The Emergency Department: Rising wait times, costs, and possible remedies

Emergency Departments (EDs) and Emergency Rooms (ERs) are designed to manage trauma, respond to disasters, and serve as the initial care for those with serious illnesses. However, because of many factors, the ED has become the doorway to the hospital and a “catch-all net” for patients including those with non-urgent needs. This increase in the population in the ED has lead to an increase in wait times for patients. It has been well documented that there has been a constant and consistent rise in the number of patients that frequent the ED (National Center for Health Statistics, 2002); the wait time for patients in the ED has increased (Pitts, Niska, Xu, & Burt, 2008); and the cost of the treatment in the ER has risen (Everett Clinic, 2008). Because the ED was designed to treat patients who need quick diagnoses and may be in potential life-threatening circumstances, management of time can be the ultimate enemy. If a system was implemented to decrease wait times in the ED, decrease the use of ED resources, and decrease costs endured by patients seeking care, better outcomes for patients and patient satisfaction could be achieved. The goal of this research was to explore potential changes and/or alternatives to relieve the burden endured by the ED. In order to explore these options, data was collected by conducting one-on-one interviews with seven physicians closely tied to a Level 1 ED (Emergency Room physicians, Trauma Surgeons and Primary Care physicians). A qualitative analysis was performed on the responses of one-on-one interviews with the aforementioned physicians. The interviews were standardized, open-ended questions that probe what makes an effective ED, possible solutions to improving patient care in the ED, potential remedies for the mounting problems that plague the ED, and the feasibility of bringing Primary Care Physicians to the ED to decrease the wait times experienced by the patient. From the responses, it is clear that there needs to be more research in this area, several areas need to be addressed, and a variety of solutions could be implemented. The most viable option seems to be making the ED its own entity (similar to the clinic or hospital) that includes urgent clinics as a part of the system, in which triage and better staffing would be the most integral part of its success.^

An ethnographic study of home remedy use for African-American children

Background and significance. The use of herbs and other remedies by adult and elderly African-Americans has been documented. However, little is understood regarding the use of herbs for African-American children. The purpose of this study was to document and describe the historical and present day uses of herbal and other remedies, specifically for the health and illness of African-American children. This information will provide health care providers with a better understanding of their African-American patients. This information may also contribute to the emerging appreciation of indigenous uses of phytotherapeutics. ^ Methods. A focused ethnographic approach was used to describe the cultural context, including the beliefs, values, customs, and behaviors of a particular culture. The use of intensive fieldwork, including participant observation, audiotaped formal interviews, photographs, and specimen collection of plants helped to describe herb use in this population. Information on the growing, harvesting, preparation, and storage of these plant remedies, as well as the amount and dosage of these compounds was collected in a typology. Detailed information was gathered to discern how, when, and under what conditions these remedies were used and their expected results. Further data collection focused on the history of herbal use, and explanations for how and why informants thought the herbs work. ^ Setting and participants. The setting for this study was in East Texas and field work extended over the period of one year. Thirty African-Americans, age 38 to 98, were interviewed for the study. The African-American population in this area has been relatively stable, with roots dating back prior to the reconstruction period, which allowed excellent historical information. Informants were chosen by a nominated sampling technique starting with two key informants knowledgeable about the use of home remedies for children. ^ Findings. The findings of this study suggest that African-American children in East Texas have a long history of receiving herbs and home remedies for health promotion and illness. Data further suggests that there is a strong connection between spirituality and the health beliefs and practices of this community. This spiritual component underlies the accuracy of oral recall for remedies that have been used over many generations and the use of natural folk remedies. A typology of the herbal remedies was developed with folk and Latin name, herb place of origin, known scientific properties, and informant folk usage and dosage information. ^

The use of culturally related health practices and health care utilization among Hispanic women in farmworker communities

Breast and cervical cancer screening rates continue to be lower in Hispanic women than other ethnic subgroups. Several factors have been identified that influence health care utilization. The use of preventive services (cancer screenings and adherence) in addition to yearly doctor visits are often used to measure health care utilization. A secondary analysis of an existing dataset containing baseline survey data collected from participants of an intervention trial to test the Cultivando La Salud (CLS) program was used to analyze the association between cultural health practice use (use of curandero,s obador, and herbal remedies) and health care utilization. The sample consisted of women 50 years of age and older living in farmer communities in four sites: Eagle Pass, TX, Anthony, NM, Merced, CA, and Watsonville, CA (n=708). Participants reported using a curandero (5.67%), sobador (29.79%), and herbal remedies (46.65%) at some point in their lives. The use of cultural health practices was found to significantly influence utilization of certain health care services: use of herbal remedies influence doctor visits, adherence to mammography screening and adherence to Pap test screening; use of a curandero influenced ever having a mammogram; use of a sobador influenced ever having a mammogram, ever having a Pap test, and Pap test adherence. In addition, women reporting use of curandero or herbal remedies were found to be more avoidant of the health care system than those that reported not using them. Further research is needed to further analyze the influence of cultural health practices on health care utilization. ^

Understanding disparities in emergency department visits for asthma

Asthma is the most common chronic disorder in childhood, affecting an estimated 6.2 million children under 18 years (1). The purpose of this study was to look at individual- and community-level characteristics simultaneously to examine and explain the factors that contribute to the use of emergency department services by children 18 years old or less and to determine if there was an association between air quality and ED visits in the same population, from 2005-2007 in Houston/Harris County. Data were collected from the Houston Safety Net Hospital Emergency Department Use Study and the 2000 US Census. Bivariate and multivariate logistic regression models and mixed effects models were used to analyze data that was collected during the study period.^ There were 704,902 ED visits made by children 18 and younger, who were living in Houston from January 1, 2005 to December 31, 2007. Of those, 19,098 had a primary discharge diagnosis of asthma. Asthma ED visits varied by season, with proportions of ED visits for asthma highest from September-December. African-American children were 2.6 (95% CI, 2.43-2.66) times more likely to have an ED visit for asthma compared to White children. Poverty, single parent headed households, and younger age all a greater likelihood of having gone to the ED for asthma treatment. Compared to Whites living in lightly-monitored pollution areas, African-Americans and Hispanics living in heavily monitored areas were 1.15 (95% CI, 1.04-1.28) times more likely to have an ED visit for asthma.^ Race and poverty seem to account for a large portion of the disparities in ED use found among children. This was true even after accounting for multiple individual- and community-level variables. These results suggest that racial disparities in asthma continue to pose risks for African American children, and they point to the need for additional research into potential explanations and remedies. Programs to reduce inappropriate ED use must be sensitive to an array of complex socioeconomic issues within minority and income populations. ^

The social construction of infant mortality: From grassroots to medicalization

Infant mortality as a problematic situation has been recognized for some 130 years in one form or another. It has undergone various changes in its empirical dimensions relative to whom we study within the population, what we study--low birth-weight vs. pre-term births--and how we study it--whether demographically or medically. An analysis of the process by which the condition was raised by claims makers as an intolerable situation among America's urban residents reveals that demographic and medical data were sparse. Nonetheless, a judgement about the meaning and significance of the condition was made, and that interpretation led to the promulgation of systems to both document and address the condition as it has come to be defined.^ This investigation depicts the historical context and natural history of infant mortality as one of a number of social problems that came to be defined through the interplay among groups and individuals making claims and how their claims came to the public policy agenda as worthy of collective resources--who won, who lost and why. The process of social definition focuses attention on the claims makers and the ways they contrast the meaning, origins and remedies for this troubling condition. The historical context becomes the frame of reference for understanding the actions of the claims makers and the meaning and significance they attached to the problem.^ We purport that "context" provides a closer reality than disjoined "value free" accounts. Context provides the evidence for the definition, who participated in the process, why and by what means.^ The role of women in the definitional process reveals the differences in approaches utilized by the women of the settlement house reform movement and African-American women working at the grass-roots. Much of the work done by these two groups provided options to the problem's remedy; however, their differences paved the way to our current (principally medically-oriented) definition and its inherent limitations. ^