How do you deal with Non-Urgent Patients

[mom2michael]

I'm really getting burned out very quickly with the life sucking force of non-urgent patients in the ER. I've been in ER for 3 years now (2 nursing NS as a tech, 1 as an RN). I'm not new to the obvious abuse of the system but lately I would rather hear nails down a chalkboard that listen to these people in triage with their c/o they've had for 6-7 months.

It seemed to plauge us Wed night something awful. Our entire ER filled up in 15 mins. with things that obviously could've been addressed at a PCP or Urgent Care. Which, BTW, those are abudent in our area. And, you don't have to wait to get into a PCP, most have same day appts. We even have a great Urgent Care that sees patients until midnight down the road from the ER.

How do others deal with this?

Let me give you examples of Wed night. URI s/s for 30+ days. It hurts when I insert a tampon. Back pain for 6 months. I hit a wall 3 weeks ago and I just now think it needs to be checked depite the fact I have full ROM and no swelling and/or pain right now. My child has a "fever" of 98.6. My child was exposed to chicken pox 3 days ago. A man with totally vague s/s during triage and later we find out, he just wants a physical and a work note. A woman with chronic dental pain, on ATB already, the tooth has been pulled AND she already had pain meds at home.

Our Urgent Care and PCP can all order labs/X-rays from their office and people can come to hospital for OUTPATIENT stuff. Our Urgent Care is open until midnight 7 days a week. Our lab and/or X-ray will see patients until midnight as well. We even have 2 PCP's that see patients until 7p.m. at night. Obviously they have bent over backwards to address the needs of working people here.

Usually I don't even mind people who come in with minor c/o and not really emergencies,. But for the last couple of months I find myself having this urge to just scream whenever I hear WEEKS or MONTHS in their sentences during triage. I can't even begin to describe the feeling I get when I hear "nothing" when I ask what they've done for the said complaint that has plauged them for WEEKS or MONTHS.

Then we have a staff meeting about the stupid PG and how we are slacking and how we need to improve customer satisfaction. I could come up with the ways, but I don't think the hospital would find my ways very funny.

I'm at my wits end I really am.

I need some great words of wisdom or some humor or something to continue this madness.

[rph3664]

Oh yes, we are a Medicaid heavy area.

But you see, they have only so many "punches" on their card.

And to be honest, just making them pay 3 dollars is good for our morale!

When I lived in Iowa, prescription copays for pregnant women, and people under 21, was zero. For everyone else, it was $1.00 and this greatly reduced the number of "lost" prescriptions, based on what I heard from people who had worked in other states with zero copays. Around 2000, they also made birth control zero copay to, which I totally agreed with. :cheers: Some of our senior citizen customers had zero copays as well, but I'm not sure why some did and others didn't; I believed that senior clients should have a zero copay as well.

Over the years, I had a number of Medicaid customers who were disabled people with low-paying jobs. (Two in particular were each married with 2 kids; one was a mildly retarded woman, and another was a man with a seizure disorder that proved impossible to control.) Who could be more deserving of public assistance than a disabled person who's working?

[santhony44, MSN, RN, NP]

I think Leah's hospital's strategy may just be a very good one. I hope, if it succeeds, it encourages more and more facilities to do similar things.

I also think that copays for Medicaid could be a very good thing. Even a minimal copay of $1-$5 could cut out some of the nonsense seen both in ERs and in offices and clinics.

(For example: a kid came in recently. He'd vomited twice, had diarrhea two or three times. Two days ago!! Yep, the kid is running around attempting to dismantle the waiting room)

I too have had the cases of the disabled who are truly trying and doing the best they can but who need some extra help, and the elderly who have always worked, etc.

However, I am sick to death of taking care of people who believe that they not only have the right to make their own poor choices, but also have the right to force everyone else to take responsibility for those choices.

[mmutk, BSN, RN, EMT-I]

I know what you mean...

Get this, on a 1am Saturday morning! A 19yo male walks into the triage area for me to check him in, he has written "need an MRI" on his sign in sheet. Hey my name is so and so I'm you're triage nurse today what's seems to be the problem..."

"I was scheduled for an MRI for a hernia last week but I missed the apointment, now I'm ready for it and surgery if it's indeed a hernia."

:icon_roll:icon_roll:icon_roll:icon_roll

Ok sir....quick triage....he ended up lobby for 2 hours, got no MRI as the techs go home at 1800, and are only on call, and he couldn't understand why THIS wasn't an emergency...

[mmutk, BSN, RN, EMT-I]

We are starting something in our ED next week that everyone is really excited about.

If the patient is triaged a 4 or 5, they go to a small exam room with a nurse practitioner for their medical screening. If the NP agrees this pt. is non-urgent, they will be promptly sent to the Financial Person.

We will be glad to see non-urgent patients but they have to PAY first!!

This is supposed to decrease our volumes by 20-30%. I don't really think it will be that much..... more like 10-15%.... but it really does help knowing that they can't just waltz in and out without a care in the world!

I hope word of mouth gets out that the free ride is OVER!

We do this also at our hospital, the minumun payment is $200 and we only do it to level 5's. However allot of the patient's have learned the game and now add complaints to their check-ins.

[mom2michael, MSN, RN, NP]

I live in a very rural area where min. wage jobs are the norm and obviously you can't raise a family on a min. wage job, so a large portion of the population is on state assistance of some sort with Medicaid being the #1 most used assistance.

All ER visits where I live require a $3.00 co-pay for Medicaid. Rx are free for children/preg woman, $1.00 for everyone else. If they go to their PCP it is $2.00 (free for children/preg woman). This is stricly Medicaid.

For me to go to the ER is $150.00 with private insurance, which must be paid up front before I walk out the door, even at my own facility that pays for a majority of my health insurance. My Rx ranges from $25-$75 per script unless I get something off the $4.00 list from Wal-Mart. Again, I have to pay for that up front.

I think twice about going to the ER for something that can obviously be handled at my local PCP, where my co-pay is just $10.

However - if I didn't have a co-pay or it was virtually the same if I went to my PCP or the local ER, I would probably consider the ER as an alternative to my PCP especially if I wasn't educated as to what an ER is used for.

And I do work for a facility that requires payment for all non urgent visits BEFORE they are seen. They shell it out and it hasn't slowed down business one bit yet.

I have no idea what the answer is though......

[ok2bout]

If anyone hears of a real solution to this problems...please let me know. I work in an ER that tx's close to 100,000 pt's a year, thats about 300 pts a day. There is another local hospital less than 1 mile away that tx's on an average of 40-50 pts a day and the other hospital tx's around 30 a day. So as you can see were are extremely busy...were are often on divert, we does absolutely nothing b/c you can not tell your pt's coming in through triage and 99% of your pt's coming by ambulance dont care and still want to come to our ER. Fortunately we have an area of our ER that has 14 beds, 2 family practice MD's, 3 nurses, a unit clerk, and 2-3 NA's. Pt's tx in this area are fractures, sprains, strains, migraines, URI, back pain, lacerations, ear/tooth pain, most kids, etc. These type's of pt's are usually turned over very quickly and normally your able to keep this area running pretty quickly. This takes a huge burden off the main ER where higher acuity pt's can be seen quicker. Even with this system, we have pt's in hall bed's daily. Last week we had a pt code in a hall bed, unfortunately this can happen in any part of the ER. What frustrates me is the frequent fliers that we see weekly that refuse to follow up with a PCP. Many of them are drug seeking, but unfortunately it easier for the ER doc's to medicate them and move them out of the ER than to deal with their drug issues. We will usually see these pt's over and over until one of our doc's finally confronts the pt and they move on to another local hospital for several months and then back to our ER. I dont have the solution to the overcrowding and especially to the pt's utilizing the ER as their PCP. I think better education is needed for these pt's. The other day I noticed on my radio station that pt's who had Gateway insurance were being encouraged to call an 800 number before going to the ER for minor problems....too many to list here that they were addressing. I think if insurance companies started to aggressively address these types of people for abusing the ER before contacting their PCP by denying their claims just may start to educate pt's. Just maybe other insurance companies will get wise to this and start requiring their pt's to contact their PCP's before running off to the ER for minor problems that are not emergencies. I feel we have come to the point that we are no longer an ER just an extension of the health system. Some times I feel I just working for the local clinic with the types of pts I see all night. I went into emergency medicine to tx sick and emergent pt's which is rare lately.

[33-weeker]

Part of it is lack of education. Also... no matter how many urgent care facilities there are, if your insurance doesn't cover them then its off the the ER you go after hours and on weekends.

[TraumaNurseRN]

I feel you PCP essentially was the problem. So many of them are. They're busy so they dump to the ER.

[hospitalstaph]

How severly the non-urgent visits affect our ED depends almost entirely on which doctors are working. Some of them do full work ups on minor complaints, which seems to justify the ED visit to the patient. Often the "extra tests" uncover another problem which seems to just further justify the visit to the ED instead of a PCP. The doctors that focus on the complaint and the complaint only are the ones that make the non-urgent patients easier to deal with. I can handle non-urgent complainers for 1 hour, but when I am caring for a pt with cold/flu symptoms times 5 days that has not even attempted to visit urgent care or PCP and the doctor orders a full work up lasting 6 hours, I begin to feel burnt out.

[RNRRTCEP]

You put them in the waiting room and let them rot or get tired of waiting and go home.

[scattycarrot, BSN, RN]

You put them in the waiting room and let them rot or get tired of waiting and go home.

:yeahthat:

[hospitalstaph]

You put them in the waiting room and let them rot or get tired of waiting and go home.

Some of them are VERY patient though! I guess I would be too if I brought along ALL of my family to visit with.

That's another HUGE pet peeve of mine: Why on earth do you need to bring all of your family to the ED with you to get treated for a runny nose? And it never fails, one of the family member thinks "hmmm, since I'm here anyway I think I'll get this red spot on my butt that I have had for 2 years checked out."

I truly do feel for those that do not have insurance and feel that they have no other choice but to come to the ER. These are the ones that listen and thank you when you give them a list of the free clinics nearby. However, we are dealing with a very high level of entitlement in many, many cases often drapped in designer clothes and carrying a Coach handbag with an IPhone clutched in their acrylic nailed hand.

But in the end, I absolutely LOVE my job. If for nothing else, the entertainment value!