Impact of Pediatric Urgent Care Clinics on Emergency Department Utilization and Patient Flow: A Pre–Post Cohort Study in Saudi Arabia

Impact of Pediatric Urgent Care Clinics on Emergency Department Utilization and Patient Flow: A Pre–Post Cohort Study in Saudi Arabia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Pediatric Urgent Care Clinics on Emergency Department Utilization and Patient Flow: A Pre–Post Cohort Study in Saudi Arabia Abdulhameed Al Khalaf, Alla Albisher, Ahmed Al Shams, Mohammed Al Khalaf, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8533383/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Background Pediatric emergency departments (PEDs) face persistent overcrowding, largely driven by low-acuity visits that could be managed in outpatient settings. Pediatric Urgent Care Clinics (PUCCs) have been introduced to redirect such demand, yet evidence from the Gulf region remains limited. Objectives To evaluate the impact of implementing a PUCC on emergency department utilization, patient acuity mix, flow indicators, and disposition patterns at the Maternity and Children’s Hospital in Alahsa, Saudi Arabia. Methods A retrospective pre–post cohort study was conducted using electronic health record data from October 2023–June 2024 (pre-implementation) and October 2024–June 2025 (post-implementation). Variables included Canadian Triage and Acuity Scale (CTAS) level, timestamps (triage, physician start, discharge), demographics, and disposition. Predefined cleaning rules excluded implausible or negative intervals. Outcomes were visit volumes, acuity distribution, door-to-doctor time, length of stay (LOS), and admission fraction. Comparative analyses used risk ratios (RR), interquartile ranges (IQR), trimmed means, and chi-square or rank-sum tests as appropriate. Results A total of 147,175 encounters were analyzed (pre: 84,595; post: 62,580). The proportion of low-acuity visits (CTAS 4–5) decreased from 81.1% to 50.2% (RR 0.62; 95% CI 0.61–0.62; p < 0.001). Median door-to-doctor time remained stable (37 vs 39 min; p = 0.12), while median LOS increased from 62 to 76 min (trimmed mean 78.7 vs 92.7 min; p < 0.001). Harmonized admissions rose from 1.8% to 11.6% (RR 6.48; 95% CI 6.14–6.84; p < 0.001), partly reflecting changes in disposition coding. Conclusion PUCC implementation was associated with a marked reduction in low-acuity PED visits and stable front-end performance, accompanied by a modest rise in overall LOS. PUCCs represent a promising component of pediatric emergency care optimization, but sustained system-wide improvements will require integration with broader hospital flow and capacity measures. pediatric emergency department urgent care overcrowding CTAS length of stay Saudi Arabia Figures Figure 1 Figure 2 1. Introduction Pediatric emergency departments (PEDs) are vital access points for children facing serious or life-threatening conditions. However, increasing demand, particularly from low-acuity presentations, has caused significant overcrowding. Overcrowding delays care delivery, increases staff burnout, and strains healthcare systems, especially when emergency services are used for conditions that could be managed in outpatient settings [ 1 ]. Research has shown that PED crowding leads to higher admission rates, treatment delays, reduced quality of care, and more frequent return visits, particularly among children with chronic conditions such as asthma or sickle cell disease [ 2 , 3 ]. Despite enhancements to triage systems and patient-flow interventions, the gap between demand and system capacity remains a global concern [ 4 ]. The Canadian Triage and Acuity Scale (CTAS) is widely used to categorize emergency presentations according to urgency, from Level 1 (Resuscitation) to Level 5 (Non-Urgent), with recommended maximum wait times for each category [ 5 ]. In pediatric settings, a large proportion of visits fall under CTAS Levels 4 and 5, representing conditions that could be safely managed outside the ED [ 6 , 7 ]. This misallocation exacerbates crowding by diverting resources away from critically ill patients. Worldwide, non-urgent pediatric ED visits account for 15–60% of all presentations, reaching up to 83% in general EDs [ 8 ]. In Europe, pediatric emergency visits totaled 9.1 million in 2020, with nearly 80% classified as non-urgent [ 7 ]. In Singapore, about 60% of pediatric ED encounters are considered non-urgent [ 9 ]. Such figures highlight the global pressure placed on EDs by demand that may be better addressed through urgent or primary care clinics [ 10 , 11 ]. In Saudi Arabia and across the Gulf region, non-urgent presentations constitute a major share of pediatric ED utilization. For instance, over half of pediatric ED visits in Khamis Mushayt were CTAS 4–5 [ 12 ]. Regional reports consistently demonstrate similar trends, attributing this pattern to caregiver preference for faster service, limited after-hours pediatric access, and perceived higher quality of emergency care [ 12 , 13 ]. These factors underscore the need for structured, pediatric-focused alternatives such as Pediatric Urgent Care Clinics (PUCCs). These findings highlight the need for structured alternatives, such as Pediatric Urgent Care Clinics (PUCCs). To our knowledge, this represents the first pre–post quantitative evaluation of a pediatric-specific urgent care intervention in Saudi Arabia. PUCCs are designed to address common acute pediatric conditions such as fever, respiratory infections, and minor injuries without requiring full emergency-level intervention. They typically operate after hours, offer walk-in access, and are staffed by pediatric-trained clinicians with diagnostic support [ 14 , 15 ]. Unlike general urgent care centers, PUCCs provide child-friendly environments, age-appropriate tools, and integration with higher-level care when necessary [ 16 ]. In 2019, more than one in four U.S. children visited a retail or urgent care clinic, reflecting families’ growing reliance on such alternatives [ 17 ]. In some settings, PUCCs have reduced non-emergent ED visits by more than 70% during operating hours [ 18 ]. Although several studies have evaluated urgent care centers and their impact on ED utilization particularly in adults, there is limited research focused on pediatric-specific clinics, and concerns remain about fragmented care delivery [ 16 ]. To date, no published studies in Saudi Arabia or the Gulf region have evaluated the impact of PUCCs using a pre–post cohort design. Addressing this evidence gap is essential for informing scalable and sustainable solutions to pediatric ED overcrowding in high-demand health systems. This study aimed to assess the impact of introducing a PUCC at the Maternity and Children’s Hospital in Alahsa, Saudi Arabia. Specifically, we evaluated changes in low-acuity (CTAS 4–5) visit volume, key performance indicators (door-to-doctor time, length of stay), and patient disposition. By using a retrospective pre–post cohort design, this study provides real-world evidence on whether PUCCs can reduce PED overcrowding, improve operational efficiency, and serve as a sustainable model for pediatric urgent care delivery in comparable healthcare systems. 2. Materials and methods 2.1. Study Design We conducted a pre–post observational cohort study using routinely collected electronic health record (EHR) data to evaluate the impact of Pediatric Urgent Care Clinics (PUCCs) on pediatric emergency department (PED) utilization and patient flow at Maternity and Children’s Hospital (MCH), Al-Ahsa, Kingdom of Saudi Arabia. To mitigate seasonality, two nine-month observation windows were defined a priori: October 1, 2023–June 30, 2024 (pre-implementation) and October 1, 2024–June 30, 2025 (post-implementation). The primary analytic cohorts were PED encounters in the pre-implementation window (“PED Pre”) and PED encounters in the post-implementation window (“PED Post”). In addition, encounters managed in PUCCs during the post-implementation window (“PUCC”) were identified using clinic/location codes and described separately to characterize the activity and acuity profile of the new urgent care service. The primary exposure was implementation status (pre vs post) for PED encounters; PUCC data were not treated as a “post” ED cohort and were not directly compared with PED encounters in pre–post analyses. 2.2. Setting and Population The study setting comprised the PED and PUCCs within MCH. Pediatric status followed the hospital’s operational age definition, applied uniformly by triage and registration staff. Analyses were based on de-identified EHR extracts generated by the hospital data team according to standardized queries and transferred under institutional data-use agreements. 2.3. Inclusion and Exclusion Criteria Eligible encounters included all unscheduled pediatric presentations during the study windows managed either in the PED or PUCCs, irrespective of final disposition (e.g., discharge, admission, transfer, leaving without being seen [LWBS], or leaving against medical advice [LAMA]). Exclusions were scheduled or elective visits, direct ward admissions without PED/PUCC triage or physician assessment, non-clinical/test registrations, duplicate identifiers, encounters occurring outside MCH, and records with impossible time sequences after quality checks. For time-based outcomes, encounters lacking required timestamps after plausibility screening were excluded pairwise from the corresponding analyses but retained for other outcomes. For acuity analyses, CTAS values were restricted to valid levels 1–5; encounters coded as 0 or missing were retained in overall counts but excluded from CTAS-stratified analyses. 2.4. Data Sources and Variables Data extracts included administrative fields (registration, triage, physician start, decision/disposition order, discharge), clinical fields (Canadian Triage and Acuity Scale [CTAS] level, chief complaint, disposition category), demographics (age, sex, nationality), and site identifiers (PED vs PUCC). All datasets were de-identified, with direct identifiers removed and free-text fields screened to prevent inadvertent disclosure. Primary outcomes (PED cohort): CTAS distribution in the PED, with low acuity defined as CTAS 4–5 among CTAS 1–5; and patient-flow indicators in the PED: door-to-doctor time (physician start minus triage) and length of stay (LOS; discharge minus triage). Secondary outcomes (PED cohort): disposition (admitted vs other), LWBS, and daily/weekly PED encounter volumes overall and by CTAS strata (levels 1–3 vs 4–5). PUCC descriptive outcomes: total PUCC encounter volume, CTAS distribution, and disposition categories during the post-implementation window, reported descriptively without inferential comparison to PED encounters 2.5. Data Management Dates and times were parsed in day-first format and combined into ISO-8601 datetimes. Negative intervals were excluded from time-based analyses but retained with flags in the master dataset. Plausibility caps were applied as follows: 0–360 minutes for door-to-doctor time, 0–720 minutes for doctor-to-decision time (exploratory only), and 0–1,440 minutes for LOS. Values outside these ranges were excluded from primary analyses and examined separately. CTAS values outside 1–5 were treated as missing in stratified analyses. Data-cleaning rules and dictionaries were maintained under version control. 2.6. Statistical Analysis Analyses were two-sided with a significance threshold of 0.05, and reporting followed STROBE guidelines. Continuous variables were summarized as medians with interquartile ranges (IQRs) and 5% trimmed means. Primary group comparisons focused on PED Pre versus PED Post. The Mann–Whitney U test was used to compare medians (reporting Hodges–Lehmann median differences and 95% confidence intervals), and Welch’s t-test on trimmed means served as a robustness check. Categorical variables were summarized as counts and percentages and compared using chi-square tests. Effect sizes for binary outcomes were expressed as risk ratios (RRs) with 95% confidence intervals. Sensitivity analyses examined alternative handling of missing triage timestamps (using registration time as a proxy) and the influence of outlier treatment. PUCC encounters were summarized descriptively using the same metrics but were not included in formal pre–post hypothesis tests. 2.7. Sample Size and Ethics All eligible encounters during the study periods were included; no formal sample size calculation was performed. The large operational dataset was expected to provide precise estimates for the primary outcomes. The study utilized de-identified electronic health record (EHR) data without direct patient contact. Institutional Review Board (IRB) approval was obtained from the Maternity and Children’s Hospital, Alahsa (IRB No. MCH-PED-2024-047), which granted a waiver of informed consent in accordance with national regulations. All data were stored on secure hospital servers with restricted access. Statistical analyses were conducted using R (version 4.x) and Python (version 3.11). 3. Results Across the observation windows, there were 84,595 encounters in the pre-implementation period (1 Oct 2023–30 Jun 2024) and 62,580 in the post-implementation period (1 Oct 2024–30 Jun 2025). Within the PED extract, the proportion of low-acuity visits (CTAS 4–5) declined markedly post-implementation, median door-to-doctor time was essentially stable, and length of stay (LOS) increased. Key timestamps were highly complete and improved in the post period: triage was recorded for 82.3% pre vs 91.8% post; doctor-start for 85.3% vs 94.0%; and discharge time for 100% in both periods. Valid CTAS (levels 1–5) increased from 91.6% pre to 97.1% post ( Table 1 ) . Table 1 Cohort size and data completeness by period. Metric PED Pre PED Post Total encounters, n 84,595 62,580 Triage time, n (%) 69,583 (82.3) 57,439 (91.8) Doctor-start, n (%) 72,184 (85.3) 58,796 (94.0) Discharge time, n (%) 84,595 (100) 62,580 (100) Valid CTAS 1–5, n (%) 77,498 (91.6) 60,737 (97.1) “PED Pre” = pediatric emergency department encounters from 1 Oct 2023–30 Jun 2024 (pre-implementation). “PED Post” = pediatric emergency department encounters from 1 Oct 2024–30 Jun 2025 (post-implementation). CTAS = Canadian Triage and Acuity Scale; valid levels are 1–5. Patient demographics and visit characteristics for PED encounters are summarized in Table 2 . The median age of children presenting to the PED decreased from 4.67 years in the pre-implementation period to 3.42 years in the post-implementation period, with a similar sex distribution across both cohorts (56.5% vs 55.8% male). The majority of encounters occurred on weekdays, accounting for 66.9% of visits pre-implementation and 68.5% post-implementation. Arrival-time distribution shifted modestly between periods: daytime presentations decreased from 29.7% to 25.4%, evening presentations from 42.4% to 38.8%, while night-time arrivals increased from 27.9% to 35.8%. These trends suggest that after PUCC implementation, PED demand included a relatively greater proportion of younger children and higher night-time utilization, while weekday versus weekend patterns remained stable. Table 2 Demographic and visit characteristics of PED encounters. Characteristic PED Pre PED Post Age, median (years) 4.67 3.42 Male, % 56.5 55.8 Weekday arrivals, % 66.9 68.5 Weekend arrivals, % 33.1 31.5 Daytime, % 29.7 25.4 Evening, % 42.4 38.8 Night, % 27.9 35.8 Weekday = Monday–Friday; Weekend = Saturday–Sunday. Time blocks: Daytime 08:00–15:59, Evening 16:00–23:59, Night 00:00–07:59. “Pre” = 1 Oct 2023–30 Jun 2024 (pre‑implementation); “Post” = 1 Oct 2024–30 Jun 2025 (post‑implementation). Daily encounter rates decreased significantly in the post-implementation period. Over 274 pre-implementation days, the mean was 308.7 encounters/day, compared with 229.3/day across 273 post-implementation days. This corresponds to an IRR of 0.74 (95% CI 0.74–0.75; p < 0.001), indicating a 26% relative reduction in daily PED volumes after PUCC implementation ( Table 3 ). Table 3 Daily pediatric emergency department encounter rates. Metric PED Pre PED Post Incidence Rate Ratio (IRR) 95% CI P-value Observed days, n 274 273 0.74 0.74–0.75 < 0.001* Total encounters, n 84,595 62,580 Daily rate, mean 308.7 229.2 IRR = incidence rate ratio; CI = confidence interval; *Significant p-value During the post-implementation window, the PUCC managed 24,962 triaged encounters; 24,719 (99.0%) were CTAS 4–5 (CTAS 3: 243; CTAS 4: 7,384; CTAS 5: 17,335; CTAS 1–2: 0). In the pre-implementation window, the PED triaged 77,498 encounters, of which 62,856 (81.1%) were CTAS 4–5. The proportion of low-acuity presentations was therefore higher in PUCC than in the PED pre-implementation cohort (RR 1.22; 95% CI 1.22–1.23; p < 0.001), consistent with preferential diversion of non-urgent cases to the PUCC while higher-acuity care remained concentrated in the PED ( Table 4 ; Fig. 1 ). Table 4 Acuity distribution in PUCC and PED encounters. CTAS level PED Pre, n PED Post, n RR (low‑acuity) 95% CI p‑value CTAS-1 12 0 CTAS-2 394 0 CTAS-3 14,236 243 CTAS-4 58,246 7,384 CTAS-5 4,610 17,335 Total (CTAS 1–5) 77,498 24,962 Low‑acuity (CTAS 4–5), n (%) 62,856 (81.1%) 24,719 (99.0%) 1.221 1.217–1.225 < 0.001* CTAS = Canadian Triage and Acuity Scale. Low-acuity defined as CTAS 4–5. RR = risk ratio (post vs pre), 95% CI by log method. *Significant p-value. Figure 2 illustrates the daily encounter trends in the PED during the pre- and post-implementation periods. A clear and sustained decline in total daily volumes was observed after the launch of the PUCC, with pre-implementation averages around 309 encounters/day compared to 229/day post-implementation (IRR = 0.74; 95% CI 0.74–0.75; p < 0.001). The visualized time series shows substantial week-to-week variability before implementation, followed by stabilization at lower daily volumes once the PUCC became operational. This downward shift reflects successful diversion of low-acuity cases away from the PED while maintaining consistent service continuity for higher-acuity presentations. Analysis of unadjusted patient-flow metrics in the PED demonstrated minimal change in door-to-doctor time, with medians of 37 min (IQR 22–63) pre-implementation and 39 min (IQR 22–65) post-implementation (p < 0.001). In contrast, length of stay (LOS) increased significantly, from a median of 62 min (IQR 34–112) to 76 min (IQR 43–131) (p < 0.001). Trimmed means were consistent with these findings, confirming a modest but statistically significant prolongation of door-to-doctor time and a more clinically relevant extension of LOS following PUCC implementation ( Table 5 ) . Table 5 Patient-flow indicators before and after PUCC implementation. Indicator PED Pre PED Post p-value Door-to-doctor time (min) N 59708 53673 < 0.001* Median, IQR 37.0 (IQR 22.0–63.0) 39.0 (IQR 22.0–65.0) Trimmed mean 43.58 45.03 Length of stay (min) N 51417 48141 < 0.001* Median, IQR 62.0 (IQR 34.0–112.0) 76.0 (IQR 43.0–131.0) Trimmed mean 78.65 92.74 Values shown as N, median (IQR), and 5% trimmed mean. *Significant p-values from Mann–Whitney U test comparing distributions between periods. Although the median door-to-doctor time difference (37 → 39 min) reached statistical significance (p < 0.001), this 2-minute gap is clinically negligible given the large sample size. The effect therefore reflects statistical rather than operational significance. In contrast, the 14-minute increase in length of stay likely represents a meaningful system-level change affecting patient throughput. Applying a harmonized classification that treated any record labeled “ADMITTED,” “WARD,” or “NICU” as an admission, the proportion of PED encounters resulting in admission increased from 1.80% (1,520/84,595) in the pre-implementation period to 11.64% (7,286/62,580) post-implementation. This apparent rise reflects both a genuine shift in case mix and changes in documentation practices. Because the underlying disposition label taxonomies differed between periods, these estimates should be interpreted cautiously and, where possible, validated against the hospital’s admissions master file to ensure accuracy ( Table 6 ) . A sensitivity checks restricting analyses to stable disposition codes present in both periods showed a smaller increase (1.8% to 6.5%), supporting the interpretation that taxonomy changes partially account for the observed rise. Table 6 Disposition outcomes before and after PUCC implementation. Indicator PED Pre PED Post Risk Ratio (RR) 95% CI P-value Total encounters, n 84,595 62,580 Admissions n (%) 1,520 (1.80%) 7,286 (11.64%) 6.48 6.14–6.84 p < 0.001* Admissions defined conservatively as any disposition labeled 'ADMITTED', 'WARD', or 'NICU'. RR = risk ratio (post vs pre) with 95% CI from log method. *Significant p-value from chi-square test. 4. Discussion PUCC implementation was associated with reduced PED volumes and stable door-to-doctor times. Interpreted together, these patterns are consistent with diversion of low-acuity demand away from the PED after PUCC implementation, while residual throughput pressures (e.g., boarding or inpatient flow) may have limited downstream gains in LOS. This interpretation aligns with prior work showing that shifting low-acuity patients to alternative sites (fast tracks/urgent care) reduces crowding and resource use but may not, by itself, solve hospital-wide flow constraints that drive LOS [ 19 – 21 ]. International benchmarks suggest CTAS-based targets for time-to-physician and a system-wide goal that ≥ 95% of ED patients are admitted, discharged, or transferred within 4 hours (UK NHS standard). In our setting, while door-to-doctor times remained stable after PUCC implementation, the overall LOS increased; this pattern is consistent with literature indicating that boarding and inpatient flow constraints dominate LOS, so front-door demand management alone may not meet the 4-hour target across all acuity groups. These benchmarks provide context for interpreting our flow metrics and support the role of PUCCs as demand-diversion tools that should be paired with hospital-wide flow measures to improve LOS. Multiple quasi-experimental and observational studies have shown that non-ED venues community urgent care, retail clinics, and ED fast tracks absorb low-acuity demand and can shorten visit times for these cohorts without compromising safety. Our observed decline in CTAS 4–5 share is directionally concordant with this literature, including pediatric-focused fast-track implementations and system-level analyses of urgent care supply versus ED volume [ 22 , 23 ]. Door-to-doctor times remained essentially stable across periods, a pattern compatible with maintained front-end capacity. However, LOS increased despite the drop in low-acuity mix. Prior evidence highlights that ED LOS is often dominated by hospital-wide constraints, especially boarding of admits, rather than front-end arrivals, so reductions in low-acuity traffic do not necessarily translate into shorter overall LOS [ 21 , 24 – 26 ]. In pediatrics specifically, crowding is associated with higher admission at the index visit for the sickest children and higher short-term revisits among the least sick, underscoring that throughput pressures can affect outcomes even when initial assessment speed is preserved [ 25 , 27 , 28 ]. Because our primary acuity stratification uses CTAS, it is important to note that PaedCTAS has demonstrated validity and inter-rater reliability across multiple settings and correlates with admission, PICU use, resource utilization, and ED LOS. This supports the use of CTAS 4–5 share as a reasonable low-acuity proxy in before–after comparisons [ 29 – 31 ]. Local implementations in Saudi Arabia further document feasibility and performance of CTAS in regional contexts [ 32 ]. National and single-center studies from Saudi Arabia report median ED LOS around 60–120 min, with strong associations between LOS and triage level, admission, shift, and hospital type factors that could plausibly influence our post-period LOS even as low-acuity arrivals fell [ 33 ]. Our harmonized classification of disposition suggested a higher admission fraction post-PUCC, but because disposition label taxonomies changed between periods, these results must be interpreted cautiously and ideally cross-checked against the admissions master file. Differences in coding or data pipelines can bias crude rates in pre–post evaluations [ 21 , 24 ]. The strengths of this study include the large sample size, pre-specified data cleaning protocols (excluding implausible intervals and capping outliers), and acuity-aware comparative analyses. However, key limitations are inherent to before–after designs, which remain susceptible to secular trends, seasonality, and shifts in case mix. Additional constraints include the reliability of time-stamp variables (particularly “decision/diagnosis time” as a proxy for physician decision-making) and changes in disposition taxonomies. Further analyses such as segmented time-series modeling, seasonal adjustment, weekday or shift fixed effects, and admission/boarding proxies would enhance causal inference and strengthen the robustness of findings [ 21 , 24 – 26 ]. If the primary objective is to decompress the PED while protecting timely care for high-acuity patients, these findings suggest PUCCs are directionally effective at off-loading low-acuity visits. Realizing improvements in whole-visit LOS, however, will likely require hospital-wide flow interventions (e.g., discharge-before-noon, smoothing elective admissions, and full-capacity protocols) alongside PUCC operations [ 21 , 34 ]. Scaling PUCCs across the region, supported by integrated electronic triage or tele-consultation systems, may further relieve tertiary PEDs while maintaining continuity of pediatric care. Conclusion Implementation of PUCCs in Alahsa was associated with a substantial reduction in low-acuity visits to the pediatric emergency department and preserved door-to-doctor times, but with a concurrent increase in overall length of stay. The observed rise in admission fraction likely reflects both real shifts in patient acuity and changes in documentation practices, warranting cautious interpretation. Together, these findings highlight the potential of PUCCs to decompress high-demand pediatric emergency services while underscoring that hospital-wide flow and inpatient capacity remain critical determinants of patient throughput. Sustained improvements in pediatric emergency care will therefore require integrating PUCC operations with broader system-level strategies addressing admissions, boarding, and discharge processes. Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board of the Maternity and Children’s Hospital, Alahsa, Kingdom of Saudi Arabia (IRB No. MCH-PED-2024-047). The requirement for informed consent was waived because the study used retrospectively collected, de-identified electronic health record data and involved no direct patient contact, in accordance with national regulations and institutional policies. Consent for publication Not applicable. This study used anonymized routinely collected data, and no individual patient identifiers or images are included in the manuscript. Availability of data and materials The datasets supporting the conclusions of this article are available from the corresponding author upon reasonable request. The data are not publicly available due to institutional data governance policies and restrictions related to patient confidentiality. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions AAK conceived and designed the study and served as corresponding author. AAB and AAS contributed to clinical oversight and interpretation of emergency department workflows. MAlK participated in data acquisition and coordination with pediatric emergency services. JA, JAE, and AAA contributed to data collection, verification, and nursing workflow documentation. MAW and HA contributed to data interpretation and contextualization within family medicine practice. AAK performed the statistical analysis and drafted the initial manuscript. All authors critically reviewed the manuscript for important intellectual content, approved the final version, and agree to be accountable for all aspects of the work. Acknowledgements The authors thank the hospital information technology and medical records teams at the Maternity and Children’s Hospital, Alahsa, for their assistance with data extraction and data management. References Doan Q, Wong H, Meckler G, et al. The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicentre cohort study. CMAJ . 2019;191(23):E627–35. doi:10.1503/cmaj.181426 Meyer-Macaulay CB, Truong M, Meckler GD, Doan QH. Return visits to the pediatric emergency department: A multicentre retrospective cohort study. CJEM . 2018;20(4):578–85. doi:10.1017/cem.2017.40 Savioli G, Ceresa IF, Gri N, et al. Emergency department overcrowding: understanding the factors to find corresponding solutions. J Pers Med . 2022;12(2):279. doi:10.3390/jpm12020279 Sartini M, Carbone A, Demartini A, et al. Overcrowding in emergency department: causes, consequences, and solutions—A narrative review. Healthcare (Basel) . 2022;10(9):1625. doi:10.3390/healthcare10091625 Bullard MJ, Musgrave E, Warren D, et al. Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) Guidelines 2016. CJEM . 2017;19(S2):S18–27. doi:10.1017/cem.2017.365 Dut R. Usage of pediatric emergency department for non-urgent complaints. Eurasian J Emerg Med . 2017;16(1):23–8. doi:10.5152/eajem.2017.63935 Barca-Ruso Z, Montoro-Pérez N, Montejano-Lozoya R, et al. Interventions aimed at reducing non-urgent presentations and frequent attendance in paediatric emergency departments: a rapid systematic review. Emerg Care Med . 2025;2(1):7. doi:10.3390/ecm2010007 Farion KJ, Wright M, Zemek R, Neto G, Karwowska A, Tse S, Reid S, Jabbour M, Poirier S, Moreau KA, Barrowman N. Understanding Low-Acuity Visits to the Pediatric Emergency Department. PLoS One. 2015 Jun 17;10(6):e0128927. doi: 10.1371/journal.pone.0128927. Ganapathy S, Lim SY, Kua JPH, Ng KC. Non-Urgent Paediatric Emergency Department Visits: Why Are They So Common? A Singapore Perspective. Annals, Academy of Medicine, Singapore. 2015 Jul;44(7):269-71. doi:10.47102/annals-acadmedsg.V44N7p269 Ravi N, Gitz KM, Burton DR, Ray KN. Pediatric non-urgent emergency department visits and prior care-seeking at primary care. BMC Health Serv Res . 2021;21:466. doi:10.1186/s12913-021-06480-7 National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2021 Emergency Department Summary Tables. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2021-nhamcs-ed-web-tables-508.pdf. Accessed 15 Jan 2026 . Al Jabir W, Al-Alfard BA, Muhaya AA, Al Farhan A. Non-urgent pediatric presentations to the emergency department, Khamis Mushayt Maternity and Children Hospital, Saudi Arabia. World Fam Med . 2023;21(8):87–97. Al-Qahtani MH, Yousef AA, Awary BH, Albuali WH, Al Ghamdi MA, AlOmar RS, AlShamlan NA, Yousef HA, Motabgani S, AlAmer NA, Alsawad KM, Altaweel FY, Altaweel KS, AlQunais RA, Alsubaie FA, Al Shammari MA. Correction to: Characteristics of visits and predictors of admission from a paediatric emergency room in Saudi Arabia. BMC Emerg Med. 2021 Aug 29;21(1):99. doi: 10.1186/s12873-021-00492-6. Weinick RM, Bristol SJ, DesRoches CM. Urgent care centers in the U.S.: findings from a national survey. BMC Health Serv Res . 2009;9:79. doi:10.1186/1472-6963-9-79 Remick K, Gausche-Hill M, Joseph MM, Brown K, Snow SK, Wright JL; AMERICAN ACADEMY OF PEDIATRICS, Committee on Pediatric Emergency Medicine, Section on Surgery; AMERICAN COLLEGE OF EMERGENCY PHYSICIANS, Pediatric Emergency Medicine Committee; EMERGENCY NURSES ASSOCIATION, Pediatric Committee; Pediatric Readiness in the Emergency Department; POLICY STATEMENT; Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children. Pediatric Readiness in the Emergency Department. Ann Emerg Med. 2018 Dec;72(6):e123-e136. doi: 10.1016/j.annemergmed.2018.08.431. Saidinejad M, Paul AZ, Heins A, et al. ACEP Pediatric Committee Statement on Urgent Care Centers and Retail Clinics. 2016 Jun. Columbus, OH: American College of Emergency Physicians. Available from: https://www.acep.org/siteassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/pediatrics/urgent-care-center-peds-committee-ip-june-2016.pdf. Accessed 15 Jan 2026. Black LI, Zablotsky B. Urgent Care Center and Retail Health Clinic Utilization Among Children: United States, 2019. NCHS Data Brief. 2020 Dec;(393):1-8. PMID: 33270552. Bristow, Peter and Lenzen, Sabrina and Connelly, Luke, The Effect of Urgent Care Centers on Emergency Department Attendance and Waiting Times. http://dx.doi.org/10.2139/ssrn.5243075 Allen L, et al. Impact of retail clinics on emergency department visits and costs. Health Serv Res . 2021;56(6):1100–11. doi:10.1111/1475-6773.13631 Wang MC, et al. Urgent care centers: impacts on emergency department visits. Health Aff (Millwood) . 2021;40(8):1281–90. doi:10.1377/hlthaff.2020.01869 Carlson LC, Raja AS, Dworkis DA, Lee J, Brown DFM, Samuels-Kalow M, Wilson M, Shapiro M, Kim J, Yun BJ. Impact of Urgent Care Openings on Emergency Department Visits to Two Academic Medical Centers Within an Integrated Health Care System. Ann Emerg Med. 2020 Mar;75(3):382-391. doi: 10.1016/j.annemergmed.2019.06.024. Hampers LC, Cha S, Gutglass DJ, Binns HJ, Krug SE. Fast track and the pediatric emergency department: resource utilization and patients outcomes. Acad Emerg Med. 1999 Nov;6(11):1153-9. doi: 10.1111/j.1553-2712.1999.tb00119.x. Martin HA, Noble M, Wilmarth J. Improving Patient Flow and Decreasing Patient Length of Stay in the Pediatric Emergency Department Through Implementation of a Fast Track. Adv Emerg Nurs J. 2021 Apr-Jun 01;43(2):162-169. doi: 10.1097/TME.0000000000000351. McKenna P, et al. ED/hospital crowding: causes and cures. Clin Exp Emerg Med . 2019;6(3):189–95. doi:10.15441/ceem.18.022 Carter EJ, Pouch SM, Larson EL. The relationship between emergency department crowding and patient outcomes: a systematic review. J Nurs Scholarsh. 2014 Mar;46(2):106-15. doi: 10.1111/jnu.12055. Moylan A, Maconochie I. Demand, overcrowding and the pediatric emergency department. CMAJ. 2019 Jun 10;191(23):E625-E626. doi: 10.1503/cmaj.190610. Abudan A, Merchant RC. Multi-dimensional Measurements of Crowding for Pediatric Emergency Departments: A Systematic Review. Glob Pediatr Health. 2021 Feb 27;8:2333794X21999153. doi: 10.1177/2333794X21999153. Gravel J, Manzano S, Arsenault M. Validity of the Canadian Paediatric Triage and Acuity Scale in a tertiary care hospital. CJEM. 2009 Jan;11(1):23-8. doi: 10.1017/s1481803500010885. Gravel J, Gouin S, Goldman RD, Osmond MH, Fitzpatrick E, Boutis K, Guimont C, Joubert G, Millar K, Curtis S, Sinclair D, Amre D. The Canadian Triage and Acuity Scale for children: a prospective multicenter evaluation. Ann Emerg Med. 2012 Jul;60(1):71-7.e3. doi: 10.1016/j.annemergmed.2011.12.004. Zachariasse JM, van der Hagen V, Seiger N, Mackway-Jones K, van Veen M, Moll HA. Performance of triage systems in emergency care: a systematic review and meta-analysis. BMJ Open. 2019 May 28;9(5):e026471. doi: 10.1136/bmjopen-2018-026471. Elkum NB, Barrett C, Al-Omran H. Canadian Emergency Department Triage and Acuity Scale: implementation in a tertiary care center in Saudi Arabia. BMC Emerg Med. 2011 Feb 10;11:3. doi: 10.1186/1471-227X-11-3. Alharbi AA, Muhayya M, Alkhudairy R, Alhussain AA, Muaddi MA, Alqassim AY, AlOmar RS, Alabdulaali MK. The pattern of emergency department length of stay in Saudi Arabia: an epidemiological Nationwide analyses of secondary surveillance data. Front Public Health. 2023 Dec 12;11:1265707. doi: 10.3389/fpubh.2023.1265707. van der Linden MCC, van Ufford HMEJ; Project Group Medical Specialists; van der Linden NN. The impact of a multimodal intervention on emergency department crowding and patient flow. Int J Emerg Med. 2019 Aug 27;12(1):21. doi: 10.1186/s12245-019-0238-7. Barata I, Brown KM, Fitzmaurice L, Griffin ES, Snow SK; American Academy of Pediatrics Committee on Pediatric Emergency Medicine; American College of Emergency Physicians Pediatric Emergency Medicine Committee; Emergency Nurses Association Pediatric Committee. Best practices for improving flow and care of pediatric patients in the emergency department. Pediatrics. 2015 Jan;135(1):e273-83. doi: 10.1542/peds.2014-3425. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8533383","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587406047,"identity":"8dc437c0-0759-4513-80fd-1a0fa59c5625","order_by":0,"name":"Abdulhameed Al Khalaf","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYDACCQZmhg8VNglgTkIBkVoYZ5xJS2BgA2kxIFILM2/bYYgWBmK08M9uf2w448z5PH757sQPDwwY5PnFDhCw5M4Z44QPFbeLJdt4N0sAHWY4c3YCAWtu5DAfnHHmduKGY7wbQFoSDG4T0CJ/I/3xYd62cyAtm38QpcXgRoJxMm/bAZCWbcTZYgj0C9D7yYkz23K3WSQYSBD2i9zt9scSHyrsEvuZz26++aPCRp5fmoAWdCBBmvJRMApGwSgYBdgBABprSNDOAbXaAAAAAElFTkSuQmCC","orcid":"","institution":"Family Medicine Department","correspondingAuthor":true,"prefix":"","firstName":"Abdulhameed","middleName":"Al","lastName":"Khalaf","suffix":""},{"id":587406048,"identity":"abe01fa1-dac8-413a-a1f9-9e6d953cdc8d","order_by":1,"name":"Alla Albisher","email":"","orcid":"","institution":"Pediatric Emergency Department, Alahsa Health Cluster","correspondingAuthor":false,"prefix":"","firstName":"Alla","middleName":"","lastName":"Albisher","suffix":""},{"id":587406050,"identity":"d32831be-6ceb-4e59-b3d1-52584381b557","order_by":2,"name":"Ahmed Al Shams","email":"","orcid":"","institution":"Pediatric Emergency Department, Alahsa Health Cluster","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Al","lastName":"Shams","suffix":""},{"id":587406052,"identity":"48d2cbba-be01-46df-a1fc-05003edf8f12","order_by":3,"name":"Mohammed Al Khalaf","email":"","orcid":"","institution":"Pediatric Emergency Department, Alahsa Health Cluster","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"Al","lastName":"Khalaf","suffix":""},{"id":587406054,"identity":"5ebca9ba-8da5-40f1-8167-540fd3adf8f0","order_by":4,"name":"Jassem Althani","email":"","orcid":"","institution":"Emergency Nursing Services, Alahsa Health Cluster","correspondingAuthor":false,"prefix":"","firstName":"Jassem","middleName":"","lastName":"Althani","suffix":""},{"id":587406056,"identity":"a330d79b-5d05-4a83-a511-a60959f4e98d","order_by":5,"name":"Jassim Al Essa","email":"","orcid":"","institution":"Emergency Nursing Services, Alahsa Health Cluster","correspondingAuthor":false,"prefix":"","firstName":"Jassim","middleName":"Al","lastName":"Essa","suffix":""},{"id":587406061,"identity":"dda94bdd-3a74-4f09-a396-7ed5c452ce55","order_by":6,"name":"Ali Al Ali","email":"","orcid":"","institution":"Emergency Nursing Services, Alahsa Health Cluster","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"Al","lastName":"Ali","suffix":""},{"id":587406063,"identity":"b95853ee-c93d-4354-8b9d-12d0e2abe4f6","order_by":7,"name":"Mohammed Alwabari","email":"","orcid":"","institution":"Family Medicine Department","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Alwabari","suffix":""},{"id":587406064,"identity":"7931f204-fe72-4624-9f8c-dfc3842cb4e6","order_by":8,"name":"Haidar Alhassan","email":"","orcid":"","institution":"Family Medicine Department","correspondingAuthor":false,"prefix":"","firstName":"Haidar","middleName":"","lastName":"Alhassan","suffix":""}],"badges":[],"createdAt":"2026-01-06 16:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8533383/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8533383/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102260931,"identity":"8e0d41e0-07b4-490e-9364-cc388a82d89d","added_by":"auto","created_at":"2026-02-10 00:36:09","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":55663,"visible":true,"origin":"","legend":"\u003cp\u003eCTAS distribution PED pre vs PUCC post.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8533383/v1/d219aa2c9af054cd9f143a70.jpg"},{"id":102260929,"identity":"926ddaa4-5f68-467f-be4a-3f86da2b4d76","added_by":"auto","created_at":"2026-02-10 00:36:09","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":61039,"visible":true,"origin":"","legend":"\u003cp\u003eDaily pediatric emergency department encounter volumes before and after PUCC implementation. Blue lines show total daily PED encounters during the pre-implementation window (1 Oct 2023–30 Jun 2024), orange lines show encounters during the post-implementation window (1 Oct 2024–30 Jun 2025), and the vertical red line marks the date of PUCC launch.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8533383/v1/d23242e96b47f8fdba568395.jpg"},{"id":102297288,"identity":"10b6da0a-845a-4de8-8aaa-6dbbfdd07974","added_by":"auto","created_at":"2026-02-10 10:26:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":896954,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8533383/v1/3910ef9c-49c5-4f7d-8d9c-4725cfcef0de.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Pediatric Urgent Care Clinics on Emergency Department Utilization and Patient Flow: A Pre–Post Cohort Study in Saudi Arabia","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePediatric emergency departments (PEDs) are vital access points for children facing serious or life-threatening conditions. However, increasing demand, particularly from low-acuity presentations, has caused significant overcrowding. Overcrowding delays care delivery, increases staff burnout, and strains healthcare systems, especially when emergency services are used for conditions that could be managed in outpatient settings [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Research has shown that PED crowding leads to higher admission rates, treatment delays, reduced quality of care, and more frequent return visits, particularly among children with chronic conditions such as asthma or sickle cell disease [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite enhancements to triage systems and patient-flow interventions, the gap between demand and system capacity remains a global concern [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Canadian Triage and Acuity Scale (CTAS) is widely used to categorize emergency presentations according to urgency, from Level 1 (Resuscitation) to Level 5 (Non-Urgent), with recommended maximum wait times for each category [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In pediatric settings, a large proportion of visits fall under CTAS Levels 4 and 5, representing conditions that could be safely managed outside the ED [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This misallocation exacerbates crowding by diverting resources away from critically ill patients.\u003c/p\u003e \u003cp\u003eWorldwide, non-urgent pediatric ED visits account for 15\u0026ndash;60% of all presentations, reaching up to 83% in general EDs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In Europe, pediatric emergency visits totaled 9.1\u0026nbsp;million in 2020, with nearly 80% classified as non-urgent [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In Singapore, about 60% of pediatric ED encounters are considered non-urgent [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Such figures highlight the global pressure placed on EDs by demand that may be better addressed through urgent or primary care clinics [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Saudi Arabia and across the Gulf region, non-urgent presentations constitute a major share of pediatric ED utilization. For instance, over half of pediatric ED visits in Khamis Mushayt were CTAS 4\u0026ndash;5 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Regional reports consistently demonstrate similar trends, attributing this pattern to caregiver preference for faster service, limited after-hours pediatric access, and perceived higher quality of emergency care [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These factors underscore the need for structured, pediatric-focused alternatives such as Pediatric Urgent Care Clinics (PUCCs). These findings highlight the need for structured alternatives, such as Pediatric Urgent Care Clinics (PUCCs). To our knowledge, this represents the first pre\u0026ndash;post quantitative evaluation of a pediatric-specific urgent care intervention in Saudi Arabia.\u003c/p\u003e \u003cp\u003ePUCCs are designed to address common acute pediatric conditions such as fever, respiratory infections, and minor injuries without requiring full emergency-level intervention. They typically operate after hours, offer walk-in access, and are staffed by pediatric-trained clinicians with diagnostic support [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Unlike general urgent care centers, PUCCs provide child-friendly environments, age-appropriate tools, and integration with higher-level care when necessary [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In 2019, more than one in four U.S. children visited a retail or urgent care clinic, reflecting families\u0026rsquo; growing reliance on such alternatives [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In some settings, PUCCs have reduced non-emergent ED visits by more than 70% during operating hours [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough several studies have evaluated urgent care centers and their impact on ED utilization particularly in adults, there is limited research focused on pediatric-specific clinics, and concerns remain about fragmented care delivery [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. To date, no published studies in Saudi Arabia or the Gulf region have evaluated the impact of PUCCs using a pre\u0026ndash;post cohort design. Addressing this evidence gap is essential for informing scalable and sustainable solutions to pediatric ED overcrowding in high-demand health systems.\u003c/p\u003e \u003cp\u003eThis study aimed to assess the impact of introducing a PUCC at the Maternity and Children\u0026rsquo;s Hospital in Alahsa, Saudi Arabia. Specifically, we evaluated changes in low-acuity (CTAS 4\u0026ndash;5) visit volume, key performance indicators (door-to-doctor time, length of stay), and patient disposition. By using a retrospective pre\u0026ndash;post cohort design, this study provides real-world evidence on whether PUCCs can reduce PED overcrowding, improve operational efficiency, and serve as a sustainable model for pediatric urgent care delivery in comparable healthcare systems.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study Design\u003c/h2\u003e \u003cp\u003e We conducted a pre\u0026ndash;post observational cohort study using routinely collected electronic health record (EHR) data to evaluate the impact of Pediatric Urgent Care Clinics (PUCCs) on pediatric emergency department (PED) utilization and patient flow at Maternity and Children\u0026rsquo;s Hospital (MCH), Al-Ahsa, Kingdom of Saudi Arabia. To mitigate seasonality, two nine-month observation windows were defined a priori: October 1, 2023\u0026ndash;June 30, 2024 (pre-implementation) and October 1, 2024\u0026ndash;June 30, 2025 (post-implementation).\u003c/p\u003e \u003cp\u003eThe primary analytic cohorts were PED encounters in the pre-implementation window (\u0026ldquo;PED Pre\u0026rdquo;) and PED encounters in the post-implementation window (\u0026ldquo;PED Post\u0026rdquo;). In addition, encounters managed in PUCCs during the post-implementation window (\u0026ldquo;PUCC\u0026rdquo;) were identified using clinic/location codes and described separately to characterize the activity and acuity profile of the new urgent care service. The primary exposure was implementation status (pre vs post) for PED encounters; PUCC data were not treated as a \u0026ldquo;post\u0026rdquo; ED cohort and were not directly compared with PED encounters in pre\u0026ndash;post analyses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Setting and Population\u003c/h2\u003e \u003cp\u003eThe study setting comprised the PED and PUCCs within MCH. Pediatric status followed the hospital\u0026rsquo;s operational age definition, applied uniformly by triage and registration staff. Analyses were based on de-identified EHR extracts generated by the hospital data team according to standardized queries and transferred under institutional data-use agreements.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Inclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003eEligible encounters included all unscheduled pediatric presentations during the study windows managed either in the PED or PUCCs, irrespective of final disposition (e.g., discharge, admission, transfer, leaving without being seen [LWBS], or leaving against medical advice [LAMA]). Exclusions were scheduled or elective visits, direct ward admissions without PED/PUCC triage or physician assessment, non-clinical/test registrations, duplicate identifiers, encounters occurring outside MCH, and records with impossible time sequences after quality checks.\u003c/p\u003e \u003cp\u003eFor time-based outcomes, encounters lacking required timestamps after plausibility screening were excluded pairwise from the corresponding analyses but retained for other outcomes. For acuity analyses, CTAS values were restricted to valid levels 1\u0026ndash;5; encounters coded as 0 or missing were retained in overall counts but excluded from CTAS-stratified analyses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Data Sources and Variables\u003c/h2\u003e \u003cp\u003eData extracts included administrative fields (registration, triage, physician start, decision/disposition order, discharge), clinical fields (Canadian Triage and Acuity Scale [CTAS] level, chief complaint, disposition category), demographics (age, sex, nationality), and site identifiers (PED vs PUCC). All datasets were de-identified, with direct identifiers removed and free-text fields screened to prevent inadvertent disclosure.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePrimary outcomes (PED cohort): CTAS distribution in the PED, with low acuity defined as CTAS 4\u0026ndash;5 among CTAS 1\u0026ndash;5; and patient-flow indicators in the PED: door-to-doctor time (physician start minus triage) and length of stay (LOS; discharge minus triage).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSecondary outcomes (PED cohort): disposition (admitted vs other), LWBS, and daily/weekly PED encounter volumes overall and by CTAS strata (levels 1\u0026ndash;3 vs 4\u0026ndash;5).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePUCC descriptive outcomes: total PUCC encounter volume, CTAS distribution, and disposition categories during the post-implementation window, reported descriptively without inferential comparison to PED encounters\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Data Management\u003c/h2\u003e \u003cp\u003eDates and times were parsed in day-first format and combined into ISO-8601 datetimes. Negative intervals were excluded from time-based analyses but retained with flags in the master dataset. Plausibility caps were applied as follows: 0\u0026ndash;360 minutes for door-to-doctor time, 0\u0026ndash;720 minutes for doctor-to-decision time (exploratory only), and 0\u0026ndash;1,440 minutes for LOS. Values outside these ranges were excluded from primary analyses and examined separately. CTAS values outside 1\u0026ndash;5 were treated as missing in stratified analyses. Data-cleaning rules and dictionaries were maintained under version control.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Statistical Analysis\u003c/h2\u003e \u003cp\u003e Analyses were two-sided with a significance threshold of 0.05, and reporting followed STROBE guidelines. Continuous variables were summarized as medians with interquartile ranges (IQRs) and 5% trimmed means. Primary group comparisons focused on PED Pre versus PED Post. The Mann\u0026ndash;Whitney U test was used to compare medians (reporting Hodges\u0026ndash;Lehmann median differences and 95% confidence intervals), and Welch\u0026rsquo;s t-test on trimmed means served as a robustness check. Categorical variables were summarized as counts and percentages and compared using chi-square tests. Effect sizes for binary outcomes were expressed as risk ratios (RRs) with 95% confidence intervals. Sensitivity analyses examined alternative handling of missing triage timestamps (using registration time as a proxy) and the influence of outlier treatment. PUCC encounters were summarized descriptively using the same metrics but were not included in formal pre\u0026ndash;post hypothesis tests.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7. Sample Size and Ethics\u003c/h2\u003e \u003cp\u003eAll eligible encounters during the study periods were included; no formal sample size calculation was performed. The large operational dataset was expected to provide precise estimates for the primary outcomes. The study utilized de-identified electronic health record (EHR) data without direct patient contact. Institutional Review Board (IRB) approval was obtained from the Maternity and Children\u0026rsquo;s Hospital, Alahsa (IRB No. MCH-PED-2024-047), which granted a waiver of informed consent in accordance with national regulations. All data were stored on secure hospital servers with restricted access. Statistical analyses were conducted using R (version 4.x) and Python (version 3.11).\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eAcross the observation windows, there were 84,595 encounters in the pre-implementation period (1 Oct 2023\u0026ndash;30 Jun 2024) and 62,580 in the post-implementation period (1 Oct 2024\u0026ndash;30 Jun 2025). Within the PED extract, the proportion of low-acuity visits (CTAS 4\u0026ndash;5) declined markedly post-implementation, median door-to-doctor time was essentially stable, and length of stay (LOS) increased.\u003c/p\u003e \u003cp\u003eKey timestamps were highly complete and improved in the post period: triage was recorded for 82.3% pre vs 91.8% post; doctor-start for 85.3% vs 94.0%; and discharge time for 100% in both periods. Valid CTAS (levels 1\u0026ndash;5) increased from 91.6% pre to 97.1% post \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCohort size and data completeness by period.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetric\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePED Pre\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePED Post\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal encounters, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84,595\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62,580\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTriage time, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69,583 (82.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57,439 (91.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor-start, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72,184 (85.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58,796 (94.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDischarge time, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84,595 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62,580 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValid CTAS 1\u0026ndash;5, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77,498 (91.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60,737 (97.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;PED Pre\u0026rdquo; = pediatric emergency department encounters from 1 Oct 2023\u0026ndash;30 Jun 2024 (pre-implementation). \u0026ldquo;PED Post\u0026rdquo; = pediatric emergency department encounters from 1 Oct 2024\u0026ndash;30 Jun 2025 (post-implementation). CTAS\u0026thinsp;=\u0026thinsp;Canadian Triage and Acuity Scale; valid levels are 1\u0026ndash;5.\u003c/p\u003e \u003cp\u003ePatient demographics and visit characteristics for PED encounters are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The median age of children presenting to the PED decreased from 4.67 years in the pre-implementation period to 3.42 years in the post-implementation period, with a similar sex distribution across both cohorts (56.5% vs 55.8% male). The majority of encounters occurred on weekdays, accounting for 66.9% of visits pre-implementation and 68.5% post-implementation. Arrival-time distribution shifted modestly between periods: daytime presentations decreased from 29.7% to 25.4%, evening presentations from 42.4% to 38.8%, while night-time arrivals increased from 27.9% to 35.8%. These trends suggest that after PUCC implementation, PED demand included a relatively greater proportion of younger children and higher night-time utilization, while weekday versus weekend patterns remained stable.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and visit characteristics of PED encounters.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePED Pre\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePED Post\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeekday arrivals, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeekend arrivals, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaytime, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvening, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNight, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eWeekday\u0026thinsp;=\u0026thinsp;Monday\u0026ndash;Friday; Weekend\u0026thinsp;=\u0026thinsp;Saturday\u0026ndash;Sunday. Time blocks: Daytime 08:00\u0026ndash;15:59, Evening 16:00\u0026ndash;23:59, Night 00:00\u0026ndash;07:59. \u0026ldquo;Pre\u0026rdquo; = 1 Oct 2023\u0026ndash;30 Jun 2024 (pre‑implementation); \u0026ldquo;Post\u0026rdquo; = 1 Oct 2024\u0026ndash;30 Jun 2025 (post‑implementation).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDaily encounter rates decreased significantly in the post-implementation period. Over 274 pre-implementation days, the mean was 308.7 encounters/day, compared with 229.3/day across 273 post-implementation days. This corresponds to an IRR of 0.74 (95% CI 0.74\u0026ndash;0.75; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating a 26% relative reduction in daily PED volumes after PUCC implementation \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDaily pediatric emergency department encounter rates.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetric\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePED Pre\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePED Post\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncidence Rate Ratio (IRR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObserved days, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e274\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.74\u0026ndash;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal encounters, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84,595\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62,580\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily rate, mean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e308.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e229.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eIRR\u0026thinsp;=\u0026thinsp;incidence rate ratio; CI\u0026thinsp;=\u0026thinsp;confidence interval; *Significant p-value\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDuring the post-implementation window, the PUCC managed 24,962 triaged encounters; 24,719 (99.0%) were CTAS 4\u0026ndash;5 (CTAS 3: 243; CTAS 4: 7,384; CTAS 5: 17,335; CTAS 1\u0026ndash;2: 0). In the pre-implementation window, the PED triaged 77,498 encounters, of which 62,856 (81.1%) were CTAS 4\u0026ndash;5. The proportion of low-acuity presentations was therefore higher in PUCC than in the PED pre-implementation cohort (RR 1.22; 95% CI 1.22\u0026ndash;1.23; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), consistent with preferential diversion of non-urgent cases to the PUCC while higher-acuity care remained concentrated in the PED \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAcuity distribution in PUCC and PED encounters.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCTAS level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePED Pre, n\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePED Post, n\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRR (low‑acuity)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep‑value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCTAS-1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"5\" rowspan=\"6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"5\" rowspan=\"6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"5\" rowspan=\"6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCTAS-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e394\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCTAS-3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14,236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e243\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCTAS-4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58,246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7,384\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCTAS-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,610\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17,335\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal (CTAS 1\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77,498\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24,962\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow‑acuity (CTAS 4\u0026ndash;5), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62,856 (81.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24,719 (99.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.221\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.217\u0026ndash;1.225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eCTAS\u0026thinsp;=\u0026thinsp;Canadian Triage and Acuity Scale. Low-acuity defined as CTAS 4\u0026ndash;5. RR\u0026thinsp;=\u0026thinsp;risk ratio (post vs pre), 95% CI by log method. *Significant p-value.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the daily encounter trends in the PED during the pre- and post-implementation periods. A clear and sustained decline in total daily volumes was observed after the launch of the PUCC, with pre-implementation averages around 309 encounters/day compared to 229/day post-implementation (IRR\u0026thinsp;=\u0026thinsp;0.74; 95% CI 0.74\u0026ndash;0.75; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The visualized time series shows substantial week-to-week variability before implementation, followed by stabilization at lower daily volumes once the PUCC became operational. This downward shift reflects successful diversion of low-acuity cases away from the PED while maintaining consistent service continuity for higher-acuity presentations.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAnalysis of unadjusted patient-flow metrics in the PED demonstrated minimal change in door-to-doctor time, with medians of 37 min (IQR 22\u0026ndash;63) pre-implementation and 39 min (IQR 22\u0026ndash;65) post-implementation (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In contrast, length of stay (LOS) increased significantly, from a median of 62 min (IQR 34\u0026ndash;112) to 76 min (IQR 43\u0026ndash;131) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Trimmed means were consistent with these findings, confirming a modest but statistically significant prolongation of door-to-doctor time and a more clinically relevant extension of LOS following PUCC implementation \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003ePatient-flow indicators before and after PUCC implementation.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePED Pre\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePED Post\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDoor-to-doctor time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59708\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53673\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian, IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.0 (IQR 22.0\u0026ndash;63.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.0 (IQR 22.0\u0026ndash;65.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrimmed mean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLength of stay (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51417\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian, IQR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.0 (IQR 34.0\u0026ndash;112.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76.0 (IQR 43.0\u0026ndash;131.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrimmed mean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eValues shown as N, median (IQR), and 5% trimmed mean. *Significant p-values from Mann\u0026ndash;Whitney U test comparing distributions between periods.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAlthough the median door-to-doctor time difference (37 \u0026rarr; 39 min) reached statistical significance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), this 2-minute gap is clinically negligible given the large sample size. The effect therefore reflects statistical rather than operational significance. In contrast, the 14-minute increase in length of stay likely represents a meaningful system-level change affecting patient throughput.\u003c/p\u003e \u003cp\u003eApplying a harmonized classification that treated any record labeled \u0026ldquo;ADMITTED,\u0026rdquo; \u0026ldquo;WARD,\u0026rdquo; or \u0026ldquo;NICU\u0026rdquo; as an admission, the proportion of PED encounters resulting in admission increased from 1.80% (1,520/84,595) in the pre-implementation period to 11.64% (7,286/62,580) post-implementation. This apparent rise reflects both a genuine shift in case mix and changes in documentation practices. Because the underlying disposition label taxonomies differed between periods, these estimates should be interpreted cautiously and, where possible, validated against the hospital\u0026rsquo;s admissions master file to ensure accuracy \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. A sensitivity checks restricting analyses to stable disposition codes present in both periods showed a smaller increase (1.8% to 6.5%), supporting the interpretation that taxonomy changes partially account for the observed rise.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDisposition outcomes before and after PUCC implementation.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePED Pre\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePED Post\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRisk Ratio (RR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal encounters, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84,595\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62,580\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmissions n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,520 (1.80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7,286 (11.64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.14\u0026ndash;6.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eAdmissions defined conservatively as any disposition labeled 'ADMITTED', 'WARD', or 'NICU'. RR\u0026thinsp;=\u0026thinsp;risk ratio (post vs pre) with 95% CI from log method. *Significant p-value from chi-square test.\u003c/em\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003ePUCC implementation was associated with reduced PED volumes and stable door-to-doctor times. Interpreted together, these patterns are consistent with diversion of low-acuity demand away from the PED after PUCC implementation, while residual throughput pressures (e.g., boarding or inpatient flow) may have limited downstream gains in LOS. This interpretation aligns with prior work showing that shifting low-acuity patients to alternative sites (fast tracks/urgent care) reduces crowding and resource use but may not, by itself, solve hospital-wide flow constraints that drive LOS [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInternational benchmarks suggest CTAS-based targets for time-to-physician and a system-wide goal that \u0026ge;\u0026thinsp;95% of ED patients are admitted, discharged, or transferred within 4 hours (UK NHS standard). In our setting, while door-to-doctor times remained stable after PUCC implementation, the overall LOS increased; this pattern is consistent with literature indicating that boarding and inpatient flow constraints dominate LOS, so front-door demand management alone may not meet the 4-hour target across all acuity groups. These benchmarks provide context for interpreting our flow metrics and support the role of PUCCs as demand-diversion tools that should be paired with hospital-wide flow measures to improve LOS.\u003c/p\u003e \u003cp\u003eMultiple quasi-experimental and observational studies have shown that non-ED venues community urgent care, retail clinics, and ED fast tracks absorb low-acuity demand and can shorten visit times for these cohorts without compromising safety. Our observed decline in CTAS 4\u0026ndash;5 share is directionally concordant with this literature, including pediatric-focused fast-track implementations and system-level analyses of urgent care supply versus ED volume [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDoor-to-doctor times remained essentially stable across periods, a pattern compatible with maintained front-end capacity. However, LOS increased despite the drop in low-acuity mix. Prior evidence highlights that ED LOS is often dominated by hospital-wide constraints, especially boarding of admits, rather than front-end arrivals, so reductions in low-acuity traffic do not necessarily translate into shorter overall LOS [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In pediatrics specifically, crowding is associated with higher admission at the index visit for the sickest children and higher short-term revisits among the least sick, underscoring that throughput pressures can affect outcomes even when initial assessment speed is preserved [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBecause our primary acuity stratification uses CTAS, it is important to note that PaedCTAS has demonstrated validity and inter-rater reliability across multiple settings and correlates with admission, PICU use, resource utilization, and ED LOS. This supports the use of CTAS 4\u0026ndash;5 share as a reasonable low-acuity proxy in before\u0026ndash;after comparisons [\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Local implementations in Saudi Arabia further document feasibility and performance of CTAS in regional contexts [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNational and single-center studies from Saudi Arabia report median ED LOS around 60\u0026ndash;120 min, with strong associations between LOS and triage level, admission, shift, and hospital type factors that could plausibly influence our post-period LOS even as low-acuity arrivals fell [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Our harmonized classification of disposition suggested a higher admission fraction post-PUCC, but because disposition label taxonomies changed between periods, these results must be interpreted cautiously and ideally cross-checked against the admissions master file. Differences in coding or data pipelines can bias crude rates in pre\u0026ndash;post evaluations [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe strengths of this study include the large sample size, pre-specified data cleaning protocols (excluding implausible intervals and capping outliers), and acuity-aware comparative analyses. However, key limitations are inherent to before\u0026ndash;after designs, which remain susceptible to secular trends, seasonality, and shifts in case mix. Additional constraints include the reliability of time-stamp variables (particularly \u0026ldquo;decision/diagnosis time\u0026rdquo; as a proxy for physician decision-making) and changes in disposition taxonomies. Further analyses such as segmented time-series modeling, seasonal adjustment, weekday or shift fixed effects, and admission/boarding proxies would enhance causal inference and strengthen the robustness of findings [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIf the primary objective is to decompress the PED while protecting timely care for high-acuity patients, these findings suggest PUCCs are directionally effective at off-loading low-acuity visits. Realizing improvements in whole-visit LOS, however, will likely require hospital-wide flow interventions (e.g., discharge-before-noon, smoothing elective admissions, and full-capacity protocols) alongside PUCC operations [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Scaling PUCCs across the region, supported by integrated electronic triage or tele-consultation systems, may further relieve tertiary PEDs while maintaining continuity of pediatric care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eImplementation of PUCCs in Alahsa was associated with a substantial reduction in low-acuity visits to the pediatric emergency department and preserved door-to-doctor times, but with a concurrent increase in overall length of stay. The observed rise in admission fraction likely reflects both real shifts in patient acuity and changes in documentation practices, warranting cautious interpretation. Together, these findings highlight the potential of PUCCs to decompress high-demand pediatric emergency services while underscoring that hospital-wide flow and inpatient capacity remain critical determinants of patient throughput. Sustained improvements in pediatric emergency care will therefore require integrating PUCC operations with broader system-level strategies addressing admissions, boarding, and discharge processes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the Maternity and Children’s Hospital, Alahsa, Kingdom of Saudi Arabia (IRB No. MCH-PED-2024-047). The requirement for informed consent was waived because the study used retrospectively collected, de-identified electronic health record data and involved no direct patient contact, in accordance with national regulations and institutional policies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This study used anonymized routinely collected data, and no individual patient identifiers or images are included in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets supporting the conclusions of this article are available from the corresponding author upon reasonable request. The data are not publicly available due to institutional data governance policies and restrictions related to patient confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAAK conceived and designed the study and served as corresponding author. AAB and AAS contributed to clinical oversight and interpretation of emergency department workflows. MAlK participated in data acquisition and coordination with pediatric emergency services. JA, JAE, and AAA contributed to data collection, verification, and nursing workflow documentation. MAW and HA contributed to data interpretation and contextualization within family medicine practice. AAK performed the statistical analysis and drafted the initial manuscript. All authors critically reviewed the manuscript for important intellectual content, approved the final version, and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the hospital information technology and medical records teams at the Maternity and Children’s Hospital, Alahsa, for their assistance with data extraction and data management.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDoan Q, Wong H, Meckler G, et al. The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicentre cohort study. \u003cem\u003eCMAJ\u003c/em\u003e. 2019;191(23):E627\u0026ndash;35. doi:10.1503/cmaj.181426\u003c/li\u003e\n\u003cli\u003eMeyer-Macaulay CB, Truong M, Meckler GD, Doan QH. Return visits to the pediatric emergency department: A multicentre retrospective cohort study. \u003cem\u003eCJEM\u003c/em\u003e. 2018;20(4):578\u0026ndash;85. doi:10.1017/cem.2017.40\u003c/li\u003e\n\u003cli\u003eSavioli G, Ceresa IF, Gri N, et al. Emergency department overcrowding: understanding the factors to find corresponding solutions. \u003cem\u003eJ Pers Med\u003c/em\u003e. 2022;12(2):279. doi:10.3390/jpm12020279\u003c/li\u003e\n\u003cli\u003eSartini M, Carbone A, Demartini A, et al. Overcrowding in emergency department: causes, consequences, and solutions\u0026mdash;A narrative review. \u003cem\u003eHealthcare (Basel)\u003c/em\u003e. 2022;10(9):1625. doi:10.3390/healthcare10091625\u003c/li\u003e\n\u003cli\u003eBullard MJ, Musgrave E, Warren D, et al. Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) Guidelines 2016. \u003cem\u003eCJEM\u003c/em\u003e. 2017;19(S2):S18\u0026ndash;27. doi:10.1017/cem.2017.365\u003c/li\u003e\n\u003cli\u003eDut R. Usage of pediatric emergency department for non-urgent complaints. \u003cem\u003eEurasian J Emerg Med\u003c/em\u003e. 2017;16(1):23\u0026ndash;8. doi:10.5152/eajem.2017.63935\u003c/li\u003e\n\u003cli\u003eBarca-Ruso Z, Montoro-P\u0026eacute;rez N, Montejano-Lozoya R, et al. Interventions aimed at reducing non-urgent presentations and frequent attendance in paediatric emergency departments: a rapid systematic review. \u003cem\u003eEmerg Care Med\u003c/em\u003e. 2025;2(1):7. doi:10.3390/ecm2010007\u003c/li\u003e\n\u003cli\u003eFarion KJ, Wright M, Zemek R, Neto G, Karwowska A, Tse S, Reid S, Jabbour M, Poirier S, Moreau KA, Barrowman N. Understanding Low-Acuity Visits to the Pediatric Emergency Department. PLoS One. 2015 Jun 17;10(6):e0128927. doi: 10.1371/journal.pone.0128927.\u003c/li\u003e\n\u003cli\u003eGanapathy S, Lim SY, Kua JPH, Ng KC. Non-Urgent Paediatric Emergency Department Visits: Why Are They So Common? A Singapore Perspective. \u003cem\u003eAnnals, Academy of Medicine, Singapore.\u003c/em\u003e 2015 Jul;44(7):269-71. doi:10.47102/annals-acadmedsg.V44N7p269\u003c/li\u003e\n\u003cli\u003eRavi N, Gitz KM, Burton DR, Ray KN. Pediatric non-urgent emergency department visits and prior care-seeking at primary care. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e. 2021;21:466. doi:10.1186/s12913-021-06480-7\u003c/li\u003e\n\u003cli\u003eNational Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2021 Emergency Department Summary Tables. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2021-nhamcs-ed-web-tables-508.pdf. \u003cstrong\u003eAccessed 15 Jan 2026\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/li\u003e\n\u003cli\u003eAl Jabir W, Al-Alfard BA, Muhaya AA, Al Farhan A. Non-urgent pediatric presentations to the emergency department, Khamis Mushayt Maternity and Children Hospital, Saudi Arabia. \u003cem\u003eWorld Fam Med\u003c/em\u003e. 2023;21(8):87\u0026ndash;97.\u003c/li\u003e\n\u003cli\u003eAl-Qahtani MH, Yousef AA, Awary BH, Albuali WH, Al Ghamdi MA, AlOmar RS, AlShamlan NA, Yousef HA, Motabgani S, AlAmer NA, Alsawad KM, Altaweel FY, Altaweel KS, AlQunais RA, Alsubaie FA, Al Shammari MA. Correction to: Characteristics of visits and predictors of admission from a paediatric emergency room in Saudi Arabia. BMC Emerg Med. 2021 Aug 29;21(1):99. doi: 10.1186/s12873-021-00492-6.\u003c/li\u003e\n\u003cli\u003eWeinick RM, Bristol SJ, DesRoches CM. Urgent care centers in the U.S.: findings from a national survey. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e. 2009;9:79. doi:10.1186/1472-6963-9-79\u003c/li\u003e\n\u003cli\u003eRemick K, Gausche-Hill M, Joseph MM, Brown K, Snow SK, Wright JL; AMERICAN ACADEMY OF PEDIATRICS, Committee on Pediatric Emergency Medicine, Section on Surgery; AMERICAN COLLEGE OF EMERGENCY PHYSICIANS, Pediatric Emergency Medicine Committee; EMERGENCY NURSES ASSOCIATION, Pediatric Committee; Pediatric Readiness in the Emergency Department; POLICY STATEMENT; Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children. Pediatric Readiness in the Emergency Department. Ann Emerg Med. 2018 Dec;72(6):e123-e136. doi: 10.1016/j.annemergmed.2018.08.431.\u003c/li\u003e\n\u003cli\u003eSaidinejad M, Paul AZ, Heins A, et al. ACEP Pediatric Committee Statement on Urgent Care Centers and Retail Clinics. 2016 Jun. Columbus, OH: American College of Emergency Physicians. Available from: https://www.acep.org/siteassets/uploads/uploaded-files/acep/clinical-and-practice-management/resources/pediatrics/urgent-care-center-peds-committee-ip-june-2016.pdf. Accessed 15 Jan 2026.\u003c/li\u003e\n\u003cli\u003eBlack LI, Zablotsky B. Urgent Care Center and Retail Health Clinic Utilization Among Children: United States, 2019. NCHS Data Brief. 2020 Dec;(393):1-8. PMID: 33270552.\u003c/li\u003e\n\u003cli\u003eBristow, Peter and Lenzen, Sabrina and Connelly, Luke, The Effect of Urgent Care Centers on Emergency Department Attendance and Waiting Times. http://dx.doi.org/10.2139/ssrn.5243075\u003c/li\u003e\n\u003cli\u003eAllen L, et al. Impact of retail clinics on emergency department visits and costs. \u003cem\u003eHealth Serv Res\u003c/em\u003e. 2021;56(6):1100\u0026ndash;11. doi:10.1111/1475-6773.13631\u003c/li\u003e\n\u003cli\u003eWang MC, et al. Urgent care centers: impacts on emergency department visits. \u003cem\u003eHealth Aff (Millwood)\u003c/em\u003e. 2021;40(8):1281\u0026ndash;90. doi:10.1377/hlthaff.2020.01869\u003c/li\u003e\n\u003cli\u003eCarlson LC, Raja AS, Dworkis DA, Lee J, Brown DFM, Samuels-Kalow M, Wilson M, Shapiro M, Kim J, Yun BJ. Impact of Urgent Care Openings on Emergency Department Visits to Two Academic Medical Centers Within an Integrated Health Care System. Ann Emerg Med. 2020 Mar;75(3):382-391. doi: 10.1016/j.annemergmed.2019.06.024. \u003c/li\u003e\n\u003cli\u003eHampers LC, Cha S, Gutglass DJ, Binns HJ, Krug SE. Fast track and the pediatric emergency department: resource utilization and patients outcomes. Acad Emerg Med. 1999 Nov;6(11):1153-9. doi: 10.1111/j.1553-2712.1999.tb00119.x. \u003c/li\u003e\n\u003cli\u003eMartin HA, Noble M, Wilmarth J. Improving Patient Flow and Decreasing Patient Length of Stay in the Pediatric Emergency Department Through Implementation of a Fast Track. Adv Emerg Nurs J. 2021 Apr-Jun 01;43(2):162-169. doi: 10.1097/TME.0000000000000351.\u003c/li\u003e\n\u003cli\u003eMcKenna P, et al. ED/hospital crowding: causes and cures. \u003cem\u003eClin Exp Emerg Med\u003c/em\u003e. 2019;6(3):189\u0026ndash;95. doi:10.15441/ceem.18.022\u003c/li\u003e\n\u003cli\u003eCarter EJ, Pouch SM, Larson EL. The relationship between emergency department crowding and patient outcomes: a systematic review. J Nurs Scholarsh. 2014 Mar;46(2):106-15. doi: 10.1111/jnu.12055. \u003c/li\u003e\n\u003cli\u003eMoylan A, Maconochie I. Demand, overcrowding and the pediatric emergency department. CMAJ. 2019 Jun 10;191(23):E625-E626. doi: 10.1503/cmaj.190610.\u003c/li\u003e\n\u003cli\u003eAbudan A, Merchant RC. Multi-dimensional Measurements of Crowding for Pediatric Emergency Departments: A Systematic Review. Glob Pediatr Health. 2021 Feb 27;8:2333794X21999153. doi: 10.1177/2333794X21999153. \u003c/li\u003e\n\u003cli\u003eGravel J, Manzano S, Arsenault M. Validity of the Canadian Paediatric Triage and Acuity Scale in a tertiary care hospital. CJEM. 2009 Jan;11(1):23-8. doi: 10.1017/s1481803500010885. \u003c/li\u003e\n\u003cli\u003eGravel J, Gouin S, Goldman RD, Osmond MH, Fitzpatrick E, Boutis K, Guimont C, Joubert G, Millar K, Curtis S, Sinclair D, Amre D. The Canadian Triage and Acuity Scale for children: a prospective multicenter evaluation. Ann Emerg Med. 2012 Jul;60(1):71-7.e3. doi: 10.1016/j.annemergmed.2011.12.004. \u003c/li\u003e\n\u003cli\u003eZachariasse JM, van der Hagen V, Seiger N, Mackway-Jones K, van Veen M, Moll HA. Performance of triage systems in emergency care: a systematic review and meta-analysis. BMJ Open. 2019 May 28;9(5):e026471. doi: 10.1136/bmjopen-2018-026471. \u003c/li\u003e\n\u003cli\u003eElkum NB, Barrett C, Al-Omran H. Canadian Emergency Department Triage and Acuity Scale: implementation in a tertiary care center in Saudi Arabia. BMC Emerg Med. 2011 Feb 10;11:3. doi: 10.1186/1471-227X-11-3. \u003c/li\u003e\n\u003cli\u003eAlharbi AA, Muhayya M, Alkhudairy R, Alhussain AA, Muaddi MA, Alqassim AY, AlOmar RS, Alabdulaali MK. The pattern of emergency department length of stay in Saudi Arabia: an epidemiological Nationwide analyses of secondary surveillance data. Front Public Health. 2023 Dec 12;11:1265707. doi: 10.3389/fpubh.2023.1265707.\u003c/li\u003e\n\u003cli\u003evan der Linden MCC, van Ufford HMEJ; Project Group Medical Specialists; van der Linden NN. The impact of a multimodal intervention on emergency department crowding and patient flow. Int J Emerg Med. 2019 Aug 27;12(1):21. doi: 10.1186/s12245-019-0238-7.\u003c/li\u003e\n\u003cli\u003eBarata I, Brown KM, Fitzmaurice L, Griffin ES, Snow SK; American Academy of Pediatrics Committee on Pediatric Emergency Medicine; American College of Emergency Physicians Pediatric Emergency Medicine Committee; Emergency Nurses Association Pediatric Committee. Best practices for improving flow and care of pediatric patients in the emergency department. Pediatrics. 2015 Jan;135(1):e273-83. doi: 10.1542/peds.2014-3425. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pediatric emergency department, urgent care, overcrowding, CTAS, length of stay, Saudi Arabia","lastPublishedDoi":"10.21203/rs.3.rs-8533383/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8533383/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePediatric emergency departments (PEDs) face persistent overcrowding, largely driven by low-acuity visits that could be managed in outpatient settings. Pediatric Urgent Care Clinics (PUCCs) have been introduced to redirect such demand, yet evidence from the Gulf region remains limited.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eTo evaluate the impact of implementing a PUCC on emergency department utilization, patient acuity mix, flow indicators, and disposition patterns at the Maternity and Children\u0026rsquo;s Hospital in Alahsa, Saudi Arabia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective pre\u0026ndash;post cohort study was conducted using electronic health record data from October 2023\u0026ndash;June 2024 (pre-implementation) and October 2024\u0026ndash;June 2025 (post-implementation). Variables included Canadian Triage and Acuity Scale (CTAS) level, timestamps (triage, physician start, discharge), demographics, and disposition. Predefined cleaning rules excluded implausible or negative intervals. Outcomes were visit volumes, acuity distribution, door-to-doctor time, length of stay (LOS), and admission fraction. Comparative analyses used risk ratios (RR), interquartile ranges (IQR), trimmed means, and chi-square or rank-sum tests as appropriate.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 147,175 encounters were analyzed (pre: 84,595; post: 62,580). The proportion of low-acuity visits (CTAS 4\u0026ndash;5) decreased from 81.1% to 50.2% (RR 0.62; 95% CI 0.61\u0026ndash;0.62; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Median door-to-doctor time remained stable (37 vs 39 min; p\u0026thinsp;=\u0026thinsp;0.12), while median LOS increased from 62 to 76 min (trimmed mean 78.7 vs 92.7 min; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Harmonized admissions rose from 1.8% to 11.6% (RR 6.48; 95% CI 6.14\u0026ndash;6.84; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), partly reflecting changes in disposition coding.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePUCC implementation was associated with a marked reduction in low-acuity PED visits and stable front-end performance, accompanied by a modest rise in overall LOS. PUCCs represent a promising component of pediatric emergency care optimization, but sustained system-wide improvements will require integration with broader hospital flow and capacity measures.\u003c/p\u003e","manuscriptTitle":"Impact of Pediatric Urgent Care Clinics on Emergency Department Utilization and Patient Flow: A Pre–Post Cohort Study in Saudi Arabia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 00:36:05","doi":"10.21203/rs.3.rs-8533383/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-19T03:46:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-07T20:36:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-02T10:46:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-16T20:14:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168567728318851479160662644148663827271","date":"2026-02-16T19:39:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175352036086046220448601014116704533134","date":"2026-02-14T11:41:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"55899331523627880025797441667824793590","date":"2026-02-07T02:34:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T06:03:20+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-08T11:24:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-07T09:59:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-07T09:59:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Emergency Medicine","date":"2026-01-06T15:59:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8ea7b53e-810d-4036-bf29-7974c23a4116","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T02:25:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-10 00:36:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8533383","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8533383","identity":"rs-8533383","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}