Acta Pædiatrica, 2006; 95: 208
/213

Children with chronic conditions in a paediatric emergency

department

MARTIAL M. MASSIN1, JESSICA MONTESANTI1, PAUL GÉRARD2 &

PHILIPPE LEPAGE1
1
Department of Paediatrics and 2Mathematical Institute, University of Liège, Liège, Belgium

Abstract
Aim: To describe the use of a paediatric emergency department by children with chronic conditions. Material and
methods: We prospectively indexed all the children seen in our emergency department during 1 y to describe the population
of children with chronic conditions, and to compare it with the general paediatric population. Results: There were 11 483
patient visits, of which 11% were by chronically ill children. Six subspeciality areas accounted for the vast majority of the
chronic conditions seen: neurology (30%), cardiology (18%), pulmonology (18%), nephro-urology (16%), haemato-
oncology (9%) and endocrinology (4%). Admission rate to the hospital was significantly higher for chronically ill patients
(38% vs 23%). Among chief complaints, fever, respiratory distress, headache and seizures were overrepresented in
chronically ill children. The chief complaint was related to the child’s chronic condition in 51% of the visits. In both
chronically and non-chronically ill patients, the majority of final diagnoses were related to infection (57% and 65%,
respectively). Among diagnoses, bacterial infections, seizures, vasovagal syncopes and asthma were overrepresented in
chronically ill children.
Conclusion: From the analysis of our data, we conclude that children with chronic conditions account for a tenth of all
visits to a paediatric emergency department. The paediatric emergency physicians provide an important service to both the
children with chronic conditions and the subspecialists who care for them.

Key Words: Child emergency department, chronic conditions, complaints, diagnoses

Introduction one or more chronic conditions and also used health

Knowledge of the spectrum and relative frequencies of
paediatric emergencies is an important factor in
developing appropriate training curricula for paedia-
tric residents and in optimizing training and staffing in
emergency departments. Previous studies have re-
ported information for illness presenting to a paedia-
tric emergency department (PED) [1] or for paediatric
illness presenting to a general community hospital
emergency department [2,3]. Inappropriate utilization
of the PED is a major problem in Belgium: the
majority of patients come directly to the hospital,
with no first-line selection by primary care providers
[4]. For this reason, the spectrum and frequency of
illness presenting to our paediatric emergency depart-
ments may be quite different to that of other countries.
Compared to general emergency departments,
PEDs care for more children with chronic conditions
[2]. Results from previous studies in the United States
indicated that 12
/13% of US children B/18 y old had
and related services beyond those required by children
generally [5,6]. Further analyses indicated that an
additional 6% of children had a presumed need for
health or related services beyond those required by
children generally, even though they were not identi-
fied as using an elevated level of services at the time of
the surveys [5]. Other studies also showed that 24 to
31% of chronically ill children make a visit each year to
an emergency department [7,8]. Our study was
designed to describe the use of a PED by Belgian
children with chronic illness. To provide these data, we
analysed the records of a large PED that serves as both
a primary provider for children in the immediate
geographic area and a tertiary centre for a large region.
Material and methods
We prospectively indexed all patients who presented
to our PED between 1 January 2003 and 31 Decem-

Correspondence: Martial Massin, Department of Paediatrics, C. H. R. Citadelle (University of Liège), Boulevard du 12è de Ligne, 1, B-4000 Liège, Belgium.
Tel: /32 42257312. Fax: /32 42264747. E-mail: martial.massin@chrcitadelle.be

(Received 8 March 2005; revised 12 July 2005; accepted 9 September 2005)

ISSN 0803-5253 print/ISSN 1651-2227 online # 2006 Taylor & Francis
DOI: 10.1080/08035250500346443
 Chronic conditions in the paediatric emergency room 209
ber 2003. The hospital was located in an urban setting Statistical analysis
with a census of 11 483 visits during the year 2003 in
Data were entered and analysed using an Excel
the emergency room of the Paediatric Department of
program for Windows software. Categorical data
the University of Liège, Belgium. During the same
were compared using x2 testing for standard dichot-
period, there were 50 650 visits to the emergency
omous variables, and significant differences between
room of the Departments of Medicine and Surgery.
Children with trauma but no neurological signs are observed and expected frequencies were determined
not seen in the PED but by surgeons, and are not by standardized residues. Mann-Whitney and Krus-
included in the study. kal-Wallis tests were used for comparison of data for
The investigators systematically analysed the clin- which the normality of distribution was not observed
ical charts of all children included in the study after (age distribution). Significance was determined as
discharge from the hospital. The study was approved p B/0.05.
by the Institutional Review Board. The patients
studied were considered with regard to demographic
information, date and time of visit, chief complaints, Results
diagnoses, and final disposition. Visits
The chief complaint was derived from the patient’s
description of the problem on presentation to the During the study period there were 11 483 patient
PED. For the purpose of this analysis, only the visits to our PED, of which 1094 (11%) were by 762
principal reason, as judged by the health provider, children with one or more chronic conditions. Six
was used. Twenty-six chief complaints had a frequency subspeciality areas accounted for the vast majority of
/0.3%: injury, fever, respiratory distress, vomiting, the chronic conditions seen: neurology (30%), cardi-
abdominal pain, rash, earache, upper respiratory in- ology (18%), pulmonology (18%), nephro-urology
fection, sore throat, diarrhoea, seizure without fever, (16%), haemato-oncology (9%) and endocrinology
febrile seizures, headache, toxic ingestion, foreign body (4%). None of the other chronic conditions (Table I)
ingestion, chest pain, irritability
/crying
/colic, cough, accounted for more than 3% of all the conditions.
epistaxis, psychological disorders, fainting, bites, pol- Two or more significant chronic conditions were
lakiuria, aphtous ulcers, red eyes, and nursing pro-
blems. The other complaints were grouped in the Table I. Distribution of chronic conditions.
‘‘miscellaneous’’ category. Diagnoses were derived
from the healthcare provider’s diagnoses rendered at Number
Subspecialities of visits Details
the completion of the visit for patients who were not
admitted and at discharge for those who were admitted Neurology 332 Seizure, n/158
to hospital. The diagnosis corresponding to the chief Cerebral palsy, n/91
complaint was used for the purpose of this analysis. Ventriculoperitoneal shunt, n /41
Developmental delay, n/26
Twenty-five diagnoses had a frequency /0.3%: minor
Other neurological and
trauma (trauma not requiring hospitalization), viral neurosurgical conditions, n/39
syndrome, bacterial infections, asthma, abdominal Cardiology 202 Congenital heart disease, n /181
pain, dermatitis, upper respiratory infections, lower Arrhythmias, n /18
respiratory infections, gastroenteritis, seizures, Acquired heart disease, n/3
Pulmonology 199 Asthma, n/179
poisoning, allergy, major trauma (trauma requiring
Cystic fibrosis, n / 13
hospitalization), constipation, appendicitis, epistaxis, Bronchopulmonary dysplasia, n/7
gastro-oesophageal reflux, psychological disorders, Nephro-urology 180 Vesicoureteral reflux, n /129
vasovagal syncope, bites, cystitis, foreign body Other urinary tract anomalies, n/34
ingestion, stomatitis, conjunctivitis, and nursing Chronic renal insufficiency, n/10
Nephrotic syndrome, n/7
problems. The other ones were grouped in the
Haemato- 99 Haemoglobinopathies, n /36
‘‘miscellaneous’’ group. oncology Coagulation disorders, n/22
A chronic condition was defined as any disease that Cancer, n/19
the investigators judged to have lasted more than 3 mo Immunodeficiency (including VIH),
or caused functional impairment or required more n /16
Neutropenia, n /6
medical care than is usual for a healthy child of the
Endocrinology 40 Diabetes mellitus, n/26
same age [9]. Information about chronic conditions Other endocrine problems, n/14
was obtained from the past medical history section of Other 57 Psychiatric disorders, n /30
the emergency chart systematically filled out by conditions Gastroenterological problems, n /13
paediatric emergency physicians and from the analysis Orthopaedics, n /7
Ear, nose and throat problems, n/7
of global clinical charts, by the investigators, after
Other conditions, n /16
discharge.
210 M. M. Massin et al.

NIC: non-chronically ill children; CIC: chronically ill children; Admission /rate in%; PICU: paediatric intensive care unit; hospital’s duty:% of visits during evening/night-time weekday hours or on
present in 51 visits (5%). The mean age of the non-
chronically ill children was 3.89/4.2 y, and that of the

Endocrinology
chronically ill children 5.19/4.9 y (p B/0.0001).

7.9 9/5.6
When comparing separately the subspeciality sub-

63%

45%
33%
60%
25%
50%
25%
5%
0.7
groups to the group of non-chronically ill children,
the mean age was significantly higher in chronically
ill children than in non-chronically ill children, with

Haemato-oncology
the exception of children with cardiological and
nephro-urological conditions for whom the mean

5.5 9/5
age was significantly lower (p B/0.0001, Table II).

43%

56%
59%
61%
46%
41%
13%
2%
The male/female ratio was 1.1 in non-chronically ill

1.1
patients and 1.0 in chronically ill patients (p /0.05).
Males were overrepresented in the group of children

Nephro-urology
with chronic respiratory diseases, and females in the

2.5 9/3.2
group of children with chronic nephro-urological

76% b
problems (Table II). Patients were also divided

27%

85%
63%
47%
34%
18%
1%
0.7
according to the distance from home to the hospital:
it was less than 10 km for 66% of the non-chronically
ill patients and 55% of the chronically ill patients
(p B/0.0001), between 10 and 30 km for 26% of the

Pulmonology

6.4 9/5.1
non-chronically ill patients and 31% of the chroni-
cally ill patients (p/0.0006), and more than 30 km

34%

46%
53%
62%
66%
25%
1%

9%
2.1
for 8% of the non-chronically ill patients and 14% of
the chronically ill patients (p B/0.0001). Children

Significant difference at the 5% level between the considered subspeciality and the other NIC and CIC patients.
with neurological, haemato-oncological, endocrino-
logical and nephro-urological conditions were under-
Cardiology

2.3 9/3.3
represented among those living less than 10 km from

33% b
28%

66%
55%
66%
23%
11%

weekends; distance from home to the hospital (% of patients): A 5/10 km, B 10
/30 km, C ]/30 km.
the hospital; children with haemato-oncological and
2%
0.9

endocrinological conditions were overrepresented

among those living 10 to 30 km from the hospital;
and children with neurological, endocrinological and
Neurology

nephro-urological conditions were overrepresented

6.6 9/4.7

in the group of patients travelling long distances.

46%

52%
40%
56%
50%
31%
19%
3%
0.9

Chief complaints
The spectrum of chief complaints of chronically and
a

non-chronically ill children is provided by Table III.

5.1 9/4.9
CIC

The investigators read the chief complaint given at

Significant difference at the 5% level between NIC and CIC.
38% a

57% a

55% a
31% a
14% a
2% a
51%

59%

triage and determined whether it could be related to

1

the child’s chronic condition. For example, a child

with headache and a ventricular-peritoneal shunt
could have a complaint related to his chronic condi-
tion. In contrast, a child with vesicoureteral reflux
3.8 9/4.2
NIC

who fell off his bike would not have a chief complaint
0.9%
23%

65%
62%
66%
26%
8%
1.1

related to his condition. In this study, the chief

/
Table II. Characteristics of the visits.

complaint was related to the child’s chronic condi-

tion in 51% of the visits. It was significantly higher
for children with nephro-urological conditions and
Condition-related problem
Infection-related problems

lower for cardiac children (Table II). Fever, respira-

Admission rate in PICU

tory distress, headache and seizures were overrepre-

Age, y (mean9/SD)

sented in chronically ill children, whereas upper

Sex ratio (M/F)

respiratory tract infections, diarrhoea, abdominal

Hospital’s duty
Admission rate

pain and injury were underrepresented in the same

Distance C
Distance A
Distance B
Parameters

group (Table III). Among subspeciality groups, fever

was overrepresented in children with urological
conditions, respiratory distress and cough in children
b
a
 Chronic conditions in the paediatric emergency room 211
Table III. Distribution of chief complaints. Table IV. Distribution of diagnoses.

% visits of non- % visits of % visits of non- % visits of

Chief complaint chronically ill patients chronically ill patients Diagnosis chronically ill patients chronically ill patients
a a
Fever 21.6 27.2 Upper respiratory 27.5 18.8
a
Upper respiratory 13.6 8.7 tract infection
tract infection Viral syndrome 12.9 15.3
a a
Diarrhoea 10.5 5.4 Gastroenteritis 11.2 5.7
a
Abdominal pain 8.9 5.9 Lower respiratory 7.6 9.3
a
Injury 7.7 4.5 tract infection
a
Cough 5.9 4.5 Minor trauma 5.7 3.1
a
Rash 4.4 2.7 Bacterial infections 2.9 5.4
a
Respiratory 3.6 8.0 Constipation 3.1 1.6
distress Abdominal pain 3.0 2.7
Vomiting 2.9 2.9 Nursing problems 2.4 1.6
Sore throat 1.7 1.2 Dermatitis 2.1 1.4
Irritability
/ 1.5 0.7 Major trauma 2.0 1.4
crying
/colic Psychological 1.4 0.7
Psychological 1.3 0.6 disorders
disorders Poisoning 1.3 0.7
Toxic ingestion 1.3 0.6 Allergy 1.1 0.6
Fainting 1.2 1.7 Gastro-oesophageal 1.0 0.8
a
Headache 1.0 3.0 reflux
Earache 0.8 0.1 Stomatitis 0.8 0.4
Febrile seizures 0.8 1 Appendicitis 0.8 0.4
Aphtous ulcers 0.8 0.4 Conjunctivitis 0.7 0.5
Red eyes 0.7 0.5 Bites 0.7 0.4
a
Bites 0.7 0.4 Vasovagal syncope 0.6 1.5
Foreign body 0.7 0.2 Cystitis 0.5 0.6
Pollakiuria 0.5 0.6 Epistaxis 0.5 0.5
Epistaxis 0.5 0.6 Foreign body 0.4 0.2
a
Chest pain 0.4 0.5 Seizures 0.3 7.4
a a
Seizures 0.3 7.5 Asthma 0.3 4.4
a
Nursing problems 0.3 0.1 Miscellaneous 9.5 15.1
a
Miscellaneous 6.3 10.1
a
Standardized residues /3 or B/ /3 in the group of chronically ill
a
Standardized residues /3 or B/ /3 in the group of chronically ill children.
children.
infections in patients with respiratory conditions,
with respiratory problems, epistaxis in children with seizures and major trauma in neurological patients,
haematological problems, and headache, febrile and and epistaxis in children with haemato-oncological
non-febrile seizures in children with neurological conditions.
conditions.

Admission to the hospital

Final diagnoses
Table IV gives the overall distribution of final diag-
noses. In both chronically and non-chronically ill
patients, the majority of final diagnoses were related
to infection (57% and 65%, respectively; p B/0.0001).
Infection-related problems were more frequent in
children with nephro-urological conditions and un-
derrepresented in children with respiratory, neurolo-
gical and endocrinological conditions (Table II).
Bacterial infections, seizures, vasovagal syncopes and
asthma were overrepresented in chronically ill chil-
dren, whereas upper respiratory tract infections,
gastroenteritis and minor trauma were underrepre-
sented in the same group (Table IV). Among sub-
speciality groups, viral and bacterial infections were
overrepresented in patients with nephro-urological
conditions, asthma and lower respiratory tract
Thirty-eight per cent of the chronically ill patients
were admitted compared to 23% of the non-chroni-
cally ill patients (p B/0.0001). When comparing sepa-
rately the subspeciality groups to the group of
non-chronically ill children, admission rate was
significantly higher in children with chronic respira-
tory, neurological, haemato-oncological and endocri-
nological conditions (Table II). Two per cent of the
chronically ill patients were admitted to the paediatric
intensive care unit compared to 0.9% of the other
patients (p/0.0007). The admission rate to the
paediatric intensive care unit by subspeciality category
varied widely (Table II). It was significantly higher for
patients with neurological and endocrinological
conditions.
Only one-third of the patients sought care between
09.00 and 18.00, Monday through Friday (this time
212 M. M. Massin et al.
period represents 27% of the study period): 38% of
the non-chronically ill children and 41% of the
chronically ill children (p/0.054). The percentage
of patients seen during the evening/night-time or on
the weekends was similar in the subspeciality groups
(Table II).
Discussion
In this study we sought to describe the utilization of
the PED by children with chronic conditions. This
study contributes to a profile of healthcare use among
children with chronic conditions by providing data
that population-based studies do not detail. Improved
medical care for children with previously fatal condi-
tions has increased the number of children with
chronic conditions. As medical science continues to
make great strides in multiple areas, the number of
children with chronic conditions will only increase.
Previous studies performed in the United States in the
1980s and at the beginning of the 1990s [7,8] showed
that 24 to 31% of US patients visiting PEDs had
chronic illnesses. However, in this study, children with
chronic conditions accounted for only a tenth of all
visits to our PED.
The first parameter that may explain such a
difference is the fact that, in our socialized healthcare
system, the majority of patients come directly to the
hospital, with no first-line selection by primary care
providers [4]. The population encountered in the
PED, even in a tertiary care centre, is more similar to
that encountered by primary and secondary health-
care providers in Western Europe than to that
encountered by specialists in tertiary care paediatrics
[4], and the patients with chronic conditions may be
‘‘diluted’’ in the flow of inappropriate users. However,
in this study, the chief complaint was related to the
child’s chronic condition in only half of the visits, and
it seems that chronically ill patients also inappropri-
ately utilize the PED, just like other people do in
Belgium.
As the previous studies were performed 15 to 20
years ago [7,8], the second parameter that may
explain such differences is the improvement of
healthcare for chronically ill children in recent
decades. This concerns the quality of therapies but
also the development of educational programmes
and of outpatient and home healthcare programmes
that can be used to prevent PED visits and
hospitalizations. Such an influence is suggested by
comparison of the data in the different studies. In
1991 [8], the most common chronic condition was
asthma, which accounted for 43% of the chronic
conditions seen. The prevalence of childhood
asthma has risen significantly in recent decades.
However, the goal of asthma therapy is no longer
just the acute care of asthma exacerbation but also
chronic care that focuses on controlling asthma by
treating the underlying airway inflammation. Educa-
tional programmes for caregivers and self-manage-
ment training also improve outcomes. The
consequence [10] is a decrease in the rate of
hospitalization and PED visits of children with
asthma, which accounted for only 16% of the
chronic conditions seen in our study. Similarly,
thanks to improved therapy strategies, only 26 visits
concerned diabetic patients, whereas nearly 200
children and adolescents with type 1 diabetes
regularly attend our outpatient clinic. Subgroups
of chronically ill children with related severe acute
illness, such as neurology or haemato-oncology,
were equally represented in the different studies
and had a high hospitalization rate. Neurology,
which is the most frequent subspeciality in our
study, was previously shown to be the most com-
mon paediatric chronic condition associated with
acute illness, resulting in 15% of unscheduled
admissions [11]. Finally, subspecialities with related
but non-severe acute illness were overrepresented in
our study. Patients with cardiological and nephro-
urological conditions most often sought care for
fever or other infectious signs. It was perceived by
some of our PED physicians that those patients
sought care in the PED for problems that could
have been resolved by a primary care physician. As
chronically ill patients more often travelled long
distances, it may be supposed that those children
and their families are more reassured if the patient
is examined in his/her usual tertiary care centre by a
paediatrician who has easy access to his clinical
chart and to technical resources, and who may more
easily have contact with subspecialists.
In this study, as in the previous ones, many
chronically ill patients were seen during the evening/
night-time or on the weekends, implying that the
maximum benefit from having experienced paediatric
physicians on staff at a PED is not limited to classical
daytime, between 09.00 and 18.00, Monday through
Friday. Families of children with chronic diseases
often complain of having to deal with physicians and
nurses who do not know their child, or even specific
rare conditions. However, those children with chronic
illnesses and disabilities often require care over many
years. In these long-term relationships, factors im-
portant to total quality management and consumer
satisfaction relate to continuity, communication and
partnership. It would be difficult for each subspeci-
ality service to provide on-site care 24 h a day, 7 days a
week. It is therefore important to improve and
expedite the care of patients with chronic conditions
by training paediatric residents and emergency med-
icine physicians to care for those children. Physicians
need to stay educated regarding best practices and
evidence-based care for those complex patients. The
 Chronic conditions in the paediatric emergency room
diversity of patients illustrates one of the inherent
challenges posed by childhood chronic conditions,
which are characterized by their heterogeneity, and
often present as rare or even singular diagnostic or
management challenges for the community healthcare
system. Efforts to promote communication and col-
laboration between all care providers must therefore
be improved by ensuring that subspecialists, PED
physicians, primary care physicians and all other
support systems are flexible, accessible and compre-
hensive in responding to diverse family-identified
needs.
Conclusion
From the analysis of our data, we conclude that
children with chronic conditions account for a tenth
of all PED visits in Belgium. Paediatric emergency
physicians provide an important service to both the
children with chronic conditions and the subspecia-
lists who care for them. Paediatric emergency depart-
ments may need to refine their systems in order to
serve this group of patients as efficiently and effec-
tively as possible.
Acknowledgements
We thank the Belgian ‘‘National Foundation for
Research on Paediatric Cardiology’’ for financial
support of the research work of Prof. Massin.
213
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