The epidemiology of minor surgical problems during specialists' absence: Single center, descriptive study

Abstract Background In Japan, even if physicians have not experienced surgical training, they face many instances in which they must provide initial surgical treatment, especially during off‐hours. This study aimed to identify the frequency and fields of commonly encountered problems in a Japanese emergency department. Methods A retrospective review was performed to identify walk‐in outpatients with exogenous problems visiting during off‐hours in the Japanese educational hospital providing primary to tertiary emergency care between January 1 and December 31, 2014. Diseases were aggregated according to International Classification of Primary Care (Second Edition; ICPC‐2). Results During the study period, 33 424 patients visited and 7476 were classified into the “exogenous” group. We analyzed the data of 7421 patients after excluding 55 who were deemed undiagnosable based on reviews of the charts. The median age of patients who visited the ED during off‐hours was 29 years (range: 0‐101 years, IQR: 8‐60 years). Altogether, 226 types of problems included in ICPC‐2 were identified during the study period. The majority fields of exogenous problems were ‘skin,’ ‘Musculoskeletal,’ and ‘eye.’ The 15 problems with the highest frequencies accounted for 50.2% of the total problems. Conclusions We identified surgical problems with high treatment frequencies among patients visiting the ED during off‐hours. Providing education focusing on these frequent surgical problems can help to improve the initial treatment quality and reduce the anxiety for those doctors who provide initial surgical treatment.


| Study design and settings
We conducted a descriptive study through a retrospective review of patients who attended our outpatient department during off-hours between January 1 and December 31, 2014. Our hospital is a 1000bed educational hospital located in a suburban area in Japan. The hospital's emergency medical center is the only one in the region, providing primary to tertiary emergency care and covering approximately 180 000 people in the medical area. 9 Annual numbers of emergency walk-in outpatients and ambulances accepted were approximately 30 000 and 8000, respectively.

| Study participants
Walk-in outpatients who visited during off-hours (16:30-8:30 on weekdays and all hours on weekends) were classified by trained nurses into five groups based on their complaints and vital signs: endogenous, exogenous, pediatric, obstetrics-gynecology, and critically ill. Patients who had unstable vital signs at any time were sorted into the critically ill group. For the purpose of this study, we included only those patients who were classified as the exogenous group. Further, we excluded patients whose presenting disease was unidentifiable through a review of their medical records.

| Measurements
The data were collected from the hospital medical records included age, gender, and clinical modification codes from the International Classification of Diseases, 10th Revision (ICD-10). When the presenting disease was unidentifiable, two physicians (TA and TM) who are board-certified members of the Japanese Society of Internal Medicine and were trained in primary care and emergency medicine examined the medical charts.
Subsequently, the ICD-10 codes were transferred to the corresponding International Classification of Primary Care (Second Edition; ICPC-2) codes using the ICPC-2 comparison table (electronic version 7.0). 10,11 The ICD-10 involves comprehensive classifications combining lesion site and etiology; however, this was too detailed for the present study and there was the possibility that what we considered individual problems may have been separated into numerous minor conditions in the ICD-10. Therefore, we decided to convert the diagnosis to ICPC-2, which uses general disease or problem names.
We aimed to uncover the frequency and disease composition of minor surgical problems in patients who attended the outpatient department during off-hours. In addition, we examined whether the disease frequency changed with age. Therefore, we also divided the patients into three age subgroups: children (0-14 years old), adults (15-64 years old), and elderly (65 years and older). F I G U R E 1 Study flow

| Statistical analysis and ethics
Comparison between the ages of the participants using the ICPC-2 field was performed using a chi-square test or Fisher's exact test.
A 2-sided P-value < .05 was considered statistically significant.
Numerical variables were expressed as median, range, and interquartile range (IQR), and categorical variables were expressed as number and percentage. The data were analyzed using STATA 14.0 (StataCorp).
The ethics committee approved this study (approval no. 15 194).
This study was conducted in accordance with the principles of the Declaration of Helsinki. 12 This manuscript was written according to the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) guidelines. 13

| RE SULTS
During the study period, 33 424 patients visited the ED during offhours; of these, 7476 were classified into the exogenous group. We  Table 1. In addition, the differences of the disease frequency were observed between age-groups (children, adults, and elderly) in S, L, and F as well as the General and unspec-   [L72: Fracture: radius/ulna] (n = 166, 2.2%). The 25 surgical problems with the highest frequencies, excluding "other," are shown in Table 2.
The 15 items with the highest frequencies accounted for 50.2% of the total.
The disease compositions and frequencies for each age-group are shown in Table 3. The 9, 18, and 13 items accounted for over 50% of the subgroup total in the children, adults, and elderly group, respectively.

| D ISCUSS I ON
This study examined the types and frequencies of minor surgical problems treated at an ED during off-hours in Japan. Of the patients who visited the ED during off-hours, 22% had surgical problems; specifically, the problems with the highest frequencies were those related to the skin (ICPC-2 code "S": 38.3%), musculoskeletal (ICPC-2 code "L": 31.6%), and eye (ICPC-2 code "F": 8.6%). A Greek study has also shown high treatment frequencies for these fields. of problems included in ICPC-2 were encountered over the entire study period, these 15 problems accounted for a large proportion of the surgical problems. Further examination of the age subgroups revealed that 9 and 13 items accounted for over 50% of the total, in children and the elderly group, respectively. Although the disease frequencies were somewhat varied, the disease composition of the top-ranking diseases shared many items across all groups. These results suggest that there was a specific trend of disease frequencies encountered during off-hours; these 15 problems can be leverage points. In addition, the initial treatment for these 15 problems could include procedures that do not require a high degree of expertise.
Thus, although it is necessary to consider whether the prognosis of these problems can be improved through treatment intervention in 15 problems, the results underscore the fact that the doctors treating surgical problems in the ED should prioritize the acquisition of knowledge about these truly common surgical problems as well as treatment for critical conditions. Nonetheless, our results can assist clinicians in identifying the frequency of minor surgical problems in the ED. Finally, as outcome evaluations were not performed, it is unclear whether training based on disease frequency obtained from this study will improve patients' outcomes.

| CON CLUS ION
We identified problems with high treatment frequencies among patients with surgical problems who visited the ED during off-hours. If doctors improve their knowledge about these problems, it may be possible to improve the initial treatment quality.
Providing education focusing on these frequent surgical problems may help to improve the initial treatment quality and reduce the anxiety of the doctors who provide initial surgical treatment.

ACK N OWLED G EM ENTS
None.

CO N FLI C T O F I NTE R E S T
The authors have stated explicitly that there are no conflicts of interest in connection with this article.