We all seem to get frustrated by the use of the ER for problems best dealt with by primary care. More to the point, we get frustrated with the patients. But, look at it from the pt's point of view.
Devil's Advocate- I'll look at it from the point of view from one of my pt's yesterday:
I have had back pain off and on for years. I was in a few days ago, and you told me to follow up, but I haven't made an appointment yet. Now my back really hurts, and I have trouble moving.
I come into the ER, get IV morphine, and and MRI. I leave with a percocet prescription. Immediate pain relief, an expensive test done on the spot, and some kick ass narcotics for home.
If I strike out at one ER, I can always go a few blocks to the next one. They don't communicate, and are in direct competition for market share and high customer ratings.
Compare that to the process, had I made a PCP appointment. A long wait for an appointment, no immediate pain relief, a long wait fr an MRI (if any is done) and who knows what I might get for a prescription.
Why on earth should I go to my PCP? I pay the exact same price for either service, and one is far superior to the other.
Can any of you nurses convince me to use my PCP?
(BTW- as this pt's nurse, I did use our system to actually get her a PCP, and and appointment. I gave an earnest explanation as to why it would be in her best interests to use a PCP.)
Someone earlier said "They hospitals don't talk to each other" but that's not true. Here, the providers look up a pt on the system say "You were see at XX Hospital just an hour ago, why are you here now?" or "You been to three hospitals this week."
The ERs in my area sure do communicate. Also doesn't hurt that one of our nurses is also an EMT in a neighboring county. We call each other all the time about patients.
It's an obnoxious and vicious cycle that, as a nurse, makes me cringe. But what is the alternative when you have a problem that needs attention but cannot go to primary care or urgent care regardless of the fact that this could easily be solved there? I know that Tricare leads to non emergent patients overcrowding the ER. It will continue until there is a change in the delivery of healthcare to military family members.
This is exactly why I don't give people attitude when they come to our ER when they can't see their PCM for acute issues. I do, however, ask if they've called to make an appointment, because there are often opportunities to educate patients on how to make appointments to see their PCMs (and they should call anyway to make a follow-up appointment). With the implementation of the Medical Home model in many family practice clinics across the military, there were growing pains that resulted in, among other things, a lack of same-day appointments. At my Army hospital, things have been adjusted to allow for more same-day appointments. Sometimes in the morning, we are able to call and get appointments for patients whose complaints are more suited to being address in Family Practice or the Peds clinics, and it cuts down on the wait for these patients.
Our ED is still very crowded and overutilized for non-emergent issues, but patients generally understand that we'll see them sooner than their PCM, even if their wait is 6 hours (vs. 3 weeks to PCM). I have to say we do a darn good job of picking the true emergencies out of the pack. The military system does funnel a lot of patients to the ER, but hey, it makes the day pass quickly. Haha.
Edited to add: I am in Afghanistan right now as a trauma nurse, and it is weirdly refreshing to be doing nothing but trauma. However, we still see some Afghan patients who clearly just don't feel like navigating the Afghan health system, so they will tell stories that make them seem eligible for treatment by our forward surgical team. Shades of home. LOL
I have never fully understood why ED's don't establish Urgent Care Centers at the same location. Patient comes in off the street ... is triaged quickly to either the Emergency Service or to the Urgent Care Service -- both located in the same building, but staffed by different people. The patient doesn't get a choice about it. That's what my hospital does -- though they use a different term for the Urgent Care Service.
I'm sure the failure to develop such a system is due to finances and regulations -- but it seems to me that there is such an obvious need for a solution to this huge (expensive) problem that the government and the health care providers could work things out.
llg, I recently picked up another PRN position in a freestanding ER. This system of Urgent v. Emergent with different sides of the building is implemented there. Perhaps this is the beginning of the way ERs will be designed in the future.
that's why there's "Fast Track" where patients are seen for non critical complaints by NPs and PAs - usually a much longer wait time too.
I suppose it depends on the health complaint, but I know my ED doesn't give MRIs for back pain - CTs sure, but MRIs are expensive and time consuming, especially when 70% of your patients are complaining of chronic back pain. That's what your PCP is for - the chronic stuff.
the only thing I would try to convince a patient of is that each time they come to the ER, they see a different team as opposed to one health care provider who can make better decisions based on knowing your full history and building a relationship over time. I would explain that the ED will ONLY treat the most acute part of the problem - in chronic back pain, they'll treat the pain temporarily, but will most likely not be able to Dx and Tx the cause so coming to the ER each time is just a bandaid solution that won't actually solve anything long term.
We have a prompt care next to the emergency room, but the emergency team is not allowed (i don't know why really) to triage to the prompt care. Prompt care is allowed (of course) to triage to the emergency room.
I wonder if it's tricky to send patients to the Urgent Care next door because of EMTALA? The triage process is not a substitute for a medical screening exam, so when you triage someone low acuity and send them to a lower level of care, you've basically violated EMTALA, right?
Also, it is true that sometimes people are sicker than they appear. Sometimes it's due to poor triage (like not asking the 9yo complaining of arm pain to take off his jacket and so not seeing his silver fork deformity), and sometimes people are just sicker than they look, or they may come in complaining of chronic low back pain, but you don't see the oozing, purulent diabetic foot ulcer until you dig a little deeper, and then they need to be admitted for an infectious disease consult, surgical debridement, PICC line placement, and antibiotic therapy. Or while they're sitting there waiting to be seen for their "spider bite", you notice that ugly sounding cough and it turns out they have a raging pneumonia.
I think because of EMTALA and because the triage process is not infallible, it could be dangerous to get into the practice of sending your low acuities to a lower level of care. I like having a Fast Track right in the ED area; if someone turns out to be sicker than they appeared at triage, they're still inside the ED and don't have to be transferred to a higher level of care.
I am an RN working in a rural area, and close to state lines. With Each inky dinky ER40 minutes away, one we are affiliated with (the one that is in our state)I am working at a high functioning Urgent Care. We have US, CT, Lab capability. The senior admin is straight out of deliverance, nepotism abounds, and very few admins have any sort of medical degree. But they don't know what they don't know...that makes them even scarier. The reason I work here is great schools, small community, its a vacation destination, and the natural beauty of the place is paradise to me.
So many of us just do our jobs and shake our heads at these idiots. The buliding I work in also has Primary care doctors,specialty peeps like visiting urologist, cardiologists, orthos, pain mang, and infusion center. Its a busy place. Our community is growing and the PCPs are bursting at the seams with patients. Not much else is available to these people in this town except a few other private practice primary care.
So our senior admin in all their vast medical experience has decided that the urgent care i work for is going to turn into a stand-alone ER. Urgent care will become "same day" and move to the other side of the building.More medical services are greatly needed in this area, these residents need an ER, but they need a safe and functioning one. The two ERs that are 40 miles away in either direction are already too small. I have worked in one of them. 10 beds, taking sometimes over 20 EMS's a day. The new stand alone ER will have less the half of those beds. Also due to proximity, the free standing will inherit at least half of these EMS calls,and by 900am i predict those beds to be full with sepsis, Cardiac r/o, and abd pains. There will be no where for these people to go. Wait times will reach astronomic proportions. And I, and many others don't want to touch it. We all know how psycho ERs get. It will be a very litigis environment.
I would be fine to be in "same day".
I am soooooo burned out on ER nursing, I don't have the will nor desire to work in one anymore. Thats why I am where I am.
The New ER I don't think will be able to satisfy EMTALA. There is not enough room for the ER to absorb Same day and become a fast track with a mid level intriage to satisfy the emtala regs. So these banjo pickers (senior admin) think that pts will "self triage"
meaning that when a person comes in, they will see a sign ;colds, flus, sprains,strains, med refills>>>>>this way to same day. abd pains, n/v, chest pain etc>>>>>ER. the patient will then register telling registration clerk where they will want to go.
Since this situation is kind of unique, and there are no other stand alones in the state, I cant find any definative info on emtala/medical screening pertaining to our situation.
My questions are:
If I am in same day, and a patient walks over to my clinic after being seen by registration.....Is that emtala violation?and I self report within 48 hours. Because the patient did not have a medical screening exam?
Thanks...I know this is long, but this situation is unique.
Hello-just joined so just chiming in. I work in a rural UC. Its a young one, only 4 years old. Its staffed by all seasoned ER Nurses and Pas. It $188 up front if there insurance is not accepted. The community is a retirement and vacation community. People come to us for everything. We are higher functioning, lab, CT, US, MRI 3days weekly. People roll through the door with all sorts of inappropriate/ grisly things. But the nearest ER is 45 minutes away. They don't want the ambulance bill, or they can't/ wont make the the drive, or they are simply unaware the difference. In our situation, "Urgent Care" is a inappropriate word. It's confusing to them, they don't know. So alls we can do is try to educate them. We need to be an immediate care or something like that.
I have to say we do a darn good job of picking the true emergencies out of the pack. The military system does funnel a lot of patients to the ER, but hey, it makes the day pass quickly. Haha.
NurseOnAMotorcycle, ASN, RN
1,066 Posts
Someone earlier said "They hospitals don't talk to each other" but that's not true. Here, the providers look up a pt on the system say "You were see at XX Hospital just an hour ago, why are you here now?" or "You been to three hospitals this week."