Emergency medicine is an upcoming discipline that is still under development in many countries. Therefore, it is important to gain insight into the organization and patients presenting to the Emergency Department (ED). The aim of this cross-sectional study was to provide an epidemiological description of complaints and referrals of the patients visiting the ED of the Ruijin Hospital in Shanghai, China. A questionnaire was developed and completed for a convenience sample of all patients presenting to the Triage Desk of the ED. The study was performed in June 2008. A total of 2183 questionnaires were completed. The most common complaints were fever (15%), stomach/abdominal pain (15%), vertigo/dizziness (11%), and cough (10%). Following triage, patients were predominantly referred to an internist (41%), neurologist (14%), pulmonologist (11%), or general surgeon (9%). This study provides a better understanding of the reason for the ED visit and the triage system at the ED of the Ruijin Hospital. The results can be used in order to improve facilities appropriate for the specific population in the ED.
Emergency medicine (EM) is an evolving discipline in China as the economy modernization and urbanization are progressing rapidly. Consequently, there is an increasing need for a well-organized healthcare system that keeps up with the changing needs [
In order to estimate EM organization, a cooperative project between the Ruijin Hospital in Shanghai (China) and the Erasmus MC (Rotterdam, The Netherlands) was initiated. The primary aim of this collaboration is to perform research into the current situation and development of care provided at the Emergency Department (ED). An early step for the development and modernization of any ED is an assessment of needs, which will define areas of attention for improvements [
At the Ruijin Hospital, emergency care is organized following a multidisciplinary model that is also widely applied in Europe [
All patients, either walk-in (i.e., self-referral) or transported by ambulance, are first registered at the triage desk. The triage nurses subsequently refer them to one of the physicians. Before being seen by a physician, patients or their accompanying family should register the patient at the registration area where the consultation fee should be paid. The triage nurses refer patients to the appropriate physician for consultation, examination, and treatment. Any necessary complementary diagnostic examinations or laboratory tests need to be paid before being performed except for the critically ill patients. All diagnostic facilities for performing radiography, ultrasonography, computed tomography, electro cardiography, and laboratory tests are available 24 hours a day within the ED.
Every hospital department of the Ruijin Hospital, including the ED, has its own pharmacy where patients should obtain and pay for their prescribed medication upon discharge from the hospital. Depending upon the nature and severity of complaints or injuries, patients are either admitted to the ED or to one of the hospital departments of the consulting physicians. In addition to a general and trauma ward, the ED also has its own observation unit and ICU.
Until now, no demographic description of patients visiting the ED of the Ruijin Hospital has been published in the international literature [
The current study was performed from June 5 to June 27, 2008, at the ED of the Ruijin Hospital (Shanghai, China). The Ruijin Hospital is the largest teaching hospital in Shanghai with 1800 beds and is affiliated to Shanghai Jiao Tong University School of Medicine. Data were collected for all patients referred to the triage desk at the ED. Patients reporting directly to the pediatric ED or the resuscitation room as well as patients visiting the ED for routine antibiotic infusion were not included.
A questionnaire was developed in order to collect data. The triage desk is staffed by nurses. Based upon their experience, these nurses refer the patients. There is currently no written protocol or formal triage system. At the Triage Desk the following information of the questionnaire were recorded: gender, date of birth, race (i.e., Asian or Non-Asian), date of visit, time of visit, type of transportation to the hospital (i.e., ambulance or self-referred), chief complaints (separated into 21 categories), and which specialist the patient was referred to (with the choice of 11 types of specialists and a free text field for options not listed). The triage nurses completed the questionnaires during office hours on Monday to Friday.
The questionnaire was developed after extensive discussion with local specialists. Subsequently, five medical specialists and four medical students translated the questionnaire into Chinese. Another group of medical specialists verified the translation and made changes when necessary. This process was repeated until the translation was considered fully sufficient. The final questionnaire was bilingual, combining both the English and Chinese text.
Data were entered into a database and analyzed using the Statistical Package for the Social Sciences version 16.0 (SPSS, Chicago, Ill, USA). Frequencies were calculated for all items of the questionnaire. Age was presented as median with the 1st and 3rd quartile. Eight questionnaires that lacked details on complaints and consulting specialist were excluded from the analysis.
A total of 2183 questionnaires were completed at the Triage Desk. Demographic data for this population are given in Table
Demographic description of patients reporting to the Triage Desk.
Total population | Patients with one | |||
% | % | |||
Gender | ||||
Male | 985 | 45.1 | 734 | 44.5 |
Female | 1184 | 54.2 | 906 | 54.9 |
Unknown | 14 | 0.6 | 11 | 0.7 |
Race | ||||
Asian | 2075 | 95.1 | 1559 | 94.4 |
Non-Asian | 11 | 0.5 | 10 | 0.6 |
Unknown | 97 | 4.4 | 82 | 5.0 |
Transport | ||||
Ambulance | 95 | 4.4 | 72 | 4.4 |
Self-referral | 2088 | 95.6 | 1579 | 95.6 |
Complaints | ||||
Headache | 164 | 7.5 | 86 | 5.2 |
Vertigo/dizziness | 236 | 10.8 | 199 | 12.1 |
Earache or ear infection | 17 | 0.8 | 13 | 0.8 |
Throat symptoms | 67 | 3.1 | 31 | 1.9 |
Chest pain | 154 | 7.1 | 140 | 8.5 |
Shortness of breath | 76 | 3.5 | 24 | 1.5 |
Cough | 219 | 10.0 | 87 | 5.3 |
Stomach and abdominal pain | 324 | 14.8 | 256 | 15.5 |
Urologic | 128 | 5.9 | 74 | 4.5 |
Gynecologic symptoms | 19 | 0.9 | 12 | 0.7 |
Spine | 21 | 1.0 | 12 | 0.7 |
Upper extremity | 55 | 2.5 | 18 | 1.1 |
Lower extremity | 129 | 5.9 | 74 | 4.5 |
Skin | 112 | 5.1 | 101 | 6.1 |
DM related | 4 | 0.2 | 4 | 0.2 |
Fever | 338 | 15.5 | 205 | 12.4 |
Trauma | 164 | 7.5 | 72 | 4.4 |
Blood transfusion | 39 | 1.8 | 34 | 2.1 |
Intoxication | 8 | 0.4 | 5 | 0.3 |
Other | 181 | 8.3 | 141 | 8.5 |
Unknown | 90 | 4.1 | 63 | 3.8 |
Specialist | ||||
Neurosurgeon | 40 | 1.8 | 31 | 1.9 |
Neurologist | 299 | 13.7 | 264 | 16.0 |
Ear-nose-throat specialist | 52 | 2.4 | 42 | 2.5 |
Ophthalmologist | 23 | 1.1 | 21 | 1.3 |
Dentist | 16 | 0.7 | 14 | 0.8 |
Pulmonologist | 239 | 10.9 | 106 | 6.4 |
General surgeon | 197 | 9.0 | 154 | 9.3 |
Urologist | 79 | 3.6 | 54 | 3.3 |
Obstetrist/gynecologist | 25 | 1.1 | 18 | 1.1 |
Orthopedic surgeon | 187 | 8.6 | 114 | 6.9 |
Internist | 902 | 41.3 | 713 | 43.2 |
Dermatologist | 104 | 4.8 | 96 | 5.8 |
Unknown | 43 | 1.9 | 36 | 2.2 |
Data are shown as numbers with percentages. On the right-hand side, data are given for patients reporting to the ED with only one complaint.
The majority of patients visiting the ED were self-referred (95.6%). Of these, 59.2% arrived by car or taxi; all other patients were pedestrians or arrived by bicycle. Only 95 patients arrived at the ED by ambulance.
The four most common complaints were fever (
Overall, 41.3% of patients were referred to an internist (Table
For the six most consulted disciplines, Table
Frequencies of complaints for the six most commonly consulted disciplines.
Complaint | Internist | Neurologist | Pulmonologist | General surgeon | Orthopedic surgeon | Dermatologist |
Headache | 60 | 93 | 3 | 0 | 0 | 0 |
Vertigo/dizziness | 25 | 206 | 0 | 0 | 0 | 0 |
Ear ache or ear infection | 12 | 0 | 0 | 0 | 0 | 0 |
Throat symptoms | 35 | 0 | 2 | 1 | 0 | 0 |
Chest pain | 149 | 0 | 4 | 1 | 0 | 0 |
Shortness of breath | 14 | 1 | 60 | 0 | 0 | 0 |
Cough | 21 | 0 | 197 | 0 | 0 | 0 |
Stomach and abdominal pain | 179 | 0 | 1 | 108 | 1 | 0 |
Urologic | 52 | 2 | 0 | 1 | 1 | 0 |
Gynecologic symptoms | 1 | 0 | 0 | 0 | 0 | 1 |
Spine | 0 | 0 | 0 | 2 | 19 | 0 |
Upper extremity | 1 | 5 | 0 | 17 | 29 | 3 |
Lower extremity | 3 | 2 | 0 | 16 | 110 | 0 |
Skin | 3 | 0 | 0 | 1 | 5 | 95 |
DM related | 4 | 0 | 0 | 0 | 0 | 0 |
Fever | 293 | 6 | 22 | 5 | 0 | 2 |
Trauma | 0 | 0 | 0 | 48 | 86 | 0 |
Blood transfusion | 39 | 0 | 0 | 0 | 0 | 0 |
Intoxication | 6 | 2 | 0 | 0 | 0 | 0 |
Other | 100 | 6 | 5 | 9 | 3 | 4 |
Unknown | 46 | 6 | 6 | 15 | 5 | 4 |
Data are shown for the entire study population.
Frequencies of specialist referral for the five most common complaints.
Specialist | Stomach/abd. pain | Fever | Vertigo/dizziness | Chest pain | Skin |
Neurosurgeon | 0 | 0 | 1 | 0 | 0 |
Neurologist | 0 | 3 | 179 | 0 | 0 |
Pulmonologist | 1 | 4 | 0 | 1 | 0 |
General surgeon | 94 | 1 | 0 | 1 | 0 |
Urologist | 5 | 0 | 0 | 0 | 0 |
Obstetrist/gynecologist | 7 | 0 | 0 | 0 | 0 |
Internist | 148 | 196 | 18 | 138 | 0 |
Dermatologist | 0 | 0 | 0 | 0 | 89 |
Unknown | 1 | 1 | 1 | 0 | 12 |
Data are shown only for patients reporting to the ED with one complaint.
This study provides a demographic description of the patients who visited the ED of the Ruijin Hospital in Shanghai, China, and gives a better understanding of the organization and patient flow.
Although emergency medicine is a separate discipline and is taught at the medical schools in China [
There is no clear rationale for the relatively high prevalence of patients with skin-related problems. Most of these patients were referred to a dermatologist, indicating that these patients most likely did not suffer from traumatic skin lesions. Patients with burn wounds report directly to the Burn Center ED. Soft tissue injuries were probably treated by a general surgeon, since 48 patients with trauma were referred to a general instead of an orthopedic surgeon. A substantial number of patients reported complaints of vertigo/dizziness, for which no clear reason could be given. Most likely, this involved neurological disorders, as patients would be referred to an ENT specialist if the dizziness was due to vestibular organ disorder or to an internist if due to hypotension or anemia.
In Shanghai, unlike in other industrial countries, there is no general practitioner care system, where patients with minor acute or chronic disorders should be assessed first. The general practitioner can subsequently refer patients to the hospital for further treatment if necessary. As a consequence, physicians at the ED also treat a substantial number of patients with nonacute and nonsevere complaints. This is supported by the finding that only a small number of patients were transported to the hospital by ambulance (4.4%).
No previous demographic data of the patients and their indication for referral to a specialist of the Emergency Department in China were available. This study provides the first demographic description of patients visiting the ED of a large teaching hospital in Shanghai. Our results provide a better understanding of the reason for the ED visit and the triage system at the ED of the Ruijin Hospital in Shanghai. The results can be used in order to improve facilities appropriate for the specific population in the ED. Supplemental data on the diagnostics performed, the treatment given, and the outcome of the patients visiting the ED is needed to gain further insight into emergency medicine in the Ruijin Hospital.