Saw a news special on ER crisis...opinions?

zenman · May 5, 2004

You will never change the majority of the public. Hospitals have to have a 24 hr urgent care/primary care clinic if they want to free up the ER. Staff it with a bunch of NPs.

ERN · May 5, 2004

Hi Sharann,

You are quite right to be worried that unreasonable wait times and abuse of ER staff limiting access to ER's. The reality is that truly emergent and critical needs are taken care of immediately in a good ED and the rest are reassessed and treated as they need attention. You and your family will never wait 8-9 hrs if you truly need emergency care. The closings and diversion you speak to occur because ED's are overwhelmed, staff get burned out with the abusive environment, and hosps. can no longer afford to treat uninsured/underinsured non-emergent cases. These folks clogging the ED's needlessly are there because either it's convenient to be seen that day and/or their insurance will pay for a 2 stitch (OH MY GOD!!! The Blood was Gushing!!!!) emergency or a headcold and won't pay their regular GP.

I have had people tell me what to write down so their insurance will reimburse them for something that didn't need an ER. Believe it or not, some people use false ID and addresses and the ER bill gets sent to an empty lot in a city in another state. The patient never has a credit card and can only put ten bucks down on the bill at that moment.

Many specialty Doc's are refusing call or rearranging their practice to exclude ED patients because they have to leave a long time paying office pt to see a nonpaying pt in the ED. Hosps. and ED MD's are loathed to turn people away for fear of bad community PR and loss of revenue (if they can collect it!) A good friend of mine tells me that as an ED MD in his group of 9 Doc's working full time, they collect 40-50 cents per dollar charged......less for welfare/medicaid pts.

Solutions are cash/credit card only (Doc in the boxes) minor care free standing clinics. Hospitals/ ED MD's hate them unless they control them and collect revenue. Good place for CRNP's

Tort law is a killer.....people sue because the scar on their little girls head under all that hair is UGLY.....she will never marry that Senator now.....her life is ruined.....I quess she should have thought of that before she lied to her parents and stayed out all night at a rave and them fell in a drugged stuper fighting with the police that raided the place. Malpractice suit threats are causing hosps.to treat everyone as if they were patrons on the Queen Mary.

Just ask ER folks on this forum how they like Press Gainey and hospitality rules in a busy ED. Tort law/malpractice awards need to be changed.

Hospitals need to separate the truly emergent pts from the "clinic" pts and provide a clinic for them away from the ED. Then conduct a community education program to get folks to use both care facilities appropriately.

Sorry for the rant......I too have been both a pt and practitoner in the ED, discussed this subject at length with colleagues and attempted to change it.

ERN

RNin92 · May 5, 2004

The problems you talk about have been going on and building for years.

Some we can only influence with our right to vote...

Tort law changes

EMTALA laws REQUIRING everyone who presents to be seen, evaluated and treated. Period.

some problems are beyond our scope...

Not enough PMD hours/clinics...

Under and/or uninsured patients with no where to go...

Medicaid patients without an accepting doc in the county...

Poor community awareness...

Add to that the "too busy" lives some people lead...

Too busy to see PMD when appointment available

Too busy to make time for Pediatrician's OV in the afternoon (What? And interrup Bridge?!)

Too busy to wait for the clinic to open.

The list is endless.

It is a HUGE societal problem.

But like everything else that goes bad in the hospital...

Dump it on the ER.

They can handle it.

Surgical Hrt RN · May 5, 2004

you will never change the majority of the public. hospitals have to have a 24 hr urgent care/primary care clinic if they want to free up the er. staff it with a bunch of nps.

this is a great idea!!!!! my only question.....would hospitals and docs go for it! so much of what comes in the er is ...."my toe hurts, my kid has a fever, my head hurts." we really need a clinic! then, that way the er is freed up for the real emergencies!

TinyNurse, RN · May 6, 2004

i just wonder if they are able to be on tv answering a question....... um what again is their chief complaint??????????????

sharann, BSN, RN · May 7, 2004

i just wonder if they are able to be on tv answering a question....... um what again is their chief complaint??????????????

Their chief complaint is the long ER wait for their non-emergency.

Energizer Bunny · May 7, 2004

this is a great idea!!!!! my only question.....would hospitals and docs go for it! so much of what comes in the er is ...."my toe hurts, my kid has a fever, my head hurts." we really need a clinic! then, that way the er is freed up for the real emergencies!

i have thought this same thing for quite a while. it sure would be a great idea for the big cities anyways!

Calfax · May 7, 2004

We need a clinic!!!!!!!!!!!!! Me too! Yeah, clinics, clinics, clinics.

The thing is how do you make the place profitable in a place with no money?

In the places where ppl need clinics the most (inner cities, rural areas) they ain't got no money. Otherwise, they'd go to a doctor and a pharmacy like everyone with a decent co-pay.

In order to have a clinic be successful, it either has to be subsidized (Govt, private charity, etc) or it has to make money....and enough money to pay & retain competant doctors and nurses. Govt subsidies come with all kinds of strings.

When I was an EMT, before I became a nurse, we'd transport ppl into and out of some of the worst neighborhoods in my city. Nothing there anymore but crumbling tenements, Chop Suey shops and storefront churches....the occasional McDonalds and chicken joints.....junk shops. No more industry. No more trade or commerce....save a few pawn shops and heavy-industry hold-outs. You'd wear rubberbands over your pants legs to keep the roaches from going up your socks as you lifted ppl in and out of bed.

How are you going to make a profit in a place like that? What liquid cash there is is involved in the drug trade and not particularly accessable for a variety of reasons.

There are 2 answers. One is to provide for a national basic level of healthcare....the basics free for everybody with several tiers of fee-for service health care for anyone with enough cash for that service. This is expensive but everyone at least gets their insulin and dialysis.

The other is to break everything and force everyone to compete with each other in free market free-for-all.......an open market...with negotiable price on everything. This will effectively shut out the very poorest from healthcare....but will have the immediate effect of lowering the overall cost of healthcare for everyone....theoretically allowing more ppl access to any particular service.

The pathway lies within whether we view healthcare as a basic human right....or as a service to be bought and sold like any other commodity. There is no easy answer....except that it's almost summer and there's 4 whole months of barbequing, beer and golf to come.

BabyRN2Be · May 7, 2004

Hey all,
This news thing was about the emergency room crisis in Los Angeles county and talked about the delay in care and the long waits mainly. It sorta steamed me but as I work in PACU and not E.R. I thought I'd run this by you all. The news person interviewd several "patients"(ex-pts or those waiting by the ER)and asked how long they waited. The average response was "8 or 9 hours". My beef was that if these people are such emergencies then why are they standing around outside the ER getting on TV? I believe that the FOCUS of the story should have been "Abuse of the ER services is causing a crisis". Am I off track? What is the solution (besides what we do now which is treat everyone anyhow). More public clinics so the people go there? 24 hours urgent care places? It scares me that one day I may need to take my family or self to the ER for a real life threatning emergency and have no where to go because my local ER's are closed or diverting!
Thanks

Sounds like a "slow news day" story. Have you thought of calling or writing the station with your concerns? It's a great suggestion to them if they could report of the abuse of ER services - get at the problem instead of the complaint of long waits!

ClimbingNurse · May 7, 2004

The Washington Post ran a great article about this:

http://www.washingtonpost.com/wp-dyn/articles/A41995-2004Apr25.html

(You'll have to register to view it, but it's worth it)

Basically, some ED's are now actually turning people away. If you don't have what they deem to be an emergency and you don't have insurance, they give you the option of paying cash upfront or leaving w/ a list of low-cost clinic.

Of course, if you have insurance, and you want to stay for your stubbed toe, then that is your perogative. I think the whole thing is a wretched idea. I like what someone else posted about putting a 24-hour subsidized clinic in or next to the hospital. And I definitely like the idea of staffing it w/ NP's.

GDog7NYC · May 13, 2004

The Washington Post ran a great article about this:
http://www.washingtonpost.com/wp-dyn/articles/A41995-2004Apr25.html
(You'll have to register to view it, but it's worth it)
Basically, some ED's are now actually turning people away. If you don't have what they deem to be an emergency and you don't have insurance, they give you the option of paying cash upfront or leaving w/ a list of low-cost clinic.
Of course, if you have insurance, and you want to stay for your stubbed toe, then that is your perogative. I think the whole thing is a wretched idea. I like what someone else posted about putting a 24-hour subsidized clinic in or next to the hospital. And I definitely like the idea of staffing it w/ NP's.

It's definitely an article that provokes a lot of thought as to the direction that Emergency Care is headed, but at the same time, it makes me think about a couple of things. I have a dedicated Minor/Urgent Care area in my ED that is open until midnight and that is staffed with an ED attending, a PA and 2 RNs. I think triaging out, like the article describes, defeats the purpose of having that area (as many ED's do). Also, we have a Walk-In Clinic directly across the ED that is open during business hours that our medical and surgical residents rotate through to provide continuity of care for many of our chronically ill patients. Are we still constantly overcrowded and inappropriately utilized? Of course. Part of the problem there is that many of the Attending Physicians with admitting priveleges in our hospital constantly tell their patients things like "well, if we want to get these tests done faster, go to the ER" or "if you can't get ahold of me, then just run over to the ER and we'll get you patched up" even if it's not a medical emergency. Many times, I can't help but feel like i'm treated like the 7 Eleven of the healthcare industry - cheap, open 24 hours and most convenient for all involved. Of course, many physicians who dont work in an ED fail to tell their patients how expensive it is be seen by us, particularly for non-urgent matters. I believe that if misuse of EDs is to be tackled, then there has to be a concerted effort between all medical disciplines who constantly view our departments as the paths of least resistance and thus advise their patients to "go there".