatric patients were randomly selected from the 1997 and 1999 dataset; their charts were reviewed with the same data collected as with the adult patients.
Several measures were taken to ensure the data’s completeness and integrity. The original database was verified against 2 separate electronic records of patient visits to our ED. Any inconsistencies between the 2 records were examined and appropriate adjustments made to the database. A single reviewer performed the coding of data from the medical records to eliminate potential variability between reviewers. We tested for single reviewer bias by comparing the data collected for the 100 pediatric patients in 1997 and in 1999. There were no statistically significant differences between these 2 patient groups for any of the data points studied, suggesting that the data collection was consistent and accurate.
Statistical analysis was performed using the 2-tailed Student t test with continuous variables and the 2 test for proportions or categorical variables. The 2 test was used to analyze the changes in the number of adult patient visits over time, using the number of adult patients and the total number of patient visits during each calendar year. A P < .01 was considered significant. Data are expressed as mean ± standard deviation. All data entry and analysis were performed using the Statistical Package for Social Sciences, Version 7.5 (SPSS, Inc, Chicago, IL).
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RESULTS
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Over the study period, there were 501 033 patient visits to our CHED. Of these, 5512 (1.1%) were by adult patients. A total of 536 (9.7%) of the adult visits were by new patients never previously treated at our hospital.
There was a significant increase in the frequency of visits by adult patients over the study period (Fig 1). In 1993, a total of 443 adult patients were treated in our CHED, compared with 737 in 2001. The total number of patient visits remained relatively stable over the study period (49 397 in 1993 and 52 630 in 2001), and this represents a significant increase (P < .001). The frequency of visits by adult patients began to rise after 1998, the year EMTALA was implemented in our CHED. In 1997, 498 adult patients were seen. This number increased by 16.5% to 580 in 1999 (P = .08), by 44.4% to 719 in 2000 (P < .001), and by 48.0% to 737 in 2001 (P < .001).
These increases in the adult population correlate with a consistent increase in the presentation of new adult patients. Figure 2 illustrates the number of adults who presented with first-time visits in the years 1993 through 2001, demonstrating a sharp rise after 1998. The number of new adult patients seen in the years 1993 through 1998 ranged from 19 to 26, and then increased to 92 in 1999, 138 in 2000, and 113 in 2001 (P < .001 for all 3 years compared with 1997).
The population of new adult patients encountered over the study period was specifically examined. The age range for these new adult patients was 22 to 86 years with a mean age of 34.9 ± 11.9 years. Table 1 demonstrates the age distribution of the new adult patients compared with adults who were established patients at our hospital. Among the established adult patients, the mean age was 27.5 ± 6.4 years, which is significantly less than the mean age of the new adult patients (P < .001). Only 79 (1.6%) of the established patients were >40 years of age, compared with 145 (27.0%) of the new adult patients (P < .001). The most frequent chief complaints for the new adult patients were injuries (131; 24.4%), cardiac-related problems (41; 7.6%), and syncope (36; 6.7%). Among the new adult patients, 427 (79.7%) were treated and released, 81 (15.1%) were transferred to an outside hospital for additional care, and 15 (2.8%) were admitted to our hospital.
Table 2 compares visits by new adult patients in 1997 and in 1999. These data indicate that there were no significant differences in the presentation of the new adult populations in these 2 years. Intergroup comparisons were not statistically significant for any of the data points examined. The average ages of the patient populations were 33.7 ± 10.0 years in 1997 and 35.3 ± 11.5 years in 1999. The most common presenting problem among both adult groups was injury related to trauma, including motor vehicle crashes. The most common mode of arrival was the patient’s own transportation, with only 1 new adult patient arriving via ambulance. In both 1997 and 1999 more than one third of the new adult patients were either hospital employees or visitors who were on hospital premises when their medical condition arose. Related to this is the finding that a large proportion of the new adult populations had no chronic medical problems (72.7% and 58.7% in 1997 and 1999, respectively). The clinical evaluations conducted were similar for both adult groups and included frequent electrocardiograms with 18.2% of the adults in 1997 requiring this evaluation and 20.7% in 1999. None of the new adult patients were admitted to our hospital and the majority of the patients were treated and sent home. A total of 27.3% of the new adults presenting in 1997 and 26.1% in 1999 were transferred to an outside facility for additional care.
We compared the cohort of 92 adult patients presenting for first-time visits in 1999 to the group of established adult patients seen in the same year (Table 3). The mean age of the new adult patients was 35.3 ± 11.5 years, which was significantly greater than the mean age of 28.1 ± 6.8 years for the established adult patients (P < .001). The most common chief complaints for the new adult patients were acute medical problems including injuries, chest pain, and syncopal episodes. The frequency of both injuries and syncopal episodes was significantly greater among the new adult patients when compared with established adults (P < .001), while the increase in the frequency of chest pain was not statistically significant (P = .46). However, when we performed the same analysis on the total number of new and established adult patients in the study, we found that of the 536 new adults, 36 (6.7%) presented with chest pain, while 187 (3.8%) of the 4976 established adults presented with this chief complaint. This represents a significant increase in the frequency of chest pain among new adult patients (P < .001). The modes of arrival were also significantly different between the new and established adult groups. In particular, a total of 38.0% of the new adult patients were on hospital premises at the time they sought medical care compared with 3.9% of the established adults (P < .001). The population of new adult patients was healthier with only 41.2% of patients reporting a significant past medical history as compared with 85.7% of the established adult patients (P < .001). Consequently, the clinical evaluation was more extensive for the established adult patients with the exception of electrocardiograms. New adult patients were more likely to be treated and sent home (71.7% vs 58.6%; P = .02) or transferred to an adult facility for additional care (26.1% vs 4.3%; P < .001) when compared with established adults.
To increase the statistical power of our analysis, we pooled all adult patients for 1997 and 1999. Several intergroup differences became more significant. The chief complaint of chest pain occurred in 8.8% (10/114) of the new adults compared with 4.1% (40/964) of the established patients (P = .03), and electrocardiograms were performed in 20.2% (23/114) of the new patients and only 12.1% (117/964) of the established adults (P = .02).
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DISCUSSION
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For many individuals, the ED serves as the only available access to the health care system. This accessibility is protected by EMTALA, making emergency medical care the only health care guaranteed by federal law.10 One of the greatest barriers to health care has historically been lack of insurance,11 and the number of uninsured US residents continues to rise. It is estimated that >42 million individuals lack health insurance,12 and in 1998 alone, a total of 16.3 million ED visits were by uninsured patients.13 As a result, EMTALA has emerged as one of the most important federal health care programs for uninsured patients.13
One of the unintended consequences of EMTALA appears to be its effect on CHEDs. Over the past 10 years there has been a dramatic rise in the number of adult patients seen in our CHED. This increase was most pronounced after the provisions of EMTALA were fully implemented. Since that time, adult patients who were previously referred without evaluation to one of the neighboring adult care hospitals have been admitted and treated by the pediatric emergency medical staff.
A large number of the adult patients who presented were patients with chronic illnesses who are followed in subspecialty clinics at Children’s Hospital for conditions such as congenital heart disease or cystic fibrosis. Over the last 4 years, however, we have seen an increasing number of adult patients presenting for first-time visits. These are healthy adults who have experienced an acute medical problem such as an injury from a motor vehicle crash or chest pain, problems commonly seen in adult clinical practice. A certain number of these adult patients received comprehensive evaluations and treatment in our CHED, while others were evaluated and stabilized before being transferred to an adult facility. The decision to provide treatment and not transfer an adult patient was made by the clinical ED staff caring for the patient.
It is necessary for CHEDs to be prepared to evaluate and stabilize adult patients presenting with medical emergencies. Our children’s hospital already has a large number of adult patients who are followed in subspecialty programs. Now there are additionally an increasing number of adults who are presenting for first-time visits. Fellows in pediatric emergency medicine and pediatric house officers make up the majority of the clinical ED staff, as is common in many CHEDs. Pediatric emergency medicine fellowships require at least 4 months training in general emergency medicine. However, there are no specific recommendations on the extent, quality, or goals of training in general emergency medicine for these fellows.14 Pediatric resident training programs do not have requirements or even guidelines for the training of pediatric residents in the initial management and stabilization of common adult emergencies. This potentially represents a significant deficit in pediatric residency training.
Even with all efforts to properly manage adults in pediatric emergency departments, many adults would still be better served receiving their care in adult hospitals. EMTALA should be changed to specifically prohibit the denial of care to patients because they are uninsured or unable to pay for their care. Adult patients presenting with nonemergent medical problems to CHEDs could then be identified with a rapid screening system and be directly referred to a nearby adult facility. Adults presenting with a medical problem requiring immediate intervention would continue to be appropriately treated and stabilized before transfer.
There are several limitations to the current study, which must be considered in interpreting our findings. First, the study is retrospective in nature, although we believe all data were complete and robust. Second, we only examined patient visits at 1 CHED. It may not be possible to generalize our findings and experience to all freestanding CHEDs. However, adult patient visits have been described in at least 3 other CHEDs6,15 and based on similar descriptions of this patient population, we believe that this is a growing issue in all CHEDs. Finally, among the adult patients transferred to other facilities, we do not have information on their outcome, leaving some of our descriptions of adult visits incomplete.
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CONCLUSIONS
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CHEDs have experienced a significant increase in the number of visits by adult patients, and now must be prepared to evaluate and stabilize adults who present with medical emergencies. This requires appropriate training of both fellows in pediatric emergency medicine and pediatric house officers in the initial management and stabilization of common adult problems. The rise in adult patients receiving care in CHEDs has been in part a result of EMTALA. This has been an unintended consequence of a law enacted to prevent EDs from denying care to patients unable to pay for medical services. We recommend that EMTALA be modified to enable adult patients presenting to CHEDs with nonemergent problems (as determined by a rapid screening system performed on patient arrival) to be directly referred to adult facilities, which are better equipped to provide comprehensive care to adult patients.
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ACKNOWLEDGMENTS
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We thank Marianne Lawlor for her assistance in data quality control and quality assurance.
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FOOTNOTES
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Received for publication Jul 8, 2002; Accepted Nov 12, 2002.
Reprint requests to (F.T.B.) Department of Medicine, Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: florence.bourgeois{at}tch.harvard.edu
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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ABSTRACT
INTRODUCTION
