How many children seen in emergency rooms don’t have emergencies?

Everybody knows, especially those who work in emergency rooms, that a sizable proportion of patients there don’t have an emergency. This is true for children as well as adults. The reasons they are in the ER and not somewhere else are also pretty well known:

1.) A lot of children don’t have a regular doctor, so the ER, by default, serves as their doctor.

2.) Even if a child has a regular doctor, often appointments are hard to get and are days or even weeks in advance, something that doesn’t help very much if your child has an acute illness.

3.) Many doctors’ offices aren’t set up to have much capacity to handle walk-ins.

There is a growing number of free-standing ambulatory walk-in clinics, called by some a “doc-in-a-box,” that respond to this need, but a lot of parents end up taking their child to the ER. Of course this tends to clog up the ER, but many parents simply have no other choice. The question is, what proportion of the children being seen in America’s ERs don’t need to be there?

A recent study in Pediatrics, the journal of the American Academy of Pediatrics, tried to answer this important question. (The link is only to the abstract — unfortunately, you need a subscription to get the whole thing. If anybody wants one, let me know.) The study surveyed a national sample of 5,512 ER visits. The demographics of the group — age, sex, race, economic status — were broadly representative of the whole US population. The investigators counted the number of times the children used the ER and for what. Importantly, and a weakness in the data, is that they didn’t have access to the actual patient encounter charts, so the true severity of the children’s problems couldn’t be assessed; all they knew was what the final diagnosis was.

What they found was that yes, many children who, for one reason or another are brought to the ER, don’t need to be there. But the number of such visits — 1671, or 30% — was less than I expected. Like many pediatricians who have worked in ERs, as I did extensively for 5 years, it often seems like well over half the kids don’t really need to be there. But that’s not what the study found. Of course, 30% is still too many, because it diverts the attention of the ER staff from the sickest children and clogs the system. I think if you gave the parents of these children other options they wouldn’t use the ER. I say this because, in my experience, most parents really are excellent judges of how sick their children are.

Age also mattered; children older than two were more likely to be in the ER inappropriately than were younger children. This actually was a good thing. Infants get seriously ill faster, and with potentially worse consequences, than do older children. Those are the ones we want in the ER more frequently.

The data on socioeconomic status were the most interesting to me. Contrary to what you might think, low-income children, especially minority children, were less likely to use the ER inappropriately. Insurance status wasn’t a factor, although children with insurance had higher overall costs. This is likely an artifact of how we pay for medical care in America.

This study was a national average, and I’m sure the numbers would differ among inner-city urban, suburban, and rural hospitals.

Overuse of the ER is definitely something we need to fix if we ever are to bring down the cost of medical care. Because the overhead costs of ERs are so high (they must be constantly ready for anything), the cost of seeing common illnesses there is several times higher than the cost of the exact same thing seen in a doctor’s office or clinic.