Roughly half of children being seen in the emergency department don’t need to be there. How can you avoid being one of those parents?
There are many costs to using the emergency department for non-urgent care.
There’s the literal cost of care, given that emergency room visits generally have higher co-pays than clinic visits.
There are also plenty of figurative costs. Bringing your child to the emergency department when she does not have a serious illness or injury is likely to lead to a long wait, because she will be triaged behind the actual emergencies. After that long wait, you’re likely to receive an unsatisfying diagnosis and/or treatment: a Band-Aid for a cut, a directive to drink fluids for a run-of-the-mill cold, etc.
These experiences may erode your trust in the emergency department, especially when you receive the bill. It’s hard not to feel snubbed, like your child’s pain doesn’t matter, even when you are being told that your child is medically fine.
If you and your not-so-sick child are in the emergency department all night, both of you might miss out on a good night’s sleep, and, as a result, school and work tomorrow. While logging all that time in the waiting room, you and your child are also susceptible to hospital-acquired infections from all of the other sick patients.
Visiting an emergency department for a non-emergency can also have longer-range consequences. Taking a child to the emergency room for common ailments like ear infections can harm continuity of care, argues a recent review article in the The Journal of Pediatric Health Care.
When parents seek treatment for such issues at the ED, their children’s primary care providers (PCPs) might not receive valuable information about different illnesses. Without knowing how many ear infections or cases of strep throat a child has had, a PCP will not know whether or not to recommend interventions, like tympanostomy tubes or tonsillectomies.
All of these consequences focus on your child, but there are consequences for other people, too – including the truly sick children whose care may be delayed by overcrowded emergency departments or by overstretched hospital staff.
Given all of the negative consequences of bringing children to the emergency department for non-urgent conditions, it’s surprising that so many parents are doing it. A study of 31,076 emergency department visits from 33 different pediatric practices found that nearly half of those visits (47 percent) were classified as non-urgent by hospital staff. In other words, roughly half of children being seen in the emergency department did not need to be there.
Why are so many parents bringing their children with non-urgent conditions to the emergency department? How can you avoid being one of those parents?
It’s rarely a matter of life and death
The ED is for acute medical problems that may kill or maim if left untreated, which is why many hospitals around the country use the Emergency Severity Index to triage patients. The ESI’s triage algorithm is easy to read and worth parents’ time, because it shows exactly what a triage nurse or other healthcare professional will be asking when evaluating your child’s case.
The ESI flow chart begins with one easy question: “requires immediate life-saving intervention?” A “yes” answer leads to an ESI score of 1, and hasty attention in the ED.
A “no” answer leads to another set of questions. If the situation is not high-risk, the triage score will be somewhere between 3 and 5, depending on how many resources will be required to help a patient. If a patient does not require any resources (say, for a cold or flu), then the patient will be scored a 5. Many parents who bring their children to the ER for non-urgent categories will get a 4 or 5.
Why parents head to the ED
If their children are not at serious risk, why are so many parents heading to the ED?
One recent study found that parents’ tended to rate their children’s conditions more severely than medical professionals did. The hospital staff determined that of 381 visits, 298 (78.2 percent) were non-urgent cases.
In other words, just over two in 10 patients actually needed emergency care. However, almost 40 percent of parents asked to rate their children’s conditions reported that their children needed emergency care.
One explanation for overuse of pediatric emergency services is that parents, who are, on the whole, less experienced medical providers than doctors and nurses, are simply not good at evaluating whether or not a medical condition constitutes an emergency.
That explanation, however, fails to account for the nearly 40 percent of parents in the study who brought their children into the ED knowing that they had a non-urgent condition.
One way to better understand why parents bring their children to the emergency room is to simply ask them. Two different interview studies have done just that, questioning parents who took their children to the ED for non-urgent conditions. Both studies took place on weekdays during normal work hours, in order to determine why parents chose the emergency room over a PCP.
In the first study, researchers identified three main reasons for choosing the ED over the PCP. Some parents indicated that they chose the ED because their PCP recommended it, either after an in-person visit or after a phone call.
Another group of parents chose the ED because of problems with their PCPs, including impolite staff, confusing directions from the PCP, or even a PCP whose accent was confusing to parents. Parents also saw advantages to the ED, which was available for walk-ins and might be closer to home.
The second study found similar reasons for ED use, but went a step further in matching those reasons to parents’ health literacy. Researchers found that parents with lower health literacy tended to seek care for a diagnosis and treatment, while parents with average health literacy usually came to the ED with a diagnosis in mind but seeking reassurance from a trusted source.
Both groups feared “getting it right” when it came to their children’s diagnoses. In that sense, the ED operated as a space to reassure parents that they were providing good care to their children.
The most interesting finding of this second study was that all parents heard alarm bells over some symptoms. No matter how much health literacy they had, nearly all parents in the study panicked about fever. Parents feared ear damage, brain damage, and other consequences frequently misattributed to fever, and took their children to the ED even when it was not recommended by their children’s PCPs.
What’s the best way to keep your kids out of the ED?
Boost your own health literacy.
What’s clear from the interview studies is that parents with stronger health literacy are better assessors of risk, better able to distinguish between non-urgent, urgent, and life-threatening situations.
1 | Learn to identify true emergencies
You’ll probably know a true emergency in the unlucky case you see it, but if you need reminders, the American Academy of Pediatrics’ Healthy Children site for parents offers a useful list of situations that count as emergencies.
Although medical emergencies come from the whole alphabet, remembering just the Bs is a good start: behavior changes (like disorientation), bleeding, breathing problems, broken bones, burns, and button batteries (only if swallowed). All of those things will be considered high priority in an emergency department, because they are either life-threatening, high-risk, or causing severe pain.
When you’re on the fence about whether or not emergency care is right for the situation, your child might be better served by urgent care. Many lacerations, for example, are urgent but not life threatening, and therefore do not require a trip to the ER. In fact, they may be more quickly resolved at an urgent care center.
Some hospitals, like the Mayo Clinic, operate both emergency departments and urgent care centers, which makes it possible for parents who are unsure about the severity of a condition to be redirected by the hospital staff.
If you don’t have a combination ED and urgent care center near you, and aren’t sure which of the two to go to, check out Colorado Children’s Hospital’s helpful quiz to train you to distinguish between urgent and emergency situations. Actually, if you have time to take the quiz, you probably have an urgent care need and not an emergency.
Many other terrifying-looking medical issues, like a high fever in a child over three months old or even febrile seizure, do not require urgent care and can be handled through follow-up with your child’s PCP, which is why the next step is so crucial.
2 | Develop trust in your child’s primary care provider
Try to see the same PCP for all of your child’s well visits. Doing so can help you build trust in that person’s judgment, which you can lean on when making middle-of-the-night healthcare decisions.
Your child’s PCP is there to monitor your child’s health, but also to educate you about how best to care for him. Make sure you are receiving the resources you need, including, for example, information on urgent versus non-urgent situations.
Many PCPs operate phone services for health questions. These hotlines are different from the insurer hotlines you might call to find out about health coverage. Instead, these hotlines put you in touch with a healthcare professional, often a nurse, who will help you determine how serious your child’s health issue is. That person can also contact your PCP to get further advice about how to proceed.
If your pediatrician does not have a triage after-hours phone service, ask why not. If you don’t trust your primary care provider, get a new one.
3 | Ask what you’re buying with an emergency department visit…and where else you can buy that
The hardest part of deciding not to go to the emergency department with a sick or injured child is probably not a medical issue. It’s a philosophical one.
One possible explanation for the overuse of emergency departments for common childhood illnesses is that parents are seeking reassurance more than they are seeking medical care. Although training yourself to identify true emergencies, developing trust with your child’s PCP, and cultivating a list of after-hours resources will all help you make better decisions, what you need most is to develop trust in yourself as a parent.
If you review the above studies about the ages of children brought to the ED, you would notice a distinct drop-off after the first few years of life. That’s not because young children are necessarily any more vulnerable than preschoolers or kindergarteners. It’s because parents of one-year-olds don’t trust themselves to identify and resolve their children’s health problems.
For the first three months or so, no new parents know what they’re doing. This is also the time period when some issues, like fever, are considered emergencies. So you might choose to follow an informal three-month rule, erring on the side of caution and making frequent calls to your child’s PCP until you can start to separate urgent from non-urgent.
As you begin to learn these distinctions, and develop your health literacy, start to trust as much in yourself as in your child’s medical staff.