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Misuse of the ER

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by ShortFuse ShortFuse (New Member) New Member

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You are reading page 4 of Misuse of the ER. If you want to start from the beginning Go to First Page.

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Well, I am an idiot because I've panicked and taken my kid to the ER two times for "nothing". I paid dearly for it.

One thing I was on the fence about due to my assessment. But I'm not a pediatric nurse or a pediatrician, and I couldn't cope with the possibility that I might be wrong.

Oh come on, dont be pedantic.

You and I are parents. Of course there are times you are worried about something with a child and taken them in, only to have it turn out to be nothing.

My daughter fell from a height as a baby on to a hard wood floor and since I dont have an in home xray or CT machine I took her in.

But thats different than scaring everyone with a sore throat from jamming up an ER because they might shortly lose consciousness and die from suffocation due to epiglottitis.

I mean if you seriously believe everyone with any complaint should hit their nearest ER, then I guess we'll just have to agree to disagree.

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AnnieNP has 20 years experience as a MSN, NP and works as a Nurse Practitioner.

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OK, I had to look up "pedantic"!!!!!!!!

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Then there is the other side of the issue, the people who don't come in cause they are "not that sick" and when they finally feel sick enough to come in they have a perfed appendix and peritonitis or by the time they have a ride to the ER their stroke is outside the tpa window.

I agree that people abuse the system, but there are others that need to come in who don't. I don't want my comments to discourage people from seeking treatment, even if it turns out to be nothing because I have had patients with a chief complaint in the ER of tooth pain admitted to my tele unit with an MI.

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psu_213 has 6 years experience.

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I mean, on one hand you're right, there are people who are so dumb as to be unable to not tell the difference between bad gas from the tacos they ate tonight and appendicitis....

I have see PCPs and urgent cares sent in patients for R/O appendicitis, and some of those patients have had no more than gastroenteritis. I have seen ED docs get CT scans on patients who clearly had or did not have appendicitis.

Most of those PCPs/ED docs would not qualify at dumb, and I can't really blame patients for coming to the ED for abd pain.

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psu_213 has 6 years experience.

26 Likes; 27,417 Visitors; 3,869 Posts

2. Even before I was an RN student I could tell if I had a normal sore throat or I was in danger of suffocating.

I had a patient who checked in to the with "sore throat." No difficulty swallowing, managing secretions, etc. He was triaged ESI level 4 by the triage nurse. I was his nurse in the fast track area. After physical exam, the doc ordered a CT, which showed pharyngeal abscess. He ended up being fine, but not until he spent 2 nights in the ICU getting IV ABX and IV decadron.

I had another pt come in by ambulance for tooth pain. The pt told the nurse triaging her that she had a little bit of gum swelling by that tooth. She was triaged ESI 5 by the nurse. The doc told me to keep an eye on her, that he had a bad feeling. Over the next hour, she developed tongue swelling and then changes to her voice. She ended up being intubated with angioedema 2/2 lisinopril use. She was good after a night in the ICU, and was extubated the next day.

Both seemed like straight forward cases that some might have initially thought were "abuse" of ED services, but it goes to show you that just because someone is not suffocating, a person might not realize how ill they are.

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GaryRay has 10 years experience and works as a Radiology.

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Oh come on, dont be pedantic.

You and I are parents. Of course there are times you are worried about something with a child and taken them in, only to have it turn out to be nothing.

My daughter fell from a height as a baby on to a hard wood floor and since I dont have an in home xray or CT machine I took her in.

But thats different than scaring everyone with a sore throat from jamming up an ER because they might shortly lose consciousness and die from suffocation due to epiglottitis.

I mean if you seriously believe everyone with any complaint should hit their nearest ER, then I guess we'll just have to agree to disagree.

I've had friends with kids send me pictures of limbs on their phones and ask me if they are broken (more than once). I watch the ER tracker and have seen "primary complaints" including lice, sneezing,hiccups, rash, green poop, yellow snot, and any other random most likely harmless thing you can imagine. But parent's can't triage their own kids, they may say "tummy pain" and "they just don't look right" when the kid has necrotic bowel and is septic.

This is different from the woman who calls 911 then jumps off the stretcher in the ambulance bay and says she feels fine but she needed a ride downtown. Or the doctor using the ER instead of registration to admit his patients because the hospital doesn't have any beds and he doesn't want to have to make the calls.

People using the ER as primary care is a complicated public health problem that requires multiple agencies to decongest those ERs. Each community has unique concerns. While the ER wait times may not be a problem in rural areas, access to care paired with inappropriate reimbursement may come into play. Urban areas have the financial access problem. If we don't pay pennies for someone's insulin we are going to pay dollars for their DKA.

What I have learned as I've matured (a little bit at least) is the ER wait time belongs to the whole hospital. The waiting room in the ER is the most dangerous real-estate in the building. There is a serious possibility someone who is very sick may leave without being seen because the people who aren't sick are making them wait. Everyone can help by improving patient turnover.

Don't hold on to your discharge till after lunch, someone needs that room. If your room is empty and you've got a patient assigned, be proactive and call to do what you can to facilitate getting them moved. Pick your patient up from ER when you can (its not always possible) they will be extremely thankful.

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Jory has 10 years experience as a MSN, APRN, CNM.

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I'll be honest, I can't believe you went to your DON over this visit. The ER is there, you treat what comes in, period. Doesn't matter if it's a true emergency or not. You do educate on urgent care.

I find it interesting you don't seem to understand that she needed to be seen in the ER regardless. Depending on her age, she could be at risk for a hip fracture or fat embolism from the fall. If she's falling that much she needs a PT evaluation and possible placement in skilled nursing. You can't get placement in skilled nursing without a hospital stay.

ER isn't only for the dying. Sometimes you need an evaluation that can get results sooner than later. Older folks are very, very reluctant to call an ambulance for anything.

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hppygr8ful has 15 years experience and works as a RN - Adolescent Psych.

360 Likes; 4 Followers; 31,245 Visitors; 2,522 Posts

I work in a small rural hospital, where we deal with all areas, and the number of non-emergent ER visits I see is really making me hate my job! The other day, the Dr's clinic nurse informed me at 10:30 am that there would be a patient coming to the ER at 1:00 pm. This patient had fallen 3 days prior and had been suffering hip pain since. When I asked why the patient couldnt come now if it was an emergency, I was told that she did not have a ride until 1:00 and she did not want to call the ambulance. I then protested that if it were an emergency, she would come immediately rather than scheduling an ER appointment (i guess that's a thing?!?!?), and if it could wait then she could be seen in the clinic. The clinic nurse explained that it needed to be done in the ER because the Dr wanted the patient to be lying down for her assessment (LOLOLOL). I ended the call, then went and informed my DON of this, who found it as ridiculous as I did, and went to talk to the Dr. Upon returning, she stated that the patient was coming to the ER at 1:00 because she had told the Dr she did not want to be seen in the clinic due to her insurance coverage. Please share your thoughts on this, I see this sort of thing all the time and am just wondering if this happens anywhere else.

I guess I would not really mind if an elderly person on a fixed income wanted to come to the ER which was covered vs a clinic which was not. I was recently in the ER for for a pretty serious problem and the bill was $12,000.00 of which I paid $235.00. I actually went to urgent care first ( For an 8 cm wound dehiscence on my abdomen) and they referred me to ER. I was given a choice of going by ambulance or being driven by a family member. To save costs I had my husband drive me. Was this an emergency? Not sure but I got expedited treatment when I arrived because the ER was not too busy and the urgent care had called ahead.

The scenario you describe could have had several outcomes even an occult hip fracture so I don't believe that's unecessary use of the ER. Now when people go to the ER with a bad cold and demand instant treatment That irks me.

Hppy

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hppygr8ful has 15 years experience and works as a RN - Adolescent Psych.

360 Likes; 4 Followers; 31,245 Visitors; 2,522 Posts

I'll be honest, I can't believe you went to your DON over this visit. The ER is there, you treat what comes in, period. Doesn't matter if it's a true emergency or not. You do educate on urgent care.

I find it interesting you don't seem to understand that she needed to be seen in the ER regardless. Depending on her age, she could be at risk for a hip fracture or fat embolism from the fall. If she's falling that much she needs a PT evaluation and possible placement in skilled nursing. You can't get placement in skilled nursing without a hospital stay.

ER isn't only for the dying. Sometimes you need an evaluation that can get results sooner than later. Older folks are very, very reluctant to call an ambulance for anything.

When I called my insurance to tell them I needed to see wound care they told me straight up the fastest way to get an appointment was to go to the ER. You should have seen the faces on the nurses and docs when they peeled that dressing back. The first thing they all said was "Does it hurt?" Truth is it really didn't hurt so I didn't use to opportunity to get any pain meds which my husband thought was stupid. Anyway I am on Clindamycin for 10 days and ten will get a wound vac.

Hppy

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57 Likes; 3 Followers; 33,555 Visitors; 4,124 Posts

I've had friends with kids send me pictures of limbs on their phones and ask me if they are broken (more than once). I watch the ER tracker and have seen "primary complaints" including lice, sneezing,hiccups, rash, green poop, yellow snot, and any other random most likely harmless thing you can imagine. But parent's can't triage their own kids, they may say "tummy pain" and "they just don't look right" when the kid has necrotic bowel and is septic.

This is different from the woman who calls 911 then jumps off the stretcher in the ambulance bay and says she feels fine but she needed a ride downtown. Or the doctor using the ER instead of registration to admit his patients because the hospital doesn't have any beds and he doesn't want to have to make the calls.

People using the ER as primary care is a complicated public health problem that requires multiple agencies to decongest those ERs. Each community has unique concerns. While the ER wait times may not be a problem in rural areas, access to care paired with inappropriate reimbursement may come into play. Urban areas have the financial access problem. If we don't pay pennies for someone's insulin we are going to pay dollars for their DKA.

What I have learned as I've matured (a little bit at least) is the ER wait time belongs to the whole hospital. The waiting room in the ER is the most dangerous real-estate in the building. There is a serious possibility someone who is very sick may leave without being seen because the people who aren't sick are making them wait. Everyone can help by improving patient turnover.

Don't hold on to your discharge till after lunch, someone needs that room. If your room is empty and you've got a patient assigned, be proactive and call to do what you can to facilitate getting them moved. Pick your patient up from ER when you can (its not always possible) they will be extremely thankful.

It's not the non-sick making sick people wait. It's the triage nurse.

As for turnover - nurses would be a lot more willing to keep things moving if they weren't so crushed with too many patients.

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I had a patient who checked in to the with "sore throat." No difficulty swallowing, managing secretions, etc. He was triaged ESI level 4 by the triage nurse. I was his nurse in the fast track area. After physical exam, the doc ordered a CT, which showed pharyngeal abscess. He ended up being fine, but not until he spent 2 nights in the ICU getting IV ABX and IV decadron.

I had another pt come in by ambulance for tooth pain. The pt told the nurse triaging her that she had a little bit of gum swelling by that tooth. She was triaged ESI 5 by the nurse. The doc told me to keep an eye on her, that he had a bad feeling. Over the next hour, she developed tongue swelling and then changes to her voice. She ended up being intubated with angioedema 2/2 lisinopril use. She was good after a night in the ICU, and was extubated the next day.

Both seemed like straight forward cases that some might have initially thought were "abuse" of ED services, but it goes to show you that just because someone is not suffocating, a person might not realize how ill they are.

And Ive had a buddy who made it through a fire fight, swear he hadnt been hit (there was no external bleeding it was all pooling inside due to constriction of his body armor), and then fall over over dead a few miles down the road from internal hemorrhaging.

There will always be exceptions.

But the point remains, given the seriousness of overcrowding in the vast number of ER's across the country, we as members of the medical community should be advocating that anyone with any symptom, no matter how minor, should head to the nearest ER? I disagree.

Im studying for a test tomorrow. I have a headache. From reading over the past 48 hrs. Could it be a brain tumor or aneurysm? Sure, but I think I will live to make it to my class tomorrow.:bookworm:

We can debate this till the cows come home and you can tell me all the anecdotal stories you want, but our ER's are overburdened and adding to that burden with minor complaints that are better treated by PCPs or Urgent Care centers will hurt not help outcomes.

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GaryRay has 10 years experience and works as a Radiology.

3 Likes; 3 Articles; 4,361 Visitors; 191 Posts

It's not the non-sick making sick people wait. It's the triage nurse.

As for turnover - nurses would be a lot more willing to keep things moving if they weren't so crushed with too many patients.

Preach! I just ran screaming from my orientation shift in the ER when they wanted me to start floating PRN. Ever since I have tried to see the hospital as a whole and not blame one department for things backing up. We regularly had 16 hour wait times and were on diversion for weeks at a time. Everyone wanted to blame the ER for running badly, I realized there were things I could do to help from the ICU too.

Decreasing ratios house-wide lowered wait times pretty significantly. I think some of the CNS are working on publishing that data.

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