ER or Not? Physician's Booklet Helps Parents Decide

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Public Health Feature - June 2010

Tex Med. 2010;106(6):55-58.


By Crystal Conde
Associate Editor

A mother awakens to the sound of her newborn coughing and crying incessantly. The baby's stuffy nose and ear infection worry her. This is her first child, and she doesn't know if the symptoms warrant a visit to the emergency room (ER) or if she can wait until morning to take her baby to the doctor's office.

This scenario isn't uncommon.

"Parents have a tough call to make when an infant has an upper respiratory illness," said Ken Baker, MD, a Brenham pediatrician. "Parents need some guidance as to what symptoms are manageable at home and what symptoms require an ER visit."

Dr. Baker and his partner, Don Draehn, MD, have discovered that steering frightened parents away from the emergency room and toward their practice, Brenham Clinic Associates, for a child's nonemergency medical care is simple and inexpensive. They play a key role in a study led by Stuart Yoffe, MD, a retired Brenham pediatrician, and funded in part by the Texas Medical Association Foundation (TMAF).

The project revolves around disseminating The Pediatric After-Hours Non-Life and Death Almost-an-Emergency Booklet , written by Dr. Yoffe. Drs. Baker and Draehn gave the booklet free of charge to parents of patients younger than 12 months at their practice last year.

Dr. Yoffe studied pediatric ER admissions for one year, beginning Jan. 1, 2009. He tracked the rate of ER use by age group for Brenham Clinic Associates' pediatric patients. In one year, ER admissions of children whose families received the booklet dropped from 18 percent to 7 percent. (See "Rate of ER Use by Age Group, 2009.")

Dr. Yoffe conducted research for the project in conjunction with Amanda Nunley, MD, and Paula Lansford, DO, who work in Texas A&M University's Family Practice Program.

A $2,500 matching grant from TMAF's Medical Community Grant Program awarded in 2008 to the Washington-Burleson County Medical Society made it possible to print the booklets for distribution, says Paul Jantzi, MD, former president of the medical society and an allergy and immunology physician in Brenham. Funding for the project by TMAF is not an endorsement of the booklet by TMAF or TMA.

Thanks to TMAF's financial support, Dr. Baker says the physicians can expand booklet distribution to include parents of clinic patients aged 4 years and younger.

"Children in that group are good to target because they're the least verbal about how they feel," Dr. Baker said.

As part of the conditions of the TMAF grant, Dr. Yoffe presented a final report on the project's progress and conclusions at the fall 2009 TMAF board meeting. He reported that Drs. Draehn and Baker, along with the Washington-Burleson County Medical Society, were enthusiastic about the booklet, acknowledging that education is the first step in decreasing health care costs and preserving the medical home.

Dr. Jantzi says the booklet not only reduces unnecessary ER visits, but also lets parents know when it's important to take their children to the hospital.

"First-time parents often have little to no training in medical issues for their child," he said. "Accurate information is key for any young family. Through use of the booklet, Dr. Yoffe has tried to refine medical information and make it as simple to understand as possible so families from all educational backgrounds can make the best decisions for their children."

By the Book

Dr. Yoffe wrote his first booklet, How to Raise a Perfect Child … or the Impossible Dream , at a seventh-grade reading level for his private patients in the 1970s.

"Although I wish I could claim that I had only the purist of intentions, I had noticed in my first several years of practice that in spite of the fact that I was open every Saturday and for two hours almost every Sunday, my patients still went to the emergency room," he said.

Dr. Yoffe researched the booklet's impact on ER visits then and noticed it changed parents' behavior by directing them on appropriate courses of action given their children's symptoms. Years later, he concentrated his efforts on publishing an affordable pediatric booklet for the general population. The result was The Pediatric After-Hours Non-Life and Death Almost-an-Emergency Booklet .

The 20-page booklet provides parents with direct and easily understandable information. For example, the booklet contains the following rules for taking a child's temperature:

  • If your child is younger than 4 years, use a rectal thermometer.
  • If your child is 4 years or older, use an oral thermometer.
  • Ask your doctor about digital thermometers.
  • Know how to read a thermometer.
  • Normal rectal temperature is 97 degrees to 100 degrees Fahrenheit.
  • If your child is younger than 1 month, any fever over 101 degrees Fahrenheit is important. Call your doctor immediately.

The booklet's features include general information about uses for common medications; advice on when parents should and shouldn't take their children to the emergency room; and a sheet parents can use to fill in emergency information, such as doctor's name and phone number.

It also has sections on treating fever, ear infection, stomach pain, accidents and poisoning, cuts, animal bites, rashes, asthma, cough, colds, sore throat, vomiting, diarrhea, and feeding problems. The inside back cover has an immunization record parents can take with them to appointments. Parents can use the booklet's sick visits list to record their child's medical diagnoses.

Drs. Baker and Draehn gave parents the booklets at well-child exams, sick visits, and at any opportunity during a child's first year of life. Dr. Baker says they noticed that parents were more receptive to the booklet when the physicians handed it to them directly.

"When parents get the booklet from the doctors, that gives it a sense of endorsement," he said.

They printed 2,500 copies in English and Spanish and promoted it by posting signs encouraging parents to request a copy on every exam room door. In addition, Trinity Hospital in Brenham distributed booklets free of charge to parents of newborns.

Dr. Yoffe is dedicating a lot of time in his retirement to developing simple interventions that can lower medical costs and improve health care at the community level. He hopes collaborating with public health professionals, local organizations, hospitals, and individual physicians will create resources that benefit the entire state.

"All parents want to care for their children as best they can. Young first-time mothers don't always know what to do when their children are sick. It's not good for them to get information from nonmedical sources, so if they can get the booklet from their doctor, it's beneficial to them and their children," Dr. Yoffe said.

A Study in ER Admissions

Dr. Yoffe's goal with the booklet is to direct patients to a medical home for nonurgent care.

"Unnecessary use of the ER is expensive. It's also a quality-of-care issue. If a parent takes a child to the ER four times and sees a different doctor each time, that child probably won't get the same level of care as if he sees the same doctor four times in a row. The pediatrician or family physician has continuity with the patient and has all the records. I want to get kids out of the ER unnecessarily and into the doctor's office," Dr. Yoffe said.

According to 2006 data (the latest available) from the Texas Health and Human Services Commission (HHSC), an ER visit cost $144.51 versus $36.13 for treatment in a physician's office.

Dr. Baker says inappropriate use of the emergency room is a growing problem. According to the Centers for Disease Control and Prevention's report, National Hospital Ambulatory Medical Care Survey: 2004 Emergency Department Summary, 3.9 million infants younger than 12 months went to an emergency department in 2004, with a visit rate of 95.8 visits per 100 infants. HHSC classified 47 percent of total Medicaid ER visits in the 2005 fiscal year as nonemergent episodes. In a review of ER use during the 2003-05 fiscal years, HHSC determined "the state could have saved over $26 million if clients treated for nonurgent conditions in hospitals had been redirected to physician offices for treatment."

Educating parents about appropriate use of the ER can make a difference in every Texas community, Dr. Yoffe says. He worked with Tom Betz, MD, MPH, regional medical director of Texas Department of State Health Services (DSHS) Region 7, and the department's nurses to collect feedback for an updated version of the booklet.

Dr. Yoffe added information on mild reactions to vaccines and appropriate Tylenol dosage for children younger than 2 years. Based on health department input, he also added a section on what parents should do in a natural disaster or public health emergency. The section features helpful information for parents, such as making sure they have access to their children's immunization and medical records, as well as prescription information, if they have to evacuate their homes.

Dr. Betz says the department plans to print 10,000 copies of the updated version of the booklet and distribute it to the public for free through the region's 21 nursing clinics.

"What we need to reach out to the citizens we serve are educational materials to help them make better decisions about the health of themselves and their family members. The booklet helps us achieve that and helps people make informed decisions and reduce costs accrued for unnecessary ER visits," Dr. Betz said.

In the future, Dr. Yoffe plans to focus on continuing to get buy-in for the booklet from the community. He says the Brenham Chamber of Commerce, as well as area primary care physicians and public health departments, plans to distribute the booklet as a resource for parents.

"If the entire community gets behind the program, the results will be better health care for the patients and decreased health care costs. There are better ways in which we can spend our money than treating colds and runny noses in the ER," Dr. Yoffe said.

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by-email at Crystal Conde .

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