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Discussion

ER Abuse

The subject of ER abuse is a frequent subject around here. As I said in another thread, I believe the term is misguided. It focuses on the beneficiaries of the system, rather than the system itself.

When Cash for Clunkers cam out, I didn't look at whether the program was a good ides, based on financially sound principles. I looked at how it affected me personally. I was eligible, it worked well for me, and I took advantage of it.

Using the ER for minor complaints and primary care is a huge waste of money, and harms those that need it most. Blaming the people who use it, rather than the structure, is pointless.

Yesterday at work, I had two cases of what I consider true ER abuse.

1- 80 y/o female from a nursing home finishing a3 day course of Bactrim for a known UTI with continued UTI symptoms.

Three choices for the NH:

  • Change ABX, or continue the current course. What the hell else do you think might be causing this right flank pain?
  • Actually dip the urine. This will cost about thirty five cents.
  • Put patient in an ambulance and send her to the ER.

Guess what they chose.

2- A 60 year old woman scheduled to start dialysis. The nephrologist had not seen her for a while, and wanted her medically cleared for dialysis. That's right, her doctor wanted her seen by a doctor. Nephrology office told her to be seen by her PCP, who was unavailable, so she made an appointment with a mid-level in her PCP office. She was told by her nephrology office that this would be unacceptable, and that she should go to the ER to be seen by a doctor.

ER abuse is common. Doctors frequently dump their patients on the ER for reasons of finance and convenience.

Another point:

People frequently associate inappropriate use of the ER with insurance status: I believe this is wrong, and distracting.

When it comes to minor and chronic complaints, the choice of using the ER is based on the actual cost to the user.

People who tend to use the ER for minor and chronic complaints:

  • Uninsured who won't, or can't, pay their bill.
  • Insured who have no co-pay. These tend to be government sponsored insurance plans.

Since their options are identical in price, they will take the most convenient choice.

People who don't use the ER for minor and chronic complaints:

  • Uninsured who will actually be paying their bill.
  • Insured who have a significant co-pay.

Since there are financial ramifications to the decision, these people carefully weight the cost/benefit ratio of going to the ER.

These choices are made based on simple economics, not loftier questions of right and wrong. The only way to change the behavior is to change the economics.

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    You got it!

    :yeah:

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    Re: the patient from the nursing home: I have been on the sending side of this one and believe me it is NOT what I wanted to do. In my case it was an afebrile COPDer with acceptable sats but wheezes bilaterally. I called the MD to request an order for nebs. After 15 minutes of trying to "reason" with the MD (VS ok, sats OK, NH prefers to treat inhouse if at all possible because they have to pay for ER visit) no budging on part of the MD --- SEND TO ER! End of discussion. :rolleyes::nuke:

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    Yesterday at work, I had two cases of what I consider true ER abuse.

    1- 80 y/o female from a nursing home finishing a3 day course of Bactrim for a known UTI with continued UTI symptoms.

    Three choices for the NH:

    • Change ABX, or continue the current course. What the hell else do you think might be causing this right flank pain?
    • Actually dip the urine. This will cost about thirty five cents.
    • Put patient in an ambulance and send her to the ER.

    Guess what they chose.

    THEY didn't choose that. The provider did. Take it up with him/her.

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    How did they dx a UTI without a UA/C&S to begin with?

    I am working with a patient right now who has a family that demands that we send her out for every little glitch. Doesn't help that she is a histrionic personality to begin with. Sometimes I am soooo embarrassed to call and give report, because what I really want to say is that I am sending a patient over to your ER for no particular reason other than that the family will sue us if we don't.

    If I get a chance at time of transfer I usually try to convey that to the EMTs. So embarrassing.

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    We frequently have patients who are frequent fliers at my hospital. Pain med seekers often hospital hop. We have a problem with nursing homes sending us patients they simply do not want to have there anymore. We had one patient get sent to us for something that was common with their disease. When the ER cleared them, the nursing home refused to take them back (seriously, took about 4 hours to eval him and for the ER docs to state it was pointless for him to have even came to the ER-they ended up getting admitted because they had nowhere else to go. Wasting tax payers money). That should be illegal. Another patient was admitted for AMS- not sure how they presented in the ER, but by the time they got to my floor, they were exactly the same as they were 3 weeks ago when they were admitted for the exact same thing. Turns out, it was a new nurse who sent the patient in both times because she was not familiar with dementia patients and did not know they could have a 'baseline'? (according to the nursing home via the CM). Just a few examples.

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    We frequently have patients who are frequent fliers at my hospital. Pain med seekers often hospital hop. We have a problem with nursing homes sending us patients they simply do not want to have there anymore. We had one patient get sent to us for something that was common with their disease. When the ER cleared them, the nursing home refused to take them back (seriously, took about 4 hours to eval him and for the ER docs to state it was pointless for him to have even came to the ER-they ended up getting admitted because they had nowhere else to go. Wasting tax payers money). That should be illegal. Another patient was admitted for AMS- not sure how they presented in the ER, but by the time they got to my floor, they were exactly the same as they were 3 weeks ago when they were admitted for the exact same thing. Turns out, it was a new nurse who sent the patient in both times because she was not familiar with dementia patients and did not know they could have a 'baseline'? (according to the nursing home via the CM). Just a few examples.

    It IS illegal. They are not allowed to refuse to take back a medically stable patient. If they no longer want to have the patient stay with them, it is THEIR responsibility to find an alternative.

    You threaten to call the state ombudsman and HHS, and report this. Then you ask for the administrator of the SNF, or ALF, or AFH.

    If they are medically cleared, they are allowed to return to what is, for all intents and purposes, their "home".

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    My micro teacher who was an ER doc for over 30 years told us that he had no problem with the people who came in for non-emergent cases, because those paid for the people who came in for expensive procedures/problems or those who did not pay their bill. I thought that was an interesting view point.

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    I like the focus of this thread---instead of blaming the victims of our healthcare "system", we're pointing a finger at the actual perpetrators which created them in the first place.

    We are all familiar with the stereotypical chain-smoking, cell-phone-using, Coach-purse-carrying Medicaid patient who comes to the ER at 0200 complaining of cold symptoms. While there's no denying the fact that they do exist---understandably infuriating Americans who pay taxes, yet can't afford to go to the doctor when THEY'RE sick---a lot of the problem is that the system has broken down, and the ER is the last refuge for the mentally ill, the demented, the addicted, the dysfunctional, the homeless.

    Really, where else are people supposed to go now?

    1) The mental health system in this country is a joke; the majority of services have ceased to exist, and they are not coming back anytime soon.

    2) Neither are the low-cost options for addictions treatment; at the high end you have your Serenity Lanes, which are out of reach of the average consumer, and at the other you have AA/NA and....nothing.

    3) Then you have otherwise decent but desperate people with elderly family members they cannot care for at home, so they bring Grandma to the ER for nursing-home placement because they're at their wits' end, and they either don't have the time or don't know how to navigate the maze of elder-care options. Heck, I've been in elder care for most of my career and I can't figure out half the time which insurance will pay for what or why they'll pay for it one month and not the next.

    4) Long-term care patients get sent to the ER for many reasons, most of which could be much more easily (and cheaply) addressed by their primary care provider, AT HOME. Trouble is, geriatric patients are neither glamorous, nor lucrative for physicians; I can't tell you how many doctors I've had to threaten with turning them into the medical board for neglecting the state-mandated 90-day visit....these guys are sure not going to stop by on their way home and see the resident after office hours! That leaves us with two options at night and on weekends: a) call the on-call and hope s/he will give us a telephone order, or b) send the resident to the ER.

    5) Dysfunctional families, e.g. domestic abuse victims and their children, tend to wind up in the ER as well because there just aren't enough resources to go around. Government-funded social services dried up in the 1980s and 1990s, and given the poor economy and the mood of the taxpayers, are not going to be re-infused anytime in the foreseeable future. Now, it's mostly up to churches and charities to take care of these unfortunate souls; and while that's not necessarily a bad thing, it's going to take time for these organizations to build themselves up enough to provide for so many needs. The recession hit us hard, too; giving is still down, and some of us are having trouble keeping the lights on. Hence, ER abuse will continue.

    The person or group that can come up with a fix for all of these ills will probably not only win the Nobel Peace Prize, but surely will be guaranteed a spot in Heaven. My take is to hope for the best, but prepare for the worst......and in the meantime, learn to make do with what we have. And if all we have is the ER, well......just think of the job security!

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    Ugh, don't even start with the nursing homes. Don't you know how HARD some of us try to treat the pt in house? If I call the doctor for anything, ANYTHING, they are going straight to the ER, no way around it.

    Seriously, it's embarassing to get person after person back with "UTI & Dehydration".

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    Our LTC has standing orders that if UTI suspected we test in house. Then send for C & S. We let docs know what we have in house that will work. Sending to ER is usually last resort for us unless we have the family that threatens if we don't send for every little thing. We are blessed with docs working really well with us.

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    I have been on the sending side myself in a nursing home. After hours you get an oncall that doesn't want to deal with a sick patient. "I don't know them so send him in "I have heard this alot and believe me sending someone to the ER is not my favorite thing to do.

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    I have been on the sending side myself in a nursing home. After hours you get an oncall that doesn't want to deal with a sick patient. "I don't know them so send him in "I have heard this alot and believe me sending someone to the ER is not my favorite thing to do.

    And don't you just love it when the paramedics give you attitude, like the ER nurse you just called report to while you were waiting for them? Some of them treat us like they think we're stupid, when we're only doing our jobs. And sometimes they even fight with us over taking them to the hospital.....like THEY'RE the ones who won't get paid if the resident's insurance doesn't cover the trip, or if s/he is on Medicaid.:devil: That REALLY chaps my hide.:devil::mad::down:

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