Artículo Clínico

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Epidemiological study of oral and maxillofacial
emergencies in a general hospital
Estudio epidemiológico de las urgencias en cirugía oral y
maxilofacial en un hospital general

 

B. Peral Cagigal¹, F.J. Barrientos Lezcano¹, M. Galdeano Arenas¹,
L.A. Sánchez Cuéllar², A. Verrier Hernández³

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Abstract: Objective. The demand placed on emergency care units continues to increase at a growing rate, in special Maxillofacial Surgery. The objective of the study is to perform an epidemiological analyses in the emergency maxillofacial area. Design. Transversal observational study of the patients attended in the maxillofacial department in the Rio Hortega Hospital Emergency Services during one year (2002). 1.970 patients and 10 variables were analysed. Results. 1.970 patients were attended. Males (55,8%) were predominant all over females. The month of highest incidence was June (10,9%) and the day of the week Sunday (15,8%). The dominant group of age was 0-10 years (22,6%). Most common aetiology was the accidents (55,1%) and the diagnosis was maxillofacial trauma (55,6%). The treatment was medical in 58,5% of cases. Hospital admissions rate was 9,4% and a 33,1% need a revisions. The rate of patients in our hospital area was 90,3%. Conclusions. The age's rank more common in patients attended was between 0-10 years and most of them were male. The day with more assistencial demand was Sunday and the month June. The aetiology for assistance was accidents and traumatism was the principal diagnosis in our hospital. The treatment usually was medical. Key words: Epidemiologic study; Emergency; Maxillofacial Surgery.

Resumen: Objetivo. La demanda de asistencia en los Servicios de Urgencias Hospitalarias está en constante crecimiento desde hace varias décadas y en especial en la Cirugía Maxilofacial. El objetivo de este estudio es realizar un análisis epidemiológico de las urgencias que se producen en dicha especialidad. Diseño del estudio. Estudio transversal y observacional de pacientes atendidos por Cirugía Maxilofacial en el Servicio de Urgencias del Hospital Río Hortega de Valladolid durante el año 2002. Se analizaron 1.970 pacientes y 10 variables. Resultados. Se atendieron 1.970 pacientes, de los cuales el 55,8% fueron hombres. La mayor presión asistencial se produjo en domingo (15,8%) y en el mes de junio (10,9%). El rango de edad con mayor demanda asistencial fue de los 0 a los 10 años (22,6%). La etiología más común por la que los pacientes fueron atendidos resultaron ser los accidentes (55,1%) y el grupo diagnóstico los traumatismos (55,6%). El tipo de tratamiento inmediato más frecuente fue el médico (58,5%). Fueron ingresados el 9,4% de los pacientes y revisados en consulta un 33,1%. El 90,3% de los pacientes pertenecían al área del hospital. Conclusiones. El rango de edad más frecuente de los pacientes atendidos es de 0 a 10 años y la mayoría de los pacientes que acuden a urgencias son hombres. El día con mayor presión asistencial es el domingo y el mes con mayor número de urgencias y de ingresos es junio. La etiología por la que acuden más frecuentemente a urgencias son los accidentes y la traumatología configura la patología maxilofacial con mayor demanda de atención urgente en nuestro hospital. El tratamiento más frecuente es el médico. Palabras clave: Estudio epidemiológico; Urgencias; Cirugía Maxilofacial.

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1 Médico Residente.
2 Médico Adjunto.
3 Jefe de Servicio.
Servicio Regional de Cirugía Oral y Maxilofacial.
Hospital Universitario del «Río Hortega». Valladolid. España.

Correspondencia:
Dra. Peral Cagigal
Servicio Regional de Cirugía Oral y Maxilofacial,
Hospital Universitario del Río Hortega,
C/ Cardenal Torquemada s/n, 47010 Valladolid, España.
E-mail: beaperal77@yahoo.es

 

Introduction

The demand for assistance by hospital emergency services has been growing constantly for various decades and especially in Maxillofacial Surgery. The study was carried out in the Emergency Unit of the «Hospital Rio Hortega» in Valladolid. This hospital depends on the SACYL (Health Service of Castilla and León), with 539 beds, which attends a population of approximately 235.000 inhabitants, corresponding to western Valladolid (even though the geographical area of reference is the whole of Castilla and León in the case of Maxillofacial Surgery.

Oral and Maxillofacial Surgery has been defined by the National Commission of Specialties as a medical-surgical specialty that deals with the prevention, study, diagnosis, treatment and rehabilitation of the pathology of the oral cavity and face, as well as with cervical structures that are directly or indirectly related.

It is important to bear in mind the quality of assistance within Oral and Maxillofacial Surgery, so that the patient sees the assistance as effective, accessible, acceptable and useful, without forgetting the importance of providing adequate information. In this way a satisfactory patient-user relationship with the health system will be reached.¹

The Emergency Unit is one of the most complex departments having the greatest demand for assistance within hospital centers. Unlike other levels of hospital attention, the pressure on assistance together with the time it takes to carry out a proper clinical evaluation, and the pressure to adopt decisions that will make the Service operate faster, are factors which condition performance during emergencies. ²

In the case of the «Hospital Universitario Rio Hortega», the Emergency Unit offered initial attention at the so called «filter» point, where the emergencies are categorized according to a level of priority, so that patients are attended according to the degree of urgency of their case, independent of the order in which they arrive, and they are sent to a specialist if considered appropriate. That is to say, the patients that attend this Service are screened.

During 2002, a total of 93.311 patients were attended by the Emergency Unit in our hospital. Of these 1.970 were attended by the Service of Maxillofacial Surgery, which represented 2.1% of the total.

In the national and international literature there are several publications describing Epidemiologic studies of patients that attend the Emergency Services of different localities.^3,4

Studies of this type have been carried out in our Autonomous Community, and to be more exact, in our hospital5, but medical emergencies have been analyzed in a general way. We therefore decided on a more specific study with regard to emergencies in Maxillofacial Surgery.

Material and method

All the patients that came to the Emergency Unit in the «Hospital Universitario Rio Hortega», Valladolid during the year 2002 and that were attended by the Maxillofacial Surgeon on duty, were included in the study.

Emergencies related to patients already admitted for Maxillofacial Surgery or any other specialty were excluded, as well as patients with minor emergencies that were attended by staff in the Emergency area. A total of 1.970 patients were included.

Data collection: The study was carried out in a transversal and observational mode and the following variables were taken into account: day of the week, month, age, gender, etiological group, dignostic group, immediate treatment, admission into Maxillofacial Surgery, external follow-up care and origin of the patient.

The statistical study was carried out using the SPSS 10.0 program and a descriptive study was carried out with the data. Frequency and contingency tables could then be drawn up.

Results

During the year 2002 a total of 93.311 patients were attended by the Emergency Unit, of which 1.970 were evaluated by the Maxillofacial Surgeon, which represented 2.1% of the total number of patients attended, and an average of 5.39 patients per day.

A total of 15.915 people were admitted into our hospital through the Emergency Unit during the year 2002, which represented 17.6% of the total of patients attended. Of these 185 were admitted for Maxillofacial Surgery, which represented 1.2% of the total number of patients admitted and 9.4% of the total number of patients attended by the Maxillofacial Surgeon.

Gender. Of the 1.970 patients attended in the Maxillofacial Surgery Unit during 2002, 55.8% were men (n = 1.100) and 44.2% women (n = 870).

A total of 185 patients were attended, of which 70.8% were men (n = 131) and 29.2% were women (n = 54).

Emergencies due to wounds and/or facial trauma were more frequent in men (61.7%) than in women (38.3%).

Men made up 93.7% of the patients that attended the Emergency Unit due to accidents at work, 71.2% of those attended because of traffic accidents, and 82.6% of patients that had suffered an aggression were men (n = 30, n = 94 and n = 62 respectively).

In the rest of the diagnostic groups there were hardly any differences between males and females, with the exception of emergencies derived from the temporomandibular joint, in which 74.6% of the patients were women. (n = 53).

Age of the patients. The 0–10 age group demanded most assistance, representing 22.6% of the total (n = 445). The second most frequent age group was the 21 to 30 group with 21.2% (n = 418).

The 21 to 30 age group had the most admissions (n = 52, 28.1% of the total) and the group that most needed follow-up care 27.4% of the total number of patients seen for consultation; (n = 179). Figure 1 gives a breakdown according to the gender and age of the patients treated in the Emergency Unit.

Day of the week. The rate of assistance according to the day of the week reflected that the greatest pressure was produced on Sundays (15.8%; n = 311), and the least on Mondays (13.5%; n = 265).

The day of the week registering the greatest number of patient admissions was Thursday (18.9%; n = 35), followed by Sunday (15.7%; n = 29).

Men attended the Emergency Unit more on Sundays (16.7%; n = 184) and women on Fridays (15.7%; n = 137).

Lesions from traffic accidents were more frequent on Fridays (21.9% of the accident total) and from aggressions it was Sunday (24%).

Month. The month with the largest number of emergencies was June with 10.9% of the total (n = 214), followed by March with 9.7% (n = 192), and the lowest was August with 6.4% (n = 126).

The average number of patients attended for Maxillofacial Surgery in a month was of 164.2 patient/month. Figure 2 shows the breakdown of patients attended every month.

The month of June was the month with the greatest number of admissions (n = 28, 15.1% of the total), and November the month that had the least number of admissions (3,2%; n = 6).

The month with most work related accidents was May (21.8% of the total; n= 7), with most traffic accident was June (14.4%; n = 19) and the month with most aggressions was September (16%; n = 12).

Etiology. 55.1% attended the Emergency Unit due to accidents and other lesions, and 44.9% were attended for illness. Table 1 shows the breakdown of the different etiologies as a result of which the patients attended the Emergency Unit.

The most common cause of wounds and cervicofacial contusions were fortuitous accidents (in 77.7% of cases), the same as for fractures of facial bones (60.4%). Aggressions produced mainly wounds and cervicofacial contusions (54.7%; n = 41) and mandibular fractures (20%; n = 15).

The most common reason for patients in the 0 to 10 age group attending the Emergency Unit were fortuitous accidents (n = 385; 45.5%): and for patients between 21 and 30 it was illness (n = 259; 29.2%).

Diagnosis. The patients were divided into 8 principal diagnostic groups, trauma being the most frequent diagnosis in the Emergency Unit (55.6%; n = 1093) followed by dental emergencies (20.2%; n = 397). Table 2 shows the breakdown in percentages of the different diagnostic groups. Dental emergencies, cervicofacial infections and temporomandibular joint disorders were most common in the 21 to 30 age group. The 42.5% of facial wounds were produced in children in the 0 to 10 age group (n = 350) and 21.1% of facial fractures occurred in the 21 to 30 age group (n = 57).

The most frequent diagnosis of the patients transferred from other hospitals were also cervicofacial wounds and trauma; the «Hospital Clínico Universitario» of Valladolid transferred during the year 2002 a total of 101 patients, of which 66 were due to wounds and trauma (65.3%). The most common fracture was the mandibular fracture (n = 104; 53%) followed by dentoalveolar fractures and dental trauma.

Treatment. The type of treatment given immediately was medical treatment 58.5% of the time (n = 1.153), and surgical with local anesthesia 41% (n = 807) and surgical with general anesthesia in 0.5% (n = 10).

Medical treatment was the main treatment for toothaches and dental infections (20.9% of the total number of cases requiring medical treatment; n = 241).

Surgical treatment with local anesthesia was used principally for cervicofacial wounds (72.5% of the total number of cases having this treatment; n = 585).

Surgical treatment with general anesthesia was necessary especially in patients with cervicofacial wounds (30% of the total number of patients operated under general anesthesia; n = 3).

Admissions. Of the total number of patients attended during the year 2002, 185 patients were admitted, of which 118 belonged to our hospital area and 67 were transferred from other hospitals; the «Hospital Clínico Universitario» of Valladolid was the hospital that generated the most admissions, with 22.4% of the total number of transfer related admissions (n = 15).

Figure 3 shows the breakdown of patients depending on outcome, whether they were sent home or admitted, according to age.

In short, 9.4% of patients seen in the Emergency Unit by the Maxillofacial surgeon were admitted (n = 185).

The most common etiology leading to admission was fortuitous accidents (33.5%; n = 62), followed by illness (31.8%; n = 59) and traffic accidents (20%; n = 37).

The most common reason for being admitted were mandibular fractures (20% of the total; n = 37) followed by fractures of the orbital rim and cheekbone (13.5%; n = 25).

Follow-up. 33.1% of patients evaluated in the Emergency Unit received follow-up care by the Maxillofacial Unit (n = 653).

The most frequent etiology in relation to follow-up visits was illness (61.5%; n = 402). The pathology that resulted in the greatest number of follow-up visits were toothache and dental infections (14.2% of the follow-up visit total; n = 93).

Of the patients that came for follow-up care, 55.8% were men (n = 365).

Origin. 90.3% of patients attended belonged to the «Hospital Rio Hortega» (n = 1.779) and the rest were transfers from other hospitals (n = 191). Table 3 shows the percentage of patients transferred from the different hospitals of our Autonomous Community.

The most frequent etiology related to the transfers was fortuitous accidents (45.5%; n = 87) and the most frequent age range was 21 to 30 (20.9%; n = 40). Of the patients transferred 58.6% were men (n = 112) and the most frequent diagnosis were wounds and cervicofacial trauma (n = 134; 70.1% of the total).

Discussion

With regard to emergency care in hospitals, the epidemiologic data of the individuals requesting it has to be understood, together with the most frequent pathologies attended, and the treatments carried out.

We decided to carry out this type of observational, transverse study because it allows obtaining a good epidemiological analysis of emergencies in the field of Maxillofacial Surgery in our Community, and we were able to compare it with other hospitals as a result of the bibliographic revision carried out.

Overall, it was individuals of the male sex that attended the Emergency Unit more frequently, which coincides with the results of other publications.^3,4,6,7-9 In addition, 61.7% of wounds and trauma were produced in men (n = 674), which also corresponds with other studies.^11,12

The age range requiring most care was the 0 to 10 group representing 22.6% of the total, which coincides with some studies⁵ and differs from others,^4,6 but the group with the greatest number of admissions was in the 21 to 30 age range. The assistance per day of the week reflects that the greatest pressure for attention was produced on Sundays (15.8%), which is the same result that appears in the publications revised.⁵ The month with the greatest number of emergencies and admissions was June, which coincides with other works.⁶

The etiology resulting in more demand for emergency care was accidents and other lesions.

The most frequent cause of facial fractures was fortuitous accidents (n = 116; 60.4%), which differs from other studies in which the most common cause was traffic accidents. ^10-15 The most common fracture was the mandibular fracture (n = 104; 53%), which coincides with other publications. ¹⁴ Dental emergencies, cervicofacial infections and temporomandibular joint disorders were the most frequent in the 21 to 30 age range.¹⁶

Emergencies due to temporomandibular disturbances were more frequent in women (74.6%) than in men, which coincides with various publications.^17-19

Facial wounds and dental trauma were more common in children in the 0 to 5 age range. However, the remaining facial trauma cases were also more frequent in people between the ages of 21 to 30, which coincides with other studies.^11,12

Therefore, trauma and dental emergencies represent the maxillofacial pathology requiring most emergency care in our hospital.

Patient treatment for maxillofacial emergencies in most cases was medical.

During the year 2002, 185 patients were admitted, which represents a hospitalization rate of 9.4%, a similar result to that carried out in our hospital in the year 1994 in which the percentage of Maxillofacial Surgery admissions was 11.3%.⁵ In addition to this, a third of the patients attended in the Emergency Unit were later seen in our department.

Conclusions

According to the study carried out in our hospital we can conclude that: the most common age range of patients attended was 0 to 10, and the majority of patients that attended the Emergency Unit were men. The day with most pressure for assistance was Sundays, and the month with the greatest number of emergencies and admissions was June. The etiology resulting in most visits to the Emergency Unit were accidents, and trauma represents the maxillofacial pathology with the greatest demand for emergency care in our hospital. The most common treatment carried out immediately was medical.

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