Does the ED stand for Emergency Department or the Everything Dumpster?

[whichone'spink]

Why, why, why does it seem like we are the dumping ground for the whole medical community? From primary care providers offices, to nursing homes, to the urgent care it just seems like no one wants to be accountable for taking care of patients, so they dump patients in the ED. It's just very frustrating. It's even going to the extreme where nursing homes are sending dying patients by the transport van, instead of by ambulance. Just a couple of days ago, I had a patient that was sent over to the ED from a local nursing home by a local transport service, for altered mental status. Now why was the patient having altered mental status? Because the patient was in third degree heart block. When this patient was hooked up to the cardiac monitor, it showed that the patient's heart rate was nearly asystole. Now why this nursing home chose to send this patient by a transport van instead of by ambulance is beyond me. What if this patient died while in the transport van? The drivers are not even trained in CPR. And apparently this nursing home has sent very sick patients by transport van many times before. This is just a rant, with no particular focus at all. Just frustration with how the medical establishment sees the emergency department as a dumping ground.

[canoehead, BSN, RN]

Or you could just not use the word. You obviously know that some would birth a bovine by its use, yet your comment was really sooooo important to be offensive anyway?

Darn it, I needed an R word that expressed my feelings. Just replying to this post brings all those feelings back...sigh.

[Esme12, ASN, BSN, RN]

I have been a nurse for a long time. I have worked in the Emergency Room a long time. The last few years......I have become curious as to why the definition of what an emergency department does or does not do has been re-defined. ED's have always been the safety net...the one's open when all else is closed.

I worked in the days before EMTALA and COBRA. I remember hospitals sending patients to other facilities based on the ability to pay. I remember patients coding in the back of ambulances because they were turned away based on ability to lay to pay until a hospital that would take them answered the radio. It wasn't pretty.

Why not treat a dental abscess with antibiotics? I get no narcs.... but antibiotics?

If there were more dentists that kept better hours sure send them there...but they don't AND they won't see you if you don't have cash up front or insurance...so the solution is let them suffer until they need IV antibiotics and can be charged more for revisits. You don't write prescription for HTN so it's best to let them go without because it's not emergent enough until they stroke? Many don't have the up front cash to make the appointment with their PCP. Where do we tell these people to go? So only those who have insurance deserve treatment....I disagree.

While I agree there is a misuse of emergency Departments......like teen girl wanting a "pee test" to see if they are pregnant.....an ambulance ride a hang nail.....cure the abuse of the system. Many who do call their PCP's get the go to the ED line...so when they show up in the ED and the expectation that they were sent there....who's fault is that the trusting patient? or the lazy PCP? To VICEDRN.......I am curious.....Who is doing the MSE at your facility?

I'm all about efficiency but.....Do not punish the vulnerable.

If we are deciding that they don't need the emergency room with an abscessed tooth...where do we send them? Where do these people go when you decide they aren't sick enough to be seen? That they stroke in the parking lot. This all sounds good as well.....until something is missed and you (the collective you) is sued. Someone needs to care for those who slip through the cracks.

Many times the cluster of LTC patients coming at once is because these patients have been sick and the MD just now has made their weekly/monthly rounds...these old people (amongst the most vulnerable of our society) who deserve respect and care are just an annoyance to the ED staff. They actually needed to come days ago.....but the MD just came in now....so they are sent out.....the ED staff is NOT happy...and it shows. That bothers me....A LOT.

I'm all for cutting waste....but not at the cost of good care. I signed up to be a nurse first...the ED just happens to be my area of expertise. I do believe the system is broken and I'm not so sure how to fix it. But I do believe the most vulnerable need our protection and care. It's a complex problem.

[sapphire18]

I'd just like to give a round of applause to ESME! I could not agree more- with every single thing you said.

[morte, LPN, LVN]

I work LTC. I have a fairly good % of admits to send outs. One that wasn't admitted shouldn't have been sent, but covering doc wouldn't order in house xray. What was i supposed to do? Having worked as a clerk in an ED, I have a clue. Have mentioned to family on a few occasions, "do you want them in the ED for hours, for very little gain, in the middle of the noc".

[billyboblewis]

I have been a nurse for many years and have worked in emergency. It is not my job to determine whether or not a patient should seek this level of care. I make my assesment and listen to the doctor. Some days I am bummed out and other days are great. This is not the patients problem. I know from personal experience that er employee prejudice can cause serious illness to go untreated. If you are not interested in treating people with problems you dont recognize or care to treat perhaps you should try working in a surgical hospital without er facilities. Everyone is admitted for surgery and nothing else.

[Nascar nurse, ASN, RN]

Standing ovation to Esme!

[tewdles, RN]

Yay Esme!

[LiliaBSN]

This thread has hit on a lot of topics from both sides. I have worked both LTC and ER, and I can say Esme is correct. Those who come to us sent from PCP's and LTC's are sent because even if you do call your doc in the middle of the night, they don't have the resources to treat a patient over the phone. What I can vouch for is that even though we might vent amongst ourselves, we don't treat patients differently based on why they are in the ED. That being said, we have had an instance of a patient being transported to the ED for possible sepsis from pan-resistant psuedamonas, and when we ruled out sepsis, the LTC refuse take him back. Granted, he was on his 10th LTC in two years and had a behavioral contract a mile long, but that is a massive EMTALA violation. There wasn't an accepting physician to assume care so we ended up having to admit this patient for nothing. This is a very rare instance, but ED "dumping" does occur. But other specialties do it too, and thankfully, at least in our facility, it isn't prevalent.

[Lunah, MSN, RN]

That being said, we have had an instance of a patient being transported to the ED for possible sepsis from pan-resistant psuedamonas, and when we ruled out sepsis, the LTC refuse take him back. Granted, he was on his 10th LTC in two years and had a behavioral contract a mile long, but that is a massive EMTALA violation.

I've seen something similar -- trying to return a resident to an LTC facility only to be informed that they'd given his bed away. !!!! Good grief, he wasn't in our ED quite THAT long! It was messy, but we returned him. I've only seen that once, though.

Esme rocks my socks.

[VICEDRN, BSN, RN]

Why not treat a dental abscess with antibiotics? I get no narcs.... but antibiotics? If there were more dentists that kept better hours sure send them there...but they don't AND they won't see you if you don't have cash up front or insurance...so the solution is let them suffer until they need IV antibiotics and can be charged more for revisits. You don't write prescription for HTn

While I agree there is a misuse of emergency Departments......like teen girl wanting a "pee test" to see if they are pregnant.....an ambulance ride a hang nail.....cure the abuse of the system. Many who do call their PCP's get the go to the ED line...so when they show up in the ED and the expectation that they were sent there....who's fault is that the trusting patient? or the lazy PCP? To VICEDRN.......I am curious.....Who is doing the MSE at your facility? I'm all about efficiency but.....Do not punish the vulnerable.If we are deciding that they don't need the emergency room with an abscessed tooth...where do we send them? Where do these people go when you decide they aren't sick enough to be seen? That they stroke in the parking But I do believe the most vulnerable need our protection and care. It's a complex problem.

It is a complex problem, Esme. I think you overlook the complexities on the other side of the equation. At what point does the patient cross over from an er patient and become one of our primary care patients? If he or she gets two or three refills from us for htn meds, do they not simply continue to come into the er for primary care? Is this the right choice for the patient? No. Is it cost effective or viable for everyone involved? No.

In my first year as a nurse, a woman with a full time job, skinny non smoker and a history of hypertension stroked to death in her forties. I cry every time I think of her. I remember holding her sobbing son in my arms and I see them both in my dreams.

I wish the patient had felt she could afford primary care. (She was penny pinching because her husband had been laid off)

If we keep giving out these medications in the er, we are part of the problem, not the solution. These folks will continue to come to the er and never get the primary care they deserve.

I have seen patients with dental abcesses bounce back three and four times over a year because they never addressed the tooth. I have seen a patient with a 20 year (20!) history of getting Vicodin for his back pain in the er and never following up in ortho for the surgery he obviously needs (the things you learn when the chart is scanned and instantly available!).

But we didn't just give up writing scripts, we found dental clinics that could handle sliding scale patients and we transport them there ourselves. We have a walk in clinic that's also sliding scale and we walk patients over there ourselves so they can be seen. We refer them to places they can get primary care on the cheap.

Continuing along the "better safe than sorry and here is your script path" is an old codependent habit that we must give up. We aren't primary care providers by training, the er is not a real solution to any problem and the patients need to find other solutions. No er doctor I know can fix a bad tooth and they profess to not understand the complexities of long term htn management like a PCp.

Mse is done by the nurse practitioners in triage. This is consistent with state laws.

[LadyFree28, BSN, LPN, RN]

I have been a nurse for a long time. I have worked in the Emergency Room a long time. The last few years......I have become curious as to why the definition of what an emergency department does or does not do has been re-defined. ED's have always been the safety net...the one's open when all else is closed.

I worked in the days before EMTALA and COBRA. I remember hospitals sending patients to other facilities based on the ability to pay. I remember patients coding in the back of ambulances because they were turned away based on ability to lay to pay until a hospital that would take them answered the radio. It wasn't pretty.

Why not treat a dental abscess with antibiotics? I get no narcs.... but antibiotics?

If there were more dentists that kept better hours sure send them there...but they don't AND they won't see you if you don't have cash up front or insurance...so the solution is let them suffer until they need IV antibiotics and can be charged more for revisits. You don't write prescription for HTN so it's best to let them go without because it's not emergent enough until they stroke? Many don't have the up front cash to make the appointment with their PCP. Where do we tell these people to go? So only those who have insurance deserve treatment....I disagree.

While I agree there is a misuse of emergency Departments......like teen girl wanting a "pee test" to see if they are pregnant.....an ambulance ride a hang nail.....cure the abuse of the system. Many who do call their PCP's get the go to the ED line...so when they show up in the ED and the expectation that they were sent there....who's fault is that the trusting patient? or the lazy PCP? To VICEDRN.......I am curious.....Who is doing the MSE at your facility?

I'm all about efficiency but.....Do not punish the vulnerable.

If we are deciding that they don't need the emergency room with an abscessed tooth...where do we send them? Where do these people go when you decide they aren't sick enough to be seen? That they stroke in the parking lot. This all sounds good as well.....until something is missed and you (the collective you) is sued. Someone needs to care for those who slip through the cracks.

Many times the cluster of LTC patients coming at once is because these patients have been sick and the MD just now has made their weekly/monthly rounds...these old people (amongst the most vulnerable of our society) who deserve respect and care are just an annoyance to the ED staff. They actually needed to come days ago.....but the MD just came in now....so they are sent out.....the ED staff is NOT happy...and it shows. That bothers me....A LOT.

I'm all for cutting waste....but not at the cost of good care. I signed up to be a nurse first...the ED just happens to be my area of expertise. I do believe the system is broken and I'm not so sure how to fix it. But I do believe the most vulnerable need our protection and care. It's a complex problem.

Whoop! Whoop! Esme's!!! :) :applause: