ORIGINAL CONTRIBUTION indigent care, children
Indigent Children Who Are Denied Care in the Emergency Department We conducted a six-month prospective study of the diagnoses and outcomes of 588 children who were denied care in our emergency department under a n e w primary-care case management health system for 100,000 indigent patients. The mean patient age was 4.7 years (39% were less than 2 years old). The m o s t common presenting complaints were colds, earaches, rash, vomiting, and diarrhea. Nine percent of children presented for trauma, and 10% had fever of more than 38.2 C. Follow-up was available from the primary care physician for 388 children (66%). Of the 60% of patients who kept their arranged appointment, 42% received antibiotics, 3% were referred for further evaluation, and two children were hospitalized. Follow-up was available from the parents for 125 children (21%). No follow-up information of any kind was available for 111 children (/9%), and no follow-up regarding the health of the child was available for 265 children (45%). This last group included 10% with a chief complaint of trauma and 6% with temperature of more than 39 C. Forty-nine percent of patients in this group were less than 2 years old. [Shaw KN, Selbst SM, Gill FM: Indigent children who are denied care in the emergency department. Ann Emerg Med January 1990;19:59-62.]
Kathy N Shaw, MD*t Steven M Selbst, MD*t Frances M Gill, MDt Philadelphia, Pennsylvania From the Emergency Department* and the Division of General Pediatrics,I- The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia. Received for publication February 22, 1989. Revision received June 29, 1989. Accepted for publication September 12, 1989. Address for reprints: Kathy N Shaw, MD, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, Pennsylvania 19104.
INTRODUCTION In March 1986, the Pennsylvania Department of Public Welfare contracted with the Penn Health Corporation (a subsidiary of Health America Corporation, Nashville, Tennessee) to administer a primary-care case managem e n t health system for 100,000 medical assistance recipients who lived in south or west Philadelphia. The program, k n o w n as HeahhPass, was intended to improve accessibility, continuity, and quality of health care for indigent patients in Philadelphia, while saving m o n e y for the federal and state g o v e r n m e n t s by reducing the cost of care. 1 Enrolled beneficiaries were told to choose a primary care physician (PCP) to become the pediatrician for their children. If none was selected, a pediatrician was chosen to be the child's PCP. Physicians were paid a capitation fee for each patient and expected to act as "gatekeepers" for the delivery of care to these patients. Patients (parents) were instructed to go directly to the nearest emergency facility or call 911 whenever a "serious or disabling emergency occurs. ''z They were given a brochure containing examples of life-threatening emergencies; however, no specific examples involving children were given. Parents were instructed to call their PCP's office for advice regarding nonlife-threatening emergencies. Telephone coverage for advice and authorization for treatm e n t was provided on a seven-day-a-week, 24-hour-a-day basis. Physicians were to respond to patient telephone calls within one hour. When a HeahhPass patient requested services in a hospital emergency department, emergency personnel were instructed to determine whether the enrollee required emergency services and to provide care immediately if warranted.1 If the enrollee's condition did not warrant immediate medical care, the personnel were instructed to contact the PCP for authorization to treat. The PCP could deny authorization to treat and/or request that the patient come for an office visit or go to another facility. After implementation of this system, m a n y HeahhPass children continued to present to our ED for care. Most parents had not called their PCP
19:1 January 1990
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INDIGENT CHILDREN Shaw, Selbst & Gill
before ED arrival, which placed a significant burden on our triage and clerical personnel because many children were denied authorization for examination and treatment. Families turned away from our ED frequently left angry at our personnel, hospital, and "the system." The purpose of our study was to determine the outcome of patients who were denied care by their PCP and left our hospital without a complete evaluation by our nursing and medical personnel. Specifically, we wanted to prospectively evaluate the percentage of these children seen by their PCP and when they were seen, the chief complaints and eventual dia g n o s e s of t h e s e c h i l d r e n , and whether the decision to refuse care in the ED was correct in retrospect.
METHODS The ED of the Children's Hospital of Philadelphia includes a walk-in clinic. Children from birth through 18 years of age are seen for any comp l a i n t . Before t h e f o r m a t i o n of HealthPass, approximately 65,000 children were seen each year. Of these, about 55% received medical assistance, 17% had private insurance, and most of the others were self-paying patients. Very few patients were m e m b e r s of a health maintenance organization (HMO). All children presenting to the Children's Hospital of Philadelphia ED from September 1987 through February 1988 (six to 12 months after the start of the HealthPass program) who were enrolled in the HealthPass system and denied care by their PCP were eligible for the study. Patients were initially seen by a registered nurse who triaged patients into three categories according to the ED triage manual. All patients believed to be "acutely ill," defined as "patients with life-threatening conditions or health problems that can become life threatening or disabling," were fully evaluated without consent from the PCP and were excluded from our study. The remaining two triage categories, "urgent," defined as "patients who need prompt treatment but do not have immediately l i f e - t h r e a t e n i n g c o n d i t i o n s , " and " n o n a c u t e , " defined as " p a t i e n t s whose conditions are stable and can wait without detrimental outcome," were eligible for our study. The chief complaint, age, temperature, and re108/60
sults of a brief examination by the nurse were recorded on the nursing triage sheet. The r e g i s t r a t i o n clerk was instructed to call the PCP or his designee and convey the recorded triage information to obtain permission for the patient to be seen. If the patient was denied ED care, an attending physician was asked to evaluate the patient briefly and document that the child could be sent home or directly to the PCP. If the evaluating emergency physician believed that the child should be seen despite refusal by the PCP, the child was evaluated in the ED and excluded from our study. Daily logs of patients who were refused care and not seen in the ED were reviewed the next day; recorded were demographics, chief complaints, triage information, site of routine health care, whether the physician documented his brief assessment, and patient disposition. The parents were called 24 to 72 hours after leaving the ED and questioned regarding their child's illness, PCP contact, and their opinion of the current system. Three attempts were made to reach each family at different times of the day. A questionnaire was mailed to each child's PCP asking for follow-up information, including when or whether the child was seen, diagnosis and treatment, and their assessment of the ED triage and decision to refuse care. Statistical analysis was performed using X2 for categoric data and t test for continuous numeric data. An a priori level of statistical significance of .05 was chosen.
RESULTS There were 588 children who were enrolled in HealthPass and denied care in the Children's Hospital of P h i l a d e l p h i a ED d u r i n g the sixm o n t h study period. Seventy-seven percent of the patients received their primary health care at a clinic or health center, 18% from hospitalbased clinics, and 5% at private offices. N i n e t y - t h r e e percent could identify their HealthPass p r i m a r y care site. Forty-seven percent of these patients came to the ED between 5:00 PM and 8:00 AM on weekdays or a weekend. The remainder came during regular business hours. The mean age of the children was 4.7 years; 39% were less than 2 years Annals of Emergency Medicine
TABLE 1. Presenting complaints of
patients denied care by their PCP Complaint
Upper respiratory infection Rash Vomiting or diarrhea Fever Trauma Earache Other
% 28 24 11 10 9 4 14
old. Most of the patients presented with a chief complaint of an upper respiratory tract infection, earache, rash, vomiting, or diarrhea (Table 1). However, 9% involved trauma (21 cases of head trauma and 29 cases of extremity trauma), and 10% had a temperature of more than 38.2 C. Of these, 27 patients were less than 2 years old and had a temperature of more than 39 C. The triage nurse believed that 4% of the patients should be seen urgently (ie, not wait their turn to be seen according to time of arrival). There was documentation that an e m e r g e n c y physician had seen the patients before they left the ED in 65% of the cases. Others were seen without physician documentation, and the remainder left before a physician could conduct an evaluation. We were able to obtain follow-up information from the PCP regarding 388 patients (66%). According to records, 234 patients (60%) kept their appointments. Of these, 59% were seen on the same day as the ED visit and 22% on the next day. Of these 234 children who were seen, rash was the m o s t c o m m o n diagnosis (28%), followed by upper respiratory infection (20%), ear infection (15%), and trautna (8%). Antibiotics were prescribed for 42% of these children and other medications for 18%. Two children were hospitalized - one for dehydration and one for cellulitis. Three percent were referred for further evaluation. In seven cases, the PCP believed that the triage was inappropriate and that the p a t i e n t should have been seen in the ED. D e s p i t e m u l t i p l e a t t e m p t s , we were able to obtain follow-up information by telephone from only 125 19:1 January 1990
TABLE 2. ED ability to obtain follow-up information regarding patients
denied care
From PCP From patient (parents) From both family and physician
Any Information (%)
Information About Health of Child (%)
66* 21
40 21
6 6 19 45 *Includes 154 patients who did not keep their PCP appointment; no health information known. No follow-up information available
parents (21%). In an estimated one half of cases, the telephone numbers were either disconnected or incorrect or the parent did not have a telep h o n e . E i g h t y p e r c e n t of t h o s e reached by telephone had not called their PCP before presenting to the ED. Seventy-two percent claimed to have kept their appointment with their PCP. Fifty-eight p e r c e n t of those contacted said they did not plan to change their use of the ED; 34% said they would call their PCP first in the future; and the remainder planned to change their HealthPass site or type of health insurance. We were unable to obtain any follow-up information from the physician or family regarding 111 patients (19%). An additional 154 patients did not keep their PCP appointments; therefore, follow-up information regarding the health of 265 children (45%) was u n k n o w n after care had been denied in the ED. Of patients with no follow-up health information, 39% were not seen by an emergency physician before leaving the ED, 49% were less than 2 years old, 10% had a diagnosis of trauma, and 6% had temperatures of more than 39 C. Our ability to obtain follow-up information regarding children in our study group is summarized (Table 2). Study patients were a preselected low-risk group because all had been triaged by a registered nurse according to strict protocol, and the majority also had been screened by an attending physician. Despite this rigorous and time-consuming process, a group of "higher-risk" patients was identified and included those triaged as urgent by the registered nurse, neonates, and young children with fever. Of concern was that among patients who were classified as urgent, 19:1 January 1990
28% were not seen by an emergency physician before leaving, 38% were not seen by. their PCP, and we were unable to contact the parents or PCP for follow-up on 43%. Infants less than 3 m o n t h s old were m u c h more likely to have a PCP visit arranged for the same day before leaving the ED than were older children (57% vs 26%; P .001). However, children with fever were not more likely either to have a follow-up appointment arranged before leaving the ED or to keep followup appointments. DISCUSSION Our study shows that parents of indigent children who are denied ED care may not contact their PCP or take their child to be seen by a physician. Some parents may have taken their children to their PCP, who then did not take the time to correspond with us about the visit. Many children may have improved, and their parents then chose not to seek medical care once they were denied ED care. One study of children whose parents voluntarily left an ED without treatment demonstrated that approximately one half had improved within 48 hours and did not seek other medical care. 3 The PCPs who responded noted that 40% of the patients did not keep the appointment arranged by the ED. Our inability to obtain follow-up information concerning the health status of the 45% of children denied ED care, because they either failed to keep their PCP appointment or were unable to be contacted by telephone, illustrates a problem with managed health care systems for indigent patients that rely on established relationships and good telephone cornAnnals of Emergency Medicine
munication with PCPs. Many of our patients had disconnected or no telephones. These families often had no established relationship with the PCP. One half of the study patients came to the ED during regular clinic or office hours. Of those parents who were contacted, the majority planned to make no changes in their ED usage, and only a third said they would call their PCP before coming to the ED in the future. Our study examined one primarycare case management system established for urban medical assistance recipients in one city and their use of our ED and cannot be generalized to all HMOs and EDs. Other managed health care systems may have educated and established good communication with their recipients. However, in our study of an HMO for indigent patients, parents continued to preferentially seek ED care six to 12 months after the program was instituted. The lack of follow-up and the low percentage of patients seeking care at their primary care site make ED triage extremely important. Our policy of having an emergency physician screen patients who had been denied care in the ED by their PCPs or their designees based on the triage information prevented many ill children from being turned away. These children, initially denied care by the PCP but seen in the ED, were excluded from our study. However, despite strict triage protocols, some triage decisions may be incorrect. Of those children evaluated by their PCPs in our study, two returned for hospitalization. Shortly after our study ended, a 2-month-old infant with the chief complaint of a "cold" was denied care by her PCP. She returned by emergency transport a few hours later with respiratory arrest. During the study period, one child presented with a temperature of 40.5 C and was denied authorization for treatment. However, she then had a convulsion before leaving and received ED treatment that included endotracheal intubation. Patients in our study were usually denied authorization for ED care because the child did not have "a lifethreatening e m e r g e n c y . " A recent survey of medical directors of HMOs in 39 states and the District of Columbia found that 92% used this 61/109
INDIGENT CHILDREN Shaw, Selbst & Gill
" l i f e - t h r e a t e n i n g " d i s t i n c t i o n i n defining ED access policies. 4 However, such a d e t e r m i n a t i o n m a y often be difficult to make. It is difficult for parents to k n o w w h e n their child is s u f f e r i n g f r o m a p o t e n t i a l l y lifethreatening emergency. Brochures given enrollees i n this HealthPass program did not describe what constitutes a pediatric emergency. It is often difficult for a d u l t patients to determine the seriousness of their o w n medical problems.S, 6 It m a y be difficult for a triage nurse or ED physician to determine if an inn o c e n t - s o u n d i n g c o m p l a i n t represents a life-threatening condition without performing an appropriate h i s t o r y and p h y s i c a l e x a m i n a t i o n . Losek et al 7 reported a case of a child with suspect child abuse denied authorization for ED care who was lost to follow-up investigations. Physicians and EDs m a y be legally responsible for patients who are denied authorization for evaluation and t r e a t m e n t . In I986, a n e w s e c t i o n (1867) was added to the Consolidated O m n i b u s Budget Reconciliation Act (COBRA) of 19858 and established a federal tort for failure to "stabilize" patients seeking emergency medical care. It says h o s p i t a l s w i t h emergency services m a y be liable to any patient with an emergency medical condition (or i n active labor) who is t r a n s f e r r e d before the c o n d i t i o n is
stabilized; this applies to any person who requests e x a m i n a t i o n or treatm e n t at the hospital. Improved c o m m u n i c a t i o n between the emergency physician and the PCP m a y i n c r e a s e t h e n u m b e r of children, especially in higher-risk categories, who are authorized to receive care in the ED. Reliance on ED clerks and n o n m e d i c a l personnel for t e l e p h o n e p e r m i s s i o n is c o m m o n p r a c t i c e i n m a n y EDs a n d H M O s 4 and m a y i n h i b i t proper c o m m u n i c a tion a m o n g physicians. However, in busy pediatric EDs, the d e m a n d on m e d i c a l p e r s o n n e l to screen all patients denied care and to make direct telephone contact w i t h PCPs who are n o t always available is not feasible. Ideally, emergency physicians should a t t e m p t to get direct a u t h o r i z a t i o n from PCPs a n d see m o s t c h i l d r e n who seek care, unless the PCP agrees to provide urgent care and the patient (parent) agrees to go there promptly. Based on our experience over this six-month period, we no longer deny care i n the ED to children who cann o t be seen i m m e d i a t e l y by t h e i r PCP. The PCP is still contacted for each HealthPass patient; however, if care is refused, the child is still seen, at our expense. CONCLUSION M a n y i n d i g e n t c h i l d r e n w h o are denied ED care will be unable to be
reached for follow-up i n f o r m a t i o n regarding their health and will not seek care from their PCP. ED p e r s o n n e l and H M O PCPs should keep these facts i n m i n d w h e n d e c i d i n g w h o will be denied care in the ED.
The authors thank Ms Randi E Bell for her help with data collection and Mrs Pat Parkinson for her help with this manuscript.
REFERENCES 1. HealthPass Concepts: Definition of HealthPass as a Health Insuring Organization. Phila-
delphia, Penn Health Corporation, September 1985. 2. Emergency Care: HealthPass: Patient Information. Philadelphia,Penn Health Corporation,
1985. 3. Dershewitz RA: Patients who leave a pediatric emergencydepartment without treatment. Ann Emerg Med 1986;15:717-720. 4. Kerr HD: Access to emergencydepartments: A survey of HMO policies. Ann Emerg Med 1989;18:274-277. 5. KerrHD: Prehospital emergencyservices and health maintenance organizations.Ann Emerg Med 1986;15:727-729. 6. Knopp RK: Impact of HMOs on emergency medical services (editorial). Ann Emerg Med 1986;15:730. 7. Losek JD, Walsh-Kelly CM, Altstadt JF: HMO's and pediatric emergency care. Pediatr Emerg Care 1987;3:79-81. 8. First private COBRAlawsuit could set legal precedent. Hosp Risk Management 1988;10: 156-160.
See related editorial, p 98
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Annals of Emergency Medicine
19:1 January 1990
Indigent Children Who Are Denied Care in the Emergency Department We conducted a six-month prospective study of the diagnoses and outcomes of 588 children who were denied care in our emergency department under a n e w primary-care case management health system for 100,000 indigent patients. The mean patient age was 4.7 years (39% were less than 2 years old). The m o s t common presenting complaints were colds, earaches, rash, vomiting, and diarrhea. Nine percent of children presented for trauma, and 10% had fever of more than 38.2 C. Follow-up was available from the primary care physician for 388 children (66%). Of the 60% of patients who kept their arranged appointment, 42% received antibiotics, 3% were referred for further evaluation, and two children were hospitalized. Follow-up was available from the parents for 125 children (21%). No follow-up information of any kind was available for 111 children (/9%), and no follow-up regarding the health of the child was available for 265 children (45%). This last group included 10% with a chief complaint of trauma and 6% with temperature of more than 39 C. Forty-nine percent of patients in this group were less than 2 years old. [Shaw KN, Selbst SM, Gill FM: Indigent children who are denied care in the emergency department. Ann Emerg Med January 1990;19:59-62.]
Kathy N Shaw, MD*t Steven M Selbst, MD*t Frances M Gill, MDt Philadelphia, Pennsylvania From the Emergency Department* and the Division of General Pediatrics,I- The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia. Received for publication February 22, 1989. Revision received June 29, 1989. Accepted for publication September 12, 1989. Address for reprints: Kathy N Shaw, MD, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, Pennsylvania 19104.
INTRODUCTION In March 1986, the Pennsylvania Department of Public Welfare contracted with the Penn Health Corporation (a subsidiary of Health America Corporation, Nashville, Tennessee) to administer a primary-care case managem e n t health system for 100,000 medical assistance recipients who lived in south or west Philadelphia. The program, k n o w n as HeahhPass, was intended to improve accessibility, continuity, and quality of health care for indigent patients in Philadelphia, while saving m o n e y for the federal and state g o v e r n m e n t s by reducing the cost of care. 1 Enrolled beneficiaries were told to choose a primary care physician (PCP) to become the pediatrician for their children. If none was selected, a pediatrician was chosen to be the child's PCP. Physicians were paid a capitation fee for each patient and expected to act as "gatekeepers" for the delivery of care to these patients. Patients (parents) were instructed to go directly to the nearest emergency facility or call 911 whenever a "serious or disabling emergency occurs. ''z They were given a brochure containing examples of life-threatening emergencies; however, no specific examples involving children were given. Parents were instructed to call their PCP's office for advice regarding nonlife-threatening emergencies. Telephone coverage for advice and authorization for treatm e n t was provided on a seven-day-a-week, 24-hour-a-day basis. Physicians were to respond to patient telephone calls within one hour. When a HeahhPass patient requested services in a hospital emergency department, emergency personnel were instructed to determine whether the enrollee required emergency services and to provide care immediately if warranted.1 If the enrollee's condition did not warrant immediate medical care, the personnel were instructed to contact the PCP for authorization to treat. The PCP could deny authorization to treat and/or request that the patient come for an office visit or go to another facility. After implementation of this system, m a n y HeahhPass children continued to present to our ED for care. Most parents had not called their PCP
19:1 January 1990
Annals of Emergency Medicine
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INDIGENT CHILDREN Shaw, Selbst & Gill
before ED arrival, which placed a significant burden on our triage and clerical personnel because many children were denied authorization for examination and treatment. Families turned away from our ED frequently left angry at our personnel, hospital, and "the system." The purpose of our study was to determine the outcome of patients who were denied care by their PCP and left our hospital without a complete evaluation by our nursing and medical personnel. Specifically, we wanted to prospectively evaluate the percentage of these children seen by their PCP and when they were seen, the chief complaints and eventual dia g n o s e s of t h e s e c h i l d r e n , and whether the decision to refuse care in the ED was correct in retrospect.
METHODS The ED of the Children's Hospital of Philadelphia includes a walk-in clinic. Children from birth through 18 years of age are seen for any comp l a i n t . Before t h e f o r m a t i o n of HealthPass, approximately 65,000 children were seen each year. Of these, about 55% received medical assistance, 17% had private insurance, and most of the others were self-paying patients. Very few patients were m e m b e r s of a health maintenance organization (HMO). All children presenting to the Children's Hospital of Philadelphia ED from September 1987 through February 1988 (six to 12 months after the start of the HealthPass program) who were enrolled in the HealthPass system and denied care by their PCP were eligible for the study. Patients were initially seen by a registered nurse who triaged patients into three categories according to the ED triage manual. All patients believed to be "acutely ill," defined as "patients with life-threatening conditions or health problems that can become life threatening or disabling," were fully evaluated without consent from the PCP and were excluded from our study. The remaining two triage categories, "urgent," defined as "patients who need prompt treatment but do not have immediately l i f e - t h r e a t e n i n g c o n d i t i o n s , " and " n o n a c u t e , " defined as " p a t i e n t s whose conditions are stable and can wait without detrimental outcome," were eligible for our study. The chief complaint, age, temperature, and re108/60
sults of a brief examination by the nurse were recorded on the nursing triage sheet. The r e g i s t r a t i o n clerk was instructed to call the PCP or his designee and convey the recorded triage information to obtain permission for the patient to be seen. If the patient was denied ED care, an attending physician was asked to evaluate the patient briefly and document that the child could be sent home or directly to the PCP. If the evaluating emergency physician believed that the child should be seen despite refusal by the PCP, the child was evaluated in the ED and excluded from our study. Daily logs of patients who were refused care and not seen in the ED were reviewed the next day; recorded were demographics, chief complaints, triage information, site of routine health care, whether the physician documented his brief assessment, and patient disposition. The parents were called 24 to 72 hours after leaving the ED and questioned regarding their child's illness, PCP contact, and their opinion of the current system. Three attempts were made to reach each family at different times of the day. A questionnaire was mailed to each child's PCP asking for follow-up information, including when or whether the child was seen, diagnosis and treatment, and their assessment of the ED triage and decision to refuse care. Statistical analysis was performed using X2 for categoric data and t test for continuous numeric data. An a priori level of statistical significance of .05 was chosen.
RESULTS There were 588 children who were enrolled in HealthPass and denied care in the Children's Hospital of P h i l a d e l p h i a ED d u r i n g the sixm o n t h study period. Seventy-seven percent of the patients received their primary health care at a clinic or health center, 18% from hospitalbased clinics, and 5% at private offices. N i n e t y - t h r e e percent could identify their HealthPass p r i m a r y care site. Forty-seven percent of these patients came to the ED between 5:00 PM and 8:00 AM on weekdays or a weekend. The remainder came during regular business hours. The mean age of the children was 4.7 years; 39% were less than 2 years Annals of Emergency Medicine
TABLE 1. Presenting complaints of
patients denied care by their PCP Complaint
Upper respiratory infection Rash Vomiting or diarrhea Fever Trauma Earache Other
% 28 24 11 10 9 4 14
old. Most of the patients presented with a chief complaint of an upper respiratory tract infection, earache, rash, vomiting, or diarrhea (Table 1). However, 9% involved trauma (21 cases of head trauma and 29 cases of extremity trauma), and 10% had a temperature of more than 38.2 C. Of these, 27 patients were less than 2 years old and had a temperature of more than 39 C. The triage nurse believed that 4% of the patients should be seen urgently (ie, not wait their turn to be seen according to time of arrival). There was documentation that an e m e r g e n c y physician had seen the patients before they left the ED in 65% of the cases. Others were seen without physician documentation, and the remainder left before a physician could conduct an evaluation. We were able to obtain follow-up information from the PCP regarding 388 patients (66%). According to records, 234 patients (60%) kept their appointments. Of these, 59% were seen on the same day as the ED visit and 22% on the next day. Of these 234 children who were seen, rash was the m o s t c o m m o n diagnosis (28%), followed by upper respiratory infection (20%), ear infection (15%), and trautna (8%). Antibiotics were prescribed for 42% of these children and other medications for 18%. Two children were hospitalized - one for dehydration and one for cellulitis. Three percent were referred for further evaluation. In seven cases, the PCP believed that the triage was inappropriate and that the p a t i e n t should have been seen in the ED. D e s p i t e m u l t i p l e a t t e m p t s , we were able to obtain follow-up information by telephone from only 125 19:1 January 1990
TABLE 2. ED ability to obtain follow-up information regarding patients
denied care
From PCP From patient (parents) From both family and physician
Any Information (%)
Information About Health of Child (%)
66* 21
40 21
6 6 19 45 *Includes 154 patients who did not keep their PCP appointment; no health information known. No follow-up information available
parents (21%). In an estimated one half of cases, the telephone numbers were either disconnected or incorrect or the parent did not have a telep h o n e . E i g h t y p e r c e n t of t h o s e reached by telephone had not called their PCP before presenting to the ED. Seventy-two percent claimed to have kept their appointment with their PCP. Fifty-eight p e r c e n t of those contacted said they did not plan to change their use of the ED; 34% said they would call their PCP first in the future; and the remainder planned to change their HealthPass site or type of health insurance. We were unable to obtain any follow-up information from the physician or family regarding 111 patients (19%). An additional 154 patients did not keep their PCP appointments; therefore, follow-up information regarding the health of 265 children (45%) was u n k n o w n after care had been denied in the ED. Of patients with no follow-up health information, 39% were not seen by an emergency physician before leaving the ED, 49% were less than 2 years old, 10% had a diagnosis of trauma, and 6% had temperatures of more than 39 C. Our ability to obtain follow-up information regarding children in our study group is summarized (Table 2). Study patients were a preselected low-risk group because all had been triaged by a registered nurse according to strict protocol, and the majority also had been screened by an attending physician. Despite this rigorous and time-consuming process, a group of "higher-risk" patients was identified and included those triaged as urgent by the registered nurse, neonates, and young children with fever. Of concern was that among patients who were classified as urgent, 19:1 January 1990
28% were not seen by an emergency physician before leaving, 38% were not seen by. their PCP, and we were unable to contact the parents or PCP for follow-up on 43%. Infants less than 3 m o n t h s old were m u c h more likely to have a PCP visit arranged for the same day before leaving the ED than were older children (57% vs 26%; P .001). However, children with fever were not more likely either to have a follow-up appointment arranged before leaving the ED or to keep followup appointments. DISCUSSION Our study shows that parents of indigent children who are denied ED care may not contact their PCP or take their child to be seen by a physician. Some parents may have taken their children to their PCP, who then did not take the time to correspond with us about the visit. Many children may have improved, and their parents then chose not to seek medical care once they were denied ED care. One study of children whose parents voluntarily left an ED without treatment demonstrated that approximately one half had improved within 48 hours and did not seek other medical care. 3 The PCPs who responded noted that 40% of the patients did not keep the appointment arranged by the ED. Our inability to obtain follow-up information concerning the health status of the 45% of children denied ED care, because they either failed to keep their PCP appointment or were unable to be contacted by telephone, illustrates a problem with managed health care systems for indigent patients that rely on established relationships and good telephone cornAnnals of Emergency Medicine
munication with PCPs. Many of our patients had disconnected or no telephones. These families often had no established relationship with the PCP. One half of the study patients came to the ED during regular clinic or office hours. Of those parents who were contacted, the majority planned to make no changes in their ED usage, and only a third said they would call their PCP before coming to the ED in the future. Our study examined one primarycare case management system established for urban medical assistance recipients in one city and their use of our ED and cannot be generalized to all HMOs and EDs. Other managed health care systems may have educated and established good communication with their recipients. However, in our study of an HMO for indigent patients, parents continued to preferentially seek ED care six to 12 months after the program was instituted. The lack of follow-up and the low percentage of patients seeking care at their primary care site make ED triage extremely important. Our policy of having an emergency physician screen patients who had been denied care in the ED by their PCPs or their designees based on the triage information prevented many ill children from being turned away. These children, initially denied care by the PCP but seen in the ED, were excluded from our study. However, despite strict triage protocols, some triage decisions may be incorrect. Of those children evaluated by their PCPs in our study, two returned for hospitalization. Shortly after our study ended, a 2-month-old infant with the chief complaint of a "cold" was denied care by her PCP. She returned by emergency transport a few hours later with respiratory arrest. During the study period, one child presented with a temperature of 40.5 C and was denied authorization for treatment. However, she then had a convulsion before leaving and received ED treatment that included endotracheal intubation. Patients in our study were usually denied authorization for ED care because the child did not have "a lifethreatening e m e r g e n c y . " A recent survey of medical directors of HMOs in 39 states and the District of Columbia found that 92% used this 61/109
INDIGENT CHILDREN Shaw, Selbst & Gill
" l i f e - t h r e a t e n i n g " d i s t i n c t i o n i n defining ED access policies. 4 However, such a d e t e r m i n a t i o n m a y often be difficult to make. It is difficult for parents to k n o w w h e n their child is s u f f e r i n g f r o m a p o t e n t i a l l y lifethreatening emergency. Brochures given enrollees i n this HealthPass program did not describe what constitutes a pediatric emergency. It is often difficult for a d u l t patients to determine the seriousness of their o w n medical problems.S, 6 It m a y be difficult for a triage nurse or ED physician to determine if an inn o c e n t - s o u n d i n g c o m p l a i n t represents a life-threatening condition without performing an appropriate h i s t o r y and p h y s i c a l e x a m i n a t i o n . Losek et al 7 reported a case of a child with suspect child abuse denied authorization for ED care who was lost to follow-up investigations. Physicians and EDs m a y be legally responsible for patients who are denied authorization for evaluation and t r e a t m e n t . In I986, a n e w s e c t i o n (1867) was added to the Consolidated O m n i b u s Budget Reconciliation Act (COBRA) of 19858 and established a federal tort for failure to "stabilize" patients seeking emergency medical care. It says h o s p i t a l s w i t h emergency services m a y be liable to any patient with an emergency medical condition (or i n active labor) who is t r a n s f e r r e d before the c o n d i t i o n is
stabilized; this applies to any person who requests e x a m i n a t i o n or treatm e n t at the hospital. Improved c o m m u n i c a t i o n between the emergency physician and the PCP m a y i n c r e a s e t h e n u m b e r of children, especially in higher-risk categories, who are authorized to receive care in the ED. Reliance on ED clerks and n o n m e d i c a l personnel for t e l e p h o n e p e r m i s s i o n is c o m m o n p r a c t i c e i n m a n y EDs a n d H M O s 4 and m a y i n h i b i t proper c o m m u n i c a tion a m o n g physicians. However, in busy pediatric EDs, the d e m a n d on m e d i c a l p e r s o n n e l to screen all patients denied care and to make direct telephone contact w i t h PCPs who are n o t always available is not feasible. Ideally, emergency physicians should a t t e m p t to get direct a u t h o r i z a t i o n from PCPs a n d see m o s t c h i l d r e n who seek care, unless the PCP agrees to provide urgent care and the patient (parent) agrees to go there promptly. Based on our experience over this six-month period, we no longer deny care i n the ED to children who cann o t be seen i m m e d i a t e l y by t h e i r PCP. The PCP is still contacted for each HealthPass patient; however, if care is refused, the child is still seen, at our expense. CONCLUSION M a n y i n d i g e n t c h i l d r e n w h o are denied ED care will be unable to be
reached for follow-up i n f o r m a t i o n regarding their health and will not seek care from their PCP. ED p e r s o n n e l and H M O PCPs should keep these facts i n m i n d w h e n d e c i d i n g w h o will be denied care in the ED.
The authors thank Ms Randi E Bell for her help with data collection and Mrs Pat Parkinson for her help with this manuscript.
REFERENCES 1. HealthPass Concepts: Definition of HealthPass as a Health Insuring Organization. Phila-
delphia, Penn Health Corporation, September 1985. 2. Emergency Care: HealthPass: Patient Information. Philadelphia,Penn Health Corporation,
1985. 3. Dershewitz RA: Patients who leave a pediatric emergencydepartment without treatment. Ann Emerg Med 1986;15:717-720. 4. Kerr HD: Access to emergencydepartments: A survey of HMO policies. Ann Emerg Med 1989;18:274-277. 5. KerrHD: Prehospital emergencyservices and health maintenance organizations.Ann Emerg Med 1986;15:727-729. 6. Knopp RK: Impact of HMOs on emergency medical services (editorial). Ann Emerg Med 1986;15:730. 7. Losek JD, Walsh-Kelly CM, Altstadt JF: HMO's and pediatric emergency care. Pediatr Emerg Care 1987;3:79-81. 8. First private COBRAlawsuit could set legal precedent. Hosp Risk Management 1988;10: 156-160.
See related editorial, p 98
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