Nudging towards efficiency: Reducing emergency room usage in pediatric population

Introduction In recent years, hospitals have seen an overuse of emergency room (ER) facilities. This problem is particularly worse among the pediatric population as guardians approach the ER for low acuity reasons too. Thus, there is a need to explore the reasons behind this practice and review interventions to reduce it. Methods Based on a registered protocol, studies were systematically searched in PubMed, using a developed search strategy with critical words by all four reviewers. Studies were included if they discussed emergency room overuse in pediatric populations, behavioral interventions to decrease this, causes of overuse or quality improvement projects assessing this problem; were published after 2014; were available as free full text; were Randomized Controlled Trials (RCTs), qualitative studies, case controls/cohort studies, descriptive studies; and were in English. The bias assessment was done using CASP Tool Kits and scored internally by one reviewer and checked by two more. Data extraction was done by two reviewers and then independently checked for completeness and accuracy by the other two. Results Of 240 studies found by initial database search, 48 were selected based on inclusion criteria and data was extracted from only 23 studies after all parameters were checked. Almost all the studies were from 2017-2022. 11 of the studies were conducted in the North America (Canada and US). There were 7 RCT and 7 experimental studies and 6 qualitative studies. The mean sample size for studies dealing with patient population was 1028 after excluding one outlier. Causes like gastroenteritis, fever, asthma and trauma were primary reasons for presentation. Younger children, patients without PCP, those coming in office hours and those from low education households overused ER more often. CT scan was the most overused imaging technique across studies. The relationship between physician prescription habits and ER overuse was studied across multiple studies, specially under the lens of over ordering chest X-ray plus antibiotics in bronchiolitis cases. Using tailored social resources handout, managing toddler behavior, better triage models and using video discharge instructions post-ER visit was associated with a much notable decrease in child hospitalization and ER visit frequency. Conclusion Although numerous studies discuss components of ER overuse among the pediatric population, there is still a scant number of studies that discuss interventions and their efficacy. Therefore, more studies need to be conducted introducing new interventions, specifically behavioral ones based on the existing studies talking about the causes, protocols, overused parameters and demographics. Although numerous studies discuss components of ER overuse among the pediatric population, there is still a scant number of studies that discuss interventions and their efficacy. Therefore, more studies need to be conducted introducing new interventions, specifically behavioral ones based on the existing studies talking about the causes, protocols, overused parameters and demographics.

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