Tired of Seeing Your Patients in the ED? Texas Medicine February 2012

Let's Give Parent Education Another Look!

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The Journal – February 2012

Tex Med. 2012;108(2):e1.

By Stuart J. Yoffe, MD; David A. McClellan, MD; Homer Tolson, PhD; Robert W. Moore, PhD; and Rebecca McKay, MA, MLIS  

Dr Yoffe, Innovative Health Care, Brenham, Texas; Dr McClellan, Texas A&M Family Medicine Residency, Texas A&M Health Science Center, College Station, Texas; Dr Tolson, Texas A&M University, College Station, Texas; Dr Moore (retired), Family Practice Foundation of the Brazos Valley, Bryan, Texas; and Ms McKay, Texas A&M University Health Science Center Library, College Station, Texas. Send correspondence to Stuart J. Yoffe, MD, Innovative Health Care, 6522 FM 50, Brenham, TX 77833; e-mail sgyoffe[at]sbcglobal[dot]net

This project was supported by a grant from the Texas Medical Association Foundation. 

Conflict of Interest: Dr. Yoffe is the author and sole owner of the educational booklet used in the study group. No other coauthor or pediatric researcher has any other conflict of interest. 


This study was conducted to determine if a parent-oriented educational intervention reduces the use of emergency department (ED) services for the care of infants. Infants aged 7 days to 1 year and older children aged 2 to 10 years were tracked for 3 years in two separate primary care (PC) practices in Washington County, Texas, with the last year being the interventional study period. Also, infants aged 7 days to 1 year and older children aged 7 days to 5 years were tracked in a third PC practice in Burleson County, Texas. The study group consisted of all parents of patients aged 7 days to 1 year seen by the pediatric group in Washington County during the 1-year interventional period. Only parents of infants in the study group received a specific educational intervention booklet. Five separate control groups were followed in this study. The control groups received usual care with standardized patient information, but they did not receive the educational intervention booklet. Each group was evaluated by calculating its monthly ED utilization rate, which is the quotient derived from dividing the number of children from that particular group seen in the ED per month by the number of children from the same group seen in the PC clinic per month.  A difference of proportions test was applied to test for statistical significance regarding ED utilization. Compared with parents in the control group, parents receiving the intervention booklet (the study group) showed significantly (P < .05) lower use of ED services for care of their infants. We found no change in ED utilization for children of parents receiving other standard educational information. 


For hospital emergency departments (EDs) to provide a substantial quantity of nonurgent care to both children and adults has become usual practice.1 The advantages of this practice include convenience for the patients and revenue for the hospitals.2 The disadvantages include the consumption of resources by nonemergency visits at the expense of those with true emergencies and the relatively higher charges for ED services as compared with the same charges for the same services provided in a primary care (PC) setting.3,4 A second disadvantage is the exposure of young children to the ED environment that may have a potentially high incidence of pathogens.5 A third disadvantage is the exposure of children to physicians, hospital staff, and a medical care environment that is often less familiar with evaluating and treating infants; this may result in potential overtesting, including unnecessary diagnostic radiation exposure, overdiagnosis, and possible overtreatment. 

Parents often seek care in the ED for their small children with common, nonurgent medical conditions because of the lack of appropriate, readily accessible, usable medical information.6 This situation can be aggravated by a lack of parental confidence and competence to care for their children at home because they fail to recognize the nonurgent nature of a condition.7 Thus, parents use EDs for routine care rather than seeking more appropriate care in a PC setting.2 Increasing parental knowledge of common, nonurgent pediatric medical conditions and ways to manage them without resorting to hospital EDs may reduce visits to the ED in such cases.8,9 We have previously shown this to be the case among children aged 10 years and younger with a specific intervention in one PC setting.10  The evidence for the effectiveness of such intervention is mixed in other previous reports. In some studies, increased parent education in management of nonurgent illnesses of their children resulted in the expected reduction in ED use,8,11-14 and in others it did not.15-18

Our study used one specific interventional booklet. To investigate the internal validity of using this educational booklet, an intervention to educate parents of infants in common childhood illnesses was devised with the control groups receiving only routine patient educational information. Parental utilization of ED services for their infants was monitored to track usage in the various groups over time. 

The objective of this research was to determine whether or not a specific educational intervention directed at parents would reduce the use of ED services for infant care. 

Patients and Methods

The setting for the research was two adjoining nonmetropolitan counties in the Brazos River Valley of South Central Texas: Washington and Burleson counties. Washington County has a hospital with an ED, several independent groups of family physicians, and a multispecialty group practice that includes specialists, family physicians, and pediatricians. Burleson County has one hospital with an ED and a group of family physicians but no pediatricians. Each of these EDs was part of the same health care system, St. Joseph Health System. Therefore, by using the centralized database of this regional medical center, we obtained data on ED use in both hospitals retrospectively for 24 months (January 2007 to December 2008) and prospectively for 12 months (from January 2009 to December 2009). 

The number of children in each county aged 7 days through 1 year and aged 2 years through 10 years who used PC and ED services was observed for 36 months. Children from birth through age 7 days were not included because of the highly variable number of children presenting to the EDs to merely receive neonatal blood testing. Furthermore, children aged 1 year to 2 years were excluded from this study because of the predictable overflow of children into this population from the group of children aged 7 days to 1year as the year-long study progressed. For each month, the number of ED visits in each specific group (study group or control groups) was divided by of the number of children of the same age group visiting the PC clinic. The quotient was termed "the monthly ED utilization rate" for each group. In addition, in Washington County, children seen by physicians in the pediatric PC practice were monitored separately from the children seen in the family medicine PC practices. The results from Washington County monthly ED utilization rates were graphed for 36 months by age group and type of practice (Figure 1). 

The single intervention variable to consider in this study was whether or not the parents of the described children received the specific educational intervention booklet designed to increase their knowledge, competence, and confidence in treating common pediatric conditions. The only group that received the intervention consisted of the parents of children aged 7 days to 1 year who were seen in Washington County in the pediatric PC practice. Furthermore, all parents with newborns born at the local hospital in Washington County who were under the care of the pediatricians were also provided the educational booklet during their neonatal hospital stay. No other parents received the specific educational booklet. 

This particular educational booklet was written at a 4.2 grade reading level in English and in colloquial idiomatic Spanish. The booklet specified brand-named rather than generic-named medications. Written with humor, the booklet used poetry, anecdotes, and captioned children's photographs. Also included was general information to define what was and was not a true emergency as well as what medications should be kept at home. Furthermore, the booklet contained sections on fever control, ear pain, stomach pain, accidents and poisonings, cuts, animal bites, rashes, asthma, cough, cold, sore throat, vomiting and diarrhea – most of the common causes of ED visits. In short, this book is easy to read and easy for parents with a limited educational background to use.  

Statistical analysis

The data obtained were displayed in tabular and graphic forms. The tests of significance were conducted by using a z test for proportions. Significance was indicated if the P value obtained was equal to or less than .05 and was indicated as a Yes response in the Table of Proportions.  


Figure 2 demonstrates the number of children younger than 1 year seen in the ED for both the study group and the control group of the participating family physicians in Washington County during the 1-year prospective period of 2009. The z test for proportions showed the results of the study group to be statistically significant (P<.05) compared with the control group. The differences in results in the "monthly utilization rate" are statistically significant (P <.05) and designated as Yes in Table 1

Figure 3 shows the percent of children younger than 1 year seen in the ED for both the study group and the control group of family physicians in Washington County during the 1-year prospective period of 2009.    

The information shown in Figure 4 represents the monthly ED utilization rate both for children in the study group (aged 7 days to 1 year) and in the control group (aged 2-10 years) seen in the pediatric clinic during the study period of 2009.  The pediatricians distributed the interventional tool to the study group, which consisted of all parents of their patients aged 1 year and younger who visited their clinic during the 2009 year. These same booklets were also distributed to all the new parents in the hospital postdelivery whose offspring were to be patients of the pediatricians after discharge, as these patients also fulfilled the criteria for the study population. Books were not distributed by the pediatricians to parents of the children aged 2 to 10 years. The pediatricians' patients aged 1 to 2 years were not included in either the study or control group so as to avoid contamination of the study during the 1-year period. All groups were tracked prospectively for 1 year.  

A total of 12,517 children aged 10 years and younger were seen in the pediatric clinic in 2009 in Washington County: aged  <1 year, 2691; aged 2-10 years, 9826. A total of 2845 children were seen in the Washington County ED in 2009; sorted by practice, the 1086 patients aged  <1 year seen in the ED came from the pediatric practice (352) and from the family practices (734). The 1759 patients aged 2-10 years seen in the ED came from the pediatric practice (692) and from the family practices (867). 

During 2009, the study group of children aged 1 year and younger demonstrated a significant decrease (P<.05) in ED use from 18% to 8% (Figure 4). The control group showed no statistically significant decrease (P>.05) in the patients' ED use.  

The study showed that of all the children seen in the ED aged either from 7 days to 1 year or from 2 to 10 years, those children in the study group decreased the ED population in 2009 from 48% to 24% (Figure 1, Table 2). Children aged from 2 to 10 years in the pediatric practice also showed a slight decrease in the percentage of ED use during the same period, declining from 32% to 30%. Children aged from 7 days to 1 year and from 2 to 10 years in the family physicians' practices did not show a decrease in the percentage of children being evaluated in the ED during this same 1-year period. Figure 1 shows also that in the 2-year run-in period preceding the study, none of the four groups being evaluated demonstrated any change in overall ED use other than the expected seasonal variations. 

Burleson County, contiguous with Washington County, is also a rural community with one hospital. Figure 5 demonstrates a 3-year evaluation period of two groups of children in Burleson County. Both groups were considered control groups as neither received the interventional booklet. The first group corresponded in age to the Washington County study group that did receive the booklets (7 days to 1 year). The second control group in Burleson County was aged from 7 days to 5 years, as the information for 7 days-10 years was not available for analysis. During the 3-year observation of ED utilization rates, no changes other than seasonal variations in either group were noted. Specifically, the children aged 7 days to 1 year demonstrated no decline in the use of the local ED over the entire 3 years of evaluation, which included a 2-year run-in period preceding the study period and the 1-year study period. However, because the age groups of the Washington County and the Burleson County are different, this information is not included in any statistical evaluation. Instead, it is presented for observation only, as it seems to demonstrate that during the 3-year period, other than seasonal variations, no changes in ED utilization rates occurred.  


In a previous study with the Texas A&M Family Medicine Residency training program, the distribution of this educational tool to parents was associated with a statistically significant difference in the ED utilization of children when compared with a variety of control groups.19 In that initial study, the participating group of physicians was associated with the Texas A&M Family Residency training program in Bryan, Texas. Reported here, the second study was performed to establish cross-validation in a different geographical location, with different participating physicians acting as caregivers and with a different population. Involved in this second study was a group of physicians in private pediatric practice at the Brenham Clinic Association in Washington County, Texas. By comparing the study group with the internal control group of children seen in the same clinic by the same physicians and nurses with the same office hours of service and within the same physical space, all of these factors are eliminated as causative factors resulting in the decrease in ED utilization (Figure 3). The fact that a slight decline was seen also in the pediatricians' patients aged 2 to 10 years who used the ED is likely explained by the fact that many of these children have younger siblings in the study group whose parents were provided the booklet as part of the study. We suspect, although no data were collected that would validate this conclusion, that when the parents who had received the interventional booklet for the child in the study group had other children in the family, they would likely use the information in the educational tool when an older sibling was sick as a means of avoiding an ED visit.

During the two-year run-in period prior to introducing the book, Figure 4 shows that seasonality was the only factor affecting the ED utilization of either the age 7 day to 1 year group or the 2 to 10 year group in Washington County, Texas. This included patients both of the pediatricians and the family physicians in Washington County. 

Finally, this study also demonstrates that in adjacent Burleson County no factor other than seasonality affected the control group aged 7 days to 1 year and those aged from 7 days to 5 years that resulted in any change in their ED use (Figure 5). One interesting point is that the slight peak in the ED utilization in 2007-2008 at the end of the year was probably the result of fewer staff available in the clinic for pediatric care, which resulted in a slight overflow to the hospital ED during the holiday season.   


An educational intervention directed toward parents of infants can reduce the use of ED services for their children if an appropriate interventional tool is used. A new round of questions must be answered: Is this booklet the best tool? How can this educational tool be improved? What is the most effective method of distributing and using any educational information? 


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Accompanying Tables and Figures:  Table 1   Table 2   Figure 1   Figure 2    Figure 3    Figure 4    Figure 5

February 2012 Texas Medicine Contents
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Last Updated On

November 13, 2017

Originally Published On

March 15, 2012