Presenting patterns of dermatology conditions to an Australian emergency department

Emily Shao, Chantelle Judge, Erin McMeniman, Tina Bazianas, Rob Eley

1 Emergency Department, Princess Alexandra Hospital, Brisbane, Australia

2 Faculty of Medicine, University of Queensland, Brisbane, Australia

3 Dermatology Department, Princess Alexandra Hospital, Brisbane, Australia

KEY WORDS: Pcellulitis; Skin; Dermatology; Emergency department

INTRODUCTION

Around the world, up to 8% of emergency department(ED) presentations are reported to be due to a dermatology condition.[1]In Australia, this has been quoted as 2% at the Royal Adelaide Hospital[2]and 4% at St Vincent’s Hospital in Melbourne.[3]The majority of dermatology conditions do not require emergency medicine input.[1]

ED crowding is an ongoing issue and there is a need to identify ways to shift the appropriate (non-urgent presentations) patient load from the emergency setting to the subacute setting.[4]This would benefit both ED patients and health service outcomes, with improved patient flow, shorter waiting times, reduced length of stay, and a reduced strain on the health budget.[4]

There are no studies that characterise dermatologyrelated conditions that present to the ED in Queensland Australia. This study aimed to define the number of patients presenting to the ED with a dermatologyrelated condition, and to characterise the demographic and clinical information of these patients. A second aim was to identify low-acuity patients presenting to the ED with a dermatology-related condition and to investigate reasons why the ED was chosen for medical care.

METHODS

This study was conducted at the Princess Alexandra Hospital, a major Australian tertiary hospital in Queensland with all major medical and surgical specialities and sees over 60,000 ED presentations per year.

To address the first aim, information from the electronic medical records database (Emergency Department Information System, or EDIS and FirstNet)at the Princess Alexandra Hospital ED was collected.Data collected included sex, age, length of stay in the ED, time of arrival, Australasian Triage Scale (ATS)category, and discharge destination.

All ED presentations from January 1st 2012 to December 31st 2016 were screened for dermatologyrelated conditions. Patients were identified using a number of key words which were used to search their presenting complaint description and final diagnosis.Key words were based on previous Australian studies.[1,2]This search process also identified patients for whom a dermatological condition was incidental, or where a keyword used in the search process was identif ied in an unrelated free text or diagnosis. Diagnoses irrelevant to dermatology were then excluded, with ambiguous cases being discussed by the authors.

Descriptive statistics were provided for all variables collected. Differences between the dermatology population and the total ED population were analysed using means and t-test for continuous variables and cross tabulation with chi-square test for categorical variables.Significance was met at the P=0.05 level. All statistical testing was performed using SPSS Statistics 21 (IBM Solutions).

To address the second aim, patients presenting to the ED with dermatology-related complaints were prospectively surveyed over a three-month period (July-September 2018). Only ATS category 4 and 5 patients were selected as to represent a low acuity presentation group. The same inclusion criterion as the retrospective study was used. The survey aimed to identify reasons these patients presented to the emergency department for their condition, and were adapted from a paper by Masso et al.[5]Patients were consented and interviewed in the ED during their presentation or contacted by phone at a later date.

Ethics approval for the study was received from the hospital Human Research Ethics Committee (HREC/17/QPAH/139).

RESULTS

Retrospective

Over the period from January 1st 2012 to December 31st 2016, there were 281,718 presentations to the Princess Alexandra Hospital ED. Our screening of presenting complaint description and final diagnosis identified 38,081 records, and application of the exclusion criterion of not relevant diagnosis removed 26,320. This resulted in a total of 11,761 dermatologic presentations identified for final inclusion of analysis.This made up 4.2% of total ED presentations during that time period.

The most common presentations were cellulitis,abscess, rash unspecified, and ulcer. The average age of patients in the dermatology group was 47 years old.About 41.5% were female. Dermatology patients most commonly presented during the working day. There were some signif icant differences in presentations when compared to the general ED population. Dermatologyrelated presentations were more likely to arrive in summer, were more likely a lower triage category, and were more likely to be discharged from the ED (Table 1).

Of the dermatology conditions admitted to hospital,there was a signif icantly longer length of stay in ED, an increased age, and a higher likelihood of being male.There was a more urgent triage category presentation.The majority of patients being admitted had an infectious etiology.

Prospective

Of 214 participants approached, 100 patients were recruited into the study. Three quarters of presenting complaints were identified as being new. All but three of the patients did have a regular General Practitioner(GP) and two thirds had seen a health professional prior to coming to the ED. Urgency of the condition and lack of immediate access to their GP were the most common reasons for coming to the ED (Table 2).

DISCUSSION

This is the f irst paper to describe dermatology-related conditions presenting to an ED in Queensland, Australia.

The proportion of dermatology-related presentations in this study (4.2%) is higher than that of a tertiary hospital in South Australia where only 2% of presentations were dermatology-related.[2]It is also slightly higher than studies reported from other countries(Spain, Singapore, Korea, Canada and Portugal),where between 2.6% and 3.9% made up the proportion of presentations to ED.[6-10]However the result is comparable to another Australian tertiary hospital with 4% reported in St Vincent’s Hospital in Melbourne,Australia, and this study.[1]This is expected as the study in Melbourne Australia provided the basis for the search criteria used in this study.[1]

Table 1. Comparison of dermatology-related presentations and all ED presentations from 2012–2016, n (%)

Table 2. Characteristics of interviewed patients (n=100)

A number of f indings in this paper concur with results of previous studies. Cellulitis is commonly cited as one of the most common presentations which is consistent with our findings.[3,7,8]It should be noted that this could be over diagnosed, as there may be less familiarity with possible mimickers such as lipodermatosclerosis or contact dermatitis in the ED,[10]or the medical software used in EDs may not include these as input options for diagnosis. A retrospective study found that one third of 196 inpatient dermatology consults for cellulitis was instead a mimicker.[11]

Our study found the majority of patients presenting to the ED for a dermatological condition were male, which was similar to a Singaporean and Indian study.[9,12]While the reasons for this are likely multifactorial, one factor may be due to sex differences in immunity and response to infection. It is thought that women cope better with infectious diseases due to higher CD4 lymphocyte levels and higher propensity to develop a T-helper 1 response.[6]However the sex differential is not universally reported,as a study in Portugal reported that women made the majority of presentations to the ED for a dermatological condition.[10]

The seasonal variation found in this study is also reflected in the literature. A Korean study found that dermatology presentations peaked in summer. They propose that factors like humidity, UV, temperature,and immune function variation are the cause.[6]Summer was also the peak in dermatology conditions in Canada and the authors suggested that increased outdoor activities and insect bites could be related to this.[8]In the Korean and Canadian studies, the presentation rates varied widely with seasonal variation, up to doubling in number of presentations. As Brisbane has a sub-tropical climate, the extremes of weather are far less compared to temperate climates. This may be ref lected in the smaller amount of seasonal variation seen in the dermatology presentations in this study.

Factors associated with admission included increased age, longer length of stay, higher triage category; all factors that would be expected to be associated with a more critical illness requiring admission.[1]The admission rate of the Princess Alexandra Hospital dermatology-related conditions was 35%, which is considerably higher than that found by other studies. In Melbourne Australia, 20%of dermatology presentations were admitted (most commonly cellulitis, boils/furuncles/sinuses or nonspecif ic skin infection) and of these 12% were admitted under dermatology (most commonly psoriasis, eczema,and cellulitis).[1]Reasons for the high rate of admission in this this study may be due to the large proportion of infectious related complaints attending the ED, with cellulitis and abscess being the top two presentations.About 83% of admissions were for an infectious related presentation, with some reasons including for intravenous antibiotics or surgical incision and drainage.

The prospective survey found that most patients presenting with a low-acuity dermatology-related condition did indeed have a GP but the urgency of their condition and lack of immediate access to that GP prompted their visit, consistent with the literature in that poor GP accessibility has been associated with low acuity ED presentations.[13]For some patients, costs were a driver as there is no charge for ED presentations in a public hospital while GP visits may incur some out of pocket expenses.[1]Despite lack of access being an important contributor to low-acuity presentations, the prospective survey found that most patients presenting with a low-acuity dermatology condition were referred to the ED by a health professional.

The results of this study have implications for EDs in Australia, where ED crowding is an ongoing issue.This study found the majority of dermatology-related presentations are infectious, and it may be beneficial for EDs to employ a streamlined service for hospital in the home.[14]Hospital in the home services provide intravenous antibiotics for patients at half the cost as inpatient care, with a lower risk of delirium, functional decline, or admission to residential care.[14]Identifying patients in the ED who may benef it from this service may be able to reduce length of stay in the ED, reduce inpatient admissions from the ED, and improve ED crowding.

The Queensland government advertising campaign“Keep Emergency for emergencies” focused on behaviour change in the general public, encouraging patients to see a general practitioner for non-urgent conditions.[15]This study found that most patients presenting with low triage priority dermatology-related conditions attended the ED on advice of a health professional, or because their GP was unavailable.Further efforts to reduce ED crowding in Australia may need to support an increased practice scope among GPs as well as increased after-hours access.[16]

Limitations

This study aimed to capture all dermatologyrelated presentations and used a broad inclusion criteria(identifying 38,081 presentations) with more than half of these were excluded in the final analysis. There is a possibility of misclassification bias. However, as the percentage of proportion of dermatology-related ED presentations is comparable to other studies this is unlikely to be significant. The inclusion criteria were based on what previous Australian studies had included in their inclusion criteria which allows some comparability.[1,2]

Selection bias was present in the prospective survey.As our study did not have the funding for a translator,we were unable to include non-English speakers. A number of participants were contacted by phone, and thus patients who did not answer or did not have a listed phone number were unable to be included. A comparison with our retrospective study did not find any major differences in age distribution.

CONCLUSION

Dermatology-related presentations are common in EDs. Those that required inpatient medical care were likely to be infectious related and likely to be of a more acute triage. Even amongst low acuity triage groups, the majority of patients see a health professional before coming to the ED if available to them. As the majority of presentations requiring resources are infectious related, a streamlined hospital in the home service help reduce length of stay in EDs and in hospitals, and ultimately reduce the cost of these presentations to the healthcare system.ACKNOWLEDGEMENTS

We would like to acknowledge the Emergency Medicine Foundation for providing a grant that supported this research.

Funding:Emergency Medicine Foundation (EMSS-360R28-2017).

Ethical approval:Approval for the study was received from the hospital Human Research Ethics Committee (HREC/17/QPAH/139).

Conf icts of interest:Authors have no f inancial or other conf licts of interest related to this submission.

Contributors: ES wrote the manuscript with significant editing and input from CJ, EM, TB, and RE. ES and CJ did the data collection. ES and RE were involved in statistical analysis. RE provided oversight and conceptualised the study.