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.
Specializes in LTC, assisted living, med-surg, psych.
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. That REALLY chaps my hide.
We have a local nursing home with a locked dementia unit that sends at least two patients to the ER everyday for agitation...I'm not talking about severe, tie down and medicate agitation, I'm talking about they have a two minute period of increased agitation without violence, not even a need for PRN medication, and they still package them up and send them to the ED for an eval for increased agitation. We don't even work them up anymore, the ER doc gives them a once over and sends them right back. HELLO!!!
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. That REALLY chaps my hide.
And sometimes the nursing home folks would treat us paramedics like we're uneducated "ambulance drivers." Seems the whole healthcare world would benefit from a little kindness and understanding...
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
The system is broken and the system can't and won't get fixed while those entrusted to fix it don't use it........Dick Chaney and even Gabby Giffords use a separate health care payor and will never use medicare/medicaid/social security...in fact they don't even have to contribute to the system while they make their insider trading Wall street investment that they can't be prosecuted for off their salaries they will receive for the rest of their lives. Dick Chaney with his VAD and Gabby Giffords being flown to different states for the Best rehab are being given treatments that aren't available to you and I without serious debt if at all. I don't begrudge their ability for the best as I guess I could run for office....I do however resent the cuts in the system that supports our most vulnerable population....our elderly and handicapped.
I am disabled right now from a neuro-musclar disorder the make me unable walk. It is tough to try to navigate the system and I panic every time I hear the words "cut back"......how will I care for my kids, what will I do? I thought I had great financial planning....until I became ill. You have no idea how expensive it is and how little is paid and how fast the money disappears.....until you are in the throws of it all. I remain on a waiting list for an opening at the premier center that cares for my rare disorder (for almost a year now) and that was after sending all my records to them to see if they would take me. The reality bites.
I've worked hard my entire life serving others which means nothing now....
I guess it the survival of the richest....I mean the fittest. JMHO
"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. That REALLY chaps my hide"
If you think about it, Medicaid only reimburses pennies on the dollar....if you have a small community hospital ER with several NH contracts, then yes, you do run the risk of the employees not getting paid....because a hospital cannot survive on bogus repeat workups under Medicaid....
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.
We have those too... but if you have lazy nurses that don't want to do anything but hand out the pills... yep- then it goes unnoticed until they are COMPLETELY off the wall- or unresponsive. Yep.
Lynx25...I understand what you are saying. However, we do not have that problem. As RNs one of us is making rounds every hour. And it takes an hour to an hour and a half to talk to all residents. Time depends on activities going on and whether it is morning or afternoon. PT is in AM so not as many residents in their rooms. So as soon as one finishes the next is starting. Our LPNs are wonderful and catch things even quicker than us at times. They do work closer to the patient. Approx 26 residents per LPN. The RNs round entire facility. The CNAs let us or LPNs know if there is foul smelling urine. We are always watching for any mental status change. UA is first thing we do. It has to be serious before we send to ER. Most minor issues we handle in house. Docs work well with us and resident(docs in training) come to NH often. Often when I read the posts on here I realize our facility is not the norm but the exception. And I thank God daily for the facility I work in and the wonderful job He has provided for me. Our residents truly come first.
Specializes in Aged Care, Midwifery, Palliative Care.
Its common sense. I have used the ED a few times. 1. when eldest daughter has an uncontrolled asthma attack, and its an emergency... this has happened twice. 2. when youngest daughter had an anaphylactic reaction to erythomysin and 3. when I had a heart attack. We have always been triaged as a priority and rushed straight in... get some good filthy looks from those who have been waiting hours but thats not our problem. I put myself in their hands once I'm there and have absolutely no complaints about the staff or my experience.
I was especially impressed with the treatment I received when I had the M.I because I am a woman, in my early 40's and besides being a smoker (at the time, quit now) I was a low risk factor. ECG and Chest Xray were NAD and vitals including BP was within normal limits (BP 110/70). But troponin was elevated so they admitted me for a second test 12hrs later, which showed further elevation. They caught it and thank god didn't send me home.
My daughter is handicapped and recieves medicare. I haven't been able to find a doctor who will see her. Well, thats not true, if you include ones who shouldn't even be allowed to place a bandaide. Last year my dtr was hurt at school, fx her foot. You have no idea the inferior doctors you will find. I was shocked and very dismayed at the level of doctors that would see her. It was awful. We did resolve it, finally, but to go to the ER because you can't find compentent care elsewhere I believe is warrented.
I also work longterm care. I have 60 patients. If a resident becomes a 1:1 nurse care project, and it means I am not able to attend to the needs of my other residents, I call the doctor for help. Now, most assurdly there is no return call, but if I get an order to send someone out, you will not hear me complaining. I have no backup, so if I have to choose between a trach suctioning and keeping Mr. Crazypants from injuring his roomate, I have little choice.
Sometimes the hospitals dump on nursing homes as well. I suppose that comes as a surprise to some ER people. We get people who are unstable and need a higher level of care than we can supply given to us under false pretenses. The EMT's drop them off drugged out of their minds, and when it wears off, we have a nut and no orders to control them.
In reality, it is the system. Everyone is getting a bad attitude. There are just levels of care that each of us can handle. You in the ER get slammed with people who may not need to be there, and we get slammed with people who are above what we can properly care for. Neither case should be happening. Blame it on the politians.
To make matters worse, I was in the ER a couple of days ago. It was really late, everything was closed, and my leg gave out from under me, I couldn't stand on it. I didn'tn want narcs, just to make sure I didn't fx it. I was in the ER waiting room for 4 hours, and I understood I wasn't a priority. Last year I brought my son in hardly able to breath with pneumonia and they pushed right in, in front of other people. His need was urgent. Mine the other night was not. I expected the urgent to go in front of me.
However, as I looked out over the room, I saw a sea of people that were walking, talking, eating, laughing, and it wasn't possible to guesse what was wrong with them. I have to admit I was shocked. I had come in asking for the lower level part of the ER, and was refused, as I was too SICK. I felt really bad about being there at all, but that I couldn't even bear wt on my leg. Most of these people with the exception of maybe one or two weren't even sick enough to go to their doctor the next day.
I needed to take care of my leg in order to get back to work on a timely basis, these people were either looking for drugs, or to get a little company. As a nurse I could understand your viewpoint. However, my discharge was from a nurse who gave me cast care instuctions. I had no cast. When I told her that, she continued to tell me how to take care of my cast. When I asked her to show me, my cast, she said, oh you don'thave a cast. Then continued to tell me to call if the cast became to tight. I understood this was a little nutso, and I let her continue, as there was no stopping her. She told me to come back in if my toes turned grey and started to shrivel up. Good night. I did get good care, but my discharge instructions could have been given better by one of my CNA's.
So there are problems on both ends. There aren't any good answers are there?
In terms of nursing homes versus ED's, to solve the problem would be quite easy; except it would also be politically impossible. The simple solution is to merge hospitals with nursing homes. However, this creates a huge political minefield as owners (politically powerful) of nursing homes would then be denied the huge stream of medicare or medicaid dollars upon which they rely as a business.
For example, in New York state, IIRC, it is not legally possible for hospitals to participate in or bill for what is otherwise known as nursing home care. But, if you can imagine if a patient is indeed in a facility that can do the simple things of a nursing home, plus more complicated hospital things as a patient condition warrants, but without all the moving around and stops in the ED, it would save a tremendous amount of money and time. Further, both medical and nsg staff would know the patients a lot more intimately and provide greater fine tuned and appropriate care.
However, a nursing home owner will thus be driven out of business; he has some very powerful and connected friends to ensure that something like that would never ever come to pass.
I am not even going to comment on situation 1 (the NH pt). This is a can of worms, and someone is going to be mad with any answer that I give.
As for situation 2 (dialysis clearance)....that is ridiculous. What does the nephrologist think is going to be done in the ER to clear the pt? I will definitely be less of a workup than the midlevel does.
We have some PCPs around us that abuse the system. I understand sending in a pt at 10 pm on Friday evening. However, they send people in for non-emergencies (such as low back spasm after lifting something heavy) at 11 am on a Tuesday morning. That is an abuse of the system.
I have often thought that the system needs to include a high copay for certain ER visits (i.e. chronic low back pain with "lost" pain meds)--including for people with government coverage who otherwise have free ER visits. Then again, there will be someone who stays home because they can't pay the copay (or are afraid of paying it) when they are actually having an MI or their appendix is rupturing.
That REALLY chaps my hide.
Seems the whole healthcare world would benefit from a little kindness and understanding...
VivaLasViejas, ASN, RN
22 Articles; 9,996 Posts
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.
That REALLY chaps my hide.
