INVESTIGATING ASSOCIATED FACTORS BETWEEN ADMISSION TO PEDIATRIC EMERGENCY AND REFERRAL TO INTENSIVE CARE UNIT: A RETROSPECTIVE COHORT STUDY

Aim: We aimed to evaluate the patients who were admitted to Pediatric Emergency Department regarding the ratio of referral to Intensive Care Unit (ICU), and the relationship between the time of waiting in Emergency Department and the length of stay in Intensive Care Unit between January 2013 and December 2018. Materials and Methods: The patients’ records who were admitted to our Pediatric Emergency Department between January 2013 and December 2018 were evaluated retrospectively. The referrals to Neonatal and Pediatric ICU were evaluated. Due to the absence of an Intensive Care Unit in our hospital, we compared the duration of referral to ICU and length of stay in ICU. Results: The total number of patients who were admitted to Emergency Service was 673023, the number of the patients referred to ICU was 1327, 302 of these patients were referred to the Pediatric ICU (PICU), and the rest of them were referred to Neonatal ICU (NICU). While 47.35% of the patients who were referred to the PICU presented with respiratory tract diseases, 19.86% had neurological causes, 13.9% were intoxications, and 7.8% were gastrointestinal causes. 28.78% of the patients who were referred to the PICU had an accompanying chronic disease at the time of admission. Mean duration of referral to the PICU was 8.4 ± 6.3 hours. The length of stay of in PICU in 2017 and 2018 was investigated by asking on the phone (n = 122), and the mean length of stay of the patients in the PICU was 5.18 ± 2.1 days. There was no statistically significant correlation between the duration of referral to the ICU and the length of stay in the PICU (p; 0.089), whereas in 54 patients who presented to the emergency department due to respiratory distress and had no underlying chronic disease, there was a statistically significant correlation between the duration of referral to ICU and the length of stay in ICU (p: 0.012). Conclusion: The number of Pediatric Emergency Department admissions is very high in our country and most of these patients present with respiratory complaints. 0.19% of the patients who were admitted to the emergency service were in need of intensive care. Patients who had no underlying disease and who needed intensive care for respiratory distress were shown to have a shorter length of stay, and their referrals were faster. These patients should be referred to intensive care units without delay in the emergency service. As a conclusion, there is a need for more PICU in our country.


INTRODUCTION
An emergency is described as a sudden, life-threatening medical condition that can impair the quality of life 1 . Hence pediatric emergency departments admit all the children under the age of 18 years old, these units serve to a wide range of patients in Turkey. Children constitute 25-30% of all cases that are admitted to the emergency department 2 . In 2015, 17% of the children living in the United States were applied and admitted to an emergency department at least one time 3 . Although the reasons for emergency department admission vary in children, the most commonly seen symptoms are fever, cough, nausea, vomiting and abdominal pain 4,5 .
Diseases can progress rapidly in children. The most important feature of an urgent or injured patient is that their vital signs are not safe and the consequences cannot be predicted 6 . More than 80% of the mortality in children is due to emergencies, and early recognition and hospitalization of high-risk patients decrease both morbidity and mortality 7 . In the Pediatric Emergency Department, it may be necessary to refer the patients to the pediatric intensive care unit and the neonatal intensive care unit.
This fact shows that all complaints of pediatric patients who are admitted to the emergency service should be examined carefully.
Asphyxia and birth trauma due to a lack of pregnancy follow-up, inadequate birth conditions and inadequate neonatal care, and neonatal emergencies such as respiratory distress syndrome, hypoglycemia are the frequently encountered in developing countries 8 .
It is assumed that approximately 60000 children are in need of intensive care. Current Pediatric Intensive Care Units do not even meet 20% of this need 9 . It was found that 41.5-76% of the patients admitted to PICU were referred from Pediatric Emergency Departments (10)(11). The inadequate number of Pediatric ICU leads to an increase in the referral time to an appropriate ICU in patients who were admitted to the emergency department and were in need of intensive care.
This study aims to determine the number of pediatric emergencies in our hospital, the number of patients in need of intensive care, the number of admissions by age and months, the time of referral to the appropriate intensive care unit, and to evaluate the relationship between the time spent in the emergency department and the length of ICU stay. Data were analyzed using Microsoft Excel XP and SPSS (version 13.0, SPSS Inc). Values were given as mean ± standard deviation (SD), median, minimum-median-maximum or number of cases (%) according to the test applied. The relationship with the number of patients was evaluated by regression analysis, and the Mann-Whitney U test was used for the abnormally distributed variables. P <0.05 was considered as statistically significant. Building were referred to the PICU or NICU. Three hundred and two patients were referred to the NICU, and 1025 patients were referred to NICU.

Between
The distribution of patients admitted to the pediatric emergency department by age and months is given in Table 1. The number of patients who were admitted to the pediatric emergency department has increased over the years, and the number of admissions is higher in October, November, December, and January. The distribution of 302 patients referred to the PICU and 1025 patients referred to the NICU according to age are given in Table 2. There was a statistically significant increase in the number of patients in need of intensive care unit and the number of patients who applied to the emergency department for various reasons over the years (p: 0.025).   The length of stay of patients who were referred to other centers (n = 122) in 2017 and 2018, were obtained from the hospitals by telephone and the mean length of stay in the pediatric intensive care units was 5.18 ± 2.1 days. No statistically significant correlation was found between the time of referral and the length of stay in the pediatric intensive care unit in the last two years (p; 0.089). A statistically significant relationship between the time of referral and the length of stay in the pediatric intensive care unit was found in 54 patients who applied to the emergency department due to respiratory distress and had no underlying chronic disease (p: 0.012).

DISCUSSION
We conducted a large-scale study examining six years of data to evaluate the number of patients admitted to the pediatric emergency department and patients in need of intensive care. This study is the first long-term study in our country in which the time of referral to the appropriate intensive care unit is evaluated.
The reason for hospitalization in pediatric intensive care units is often the referral from pediatric emergency departments. In a study conducted by Hague et al., it was found that 46% of hospitalizations in pediatric intensive care units were referred from pediatric emergency departments, whereas in another study conducted by Odetola et al., the ratio increased to 74% 10,11 .
In a study by Evans et al., the most common diagnoses of patients referred from the pediatric emergency department to the intensive care unit were respiratory problems, intoxications, and neurological problems, respectively, and the results were similar to our study 14 . In a study by Hague et al. which evaluated patients referred from the emergency department to the intensive care unit, the most common reason for referral was neurological diseases and the second most common was respiratory problems. Because the trauma patients were admitted to pediatric emergency departments in Hague et al. 's study, the prevalence of neurological disease was high. In our country, trauma patients are admitted to adult emergency departments 10 . In the USA, all pediatric patients admitted to the pediatric emergency department between 2011 and 2015 were evaluated, and it was found that respiratory and traumatic injuries increased between November and March, and trauma and injuries peaked in April. In 2015 data, the most common causes of admission to the pediatric emergency department were respiratory tract diseases, trauma, and intoxication 2 . In our study, although respiratory diseases increased in winter, they were not affected by seasonal changes and were the most common reason for referral.
The intensity of emergency services is an increasing problem. It has been shown that the increase in the intensity of the emergency departments decreases the service quality and increases the morbidity [13][14][15][16] . In our study, it has been determined that there has been a positive correlation between the number of children admitted to the emergency department and the number of patients referred to the Namık Kemal Tıp Dergisi 2020; 8(  18 . Based on this, we retrospectively analyzed children (n = 54) who had no underlying chronic disease and were referred to the PICU only because of respiratory disease. First of all, we analyzed the records of the patients who admitted in 2018 and then in 2017, we did not evaluate the previous years because the information of the previous years was incomplete and as a result, we found that the increased waiting time in these patients prolonged the length of stay in the intensive care unit.

Limitations
Since the data of our study were collected from a hospital in which children of low-income families were admitted, this may not reflect the whole population. Another limitation is that our study is a single center study and the data were collected retrospectively. Hence there are not many studies on this topic, we could not make a comparison. Therefore, comprehensive studies on the subject should be conducted, and the problems and needs related to the pediatric emergency should be established.
The retrospective data we have obtained may lead to more extensive studies.
In conclusion, our study shows the number of patients referred to the PICU and the NICU from the pediatric emergency departments and the waiting times in the pediatric emergency department.
Patients in need of pediatric intensive care should be considered in a high-risk group and waiting times in the pediatric emergency services should be reduced. There is a need for more PICU in our country.