Can sick children tell time?: emergency department presentation patterns of critically ill children

Children show a consistent pattern of ED use, with the majority of patients presenting during the late afternoon and evening hours. This study evaluated whether such a diurnal pattern also exists for critically ill children and the implications of such a presentation pattern on ED staffing.

A review was performed of the ED diagnoses and times of presentation for children less than 12 years of age at 28 nonpediatric hospitals over the six-year period from July 1990 to October 1996. In addition to total ED pediatric visits, a subset of critically ill children (CIC) were identified as those with an ED diagnosis of: meningitis, cardiac arrest, diabetic ketoacidosis, status epilepticus, meningococcemia, or epiglottitis, or those undergoing endotracheal intubation in the ED. A second group of non-critically ill children (NCIC) was composed of children with an ED diagnosis of otitis media, tonsillitis, or pharyngitis. Data collected on each patient included age, diagnosis, site of care, and time of service. Presentation patterns for all three groups were compared for time of day, with statistical analysis through chi-square, ANOVA, and Spearman's rho correlation.

A total of 409,820 pediatric ED visits were examined, with 688 CIC children and 28,344 NCIC identified. Presentation patterns for NCIC visits mirrored those of the total pediatric population, with the traditional increase in the late afternoon and evening hours (correlation 0.96). CIC presented much more erratically, with a distribution spread more uniformly throughout the day compared with the total pediatric population (correlation 0.72). Thirty-seven percent of CIC presented during the evening hours of 16:00 to 24:00, compared with 49% for NCIC and 53% for the total pediatric population, while 22% of CIC presented from 24:00 to 08:00 compared with only 13% of NCIC and 10% of total pediatric patients (p < 0.001).

Critically ill children present more uniformly throughout the day and do not have the same presentation patterns as ambulatory children. ED staffing should reflect this difference and not focus pediatric ED services simply on hours of peak pediatric visits.