Ghosts of the ER (Clerks)

[Cody1991]

Hello, I read AN all the time. I’m a clerk in the ER (I mostly do bedside registration, co-pays, etc.) I really like the job and for me, I’m seeing all kinds of crazy stuff, meeting all kinds of interesting patients, it’s a step up from doing phlebotomy for years and nurse aide. I wanted to be a nurse for a long time, but I honestly couldn’t hack the schooling. I found it very difficult and stressful and dropped out.

But, I’m still involved in healthcare and I’m making the most money I’ve ever made in my life with excellent benefits and I have a shift I like. However…

I may be in a toxic work environment but the nursing staff in our ED are incredibly cliquey. They all go out to breakfast after work with the medical residents, play music in the station and dance around with each other and have a kind of fraternity/sorority vibe. Many of them are always making plans for daytrips and other bar-going type adventures. Many of them are in their twenties. No big deal but I’m starting to really get the feeling that they just absolutely think of us as scum. They interrupt us when we’re talking to patients, they almost crash into us (we have mobile computers we push around) as in, they WILL NOT MOVE, they wait for us to move one recently collided into one of our elderly updaters and didn’t even apologize. Each area of the ER has a nurses station where we have to sit alongside the nursing staff. They do things like throw our coats into the floor to take chairs (we don’t have lockers), never offer us any candy or anything when they do and won’t make eye contact if we ask them anything or even snap answers like we’re super annoying. They’ll even talk about us (Registration, not individually) right as we’re sitting there. There are a few nice ones but very few.

My question really is just about nursing in general. If I’m standing in a room with a patient holding their credit card and the patient has a clipboard and is signing consents --- is it normal or right for a nurse to push in , not even acknowledge us and start trying to do an IV or distribute medicines? Last night, a patient was paying $100 in cash and the rest on credit ($150) and had cash in her hands and the nurse came in and said “You need to drink this” and handed her a little vial of some kind of gastro medicine. She had to literally swap hands with the money and wasn’t sure what to do so she handed the medicine to me because her table was too out of her reach, the nurse began checking her IVs. I said, “Hey, I’m almost finished, she’s trying to pay her copay…” and the nurse said (without looking at me) “She has to take the medicine now” and walked out. Completely ignoring that she had MONEY IN HER HAND and consent forms on her lap. I walked out to the station afterward and politely said, “I know the ER is busy and we get in each other’s way, but we have to work together.” She literally got up and left. A co-worker tried to explain to another nurse the other night that we had jobs to do , too and the nurse said, “Well ours is more important.” True but…? (We literally are being timed by management on how fast and efficiently we do registration and insurance.) I never know how to deal with this kind of interruption. Doctors do it all the time, too.

Do you think it’s actually personal or do nurses just get so busy that they don’t even really notice us or is this just this ER or is this just a common thing?

I think it must be trickling down from the charge nurse. She’s only 28 or so and has a mean girl attitude. Someone had brought in a tray of cookies for the ER as a thank you. And a tech was passing them out. She approached two of us (registration) and the charge nurse yelled out, “Nuring staff only.”

It’s so demeaning. Like I said, otherwise I like the job. And if I’m being honest, like many, I’m relying on the pay to live my life. I try to ignore it but these things are starting to happen at least twice a shift. I’m starting to look for jobs elsewhere in the hospital in the paygrade. I really do admire nurses, I wanted to be one and I like working around them and helping them out. But this feels really dumb and hateful. I really don’t know how to handle it. Mostly I just let the nurse do what she has to do, smile and carry on after they walk away. But sometimes it’s so belittling that it takes me a minute or two to readjust to the blow. Even patients comment on how rude it is. Does anyone have any thoughts or helpful advice? I’ve heard that in a year, half these nurses won’t even be here, so it may just be a bad batch. A few evenings ago, a student doctor was so nice to me in the room that I felt like crying which is how I knew this has just built up... lol.

[JKL33]

8 minutes ago, egg122 NP said:

And unless it is an true emergency (which will happen more often than in other settings given it is the ER), the medical and nursing staff can wait for you to finish your transaction with the patient before busting in like that.

You are not correct. If the basic EMTALA obligations have not been satisfied, then payment operations may not delay the provision of screening or the care required to complete the screening or stabilization.

Secondly, beyond EMTALA, all clinical staff are being timed on everything and being judged by such speed without regard to patient acuity, and not just by our employers' policies or harebrained initiatives as in the OP situation: ED throughput is a CMS quality measure. That does mean that the actual care and treatment of the patient is being used to officially judge quality of care. There's nothing about making sure to collect $50 in those quality measures. Granted, those procedures are important, but for different reasons. Therefore, different approaches for satisfactory performance of those duties are needed.

Lastly, if you were the patient which would you prefer:

1. Nurse or provider is extremely rude to clerical personnel who are interacting with you and tells them to leave.

2. Nurse or provider stands in corner while you are uncomfortable and/or anxious, delaying the resumption of care provision until you are done providing your payment information and fumbling around for your various cards.

3. Nurse or provider (the people you came to the ED to see) pop their head in and see that you are engaged with billing procedures and say they will come back later, which is likely going to be 10-20 minutes from now.

4. Your actual care is prioritized and the business end of things is taken care of efficiently without interrupting or delaying any other aspect of your hands-on care.

You would not appreciate #1, 2 or 3 as a patient. You would appreciate #4.

[egg122 NP, MSN, APRN]

54 minutes ago, egg122 NP said:

JKL33,

I don't see how those are the only 4 scenarios available. I will provide a 5th. The provider or RN addresses the clerk as a human being and advises that we need to do something urgently and that they need to come back later. That would take 10 seconds or less. As a patient, I would want to be ensured that my care team can communicate with each other clearly and with basic courtesy. Patients also become uncomfortable when they see negative interactions between health professionals. Teams that cannot communicate effectively or treat each other with respect have poorer outcomes. The clerk is a part of your team. Would you not agree that direct communication is best?

[JKL33]

Yes, your #5 is part and parcel of #4; it's exactly how #4 happens.

I've already described my practice in a previous post so I won't repeat myself.

[egg122 NP, MSN, APRN]

16 minutes ago, JKL33 said:

JKL33

This is your scenario 4: "4. Your actual care is prioritized and the business end of things is taken care of efficiently without interrupting or delaying any other aspect of your hands-on care."

Then it should be addressed issue with their manager or your manager and treating front line co-workers with respect. Or communicating with the registration staff about how to handle scenarios for the shift directly. There are ways of doing this without degrading or being passive aggressive to coworkers.

[JKL33]

Yes. That's what the whole discussion has been about.

It seems we agree on all of that. I only disagree with your assertion along the lines that we're all equal and so clinical staff should wait their just as much as anybody in this scenario. I don't think they should and the law agrees with me, but that doesn't condone rudeness on the parts of these RNs. My comments to you are only to point out that there are some pretty official reasons why decent places try very hard to incorporate reg/billing in a way that doesn't approach interference with medical/nursing care.

I make no excuses for these RNs. As I said, they are official mean girl.

I also believe that there is no excuse for these RNs' behavior, but at the same time this toxic process (and many others like it in EDs around the country) is ultimately to blame. It's much easier for me to try to see my coworkers' POVs and try to work together with them, than it is to try to defend anything as asinine as telling registration personnel to run into the room the instant it's time for nursing interventions to get underway. That is not fair to anyone involved, not the OP, the nurses, or the patient.

[egg122 NP, MSN, APRN]

Just now, JKL33 said:

I only disagree with your assertion along the lines that we're all equal and so clinical staff should wait their just as much as anybody in this scenario. I don't think they should and the law agrees with me, but that doesn't condone rudeness on the parts of these RNs.

My original post also clearly stated that if it is a true emergency that the registrar needs to wait. You can be EMTALA compliant and have the clerk collect information in the room once the case has been screened and deemed not emergent.

[JKL33]

16 minutes ago, egg122 NP said:

You can be EMTALA compliant and have the clerk collect information in the room once the case has been screened and deemed not emergent.

Yes, but now you're getting into weeds that are simply not going to be porificed out each time registration visits a patient room.

Is registration making an attempt to know whether the patient 1) has been screened and cleared 2) whether an EMC has been found to exist or 3) whether the testing has been ordered to rule out an EMC or 4) the treatment has been ordered to treat an EMC? No. They do not know these things and #2, 3, and 4 are all situations where EMTALA obligations are not yet satisfied.

They operate from one basic process and therefore it needs to cover all scenarios. Patients to whom the hospital technically no longer has an EMTALA obligation could be asked for payment/co-payment before any further care is rendered and they can even altogether be referred elsewhere. But all of that gets into very dicey territory and so it is just not the way things are.

[egg122 NP, MSN, APRN]

1 hour ago, JKL33 said:

Yes, but now you're getting into weeds that are simply not going to be porificed out each time registration visits a patient room.

Is registration making an attempt to know whether the patient 1) has been screened and cleared 2) whether an EMC has been found to exist or 3) whether the testing has been ordered to rule out an EMC or 4) the treatment has been ordered to treat an EMC? No. They do not know these things and #2, 3, and 4 are all situations where EMTALA obligations are not yet satisfied.

They operate from one basic process and therefore it needs to cover all scenarios. Patients to whom the hospital technically no longer has an EMTALA obligation could be asked for payment/co-payment before any further care is rendered and they can even altogether be referred elsewhere. But all of that gets into very dicey territory and so it is just not the way things are.



We will have to agree to disagree. I think this post is going into the weeds. Thanks.

[JKL33]

Okay...?

We do not disagree about basic kindness and consideration of one another. I'm not sure why you would disagree about the rest of it; it's pretty straightforward.

But--as you wish.

[PollywogNP, ADN, BSN, MSN, LPN, NP]

Why do you have to wait until the doctor has seen them ? (“Moves from waiting to be seen to treatment in progress”) before you can see them to complete the registration???

What is to be gained ? In a busy ER patients could wait quite a while before the doc/pa/np sees a patient and writes treatment orders.

The Lobby wait time can be hours long ( recently waited 2 hours), another opportunity to finish the registration?

[JKL33]

6 hours ago, PollywogNP said:

Why do you have to wait until the doctor has seen them ? (“Moves from waiting to be seen to treatment in progress”) before you can see them to complete the registration???

What is to be gained ? In a busy ER patients could wait quite a while before the doc/pa/np sees a patient and writes treatment orders.

The Lobby wait time can be hours long ( recently waited 2 hours), another opportunity to finish the registration?

Technically you don't have to. The law only says that the screening for an emergency medical condition or the care required to stabilize an emergency condition may not be delayed in order to inquire about the patient's finances/insurance, and we all know that if there is a delay in screening it is likely due to patient volume vs. resources, and more efficient or less efficient processes.

The problem is having to prove the why beyond a shadow of a doubt after an allegation has been made. No one wants to be investigated for an EMTALA violation or, as I said earlier, give even the appearance that someone's screening or care was delayed in order to inquire about their payment method.

[egg122 NP, MSN, APRN]

I think the EMTALA thing is a distraction to this thread and frankly derailed it in an attempt to show who is top dog in all things nursing. I'm not clear why we had to go there, particularly when there is nothing about the OPs post that indicate there is anything non-compliant going on and implying that collecting money in a room was some how a violation was factually incorrect.

Getting back to the original purpose of the post... The fact is, no one has the right to treat the OP in the ways described in this post. OP- I am sorry you are experiencing this.