Otorhinolaryngology emergency unit care: The experience of a large university hospital in Italy.

Abstract

We recorded the symptoms and disposition of every patient who visited the otorhinolaryngology emergency department at our hospital in Rome, Italy, during 1996. During that time, our ENT specialists saw 21,548 patients. Only 311 of these patients (1.4%) required immediate hospitalization, while another 2,391 patients (11.1%) received treatment and were released. The other 18,846 patients (87.5%) did not have any pathology or condition that qualified as an actual emergency, and they were examined and released, often with a prescription or instructions for home care. These patients could have easily been treated by a family physician.

The fact that emergency care in Italy is rendered free of charge (unlike ambulatory care, for which fees are charged) provides patients with a strong incentive to misuse the system. Such overutilization drives up the cost of health care and stretches the capacity of the medical staff. Steps need to be taken to redirect patients who misuse emergency services to seek medical care in ambulatory care centers.

Introduction

The disposition of emergencies in general surgery wards and their influence on staff workloads have been previously described. [1-3] According to the Royal College of Surgeons of England (RCSE), 30 to 50% of admissions to general surgery wards are the result of emergencies. [4] Very little has been written about the use of emergency services in otorhinolaryngology. The RCSE has calculated that fewer than 10% of admissions to otorhinolaryngology wards are the result of an emergency. [5] Studies show that approximately 35% of patients who were admitted to general surgery wards following an emergency were there only for observation; many of these patients had experienced a concussion. [3,6] The ENT emergency that most often requires surgery is the lodging of a foreign body in the upper aerodigestive tract. [7] Other emergencies that can require immediate surgery are severe epistaxis, hemorrhage following tonsillectomy, complications of orbital sinusitis, acute mastoiditis, and deep neck space infection.

This study was undertaken to analyze the use of services in a specialized ENT emergency department at La Sapienza University Hospital in Rome, which is the largest hospital in the city. At this hospital, as in all the hospitals in the region, emergency care is rendered free of charge to the patient, while ambulatory care is not.

Materials and methods

The Otorhinolaryngology Institute at the Umberto I Policlinico in Rome consists of two inpatient wards totalling 48 beds; a "day hospital" ward with 12 beds; a department offering services in speech (phoniatry), rhinoallergology, and audiovestibology; three operating theaters that are open 5 days per week; and an emergency department (the ENT Casualty Centre).

The ENT Casualty Centre is an autonomous service run by an independent staff. At the time of this study, the staff included a chief physician, four senior ENT surgeons, and four clinical assistants. The ENT Casualty Centre is open to all persons 24 hours a day, 7 days a week. It is frequented not only by patients who are sent from the General Casualty Centre and the Pediatric Casualty Centre, but by patients who present without any referral from a physician. Patients are not charged for these emergency services.

We recorded the disposition of all patients who came to the Otorhinolaryngology Institute between Jan. 1 and Dec.31, 1996. Patients were categorized according to the diagnosis and treatment each received. A distinction was made between patients who received medical or surgical treatment (e.g., nasal packing, incision of abscesses, suturing of wounds, etc.) directly at the ENT Casualty Centre and those who had to be admitted to the ENT ward of the hospital for further tests or procedures.

Results

During the 366 days from Jan. 1 through Dec. 31, 1996, 21,548 patients were examined at the ENT Casualty Centre, an average of 59 patients per day. Most came during daylight hours: 6% between midnight and 8 a.m., 35% between 8 a.m. and 2 p.m., 38% and between 2 p.m. and 8 p.m., and 21% between 8 p.m. and midnight (figure).

Patients were placed in one of three categories: hospitalized, treated and released, or examined and released (table 1). Only 311 of the 21,548 patients (1.4%) required hospitalization, while another 2,391 patients (11.1%) required some treatment before they were released. The other 18,846 patients (87.5%) did not have any pathology or condition that qualified as an actual emergency, and they were examined and released, often with a prescription or instructions for home care.

Hospitalized. The most common condition that required hospitalization was fracture of the nasal bone, a condition experienced by 81 of the 311 patients (26%) who were admitted (table 2). At some ENT emergency departments in Italy, these cases are treated with local anesthesia and surgery on the spot, and patients are not admitted. We prefer to perform such a correction with general anesthesia, and our patients have at most a 2-day hospital stay. We also saw 1,014 other patients who had experienced trauma to the nasal pyramid, but hospitalization was not deemed necessary either because the fracture lines could not be seen on x-ray or because the x-ray showed no signs of a medial shift of the nasal bone, even where there was discontinuity of the bone, which otherwise is a clear indication of the need to operate. These patients were sent home with frontal nasal packing and instructed to return for a followup examination 5 days later.

We also admitted 61 patients (19.6%) who had experienced vertigo. These patients underwent tests to detect neurologic or vestibular pathologies. They were kept under observation for several days before being given specific medical treatment. Another 40 patients (12.9%) who experienced acute laryngeal dyspnea were immediately taken to the operating theater, where they underwent an emergency tracheostomy. Once their risk of acute respiratory failure had been eliminated, we proceeded to consider which therapy should be adopted to treat their underlying pathology. Most of these underlying causes were laryngeal or tracheolaryngeal stenoses, which were caused either by a caustic substance, by a growing laryngeal neoplasm, or as a result of scarring from previous operations.

A foreign body in the esophagus necessitated the hospitalization of 21 patients (6.8%) for esophagoscopic removal. Another 32 patients who presented with a complaint of an esophageal foreign body did not require hospitalization. In fact, some of these 32 patients had actually experienced globus hystericus, while others had either expelled or swallowed the foreign body, which resulted in a negative esophagoscopic examination.

Treated and released. A total of 2,391 patients required some treatment or testing before they were sent home (table 3). In particular, 1,108 patients (46.3%) underwent frontal nasal packing for epistaxis, and 44 (1.8%) underwent back nasal packing. Another 422 patients (17.6%) were sent to the audiology service for an urgent audiometric examination to identify any cases of sudden hypoacusis that required immediate treatment, either medically or with hyperbaric oxygen therapy. We also recorded 585 cases that required the removal of foreign bodies: 275 patients (11.5%) had a foreign body in the oropharynx, 183 (7.7%) in the external ear, and 127 (5.3%), mostly infants, in the nose.

Examined and released. A total of 18,846 patients were examined and released (table 4). The most common pathologies were acute otitis media (n = 4,291 [22.8%]) and acute otitis externa (n = 3,175 [16.8%]). A significant number of patients (n = 1,846 [9.8%]) came to the ENT Casualty Centre because they had a plug of wax in the ear; they were sent to the medical center to have it removed. The ENT clinical examination was negative in 1,571 patients (8.3%).

A significant number of patients presented with minor pathologies, including pharyngitis (7.7%), tonsillitis (5.2%), laryngitis (1.2%), inflammatory or allergic rhinitis (0.8%), and sinusitis (0.7%). The rather high incidence of these minor pathologies in an emergency setting illustrates the extent of the desire of these patients to avoid long waits and the payment of fees in ambulatory care centers.

Discussion

The range of conditions seen at the ENT Casualty Centre was wide. Many of these visits were referrals. Before coming to the Otorhinolaryngology Institute, about 20% of patients had already been examined at the General

Casualty Centre or the Pediatric Casualty Centre. Patients with symptoms such as vertigo, nasal trauma, dyspnea, and hemorrhage of the aerodigestive tract were sent to us after they had undergone a series of tests (x-ray, cranial computed tomography, clinical evaluation, etc.) in order to exclude any pathologies of the central nervous system, the lungs, and the abdomen. Once other pathologies had been ruled out and the patient was considered a probable ENT case, he or she was sent to the Otorhinolaryngology Institute for an immediate ENT examination.

The important finding that emerges from this study is that only 311 of the 21,548 patients (1.4%) who came to the ENT Casualty Centre throughout the year did in fact have an emergency condition serious enough to require admission to the hospital. The vast majority of patients did not require any treatment at all. Nevertheless, they still received an examination by a specialist, which could have been easily performed at an ambulatory care center.

The fact that the ENT Casualty Centre provides care free of charge, that it is always open, and that waiting times are shorter appears to be a powerful inducement for patients to misuse these services. Such a practice not only drives up the cost of health care, it places a heavy burden on the workload of the unit's medical and paramedical staff.

It is obvious that an open-to-all general emergency department working in collaboration with an ENT emergency service could function more efficiently than was the case in this study. Educating patients to reserve their use of the ENT Casualty Centre for real emergencies will not have any impact as long as the incentives to continue this practice are so attractive. Perhaps the problem could be alleviated somewhat if the general medical centers would extend their hours of operation to 8 p.m., and if they would remain open on Saturdays so that patients would not be forced to miss work. However, as long as there is no charge for emergency services, they will continue to be overutilized.

From the Institute of Otorhinolaryngology, Policlinico Umberto I, University La Sapienza (Dr. Gallo, Dr. Moi, Dr. Minni, and Dr. de Vincentlis), and the Santa Lucia Hospital (Dr. Simonelli), Rome.

References

(1.) Bleach NR, Williamson PA, Mady SM. Emergency workload in otolaryngology. Ann R Coll Surg Engl 1994;76:335-8.

(2.) Schein M, Decker GA. Surgical audit--workload, utilisation of manpower and beds, pattern of admission and operations in a community teaching hospital. S Afr J Surg 1989;27:93-5.

(3.) Sellu DP, McGladdery SD. Accident and emergency content of general surgical workload. Injury 1985;16:457-60.

(4.) The Royal College of Surgeons of England. General Surgical Workload and the Provider/Purchaser Contract: Notes for the Guidance, 1990.

(5.) The Royal College of Surgeons of England Commission on the Provision of Surgical Services. Report of the Working Party on the Composition of a Surgical Team--General Surgery, Orthopaedics and Otolaryngology, 1988.

(6.) Delamotte T. Surgeons doing sums. Br Med J 1990;301:1l18.

(7.) McShane DP. Analysis of night-time and weekend otolaryngology service. Ir J Med Sci 1989;158:150-2.

                 A breakdown of the percentages of visits
                            periods of the day
Midnight-8 a.m.  6%
8 a.m.-2 p.m.   35%
2-8 p.m.        38%
8 p.m.-Midnight 21%
                 Disposition of patients presenting to the
                     ENT Casualty Centre (n = 21,548)
Disposition           No. patients  Pct.
Hospitalized                311     1.4%
Treated and released      2,391    11.1%
Examined and released    18,846    87.5%
                      Patients hospitalized (n = 311)
Diagnosis                    No. patients  Pct.
Nasal fracture                    81      26.0%
Vertigo                           61      19.6%
Laryngeal dyspnea [*]             40      12.9%
Foreign body: esophagus           21       6.8%
Laryngeal neoplasm                17       5.5%
Facial palsy                      10       3.2%
Tonsillar abscess                  9       2.9%
Epistaxis                          8       2.6%
Head injury                        7       2.3%
Sudden hypoacusis                  6       1.9%
Ear injury                         6       1.9%
Acute or chronic                   6       1.9%
 otitis media
Acute mastoiditis                  5       1.6%
Tracheostomy hemorrhage            5       1.6%
Acute infection of the             4       1.3%
  salivary glands
Hemorrhage of the                  3       1.0%
  respiratory tract
Laryngeal injury                   3       1.0%
Posttonsillectomy hemorrhage       2       0.6%
Complications of sinusitis         2       0.6%
Other                             15       4.8%
(*.)Treated with emergency tracheostomy.
                 Patients treated and released (n = 2,391)
Disposition                      No. patients            Pct.
Frontal nasal packing              1,108                46.3%
Audiometric examination              422                17.6%
Foreign body removal: oropharynx     275                11.5%
Foreign body removal: ear [*]        183                 7.7%
Septum varices                       135                 5.6%
 without nasal packing
Foreign body removal: nose           127                 5.3%
Peritonsillar abscess (lancing)       48                 2.0%
Wax occlusion                         46                 1.9%
Back nasal packing                    44                 1.8%
Laryngeal biopsy                       2      [less than]0.1%
Foreign body removal: larynx           1      [less than]0.1%
(*.)Four foreign bodies were removed with car washing.
                Patients examined and released (n = 18,846)
Diagnosis                  No. patients  Pct.
Acute otitis media            4,291     22.8%
Acute otitis externa          3,175     16.8%
Wax occlusion                 1,846      9.8%
Examination negative          1,571      8.3%
Pharyngitis                   1,458      7.7%
Nasal trauma (no fracture)    1,014      5.4%
Tonsillitis                     988      5.2%
Removal of nasal packing        700      3.7%
 (epistaxis)
Vertigo                         585      3.1%
Epistaxis                       371      2.0%
Traumatic perforation of        244      1.3%
 the tympanic membrane
Laryngitis                      227      1.2%
Rhinitis                        145      0.8%
Sinusitis                       131      0.7%
Dyspnea                         131      0.7%
Sudden hypoacusis               110      0.6%
Other                         1,859      9.9%