Many Parents Bring Children to the ED for Nonurgent Care

Children under age 15 make more than 22 million visits to US hospital emergency departments each year, according to the American Academy of Pediatrics, and a growing percentage of those visits are for nonurgent care that could have been handled in a primary care provider's office.

As the high volume of non-emergency cases strains hospitals, researchers at the Medical College of Wisconsin are taking a detailed look at why so many kids' parents choose to go the emergency department route. One study conducted by the MCW Department of Pediatrics indicated that a big reason many kids are brought to the ED is the long waiting time in doctors' offices experienced or perceived by caregivers.

"From this study we showed that those parents who reported difficulty accessing their primary care provider in a timely manner for either injury or illness care, as would be expected, was a predictor of nonurgent emergency department utilization," said David C. Brousseau, MD, MS, Medical College Assistant Professor, Pediatrics.

"The measure that we used was the nationally validated CAHPS (Consumer Assessment of Health Plans) measure," said Dr. Brousseau. "What they look at is parental perceptions where the parents rate their experiences with care, their ability to get routine and sick care, in a timely manner. That's essentially defined as 'as quickly as they wanted' or 'as quickly as they think it is needed.'

"There might be differences in people's perceptions of how fast they need things, but the interesting thing for us is that people make decisions based on their own perceptions. Somebody else may not think that it is too long to wait, but if the parent thinks it's too long to wait they're going to come in to the emergency department. Certainly, the inability to get care quickly from their primary care provider is associated in our study with nonurgent emergency department use."

Survey Work at Children's Hospital
A total of 719 parents and other caregivers were surveyed at the Children's Hospital of Wisconsin emergency department for the initial study, which was published in January 2004 in the Archives of Pediatric and Adolescent Medicine (Vol. 158). About half the cases were identified as 'nonurgent' and the other half were control cases identified as 'emergent', or true emergencies used as the control group for the study.

"We took people who came into our emergency department and broke them down by chief complaint into those that were clearly emergent," said Dr. Brousseau, "things like anaphylaxis (a state of shock caused by exposure to an antigen such as wasp venom or penicillin), severe trauma, or broken bones, and into conditions that were considered nonurgent.

"The nonurgent conditions are based on triage criteria and other factors, things like having a rash for more than a couple of days, a sore throat with no fever and no coughing or difficulty breathing, things that could easily wait more than 24 hours to be seen without any significant deterioration.

"What we used this study for was to try and identify people who are at high risk (for nonurgent ED use). What we're beginning to show with studies like this is that those people who identity themselves as having lower quality care, or who are less satisfied with the speed with which they're able to obtain care, are far more likely to use the emergency department for nonurgent conditions."

Targeting Interventions
The federal Agency for Health Care Research and Quality supported the initial CAHPS survey work at Children's Hospital, which included cases involving children age 6 months to 12 years. Dr. Brousseau said that additional funding is being sought to take the research forward.

"We're doing some prospective work now to be able to give this survey to people either in an emergency department or a primary care office to identify those at high risk and then intervene for those people," said Dr. Brousseau. "Therefore, we can target an intervention rather than targeting a practice, where most people might think everything is fine, but we can target the individual by letting them fill out a fairly brief survey.

"This way we can further explore from an individual perspective rather than just looking at large databases where we know health insurance, for example, is a factor. We controlled for the insurance, we controlled for whether subjects had a primary care provider. It's not just moving to a primary care provider. You have to be happy with the quality of care you're getting and to be satisfied that they're giving care as quickly as you want it."

Dr. Brousseau stressed that even though using an emergency room for nonurgent pediatric care may make sense to parents for a variety of reasons, it's not necessarily in the best interests of their children's long-term health care.

Advice for Parents
"We see it all the time," said Dr. Brousseau. "We ask caregivers what made them come to the emergency department instead of their doctor, and they say 'well, every time I go to my doctor they tell me to go to the emergency department.' Some families make it known: the emergency department is the 'sick place' and their practice is the 'well place.' I hope they're not trying to do it that way.

"From the medical perspective and perhaps the societal and health care financing perspectives, perhaps a nonurgent emergency department visit isn't a good thing. But to a parent, it might be the most efficient use of their time and effort. Interventional changes or structural changes in the health care system aren't going to affect them, because they're doing what they want to do. They're not feeling like they're forced to the emergency department."

Other things that the CAHP questions try to get at, Dr. Brousseau said, are how well parents communicate with their health care provider and whether they're able to get needed care and referrals. Those things were associated with nonurgent utilization, just not as strongly as the matter of getting care without long waits.

"Some people don't have a lot of options in where they go for care," said Dr. Brousseau. "But I do think it's up to families to assess the care they're receiving. I think most of the medical community believes that the interrupted care, seeing a different provider each time, is not the best thing for your child. I'm not sure that most families agree with that. But we don't have the ED chart that we can pull that has your history. We're getting there, but it's not at our fingertips. In your own medical office they've got your child's heights, weights, and every visit they've ever had, and it's a lot easier and a lot more efficient.

"The individual family needs to find a physician practice or nurse provider, whoever is going to be their primary care provider, and really establish that person as their 'medical home' where their care is coordinated, comprehensive, and where everything is directed. There is a drawback to coming to the emergency department for care."

Dan Ullrich
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.