EVALUATION OF NON-URGENT EMERGENCY DEPARTMENT VISIT IN PEDIATRIC PRIMARY CARE POPULATION Mei Lin Chen-Lim, BSN, RN, CCRC

Study Team

Sharon J. Barton, PhD, RN, PCNS-BCAssistant VP, Nursing Research and EBP; Education; And Outcomes

Susan M. Brennan, RN, CPNStaff Nurse, Outpatient, Level II; CHOP Care Network, South Philadelphia

Rachel E. Cohen, MSN, CRNPNurse Practitioner; CHOP Care Network, South Philadelphia

Mei Lin Chen-Lim, BSN,RN, CCRCSr. Nurse Research Coordinator; Center for Pediatric Nursing Research & Evidence Based Practice

Brooke Bazz Park, BSN, RNClinical Nurse Research Coordinator I; Children’s Anesthesia Associate

Phyllis Slutsky, M.Ed., RNEducation Nurse Specialist; Nursing Education Department

Background• Approximately 20% of patients nationwide, with at least one

Emergency Department (ED) visit, were children (ages 0-17 years); half or more of these visits were for non-urgent conditions.1,2

• An Evidence Based Practice review confirms that the misuse of ED contributes to: 3,4,5

• High health care costs • Poor continuity of care within the primary care system• Parent inability to identify and prioritize situations requiring ED use

• Patients continue to seek care in the ED when access to a primary care office (PCP) or after hours program (AHP) is available.6

Purpose

Evaluate the reasons that families use the ED for their child’s non-urgent care when primary or after hours care

is available

Method• Institutional Review Board (IRB) approved

• Target Population

Patients of South Philadelphia Primary Care site, Level 4 or 5 ED visits, during year 2011

• Chart Review

Confirm urgent or non-urgent status; Nurse Practitioner to review as needed

• Scripted Phone InterviewsPatients classified as non-urgent visits not referred by PCP or AHP

Reasons for going to ED for care; knowledge of the AHP program, and treatment administered at home prior to ED visit

Results: Non-urgent ED Visits

Total N = 869 Non-Urgent

n (%)

ED Visits (n) 742 (85)

Age (Mean yrs) 4.11

Gender Male Female

371 (50)371 (50)

Race Black White Hispanic Asian Other

474 (64)105 (14) 77 (10) 57 ( 8)

29 ( 4) Insurance (Yes) State Private

714 (96)614 (86)100 (14)

Referral by PCP/AHP Yes No

82 (11)660 (89)

ED Visit Duration (Mean hrs) 3.12

Top Rank

n = 742Chief Complaint (n) Discharge Diagnosis: ICD9 (n)

1 Fever (247) Fever: 780.6 (239)

2 Vomiting (96)Acute upper respiratory tract

infection: 465.9 (156)

3 Rash (78)Viral Syndrome, not otherwise

specified: 79.99 (121)

4 Cough (68) Cough: 786.2 (89)

5 Ear pain (60)Suppurative and unspecified otitis

media, acute, without eardrum rupture: 382 (78)

Results: Non-urgent ED Visits

Mon

day

Tuesd

ay

Wed

nesd

ay

Thurs

day

Friday

Satur

day

Sunda

y0

20

40

60

80

100

120

140

160

Non-urgent ED Visits for Days of Week

Total

Day Evening Night0

50

100

150

200

250

300

350

400

ED Visit Arrivals by Shifts

Results: Phone Interview• 70 phone interviews were evaluated.

• Treatment Prior to ED visit:

73% reported giving medication and/or non-medication treatment prior to ED visit

21% reported no treatment given due to fear

6% was seen at clinic few days prior to ED visit

• Wait Time: 60% reported that wait time at clinic would be same or shorter than ED.

• Comparison of Services/Treatment: 61% reported that treatment/service administered from ED visit would have been the same as clinic.

Services received from ED was reported as different compare to clinic: Equipment/treatment related (13%): “2 hour continuous respiratory treatment”; “x-ray” Tests (6%): “Did urine cath in ED - not sure if they can at CCNSP“; “Instant gratification to reassure

not MRSA” Confidence better at hospital (11%): “Think hospital is better”; “Saw 3 doctors in ED - only 1 at

CCNSP”

Conclusion• Fever was the primary chief complaint and discharge diagnosis for

non-urgent ED visits

• Majority of the patients are using the ED for non-urgent care especially during the times when appointments are available.

• 1/3 reported going to ED because of tests, equipment, or better confidence at the hospital.

• 60% reported that wait time at PCP would be same or shorter than ED

• Only 60% reported knowledge of AHP; however, majority who used AHP reported as helpful.

Implementation to Practice

Reduce Non-urgent ED Use

ED Use Education

Providers can order "ED use education" within electronic medical record system for nurses to teach about non-

urgent ED usage

Access to Care Guide

Creation of document to summarize office policies and

procedures for families

Parent Education Toolkit on Fever

Implementation of RN fever teaching at newborn, 5 week and 2 month well visit or any other age group as requested

by provider

Office Video Education while Waiting

Creation of office video (English & Spanish) to

educate about common concerns that can be

addressed at home or in the office

Video While Waiting• Education provided by familiar staff• Topics include many reasons people go to the ED for non-

urgent usage• Families in waiting room are “captive audience”• Education provided in English and Spanish for key topics

http://www.youtube.com/watch?v=6su8HrofjY8&list=HL1344348822&feature=mh_lolz

Access to Care Guide

Provider Order set in EMR (EPIC)Indentifying ED Usage1

Document counseling for Non-urgent ED use

2

Order in-office teaching3

RN Fever Teaching Guide

Newborn Visit

5 Week Visit

2 Month Visit

Fever Teaching

Fever Post-test for Parents

References1. Garcia, T.C., Bernstein, A.B., & Bush, M.A. (2010, May).

Emergency department visitors and visits: Who used the emergency room in 2007? NCHS data brief, no 38. Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db38.pdf

2. Zandieh, S., Gershel, J., Briggs, W., Mancuso, C., & Kuder, J. (2009). Revisiting predictors of parental health care-seeking behaviors for nonurgent conditions at one inner-city hospital. Pediatric Emergency Care, 25(4), 238-243.

3. Berry, A., Brousseau, D., Brotanek, J., Tomany-Korman, S., & Flores, G. (2008). Why do parents bring children to the emergency department for nonurgent conditions? A qualitative study. Ambulatory Pediatrics, 8(6), 360-367.

References4. DeSalvo, A., Rest, S.B., Nettleman, M., Freer, S., Knight, T.

(2000). Patient Education and Emergency Room Visits. Clinical Performance and Quality Health Care, 8, 35-37.

5. Woolfenden, S., Ritchie, J., Hanson, R., & Nossar, V. (2000). Parental use of a peadiatric emergency department as an ambulatory care service. Australian and New Zealand Journal of Public Health, 24(2), 204-206.

6. Rocovich, C. & Patel, T. (2012). Emergency department visits: Why adults choose the emergency room over a primary care physician visit during regular office hours? World Journal of Emergency Medicine, 3, 2, 91-97. DOI: 10.5847/ wjem.j.1920-8642.2012.02.002

Thank You! Sharon J. Barton

Susan M. BrennanRachel E. CohenMei Lin Chen-LimBrooke Bazz Park

Phyllis Slutsky