A Nationwide Study on Emergency Department Utilization among Pediatric Patients in Korea: A Special Focus on Pediatric Emergency Medical Centers

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Abstract

INTRODUCTION

South Korea grapples with an exceptionally low fertility rate, standing at 0.81 as of 2021, marking the lowest among the Organization for Economic Cooperation and Development countries [1]. In stark contrast to this demographic trend, the number of pediatric patients seeking care in emergency medical centers (EMCs) has been steadily increasing, aligning with a global phenomenon [2–5]. While preliminary studies on pediatric emergency department (ED) utilization in South Korea have indicated a gradual rise in recent years, comprehensive epidemiological data for the past decade have been lacking, excluding reports related to the recent impact of the coronavirus disease 2019 (COVID-19) pandemic [6,7].

Over the last decade, the field of pediatric emergency medical services system (EMSS) has undergone several significant changes. Initiatives by the government since 2012 to designate pediatric emergency medical centers (PEMCs) have resulted in the establishment of 10 PEMCs as of June 2023 [8]. Another crucial shift was the abrupt decrease in pediatric emergency patients, beginning in late 2019 due to the COVID-19 pandemic [6]. The resulting challenges include a notable contraction in pediatric emergency care services and a substantial reduction in the workforce of pediatric emergency medical personnel. As of 2024, the recruitment rate for pediatrics residents stands at a mere 26.4% [9].

Our study aims to provide a comprehensive overview of these dynamics, particularly focusing on the role and characteristics of PEMCs in comparison with other EMCs. The study is motivated by the need to understand the changes in pediatric emergency care following the establishment of PEMCs and during the COVID-19 pandemic. It aims to highlight the distinctions between PEMCs and other institutions in terms of pediatric care delivery and the changes in the volume of pediatric patients, particularly in the context of the COVID-19 pandemic. Additionally, the study seeks to compare the patterns of pediatric care between government-designated PEMCs and other EMCs.

MATERIALS AND METHODS

RESULTS

1. General demographic data and visiting information of pediatric patients

During the study period, a total of 176 emergency medical centers were included, comprising eight PEMCs, 33 REMCs, and 135 LEMCs. The number of pediatric patients visiting 176 EMCs nationwide drastically decreased from approximately 1.35–1.38 million before the COVID-19 pandemic in 2020 plummeting to 710,000–720,000 in 2020 and 2021, reflecting a 48% reduction. In total period, the number of patients visiting PEMCs, totaling around 580,000 accounted for 14% of the total, with REMCs and LEMCs contributing 26.3% and 59.8%, respectively. The average daily number of visits per center ranked in the order of PEMC, REMC, and LEMC, with 49.9, 22.8, and 12.6 patients, respectively. Male patients constituted 56.7%, and the age groups with the highest representation were 1–4 years and 5–9 years. The overall median age was 4 years, with PEMC having the youngest median age at 3 years, followed by REMC (4 years) and LEMC (5 years). The number of visits per 1,000 population decreased from 155 and 157 in 2018 and 2019, respectively, to 86 and 88 in 2020 and 2021 during the COVID-19 pandemic, marking a 44% reduction. This decline was predominantly driven by a decrease in young children under the age of 9 years, particularly evident in the age group of less than 1 year. When comparing the two periods, the decrease in the number of EMC visits per 1,000 population was the smallest in the 15–18 age group (Tables 1, 2).

Table 1

General characteristics of pediatric patients visiting 176 EMCs in Korea

Table 2

Population and number of children visiting 176 EMCs in Korea, 2018–2021

The most common time for patient visits was from 6:00 PM to midnight, accounting for 45% of all visits, with more patients visiting on weekends than weekdays (19.2% versus 12.3%). Excluding PEMCs, patients visiting emergency centers located in provinces outnumbered those in metropolitan areas. However, the proportion of patients seeking emergency care outside their residential area was highest in PEMCs (Table 1).

Patients seeking care for medical conditions outnumbered those for injuries (66% versus 34%), with this difference being particularly pronounced in PEMCs. Patients transferred from other hospitals were more common in PEMCs and REMCs, and approximately 8.5% of patients utilized ambulances. Patients with severe conditions corresponding to KTAS 1–3 accounted for 0.3%, 3.1%, and 32.2%, respectively, showing a decreasing severity from PEMC to LEMC (Table 1).

2. Results of ED management, most common chief complaints, and diagnoses

The main departments that treated patients were emergency medicine (52.7%), pediatrics (34.6%), plastic surgery (3.5%), and orthopedic surgery (2.9%). In PEMCs and LEMCs, the proportion of emergency medicine as the main treating department was higher (57.5% and 56.0%, respectively), and the consultation rates with other specialists were also higher (58.6% and 60.5%) than in REMCs. In REMCs, pediatrics had a higher proportion as the main treating department (41.7%). Of the patients, 88% were discharged after emergency treatment, 0.5% were transferred, and 11.2% were admitted. Although admission rates were highest in REMCs (14.7%), the intensive care unit (ICU) admission rate was higher in PEMCs. Over the study period, there were 1,999 deceased patients, averaging 1.4 per day. The median length of stay (LOS) for patients was 85 minutes (Table 3).

Table 3

Outcomes of pediatric patients visiting 176 EMCs in Korea

The 10 most common chief complaints and diagnoses are outlined in Table 4. The top three chief complaints, common to both PEMCs and general emergency medical centers (GEMCs), were fever, abdominal pain, and vomiting. These three primary symptoms accounted for 41.1% and 37.5% of all patient presentations in PEMCs and GEMCs, respectively. Most diagnoses pertained to conditions of moderate to mild severity (Table 4).

Table 4

Ten most common chief complaints and diagnosis in PEMCs and GEMCs

To examine the characteristics and treatment outcomes of patients visiting the PEMCs, logistic regression analysis was conducted. There were no gender differences among patients at the PEMCs, but there was a higher proportion of patients under 1 year of age. The majority of patients visited between 6 AM and noon, with a relatively even distribution throughout the day. Weekday and seasonal variations were minimal. Patients visiting centers located in metropolitan areas were more than twice as many, and a substantial number came from outside their residential areas. There was a higher prevalence of patients seeking care for medical conditions, and a higher proportion of patients were either transferred from other hospitals or had outpatient visits. While more patients were falling under KTAS 1 and 2 than other centers, there was no significant difference in ambulance usage. The ratio of primary care provided by emergency medicine specialists was high, but a significant number of patients were discharged after emergency treatment (Table 5).

Table 5

Multivariable analysis for pediatric emergency medical center (n=583,278)

DISCUSSION

The utilization of EMCs by pediatric patients in South Korea exhibited a gradual increase, followed by a sharp decline after the onset of the COVID-19 pandemic. The age group of 1–4 years demonstrated the highest frequency of EMC visits, with two-thirds of patients seeking care for medical conditions, and a discharge rate of nine out of 10 patients. PEMCs managed 14% of the total patient volume, with an average daily patient count exceeding twice that of other emergency centers. This trend persisted consistently beyond the typical visitation hours. This study represents the first report on the utilization patterns of PEMCs since their designation and operation in 2012. Furthermore, it provides a novel insight into the EMC usage of pediatric patients in South Korea on a national scale, especially during the pandemic such as COVID-19. The absence of recent reports on the EMC utilization of pediatric patients, particularly in the context of the COVID-19 pandemic, underscores the significance of this nationwide dataset, contributing valuable information to the current understanding of pediatric emergency care dynamics.

PEMCs in South Korea are mainly situated in densely populated metropolitan area such as Seoul and Gyeonggi-do. This strategic placement aims to cater to regions with significant pediatric populations. However, a critical evaluation reveals that the Ministry of Health and Welfare’s method of designating PEMCs lacked the necessary precision in its initial stages. Specifically, designations were not adequately based on detailed analyses, such as patient occurrences in relation to the population demographics. This oversight has led to a somewhat ambiguous purpose behind the establishment of PEMCs, challenging the effectiveness of such centers in providing targeted pediatric emergency care.

Ideally, the designation of PEMCs should prioritize institutions capable of offering comprehensive care to pediatric emergencies, thereby ensuring that children receive the final phase of treatment efficiently and effectively. Contrary to this expectation, the approach to designating PEMCs has been somewhat indiscriminate, with a public recruitment process for medical institutions that did not consider precise reginal needs. As a result, PEMCs have become overwhelmed with both critical and mild cases, leading to significant overcrowding issues. The scenario underscores the need for a more calculated approach in the distribution and designation of PEMCs, ensuring that these centers are not only equipped to handle the volume of cases but are also strategically located to serve the intended pediatric population effectively.

This study focused on pediatric patients under the age of 19 years, collected through the NEDIS. The results revealed that the age group of 1–4 years exhibited the highest EMC visitation rate. A more detailed examination within the 1-year age intervals showed that the visitation rate was highest at the ages of 1, 0, and 2 years, decreasing significantly at 12 years, followed by a slight increase. This pattern aligns with findings from a similar nationwide preliminary study conducted 12 years ago (Fig. 1) [3].

Fig. 1

The proportion of pediatric patients by emergency medical centers (EMCs). Visitation rate was highest at the ages of 1, 0, and 2, decreasing significantly at 12 years, followed by a slight increase. PEMC, pediatric emergency medical center; REMC, regional emergency medical center; LEMC, local emergency medical center.

This study specifically focused on PEMCs, REMCs, and LEMCs as the targeted emergency centers. In South Korea, the tier classification for EMCs comprises REMC, LEMC, and LEMI, forming a three-tiered system. However, PEMCs are separately designated, aligning with specific criteria for pediatric emergency care facilities, equipment, and staffing. As evident in the study results, since the government initiated the designation of PEMCs in 2012, these centers have handled a significant volume of pediatric patient care. Despite this, there has been limited analysis of statistics related to PEMCs.

Additionally, LEMIs were excluded from this study. The NEDIS data collected during the study period indicated that the average daily patient count for all 242 LEMIs nationwide was merely 2.7 patients. This exclusion was based on substantial differences observed in personnel, facilities, and equipment between LEMIs and the EMCs focused on in this study, namely PEMCs, REMCs, and LEMCs.

During the observed period of the COVID-19 pandemic in this study, there was a 49% reduction in the number of patients, a trend consistent with the global pattern reported in previous studies, ranging from 45% to 58% [12–14]. However, the reduction trend varied based on age and the reason for hospital visits. The most significant decrease was observed in infants under the age of 1 year, while adolescents aged 15–18 years experienced the smallest decrease.

This discrepancy is attributed to the fact that, in younger children, acute respiratory illnesses constitute a significant portion of EMC utilization, whereas in adolescents, a higher proportion of visits are related to trauma [13]. This trend is also supported by research in Korea, where studies have shown an increase in the proportion of patients presenting with intussusception, mental illness, and injury despite a decrease in overall numbers during the COVID-19 pandemic [10,15,16].

The findings of this study provide valuable insights into potential policy ideas for improving pediatric EMSS that are currently facing significant challenges. In a preceding study on ED utilization by pediatric patients, first reported in South Korea in 2012, the ambulance utilization rate was 4.2%, with admission and discharge rates at 15.5% and 83.1%, respectively. The reasons for hospital visits were categorized as disease and injury, constituting 71% and 29%, respectively. In contrast, during the current study period, the ambulance utilization rate increased to 8.5%, and the discharge rate rose to 88%, with admission rates at 11.2%. Notably, the proportion of EMC visits due to injuries increased to 34%, suggesting a higher incidence of trauma-related visits. The increased discharge rate implies a likely rise in the proportion of mild cases; however, with the rise in ambulance utilization, further research is needed to explore the appropriate use of ambulances. Additionally, the decrease in disease-related visits indicates a decline in infectious diseases, which typically account for a significant portion of pediatric EMC visits, likely influenced by societal measures such as social distancing, mandatory mask usage, and school closures.

Similar to previous studies, this study observed a higher frequency of patient visits during evening hours from 18:00 to midnight and on weekends. The majority of patients, constituting 65%, fell into the category of mild cases with KTAS scores of 4–5. Furthermore, most patients were discharged from the EMC, and the average LOS was short, approximately 85 minutes. These results provide insights into tips for after-hours care (AHC) operations within pediatric EMS system in South Korea. In other countries, various forms of AHC are being implemented as alternatives to address ED overcrowding and high medical costs [17,18]. Analysis of the top 10 diagnoses for patients visiting PEMCs and GEMCs revealed that approximately 54% and 50%, respectively, could be categorized under around 10 chief complaints. This finding can be utilized for the education of emergency medical staff and preparedness strategies for both EMCs and AHCs.

This study compared the characteristics of PEMCs, designated for pediatric emergency care since 2012, with other EMCs, namely REMCs and LEMCs. Despite the limited number of PEMCs (only eight during the study period), they handled 14% of all ED visits. The majority of patients were infants under 1 year old, and there were no significant differences in the number of patients based on time of day or day of the week. However, a higher number of patients visited centers located in metropolitan areas, and a considerable proportion of patients lived in a different location than the hospital. Compared to other centers, PEMCs had a higher proportion of patients with a KTAS score of 1, but the discharge rate was high at 89%, and 0.5% of patients were transferred to other hospitals. This suggests that specialized PEMCs responsible for the final treatment of pediatric emergency patients are suffering from ED overcrowding due to mild cases. It also highlights the fact that there are cases where transfers are necessary. The insufficient number of PEMCs, predominantly located in metropolitan areas, indicates regional imbalances. Notably, reasons for transfer from PEMCs to other hospitals, such as the inability to perform emergency surgery and insufficient ICU beds, warrant attention. This indicates that although PEMCs have facilities, equipment, and personnel equivalent to emergency centers, they reveal vulnerability in the backend healthcare system (Table 6). The current designation criteria for PEMCs have mostly focused on hardware. Future criteria should align with the presence of a comprehensive backend healthcare system, and government support should be directed towards strengthening this aspect.

Table 6

Reasons for transferring patients to other hospitals after emergency treatment

This study has limitations due to the retrospective nature of the analysis using the NEDIS dataset, which does not provide detailed information on the facilities, equipment, and personnel at each institution. Therefore, the analysis was conducted at the institutional level, classifying them into PEMC, REMC, and LEMC, assuming PEMC as a level 1 center for pediatric emergency care. However, in the real world, there are a considerable number of REMCs that effectively treat more patients than PEMCs.

As the hospital data provided is anonymized in this study, there may be differences from actual PEM practices in the field. Additionally, this study does not delve into the specifics of how PEMCs and other emergency medical centers handle the treatment of mild pediatric cases and the resultant overcrowding issues. Addressing these aspects in detail remains a limitation of this work. Utilizing national data, this study inherently carries a substantial risk of type I errors due to the large sample size. To address this issue, a more stringent significance threshold of P<0.01 has been applied. Future research and detailed analyses are warranted to not only contribute to strengthening the preparedness of PEMCs but also to thoroughly examine the management of mild pediatric cases in emergency settings and its implications for overcrowding. Such investigations are crucial for enhancing the Pediatric EMS system.

Due to the COVID-19 pandemic, the number of pediatric patients in EMCs in South Korea has sharply decreased. EMC utilization was higher among children aged 1–4 years, with a majority of patients seeking care for illnesses, and nine out of 10 patients were discharged. It is imperative to devise strategies for managing non-emergent mild pediatric cases to alleviate overcrowding in PEMCs.

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