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?”

This 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 university to work on issues that are important to both of them?’” explains IE’s Dr. Tommy Darwin. “What does that model look like?”

IE 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 in 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 parent.

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 children’s issues 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 ER use.

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 levels.

“Fundamentally, the goal of the IE program is to foster greater collaboration, teamwork and collective ownership of issues and 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.

The 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. Rimal’s 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 utilizers,” Rimal says.

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 year.”

His class also did an assessment of other resources in the community and found that there were few after-hours resources for low-income 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 that 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.”

Gottlieb’s 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.”

The 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.

After 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 the future.

“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 Sister Helen.

Vivé Griffith

Photos: Marsha Miller