ERs fail as the nation's safety net

[NRSKarenRN]

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.

[santhony44, MSN, RN, NP]

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:

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

Well, move over on the soapbox and make room for me.

I work for a small rural critical access hospital and do some ER coverage. Most of the people we see are not uninsured and have a PCP. Most of the ones I've seen who have neither are there for true ER stuff.

I've come to the conclusion that common sense is actually pretty uncommon, and I agree with the convenience store analogy. "Fix me, NOW!" seems to be a common attitude.

And if you think it's fun being the ER nurse and dealing with these folks, imagine how much more fun it can be for the provider, to be woken out of a sound sleep at 3 AM for someone's hemorrhoids!

[Katie82, RN]

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.

Very true... I am a case manager for Medicaid/Medicare population. Each month, I receive a report from the State listing the patients in my assigned practices who have utilized the ER. The report is divided into two parts: emergent and non-emergent visits. Needless to say, the non-emergent side is much longer. Luckily, our local hospital has a non-emergent department that sees ambulatory patients who have missed the turn for their PCP's parking lot. I am amazed by the excuses I get when I ask them why they are abusing the ER, with heavy emphasis on the work abuse. Many have been discharged by their PCP for various reasons and haven't made an effortto find a new one. But most of the answers I get revolve around two issues - the ER is usually more convenient, and they resent the thought that someone should object to spending more money in the ER as opposed to a PCP office. I can give them all the right arguements - continuity of care, exposure to other infections, distracting the staff from true emergencies. Doesn't work. I get the same comment: "you don't think I should use the ER because I'm on Medicaid"....I thin the only solution is to mandate non-emergent cases to a lower level of care, like our hospital does, then slap them with a high copay.

[Katie82, RN]

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.

You're right, procedures like sutures are impractical in an office setting when you expect your providers to see 20 - 25 patients a day. I was a practice administrator in a Family Medicine practice, and I would triage those appts to Urgent Care. Peds are a tough call, I usually sent them to the Urgent Care or ER if we couldn't fit them in. My favorites were the ones who would call with "I have had this stuffy nose for two weeks, if you can't see me today, I want permission to go to the ER" Sorry, no way - I'll get you in tomorrow.

[angel337, MSN, RN]

society is so litigious. everyone wants to sue for everything, so in that respect i don't blame the pcp suggesting patients go to the ER if they can't see the the patient. God forbid something happens or goes wrong, its automatically the doctors fault. patients also need to use their own judgement and take responsibility for their decisons. i can't tell you how many times i had a patient say "i just come to the ER because i don't want to miss work"..... usually this is for very minor complaints and these are the same people that get very upset when they are waiting 3-4 hours. unfortunately, i don't see this behavior changing anytime soon.

[santhony44, MSN, RN, NP]

society is so litigious. everyone wants to sue for everything, so in that respect i don't blame the pcp suggesting patients go to the ER if they can't see the the patient. God forbid something happens or goes wrong, its automatically the doctors fault. patients also need to use their own judgement and take responsibility for their decisons.

Thank you! That's exactly what I meant when I said defensive medicine!

What I find very scary are cases where patients sue providers for their own lack of responsibility, and win! A theoretical example: A FNP does an annual exam on a female patient. The Pap shows an abnormal result. The FNP notifies the patient and sets up a referral. The patient never bothers to go nor to follow up. Three years later, the patient has advanced cancer. She sues the FNP, and wins! Now, that's theoretical, but I've read very similar cases in journals.

When that kind of thing is going on, then really, it's hard to blame any provider for telling a patient who can't be seen that day to go to the ER. I understand how it makes the ER situation worse, but I surely do understand the provider's point of view.

Where I am, though, that's not what I usually see in our ER. I usually see people who couldn't be bothered to go to a clinic, or who have gone but aren't 100% better in 24 hours.

[EmmaG, RN]

On one of my assignments, I had to call in because of severe ear pain, vertigo and n/v. Every time I lifted my head up, the room would spin furiously. She told me I had to come to the ER since I was under contract to work. I argued with her; come in with an earache? Was she serious?? Yep, she was. I asked if there was an urgent care in town that I could go to in the AM. Nope. No such beast.

So I spent half the night in the ER, apologizing to everyone I saw for taking up their time with such a thing.

Ridiculous.

My ex-hospital's ER tried to solve this problem by starting a unit specifically for this kind of thing; kind of an urgent care within the ER, I guess you'd say. It was located adjacent to the ER (the patients went through the same triage as everyone else) and the ER nurses and docs rotated through the unit.

It was a dismal failure because patients were refusing to be seen there. They were indignant at being triaged to the urgent care area and demanding to be treated in the "real" ER. The concept was great. Too bad it never worked out...

[Roy Fokker, BSN, RN]

Wait! ERs are the "safety net" ?

News to me! I never knew that was their function/job-profile!

cheers,

[NRSKarenRN, BSN, RN]

My ex-hospital's ER tried to solve this problem by starting a unit specifically for this kind of thing; kind of an urgent care within the ER, I guess you'd say. It was located adjacent to the ER (the patients went through the same triage as everyone else) and the ER nurses and docs rotated through the unit.

It was a dismal failure because patients were refusing to be seen there. They were indignant at being triaged to the urgent care area and demanding to be treated in the "real" ER. The concept was great. Too bad it never worked out...

"Urgent Care" just needed the right name to impress: FAST TRACK ER

Both DS and I waited 5 hrs to be seen post triage with our first kidney stones...almost on the floor due to pain, had patients tell the triage RN to take us first---still ambulances rolled in.

As homecare RN, whenever I call with pt issue needs to be seen within 24hrs, get "send em to the ER" . Appointment times with specialist: 3-4 months. Many PCP 3-4 wks. Some PCP I can NEVER get through phone system to inform doc of homecare admission. Some things gotta change.

[EmmaG, RN]

"Urgent Care" just needed the right name to impress: FAST TRACK ER

No kidding. Make 'em think they are special.

[pickledpepperRN]

Wait! ERs are the "safety net" ?

News to me! I never knew that was their function/job-profile!

cheers,

Roy, here in LA LA land so many ERs have closed in that last 20 years that it is quite possible for an accident vistim to take a long time to get to the nearest hospital by ambulance during "rush hour" (Actually 7-10:30 am and 3-7:30 pm)

Worse the President told us to just go to the ER.

They miss the "golden hour" and die.

[Simplepleasures]

"Urgent Care" just needed the right name to impress: FAST TRACK ER

Both DS and I waited 5 hrs to be seen post triage with our first kidney stones...almost on the floor due to pain, had patients tell the triage RN to take us first---still ambulances rolled in.

As homecare RN, whenever I call with pt issue needs to be seen within 24hrs, get "send em to the ER" . Appointment times with specialist: 3-4 months. Many PCP 3-4 wks. Some PCP I can NEVER get through phone system to inform doc of homecare admission. Some things gotta change.

Wow, and some folks say that Canada has long waiting times and their care is universal.

[Chaya, ASN, RN]

From what I've been hearing sounds like 75% of the demand is for walk-in, urgent but not emergent care that are staffed, say from about 7A to 11P. I'm not sure what kind of effort it would take to convert the focus of our point-of-care medical services to this (besides A LOT of public education anad some financial dis-incentives to using ER services) but seems like it would be a lot more efficient and cost-effective.