Injury (1984) 10, 35-37 Printed in Great Britain 35

Who uses the Accident Service?

Keith Williams

North Staffordshire Health Authority, Stoke-on- Trent

Summary Cards recording attendances at a large Accident and Emer- gency Department for 1 year were reviewed by means of a 1 in 76 random sample, which provided 1027 cards for scrutiny. Injuries were found in 79.9 per cent of attenders; 357 per cent underwent X-ray examination and 13.0 per cent were found to have a fracture. Males and those under 45 years had higher attendance rates than females and older people (46 years and over). Those in social classes IV and V had higher attendance rates than those in social classes I, II and III. Living near the hospital did not seem to be associated with a high attendance rate.

INTRODUCTION DATA on the use of Accident and Emergency Depart- ments tend to be harder to find than those on inpatient matters, probably because there is no national equiva- lent to Hospital Inpatient Enquiry (HIPE) or Hospital Activity Analysis (HAA). Routine returns made by each hospital on statutory form SH3 tell us only the total number of patients attending each Accident and Emer- gency Department. Indeed, the Korner Working Party in Health Services Information (DHSS, 1982) has com- mented on the lack of available information concerning Accident and Emergency Departments.

Only the results of ad hoc studies are available, many of which are American, and several were conducted many years ago. Nevertheless, it seems that the number of new attendances at British Accident and Emergency Departments is increasing annually (HMSO, 1980). This has led some to question if many of the patients treated at such departments might be better treated by their general practitioners (Peppiatt, 1980).

A common finding is that those attending Accident and Emergency Departments are younger than the popu- lation at large (Pease, 1973; O’Flanagan, 1976; Walker, 1976) and that of people of working age more males than females attend (Dixon, 1971; Pease, 1973; O’Flanagan, 1976; Walker, 1976). When information about social class has been collected it is conflicting. One study found an increased consultation rate amongst the lower social classes (Trinker, 1975) whereas others (Vayda, 1975; Stacey, 1976; Walker, 1976) found no such difference. As far as area of residence is concerned, there is again disagreement, with one study (Dixon, 1971) finding increased attendance rates in persons living close to the hospital, whilst another (Walker, 1976) found this not to be the case.

Most studies agree that morning is the busiest time in an Accident and Emergency Department as far as

numbers of attenders is concerned (Dixon, 1971; Naylor, 1982) and one found Mondays to be the busiest day of the week (Wilkinson, 1977). In almost all studies (Wilkinson, 1977) the majority of patients attending are self-referred, and between 57 per cent (Wilson 1972) and 89 per cent (Stacey, 1976) have been injured.

In view of such patchy and varied data, it was decided to study the patients attending the Accident and Emer- gency Department at the North Staffordshire Royal Infirmary, Stoke-on-Trent. This is a busy Accident and Emergency Department which saw about 78000 new patients in 1982.

METHODS The best method of collecting routine information about the use of an Accident and Emergency Department would probably be something akin to HAA but per- formed on all outpatients, preferably with computerized record linkage. Such a possibility is, some would say fortunately, a long way off. There thus remained the possibility of collecting the required data from depart- mental record cards, or developing a questionnaire to administer to attenders.

A preliminary study of record cards suggested that they had been diligently filled in, and it was thus decided to attempt to abstract data from these, realizing fully the difficulties of this method of collecting data.

Using random numbers, an approximately 1 in 76 sample was made of the new attenders from 1 November 1981 to 31 October 1982, so as to give at least 1000 record cards to be studied. Each card was looked at by the authors, and the following information was recorded:

1.

2. 3. 4.

5. 6. 7. 8.

9. 10. 11. 12. 13.

Number of days between onset of symptoms and consultation (if stated). Sex. Address (coded by electoral ward). Social class (where occupational data allowed a reliable coding). Age in complete years. Hour of attendance. Day of the week. Casualty Officer’s diagnosis (using International Class@ication of Diseases, 9th ed.) Whether the patient had been referred by anyone. The patient’s disposal (home, admitted, etc.). Whether X-ray examination was performed. Whether the attendance was due to injury. The site of the accident.

Injury: the British Journal of Accident Surgery (1984) Vol. 1 ~/NO. 1

result of a road traffic accident), 10.4 per cent as a result of a road traffic accident, 23.5 per cent occurred at work and 11.2 per cent resulted from some leisure or sporting activity.

RESULTS A total of 1027 records was studied. Monday was by far the busiest day at the Department (an average of 294 new attendances each Monday as against an average of 202 for the other days). Only 68 attendances per day (6.62 per cent) were between the hours of midnight and 8.00 am.

Men considerably outnumbered women in the sample; there were 606 male attenders and 421 females. Had consultation rates for the sexes been equal we would have expected 504 men and 523 women, judging from the mid-1981 Home Population Estimates for North Staffordshire. This difference was very unlikely to have been due to chance (x2 =40.53, P<O*OOl).

In 130 cases (12.7 per cent) it was stated that symp- toms had begun more than 24 hours before consultation; 127 cases (12.4 per cent) had been referred by their general practitioner. Those living near to the hospital had a consultation rate of 113.2 per 1000 population per year, compared with a rate of 158.4 for the population of North Staffordshire as a whole.

Social classification presented certain difficulties, as occupation was often not written down in the case of married women, and father’s occupation was almost never recorded in the case of children. On the other hand, for men between 18 and 65, enough information was provided to allow reasonably certain classification of these male attenders, compared with that of the popula- tion of North Staffordshire as a whole. There was a considerable excess of those in social classes IV and V in the sample (x2 = 72.7, P<O.OOl) (Table Z).

Table I. Distribution of male attenders (aged 18-65) by social class compared with mid-l 981 population estimates for North Staffordshire

Social class

Attenders North Staffs at casualty population

No. % No. %

I and II 47 13.6 72 356 17.3 III not manual 17 4.9 35 548 8.5 III manual 130 37.6 208 248 49.8 IV and V 152 43.9 102 201 24.4 Unclassified 70

Total 416 418 353

There was a considerable excess of patients in each age-group under 45 years in the sample, and a deficit of persons aged 45 and over (Table ZZ). This difference was statistically highly significant (x2 = 142.77, P<O.OOl). Fractures were found in 134 patients (13 per cent); X-ray examination was performed in 367 patients (35.7 per cent). Ninety-six (9.3 per cent) had conditions requiring admission. A total of 821 patients (79.9 per cent) had been injured, defined as ICD classifications 800-959, plus any other conditions where a history of accident, violence or injury from an external cause was mentioned on the Accident and Emergency record.

The fact that 12.7 per cent of patients had symptoms for more than 24 hours before presenting themselves might be taken as ammunition by those who feel that many people attend Accident and Emergency Depart- ments unnecessarily. However, one could easily envisage occasions when, for example, someone hurts his leg and rests it for 48 hours; only when the swelling and bruising shows up, and he finds that the leg will not now bear weight, does he go to Casualty and have his fracture discovered. Is such a person acting unreasonably in bypassing his general practitioner?

Of the patients attending, 87.6 per cent came of their own accord. This figure is higher than that found by Morris (1979) but slightly lower than that of Wilkinson (1977). It is interesting to note that those living near the hospital had a lower consultation rate; the results are somewhat confounded by the fact that this area is one of the more salubrious areas of the city (even some consul- tants live there!), and presumably has a favourable social class distribution.

Of the 821 injured patients, 565 (68.8 per cent) had Regarding the social distribution of the attenders, we the place of the accident recorded; 35.3 per cent had oc- must be careful to draw only guarded conclusions; it was curred at home, 19.6 per cent in the street (not as the possible to look at males from 18 to 65, and even here the

Tab/e II. Distribution of attenders by age compared with mid-l 981 population estimates for North Staffordshire

Attenders at casualty

North Staffs population

Age (yrs) No.

O-4 93 5-l 4 177

15-29 333 30-44 215 45-64 114 65-74 55 75+ 38

% No. l %

9.1 27 800 6.0 17.3 66 600 14.3 32.5 101900 21.9 21 .o 91200 19.5 11 .l 111600 23.9

5.4 43 400 9.3 3.7 24 200 5.2

l To nearest 100.

DISCUSSION The diligence with which the record cards had been filled in, and the legibility of the Casualty Officers’ hand- writing, came as a pleasant surprise. The fact that Monday was the busiest day of the week was no great surprise, according to the findings of Wilkinson (1977). One can reasonably expect that some patients suffering a minor injury over the weekend would wait until Monday before seeking treatment. The numbers attending between midnight and 8.00 agree with the findings of Dixon (1971) and Naylor (1982), but the work load may be disproportionately heavy because of severe injuries.

The excess of males amongst attenders is interesting, and agrees with the findings of O’Flanagan (1976) and others. Men are known to sustain more accidents than women and hence might be reasonably expected to be over-represented at Accident and Emergency Departments.

Williams: Use of the Accident Service

data were incomplete. However, the excess of consul- tations in social classes IV and V was very marked, and would persist even if all those males between 18 and 65 who were not classified had belonged to social classes I, II and III. We know from the Black Report (Townsend, 1982) that those in the lower social classes have higher morbidity than those in the upper classes, and also that their consultation rates, although higher than those in social classes I-III, are not so much higher as is their morbidity. The higher consultation rate could be taken as either alarming or reassuring according to one’s viewpoints. Possible statements might be: ‘The unintelli- gent lower classes are abusing our accident services by loading upon them trivia which could be dealt with by general practitioners or at home by persons showing greater responsibility’, or ‘the oppressed working classes, who have been turned away from their family doctors by administrative difficulties, have here found a caring service which sees them whenever they need help, erect- ing no artificial barriers to consultation’.

Both of these are, of course, extreme viewpoints. In the author’s opinion one would have to think long and hard before doing anything which might discourage the less fortunate in society from seeking medical help, even if they might occasionally be seeking it in an inappropriate place.

The higher consultation rate of younger people ac- cords well with other studies, for example that of Pease (1973). It is known that the young and the employed are more prone to accidents than others. The 9.3 per cent admission rate accords well with that of other studies, for example that of Morris (1979). The number of patients undergoing X-ray examination is similar to that in other studies, as is the 13 per cent fracture rate.

The fact that 79.9 per cent of all patients had been injured is reassuring; this figure is higher than in most other studies and perhaps suggests that abuse of the Accident and Emergency Department has been a little overstated in the past. The large number of home and work accidents is interesting; perhaps there might be scope for health education to try and reduce them?

37

ACKNOWLEDGEMENTS I should like to thank the staff of the Accident Depart- ment, North Staffordshire Royal Infirmary, Dr Myrtle Summerly, Specialist in Community Medicine, North Staffordshire Health Authority, and Mrs Mary Adderley, my secretary, for their help.

REFERENCES Department of Health and Social Security (1982) Steering

Group on Health Services Information. First report to the Secretary of State, London: HMSO

Dixon P. (1971) Casual attendance at an Accident Department and a Health Centre. Br. Med. .I. 4, 214.

Her Majesty’s Stationery Office (1980) Sociul Trends, No. IO. London; HMSO.

Morris J. (1979) A survey of new attenders at the Accident and Emergency Department of a small specialist hospital (Angus District). Health Bull. (Edin.) 37(4), 108.

Naylor A. (1982) The Bradford Accident Service. Injury 3, 148. O’Flanagan P. (1976) The work of an Accident and Emergency

Department. J. R. Coll. Gen. Pratt. 26, 54. Pease R. (1973) A study of patients in a London Accident and

Emergency Department with special reference to General Practice. Practitioner 211, 634.

Peppiatt R. (1980) Patients’ use of General Practitioners or Accident and Emergency Departments. Practitioner 224, 11.

Stacey M. (1976) The Sociology ofthe N.H.S. Keele; University of Keele.

Townsend P. (1982) Inequalities in Health. London: Pelican. Trinker F. (1975) Study of patients who come by choice to the

Casualty Department of the Royal Melbourne Hospital. Med. J. Aust. 1(17), 528.

Vayda E. (1975) Emergency Department use at two Hamilton hospitals. Can. Med. Assoc. J. 112 (8); 961.

Walker L. (1976) inpatient and Emergency Department utilisation-the effects of distance, social class, age, sex and marital status. J. Am. CoZI. Emerg. Phys. 5 (2), 105.

Wilkinson A. (1977) Attendance at a London Casualty Depart- ment. J. Coil. Gen. Pratt. 27; 727.

Wilson R. (1972) The Belfast Accident Service. Injury 3, 169.

Paper accepted 27 November 1983.

Requestsfor reprints should be addressed fo: Dr K. Williams, Registrar in Community Medicine, North Staffordshire Health Authority, 79 London Road, Stoke-on-Trent ST4 7PZ.