Posts Tagged ‘ED’

Do after hours nurse call centers send too many kids to the emergency room?

November 23, 2013  |  General  |  No Comments

A large number of pediatric practices these days use after-hours call centers for parents who have questions about a sick child. I’ve been looking around to find some data about how common this is, but my sense is that the majority of pediatricians use them. There is no question these call centers make live easier for the doctor; having somebody screen the calls, answer easy questions, and only call you for important issues is a great boon. But that boon comes at a cost: the people staffing the call centers are not doctors. They are often experienced nurses, but that is not the same thing. So deciding what is important and what can wait can be a problem.

The call centers generally use predetermined protocols drawn up by experts to help guide decision-making. This is a good way to ensure consistent, quality advice. But not every child fits the protocol, and a set of guidelines is not a substitute for actual clinical experience. Really, these days a savvy parent can get almost as much useful guidance from consulting Dr. Google (or my latest book). A study presented at the most recent meeting of the American Academy of Pediatrics examines another question: do these call centers send too many children to the emergency department?

My assumption would be that they do. After all, they are hard-wired to do so. If you call one, the person giving you advice not only is not a doctor, they do not know your child. Also, the decision-making protocols they use necessarily err on the safe side. So if there is any doubt about what to do they will advise you to take your child to the emergency department even though your child’s doctor often might not do that.

The study bears out this presumption. The investigators, from Children’s National Medical Center in Washington, D.C., examined the records of 220 children for whom the call center advised parents to take their child to the emergency department. They used a panel of evaluators to see if the visit to the ED was appropriate. They found that, for a third of the children, they could have safely stayed home.

After-hours call centers have made doctors’ lives less hectic, and I’m not suggesting we do away with them. They give thousands of parents useful advice. Plus, what we don’t know is if even more of those 220 children would have ended up in the ED if the call center didn’t exist: who knows, perhaps they steered a significant fraction of children away from an inconvenient and expensive ED visit. However, in my own anecdotal experience the call centers do increase ED use. I have had many parents tell me, after I’ve seen their child in the ED, that the only reason they came was that the call center told them t0 — that they were surprised by that advice and otherwise would have stayed home.

My own father was a small town pediatrician. He didn’t have an answering service. When parents wanted to ask about their sick child they just called him at our home. His phone number was in the directory just like everybody else’s. He didn’t have any sort of pager. If he wasn’t home, people called back or else called whatever number one of us kids or my mother told them to call to find him. Those were simpler times, and not necessarily better ones. Now we have call centers, and we need to figure out how best to use them.

I’d be interested in any experiences, good or bad, that parents have had with after-hours call centers. Were they helpful? Were they a problem?

Are smaller emergency departments increasingly less able to handle children? The problem of lateral transfer

Are smaller emergency departments increasingly less able to handle children? The problem of lateral transfer

August 2, 2012  |  General  |  No Comments

There are about 27 million visits by children to America’s emergency departments each year. About a quarter of those are to rural EDs or ones at some distance from a dedicated children’s facility, such as a children’s hospital. Over the last decade or so it’s become clear that, for critically ill children, early transfer to an advanced pediatric facility improves outcomes. The children do better if they can be transferred early in their care to a pediatric intensive care unit. This has prompted attempts to regionalize pediatric critical care, and pediatric transport, in some formal way. That’s all reasonable and good.

What has also happened, though, is an increasing tendency to transfer children from one emergency department to another, from a facility not dedicated to pediatric care to one that is. And this may not be best for children and their families; transfer adds risk and cost, especially if it is unnecessary. What may be happening is an unwillingness of general purpose EDs to provide even fairly ordinary pediatric care.

A recent article in Pediatrics, the journal of the American Academy of Pediatrics, examined this group of children — those not critically ill but who were transferred to a pediatric emergency department for care. The authors premise is that, if a significant number of those children were discharged home from the receiving emergency department, they most likely could have been handled appropriately at the ED that sent them. There should be some caveats with that assumption, though. One is that sometimes the availability of a pediatric subspecialist, for example a pediatric cardiologist to evaluate a child with a possible heart problem, allows a dedicated pediatric ED to send home children because they have the expertise to make that decision. But I have certainly seen children flown in by helicopter from another hospital and then get sent home. They didn’t need the expensive (and sometimes dangerous) helicopter ride.

The authors of the article looked at the records for 42 pediatric hospitals to identify such interfacility ED to ED transfers. There were about 25,000 of them, a pretty large group. It turned out that a full quarter of these children were sent home from the pediatric ED. Another 17% were admitted to the hospital for less than 24 hours.

The authors’ conclusions are judiciously phrased:

 A significant proportion of interfacility transfers to academic pediatric EDs is discharged directly from the ED or is admitted for less than a day. These patients and their clinical outcomes provide insight into the educational needs and medical capabilities of referring hospitals and clinicians.

What can be done about this? One solution is to continue to regionalize pediatric care. This allows doctors in a nonpediatric ED to have easy access to pediatric specialists by phone at least, or even better by telemedicine links. This allows remote consultation with an expert. A lot of this already happens — I get many such calls — but formalizing these interfacility relationships does improve care. Transport mishaps are uncommon, but they do occur. It would be terrible for a child to suffer injury or death from a transport that did not need to happen.

Are smaller emergency departments increasingly less able to handle children? The problem of lateral transfer

August 2, 2012  |  General  |  No Comments

There are about 27 million visits by children to America’s emergency departments each year. About a quarter of those are to rural EDs or ones at some distance from a dedicated children’s facility, such as a children’s hospital. Over the last decade or so it’s become clear that, for critically ill children, early transfer to an advanced pediatric facility improves outcomes. The children do better if they can be transferred early in their care to a pediatric intensive care unit. This has prompted attempts to regionalize pediatric critical care, and pediatric transport, in some formal way. That’s all reasonable and good.

What has also happened, though, is an increasing tendency to transfer children from one emergency department to another, from a facility not dedicated to pediatric care to one that is. And this may not be best for children and their families; transfer adds risk and cost, especially if it is unnecessary. What may be happening is an unwillingness of general purpose EDs to provide even fairly ordinary pediatric care.

A recent article in Pediatrics, the journal of the American Academy of Pediatrics, examined this group of children — those not critically ill but who were transferred to a pediatric emergency department for care. The authors premise is that, if a significant number of those children were discharged home from the receiving emergency department, they most likely could have been handled appropriately at the ED that sent them. There should be some caveats with that assumption, though. One is that sometimes the availability of a pediatric subspecialist, for example a pediatric cardiologist to evaluate a child with a possible heart problem, allows a dedicated pediatric ED to send home children because they have the expertise to make that decision. But I have certainly seen children flown in by helicopter from another hospital and then get sent home. They didn’t need the expensive (and sometimes dangerous) helicopter ride.

The authors of the article looked at the records for 42 pediatric hospitals to identify such interfacility ED to ED transfers. There were about 25,000 of them, a pretty large group. It turned out that a full quarter of these children were sent home from the pediatric ED. Another 17% were admitted to the hospital for less than 24 hours.

The authors’ conclusions are judiciously phrased:

 A significant proportion of interfacility transfers to academic pediatric EDs is discharged directly from the ED or is admitted for less than a day. These patients and their clinical outcomes provide insight into the educational needs and medical capabilities of referring hospitals and clinicians.

What can be done about this? One solution is to continue to regionalize pediatric care. This allows doctors in a nonpediatric ED to have easy access to pediatric specialists by phone at least, or even better by telemedicine links. This allows remote consultation with an expert. A lot of this already happens — I get many such calls — but formalizing these interfacility relationships does improve care. Transport mishaps are uncommon, but they do occur. It would be terrible for a child to suffer injury or death from a transport that did not need to happen.

Some statistics about children’s use of emergency departments

November 30, 2011  |  General  |  No Comments

It’s pretty well known that emergency room use is on the increase. This recent study summarized the trend over the past decade (the complete article is behind a paywall — let me know if anybody wants a complete copy). The authors compared 1997 with 2007, looking at the number of ED visits per 1000 population. They found that the total number of visits had increased from 353 per 1000 persons in 1997 to 390 per 1000 persons. The total increase in number of visits was about double what you would predict just from population growth. So more folks have been going to the ED over the past decade. How many of these were children?

It turns out that the rate among children has not changed significantly over the past decade — it’s stable at 362 per 1000 population. So the past decade’s growth in ED use has come from other age groups. The study found all adults between 18 and 64 years of age increased their rate of use. Interestingly, older people, those over 65, did not.

ED use by insurance status confirmed what all of us have known for quite some time: the uninsured and those with Medicaid have the highest rate of ED use. A patient with Medicaid was roughly twice likely as a patient with insurance to go to the ED for care, and someone with no insurance was half again as likely to go to the ED as an insured person. The reason for this is most likely little or no access to regular primary care, care which would keep them out of the ED. It’s getting harder and harder for kids on Medicaid to find a doctor, largely because the reimbursement rate is so bad. In my state, for example, a pediatrician gets paid less to see a child with complicated health problems than it costs to change the oil in your car.

Another recent study, this one just involving children, examines the issue of inappropriate ED use. After all, if children can get care from a regular doctor, they are less likely to use the ED to get routine care. (Unfortunately there’s a paywall on this article, too.)

The authors examined the characteristics of what they called “inappropriate” use of the ED — essentially things for which, if the child had a regular doctor, they would not have come to the ED. Their findings also confirmed what we would have suspected: poor kids, kids on Medicaid, and uninsured kids — those who had trouble finding a regular doctor — were more likely to use the ED for routine care. ED care is extremely expensive care: the same visit for asthma, for example, is far cheaper in the office than in the ED. But if you’re a parent whose child is without regular healthcare, where are you supposed to go, if not the ED? From the article:

“Specifically, patients identified access barriers in the primary care clinic as the major reason for choosing the ED instead of the clinic. They reported a cumbersome scheduling system, long waiting times for appointments, and no availability of walk-in care.”

All this seems obvious. But sometimes we need actual research studies to confirm the intuitively obvious. And excessive ED use is one of the engines in our ever-increasing healthcare bills.

Statistics about children’s use of emergency departments

December 17, 2010  |  General  |  No Comments

It’s pretty well known that emergency room use is on the increase. This recent study summarized the trend over the past decade (the complete article is behind a paywall — let me know if anybody wants a complete copy). The authors compared 1997 with 2007, looking at the number of ED visits per 1000 population. They found that the total number of visits had increased from 353 per 1000 persons in 1997 to 390 per 1000 persons. The total number of visits was about double what you would predict just from population growth. So more folks have been going to the ED over the past decade. How many of these were children?

It turns out that the rate among children has not changed significantly over the past decade — it’s stable at 362 per 1000 population. So the past decade’s growth in ED use has come from other age groups. The study found all adults between 18 and 64 years of age increased their rate of use. Interestingly, older people, those over 65, did not.

ED use by insurance status confirmed what all of us have known for quite some time: the uninsured and those with Medicaid have the highest rate of ED use. A patient with Medicaid was roughly twice likely as a patient with insurance to go to the ED for care, and someone with no insurance was half again as likely to go to the ED as an insured person. The reason for this is most likely little or no access to regular primary care, care which would keep them out of the ED. It’s getting harder and harder for kids on Medicaid to find a doctor, largely because the reimbursement rate is so bad. In my state, for example, a pediatrician gets paid less to see a child with complicated health problems than it costs to change the oil in your car.

Another recent study, this one just involving children, examines the issue of inappropriate ED use. After all, if children can get care from a regular doctor, they are less likely to use the ED to get routine care. (Unfortunately there’s a paywall on this article, too.)

The authors examined the characteristics of what they called “inappropriate” use of the ED — essentially things for which, if the child had a regular doctor, they would not have come to the ED. Their findings also confirmed what we would have suspected: poor kids, kids on Medicaid, and uninsured kids — those who had trouble finding a regular doctor — were more likely to use the ED for routine care. ED care is extremely expensive care: the same visit for asthma, for example, is far cheaper in the office than in the ED. But if you’re a parent whose child is without regular healthcare, where are you supposed to go, if not the ED? From the article:

“Specifically, patients identified access barriers in the primary care clinic as the major reason for choosing the ED instead of the clinic. They reported a cumbersome scheduling system, long waiting times for appointments, and no availability of walk-in care.”

All this seems obvious. But sometimes we need actual research studies to confirm the intuitively obvious. And excessive ED use is one of the engines in our ever-increasing healthcare bills.