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New Zealand welcomes 322,000 tourists and 93,000 crew members annually from cruise ships. Prior to the COVID-19 pandemic, cruise ship numbers were rising yearly and contributing nearly $600 million to the New Zealand economy annually.[[1]] Inevitably, some of these visitors require medical care for minor or major ailments. Modern cruise ships often have a medical team on board and varying access to investigations and treatment. The American College of Emergency Physicians make recommendations for cruise ship medical facilities,[[2]] which are supported by the Cruise Line International Association, but this still allows for significant variability of resources and standards between ships.

Providing medical care aboard a cruise ship is a unique clinical environment often complicated by geographical remoteness, resource limitation and rotating staff. Often passengers are elderly with a variety of co-morbidities, differing health beliefs and different brands and types of medications.[[1,3–9]] It is also challenging for cruise ship physicians to be familiar with local healthcare systems and how to access specialist consultation.

From the limited cruise ship healthcare data available; 11% of medical conditions treated are potentially life threatening,[[3]] and 3% required immediate hospital assessment or intervention.[[4]] Therefore, it is understandable that not all conditions can be safely managed on board. On average, 1.4–7% of passengers or crew require on-shore assessment.[[3,4]] Studies report a high prevalence of respiratory conditions among passengers and dermatological disorders in crew,[[ 3–7]] the former being particularly relevant given the current global COVID-19 pandemic, as cruise ships are a potential reservoir for transmittable infectious diseases.[[10,11]] Trauma and gastrointestinal complaints also made up a large proportion of consultations.[[3–7]]

The management of ship passengers and crew in emergency medicine (EM) also has challenges. There may be language barriers, limited access to medical records and different healthcare expectations.

A patient’s need for timely return to the ship before departure can influence treatment decisions and interventions. Visa, immigration, and legal considerations may also contribute to decision making complexities. There can also be pressure on EM clinicians to provide letters declaring patients free from illness to continue cruising or for insurance purposes. Once discharged, there may be limited follow-up of their condition.

There is little data detailing the impact cruise ship patients and crew have on emergency departments (EDs) worldwide. Anecdotally, the perception of EM clinicians working in cities where ships frequent is that passengers become a resource burden, often of low acuity patients, contributing to ED overcrowding and access block. Therefore, we conducted a service evaluation to review the frequency and characteristics of cruise ship patient presentations to Wellington Regional Hospital ED during the Australasian “cruise season” (October to April). As secondary measures, the admission rates of cruise ship patients’ vs general practitioner (GP) referrals were compared as well as the rates of specialty review, imaging studies, or urgent intervention required.

Methods

This was a retrospective descriptive study of patients presenting to Wellington Hospital ED from passenger cruise ships between 2016 and 2019. All patients who were identified as presenting to Wellington Hospital ED directly from a cruise ship were included, encompassing both passengers and crew members. Patients who arrived in another city via cruise ship who then embarked on land-based tour were excluded.

Study setting and service provision

Wellington Regional Hospital is a publicly funded major referral centre within the Capital & Coast District Health Board that serves a population of 318,040.[[12]] It has an annual ED census of 75,000 patients per year. Wellington City received 222,448 passengers from cruise ships during the year 2019, an increase of 37% from 2018.[[1]] There are no published data on the patients who are treated each year in Wellington Hospital from cruise ships. The general Wellington ED admission rate over four years was 35%. Median length of stay (LOS) was three hours 58 minutes (admitted patients five hours, one min; discharged patients two hours, 52 mins). GP referrals had a 41.1% admission rate (10,225/24,855).

Data collection

The electronic database information system (EDIS) in ED automatically extracts patient and clinical presentation related data to the hospital data service unit (DSU). A keyword search of the EDIS database was performed to identify any patients that were cruise ship crew or passengers. Keyword search included: “cruise”, “boat”, “ship”, “passenger”, “crew” and “tourist”. This screened all clinical notes including triage, presentation, and discharge diagnosis.

The individual records were then reviewed by two study investigators (AA and JB) and included if it was confirmed the patient was a cruise ship passenger or crew member. A retrospective chart review was performed, and de-identified data were extracted using a standardised Microsoft Excel sheet. Data were collected for patient demographics, LOS in the department, triage category, presenting complaint, specialty referral, advanced imaging (computed tomography [CT] scan, formal ultrasound or magnetic resonance imaging [MRI]), or interventions (angiography, interventional radiology, surgery, intensive care unit [ICU] admission or transfer to other hospital), patient disposition, discharge diagnoses and outcomes. Information regarding whether patients were crew or passenger, and if they self-referred or were referred by the cruise ship doctor were also recorded. Study investigators were not blinded to the service evaluation intentions and the data collection form was not piloted or checked for interrater reliability, but this is unlikely to have significantly affected the results given the majority of nominal discrete clinical variables.

Statistical analysis

Data were coded and statistically analysed using SPSS software (SPSS Inc. Released 2019. Version 26.0, IBM Corp, Armonk, New York, USA). To describe the data, frequency, and proportions with 95% confidence intervals (CIs), and medians with interquartile ranges (IQRs) were calculated as appropriate. Admission rates and median ED LOS of cruise patients were compared to local ED data. Comparisons between crew and passengers and those admitted and discharged were performed statistically. The null hypotheses were that there would be no difference in admission rates, LOS or interventions between the crew and passenger patients. The null hypotheses regarding patients admitted vs discharged were that there would be no differences in demographics, acuity as measured by triage category and intervention rates. Chi-squared tests or Fisher’s exact tests were used to compare proportions where appropriate and Mann–Whitney U testing was performed to compare continuous skewed data. Missing data were not included in statistical testing.

Ethical statement

This project was deemed out of scope for full HDEC review. Local authority approval was sought and approved by the CCDHB Quality Improvement Project Teams and the senior leadership team at Wellington Regional Hospital ED.

Results

A total of 214 patients were identified as presenting to the ED from cruise ships during the study period. Accepting the limitations of cruise patient identification, this equates to 0.1% of ED presentations during the cruise season, assuming the census data is divided equally across the year. Baseline characteristics are detailed in Table 1. The median age of patients was 68 (IQR 43.0–76.0), 116 (54.2%) were >65 years old and 97 (45.3%) were female. Passengers accounted for 77.1% (165/214) of the sample and 22.9% (49/214) were crew members.

A summary of presenting complaints, triage category and diagnosis are detailed in Table 2. The frequency of complaints is in keeping with what would be expected for ED presentations with chest and abdominal pain among the most common. The majority presentations had an Australasian Triage Scale (ATS) category of 3with category 4 being the next most frequent designation. Five patients had missing triage data. The most common EM diagnoses were other infections (28/214, 13.1%),respiratory infection (24/214, 11.2%), fracture (22/214, 10.3%), and acute surgical abdomen (12/214, 5.6%).

Detailed in Table 3, the median LOS was 3.8 hours (IQR 2.7–5.2).Available data demonstrated that 79/214 (36.9%) patients were referred to hospital;63/214 (29.4%) were referred to EM by a cruise ship doctor; and 16/214 (7.4%) were referred directly to an in-patient specialty. Patients self-presented in 135/214(63%) of cases. A further 97/214 (45.3%) of patients were referred to specialties by EM, meaning that 113/214 (52.8%) were reviewed by a specialty team in ED. In46/214 (21.5%) of cases advanced imaging (CT, formal ultrasound, or MRI) was required. Acute intervention (angiography, interventional radiology, surgery, ICU admission or transfer to another hospital) was required in 21/213 (9.9%) patients. Regarding disposition, 82/214 (38.3%) of patients were admitted; 35/214 (16.4%) to the ED observation unit, and 47/214 (22.0%) to a hospital ward. There were 131/214 (61.2%)discharges from ED; 65/214 (30.4%) patients were discharged after EM review, and66/214 (31.0%) were discharged after in-patient specialty review. One patient died in ED and a further death occurred after admission to a hospital ward. The admission rate for the included patient presentations from cruise ships was marginally higher when compared to 35% in the general ED population, but lower than the 41% admission rate for GP referrals.

Table 4 displays a comparison of factors amongst patients who were admitted compared to those who were discharged. Patients were more likely to be admitted if they were older (median age 72 [IQR 65.0–81.0] vs 63 [IQR 34.0–72.5], p<0.001) or if they had a higher acuity ATS triage category (66/79 [83.5%] of patients admitted had an ATS triage category of 1–3 compared to 56/130 [43.1%] of discharged patients, p<0.001). Patients who self-referred were more likely to be discharged (91/135, 67.4% vs 33/63 52.4%; p<0.001).

There were differences in presentation features between passengers and crew members, shown in Table 5. The median age of crew members was 32.0 years (IQR 27–38) vs the median age of passengers of 72.0 years (IQR 64–79). Crew members were more frequently male (37/49 [75.5%] vs 80/165 [48.5%]). Crew members were triaged with lower acuity, were less likely to require radiology, urgent intervention or be admitted. LOS and referral rates were not significantly different between the groups.

View Tables 1–5.

Discussion

Over the four-year evaluation period, a relatively small number of patients from cruise ships were seen in our ED. A wide range of presenting complaints and diagnoses were made in keeping with general ED epidemiology. Infection, particularly respiratory, accounted for the largest proportion of patient presentations. Of presentations, almost two thirds were of high acuity according to the ATS, half required in-patient specialty review, one in five required specialist radiology, one in ten required urgent intervention and 38% were admitted to hospital. Passengers were more likely to be older, have higher acuity ATS scores and higher admission rates compared to crew. This admission rate is comparable to the general ED population (35%) and GP referrals (41%). Patients referred by cruise ship doctors were more likely to be admitted with a rate of 48% compared to self-referrals at 30%.

The identified pathology among cruise ship patients aligned with current studies, noting that respiratory illness, trauma, and gastrointestinal complaints are a large proportion of presentations.[[3–7]] Recent research demonstrates the impact and spread of respiratory illness on cruise ships.[[10,11]] Ships were highlighted as vectors for the spread of the novel coronavirus. As cruise ships recommence operation, respiratory viruses from cruise ships could become a significant burden on EDs and public health internationally; especially given factors such as age and co-morbidities of passengers and prevalence of opposite-season travel.[[10]] This highlights an area in which planning with ports and cruise ship companies would be prudent to ensure appropriate care of patients, and that local health systems are not overwhelmed.

In general, the admission rates of cruise ship patients are comparable to EM and GP rates, being slightly higher than general EM and slightly lower than GP admission rates. We postulate that the rate of admission may have been higher among cruise ship patients due to limited capability for follow up if there is any diagnostic uncertainty; or may relate to appropriate assessment by cruise doctors of patients requiring admission. Another contributing factor was likely the age distribution among passengers. Previous epidemiological studies show a high proportion of elderly among tourist presentations to hospitals; they are more likely to require admission for falls or exacerbations of chronic conditions;[[9]] longer LOS in ED and the hospital, as well as higher mortality rates. These past studies advocated for education and warning for tourists prior to travel, particularly those who are older and have existing medical conditions.[[9]]

Cruise ship doctors must decide which patients need emergency care or specialist review. Our results indicate relatively high levels of admission, intervention and in-patient specialty review of patients referred to EM, suggesting these medical decisions are just and appropriate. Notably, there were high rates of self-referral, mostly among crew members, and the number of self-referrals vastly outweighed the number referred in by the ship’s doctor. The ATS category, rate of admission, and requirement for intervention was lower in this group. This potentially indicates an area for improvement—there may be limited knowledge amongst cruise ship crew and passengers about other available community urgent care or primary care options. This may be improved by better communication with cruise companies directly, education at the port on arrival, or with patients at ED reception. However, it is acknowledged that the ATS triage category assigned, used as a surrogate marker for acuity in this evaluation, is not always a direct analogue of acuity or suitability for EM assessment. We were particularly surprised by the high rates of self-referral by crew members, given that they have access and likely a relationship with the cruise ship doctor. Reasons as to why crew self-refer cannot be answered based on our data, but may be due to not wanting to disclose information to someone who is also a crew member, or potentially wanting a second opinion. The decisions behind crew members health seeking behaviors to ED require further investigation; but again, is a key area where education could be beneficial.

Other studies have commented on the difficulty for cruise doctors of navigating foreign medical systems.[[13]] Deciding which patients can be safely managed in the community settings is important to improve processes and workflow, mitigate overcrowding and provide better outcomes for all patients.[[14]] ED overcrowding is one of the biggest challenges facing clinicians today. The Australasian College of Emergency Medicine (ACEM) believe that ED overcrowding is one of the most significant issues impacting patient safety in Australian and New Zealand EDs.[[15]] It is therefore critical that any factor that exacerbates this issue is identified and remedied.

The LOS for discharged cruise ship patients was longer than the general ED population (3.4 hours vs 2.9 hours). One of the factors influencing this may be the need for EM clinicians to make safe and timely decisions regarding discharge disposition. The patient’s time pressure to return before the ship departs must be balanced against the ship’s potential geographical isolation from advanced medical care for several days or longer. Thus, a longer period of observation may be required, with more diagnostics and interventions in order to confirm or deny presence of serious pathology before safe discharge. Early recognition that cruise ship populations have different needs to the general population of EDs and may require more investigations to ensure safe discharge may improve prioritisation and help LOS.

Limitations

The main limitations relate to the nature of data collection; some of these are detailed in the methods section. A notable limitation related to the identification of study patients. As the keyword search function was used to identify cruise ship patients, we may have missed those that presented when the selected key words were not present in their medical chart. It also would not account for spelling errors given the system is largely free text. Retrospective chart review has inherent limitations. Data collected were limited to what was contained in the electronic notes and, therefore, may not be a complete accurate record of each patient encounter. The patient selection process may also have some flaws. Keywords were used to conduct a local database search for appropriate patients to include in the study. If there were spelling mistakes in the electronic record, these patients would have been missed in the extraction of data. It is also possible that there were some cruise patients who did not have any of the keywords in their electronic records. Furthermore, often a paper or handwritten referral from a cruise ship’s doctor may have been sent with the patient which was not electronically recorded. Hence, there may be missing data about referral status, which could underestimate the rate of referrals. There were also small amounts of missing data regarding triage data (n= 5); however, this is unlikely to have affected the results.

Organisational learning

The key learnings from this study are that in general cruise ship patients account for a small proportion of total ED patient load. Cruise ship doctors seem to have good judgement regarding suitable EM referrals given the high rates of admission, intervention, imaging, and specialty review. Working with cruise liner companies and ports to better educate passengers, crew and cruise ship medical teams of community health care options may reduce the volume of self-referrals. Respiratory illnesses and infections are the most common pathology seen and notably could be a significant burden to ED in the presence of a pandemic. Therefore, EDs and cruise ship medical teams should consider designing an escalation management plan to work in partnership should such an event arise.

Conclusion

Overall, the number of cruise ship patients presenting to the ED was relatively few compared to the annual ED census and therefore unlikely to significantly contribute to overcrowding in our ED. It would be prudent to identify early that the needs of a tourist patient or cruise patient may be different to a general EM patient. Communication should be improved with cruise ships and port services regarding what non-emergent or primary care services are accessible, what resources or specialist reviews the patient is likely to be able to access via our public health system, and what is an appropriate referral to hospital services. Lastly, in light of the COVID-19 pandemic, it would be beneficial to have clear guidance between hospitals and cruise ships and port services about transferring patients with transmissible illnesses.

In future we may see the continuation of growth of the tourism industry, meaning the burden of cruise ship patients and tourists may continue to increase. In this study we have initiated analysis of the impact of these patients on Wellington Hospital ED; this should be re-evaluated in the future to ensure we continue to meet our patients' changing needs and could encompass further tourist groups or other centres with high numbers of tourist patients.

Summary

Abstract

Aim

Patients presenting to emergency departments (EDs) from cruise ships are a unique cohort of patients with several management challenges. Little evidence details the effect this has on EDs in terms of resource use. Therefore, we aimed to review the frequency, characteristics, admission, and intervention rates of cruise ship patient presentations to ED.

Method

This retrospective study reviewed patient presentations to Wellington ED from cruise ships between 2016 and 2019. Data regarding presenting features, intervention and disposition were extracted via chart review.

Results

There were 214 patient presentations included with a median age of 68 (IQR 43.0–76.0); 97/214(45.3%) were female. Regarding referral, cruise ship doctors referred 79/214 (36.9%) patients; 16/79 (24.1%) to in-patient specialties and 63/79 (79.7%) to emergency medicine (EM); and 135/214 (63%) self-referred to ED. Common presenting complaints were chest pain, abdominal pain and trauma. Advanced imaging was requested for 21.5% of patients and 9.9% required urgent intervention. Regarding disposition, 38% were admitted (22% to in-patient wards, 16% to ED observation unit [OU]) and 61% were discharged (30% by ED and 31% after specialty consultation).

Conclusion

Overall, the number of cruise ship patients presenting to the ED was low and unlikely to be a significant resource burden. Referrals by cruise ship doctors were appropriate. Education for cruise ship patients and port services regarding non-emergent care options would be valuable to reduce self-referral rates.

Author Information

Dr Alice Alsweiler MBChB: Emergency Medicine Doctor, Wellington Emergency Department, Wellington Regional Hospital, New Zealand. Dr Alice Rogan MBChB, BSc: Emergency Medicine Research Fellow, Department of Surgery and Anaesthesia, University of Otago (Wellington); Emergency Medicine Registrar, Wellington Emergency Department, Wellington Regional Hospital, New Zealand. Dr Emma Carlin MB BCh BAO, BA: Emergency Medicine Research Fellow, Department of Surgery and Anaesthesia, University of Otago (Wellington), New Zealand. Dr Brad Peckler MD, FACEM, FACEP: Emergency Medicine Specialist, Wellington Emergency Department, Wellington Regional Hospital, New Zealand.

Acknowledgements

The authors would like to thank Wellington Emergency Department for their data contributions; the QUIPS office at CCDHB for their local approval and support; and the University of Otago (Wellington) Department of Surgery and Anesthesia for their expertise and support. The authors would also like to thank Dr Jeremy Brankin, Emergency Medicine Doctor in Wellington Hospital, for assisting with data collection. The data that supports the findings of this project are available from the corresponding author upon reasonable request.

Correspondence

Dr Brad Peckler: Department of Emergency Medicine, Wellington Hospital, Private Bag 7902, Wellington South 6021, New Zealand

Correspondence Email

bpeckler@yahoo.com

Competing Interests

Nil.

1) Stats NZ. Cruise ship traveler and expenditure statistics: Year ended June 2019 [Internet]. NZ: Stats NZ; 16 Aug 2020 [cited 3 June 2020]. [Available from: https://www.stats.govt.nz/information-releases/cruise-ship-traveller-and-expenditure-statistics-year-ended-june-2019].

2) ACEP. Cruise Ship Health Care Guidelines: Policy Resource and Education Paper [Internet]. American College of Emergency Physicians: Irving (TX); April 2020. [cited 3 June 2020]. [Available from: https://www.acep.org/globalassets/new-pdfs/preps/cruise-ship-health-care-guidelines---prep.pdf].

3) Peake D, Gray C, Ludwig M, Hill C. Descriptive Epidemiology of Injury and Illness Among Cruise Ship Passengers. Annals of Emergency Medicine. 1999;33(1):67-72.

4) DiGiovanna T, Rosen T, Forsett R, Sivertson K, Kelen G. Shipboard medicine: A new niche for emergency medicine. Annals of Emergency Medicine. 1992;21(12):1476-1479.

5) Dahl E. Medical practice during a world cruise: a descriptive epidemiological study of injury and illness among passengers and crew. International Maritime Health. 2005;56(1-4):115-128.

6) Carron M, Emeyriat N, Levraut J, Blondeau N. Cruise ship pathologies in remote regions. International Maritime Health. 2018;69(2):75-83.

7) Konrad R, Seibt R, Weinlich M, Blau M. Medical treatment rates on shore for crew members of cruise ships. Journal of International Maritime Safety, Environmental Affairs, and Shipping. 2018;2(1):13-21.

8) Prina L, Orazi U, Weber R. Evaluation of Emergency Air Evacuation of Critically Ill Patients from Cruise Ships. Journal of Travel Medicine. 2006;8(6):285-292.

9) Eray O, Kartal M, Sikka N, Goksu E, Yigit O, Gungor F. Characteristics of tourist patients in an emergency department in a Mediterranean destination. European Journal of Emergency Medicine. 2008;15(4):214-217.

10) Young B, Wilder-Smith A. Influenza on cruise ships. Journal of Travel Medicine. 2018;25(1).

11) Rocklöv J, Sjödin H, Wilder-Smith A. COVID-19 outbreak on the Diamond Princess cruise ship: estimating the epidemic potential and effectiveness of public health countermeasures. Journal of Travel Medicine. 2020;27(3).

12) Ministry of Health NZ. Capital & Coast DHB [Internet]. NZ: Ministry of health; [updated 25 Feb 2019; cited 3 June 2020]. [Available from: https://www.health.govt.nz/new-zealand-health-system/my-dhb/capital-coast-dhb].

13) Dahl E. Referring cruise ship patients to specialists in Norway—a welfare state with a national health care system. International Maritime Health. 2015;66(2):67-71.

14) Morley C, Unwin M, Peterson G, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLOS ONE. 018;13(8):e0203316.

15) ACEM. ACEM Position Statement: ED Overcrowding [Internet]. Australasian College for Emergency Medicine: Melbourne, Australia. June 2019. [cited 3 June 2020]. [Available from: https://acem.org.au/getmedia/dd609f9a-9ead-473d-9786-d5518cc58298/S57-Statement-on-ED-Overcrowding-Jul-11-v02.aspx].

For the PDF of this article,
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New Zealand welcomes 322,000 tourists and 93,000 crew members annually from cruise ships. Prior to the COVID-19 pandemic, cruise ship numbers were rising yearly and contributing nearly $600 million to the New Zealand economy annually.[[1]] Inevitably, some of these visitors require medical care for minor or major ailments. Modern cruise ships often have a medical team on board and varying access to investigations and treatment. The American College of Emergency Physicians make recommendations for cruise ship medical facilities,[[2]] which are supported by the Cruise Line International Association, but this still allows for significant variability of resources and standards between ships.

Providing medical care aboard a cruise ship is a unique clinical environment often complicated by geographical remoteness, resource limitation and rotating staff. Often passengers are elderly with a variety of co-morbidities, differing health beliefs and different brands and types of medications.[[1,3–9]] It is also challenging for cruise ship physicians to be familiar with local healthcare systems and how to access specialist consultation.

From the limited cruise ship healthcare data available; 11% of medical conditions treated are potentially life threatening,[[3]] and 3% required immediate hospital assessment or intervention.[[4]] Therefore, it is understandable that not all conditions can be safely managed on board. On average, 1.4–7% of passengers or crew require on-shore assessment.[[3,4]] Studies report a high prevalence of respiratory conditions among passengers and dermatological disorders in crew,[[ 3–7]] the former being particularly relevant given the current global COVID-19 pandemic, as cruise ships are a potential reservoir for transmittable infectious diseases.[[10,11]] Trauma and gastrointestinal complaints also made up a large proportion of consultations.[[3–7]]

The management of ship passengers and crew in emergency medicine (EM) also has challenges. There may be language barriers, limited access to medical records and different healthcare expectations.

A patient’s need for timely return to the ship before departure can influence treatment decisions and interventions. Visa, immigration, and legal considerations may also contribute to decision making complexities. There can also be pressure on EM clinicians to provide letters declaring patients free from illness to continue cruising or for insurance purposes. Once discharged, there may be limited follow-up of their condition.

There is little data detailing the impact cruise ship patients and crew have on emergency departments (EDs) worldwide. Anecdotally, the perception of EM clinicians working in cities where ships frequent is that passengers become a resource burden, often of low acuity patients, contributing to ED overcrowding and access block. Therefore, we conducted a service evaluation to review the frequency and characteristics of cruise ship patient presentations to Wellington Regional Hospital ED during the Australasian “cruise season” (October to April). As secondary measures, the admission rates of cruise ship patients’ vs general practitioner (GP) referrals were compared as well as the rates of specialty review, imaging studies, or urgent intervention required.

Methods

This was a retrospective descriptive study of patients presenting to Wellington Hospital ED from passenger cruise ships between 2016 and 2019. All patients who were identified as presenting to Wellington Hospital ED directly from a cruise ship were included, encompassing both passengers and crew members. Patients who arrived in another city via cruise ship who then embarked on land-based tour were excluded.

Study setting and service provision

Wellington Regional Hospital is a publicly funded major referral centre within the Capital & Coast District Health Board that serves a population of 318,040.[[12]] It has an annual ED census of 75,000 patients per year. Wellington City received 222,448 passengers from cruise ships during the year 2019, an increase of 37% from 2018.[[1]] There are no published data on the patients who are treated each year in Wellington Hospital from cruise ships. The general Wellington ED admission rate over four years was 35%. Median length of stay (LOS) was three hours 58 minutes (admitted patients five hours, one min; discharged patients two hours, 52 mins). GP referrals had a 41.1% admission rate (10,225/24,855).

Data collection

The electronic database information system (EDIS) in ED automatically extracts patient and clinical presentation related data to the hospital data service unit (DSU). A keyword search of the EDIS database was performed to identify any patients that were cruise ship crew or passengers. Keyword search included: “cruise”, “boat”, “ship”, “passenger”, “crew” and “tourist”. This screened all clinical notes including triage, presentation, and discharge diagnosis.

The individual records were then reviewed by two study investigators (AA and JB) and included if it was confirmed the patient was a cruise ship passenger or crew member. A retrospective chart review was performed, and de-identified data were extracted using a standardised Microsoft Excel sheet. Data were collected for patient demographics, LOS in the department, triage category, presenting complaint, specialty referral, advanced imaging (computed tomography [CT] scan, formal ultrasound or magnetic resonance imaging [MRI]), or interventions (angiography, interventional radiology, surgery, intensive care unit [ICU] admission or transfer to other hospital), patient disposition, discharge diagnoses and outcomes. Information regarding whether patients were crew or passenger, and if they self-referred or were referred by the cruise ship doctor were also recorded. Study investigators were not blinded to the service evaluation intentions and the data collection form was not piloted or checked for interrater reliability, but this is unlikely to have significantly affected the results given the majority of nominal discrete clinical variables.

Statistical analysis

Data were coded and statistically analysed using SPSS software (SPSS Inc. Released 2019. Version 26.0, IBM Corp, Armonk, New York, USA). To describe the data, frequency, and proportions with 95% confidence intervals (CIs), and medians with interquartile ranges (IQRs) were calculated as appropriate. Admission rates and median ED LOS of cruise patients were compared to local ED data. Comparisons between crew and passengers and those admitted and discharged were performed statistically. The null hypotheses were that there would be no difference in admission rates, LOS or interventions between the crew and passenger patients. The null hypotheses regarding patients admitted vs discharged were that there would be no differences in demographics, acuity as measured by triage category and intervention rates. Chi-squared tests or Fisher’s exact tests were used to compare proportions where appropriate and Mann–Whitney U testing was performed to compare continuous skewed data. Missing data were not included in statistical testing.

Ethical statement

This project was deemed out of scope for full HDEC review. Local authority approval was sought and approved by the CCDHB Quality Improvement Project Teams and the senior leadership team at Wellington Regional Hospital ED.

Results

A total of 214 patients were identified as presenting to the ED from cruise ships during the study period. Accepting the limitations of cruise patient identification, this equates to 0.1% of ED presentations during the cruise season, assuming the census data is divided equally across the year. Baseline characteristics are detailed in Table 1. The median age of patients was 68 (IQR 43.0–76.0), 116 (54.2%) were >65 years old and 97 (45.3%) were female. Passengers accounted for 77.1% (165/214) of the sample and 22.9% (49/214) were crew members.

A summary of presenting complaints, triage category and diagnosis are detailed in Table 2. The frequency of complaints is in keeping with what would be expected for ED presentations with chest and abdominal pain among the most common. The majority presentations had an Australasian Triage Scale (ATS) category of 3with category 4 being the next most frequent designation. Five patients had missing triage data. The most common EM diagnoses were other infections (28/214, 13.1%),respiratory infection (24/214, 11.2%), fracture (22/214, 10.3%), and acute surgical abdomen (12/214, 5.6%).

Detailed in Table 3, the median LOS was 3.8 hours (IQR 2.7–5.2).Available data demonstrated that 79/214 (36.9%) patients were referred to hospital;63/214 (29.4%) were referred to EM by a cruise ship doctor; and 16/214 (7.4%) were referred directly to an in-patient specialty. Patients self-presented in 135/214(63%) of cases. A further 97/214 (45.3%) of patients were referred to specialties by EM, meaning that 113/214 (52.8%) were reviewed by a specialty team in ED. In46/214 (21.5%) of cases advanced imaging (CT, formal ultrasound, or MRI) was required. Acute intervention (angiography, interventional radiology, surgery, ICU admission or transfer to another hospital) was required in 21/213 (9.9%) patients. Regarding disposition, 82/214 (38.3%) of patients were admitted; 35/214 (16.4%) to the ED observation unit, and 47/214 (22.0%) to a hospital ward. There were 131/214 (61.2%)discharges from ED; 65/214 (30.4%) patients were discharged after EM review, and66/214 (31.0%) were discharged after in-patient specialty review. One patient died in ED and a further death occurred after admission to a hospital ward. The admission rate for the included patient presentations from cruise ships was marginally higher when compared to 35% in the general ED population, but lower than the 41% admission rate for GP referrals.

Table 4 displays a comparison of factors amongst patients who were admitted compared to those who were discharged. Patients were more likely to be admitted if they were older (median age 72 [IQR 65.0–81.0] vs 63 [IQR 34.0–72.5], p<0.001) or if they had a higher acuity ATS triage category (66/79 [83.5%] of patients admitted had an ATS triage category of 1–3 compared to 56/130 [43.1%] of discharged patients, p<0.001). Patients who self-referred were more likely to be discharged (91/135, 67.4% vs 33/63 52.4%; p<0.001).

There were differences in presentation features between passengers and crew members, shown in Table 5. The median age of crew members was 32.0 years (IQR 27–38) vs the median age of passengers of 72.0 years (IQR 64–79). Crew members were more frequently male (37/49 [75.5%] vs 80/165 [48.5%]). Crew members were triaged with lower acuity, were less likely to require radiology, urgent intervention or be admitted. LOS and referral rates were not significantly different between the groups.

View Tables 1–5.

Discussion

Over the four-year evaluation period, a relatively small number of patients from cruise ships were seen in our ED. A wide range of presenting complaints and diagnoses were made in keeping with general ED epidemiology. Infection, particularly respiratory, accounted for the largest proportion of patient presentations. Of presentations, almost two thirds were of high acuity according to the ATS, half required in-patient specialty review, one in five required specialist radiology, one in ten required urgent intervention and 38% were admitted to hospital. Passengers were more likely to be older, have higher acuity ATS scores and higher admission rates compared to crew. This admission rate is comparable to the general ED population (35%) and GP referrals (41%). Patients referred by cruise ship doctors were more likely to be admitted with a rate of 48% compared to self-referrals at 30%.

The identified pathology among cruise ship patients aligned with current studies, noting that respiratory illness, trauma, and gastrointestinal complaints are a large proportion of presentations.[[3–7]] Recent research demonstrates the impact and spread of respiratory illness on cruise ships.[[10,11]] Ships were highlighted as vectors for the spread of the novel coronavirus. As cruise ships recommence operation, respiratory viruses from cruise ships could become a significant burden on EDs and public health internationally; especially given factors such as age and co-morbidities of passengers and prevalence of opposite-season travel.[[10]] This highlights an area in which planning with ports and cruise ship companies would be prudent to ensure appropriate care of patients, and that local health systems are not overwhelmed.

In general, the admission rates of cruise ship patients are comparable to EM and GP rates, being slightly higher than general EM and slightly lower than GP admission rates. We postulate that the rate of admission may have been higher among cruise ship patients due to limited capability for follow up if there is any diagnostic uncertainty; or may relate to appropriate assessment by cruise doctors of patients requiring admission. Another contributing factor was likely the age distribution among passengers. Previous epidemiological studies show a high proportion of elderly among tourist presentations to hospitals; they are more likely to require admission for falls or exacerbations of chronic conditions;[[9]] longer LOS in ED and the hospital, as well as higher mortality rates. These past studies advocated for education and warning for tourists prior to travel, particularly those who are older and have existing medical conditions.[[9]]

Cruise ship doctors must decide which patients need emergency care or specialist review. Our results indicate relatively high levels of admission, intervention and in-patient specialty review of patients referred to EM, suggesting these medical decisions are just and appropriate. Notably, there were high rates of self-referral, mostly among crew members, and the number of self-referrals vastly outweighed the number referred in by the ship’s doctor. The ATS category, rate of admission, and requirement for intervention was lower in this group. This potentially indicates an area for improvement—there may be limited knowledge amongst cruise ship crew and passengers about other available community urgent care or primary care options. This may be improved by better communication with cruise companies directly, education at the port on arrival, or with patients at ED reception. However, it is acknowledged that the ATS triage category assigned, used as a surrogate marker for acuity in this evaluation, is not always a direct analogue of acuity or suitability for EM assessment. We were particularly surprised by the high rates of self-referral by crew members, given that they have access and likely a relationship with the cruise ship doctor. Reasons as to why crew self-refer cannot be answered based on our data, but may be due to not wanting to disclose information to someone who is also a crew member, or potentially wanting a second opinion. The decisions behind crew members health seeking behaviors to ED require further investigation; but again, is a key area where education could be beneficial.

Other studies have commented on the difficulty for cruise doctors of navigating foreign medical systems.[[13]] Deciding which patients can be safely managed in the community settings is important to improve processes and workflow, mitigate overcrowding and provide better outcomes for all patients.[[14]] ED overcrowding is one of the biggest challenges facing clinicians today. The Australasian College of Emergency Medicine (ACEM) believe that ED overcrowding is one of the most significant issues impacting patient safety in Australian and New Zealand EDs.[[15]] It is therefore critical that any factor that exacerbates this issue is identified and remedied.

The LOS for discharged cruise ship patients was longer than the general ED population (3.4 hours vs 2.9 hours). One of the factors influencing this may be the need for EM clinicians to make safe and timely decisions regarding discharge disposition. The patient’s time pressure to return before the ship departs must be balanced against the ship’s potential geographical isolation from advanced medical care for several days or longer. Thus, a longer period of observation may be required, with more diagnostics and interventions in order to confirm or deny presence of serious pathology before safe discharge. Early recognition that cruise ship populations have different needs to the general population of EDs and may require more investigations to ensure safe discharge may improve prioritisation and help LOS.

Limitations

The main limitations relate to the nature of data collection; some of these are detailed in the methods section. A notable limitation related to the identification of study patients. As the keyword search function was used to identify cruise ship patients, we may have missed those that presented when the selected key words were not present in their medical chart. It also would not account for spelling errors given the system is largely free text. Retrospective chart review has inherent limitations. Data collected were limited to what was contained in the electronic notes and, therefore, may not be a complete accurate record of each patient encounter. The patient selection process may also have some flaws. Keywords were used to conduct a local database search for appropriate patients to include in the study. If there were spelling mistakes in the electronic record, these patients would have been missed in the extraction of data. It is also possible that there were some cruise patients who did not have any of the keywords in their electronic records. Furthermore, often a paper or handwritten referral from a cruise ship’s doctor may have been sent with the patient which was not electronically recorded. Hence, there may be missing data about referral status, which could underestimate the rate of referrals. There were also small amounts of missing data regarding triage data (n= 5); however, this is unlikely to have affected the results.

Organisational learning

The key learnings from this study are that in general cruise ship patients account for a small proportion of total ED patient load. Cruise ship doctors seem to have good judgement regarding suitable EM referrals given the high rates of admission, intervention, imaging, and specialty review. Working with cruise liner companies and ports to better educate passengers, crew and cruise ship medical teams of community health care options may reduce the volume of self-referrals. Respiratory illnesses and infections are the most common pathology seen and notably could be a significant burden to ED in the presence of a pandemic. Therefore, EDs and cruise ship medical teams should consider designing an escalation management plan to work in partnership should such an event arise.

Conclusion

Overall, the number of cruise ship patients presenting to the ED was relatively few compared to the annual ED census and therefore unlikely to significantly contribute to overcrowding in our ED. It would be prudent to identify early that the needs of a tourist patient or cruise patient may be different to a general EM patient. Communication should be improved with cruise ships and port services regarding what non-emergent or primary care services are accessible, what resources or specialist reviews the patient is likely to be able to access via our public health system, and what is an appropriate referral to hospital services. Lastly, in light of the COVID-19 pandemic, it would be beneficial to have clear guidance between hospitals and cruise ships and port services about transferring patients with transmissible illnesses.

In future we may see the continuation of growth of the tourism industry, meaning the burden of cruise ship patients and tourists may continue to increase. In this study we have initiated analysis of the impact of these patients on Wellington Hospital ED; this should be re-evaluated in the future to ensure we continue to meet our patients' changing needs and could encompass further tourist groups or other centres with high numbers of tourist patients.

Summary

Abstract

Aim

Patients presenting to emergency departments (EDs) from cruise ships are a unique cohort of patients with several management challenges. Little evidence details the effect this has on EDs in terms of resource use. Therefore, we aimed to review the frequency, characteristics, admission, and intervention rates of cruise ship patient presentations to ED.

Method

This retrospective study reviewed patient presentations to Wellington ED from cruise ships between 2016 and 2019. Data regarding presenting features, intervention and disposition were extracted via chart review.

Results

There were 214 patient presentations included with a median age of 68 (IQR 43.0–76.0); 97/214(45.3%) were female. Regarding referral, cruise ship doctors referred 79/214 (36.9%) patients; 16/79 (24.1%) to in-patient specialties and 63/79 (79.7%) to emergency medicine (EM); and 135/214 (63%) self-referred to ED. Common presenting complaints were chest pain, abdominal pain and trauma. Advanced imaging was requested for 21.5% of patients and 9.9% required urgent intervention. Regarding disposition, 38% were admitted (22% to in-patient wards, 16% to ED observation unit [OU]) and 61% were discharged (30% by ED and 31% after specialty consultation).

Conclusion

Overall, the number of cruise ship patients presenting to the ED was low and unlikely to be a significant resource burden. Referrals by cruise ship doctors were appropriate. Education for cruise ship patients and port services regarding non-emergent care options would be valuable to reduce self-referral rates.

Author Information

Dr Alice Alsweiler MBChB: Emergency Medicine Doctor, Wellington Emergency Department, Wellington Regional Hospital, New Zealand. Dr Alice Rogan MBChB, BSc: Emergency Medicine Research Fellow, Department of Surgery and Anaesthesia, University of Otago (Wellington); Emergency Medicine Registrar, Wellington Emergency Department, Wellington Regional Hospital, New Zealand. Dr Emma Carlin MB BCh BAO, BA: Emergency Medicine Research Fellow, Department of Surgery and Anaesthesia, University of Otago (Wellington), New Zealand. Dr Brad Peckler MD, FACEM, FACEP: Emergency Medicine Specialist, Wellington Emergency Department, Wellington Regional Hospital, New Zealand.

Acknowledgements

The authors would like to thank Wellington Emergency Department for their data contributions; the QUIPS office at CCDHB for their local approval and support; and the University of Otago (Wellington) Department of Surgery and Anesthesia for their expertise and support. The authors would also like to thank Dr Jeremy Brankin, Emergency Medicine Doctor in Wellington Hospital, for assisting with data collection. The data that supports the findings of this project are available from the corresponding author upon reasonable request.

Correspondence

Dr Brad Peckler: Department of Emergency Medicine, Wellington Hospital, Private Bag 7902, Wellington South 6021, New Zealand

Correspondence Email

bpeckler@yahoo.com

Competing Interests

Nil.

1) Stats NZ. Cruise ship traveler and expenditure statistics: Year ended June 2019 [Internet]. NZ: Stats NZ; 16 Aug 2020 [cited 3 June 2020]. [Available from: https://www.stats.govt.nz/information-releases/cruise-ship-traveller-and-expenditure-statistics-year-ended-june-2019].

2) ACEP. Cruise Ship Health Care Guidelines: Policy Resource and Education Paper [Internet]. American College of Emergency Physicians: Irving (TX); April 2020. [cited 3 June 2020]. [Available from: https://www.acep.org/globalassets/new-pdfs/preps/cruise-ship-health-care-guidelines---prep.pdf].

3) Peake D, Gray C, Ludwig M, Hill C. Descriptive Epidemiology of Injury and Illness Among Cruise Ship Passengers. Annals of Emergency Medicine. 1999;33(1):67-72.

4) DiGiovanna T, Rosen T, Forsett R, Sivertson K, Kelen G. Shipboard medicine: A new niche for emergency medicine. Annals of Emergency Medicine. 1992;21(12):1476-1479.

5) Dahl E. Medical practice during a world cruise: a descriptive epidemiological study of injury and illness among passengers and crew. International Maritime Health. 2005;56(1-4):115-128.

6) Carron M, Emeyriat N, Levraut J, Blondeau N. Cruise ship pathologies in remote regions. International Maritime Health. 2018;69(2):75-83.

7) Konrad R, Seibt R, Weinlich M, Blau M. Medical treatment rates on shore for crew members of cruise ships. Journal of International Maritime Safety, Environmental Affairs, and Shipping. 2018;2(1):13-21.

8) Prina L, Orazi U, Weber R. Evaluation of Emergency Air Evacuation of Critically Ill Patients from Cruise Ships. Journal of Travel Medicine. 2006;8(6):285-292.

9) Eray O, Kartal M, Sikka N, Goksu E, Yigit O, Gungor F. Characteristics of tourist patients in an emergency department in a Mediterranean destination. European Journal of Emergency Medicine. 2008;15(4):214-217.

10) Young B, Wilder-Smith A. Influenza on cruise ships. Journal of Travel Medicine. 2018;25(1).

11) Rocklöv J, Sjödin H, Wilder-Smith A. COVID-19 outbreak on the Diamond Princess cruise ship: estimating the epidemic potential and effectiveness of public health countermeasures. Journal of Travel Medicine. 2020;27(3).

12) Ministry of Health NZ. Capital & Coast DHB [Internet]. NZ: Ministry of health; [updated 25 Feb 2019; cited 3 June 2020]. [Available from: https://www.health.govt.nz/new-zealand-health-system/my-dhb/capital-coast-dhb].

13) Dahl E. Referring cruise ship patients to specialists in Norway—a welfare state with a national health care system. International Maritime Health. 2015;66(2):67-71.

14) Morley C, Unwin M, Peterson G, Stankovich J, Kinsman L. Emergency department crowding: A systematic review of causes, consequences and solutions. PLOS ONE. 018;13(8):e0203316.

15) ACEM. ACEM Position Statement: ED Overcrowding [Internet]. Australasian College for Emergency Medicine: Melbourne, Australia. June 2019. [cited 3 June 2020]. [Available from: https://acem.org.au/getmedia/dd609f9a-9ead-473d-9786-d5518cc58298/S57-Statement-on-ED-Overcrowding-Jul-11-v02.aspx].

For the PDF of this article,
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New Zealand welcomes 322,000 tourists and 93,000 crew members annually from cruise ships. Prior to the COVID-19 pandemic, cruise ship numbers were rising yearly and contributing nearly $600 million to the New Zealand economy annually.[[1]] Inevitably, some of these visitors require medical care for minor or major ailments. Modern cruise ships often have a medical team on board and varying access to investigations and treatment. The American College of Emergency Physicians make recommendations for cruise ship medical facilities,[[2]] which are supported by the Cruise Line International Association, but this still allows for significant variability of resources and standards between ships.

Providing medical care aboard a cruise ship is a unique clinical environment often complicated by geographical remoteness, resource limitation and rotating staff. Often passengers are elderly with a variety of co-morbidities, differing health beliefs and different brands and types of medications.[[1,3–9]] It is also challenging for cruise ship physicians to be familiar with local healthcare systems and how to access specialist consultation.

From the limited cruise ship healthcare data available; 11% of medical conditions treated are potentially life threatening,[[3]] and 3% required immediate hospital assessment or intervention.[[4]] Therefore, it is understandable that not all conditions can be safely managed on board. On average, 1.4–7% of passengers or crew require on-shore assessment.[[3,4]] Studies report a high prevalence of respiratory conditions among passengers and dermatological disorders in crew,[[ 3–7]] the former being particularly relevant given the current global COVID-19 pandemic, as cruise ships are a potential reservoir for transmittable infectious diseases.[[10,11]] Trauma and gastrointestinal complaints also made up a large proportion of consultations.[[3–7]]

The management of ship passengers and crew in emergency medicine (EM) also has challenges. There may be language barriers, limited access to medical records and different healthcare expectations.

A patient’s need for timely return to the ship before departure can influence treatment decisions and interventions. Visa, immigration, and legal considerations may also contribute to decision making complexities. There can also be pressure on EM clinicians to provide letters declaring patients free from illness to continue cruising or for insurance purposes. Once discharged, there may be limited follow-up of their condition.

There is little data detailing the impact cruise ship patients and crew have on emergency departments (EDs) worldwide. Anecdotally, the perception of EM clinicians working in cities where ships frequent is that passengers become a resource burden, often of low acuity patients, contributing to ED overcrowding and access block. Therefore, we conducted a service evaluation to review the frequency and characteristics of cruise ship patient presentations to Wellington Regional Hospital ED during the Australasian “cruise season” (October to April). As secondary measures, the admission rates of cruise ship patients’ vs general practitioner (GP) referrals were compared as well as the rates of specialty review, imaging studies, or urgent intervention required.

Methods

This was a retrospective descriptive study of patients presenting to Wellington Hospital ED from passenger cruise ships between 2016 and 2019. All patients who were identified as presenting to Wellington Hospital ED directly from a cruise ship were included, encompassing both passengers and crew members. Patients who arrived in another city via cruise ship who then embarked on land-based tour were excluded.

Study setting and service provision

Wellington Regional Hospital is a publicly funded major referral centre within the Capital & Coast District Health Board that serves a population of 318,040.[[12]] It has an annual ED census of 75,000 patients per year. Wellington City received 222,448 passengers from cruise ships during the year 2019, an increase of 37% from 2018.[[1]] There are no published data on the patients who are treated each year in Wellington Hospital from cruise ships. The general Wellington ED admission rate over four years was 35%. Median length of stay (LOS) was three hours 58 minutes (admitted patients five hours, one min; discharged patients two hours, 52 mins). GP referrals had a 41.1% admission rate (10,225/24,855).

Data collection

The electronic database information system (EDIS) in ED automatically extracts patient and clinical presentation related data to the hospital data service unit (DSU). A keyword search of the EDIS database was performed to identify any patients that were cruise ship crew or passengers. Keyword search included: “cruise”, “boat”, “ship”, “passenger”, “crew” and “tourist”. This screened all clinical notes including triage, presentation, and discharge diagnosis.

The individual records were then reviewed by two study investigators (AA and JB) and included if it was confirmed the patient was a cruise ship passenger or crew member. A retrospective chart review was performed, and de-identified data were extracted using a standardised Microsoft Excel sheet. Data were collected for patient demographics, LOS in the department, triage category, presenting complaint, specialty referral, advanced imaging (computed tomography [CT] scan, formal ultrasound or magnetic resonance imaging [MRI]), or interventions (angiography, interventional radiology, surgery, intensive care unit [ICU] admission or transfer to other hospital), patient disposition, discharge diagnoses and outcomes. Information regarding whether patients were crew or passenger, and if they self-referred or were referred by the cruise ship doctor were also recorded. Study investigators were not blinded to the service evaluation intentions and the data collection form was not piloted or checked for interrater reliability, but this is unlikely to have significantly affected the results given the majority of nominal discrete clinical variables.

Statistical analysis

Data were coded and statistically analysed using SPSS software (SPSS Inc. Released 2019. Version 26.0, IBM Corp, Armonk, New York, USA). To describe the data, frequency, and proportions with 95% confidence intervals (CIs), and medians with interquartile ranges (IQRs) were calculated as appropriate. Admission rates and median ED LOS of cruise patients were compared to local ED data. Comparisons between crew and passengers and those admitted and discharged were performed statistically. The null hypotheses were that there would be no difference in admission rates, LOS or interventions between the crew and passenger patients. The null hypotheses regarding patients admitted vs discharged were that there would be no differences in demographics, acuity as measured by triage category and intervention rates. Chi-squared tests or Fisher’s exact tests were used to compare proportions where appropriate and Mann–Whitney U testing was performed to compare continuous skewed data. Missing data were not included in statistical testing.

Ethical statement

This project was deemed out of scope for full HDEC review. Local authority approval was sought and approved by the CCDHB Quality Improvement Project Teams and the senior leadership team at Wellington Regional Hospital ED.

Results

A total of 214 patients were identified as presenting to the ED from cruise ships during the study period. Accepting the limitations of cruise patient identification, this equates to 0.1% of ED presentations during the cruise season, assuming the census data is divided equally across the year. Baseline characteristics are detailed in Table 1. The median age of patients was 68 (IQR 43.0–76.0), 116 (54.2%) were >65 years old and 97 (45.3%) were female. Passengers accounted for 77.1% (165/214) of the sample and 22.9% (49/214) were crew members.

A summary of presenting complaints, triage category and diagnosis are detailed in Table 2. The frequency of complaints is in keeping with what would be expected for ED presentations with chest and abdominal pain among the most common. The majority presentations had an Australasian Triage Scale (ATS) category of 3with category 4 being the next most frequent designation. Five patients had missing triage data. The most common EM diagnoses were other infections (28/214, 13.1%),respiratory infection (24/214, 11.2%), fracture (22/214, 10.3%), and acute surgical abdomen (12/214, 5.6%).

Detailed in Table 3, the median LOS was 3.8 hours (IQR 2.7–5.2).Available data demonstrated that 79/214 (36.9%) patients were referred to hospital;63/214 (29.4%) were referred to EM by a cruise ship doctor; and 16/214 (7.4%) were referred directly to an in-patient specialty. Patients self-presented in 135/214(63%) of cases. A further 97/214 (45.3%) of patients were referred to specialties by EM, meaning that 113/214 (52.8%) were reviewed by a specialty team in ED. In46/214 (21.5%) of cases advanced imaging (CT, formal ultrasound, or MRI) was required. Acute intervention (angiography, interventional radiology, surgery, ICU admission or transfer to another hospital) was required in 21/213 (9.9%) patients. Regarding disposition, 82/214 (38.3%) of patients were admitted; 35/214 (16.4%) to the ED observation unit, and 47/214 (22.0%) to a hospital ward. There were 131/214 (61.2%)discharges from ED; 65/214 (30.4%) patients were discharged after EM review, and66/214 (31.0%) were discharged after in-patient specialty review. One patient died in ED and a further death occurred after admission to a hospital ward. The admission rate for the included patient presentations from cruise ships was marginally higher when compared to 35% in the general ED population, but lower than the 41% admission rate for GP referrals.

Table 4 displays a comparison of factors amongst patients who were admitted compared to those who were discharged. Patients were more likely to be admitted if they were older (median age 72 [IQR 65.0–81.0] vs 63 [IQR 34.0–72.5], p<0.001) or if they had a higher acuity ATS triage category (66/79 [83.5%] of patients admitted had an ATS triage category of 1–3 compared to 56/130 [43.1%] of discharged patients, p<0.001). Patients who self-referred were more likely to be discharged (91/135, 67.4% vs 33/63 52.4%; p<0.001).

There were differences in presentation features between passengers and crew members, shown in Table 5. The median age of crew members was 32.0 years (IQR 27–38) vs the median age of passengers of 72.0 years (IQR 64–79). Crew members were more frequently male (37/49 [75.5%] vs 80/165 [48.5%]). Crew members were triaged with lower acuity, were less likely to require radiology, urgent intervention or be admitted. LOS and referral rates were not significantly different between the groups.

View Tables 1–5.

Discussion

Over the four-year evaluation period, a relatively small number of patients from cruise ships were seen in our ED. A wide range of presenting complaints and diagnoses were made in keeping with general ED epidemiology. Infection, particularly respiratory, accounted for the largest proportion of patient presentations. Of presentations, almost two thirds were of high acuity according to the ATS, half required in-patient specialty review, one in five required specialist radiology, one in ten required urgent intervention and 38% were admitted to hospital. Passengers were more likely to be older, have higher acuity ATS scores and higher admission rates compared to crew. This admission rate is comparable to the general ED population (35%) and GP referrals (41%). Patients referred by cruise ship doctors were more likely to be admitted with a rate of 48% compared to self-referrals at 30%.

The identified pathology among cruise ship patients aligned with current studies, noting that respiratory illness, trauma, and gastrointestinal complaints are a large proportion of presentations.[[3–7]] Recent research demonstrates the impact and spread of respiratory illness on cruise ships.[[10,11]] Ships were highlighted as vectors for the spread of the novel coronavirus. As cruise ships recommence operation, respiratory viruses from cruise ships could become a significant burden on EDs and public health internationally; especially given factors such as age and co-morbidities of passengers and prevalence of opposite-season travel.[[10]] This highlights an area in which planning with ports and cruise ship companies would be prudent to ensure appropriate care of patients, and that local health systems are not overwhelmed.

In general, the admission rates of cruise ship patients are comparable to EM and GP rates, being slightly higher than general EM and slightly lower than GP admission rates. We postulate that the rate of admission may have been higher among cruise ship patients due to limited capability for follow up if there is any diagnostic uncertainty; or may relate to appropriate assessment by cruise doctors of patients requiring admission. Another contributing factor was likely the age distribution among passengers. Previous epidemiological studies show a high proportion of elderly among tourist presentations to hospitals; they are more likely to require admission for falls or exacerbations of chronic conditions;[[9]] longer LOS in ED and the hospital, as well as higher mortality rates. These past studies advocated for education and warning for tourists prior to travel, particularly those who are older and have existing medical conditions.[[9]]

Cruise ship doctors must decide which patients need emergency care or specialist review. Our results indicate relatively high levels of admission, intervention and in-patient specialty review of patients referred to EM, suggesting these medical decisions are just and appropriate. Notably, there were high rates of self-referral, mostly among crew members, and the number of self-referrals vastly outweighed the number referred in by the ship’s doctor. The ATS category, rate of admission, and requirement for intervention was lower in this group. This potentially indicates an area for improvement—there may be limited knowledge amongst cruise ship crew and passengers about other available community urgent care or primary care options. This may be improved by better communication with cruise companies directly, education at the port on arrival, or with patients at ED reception. However, it is acknowledged that the ATS triage category assigned, used as a surrogate marker for acuity in this evaluation, is not always a direct analogue of acuity or suitability for EM assessment. We were particularly surprised by the high rates of self-referral by crew members, given that they have access and likely a relationship with the cruise ship doctor. Reasons as to why crew self-refer cannot be answered based on our data, but may be due to not wanting to disclose information to someone who is also a crew member, or potentially wanting a second opinion. The decisions behind crew members health seeking behaviors to ED require further investigation; but again, is a key area where education could be beneficial.

Other studies have commented on the difficulty for cruise doctors of navigating foreign medical systems.[[13]] Deciding which patients can be safely managed in the community settings is important to improve processes and workflow, mitigate overcrowding and provide better outcomes for all patients.[[14]] ED overcrowding is one of the biggest challenges facing clinicians today. The Australasian College of Emergency Medicine (ACEM) believe that ED overcrowding is one of the most significant issues impacting patient safety in Australian and New Zealand EDs.[[15]] It is therefore critical that any factor that exacerbates this issue is identified and remedied.

The LOS for discharged cruise ship patients was longer than the general ED population (3.4 hours vs 2.9 hours). One of the factors influencing this may be the need for EM clinicians to make safe and timely decisions regarding discharge disposition. The patient’s time pressure to return before the ship departs must be balanced against the ship’s potential geographical isolation from advanced medical care for several days or longer. Thus, a longer period of observation may be required, with more diagnostics and interventions in order to confirm or deny presence of serious pathology before safe discharge. Early recognition that cruise ship populations have different needs to the general population of EDs and may require more investigations to ensure safe discharge may improve prioritisation and help LOS.

Limitations

The main limitations relate to the nature of data collection; some of these are detailed in the methods section. A notable limitation related to the identification of study patients. As the keyword search function was used to identify cruise ship patients, we may have missed those that presented when the selected key words were not present in their medical chart. It also would not account for spelling errors given the system is largely free text. Retrospective chart review has inherent limitations. Data collected were limited to what was contained in the electronic notes and, therefore, may not be a complete accurate record of each patient encounter. The patient selection process may also have some flaws. Keywords were used to conduct a local database search for appropriate patients to include in the study. If there were spelling mistakes in the electronic record, these patients would have been missed in the extraction of data. It is also possible that there were some cruise patients who did not have any of the keywords in their electronic records. Furthermore, often a paper or handwritten referral from a cruise ship’s doctor may have been sent with the patient which was not electronically recorded. Hence, there may be missing data about referral status, which could underestimate the rate of referrals. There were also small amounts of missing data regarding triage data (n= 5); however, this is unlikely to have affected the results.

Organisational learning

The key learnings from this study are that in general cruise ship patients account for a small proportion of total ED patient load. Cruise ship doctors seem to have good judgement regarding suitable EM referrals given the high rates of admission, intervention, imaging, and specialty review. Working with cruise liner companies and ports to better educate passengers, crew and cruise ship medical teams of community health care options may reduce the volume of self-referrals. Respiratory illnesses and infections are the most common pathology seen and notably could be a significant burden to ED in the presence of a pandemic. Therefore, EDs and cruise ship medical teams should consider designing an escalation management plan to work in partnership should such an event arise.

Conclusion

Overall, the number of cruise ship patients presenting to the ED was relatively few compared to the annual ED census and therefore unlikely to significantly contribute to overcrowding in our ED. It would be prudent to identify early that the needs of a tourist patient or cruise patient may be different to a general EM patient. Communication should be improved with cruise ships and port services regarding what non-emergent or primary care services are accessible, what resources or specialist reviews the patient is likely to be able to access via our public health system, and what is an appropriate referral to hospital services. Lastly, in light of the COVID-19 pandemic, it would be beneficial to have clear guidance between hospitals and cruise ships and port services about transferring patients with transmissible illnesses.

In future we may see the continuation of growth of the tourism industry, meaning the burden of cruise ship patients and tourists may continue to increase. In this study we have initiated analysis of the impact of these patients on Wellington Hospital ED; this should be re-evaluated in the future to ensure we continue to meet our patients' changing needs and could encompass further tourist groups or other centres with high numbers of tourist patients.

Summary

Abstract

Aim

Patients presenting to emergency departments (EDs) from cruise ships are a unique cohort of patients with several management challenges. Little evidence details the effect this has on EDs in terms of resource use. Therefore, we aimed to review the frequency, characteristics, admission, and intervention rates of cruise ship patient presentations to ED.

Method

This retrospective study reviewed patient presentations to Wellington ED from cruise ships between 2016 and 2019. Data regarding presenting features, intervention and disposition were extracted via chart review.

Results

There were 214 patient presentations included with a median age of 68 (IQR 43.0–76.0); 97/214(45.3%) were female. Regarding referral, cruise ship doctors referred 79/214 (36.9%) patients; 16/79 (24.1%) to in-patient specialties and 63/79 (79.7%) to emergency medicine (EM); and 135/214 (63%) self-referred to ED. Common presenting complaints were chest pain, abdominal pain and trauma. Advanced imaging was requested for 21.5% of patients and 9.9% required urgent intervention. Regarding disposition, 38% were admitted (22% to in-patient wards, 16% to ED observation unit [OU]) and 61% were discharged (30% by ED and 31% after specialty consultation).

Conclusion

Overall, the number of cruise ship patients presenting to the ED was low and unlikely to be a significant resource burden. Referrals by cruise ship doctors were appropriate. Education for cruise ship patients and port services regarding non-emergent care options would be valuable to reduce self-referral rates.

Author Information

Dr Alice Alsweiler MBChB: Emergency Medicine Doctor, Wellington Emergency Department, Wellington Regional Hospital, New Zealand. Dr Alice Rogan MBChB, BSc: Emergency Medicine Research Fellow, Department of Surgery and Anaesthesia, University of Otago (Wellington); Emergency Medicine Registrar, Wellington Emergency Department, Wellington Regional Hospital, New Zealand. Dr Emma Carlin MB BCh BAO, BA: Emergency Medicine Research Fellow, Department of Surgery and Anaesthesia, University of Otago (Wellington), New Zealand. Dr Brad Peckler MD, FACEM, FACEP: Emergency Medicine Specialist, Wellington Emergency Department, Wellington Regional Hospital, New Zealand.

Acknowledgements

The authors would like to thank Wellington Emergency Department for their data contributions; the QUIPS office at CCDHB for their local approval and support; and the University of Otago (Wellington) Department of Surgery and Anesthesia for their expertise and support. The authors would also like to thank Dr Jeremy Brankin, Emergency Medicine Doctor in Wellington Hospital, for assisting with data collection. The data that supports the findings of this project are available from the corresponding author upon reasonable request.

Correspondence

Dr Brad Peckler: Department of Emergency Medicine, Wellington Hospital, Private Bag 7902, Wellington South 6021, New Zealand

Correspondence Email

bpeckler@yahoo.com

Competing Interests

Nil.

1) Stats NZ. Cruise ship traveler and expenditure statistics: Year ended June 2019 [Internet]. NZ: Stats NZ; 16 Aug 2020 [cited 3 June 2020]. [Available from: https://www.stats.govt.nz/information-releases/cruise-ship-traveller-and-expenditure-statistics-year-ended-june-2019].

2) ACEP. Cruise Ship Health Care Guidelines: Policy Resource and Education Paper [Internet]. American College of Emergency Physicians: Irving (TX); April 2020. [cited 3 June 2020]. [Available from: https://www.acep.org/globalassets/new-pdfs/preps/cruise-ship-health-care-guidelines---prep.pdf].

3) Peake D, Gray C, Ludwig M, Hill C. Descriptive Epidemiology of Injury and Illness Among Cruise Ship Passengers. Annals of Emergency Medicine. 1999;33(1):67-72.

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