The severity classification in association with the time of visit to and the appropriateness of using a public ambulance for visiting the emergency department (ED) have not been thoroughly evaluated, and we aimed to evaluate these aspects.
In this descriptive research, we retrospectively reviewed and analyzed the medical records of patients who visited the ED of the B General Hospital, Seoul from January to December 2019.
Of the 54,297 patients who were included in the analysis, 34,629 (63.8%) and 14,065 (25.9%) visited the ED directly and through public ambulances, respectively; 10,328 (73.4%) patients who used public ambulances were discharged home. In the daytime and nighttime, 24,891 (45.8%) and 29,406 (54.2%), respectively, visited the ED. The mean length of ED stay (LoS) of emergency and non-emergency patients was 326 and 159 minutes, respectively, and of patients classified as Korean Triage and Acuity Scale levels 1 and 2 was 427 and 430 minutes, respectively, which was longer than the total of 236 minutes.
Patients who visited the ED using public ambulances constituted nearly 25% of all ED visits, and more than 70% of these patients were discharged home. Patients with high severity had a longer mean LoS, and daytime ED visits were characterized by higher numbers and severity of patients than nighttime ED visits.
In the emergency department (ED), it is important to classify the severity of injury or disease via a primary evaluation of the patient’s condition so that safe and timely treatment can be provided according to their clinical condition [
KTAS is a five-stage emergency patient classification system developed as a research project by the Ministry of Health and Welfare in 2012 by revising and supplementing it according to the situation in Korea based on CTAS [
Therefore, this study attempted to determine the percentage of patients who visited an ED using public ambulances, and b) their severity and length of ED stay (LoS). In addition, we would like to suggest an appropriate number of emergency medical personnel by grasping the LoS according to the severity and the number of visiting patients according to the time period.
This study is a descriptive research study that retrospectively reviewed and analyzed Electronic Medical Records (EMR) for patients who visited the ED of a general hospital in Seoul, Korea.
The emergency patient classification process using KTAS is divided into four stages [
The severity is divided into levels 1 to 5. Level 1 is a life-threatening situation that requires active treatment and corresponds to patients who need immediate medical attention. Level 2 refers to a situation where there is a potential threat to life and requires quick treatment according to a doctor or medical instruction, and it is a principle that a doctor treats within 15 minutes. Level 3 refers to a condition that has the potential to progress to a serious problem requiring first aid and requires a doctor to treat it within 30 minutes. Level 4 refers to a condition that can be treated or re-evaluated within an hour or two when considering the patient’s age, pain, and the likelihood of deterioration. It is a principle that a doctor treats within 60 minutes. And Level 5 refers to a condition that is acute but not urgent (e.g. a light wound, medication, etc.) or is considered to be part of a chronic problem that has deteriorated or remains unchanged, and in principle is to be treated by a physician within 120 minutes [
This study was conducted on patients who visited the ED of the B general hospital in Seoul for one year from January to December 2019, and excluded this study when the data needed for statistical analysis were insufficient or inaccurate. Finally, a total of 54,297 patients were included in the study.
The collection of study data was approved by the Institutional Review Board of B general hospital to which the researcher belongs, and the Medical Information Center was requested to provide the data with personal information in accordance with the form of the evidentiary records. We collected the EMR of patients who had visited the ED during the period corresponding to the study and excluded them if details in the EMR that were needed for statistical analysis were missing or insufficient. The data collected included age, sex, ED time of visits, mode of arrival, visiting type, medical results, LoS, and initial severity classification results. In the classification of disease and trauma, if there is a clear history of trauma, it is classified as trauma, otherwise it is classified as a disease.
This study was approved by the B Medical Center Institutional Review Board. The collected data were used for research purposes only and will be managed and destroyed in accordance with management standards and related laws.
The collected data were analyzed using SPSS for Windows (version 26; Chicago, Illinois) software. Descriptive analyses were used to report frequencies and percentages for categorical variables and the mean ± standard deviation for continuous variables. A Chi-square test and Fisher’s exact test were conducted to confirm the KTAS classification results and disposition while in the ED according to the modes of ED visit and duty hours. An independent t test was used to compare the mean LoS according to KTAS classification and was considered statistically significant at
The total number of patients included in this study was 54,297, and 26,996 (49.7%) were women <
General characteristics of study subjects
Characteristics | Categories | n (%) or mean (SD |
---|---|---|
Gender | Male | 26,996 (49.7) |
Female | 27,301 (50.3) | |
Age | All | 54,297 (100.0) |
0~5 | 5,725 (10.5) | |
0~14 | 8,262 (15.2) | |
0~17 | 8,942 (16.5) | |
18~64 | 28,729 (52.9) | |
65~ | 16,626 (30.6) | |
Length of ED |
236.7 (318.0) | |
Visiting time 1 | Day (09:00~18:00) | 24,891 (45.8) |
Night (18:01~next day 08:59) | 29,406 (54.2) | |
Visiting time 2 | Day (07:00~14:59) | 20,508 (37.8) |
Evening (15:00~10:29) | 20,802 (38.3) | |
Night (10:30~next day 06:59) | 12,987 (23.9) | |
Mode of arrival | Direct visit | 34,629 (63.8) |
Public ambulances | 14,065 (25.9) | |
Via OPD |
1,558 (2.9) | |
Referred-in | 3,712 (6.8) | |
Etc. | 333 (0.6) | |
Visiting type | Disease | 42,336 (78.0) |
Accident | 11,957 (22.0) | |
Medical results | Discharged home | 43,029 (79.2) |
Referred-out | 915 (1.7) | |
Hospitalized | 10,017 (18.4) | |
Dead (include DOA |
263 (0.5) | |
Disappear (Escape) | 73 (0.1) | |
Initial KTAS |
KTAS level 1 | 919 (1.7) |
KTAS level 2 | 5,236 (9.6) | |
KTAS level 3 | 19,098 (35.2) | |
KTAS level 4 | 24,756 (45.6) | |
KTAS level 5 | 4,298 (7.9) | |
Emergency vs. non-emergency | Initial KTAS level 1, 2, and 3 | 25,243 (46.5) |
Initial KTAS level 4 and 5 | 29,054 (53.5) |
SD=standard deviation;
ED=emergency department;
OPD=out-patient department;
KTAS=Korean triage and acuity scale;
DOA=deathonarrival
<
Results of KTAS
Mode of arrival | Initial KTAS, n (%) ( |
|||||
---|---|---|---|---|---|---|
Level 1 | Level 2 | Level 3 | Level 4 | Level 5 | Total | |
Direct visit | 10 (0.0) | 1,078 (2.0) | 9,991 (18.4) | 19,846 (36.6) | 3,704 (6.8) | 34,629 (63.8) |
Public ambulances | 781 (1.4) | 3,386 (6.2) | 6,277 (11.6) | 3,258 (6.0) | 363 (0.7) | 14,065 (25.9) |
OPD |
14 (0.0) | 170 (0.3) | 828 (1.5) | 430 (0.8) | 116 (0.2) | 1,558 (2.9) |
Referred-in | 87 (0.2) | 568 (1.0) | 1,835 (3.4) | 1,114 (2.1) | 108 (0.2) | 3,712 (6.8) |
Etc. | 27 (0.0) | 34 (0.1) | 159 (0.3) | 106 (0.2) | 7 (0.0) | 333 (0.6) |
Total | 919 (1.7) | 5,236 (9.6) | 19,090 (35.2) | 24,754 (45.6) | 4,298 (7.9) | 54,297 (100.0) |
Direct visit | 29,881 (55.0) | 387 (0.7) | 4,287 (7.9) | 20 (0.0) | 54 (0.1) | 34,629 (63.8) |
Public ambulances | 10,328 (19.0) | 331 (0.6) | 3,176 (5.8) | 214 (0.4) | 16 (0.0) | 14,065 (25.9) |
OPD | 811 (1.5) | 13 (0.0) | 731 (1.3) | 1 (0.0) | 2 (0.0) | 1,558 (2.9) |
Referred-in | 1,785 (3.3) | 174 (0.3) | 1,744 (3.2) | 8 (0.0) | 1 (0.0) | 3,712 (6.8) |
Etc. | 224 (0.4) | 10 (0.0) | 79 (0.1) | 20 (0.0) | 0 (0.0) | 333 (0.6) |
Total | 43,029 (79.2) | 915 (1.7) | 10,017 (18.4) | 263 (0.5) | 73 (0.1) | 54,297 (100.0) |
KTAS=Korean triage and acuity scale;
OPD=out-patient department
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Length of ED
Visiting time | LoS |
Initial KTAS, n (%) (p<.001) | |||||
---|---|---|---|---|---|---|---|
Level 1 | Level 2 | Level 3 | Level 4 | Level 5 | Total | ||
Day (09:00~18:00) | 275.1 (367.3) | 465 (0.9) | 2,702 (5.0) | 9,271 (17.1) | 10,699 (19.7) | 1,754 (3.2) | 24,891 (45.8) |
Night (18:00~09:00) | 204.2 (265.0) | 454 (0.8) | 2,534 (4.7) | 9,819 (18.1) | 14,055 (25.9) | 2,544 (4.7) | 29,406 (54.2) |
Total | 236.7 (318.0) | 919 (1.7) | 5,236 (9.7) | 19,090 (35.2) | 24,754 (45.6) | 4,298 (7.9) | 54,297 (100) |
Day (07:00~14:59) | 276.8 (352.3) | 396 (0.7) | 2,280 (4.2) | 7,690 (14.2) | 8,717 (16.1) | 1,425 (2.6) | 20,508 (37.8) |
Evening (15:00~22:29) | 222.8 (316.4) | 334 (0.6) | 1,914 (3.5) | 7,059 (13.0) | 9,770 (18.0) | 1,725 (3.2) | 20,802 (38.3) |
Night (22:30~next day 06:59) | 195.8 (248 .7) | 189 (0.3) | 1,042 (1.9) | 4,341 (8.0) | 6,267 (11.5) | 1,148 (2.1) | 12,987 (23.9) |
Total | 236.7 (318.0) | 919 (1.7) | 5,236 (9.6) | 19,090 (35.2) | 24,754 (45.6) | 4,298 (7.9) | 54,297 (100) |
ED= emergency department;
KTAS=Korean triage and acuity scale;
LoS=length of emergency department stay;
SD=standard deviation
In addition, looking at the results of the initial KTAS and LoS according to nursing staff shift time, 20,508 (37.8%) patients visited from 07:00 to 15:00 with a LoS of 276.75 minutes. The number of patients who visited from 15:00 to 22:30 was 20,802 (38.3%), with a LoS of 222.83minutes. From 22:30 to 07:00 the following day, 12,987 (23.9%) visited with a LoS of 195.82 minutes. The results of the initial KTAS classification of patients who visited from 07:00 to 15:00 showed that levels 1, 2, 3, 4, and 5 were 396 (0.7%); 2,280 (4.2%); 7,690 (14.2%); 8,717 (16.1%); and 1,425 (2.6%), respectively. The results of the initial KTAS classification of patients who visited between 15:00 and 22:30 showed that levels 1, 2, 3, 4, and 5 were 334 (0.6%); 1,914 (3.5%); 7,059 (13.0%); 9,770 (18.0%); and 1,7 25 (3.2%), respectively. Finally, the results of initial KTAS classification of patients who visited the ED from 22:30 to 07:00 the following day showed that levels 1, 2, 3, 4, and 5 were 189 (0.3%); 1,042 (1.9%); 4,341 (8.0%); 6,267 (8.50%); and 1,148 (2.1%), respectively (
The number of patients classified as emergency KTAS levels 1, 2, and 3 was 25,243 (46.5%), and the mean LoS was 326.02 minutes. Conversely, non-emergency KTAS levels 4 and 5 showed 29,054 (53.5%) with a mean LoS of 159.16 minutes, statistically significantly shorter than emergency (t=60.640,
Comparison of Length of ED
Emergency vs. non-emergency | N | mean (SD |
t | |
---|---|---|---|---|
KTAS 1, 2, 3 (emergency) | 25,243 | 326.0 (394.8) | 60.64 | <.001 |
KTAS 4, 5 (non-emergency) | 29,054 | 159.2 (201.5) |
ED=emergency department;
KTAS=Korean triage and acuity scale;
SD=standard deviation
According to the initial KTAS classification results, KTAS levels 1, 2, 3, 4, and 5 were 919 (1.7%); 5,236 (9.6%); 19,090 (35.2%); 24,754 (45.6%); and 4,398 (7.9%), respectively; and LoS were 427, 403, 293, 165, and 124 m, respectively <
Average length of ED stay according to KTAS level.
Although the number of patients corresponding to KTAS level 1 and 2 was small, the length of stay in the emergency department was the longest. The number of patients corresponding to KTAS level 4, which is a non-emergency symptom, was found to be the largest, and the residence time in the emergency department was relatively short.
In this study, we analyzed around 55,000 patients who visited an ED over a period of one year three years after the start of severity classification using KTAS. Based on the results obtained through this study, we will discuss how to improve the emergency medical system and how to properly operate emergency medical personnel in order to create a safer and more efficient ED.
In this study, patients using public ambulance when visiting the ED accounted for 25.9% of all patients. The results were similar to the results of other domestic studies, which showed approximately 26% [
In addition, the severity of patients using a public ambulance was relatively higher than those who visited the hospital directly by walk-in or private vehicles. In examining the severity of patients using public ambulance, the results of this study indicate that patients classified as KTAS 1, 2, and 3 corresponding to emergencies accounted for around 70% of all those using public ambulance. These results are similar to those of several studies [
In this study, we compared the number of patients visiting the ED and the KTAS level of severity according to the time of visit, divided into working hours (09:00-17:59) and after hours (18:00-08:59), as well as nurse shift hours of daytime (07:00-14:59), evening (15:00-22:29), and nighttime (22:30-06:59), to determine the number and severity of patients at the time of visit. The results show that the number of patients visiting during working hours and after hours was almost the same, but more patients classified at KTAS levels 4 and 5 (non-emergency) visited after hours. In addition, the LoS based on the time of visit was found to be shorter during working hours than outside the normal time. Based on nurse shift hours, daytime had the largest number of patients, followed by evening and nighttime. The severity of the patients and the LoS were also the highest in the daytime, followed by evening and nighttime. These results differ from the number of patients who visited in the evening in study [
Furthermore, our study found that the proportion of patients classified as non-emergency (KTAS level 4 and 5) was higher at nighttime than daytime. The study by [
One of the best ways to address ED overcrowding is to shorten LoS [
This study has several limitations. First, the data included in the analysis of this study consisted of patients who visited the ED in a single general hospital, and it is thus difficult to generalize the results. Second, public ambulances in Korea are operated by the state and are free to use. Also, the cost of using the emergency room is cheaper than in the US or other European countries. Therefore, our results may differ from those of other US or European countries in the emergency medical system. Finally, the results of KTAS severity classification may be different because the nurse’s clinical experience, knowledge, and results of numeric rating scale that evaluate the pain intensity of patients are different.
We found that about 25% of patients visited to the ED using public ambulances, more than 25% of them were classified as non-emergency. We also found that more than 70% of patients who visited the ED using public ambulances returned home without being admitted to the ED. These results can increase the mean LoS of the ED, which can result in overcrowding. In order to provide emergency patients with public ambulances, it is necessary to supplement the system by raising public awareness of the problems caused by non-emergency use of public ambulances. In addition, we found that the higher the severity of the patients, the longer the mean LoS, and the more patients visited at nighttime, the higher the severity. Depending on the number of patients and severity, appropriate medical personnel are required. In future research, it will be necessary to study how to reduce the use of public ambulance for non-emergency patients and to suggest a way to reduce LoS for patients with high severity.