If you hear the words “emergency room,” what leaps
to mind is likely to include flashing lights, stretcher-filled
corridors and waiting rooms teeming with patients. Unfortunately,
this image conjured from prime time television isn’t far
from the truth for emergency rooms (ERs) across America. Overcrowding
of ERs is a concern for policy makers, insurers and hospital administrators,
and reducing the use of the ER for non-urgent purposes is a widely
accepted first step to relieving the burden.
Overutilization of ERs is a growing concern for hospitals
across the country.
Research suggests that
ER use for ailments that could have been treated by a primary care
physician is greatest among low income
families receiving Medicaid benefits. With this in mind, Austin’s
Seton Healthcare Network commissioned its Out of the Emergency
Room study in 2002 to understand what drives a parent’s health
care decisions and why so many parents bring their children to
the ER. When the study uncovered the need for greater outreach
and education among Texas families, Seton was left asking, “How
can we best inform parents of the appropriate use of the ER?”
is just the kind of question that gets folks at The University
of Texas at Austin’s Intellectual Entrepreneurship (IE) program
excited. IE seeks to harness and integrate the intellectual energy
and talent of graduate students in bringing about innovation and
change, inside and outside the university.
“One of our primary questions is, ‘How do you create
collaborations between people in the community and people in the
work on issues that are important to both of them?’” explains
IE’s Dr. Tommy Darwin. “What does that model look like?”
created a collaboration between university students and Seton to
start building that model. During the fall 2002 and the spring
2003 semesters, students in two different classes worked directly
with Seton Healthcare Network administrators on ER overuse issues.
In the fall, a health communication class taught by Dr. Rajiv Rimal
the College of Communication worked to uncover the various perspectives
affecting the issue. In the spring, Dr. Nell Gottleib’s kinesiology
class on intervention mapping looked at specific interventions
to keep patients out of the ER.
In May, a group of students presented
Seton with their detailed findings and recommendations. They pointed
out that even the common
term “overutilization” is a complicated one because
it is dependent on perspective. What constitutes overuse for the
hospital is different from what constitutes overuse for the individual
They also offered Seton specific strategies for educating
its constituents at all levels. These included posters, pamphlets,
videos in Spanish
and English for hospital waiting rooms and an innovative care kit
to be given to parents.
For Sister Helen Brewer, an advocate for
in Seton’s Government Relations office, the collaboration
established a relationship that can benefit both parties.
“Our experience is at the immediate point of health care,” she
says, “and it’s beneficial for us to connect with the
university and its capacity to probe and uncover and look at the
issues in a different way. The university can back up from the
problems. The two institutions together can connect to better improve
health care for the people of Texas.”
Graduate students created posters and other materials
to help Seton educate its constituents about appropriate
For university students,
the project offered a chance to see knowledge being applied in
a way that might really make a difference. One
of IE’s mottoes is “I know, therefore I must act.” Class
work may proffer knowledge, but often that knowledge is only put
to use after the class is over and the degree is completed. The
IE idea is that all the knowledge and expertise in the university
can be put to use now for the benefit of the student and the community.
“One of the main things the project offered me was to take
a real life problem and apply research to it,” says Jules
Woolf, a Ph.D. student in kinesiology who worked on the Seton project
in both classes. “You’re actually out there looking
at a real problem and trying to find ways to realistically change
that problem for the better. The representatives from Seton are
very motivated to see a change, so you feel that what you’re
doing is going to make a difference. It was more than just getting
a grade A.”
All IE initiatives ask students to look beyond
grades and beyond schoolwork to envision their education in broader
terms. IE asks
students, “What really matters to you?” and then offers
them the chance to pursue the answer. Since its inception in 1997,
IE has been considered one of the most innovative programs in the
country for expanding the definition of graduate education.
More than 3,000 students in 90 academic disciplines have benefited
from IE offerings. In addition to 18 graduate-level classes and
9 Doctoral and Master’s Portfolio Programs, IE initiatives include
the Graduate Writing Project, Ethics Project and Citizen-Scholars
Series. Through IE, students have undertaken ventures as various
as initiating arts incubators to pursuing curriculum reform.
To relieve the burden on ERs, change must happen on several
“Fundamentally, the goal of the IE program is to foster
greater collaboration, teamwork and collective ownership of issues
problems among those inside and outside of the academy who have
the requisite expertise, experiences and motivation,” says
Dr. Rick Cherwitz, IE director and associate dean of graduate studies.
Seton collaboration illustrates this perfectly. ER use is a complex
issue. The players involved range from the individual mother
unsure of how to deal with a feverish child to policymakers in
the Legislature. Thus, change is slow to happen, and the obstacles
to change are many.
Students in Rimal’s health communication
class discovered that even commonly held definitions are slippery.
students—a mix of undergraduate and graduate students who
mentored the undergrads—delved more deeply into the data
in the Out of the Emergency Room study.
“The eye-opener for us was that overutilization depends
on whose meaning we are taking into account: the providers or the
From the hospital’s perspective, use of the ER for non-emergency
reasons leads to overuse. But Rimal’s class found that wasn’t
the perspective of those who come to the ER.
“On average a family with two kids in the home was visiting
the ER about once every six months. That seems normal to them,” Rimal
says. “It’s hard to make a case and convince mothers
not to do this if on average they are only going about twice a
His class also did an assessment of other resources
in the community and found that there were few after-hours resources
families. Clinics were closed, and nurse triage lines—where
trained triage nurses answer questions over the telephone—had
very limited availability. Thus, a parent who is uninformed about
his or her child’s illness and fearful may feel the ER is
the only option.
“Among other things,” says Rimal, “the project
gave students the opportunity to engage themselves in an activity
involved other institutions, all these venues in the community.
And I think they got a better sense of what it means to not have
insurance in Austin and raise a family.”
spring intervention mapping class built on what Rimal’s class
had accomplished. Students from departments across the university
worked in small groups to approach the problem
at four levels: that of the individual parent, the primary care
physician, the ER provider and the policy maker. At each level,
they learned the process of intervention mapping in a more hands-on
way than they could have without the Seton project to focus on.
The patient care kit prototype provides information and
medication for the illnesses that most frequently bring
families to the ER.
“As a tool, intervention mapping makes you think through
every little aspect of your program. It can be applied to any type
of setting,” says
Amy Gottlieb, a Ph.D. student who worked on the program at the
policy level. “Working with a project so specifically was
empowering. It made you want to go out and do more projects and
be more involved.”
Among the many recommendations students
provided Seton was the creation of an innovative care kit. They
recognized that the ER
is seen as a one-stop cure all. If your child is sick, you take
him or her to the ER. An obvious step in intervention is positioning
something between the onset of the illness and the ER visit. Possible
interventions are clinics, nurse triage lines and primary care
physicians. Another is the care kit.
“We came up with a specific kit for the three major reasons
mothers take their kids to the ER for non-emergency reasons,” Woolf
explains. “We were trying to make a product that wasn’t
going to be thrown aside and wouldn’t be difficult to understand.”
care kit prototype has three individual compartments for each illness:
fever, vomiting and diarrhea. When the lid is opened,
instructions for each illness are on the inside with a breakdown
of what to look for and what to do. The corresponding equipment
and medicine are inside the kit. It meets a parent’s need
for information and provides tools that will in many cases help
a sick child without burdening the ER. Seeking assistance from
pharmaceutical companies is a next step in creating the care kit.
meeting with university students in May, Sister Helen and Ed Berger,
vice president for advocacy and public policy, left
with an abundance of possibilities to bring back to Seton. They
expect that many offer areas for development and expansion. And
they hope to continue the collaboration with the university into
“They have given us a great deal of assistance in advancing
a solution for what is really a critical crisis experience for
the hospital,” says