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 Med-Surg/Neuro/Oncology floor nursing..
This is one of the reasons why I miss working working at the hospital I used to. It was a small private hospital that specialized in cardiac surgery and cardiac care..it was also a full service hospital with the exception of labor and delivery services...unless you wanted to give birth in the ED(which did happened maybe 2 times I can remember). Nursing homes knew better than to send their patients to that hospital(unless they had a cardiac problem)...their were two hospitals down the road in each direction they could send the patients to.
Now I work in a huge hospital in the bright lights big city of Manhattan and I work the neurology/neurosurgery unit and oncology unit(usually two days neuro one day oncology a week). On the Neuro floor we get nursing home residents ALL THE TIME because they maybe got out of bed when they weren't supposed to and fell down and may have hit their head(maybe they didn't). They get sent to the ED by ambulance and usually bypass the more emergent walk in patients and their family or the facility usually demand a CT scan(which 9 out of the 10 times is perfectly clear)and observation overnight for a day or two. They just believe that the hospital is a hotel that they can just check their residents into. We have to eat the admission because the facility WILL NOT take the resident back until they've been observed for at least a night. Um hmmm is the facility staffed with police men to care for the residents? NO nurses are and the nurses are certainly capable of observing residents there...especially if they have clean CT scan.
Nope they become patients taking up space on the neuro unit(we are usually always full) and a poor neurosurgery patient has to spend the night in the PACU all because someone barely bumped their head and the family or facility DEMANDS that they come spend a night in out hotel I mean hospital. Its not just our unit either I have friends that work in all parts of the hospital and a med-surg bed is being taken up by a resident that coughed one too many times than they usually do or an ortho bed being taken up by a resident who's arm hurts(but not broken). I wish I was kidding or exaggerating but I am being dead serious.
We don't know what to do with these residents either except give them their medications they usually take and try to tame them. They are NOT happy to be in the hospital believe me. I've gotten cursed at, screamed at, assaulted, one man even spit at me. They miss their stuff, their routine has gotten disrupted, and they are in the hospital for basically no reason...they are also loud, disrupt their roommates and the whole floor. Not to mention the patients that REALLY need these beds, the patient that had a crani and is waiting on an uncomfortable stretcher in the pacu or the patient that has a fractured skull, or the patient who's brain is swollen. Not person that came from a nursing home, tapped their head has a clean CT and passed the neuro exam with flying colors.
Makes me glad I only have to work 3 days a week and get 4 days off..they might be long 12 hour days but they are totally worth it.
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. [color=sandybrown]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?
:lol2::omg just be glad she was not your nurse that night i fill sorry for who ever got her next
Wont go into a lot of details but last night I called my on call pa because I was in a lot of my and my pain pills ( morphine ) was not touching it . He told me my problem was beyond what he could handle and go to er !
I thought about it and I could just see what would happen
Me - " hi my morphine is not touching my pain can you please shot me up with your best "
I agree sometimes I get migraines so bad that I'm puking my guts out and they can last over 24 hours, but I haven't bothered going to the ER because of the ridiculous copay, knowing I'll be treated as a drug seeker and wait forever to be seen and then lucky if I get any medicine.
I do have pain meds, but when your nauseated and puking they are not much good. I have imitrex and take it on occasion but you can't take it often and you are limited to 9 pills a month and it is expensive! Also the risk of a CVA or MI from the imitrex makes me relunctant to take it. When I do sometimes it works, sometimes it doesn't and many times the HA comes back later anyway! I was given a new shot for migraines and I took that once and I thought I was going to die literally. First a terrible whole headache, then chest pain and throat squeezing and sob and the panic of wondering what was going to happen to me now that I had allowed myself to be a pharmaceutical guinea pig! Eventually it stopped and the HA left, but I'll never take that crap again!
So I just stay home with an ice pack and try to sleep it off!
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. omg! that's one of my eds! it's so bad i have to chart "pt instructed not to eat or drink until cleared by physician." because they will literally sit in the lobby and eat a pizza together (when i stop them they say "but i was starving!" after they come for abd pain n/v/d. nice.
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.
just plain unacceptable. i mean we've all made mistakes, been rushed, but to give such bad discharge instructions is a disgrace to the profession.
so there are problems on both ends. there aren't any good answers are there?
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.
Yup, this is exactly it.
It is easy to get irritated with the stubbed toes and stuffy noses, especially when you're getting hammered with critically ill patients right and left. But that irritation is misplaced. It belongs squarely at the feet of this so-called "system".
Well this is super frustrating to read because now I see what the LT nurses have to deal with! Although.. I did get a pt twice (same pt, 2 different times) that came in for seizures, with, A HISTORY OF SEIZURES! Just thought that was really strange. Like really?? You can't send out for labs and have the doc adjust his meds in house? 1st time not sure what happened to him if he was admitted or not, the 2nd he was sent right back once he was out of his postictal stage.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Well this is super frustrating to read because now I see what the LT nurses have to deal with! Although.. I did get a pt twice (same pt, 2 different times) that came in for seizures, with, A HISTORY OF SEIZURES! Just thought that was really strange. Like really?? You can't send out for labs and have the doc adjust his meds in house? 1st time not sure what happened to him if he was admitted or not, the 2nd he was sent right back once he was out of his postictal stage.
I'm glad you recognize the dilemma of a nurse in LTC....the "nurse" has 50 patients and one of them is seizing, another has fallen, another's in CHF....the MD doesn't come until next week and won't answer the phone/return pages. These poor nurses are overwhelmed, understaffed AND under trained/under equipped...they just can't keep thme and keep them safe. What drives me batty is the gum snapping, pierced, tatooed 14 year old (sorry for the sterotype) wanting a "Pi$$" test to see if the are "knocked up" and the "fever" patients that A) have not had tylenol B) have not called the MD C) haven't had their temperature taken they just "felt" warm.
But to be fair we have to blame the system that rewards them for going to the ED. That makes it easier to see emergency treatment than follow up with a PCP
Specializes in emergency, neuroscience and neurosurg..
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.
It is!!!!!!!! A nursing home cannot refuse return of a previously accepted resident if he/she has been cleared medically for any condition that would require treatment/care that facility is not capable of providing. They are legally responsible for the patient's care and have received payment for such.
:lol2::omg just be glad she was not your nurse that night 
i fill sorry for who ever got her next 
.thumb.jpg.0eaa9eda880b538207d78985bf1f2a41.jpg){kind=small}
Munch
349 Posts
This is one of the reasons why I miss working working at the hospital I used to. It was a small private hospital that specialized in cardiac surgery and cardiac care..it was also a full service hospital with the exception of labor and delivery services...unless you wanted to give birth in the ED(which did happened maybe 2 times I can remember). Nursing homes knew better than to send their patients to that hospital(unless they had a cardiac problem)...their were two hospitals down the road in each direction they could send the patients to.
Now I work in a huge hospital in the bright lights big city of Manhattan and I work the neurology/neurosurgery unit and oncology unit(usually two days neuro one day oncology a week). On the Neuro floor we get nursing home residents ALL THE TIME because they maybe got out of bed when they weren't supposed to and fell down and may have hit their head(maybe they didn't). They get sent to the ED by ambulance and usually bypass the more emergent walk in patients and their family or the facility usually demand a CT scan(which 9 out of the 10 times is perfectly clear)and observation overnight for a day or two. They just believe that the hospital is a hotel that they can just check their residents into. We have to eat the admission because the facility WILL NOT take the resident back until they've been observed for at least a night. Um hmmm is the facility staffed with police men to care for the residents? NO nurses are and the nurses are certainly capable of observing residents there...especially if they have clean CT scan.
Nope they become patients taking up space on the neuro unit(we are usually always full) and a poor neurosurgery patient has to spend the night in the PACU all because someone barely bumped their head and the family or facility DEMANDS that they come spend a night in out hotel I mean hospital. Its not just our unit either I have friends that work in all parts of the hospital and a med-surg bed is being taken up by a resident that coughed one too many times than they usually do or an ortho bed being taken up by a resident who's arm hurts(but not broken). I wish I was kidding or exaggerating but I am being dead serious.
We don't know what to do with these residents either except give them their medications they usually take and try to tame them. They are NOT happy to be in the hospital believe me. I've gotten cursed at, screamed at, assaulted, one man even spit at me. They miss their stuff, their routine has gotten disrupted, and they are in the hospital for basically no reason...they are also loud, disrupt their roommates and the whole floor. Not to mention the patients that REALLY need these beds, the patient that had a crani and is waiting on an uncomfortable stretcher in the pacu or the patient that has a fractured skull, or the patient who's brain is swollen. Not person that came from a nursing home, tapped their head has a clean CT and passed the neuro exam with flying colors.
Makes me glad I only have to work 3 days a week and get 4 days off..they might be long 12 hour days but they are totally worth it.