evaluation of non-urgent emergency department visit in pediatric primary care population mei lin...
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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