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When should a child go to the ER?

Six years ago, when her 3-year-old daughter developed a fever and a discharge from her ear, Latasha Anderson took her to the hospital emergency room.

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Six years ago, when her 3-year-old daughter developed a fever and a discharge from her ear, Latasha Anderson took her to the hospital emergency room.

A few weeks ago, in a basement meeting room at the Woodland Avenue Health Center in Southwest Philadelphia, she learned the visit probably hadn't been necessary.

The condition, she discovered, was quite common for a child that age and could have been treated at home. "I always thought that if your child got a fever, you went to the emergency room," Anderson said. "Now I know I probably didn't have to take her."

Anderson, 34, was attending one of a series of two-hour seminars sponsored by her health insurer, Keystone First, aimed at reducing unnecessary pediatric emergency room visits.

Y. Lily Higgins, medical director for Keystone, the largest Medicaid insurer in Southeastern Pennsylvania, said the company's reasons for this include cost, treatment quality, and convenience.

Higgins estimated an ER visit costs Keystone about $400 the minute a child is brought through the door and escalates quickly into the thousands. (Someone without insurance would be billed far more.)

And no matter how competent the ER physician, she said, in a nonemergency situation, children generally are better off being treated by physicians who know them.

That's one reason the seminar leaders encourage parents to develop a close relationship with a primary care physician.

There also is the matter of what Higgins called convenience for the parent, for whom an hours-long ER visit could mean lost work time or hassles arranging sitters for other children at home - although surveys also show some adults go directly to emergency rooms because 24-hour availability is easier than scheduling doctor's appointments.

"Part of it is economic but the bigger part is a better relationship with their primary care provider," Higgins said.

In fact, Anderson said that only in recent months had she established a good relationship with a family pediatrician.

Since 2011, about 3,000 parents have attended the seminars, which are offered two or three times a week to members at various locations. Keystone says the program reduced pediatric ER visits by 25 percent in the first year.

According to a 2010 report by the New England Healthcare Institute, overuse of emergency rooms by patients of all ages nationwide wastes $38 billion a year. And the problem has grown along with the expansion of Medicaid under the Affordable Care Act, according to an estimate released in September by the Colorado Hospital Association. Contrary to some policymakers' expectations, people with health insurance actually use emergency rooms more.

There is disagreement, however, over how many of those visits are unnecessary. There is no simple definition of appropriate ER use, Stephanie B. Abbuhl, vice chair of emergency medicine at the Hospital of the University of Pennsylvania, wrote in a commentary in the journal Academic Emergency Medicine.

Medicaid patients present particular challenges. Participants tend to be less educated, and lower incomes can lead to more stress, raising the risk of a range of health problems. Poverty also is associated with more frequent moves, which can make it hard to maintain connections with doctors.

In Keystone's experience, many Medicaid patients don't have a good relationship with a primary care physician and are used to the ER as a first rather than a last resort, Higgins said.

The ER physician "can only take care of one piece of the child," she said. "They don't really know the whole child. There's no continuity of care."

To deal with the issue, Keystone First reviews its records to find parents who have taken a child for at least one ER visit that seemed unnecessary.

Invited parents are given lunch and a $10 Walmart gift card; child care is provided. They also get medical literature and a kit of household medical supplies.

The program teaches the difference between emergency and nonemergency situations, and how to deal with common childhood ailments.

"A fever isn't considered an emergency in most situations," community health educator Alice Honeywell told Anderson and a half-dozen others at the recent gathering. "A fever fights infections."

Honeywell and her colleague Marsha Walker took them through a series of medical scenarios involving fevers, vomiting, earaches, and other common pediatric problems.

They also introduced them to Keystone's 24-hour nurse hotline. "They're there to talk you off the ledge or say you need to go to the ER," Walker said.

In addition to imparting medical knowledge, Walker sees her job as dispelling common misinformation.

She went through a variety of beliefs ranging from cold baths for a feverish child and using Q-tips to clean out ear wax to putting sliced onions in a sock to drain off illnesses, all of them useless or risky.

"Don't listen to your neighbor who says, 'When I was a child,' " Walker said.

For emergency room physicians, the trick is to be both an educator and a doctor.

"I never want families to feel unwelcome," Margaret Samuels-Kalow, a pediatric emergency room physician at Children's Hospital of Philadelphia, said in an interview. "We try hard not to judge who should be in the emergency department. But preventable visits are a burden to families."

When she sees children whose conditions could have been handled at home or at a primary care provider's office, Samuels-Kalow said, she tries to find out why they were taken to the hospital.

"Is it resources, being unable to afford home medications? Is it an issue of education?"

She said she often gives out educational materials. "What we're really hearing from families is that they want teaching that doesn't involve medical jargon," Samuels-Kalow said.

"It's an important and unrecognized part of what we do."

SHOULD YOUR CHILD GO TO THE EMERGENCY ROOM?

The following are examples of when to take a child to a hospital emergency department vs. calling your pediatrician (or your insurer's help line). These are examples; they do not represent a full list.

Doctors also caution that not every case is clear. If you have reason to believe that your child is in danger, go the emergency room.

Call the doctor's office or nurse phone line

Earache.

Low-grade fever (younger than age 6-8 weeks, 100.4 degrees; older, 101).

Skin rash.

Coughing or seems to be coming down with a cold or flu.

Nausea or stomachache.

Minor injuries such as small cuts or sprains.

Go to the emergency room

Severe dizzy spells, fainting, or blackouts.

Choking or trouble breathing, or if an asthmatic child is not responding to prescribed treatment.

Sudden loss of feeling or not being able to move (symptomatic of a seizure).

Might have ingested a poison.

Severe injuries such as burns, major cuts, broken bones.

 Urgent care centers may be a middle option. Keystone First links to clinics around the region from its "How to Get Care in an Emergency" page: http://bit.ly/1DuqNYf

SOURCE: Keystone FirstEndText