Tuesday, January 21, 2014

Too much or just right?

I need your help in evaluating this story.  Is this what I should hope for when I advocate for patient-driven care, or is this an example of over-use in a hospital?  I'm really not sure, and I'd welcome your thoughts.

The story is of a 10-year-old boy who has a fever.  He is taken to the local urgent care center at 9:00am.  The family is told that the center cannot disburse medication and that, in any event, since the child's temperature is 102 degrees, he should be taken to the emergency room of a hospital in the neighboring community.

The family arrives at the ED in the late morning.  During the many hours of diagnosis and waiting, a "child life specialist" appears.  These caregivers are apparently common in pediatric centers.  I read from the hospital's website later that these staff members:

[P]rovide emotional support for children and families. They cover the inpatient service, operating room and Pediatric Emergency Department. Child Life is active in preparation and procedural support for children undergoing testing and procedures as well as providing support to children and their families. 

At some point, the specialist asks the child if he would like to watch a movie. He says yes and is presented with a five-page listing of videos from which he can pick.  He chooses one to watch on the television screen.

Meanwhile, he is also loaned an iPad, on which he can play games.

When it comes time for a nurse to insert an IV port, the child life specialist shields the child's eyes from the procedure with a book, while he continues to watch the movie and the iPad.  Here's the scene.

Eventually, at 3:00pm, the boy is discharged with a diagnosis of a fever of unknown origin and instructions to take medication to reduce the fever.

The parents, while greatly appreciative of the demeanor and expertise of the staff, were stunned at level of costs that would be required to deliver this kind of care.  They were perplexed as to why their son needed it.

What do you think?


Barry Carol said...

While the urgent care center doctor said it couldn’t disburse medication, couldn’t he / she prescribe something? If the child had a pediatrician, couldn’t he get a same day appointment? Even if the child had no other option besides the ER, how much testing was really necessary and to what extent was it either defensive medicine or revenue driven? The delivered treatment and the presumed associated costs strike me as grossly excessive though I don’t think the loaned iPad or the video added much to costs. I wonder what the hospital’s explanation of the protocol might be aside from the infuriating “That’s the way we do it here.”

Paul Levy said...

The child's primary care doctor was not able to offer an appointment on short notice; hence the suggestion that they go to urgent care.

Unknown said...

My quarrel is with the gap presented by the urgent care center. This is where the breakdown occurred. Simple triage / initial diagnosis and basic treatment would have suited this boy and saved the ED adventure. If we dig deeper, the primary care doctor's lack of skilled nursing to at least offer intelligent telephone triage and next steps is mind boggling. How can we say much about the ED's actions beyond complete service with plenty of empathy for the child. Had the ED provided subpar care, we'd be clamoring for their heads. In this case, they took up the slack for two broken steps that essentially passed this child down to a full work up and greater expense.

Anonymous said...

I am with the other 2 commenters; the breakdown/cost driver occurred well before the ER here. Also, it gives one pause in our quest to increase funding and business for primary care. Just to say they have no appointment and to go to urgent care is certainly not patient centered and certainly will not reduce costs as everyone postulates, if this is the way the PCP's are going to conduct themselves.

At a minimum, patient education would have been helpful; as a parent I am not sure I would have presented the child to the medical establishment for a 102 degree fever at 10 years. Perhaps PCP reassurance with advice as to what 'alarm symptoms' to watch for would have served everyone, especially the child, best. I smell fear of lawyers here.

Interesting vignette from 'on the ground.' We need to hear more of these instead of our theories.


Anonymous said...

There is a lot of missing information here: how long the child had the fever, other symptoms, co-morbidities, other actions taken for relieving the fever, and other family members who were ill.

I wouldn't have taken my child to the physician's office, the urgent care center, or the emergency department with a temperature of 102. I would have given the child acetaminophen, alternated with ibuprofen as necessary, plenty of fluids, and quiet activities. There just seems to be a dearth of common sense here.

This just seems to be a very poor vignette for demonstrating a point.

As far as the activities performed at the ED? If the child was really sick, I can't imagine many children caring one way or another. Most ill children are listless and apathetic.

Nancy Thomas said...

Don't understand why an urgent care center could not prescribe medication, or administer it. Were they not "licensed" to treat children? Sounds like this hospital had had some sort of incident - when you see extraordinary response systems put in place there may have been a settlement or lawsuit that required such. That is the case at a local hospital, here, that has a Patient Emergency System put in place where a patient can call - at bedside - for an emergency response team if they feel their care is sub-par. I can see having a resource present for children, particularly those who are, not of their fault, causing a commotion - but should not this resource person work with the parent and not take over the parent's role, totally, in comforting and managing the event? In an ideal world, I suppose this is worthy of support for all hospitals - but what are the dollars associated with it?

David said...

Here’s my $0.02 on the question you pose: Whether the CLS was appropriately utilized depends on the level of anxiety the child and parents were displaying at the time. Either way, if the hospital was billing for the care, the parents should have been informed in advance of the availability of additional non-medical support and the cost associated costs. If anxiety was low/normal for the circumstances and/or CLS’s are deployed as part of routine ER care, it’s overuse, plain and simple.

Dan said...

Paul, you raise an interesting question. From my perspective as a pediatrician and advocate for quality, safety, efficiency and patient and family centered care in our children's hospital, it is clear that the benefits provided by our child life teams are tremendous. Easing the fear of children and helping them understand and prepare for pain or anxiety when receiving care is one of the things that is a differentiator among providers that families can choose between, and has been valued by not only our families, but also the ubiquitous "ranking systems" of child health care (e.g. USNWR, Parent magazine). It also can actually reduce delays and costs by ensuring tests, procedures and care can go forward in an efficient and safe manner in many situations.

One may question why we have many of the things that make our health care system more expensive-grand lobbies, patient portals for entertainment, special meals, etc. But until there is a drop in the drivers of our providing all types of comfort and amenities these costs will remain in our system. And please, if we are going to drive costs out let's look at real waste- the clinical variation that provides no benefit that you often write about- and not look to go backwards in the ways we provide true patient centered care to the children we serve.

Judith said...

What is there to be unsure of? It is blatant waste of time and money. A little extra care from a hospital volunteer would have worked just fine. Also, I sure hope they were honest with the kid about the IV insertion will feel like!

Mitch said...

I agree with the parents. Sort of patient-centered run amok, with no regard for cost.

Pam said...

If the Child Life expert was a volunteer, I'd say their service was probably lovely. If the parents had to pay for it, I'd say it was way over the top. Why couldn't a child with that high a fever be allowed to sleep?

When my kids were little, what that person did was my job -- and it didn't take a whole lot of imagination to figure out that comforting and diversion were what was needed. I didn't rely on the TV, movies and electronic toys, but somehow I managed to get my son through enough ER visits that the staff knew our names when we showed up at the door........and evidently successfully as he's a doctor today. I think were I in those parents' shoes, I would frankly resent the intervention, maybe even calling it interference -- especially if I had to pay for it.

I'll be interested to read what others say.

Paul Levy said...

The parents did not have to pay for all this. It was covered by insurance. But someone did.

There is an interesting presumption that kids should not watch while an IV is being inserted. I can understand that in some cases, but it seems to be the new standard.

Gail said...

Over use of care that inflates fees. Things should have been tried first at home.

Bob said...

Simple answer---yes; excessive and ridiculous; and a sad commentary on how patient care has devolved to its current level.

"Patient Driven Care" apparently means different things to different people.

From a patient's (parent's) standpoint, I would conclude that we received horrible and insensitive care. First, I didn't have access to or receive care from a primary care pediatrician, who should have been available to answer a few questions, to rule out potentially serious conditions and then give recommendations for lowering fever, maintaining hydration and outline conditions that would warrant further follow up. Once the family decided to go to the urgent care facility, those providers certainly should have been able to rule out any significant problems, without the need to refer to a hospital emergency room. In the hospital emergency room, a simple exam and evaluation should have been adequate, the child probably did not need an IV (administered after "many hours of diagnosis and waiting", probably causing dehydration) and the family should have been quickly discharged. If the reference to "patient driven care" translates to "feel good" or lessening emotional stress, then I would submit that enabling this child and family to avoid this entire experience, or many of the steps along the way, would have been less traumatic.

I also assume that "Patient Driven Care" may also include the idea that patients share in care and cost decisions. At no point did that occur in this story.

So when asked my opinion because you are "really not sure", it is clear to me that there may be a difference in definition, as opposed to opinion. When the definition and discussion includes hospital ED's as the appropriate venue to evaluate uncomplicated pediatric fevers, and 'child life specialists', televisions and iPads as substitutes for personal, efficient and effective care, I believe we will neither make real progress in our health care system, nor be able to provide universal affordable comprehensive care...or "patient directed (centered) care". Unfortunately (my opinion), it has seemed to me over the past thirty plus years as an obstetrician/gynecologist that my definition is diametrically opposed to others'. Purportedly with patients' interests in mind, the 'patient care' paradigm has been changed to one that does not, and can not, achieve the goals desired. (Again, my opinion; but one I am adamant about and seemingly easily defended.) We really need to have a clear definition that accomplishes our goals, before we can judge whether we have succeeded. And from a different perspective...the definition determines outcome and "success".

Barry Carol said...

From afar, I get the sense that the behavior of the primary care doctor and the staff at the urgent care center were driven by a fear of litigation if they missed something that turned out to be serious so the path of least resistance was to send the patient to the ER.

For the hospital, I wonder to what extent the protocol it followed was influenced by the famous case of the tragic death of 18 month old Josie King in 2001 at Johns Hopkins. Hospitals that now allow families to summon an emergency care team to the bedside may be largely a result of that case. Also, without interoperable electronic medical records, emergency departments that haven’t treated the patient before would rather err on the side of ordering too many tests than too few. Moreover, under the doctrine of “treat ‘em and street ‘em,” more tests could speed up the determination of a definitive diagnosis and rule out serious conditions. Finally, of course, under a fee for service payment model, the hospital gets paid more when it does more.

In the end, I think the two systemic fixes here are to reform the medical dispute resolution system and develop a reliable system of interoperable electronic medical records that are readily available to all providers as needed.

Todd Hudson said...

From a Lean perspective, if CLS is valuable to the consumer, meaning THEY are willing to pay for it, then there's nothing wrong. Sticking the bill to an insurance company is underhanded and smacks of simply piling on unnecessary features and steps to inflate the cost of care.

If this hospital is implementing Lean and has reduced wastes elsewhere that pays for CLS, which they now offer as part of their standard customer service model, then so much the better. That's how Toyota started being able to install premium features like electric windows and door locks on their standard models.

Anonymous said...

Seems to me if hospitals are paid global budgets (like Kaiser hospitals) and that is all the revenue they get for patient care--perhaps we would get a more rational system where provides invest in resources that have 'high value.'

We then stop worrying about the additional cost being born by the consumer or built into premiums.

Pat said...

Although perhaps not all of these interventions were essential for this particular child/family, I can tell you after nearly 40 years of nursing (most in pediatrics and maternal child health) that many children are so afraid of needles and iVs that this 1 day in the hospital could cause long lasting adverse effects. Preventing that was very important. Also although in this case having 2 people with the child while the IV was inserted included the CLS – it would have otherwise needed to be a second RN or other “helper” to be available to hold the child if he moved or fought the procedure.

Why not use personnel trained to distract and help the child cope with the invasive procedure instead of just be there to physically restrain him? I think this was WONDERFUL care. Even more essential resources for more painful procedures which often occur in the ER – sutures, burns etc. The videos and IPads are likely a drop in the bucket or donated by some people or local business and not a large capital expense.

Stacey Koenig said...

Child life services should be considered an essential component of quality healthcare where pediatric patients are being seen. There is evidence that child life services help to contain costs by reducing hospital length of stay, decreasing the need for analgesics and increase satisfaction. Child Life Specialists provide preparation that is “cost saving” in and of itself; if the patient is able to cooperate with the procedure at hand and the procedure only has to happen once, that is cost effective. It is not only cost effective financially but also emotionally effective for the child and life events to come. If children learn to cope and handle things they are gaining mastery that can be used throughout life in many events, not just illness/injury/hospitalization specific.

Just last week at our hospital there was a trauma where parents were not present as they were being treated in an outside facility. The patient refused to speak to the staff (RN,SW, Chaplain, and Doctors). Child Life was brought in and within a couple minutes established a rapport that “got the patient talking”. Medical staff immediately began using Child Life as the one voice in the room and were able to quickly and accurately assess the medical condition of the patient. Without child life, would this patient begin speaking to staff after a matter of time? Maybe. Would the child have to have undergone medical testing/procedures that may have been unnecessary in order to determine injury? Maybe. Did we save time and money to the hospital having Child Life present during this event? Yes, by developing quick rapport and opening the lines of communication with the child. We established a trusting relationship that no one else had been able to do. And all without removing a medical staff person from the site of care.

The blog does not clearly state the “level of care” the parents were referring to. Was the use of the CCLS or the whole experience in the ED? To me, anyone viewing the picture would see that the child was distracted and doing ok with the IV versus what the picture could have looked like if Child Life wasn’t present.

Is the real issue that the ED is used for things that might be addressed if everyone had a healthcare provider that they could access, rather than going to the ED for care?

Here is a helpful article entitled ‘Life Specialists’ Help Young Patients Cope With Illness, which appeared in the Washington Post (written by Kaiser Health News ),


Stacey Koenig, MS, CCLS | Senior Director

Child Life, Music Therapy, Volunteer Services,

Family Centered Care and Project RISE

Children's Mercy Hospitals and Clinics, Kansas City, MO

Lisa Sarao said...

As an ED nurse, I am a fan of Child Life! We nurses are often stretched thin to the point where we just don't have the time to sit down with a scared kiddo and ease them gently into ED procedures. I am now an Army nurse and we don't have Child Life, and I miss them! However, I find that if I explain what I am doing during the IV start (I call it the "magic straw" for the younger ones), they are usually okay with it.

I also find that we do a lot of teaching about Tylenol/Motrin and when a fever becomes something worth an ED visit. There does seem to be a lack of common sense.

Paul Levy said...

Many thanks to you all for your perspectives. Really helpful all around!

(Keep 'em coming!)

Thomas said...

I think your description of the episode is misleading. I doubt the CLS was constantly hovering over this one child, but was instead attending to other children in what was likely a busy ED and hospital. You should also be aware (and I am surprised you are not) that CLSs are highly valued by large pediatric providers and most parents. Additionally, I believe at least some CL departments are independently funded through philanthropy. That is they are not paid through patient revenue.

The Cereal Killer said...

There's one thing missing from this episode in particulear and from modern medicine in general: Common sense.

It's been largely replaced with defensive medicine--and the endless, and flyspeckingly exacting, rules, regulations and regulations that define modern medicine.

Anonymous said...

As an ER Doc I second the benefit of child life having worked with and without them. As far as the care recieved being questioned as excessive there is not enough info to determine that. As is the case all to often in the fish bowl of the ER the degree of hindsight on every decision made is certainly on display with these comments. If the ultimate diagnosis is benign then you did to much. God forbid you miss something because then you did to little and then hold on for the ride of complaints and administration among others throwing you under the proverbial bus. Is it too difficult to believe that these providers in the ER cared about this patient and provided care to this patient to the best of there ability.
Just a lowly ER docs opinion.
Oh, the comment about someone trying to comfort your child while they are going through this is intrusive. Really? Most parents are pretty stressed out and appreciate the help with calming/distracting the child. Guess you can't please all the people all of the time.

Barbara said...

This is an example of over-use in a hospital and of an emergency room. The emergency room was used in lieu of the child’s primary care physician. And re: the “Child Life Specialist”, a child’s mom can allay fears just as well or better than a “child life specialist” and at much less expense.

I am perplexed as to why the urgent care center cannot write prescriptions and send patients to the local pharmacy to have them filled. To dispense meds, they must have a license. It sounds as though they do not care to be a full service urgent care center and are contributing to the overuse and unnecessary use of our overburdened emergency rooms.

Not enough facts are given and other than the 102 temp, the accompanying symptoms/c/o are unknown. Does the 10 year old have a pediatrician or a family practice primary care physician? If so, did the parents try to get an appointment with the child’s doctor? If the doctor did not have a “sick” appointment available, I can understand going to the urgent care center. Or, do they use the urgent care center for their care? If they do, I would strongly encourage the parents to establish a relationship with a primary care physician for their child.

Not a sermon, just my thoughts.

Paul Levy said...

The family doctor did not have an open appointment.

Anonymous said...

There is a lot of certainty about the clinical situation in many of the above comments that is really not available to the clinician who carefully reads your post.

In fact, while defensive medicine is one explanation, the more likely Occam's Razor here is that
1. The pediatrician thought that features of the story didn't sound like a typical 102 fever with nothing else wrong, but instead, had some worrying element that could represent an atypical and dangerous problem.

2. The urgent care clinician agreed that this was not obviously a benign fever, and referred to the ED.

3. The ED agreed with both assessments! because they put in an IV--perhaps, for instance, to give IV antibiotics as a first dose before discharging, which is a common and sensible practice in treating threatening bacterial infections among people soon to become outpatients again. (We surmise, at least, that the IV went in after some assessment--because it didn't happen when the kid rolled in the door with some story about a fever.)

There is a lot of retrospective self-righteousness in the posts above about how this is an overuse of care, but
a) you can't know that on a policy level until you know the denominator of kids who presented with 102 fevers and did not get this sequence of events; and
b) clinically you can't know that in advance about someone who has any indicator of early bacteremia. This is a situation where you just have to have a higher sensitivity than specificity because you can not afford to be wrong. Unlike adults, kids often don't look especially sick until they are really dangerously sick. (Relatedly: For the commenter above--really? Are we going to wait until the kid is too lethargic to react to an IV before we get antibiotics into him? Ummm... no. Wrong answer.)

It's a common reaction among patients and parents of patients, once everything turns out OK, to say, why did everyone spend all that money/time/fuss? Everything was fine!

That's nice. It's a way of telling ones' self in retrospect that it wasn't really a scary situation. That's a nice way of remembering the story.

But that reaction doesn't amount to good health policy. Working hard to save kids' lives can cost a fair amount, and still, the economic opportunity is massive and worth an investment. You can save 10 85 year olds' lives and still not get as much QALY, economic benefit, etc, etc, as you get saving one 10 year old's life. Yet as a society we invest in the former much more than the latter.

Speaking of which, ultimately, if only the drivers of healthcare costs in America were child life specialists and social work resources!!!! Wouldn't that be a wonderful problem!?

I can also see that many of your commenters have never had to hold a screaming child down in the ED while someone tries to get an IV in, an experience that many of us adult MDs will count as among our worst of medical school. Nor have many of them apparently been putting in IVs when a patient suddenly got startled or hurt, yanked their arm away, and sent a blood-filled needle flying, for instance, into the nurse's finger.

This isn't Mary Poppins giving a spoonful of sugar. But, honestly, if every peds hospital had 100 Mary Poppinses working for them, it would still be a tiny drop in the bucket compared to the costs that older people impose on the system.

Anonymous said...

I should add to the lengthy post I just submitted: the medications that can't be disbursed in an urgent care center are IV meds. Otherwise, yes, they can prescribe (that's why they're often set up next to pharmacies!) and are glad to--in fact, on a business level, practically exist in order to do so, and can't operate without a prescriber doing the assessing. So, again, Occam's Razor, someone at the urgent care center thought the kid needed an IV, and again, apparently someone at the ED agreed.

Linda Galindo said...

A child with a 102 degree fever is sick and needs to see a provider and the urgent care center did not have the necessary and qualified personnel to do that? There is either something missing from this story - like the parent had been treating the fever for days with no success or the staff that turned the child away and sent them to the ER were not doing their job.

As far as taking the extra steps to entertain, reassure, or distract the child while in the ER, I would be surprised if the additional cost to the ER bill was significant if even outlined and charged for in the bill.

The focus needs to be on the care decisions that were made and the story lacks enough information to judge that. I will say that I'd want to know what my urgent care doesn't do, i.e. pediatric fever over 101? so I don't waste vital time by going straight to the ER!

Anonymous said...

Child life specialists (CLSs) are professionals with extensive training in child development and family systems, whose role is to focus on the psychosocial wellbeing of children and families in hospital and health care settings. They help to promote effective coping through play, preparation, education, and self-expression activities. The provision of child life services in pediatric hospital settings is widely considered best practice, with benefits that have been recognized by leading authorities, including the American Academy of Pediatrics, which in 2012 reaffirmed that child life services should be considered “essential,” and a “quality benchmark of an integrated child health delivery system.” (see http://pediatrics.aappublications.org/content/118/4/1757.full).

Child life specialists provide normalizing as well as calming activities throughout appointments and admissions, assessing any fears and identifying the child’s interests or preferences, which might prove helpful during the course of a hospital visit. These interventions typically result in enhanced cooperation, which lead to cost-savings by reducing the need for additional medications or sedatives during diagnostic testing, and allowing other members of the medical team to complete procedures quickly and see more patients.

In the scenario outlined above, the child life specialist shielding the patient’s view of the IV placement would have assessed the child’s emotional state and may have determined that the patient would cope much more effectively by knowing what was occurring during the procedure, but not watching as it happened. The length of the child life specialist’s visit in this example is unusual; in most instances, child life specialists have to triage and provide services where they are most needed, so the family was very fortunate to have received such focused attention during their visit.

It is important to note that funding for child life services is often absorbed by hospital overhead costs, in addition to grant and donor funding. Most child life specialists do not bill for their specific services, and services are generally not reimbursable by insurance companies.

Results of patient surveys have consistently demonstrated that child life services bolster children’s morale during hospitalization and heighten customer satisfaction, though there is an acknowledged need for additional research demonstrating the effectiveness and economic benefit of their work. In response, the Child Life Council (CLC) has facilitated the implementation of multi-year, grant-funded, research on “The Effectiveness of the Modality of Play for Hospitalized Children.”

CLC is an international non-profit association that provides child life specialists with professional development programs, resources, networking opportunities and information on best practices in the field. More information is available at www.childlife.org.

Rick Majzun said...

Paul, as a leader of a pediatric hospital and huge fan of your blog, I thought you might find the attached article interesting. I wrote it after spending a year working in St. Louis Children's Hospital (the first 15 years of my career had been largely on the adult side.) I can tell you that our clinicians and parents tell us child life specialists are not a nice to have, but a clinical necessity, a fact I agree with 100%.

I also asked our manager of child life for her thoughts and share those below.

Have a great weekend -
"The parents, while greatly appreciative of the demeanor and expertise of the staff, were stunned at level of costs that would be required to deliver this kind of care. They were perplexed as to why their son needed it."
It seems from the story that diagnostic tests were done which is far more costly that the hourly wage of a Child life specialist. Maybe they are confused by the high costs of the whole experience? I assure you that it is not the child life specialists that drove the costs up of a visit to the EU.

If they are perplexed to why a patient would benefit from the services of a child life specialist then..this is an easy answer. If you look at the picture that is included in this article it is clear that the child is laying calmly while an IV is either being placed or removed from the arm. I don't see any staff having to physically hold the child down or use medication to complete a medical procedure. What is not included in the article is that the child life specialist prepares the child for procedures and actually saves the family money when procedures can be done without the use of other drugs. (such as sedations)

Also there is the well being of the child to be considered. There is considerable research about children experiencing post traumatic stress brought on by medical procedures that they PERCEIVE to be threatening. To reduce the stress and anxiety of patients and increase understanding of procedures is a main focus of a Child LIfe Specialist. This child is obviously relaxed. This is the best outcome for the patient.

I shadowed the CCLS in our EU recently and a family brought their 9 year old son into our EU because he fell and needed stitches. Their reaction was totally different than what this article describes. Their statement was, "We are so glad that we brought him here because the CCLS made it so easy, now he won't be afraid to come back to a hospital".

So children's hospital's that are concerned about high quality services to their patients find that Child life specialist are essential to the clinical teams, invaluable to the patients and worth their (meager) pay.

Paul Levy said...

Note, Rick's article is called "Sometimes children are the best teachers" and is in the journal Healthcare Executive. I was unable to find a link but will keep trying.

Paul Levy said...

Here's the link: http://www.medscape.com/viewarticle/748740

Martin said...

This sounds excellent.

In the UK we call these practitioners play therapists and their role is much broader than just helping children to cope with painful, unpleasant experiences.

It is great that the little boy didn't need to stay in hospital. But what if he had needed more tests - say an MR scan. And what if he had been so scared by the needle stick that he couldn't lie still without an anaesthetic. How much would that cost?

In smaller UK hospitals you might be as likely to find a doctor doing the cannula / needle stick assisted by a nurse. Which is more expensive? A doctor and a nurse, or a nurse and a child life specialist. If the hospital has enough paediatric throughput then it makes perfect economic sense.

Finally, and to my mind most importantly. The little boy didn't go through unnecessary distress when he was feeling unwell.