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Background and Significance: Garcia et al (2010) reported approximately 20% of patients nationwide, with at least one Emergency Department (ED) visit, were children (ages 0-17 years). Past studies reported that approximately half or more of these visits were for non-urgent conditions (Zandieh, 2009). Ambulatory Care Nurses provide primary well child and illness care to assist patient and families to better manage health and illness in community settings through the use of a triage system and defined protocols for decision making. Despite our best efforts, patients often seek care in the ED when access to a primary care provider (PCP) or after hours program (AHP) is available. The increasing trend results in an interruption of continuity in care which ultimately affects the quality of patient care as while impacting negatively on health care costs.
Setting: The Children’s Hospital of Philadelphia (CHOP) South Philadelphia Primary care site is a large urban pediatric primary care site serving low income minority families – primarily African American, Asian, or Hispanic. There are approximately over 10,300 patients with an estimate of over 30,800 visits per year. Languages spoken from this population include English, Spanish, Indonesian, Arabic, Cambodian, Vietnamese, French, Urdu, Chinese, etc. Health insurance status includes state Medicaid (73.5%), Private (25.7%), and Self Pay (0.85%). The CHOP level I trauma center ED serves approximately 85,700 visits per year. Each visit is triaged based on the Emergency Severity Index (ESI) which is a 5-Level Triage System where the non-acute is rated as Level 4 and Level 5 (Gilboy, 2005).
Methods: A primary care based nursing research study was developed to evaluate the reasons for the non-urgent ED use. IRB approval was obtained and study was completed early 2012. This descriptive study consists of a retrospective chart review to determine incidence of non-urgent ED use and a prospective parent telephone interview to identify factors that led to non-urgent ED use. The sample consists of patients less than 17 years of age from an urban Philadelphia primary care center that used the CHOP ED during 2011, and who were identified as non-acute based on a level system utilized by the ED. A subsample of non-urgent, non-referred, patients was eligible for scripted telephone interviews. Non-urgent was defined as care that can be administered by the primary care office (PCP) during office hours or by telephone support that can be provided by After Hours Program (AHP) Call Center during non-office hours.
Results: During 2011, the South Philadelphia primary care site had 4484 CHOP ED visits. An estimated 1450 visits (32%) were triaged as level 4 or 5 which represented non-acute visits. Medicaid was the primary insurance (76.5%). In regards to race, utilization of the ED from the Asians group were unchanged regardless of insurance status and were primarily triaged as level 5 (33% for Medicaid and 37% for private). Similarly, the White population ED utilization was also unchanged regardless of insurance status but was primarily triaged as level 3 (36% for Medicaid and 47% for Private). For the Blacks population, the majority utilization did change with insurance status from level 5 (33% for Medicaid) to level 3 (41% for Private).
From the chart review data, a total of 869 non-acute ED visits were reviewed with 742 of those determined to be non-urgent. The mean age was 4.11 years and the gender was even with 371 females (50%). Blacks were the primary population (64%) followed by White (14%). Majority had insurance (96%) with coverage through state Medicaid (86%). Majority of the patients were not referred by primary care providers or after-hours program (89%). The duration of the ED visits last an average of 3.12 hours. The top 5 chief complaint were fever (247), vomiting (96), rash (78), cough (68), and ear pain (60). The top 5 discharged diagnoses were fever (239), acute upper respiratory tract infection (156), viral Syndrome, not otherwise specified (121), cough (89), and suppurative and unspecified otitis media, acute, without eardrum rupture (78). Other descriptive statistics include the day and time of the ED visit and frequency of non-urgent visits per patient. Reports from scripted interview include: treatments tried at home prior to visit, reason for going to ED versus using the AHP or PCP, knowledge of AHP and perception of waiting time and services provided from the ED vs. primary care. Frequently reported symptoms reflected viral illness; Fever was most commonly mentioned symptom to bring child to ED. Only 60% reported knowledge of AHP.
Conclusion: Majority of the patients are using the ED for non-urgent care especially during the times when appointments are available. Subjects were primarily less than 5 years of age from the minority population groups with state insurance. Majority have no prior contact with the PCP office or AHP Program prior to the ED visit. Frequently reported symptoms reflected viral illness; Fever was the most common mentioned symptom to bring child to ED. One-third reported coming to ED because of tests, equipment, or better confidence at the hospital. Only 60% reported knowledge of AHP; however, majority who used AHP reported as helpful.
Clinical Implications: Results of this study have led to practice care changes implemented in the primary care setting that improve the clinic workflow such as identifying and educating families who use the ED for non-urgent reasons. This has also strengthened the partnership with parents while empowering them to seek care through appropriate channels. Programs such as ED use Education, Access to Care Guide, Parent Education Toolkit on Fever, Office Video Education (English & Spanish) while waiting and Fever teaching at newborn, 5 week and two month visit have been implemented as a result of the study findings. Long term outcomes of study findings will be reduced use of the ED for non-urgent care and improved clinic systems to support ill child services.