The health of adults in sub-Saharan Africa is becoming increasingly important priority in global health policy. There has been constant increase in the absolute number of emergency admissions for defined populations over the last three decades. Adult mortality, death between the ages of 15 and 60, is 4 to 40 times higher in sub-Saharan Africa than in developed countries [
The causes of morbidity and/or mortality in sub-Saharan Africa regions are predicted to undergo a significant shift towards endemic noncommunicable diseases. A gradual change in lifestyle and improvement of socioeconomic status of the third world countries are causing substantial changes on the previously recognized public health problems. Public violence including violence to women is also becoming important causes of emergency department visits. Moreover, poorly organized emergency medical service system where prehospital services are totally lacking in several places calls for considering modifications of the adapted healthcare delivery system. In other words, the healthcare delivery system of a country must be adjusted to patterns of morbidity and mortality to mitigate and minimize consequences of prolonged ill health and premature death of adults [
Information related to the spectrum and patterns of emergency conditions for which clients visit the emergency departments and their clinical outcomes often indicates the actual magnitude of different health problems in a community. Furthermore, such information are essential in healthcare planning and provision of essential health services including key resources like equipment, hospital space, and other logistics [
However, very little or probably nothing has been known about the spectrum, pattern, characteristics, and clinical outcomes of local-community emergency problems for which they visit emergency rooms in Ethiopia. The objective of this study was therefore to assess the spectrum, pattern, characteristics, and clinical outcomes of emergency department admissions among adult people who visited EDs of the selected hospitals which ultimately contribute to works done to reduce the ever-growing mortality and complications secondary to emergencies.
This study was conducted in three zones of Wollega, located in the western part of Oromia regional state, western Ethiopia. Four zonal hospitals with a similar level of services were randomly selected from these zones: Nekemte Referral Hospital from East Wollega Zone, Gimbi and Nejo Hospitals from West Wollega Zone, and Shambu Hospital from Horo Guduru Wollega Zone. The study was carried out from February, 2017 to June 2017 among adult patients who have visited the selected hospitals for all forms of emergency conditions.
Hospital-based prospective cross-sectional study was employed to assess the pattern, spectrum, characteristics, and clinical outcomes of adult emergency department admissions in the selected hospitals.
Since the objective of the study was to determine the spectrum, patterns, and clinical outcomes of adult emergency department visits during a specified study period, no specific sampling size determination was employed. The area sampling technique was used to select the zones in which the hospitals are found. Five administrative zones, namely, Buno, Kelem Wollega, West Wollega, East Wollega, and Horo Guduru Wollega zones were selected as geographical clusters from the western Oromia region. Out of them, three zones (West Wollega, East Wollega, and Horo Guduru Wollega) were randomly selected. Then, the four mentioned hospitals were randomly included in the study. Finally, all adult patients with all forms of emergency problems who have visited and were treated in emergency departments of the respective hospitals during the study period were consecutively included.
All adult patients who have visited the ED of the selected hospitals for all emergency conditions during the study period were included.
All patients of less than 18 years old and who were critical and unconscious patients with no attendants were excluded.
Data were collected using comprehensively organized and pretested interviewer-administered questionnaires. The tool was adopted from up-to-date literature [
Initial tool prepared in English was translated to local language (Afan Oromo) and translated back to English by respective language experts. Before conducting the main study, pretest was carried out in one nonselected hospital. Based on the findings of the pretest, necessary modifications were made to the tool. In addition, investigators have closely supervised the data collection process and necessary corrections were considered on all data collection sites. Moreover, the collected data were checked again for completeness before data entry. All incomplete data found were discarded. The cleaning process was performed by running simple frequency after data entry for its consistency. Further check has been done for inconsistency by referring the hard copy of the questionnaires.
After data collection, the already coded questionnaires were checked for completeness. Data were initially entered into EpiData version 3.2 by data clerks after several steps of check for completeness and accuracy. Then, the entered data were exported to SPSS program version 20 for data analysis. Descriptive statistics was generated for spectrum, characteristics, patterns, and clinical outcomes emergency department admissions. Finally, the results of the study were presented using text, tables, charts, and graphs.
A total of 952 adult patients presented to the emergency departments of the selected four hospitals in western Ethiopia and who met the inclusion criteria were involved in the study. As incomplete questionnaires were discarded, data obtained from 889 respondents were analyzed, making the response rate 93.3%. The key findings related to sociodemographic characteristics, baseline clinical information, spectrum and forms of ED admissions, leading causes of adult ED admission, and final outcome of adult ED admissions are presented in the subsequent sections.
The mean (+SD) age of the patients admitted to adult emergency department of the hospitals was 34.98 (+15) years. The male to female ratio of adult emergency department admissions was nearly equal (1 : 1. 04) (Table
Distribution of respondents by their socio-demographic characteristics in Nekemte, western Ethiopia, 2017.
No. | Variables ( |
Category | Frequency | Percent |
---|---|---|---|---|
1 | Age of the patient | 15–24 | 243 | 27.31 |
25–34 | 215 | 24.20 | ||
35–44 | 201 | 22.62 | ||
45–54 | 127 | 14.30 | ||
55–64 | 63 | 7.10 | ||
+65 | 40 | 4.54 | ||
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2 | Sex | Male | 503 | 56.60 |
Female | 386 | 43.41 | ||
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3 | Marital status | Single | 273 | 30.70 |
Married | 542 | 61.02 | ||
Divorced | 46 | 5.20 | ||
Widowed | 28 | 3.10 | ||
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4 | Level of education attained | No schooling | 257 | 28.92 |
Primary (grade 1–6) | 247 | 27.81 | ||
Secondary (grade 7–12) | 247 | 27.80 | ||
Tertiary (>grade 12) | 138 | 15.50 | ||
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5 | Monthly income | 150–500 | 485 | 54.59 |
500–750 | 117 | 13.20 | ||
750–1500 | 54 | 6.13 | ||
1500–3,000 | 83 | 9.30 | ||
3000–5000 | 53 | 6.05 | ||
+5000 | 55 | 6.20 | ||
Unknown | 42 | 4.70 | ||
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6 | Residence | Town | 396 | 44.50 |
Rural | 493 | 55.50 | ||
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7 | Occupation | Government employee | 111 | 12.50 |
Maid/servant | 34 | 3.80 | ||
Merchant | 133 | 15.07 | ||
Farmer | 351 | 39.50 | ||
Laborer | 30 | 3.40 | ||
Driver | 82 | 9.22 | ||
No formal job | 148 | 16.71 |
This study has identified the baseline clinical characteristics of patients and reasons of emergency room visit. Out of total respondents, more than half (51.9%) of the patients were presented to the EDs as self-referral, whereas the remaining patients were referred to the hospitals from other health facilities. It was their first visit to the ED of the selected hospitals for over three-fourth (76.9%) of the patients. While levels of consciousness in about 10% of emergency patients were not determined, 127 (14.3%) of patients arrived unconscious. Vital signs were deranged in about 59.4% of the cases (Table
Distribution of emergency patients by their baseline information, Nekemte, Ethiopia, 2017.
No. | Baseline information ( |
Category | Frequency | Percent |
---|---|---|---|---|
1 | Mode of arrival | By people/shoulder | 65 | 7.30 |
Public transportation | 346 | 38.91 | ||
Ambulance | 282 | 31.72 | ||
Private car | 134 | 15.11 | ||
On foot | 59 | 6.48 | ||
Horse back | 3 | 0.30 | ||
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2 | Treatment given before arrival | Yes | 266 | 29.81 |
No | 623 | 70.10 | ||
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3 | Source of referral | Self | 461 | 51.90 |
Public health center | 304 | 34.22 | ||
Other public hospitals | 37 | 4.22 | ||
Private health facility | 38 | 4.30 | ||
Other | 49 | 5.51 | ||
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4 | Living condition | Alone | 44 | 4.90 |
With family | 763 | 85.80 | ||
With friends | 51 | 5.70 | ||
On the street | 14 | 1.61 | ||
Other | 17 | 1.90 | ||
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5 | Number of visit | First | 684 | 76.90 |
Repeated | 202 | 22.70 | ||
Unknown | 3 | 0.30 | ||
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6 | Arrival time | Weekend | 96 | 10.81 |
Night | 135 | 15.10 | ||
Day | 658 | 74.10 | ||
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7 | Time between arrival and initiation of treatment in minutes | <15 | 662 | 74.50 |
15–30 | 166 | 18.71 | ||
30–60 | 48 | 5.42 | ||
>60 | 13 | 1.50 | ||
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8 | Who brought the patient | Self | 475 | 53.40 |
Friend | 300 | 33.70 | ||
Family member | 109 | 12.32 | ||
Police | 5 | 0.60 | ||
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9 | Vital signs on arrival | Normal | 348 | 39.11 |
Deranged | 528 | 59.42 | ||
Not taken | 13 | 1.51 | ||
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10 | Level of consciousness on arrival | Conscious | 404 | 45.41 |
Subconscious | 268 | 30.14 | ||
Unconscious | 127 | 14.33 | ||
Not evaluated | 90 | 10.22 | ||
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11 | Presence of known chronic illness | Yes | 259 | 29.10 |
No | 591 | 66.55 | ||
Unknown | 39 | 4.40 | ||
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12 | Distance of patient’s home and hospital in kilometers | <5 | 350 | 39.41 |
5–15 | 242 | 27.22 | ||
16–25 | 79 | 8.93 | ||
26–35 | 51 | 5.71 | ||
36–45 | 44 | 4.90 | ||
>45 | 123 | 13.86 |
The study also explored respondents’ relevant reasons of emergency room visits. While only one-fourth (20.4%) of them arrived by ambulance or other emergency vehicles, only 40 (4.5%) of them visited the ED because they believe that they get most of care at the emergency room (Table
Respondents’ main reason for emergency room visit in Nekemte, western Ethiopia, 2017.
No. | Main reason for emergency room visit | Frequency | Percent |
---|---|---|---|
1 | Health provider advised to go | 233 | 26.20 |
2 | The problem was so serious that other clinics cannot help | 81 | 9.11 |
3 | Arrived by ambulance or other emergency vehicles | 181 | 20.38 |
4 | The patient had no other place to go | 207 | 23.30 |
5 | Emergency room is the closest provider | 85 | 9.61 |
6 | Get most of care at the emergency room | 40 | 4.50 |
7 | Unidentified reason | 62 | 7.04 |
Total | 889 | 100.0 |
In this study, the number of adult ED admissions per month was variable with peak admissions in the month of February and the lowest in the month of November (Figure
Patterns of adult emergency department admissions in Nekemte, western Ethiopia, 2017.
As to the spectrum and forms of adult ED admissions, 45.4% of the patients were of medical emergency in their types. Traumatic emergency (27.3%) and surgical emergency (15.9%) took the 2nd and 3rd ranks, respectively (Figure
Major kinds of observed emergency conditions in the selected hospitals in Nekemte, western Ethiopia, 2017.
Findings regarding the leading causes of adult emergency department admission at the selected hospitals revealed that a respiratory distress (12.43%), extremity fractures (9.61%), and hypertensive disorders (8.6%) were among the top leading causes of adult ED admissions (Figure
Leading causes of adult emergency department admission in the selected hospitals, Nekemte, Ethiopia, 2017.
Specific medical emergencies as leading causes of adult emergency room admissions were separately identified in this study. Shock of different causes, unconsciousness of different causes, respiratory distress, DM complications (DKA and hypoglycemia), nonspecified acute febrile illnesses, and serious forms of tuberculosis were among the top leading causes of ED admissions in the selected hospitals during this specified study period (Table
Identified medical emergencies as leading causes of emergency room admission, Nekemte, Ethiopia, 2017.
Forms of medical emergencies | Frequency | Percent |
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Acute chest pain syndromes | 12 | 4.63 |
Hypertensive disorders | 71 | 27.62 |
Heart failure | 29 | 11.22 |
Shock | 140 | 54.41 |
Cardiac arrest | 5 | 1.90 |
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Meningitis | 5 | 2.90 |
Stroke | 25 | 14.50 |
Seizure disorder | 14 | 8.11 |
Headache | 11 | 6.31 |
Unconsciousness (coma) | 117 | 68.00 |
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Respiratory distress | 105 | 54.60 |
Foreign body obstruction | 3 | 1.55 |
Asthma | 54 | 28.11 |
COPD | 5 | 2.63 |
Severe pneumonia | 15 | 7.86 |
Bronchitis | 7 | 3.61 |
Complicated TB | 3 | 1.54 |
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Diabetes mellitus | 34 | 35.43 |
DM complications | 62 | 64.50 |
Among the injuries presented, extremity fracture, organophosphate poisoning, and road traffic accident were among the leading causes of ED admissions in the selected hospitals. Impairment of breathing (37%) and circulatory compromises (30%), the two most common types of life-threatening problems, identified immediately on arrival (Table
Emergency room admission due to traumatic and toxicologic emergencies, in Nekemte, western Ethiopia, 2017.
Frequency | Percent | |
---|---|---|
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Contusion with intact skin surface | 3 | 0.65 |
Soft tissue injury | 47 | 9.71 |
Intracranial injury | 41 | 8.40 |
Fracture | 80 | 16.50 |
Dislocation | 4 | 0.81 |
Foreign body obstruction | 6 | 1.22 |
Burn | 69 | 14.22 |
Falling accident | 37 | 7.61 |
Road traffic accident | 99 | 20.41 |
Machinery injury | 6 | 1.22 |
Fighting | 72 | 14.90 |
Other physical abuses | 14 | 2.82 |
Sexual abuse | 5 | 1.00 |
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Suicide | 12 | 22.20 |
Human bites | 3 | 5.50 |
Animal bites | 10 | 18.51 |
Insect bites | 3 | 5.52 |
Organophosphate poisoning | 18 | 33.30 |
Carbon monoxide poisoning | 2 | 3.72 |
Drug overdose | 3 | 5.51 |
Unidentified | 3 | 5.49 |
The final clinical outcome of emergency department admissions in terms of death, survival, and length of hospital stay was one aim of this study. While the large majority (90.9%) of them survived, the final outcome was not identified in about 1.5% of the patients. Overall, among all patients who visited emergency departments in the study period, about 8.5% (2.5% arrived dead, 6.4% died in the emergency departments, and the remaining 1.6% died after ward/ICU admission) (Figure
Distribution of respondents by their consequences of emergency department visits in Nekemte, western Ethiopia, 2017.
Regarding the patients’ duration of hospital stay, more than half (58.2%) cases stayed in respective hospitals for 1–3 days. The rest of 41.8% have stayed in the hospitals for 4–7 days.
A number of studies revealed that there has been a consistent increase in the absolute number of emergency department admissions rate for defined population over the last decade. The key findings of this study related to pattern, characteristics, baseline clinical information, spectrum of emergency department admissions, leading causes of emergency department admission, and outcome of adult emergency department (ED) admissions of this study are compared and contrasted with currently existing literatures and presented briefly.
The mean age of the patients admitted to adult ED of the hospitals during the study period was 34.98 years. The adult ED admissions in this study were also found to be increasing progressively with age to reach peak at 15–24 years implying higher burden of diseases in the economically productive age group. Both findings are in line with similar studies conducted to determine the ED admission patterns in Nigeria [
The decision to seek medical attention and the choice of healthcare provider are linked with the level of urgency of the complaint. Cases where there is little or no scope for choice refer to serious emergencies where immediate care is required [
The admission patterns in the emergency room may reflect the actual burden of diseases in the immediate environment which also helps the health facilities to have a sound plan. In this study, the number of adult ED admissions per month was variable with peak admissions in the month of February and the lowest admission was in the month of November. We found that medical emergencies were found to be more frequent (45.4%) causes of adult ED admissions followed by traumatic emergencies (27.3%). The findings are in line similar other studies with little disparity from the study conducted at the University of Harcourt Teaching Hospital, in Nigeria which showed that only 17.3% (lower than 45.4% of this study) had medical emergencies [
The outcome of patients admitted to adult ED was found to vary with patients’ demographic and clinical characteristics. Overall, among patients who visited ED of the selected hospitals in this study, about 8.5% died (2.5% arrived dead, 6.4% died in ED, and the remaining 1.6% died after ward/ICU admission). Out of all patients presented to the selected hospital in the area, vast majority (90.9%) of them have survived after receiving treatment. The final outcome has not been identified in about 1.5% of patients due to referral and discharge against medical advice (DAMA). The ED mortality rate (8.5%) in this study is much greater than the finding of similar study conducted in Addis Ababa. The observed discrepancy might have been due to differences in the standard of emergency department care between the two areas. Similarly, the mean length of stay in hospitals is much longer than what has been reported in Addis Ababa and consistent with studies conducted in other similar settings [
This study has also revealed that impairment of breathing in about 37% followed by circulatory compromises in nearly 30% the emergency patients was observed as life-threatening problems. This is in line with the report found from UK, Nigeria, and similar other surveys but with slight variation with the study done in Ethiopia [
This study showed the selected hospitals received mixed cases of emergency conditions which also ended up with significant proportion of adult death. The admission rate was found to be varying with seasonal difference. The outcome of patients admitted to adult ED was found to vary with patients’ demographic and clinical characteristics. Higher proportion of the cases required admissions to the wards/ICUs implying the seriousness of the encountered emergencies. A need for action to improve the readiness of existing emergency room services and investing further on standardizing and organizing prehospital services at the community level.
Acute gastroenteritis
Critical care unit
Congestive heart failure
Discharge against medical advice
Diabetic ketoacidosis
Emergency department
Ear nose throat
Intensive care unit
Noncommunicable disease
Road traffic accident
Sub-Saharan Africa
United Kingdom.
The data used to support the findings of this study are available from the corresponding author upon request.
The authors declare that they have no conflicts of interest of any form.
Ashenafi Habte has designed and developed the research concept and involved in supervision of data collection process, statistical analysis, and preparation of the final document. Birhanu Yadecha and Getahun Fetensa have helped with research tool preparations and supervising data collection. Thanasekaran Palanichamy has involved in data analysis and revision of the final manuscript.
We would like to acknowledge Wollega University for funding the research data collection of this research. We would also like to extend our heartfelt gratitude to our study participants for their cooperation in responding the interview whilst they were in a physical and emotional suffering. Wollega University has funded this research only for data collection.