ERs fail as the nation's safety net

HM2VikingRN, RN · Feb 11, 2008

No surprises....:

GilaRRT · Feb 11, 2008

One of the major problems is the fact that emergency rooms are in fact not really emergency rooms. Sure, we have our load of high acuity patients; however, nearly every facility I know of has an ER overflowing with patients using the ER as a primary care provider. Complaints such as dental caries, rash without fever or other associated signs or symptoms, cold symptoms, and complaints of chronic pain typically take up most of my patient load. ER's are not developed with primary care in mind. How can we really expect our nations ER's to act as a "safety net," when in fact, they are already acting as a safety net for people who will not or cannot find a PCP.

emsboss · Feb 11, 2008

I heartily concur with the low acuity of patients in ER. Most(approx 85%) of pts come in C/O ailments that even a mediocre PCP can handle easily. We are used to much as primary care and have even been told "We have to pay a real doctor, not you guys." WHAT!?!?!?!? Are we chopped liver??? It gets really frustrating when we have "clinic days," usually Friday through Monday. Drives me crazy!

HM2VikingRN, RN · Feb 11, 2008

I think that we really need to work on expanding urgent care hours and sites to more communities...

Simplepleasures · Feb 11, 2008

There are discussions on other threads about Medicaid/ Medicare patients being dropped or refused by clinics and doctors, which in turn sends them looking for care at the ED. I am sure this is not the whole reason behind the misuse of our nations EDs , but it does add to the problem.

My daughter needed after hours care for my granddaughter, and ended up having to go to the ER for care because the urgent care clinic closed at 6PM. It would be great to have the clinics stay open 24 hours a day, relieving the load on the ED. My daughter has private health insurance.

dcampbell · Feb 11, 2008

Am I the only one experiencing this but does it seem that PCP's go out of their way to ENCOURAGE use of the ER for nonemergent problems? For example, I called the Ped's office for an appointment for my daughter and they could not take her that day so I was encouraged to take her to the ER (I did not). If I call the office at 4:55pm (they stop answering the phones by then) I am told by answering machine that they are closed and to go to the ER for ANY problems. If I wasn't a nurse and just a cautious parent instead it would seem that I should take my child to the ER. Pediatricians I have had in other states we have lived would sometimes have an answering service that would encourage you to go to the ER for just about anything. Even the PCP my husband and I go to will have a message on their machine or have the receptionist hint that you should just go to the ER. Is this just a CYA thing by PCP's? What about the people who are told that their PCP can't see them until next week? Some people have jobs that they need a work excuse for a legitimate illness and they can't be seen by their PCP. And I could see why some people are confused as to what to do. Nowadays it seems that PCP's don't do as many things as they used to do in their office such as stitches ect. Of course the problem of people misusing the ER is a different situation altogether. Overcrowding in the ER has so many causes that I think it will take MANY different solutions to solve.

pickledpepperRN · Feb 11, 2008

found at healthleadersmedia.com
ers fail as the nation's safety net
los angeles times, february 11, 2008
the long waits that government inspectors say endanger emergency room patients at harbor-ucla medical center can also be found in backlogged hospitals across the country, according to the american college of emergency physicians....
"overcrowding in our emergency departments is a national crisis," said dr. linda lawrence, president of the american college of emergency physicians, an advocacy group based in washington d.c. "we no longer have the capacity to serve as the safety net for society."
..the group surveyed 1,000 emergency care physicians and found that one in five knew of a patient who had died because of having to wait too long for care.

i suspect that the times reports on violations at our county facilities but not the hospitals that advertise in their paper.

once i called my doctor for a refill of my imitrex prescription. he said, "why don't you have your husband bring you to the er? i'll call ahead and order you demerol."

i told him, "i'm too sick to go to the er."

i also worked there and di not want to be in the er vomiting and photophobic as well as in pain.

he did fax the refill to the pharmacy so i could get it the next day.

Altra, BSN, RN · Feb 12, 2008

Once I called my doctor for a refill of my Imitrex prescription. He said, "Why don't you have your husband bring you to the ER? I'll call ahead and order you Demerol."

spacenurse, this strikes me as an incredibly *inconsiderate* (the best polite word I can think of right now) thing for your doctor to suggest.

1. That's not how the ER works and he damn well knows it.

2. If he has the time to make a phone call then he has time to fax an Rx now, doesn't he?

3. You are his patient, if he knows what med he wants to order then he knows what's wrong with you. Why does he want to send to you an ER with an unfamiliar doctor for a familiar problem?

This is but one example of the ER overcrowding problems pointed out by other posters above. ERs are full of people who do not have medical emergencies, and many of them are not the uninsured people without other access to primary care that you may be picturing.

I hate to get up on the same soapbox that I seem to have been on multiple times recently, but this is just a sample of my day in triage last week. All of the patients I'll list here were insured (I know because they were pulling out their insurance cards as I was triaging them) except as noted:

Patient 1: Mid-30s female, one day of 2 episodes of vomiting. No diarrhea. No fever. Normal vital signs. No significant PMH or co-morbidities.

Patient 2: Mid-20s male, sinus pressure, headache & nasal congestion x 2 days. Low fever (

Patient 3: 3-year old w/fever x approx. 12 hours. No cough, vomiting, or diarrhea. Drinking juice from sippy cup and playing with toy as they came into triage. No OTC antipyretics given by family -- mother states, "We have assistance so we get a prescription for Tylenol when we come here."

Patient 4: Early-20s male, congestion & malaise x 3 days. Had been seen in the ER on first day of s/s. Diagnosed with viral s/s, instructed on OTC meds, fluids & rest. Back in ER "because I'm not better."

Patient 5: Mother of toddler, states she brought toddler to the ER for eval of ear pain. "I talked to his pediatrician's office but the times they offered me weren't convenient." (No, I'm not kidding. I wish I were.)

I could go on until my post took up a serious amount of bandwith on this site, but it would be boring. You get the point. Once upon a time, people had the common sense to realize that garden-variety short-term illness befalls us all from time to time, and simple comfort measures at home treat the symptoms. So why are all these people in the ER? Because they want what they want when they want it, IMO.

And this is why it is increasingly next-to-impossible for ERs to function as a "safety net" for those without other options. The ER is treated as a giant high-tech, open-24-hours convenience store. :angryfire

Blee O'Myacin, BSN, RN · Feb 12, 2008

Am I the only one experiencing this but does it seem that PCP's go out of their way to ENCOURAGE use of the ER for nonemergent problems? For example, I called the Ped's office for an appointment for my daughter and they could not take her that day so I was encouraged to take her to the ER (I did not). If I call the office at 4:55pm (they stop answering the phones by then) I am told by answering machine that they are closed and to go to the ER for ANY problems. If I wasn't a nurse and just a cautious parent instead it would seem that I should take my child to the ER. Pediatricians I have had in other states we have lived would sometimes have an answering service that would encourage you to go to the ER for just about anything. Even the PCP my husband and I go to will have a message on their machine or have the receptionist hint that you should just go to the ER. Is this just a CYA thing by PCP's? What about the people who are told that their PCP can't see them until next week? Some people have jobs that they need a work excuse for a legitimate illness and they can't be seen by their PCP. And I could see why some people are confused as to what to do. Nowadays it seems that PCP's don't do as many things as they used to do in their office such as stitches ect. Of course the problem of people misusing the ER is a different situation altogether. Overcrowding in the ER has so many causes that I think it will take MANY different solutions to solve.

Or how about the patient who comes in directly from the doc's office with a scrip in hand that is requesting a lipid profile, a HgA1C, a CT scan and a 2D carotid doppler to be performed by the ER staff? First the patient gets frightened that the doc is sending them "right to the hospital to be admitted", and then angry that we don't take their complaint (all vital signs stable, no acute injury or illness) seriously, and are upset that they have to lay in a stretcher in the hall when they "have insurance, so they deserve a room", and the nurses are the ones perceived as being insensitive and ill-tempered when it is time to complain to administration.

I happen to work with a great group of docs and nurses, which is what saves me from running screaming from the health care profession on some days. I also think our docs should run a seminar for their fellow physicians on what to refer to the ER (and unless they need to call 911 from the office, do they really need to ever refer to the ER?), when to direct admit (no beds available in the hospital means that you should wait until the next day, or try another hospital!), and when to send a patient to the outpatient lab and the outpatient imaging center!!

Blee

santhony44, MSN, RN, NP · Feb 12, 2008

I'm in Family Practice and have worked in peds. I don't send people in to the ER on a regular basis, by any means.

I have done pedi telephone triage as an RN, and taken pediatric call as a NP, though, and I am sure I have sent people to the ER that had the ER staff mumbling about me under their breath. Sometimes it's really hard to get a good "feel" for what's actually going on, and you always try to err on the side of being conservative. I've also known parents to exaggerate a child's symptoms to get the OK to go to the ER.

Honestly, some of this "go to the ER" is probably defensive medicine. You don't want to be the one to miss something serious.

Oh, and someone mentioned doing sutures in the office; that kind of thing can be quite time-consuming,and if the provider has a packed schedule, it would throw everything off for the rest of the day. I've done sutures in the office, but I've also been in settings where there was no way possible to do that and see scheduled patients, too.

pickledpepperRN · Feb 12, 2008

MLOS and BLEE:

Absolutely!

I only float to ER. I will not take a child because I'm not competent. I'm also much less productive in the ER than in the ICU. (Not a CEN but CCRN)

Last year about this time a woman actually came to the ER at 7:00 am asking for a note to be off work because she had burned her finger in her own cup of coffee!

It wasn't even red.

The doc ordered me to put a squirt of Betadine in a cup of ice water, soak it for 5 minutes, wash it, and apply a dry dressing. The he wrote her a three day excuse from work!

She works for the federal government so WE paid for this!

Even the President told the people, " I mean, people have access to health care in America. After all, you just go to an emergency room."

http://www.whitehouse.gov/news/releases/2007/07/20070710-6.html

PS: I changed doctors.