Nonurgent use of the pediatric emergency department during the day

To evaluate the pattern and reasons for nonurgent use of the pediatric emergency department (PED) during regular office hours and why primary care physicians (PCP) approve such visits.

Prospective, cross-sectional, observational study.

Free-standing, university-affiliated children's hospital emergency department.

Patients presenting to the PED and triaged as nonurgent between June and November 1994, Monday through Friday from 6:30 am to 6:30 pm, and Saturday 6:30 am to 12:00 noon.

Registration and triage information and all communication with the PCP.

Of 1020 eligible patients, 364 patients and their PCP completed the study. Fifty-two percent of the study patients were enrolled in a health maintenance organization (HMO). This is consistent with the penetration of managed care in this community. Most HMO (118 of 191, 62%) and non-HMO enrollees (147 of 173, 86%) did not call their PCP prior to arrival in the PED. Comparing the reasons given by these patients (HMO enrollees versus non-HMO) for not calling, we found: convenience (HMO 17% vs non-HMO 4%, P < 0.01), "no identified PCP" (HMO 17% vs non-HMO 42%, P < 0.01), and "felt problem was an emergency" (HMO 19% vs non-HMO 10%, P = 0.03) to be important differences. HMO enrollees received approval for the visit 79% of the time. These approvals were mostly after noon, whereas most denials occurred before noon. We found a pattern in the reason for approvals. Before 3:30 pm, the most common reason was that the PCP "considered the problem medically urgent" (48 out of 106). After 3:30 pm, without significant difference in the pattern of patient's chief complaints, there was a dramatic change to "a full office schedule" (25 out of 45) as the most common reason.

Communication between the patient and PCP prior to the PED visit is poor in the study population. Convenience and physician workload appear to be important factors in the choice to use the PED for nonurgent problems.