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.

[Party-of-Five-NY]

I feel exactly the way you do, I admit, I'm very frustrated too. We have three "zones" in our ER, and one of them is "blue", which is the express care section. When I work in the blue zone, I'm guessing more than half of my patients really did not need to come to the ER.

Last week, a girl had menstrual cramps, was seen at a different hospital the day before, prescribed Motrin, did not fill the prescription, then woke up with cramps again, and came to our ER!!!! Yikes!! It's so frustrating.

I agree that more teaching is important. I always ask the patient if they have a primary doctor. Most do not. I then begin teaching the importance of having one! We also have a family health clinic, right in our hospital, that accepts those without insurance. There is no excuse for not having a primary, in most cases. (in our city anyway).

[LeahJet, ASN, RN]

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!

Just updating my previous post.....

We've been doing the "medical screening" process for a couple of weeks now and I have to say, I REALLY like it. We are collecting three times as much as before and an average of about 15-20 non-emergent pts. a day are chosing not to be seen. I think the word is getting out. There are three large hospitals in our city and I've heard the other two will be following our lead.

I LOVE IT!!

[TraumaNurseRN]

Where I work, a good number of people who "Know" the system actually have EMS bring them to the ER for their stupid complaints as they feel they will not have to wait. Well, most times now, we actually have the squad drop them off in the triage area a:yeah:nd they are made to wait just as they would have had they come through the front doors anyway. It's really frustrating to everyone. Reading all these posts though you get the sense that this is going on EVERYWHERE, and it's not going to change.

I giggled when I read about the co-pay or forcing payment for treatment:lol2:.....We have people who ask for cab vouchers to get their butts back home, cause they have no money for the bus and have no-one to call. In our area there are 2 hospitals near to each other....we both get the same crap come in. Many times they leave our ER an just go a couple miles down the road to the next hospital. Until Managment:down: decides to quit pampering the non-emergent, non-paying client who comes in with an attitude of welcome welcome...Can I get you some fries with my narcotics...:angryfire..Our ER will never change. I had an ER doc say to me when I threatened him with bodily harm:nono:when giving a drug seeker narcs he responded with, He gets into trouble if he doesn't...it affects his Press Ganey Score....and ultimately he has to feed his kids. Apparently our ER docs are forced to the urgent cares the Hospital has as punishment for low press ganey scores. Unbeleivable....The ER docs are being forced to be drug pushers.

[scattycarrot, BSN, RN]

Ok, I have seen this a few times but what is a Press Ganey score?

Thanks!

[TraumaNurseRN]

(Press Ganey) A survey patients receive where they can judge the care they received @ the Hospital.

[Altra, BSN, RN]

Ok, I have seen this a few times but what is a Press Ganey score?

Thanks!

Press Ganey is a consulting company specializing in "health care process improvement."

http://www.pressganey.com/

Their services are used by many hospitals to survey patients and determine ways to improve patient satisfaction.

[rph3664]

Press Ganey is a consulting company specializing in "health care process improvement."

http://www.pressganey.com/

Their services are used by many hospitals to survey patients and determine ways to improve patient satisfaction.

And it sounds like they're as clueless as most other consultants.

[CritterLover, BSN, RN]

ok, i have seen this a few times but what is a press ganey score?

thanks!

they are evil people who rank right up there with joint commission in terms of:

1. cluelessness

2. coming up with aggrivating crap

3. making our jobs difficult

4. missing the point

[TraumaNurseRN]

just to play devil's advocate and give a patient's perspective: sometimes the patients really don't know what to do or where to go...they may have a feeling that the er is not the most appropriate place, but figure "i'm not a nurse, i don't know".

i'll give my example: i had a snowboarding accident, no broken bones, no major complications, they kept me in the hospital for 2 days to monitor a slight pneumothorax (no chest tube required) and because i had complained of numbness in my right hand for approximately 15 mins after the accident. when i was released i was given written and verbal instructions to call a certain number if i had any difficulty breathing, chest pain or sudden change in symptoms; i even stated "well i have generalized pain right now, including chest pain" and the discharge nurse/person told me "well, just call if the chest pain gets worse"...ok so fast forward to about midnight that day and i'm in a lot of pain, especially my neck/chest area and my pain meds aren't cutting it...i know that it's probably just inadequate pain control and i'm fine, but i can't sleep and i'm a bit worried, so i call the number...they act like i'm some kind of moron and say: "well, we can't diagnose you over the phone, you need to just come into the er" well, i knew that i didn't have an emergency and the er would be overkill...so i call the rnadvice line provided by my ins. company and she said "you need to go to the er" well...again i knew that was overkill, i'm not having a heart attack, i'm not having difficulty breathing...i'm just in severe muskuloskeletal pain and they told me to call....

so....i don't go to the er and i call my pcp in the morning....they actually have available appointments, but refuse to see me because according to the receptionist i need to go to the er. so, i go to the urgent care and tell the doctor my story....he seems to think i'm some kind of idiot for not taking the advice of 3 different providers and just going to the er like i was told....but they do a chest x-ray and exam and i am fine...they just changed my pain meds...

so...i guess moral of the story is i really really didn't want to go to the er, but everyone else seemed to want me to...and i almost did...i seriously considered it 3 times because everyone was telling me to. had i shown up in the er i'm sure my signs and symptoms would have seemed ridiculous to any triage nurse and i would have been moved to "the back of the pile"...which is why i ultimately did not go.

and i am sure your pain went away. did anyone....anyone tell you you would experience more pain the next few days after your injury???? did your discharge instructions say anything about resting????

you are correct that it was not an emergency, and personally i feel those nurse help lines are half the problem...i wish i could sit behind a desk and tell everyone who calls to go to the er because it's a liability if they don't. those nurse help lines are not helpful......:angryfire

[rgroyer1RNBSN, BSN, RN]

I agree with critter over press gainey, they were made by the devil to torment us, like we keep getting ones with the complaint we didnt give them the pain meds they wanted, I say we put candy dishes at triage one with vicodin es, one with percocet/percodan, one with T3's, One with xanax, and one with Valiumfor the nursing staff, I also say we put cards/passes in an index card box with one saying Demerol 50 MG IM/IV, Morphine 10 MG IM/IV, Dilaudid 2 MG IM/IV, Nubain 10-20 MG IM/IV, take one of these cards directly to your nurse get your shot and get the he#$ out.

[Dental Hygienist]

and i am sure your pain went away. did anyone....anyone tell you you would experience more pain the next few days after your injury???? did your discharge instructions say anything about resting????

you are correct that it was not an emergency, and personally i feel those nurse help lines are half the problem...i wish i could sit behind a desk and tell everyone who calls to go to the er because it's a liability if they don't. those nurse help lines are not helpful......:angryfire

yes, the pain went away. my discharge instructions said no work for 10 days and to call if i had certain symptoms. that's just my story, i'm sure plenty of other relatively smart, but not medically knowledgable people get funneled to your ers for non-emergent stuff....i'm not saying people like me should be the er's problem....but that the problem is really global in nature. no one in the pcp world seems to want to deal with patients on a rational basis because of liability....the rnadvice line i called was a joke! :down:i could definitely read between the lines in our conversation....i could tell that she advises just about everyone who calls to go to the er because she doesn't want the liability if something goes wrong. and...i can actually empathize with her plight...it's a messed up system.

it happens in dental too, i refer oral lesions all the time for a biopsy that i'm 98% positive are benign...but if i don't refer and it turns out to be oral cancer we're all hosed! it's not your fault for smoking or chewing tobacco, it's my fault for not finding it soon enough. there's my

[loricatus]

Where I work, a good number of people who "Know" the system actually have EMS bring them to the ER for their stupid complaints as they feel they will not have to wait. Well, most times now, we actually have the squad drop them off in the triage area a:yeah:nd they are made to wait just as they would have had they come through the front doors anyway. It's really frustrating to everyone. Reading all these posts though you get the sense that this is going on EVERYWHERE, and it's not going to change.

I giggled when I read about the co-pay or forcing payment for treatment:lol2:.....We have people who ask for cab vouchers to get their butts back home, cause they have no money for the bus and have no-one to call. In our area there are 2 hospitals near to each other....we both get the same crap come in. Many times they leave our ER an just go a couple miles down the road to the next hospital. Until Managment:down: decides to quit pampering the non-emergent, non-paying client who comes in with an attitude of welcome welcome...Can I get you some fries with my narcotics...:angryfire..Our ER will never change. I had an ER doc say to me when I threatened him with bodily harm:nono:when giving a drug seeker narcs he responded with, He gets into trouble if he doesn't...it affects his Press Ganey Score....and ultimately he has to feed his kids. Apparently our ER docs are forced to the urgent cares the Hospital has as punishment for low press ganey scores. Unbeleivable....The ER docs are being forced to be drug pushers.

I worked at a hospital for couple of weeks (agency) that found the ultimate way to pamper the drug seeker and keep thos PG scores high-standing orders for pain managment: Pain scale 1-3 gets 2 mg IV morphine, 4-6 gets 4mg, 6-8 either 6 morphine or 1 dilaudid, 9 & 10 gets 2 of dilaudid. The nurse is then the one responsible for ensuring the standing orders are followed and this relieves the doc of all responsibility. 8-10 patients at this ER during my night shifts were drug seekers who heard about the policy. since nobody showed me the actually standing orders signed by some/any doc, I refused to follow such a policy.

Please don't get me wrong. I am an extremely strong advocate for pain managment; but, narcotics aren't always the best answer. This both ends of the spectrum way of dealing with this issue, certainly speaks volumes for the sorry state of healthcare delivery in the US.