Pediatrics are Being Overlooked in the Crisis of ED Overuse

Certified child life specialists become patient allies when doctors are not capable or do not have spare time. (Photo credit: Pexels.com)

Catherine Rogers*, Beth Matthews*, and I meet in the crook of two seemingly endless hallways near the adult surgery wing. Rogers and Matthews are certified child life specialists (CCLS), a profession I was wholly unaware of before making their acquaintance. In Louisville, Kentucky, they are a full-service team, rotating between hospital departments. Most of Matthews’s seven years as a CCLS have been in the emergency department (ED).

“As you work in the ED you see many people come in for a rash, ear pain, sore throat, things like that,” Matthews tells me. I pop over to the ED where five families are waiting at the admission desk. A bow-wearing baby girl on her mother’s hip smiles at me, seemingly not in distress. Rogers adds, “The number I consistently hear is that one in ten ED cases will actually be an emergency.” The emergency room is bogged down, and children are not getting the most efficient form of primary care. The overuse of the ED tends to be a hot-button topic for the United States, particularly in seasons where health care reform is on the docket. Still, data and discussion regarding pediatric overuse is underrepresented.

Dangling from Rogers’s name badge is a purple and green popper toy. After pressing the colored buttons inwards, they spring back out with a muted “click.” The white plastic and colorful silicone are purposeful. Child life specialists have an arsenal of plastic, vinyl, and silicone toys that are easy to disinfect. More importantly, they have an arsenal of knowledge and tactics to distract, encourage, and engage children during their hospital stays. With their deep understanding of childhood behavior and development, CCLSs become patient allies when doctors are not capable or do not have spare time.

In emergency situations, though, child life specialist support is more limited. Their assistance becomes procedural, such as prepping a patient for surgery or tests, as opposed to developmental, educational, or emotional. “In the ED, we are treat-and-release,” says Matthews.

“There is one boy who has come into the ED three times over the past two days, just because he has no other means of primary care,” says Rogers. Matthews adds, “I’ve seen kids grow up in the ED, which is interesting. I’ve seen kids grow up from babies, and now they’re in school.” Matthews and Rogers attribute this largely to a lack of patient and parent education in the best ways to utilize health care resources.

This is particularly true in communities that face systemic socioeconomic and structural disadvantages. According to a January 2021 article in HealthAffairs, households with two adults who are high school graduates, have access to vehicles (not including public transport), and have sound housing are less likely to rely on the ED for medical care. Interventions to reduce ED overuse in the past have mostly focused on improving health care literacy through follow-up support. The researchers, like Rogers and Matthews, agree that the results are inconsistent and insufficient in remedying the issue.

The prevalence of children and families at the ED for routine issues is not localized to Kentucky, nor to urban areas. “We struggle with patients not knowing how to navigate the system,” says Kristin Dial, the Executive Director of Coalfield Health, a rural health care initiative in Chapmanville, West Virginia. When they realized that a statistically significant number of children were not coming to their well-child visits, Dial and her coworkers began programming events that could draw children, and their adults, away from home. In between having fun, winning prizes, and snacking on free food, kids receive their annual vaccines as well.

In emergency situations, child life specialist support is more limited. Their assistance becomes procedural, as opposed to developmental, educational, or emotional. (Photo credit: Pexels.com)

Before her move to Louisville, Rogers interned at a children’s hospital in Minnesota where things were not so different. The ED staff tried stationing a primary care doctor at the ED to see patients who were not in crisis. Rogers says the approach was successful, but not practical. Matthews agrees that it is difficult to find doctors willing to take on the role.

“We need more resources, almost at the door, of the ED,” suggests Dr. Denis Godwin Antoine II, M.D., a specialist in Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine. He, like others, sees the issue as being educational, rather than procedural, in nature. Far too many parents in the United States simply are not educated in health care literacy.

“The big changes,” says Matthews, “they have to happen on a larger scale. They have to happen at the policy level, through different laws. They’re things that are really difficult to tackle only at the base level.”

The few existing comprehensive studies on pediatric ED usage make the same conclusion, including the aforementioned 2021 survey, which states, “Governments, payers, health care systems, employers, and clinicians wishing to reduce pediatric nonurgent ED visit[s] . . . should consider strategies to mitigate financial, time, transportation, and health literacy constraints that may affect families’ access to primary care.”

CCLSs, nurses, and even doctors can only do so much in the time that they have with their patients. This is particularly true in the fast-paced environment of emergency medicine.

Our chat ends right at 5 p.m., when Rogers receives a page that her help is needed in the ED. It is time for Matthews to clock out too—she has been at the hospital since nearly 6 a.m. Shortly after my departure, Rogers texts me, “When you left, we had a family of four show up for strep testing.” Until Rogers, Matthews, and the other 18 million health care workers in the United States get governmental and institutional support to increase access to and education regarding primary care, families and their children will continue to overload the emergency room.

*The names of the CCLSs in this story and their workplace have been changed to enable their free speech without violating employer agreements.