PROFILE OF CLINICAL EMERGENCIES IN THE EMERGENCY DEPARTMENT OF A TEACHING HOSPITAL

This study aimed to: investigate the demographic characteristics of patients seen in the emergency department of a teaching hospital; identify the most common clinical emergencies; and identify the ultimate destination of these patients (medical discharge, hospitalization or death). This retrospective, cross-sectional, quantitative study. Data were collected from patients’ electronic medical records. Inclusion criteria were: adult patients 18 years or older, with a diagnosis of clinical emergency, seen in the period from January 2009 through May 2010. There was a predominance of: females (56.33%), of white ethnicity (86.95%), and mean age 48.74 ± 7.8 years. The most prevalent age group was 18-29 years. Most of the patients (99.65%) declared themselves to be active workers. 60.23% were married. The most frequent neurologic diseases found were: headache (29.03%); stroke (26.09%); and upper back pain (10.25%) and cardiological diseases were: precordial pain (38.98%), heart failure (25.79%), hypertension (12.29%) and cardiac arrhythmia (8.67%). The ultimate destinations of patients seen in the emergency department were: medical discharge (55.8%) and hospitalization (43.26%). Among those patients who had been hospitalized, medical discharge was the most common outcome (87.99%), followed by death (11.47%). Further research is necessary in order to better understand the various aspects involved in the operation of an emergency department unit and to develop an institutional profile that encompasses other approaches, such as a better and more efficient health care delivery by health professionals.


INTRODUCTION
The emergency department (ED) unit is a of central importance for the functioning of the health care system.This unit provides care to patients who arrive in severe conditions, and receives, screens and refers non-urgent cases to basic or specialized outpatient services of the existing health care network. 1 ED are prepared to see and treat a limited number of patients.Thus, the excessive volume of patients due to the high demand for emergency services often results in suffering for the population.Thus, there is a need for improvements in these services. 2n Brazil, 90% of emergency cases are clinical cases.Only 10% are trauma cases.Most cases, therefore, are low-complexity cases that could be treated in primary health care services. 3hanges in morbidity and mortality profiles caused by chronic noncommunicable diseases impact general and clinical emergency health care delivery in emergency departments.The latter represents the most frequent cases.Hospitals are still important gateways to medical assistance, which can be explained by difficulties in access to primary, specialized and diagnostic services. 4oreover, the sense of urgency for the patient may not be the same as for health professionals.There must be an adequacy between emergency services and health care policies, in order to meet the population's needs for clinical emergency care. 5Studies conducted at clinical emergency services found that the most frequent diagnoses are related to the cardiovascular system, such as cerebrovascular lesions.The most frequent are ischemic stroke, followed by hemorrhagic stroke and cardiovascular lesions (left ventricular failure with pulmonary edema and acute ischemic heart disease). 6,7any strategies seek to incorporate specific therapeutic, technological and managerial advances to enable high-quality, efficient and accessible emergency care delivery for the stabilization of vital functions and proper referral of critical care patients. 8hus, this study aimed to: investigate the demographic characteristics of patients seen in the emergency department of a teaching hospital; identify the most common clinical emergencies; and identify the ultimate destination of these patients (medical discharge, hospitalization or death).

METHODS AND MATERIALS
This retrospective, cross-sectional, quantitative study was conducted at the Emergency Department of a Teaching Hospital in São José do Rio Preto, SP.Data were collected from patients' electronic medical records.
The study sample consisted of 9,756 electronic medical records from patients admitted to a clinical emergency department.Patients were selected by covenience sampling.Inclusion criteria were: adult patients 18 years or older, with a diagnosis of clinical emergency, seen in the period from January 2009 through May 2010.
For data collection, we used a form with the following variables: demographic data (age, gender, ethnicity, occupation and marital status), clinical emergencies data (diagnosis and prevailing specialties) and ultimate destination (discharge, hospitalization or death).
The research project was approved by the Research Ethics Committee of FAMERP, according to Resolution CNS 466/12, under protocol No. 3696/2011.This study is part of a wider research project entitled "Epidemiological Study of Patients seen in the Emergency Department of a Teaching Hospital".
Data were processed in Excel 2007.Statistical analyzes were performed using the Statistical Package of Social Sciences software, SPSS, 2011, version 20.0.After descriptive analysis, we applied the chi-square test to the following variables: clinical emergencies, sex, marital status, age and type of emergency.A difference was considered significant when p <0.05.

RESULTS
The 9,756 patients seen in the clinical emergency department of the Teaching Hospital from January 2009 trough May 2010 had the following demographic characteristics: predominance of female gender (5496 -56.33%), white ethnicity (8483-86.95%),and mean age of 48.74 ± 7.8 years.The most prevalent age group was 18-29 years.Minimum age was 18 years and maximum age was 104 years.Most patients (9,725 -99.65%) were active workers and 5,876 (60.23% ) were married (Table 1).
The ultimate destination of most patients seen in the emergency department was medical discharge (5444 -55.8%) and hospitalization (4221 -43.26%), while a minority of patients died.In addition, our study revealed an increase in the number of deaths after hospitalization (Table 5).
The chi-square test showed a statistically significant association (p <0.005) between the most common causes of clinical emergencies in the clinical emergency department (unknown causes, neurological and cardiac) and the variables gender, marital status, age, and type of medical discharge.The age group 21-30 years accounted for the highest number (9%) of 'unknown cause' cases (p <0.01).Among neurology cases, 3.7% of subjects were aged over 70 years; 2.8% were 61-70 years old and 2.8% were 51-60 years old (p <0.01).As for cardiac cases, the age group with the largest number of admissions (5%) was 31-50 years (p <0.01).
With regard to discharge from emergency department, 18. 1% of patients with unknown causes received medical discharge and 5. 1% were hospitalized (p <0.01).5.6% of neurology cases were given medical discharge and 7.9% were hospitalized (p <0.01).As for cardiology cases, 7.9% received medical discharge and 5.9% were hospitalized (p <0.01).

DISCUSSION
Similar to studies conducted at a university hospital in Santa Catarina and at the hospital of the Federal University of Paraná, most clinical patients seen in the emergency department were females.The aforementioned studies have emphasized the need for professionals in the emergency departments to be competent in making diagnoses and in providing effi-cient care. 9,10In practice, there is an increase in cardiovascular disease in women.This is accordance with the last census held in 2010 in the city where study was conducted. 11s for the age groups, we found a higher prevalence of the age group 18-29 years, which corroborates the data of the national literature. 12Regarding ethnicity, the majority self-identified as white.This is similar to the finding of a study on hypertensive crisis conducted at the same emergency department where this study was conducted.The study found 83.5% of cases of urgent hypertensive crisis, 86.6% of whom were white. 6ost patients (99.65%) self-declared being active workers.This disagrees with a study conducted at an emergency department of a general hospital in San Isidro, Buenos Aires province.The study aimed to characterize the sociodemographic profile of mentally affected patients.They found that 57% of patients experienced some kind of underemployment or were unemployed. 13With regard to the marital status, most patients seen in the emergency department were women in stable unions.We found an association between these two variables (p <0.01).This finding is similar to the results of a study conducted from November 1999 to 2005 at a public teaching hospital responsible for high-complexity emergency care. 14n this study, most cases of clinical emergencies (23.47% ) had unknown causes.This is in line with a study conducted at a emergency department in Alagoas.The authors found that, in 89% of cases, the clinical care was judged inadequate to make a diagnosis. 12Neurology was the prevailing clinical specialty in our study, accounting for 13.90% of cases, followed by cardiology with 13.59%.These data differ from the findings of a previous study conducted at the emergency department of a teaching hospital, which found a higher incidence of circulatory diseases in clinical care. 11n neurology, headache accounted for the majority of cases: 29.03%.This coincides with studies conducted at emergency departments in southern Brazil. 7,8Ischemic stroke and acute pulmonary edema were the most frequent lesions in target organs treated in clinical emergency departments. 4Another study aimed to compare the neurological diagnoses of young and elderly patients seen in the emergency unit of a tertiary hospital.The authors found that cerebrovascular diseases were the most common diagnoses (59.6%) among patients over 50 years of age. 10 We found similar results in our study: the higher the age group, the higher the percentage of clinical emergencies with neurological causes.
As for cardiac causes, precordial pain was the most prevalent complaint among adults of working age -between 31 and 40 years.This agrees with the findings of a literature review on thoracic pain in emergency departments.The review also highlights that the evaluation of patients suffering from thoracic pain is a challenge for health professionals in emergency departments  ried and active worker.The most prevalent causes of emergencies were unknown causes, and the prevailing clinical specialties were neurology, cardiology and pulmonology, respectively.The most frequent diagnoses were chest pain, headache and stroke.Finally, medical discharge was the most common ultimate destination of patients seen in the clinical emergency department.We found little difference between patients who had been hospitalized and later discharged.Moreover, 11.5% of patients died.
It is important to characterize patients specifically and meaningfully, identify main clinical emergencies, as well as the final destination (discharge, death or hospitalization) involving the operation of an emergency care service.These actions will assist health professionals in planning care and consequently improve the quality of health care delivery.and requires the adoption of standardized protocols to prevent misdetection of acute coronary syndrome.The latter is also relevant for reducing morbidity and hospital costs of these cases. 15nother study that aimed to evaluate the effectiveness of a systematic model of care for patients with thoracic pain and no ST-segment elevation observed that 119 out of 1,003 subjects who had been admitted with precordial pain in the period of one year and three months were referred to a specialized unit and 660 subjects remained in the emergency department. 16ccording to a study conducted at a university hospital, cardiovascular diseases are among the leading causes of emergency care in the elderly.This is due to the increase in life expectancy and maintenance of eating habits and physical activity. 17recordial pain is highlighted as one of the most prevalent cardiovascular diseases in the elderly.The results of a study conducted at a precordial pain unit agree with these data.Moreover, the authors observed that the age group with the highest prevalence was 60 years or over. 18e found that most patients seen in the clinical emergency department were medically discharged and many patients (43.26%) were hospitalized.This diverges from a survey also performed in a teaching hospital, which found that only 5% of the 2,417 cases seen in clinical emergency resulted in hospitalization. 19This may be justified because the teaching hospital is a reference hospital in northwest Sao Paulo.
The most common causes of clinical emergencies were unknown causes in young adults aged 21-30 years (9% of patients -p <0.01).This is consistent with a study that justifies the large number of ill-defined diagnoses.The authors reveal the provisional nature of the care provided and show that the set of tests used does not contribute significantly to the accuracy of diagnosis. 20he emergency health care team should deliver systematized and fast care to patients, because the emergency unit is the gateway for patients in emergency situations involving the various specialties. 4The high number of patients seen and medical discharges may indicate a failure in medical regulation and in the screening process of these patients, leading to a high demand for emergency care services.We would like to highlight that investments in training of health professionals, proper completion of medical records, and adequate and wellequipped physical structure are required for an effective care delivery in emergency departments.
Thus, health professionals should be able to make rapid, accurate diagnoses and provide high-quality and efficient health care.

CONCLUSION
The demographic characteristics of most clinical emergency cases were: young adult, female, of white ethnicity, mar-

Table 1 -
Distribution of demographic variables of clinical patients seen in the emergency department of a teaching hospital in São José do Rio Preto, Brazil, from January 2009 trough May 2010

Table 2 -
Distribution of causes of clinical emergencies of patients seen in the emergency department of a teaching hospital in São José do Rio Preto, Brazil, from January 2009 trough May 2010

Table 3 -
Distribution of neurological diseases of patients seen in the emergency department of a teaching hospital in São José do Rio Preto, Brazil, from January 2009 trough May 2010

Table 4 -
Distribution of cardiac diseases of clinial patients seen in the emergency department of a teaching hospital in São José do Rio Preto, Brazil, from January 2009 trough May 2010

Table 5 -
Distribution of the ultimate destinations of patients seen in the emergency department of a teaching hospital in São José do Rio Preto, Brazil, from January 2009 trough May 2010