Misuse of the ER

Right now, you have to make a choice. Save yourself or don't. With regard to this particular topic, you save your self (your sanity, etc.) by accepting that there is no misuse of the ED. Regardless why people come.

You have much worse things coming your way eventually. Best to make up your mind now: Smile, help people the best you can, and don't worry about others' decisions.

I cannot LIKE this post enough!

OP, you are working in a rural ER - correct? I've worked in several. JKL33 gets it right -

THERE IS NO MISUSE OF THE ED.

Welcome all who seek care and provide competent, client-centered care for all. Every patient deserves your best. Never assume, fully assess. FTR - I've found critical findings in "patients who didn't belong in the ED" - this has happened enough to be scary.

Really.

Count your blessings that you are not the patient, but you never know how your life may evolve.

Life is short, even in its longest days.

If you find yourself angry, hostile, hating patients or heading to crispy crust - burnout - do yourself a favor and go. Find another practice area before you become THAT nurse. No one deserves THAT nurse.

:angel:

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

Kooky, I'm interested in what you mean by this.

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.

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.

ERs are definitely overburdened, the healthcare system is broken. Unfortunately not all minor complaints are caused by minor problems, sometimes they can be life threatening. When you are a patient and call your PCP and have to wait weeks for an appointment, or are new to an area and try to find a PCP accepting new patients, or find a PCP that accepts your insurance you may feel the ER is your only choice to be examined and treated because waiting hours is better than waiting weeks.

Your frustrations with patients who abuse the system are also not unique to the ER setting, you see them first, you see more of them, but some get admitted.

How do we fix the system? Less primary care physicians because specialists can make more money, insurance companies that limit choices, patient consumers who make bad healthcare decisions, etc all contribute to the problem and we must continue to nurse on. Until there is a revolution that overhauls the system I am not optimistic meaningful change will occur. I will keep trying to provide quality care to my patients until I burn out, and hopefully I don't destroy my own health in the process. How much stress, overtime, missed meal breaks, meals comprised of junk food, lost sleep, tears, missed family life, and lack of appreciation from management does it take to kill a dedicated nurse?

Any ideas on how to fix the system? We all know it is broken.

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.

wrong, you can get into skilled care, it would be self pay. that is what I mean by insurance fraus.

Any ideas on how to fix the system? We all know it is broken.

Very very simply. Take profit and Wall Street OUT of health care.

Research (pharma and medical devices).

Production (pharma and medical devices).

Provider services.

Should ALL be non-profit. Not necessarily government run, but non-profit.

As long as EVERYONE involved in providing healthcare to our population has to answer to private investors, then the focus will ALWAYS be on the bottom line more than on patient outcomes.

Until that changes, then nothing will change.

Look at LTC and SNF corporations as an example. What service are they providing? Skilled nursing care to a vulnerable patient group.

But what do the corporations who own the facilities actually sell themselves as on Wall Street? Real Estate Investment Trust companies! They own land for its appreciation in value.

So do you really think their primary concern is patient care?

In my experience, people use the ER for non-emergency problems because they have no alternatives, even with insurance and a PCP.

When I lived in Boston, the city had a huge PCP shortage and no urgent care. When CVS introduced Minute Clinics, Boston's mayor publicly stated that he would not allow them in the city because people could go to a community health clinic, despite long provider waits and very limited walk-in hours.

When my PCP left the practice, dumping all of her patients, it took me over a year to find a new one. In the meantime, I had a bad sore throat that I thought might be strep. No one else in my old PCP's practice would see me. I was in nursing school at the time. Health services, which did very little besides paperwork, pamphlets, and condom distribution, referred me to the local community health center. They saw walk-ins from 10-11 am and 2-3 pm, and you had to be there an hour ahead of time. If my symptoms hadn't subsided, I would have gone to the ER.

As an ER volunteer, I checked in a lot of patients for minor complaints who were there because their PCP told them to go to the ER. Quite a few PCPs sent anyone with the slightest hint of illness to the ER, even on weekdays during business hours. Same-day appointments didn't exist unless you were in a "concierge" practice. As nurses, we have a good idea of what constitutes an emergency. Laypeople usually don't. If their PCP tells them to go to the ER, that's where they'll go.

Every time I called my insurance's nurse advice line, they told me to go to the ER. One time they told me to call an ambulance and go the the ER. The one time they didn't tell me to go to the ER was when I called about a mild, persistent headache not resolved by ibuprofen when I was 10 days postpartum. Turns out I was in hypertensive crisis, my b/p was in the 170s, and I was hospitalized for 2 days with postpartum pre-eclampsia.

Where I live now, there is one hospital and 4 urgent care centers. Three of the urgent cares are open 7 am to 7 pm. The fourth, run by the hospital, is open 8 am to 8 pm. It's the only one that takes Medicare or Medicaid. If you show up after 4pm, especially on a weekend, they send you to the ER anyway.

wrong, you can get into skilled care, it would be self pay. that is what I mean by insurance fraus.

OMG, are you really using "you can be self pay" at over $7,000 a month as justification I am incorrect? Most people don't have that laying around. It's not insurance fraud as evidence has to be sent over and the stay has to be justified and approved by insurance unless it's Medicare and then that patient had better fit the critieria.

Tell me again what the woman with a broke hip is supposed to do for rehab? What if she falls again and breaks the other one? If she has high functioning before the fall she can most likely return and she can't do that with a 3x a week PT visit from home health. She also has to bathe, ambulate herself to the bathroom, and provide for meals and take her meds. Not everyone with a broke hip can do that themselves or has a family member to stay with them...that is why we have skilled nursing facilities.

OMG, are you really using "you can be self pay" at over $7,000 a month as justification I am incorrect? Most people don't have that laying around. It's not insurance fraud as evidence has to be sent over and the stay has to be justified and approved by insurance unless it's Medicare and then that patient had better fit the critieria.

Tell me again what the woman with a broke hip is supposed to do for rehab? What if she falls again and breaks the other one? If she has high functioning before the fall she can most likely return and she can't do that with a 3x a week PT visit from home health. She also has to bathe, ambulate herself to the bathroom, and provide for meals and take her meds. Not everyone with a broke hip can do that themselves or has a family member to stay with them...that is why we have skilled nursing facilities.

If someone has Medicare Part A as their primary insurance, Medicare will pay for skilled nursing facility (SNF) care (with some copays) after the pt has a 3 day inpatient (IP) stay. If a pt is admitted with a broken hip, the will almost certainly have a 3 day hospital stay, and they will qualify for SNF care with Medicare. There are some instances, however, where a pt may not qualify for an IP hospital stay (say, difficulty ambulating with no other obvious medical issues). To qualify for SNF care, that pt would have to be admitted IP (not observation) for 3 days before Medicare would pay for a SNF. I have heard of situations where a person is admitted, even if they don't meet IP criteria, so that Medicare will pay for a SNF. Even though the person actually does need skilled nursing, this would be fraudulent based on the rules the government has established. For individuals with a Medicare Part C plan, rules are different, and the insurance company managing the pt's Medicare can authorize SNF care even with no IP stay.

If someone has Medicare Part A as their primary insurance, Medicare will pay for skilled nursing facility (SNF) care (with some copays) after the pt has a 3 day inpatient (IP) stay. If a pt is admitted with a broken hip, the will almost certainly have a 3 day hospital stay, and they will qualify for SNF care with Medicare. There are some instances, however, where a pt may not qualify for an IP hospital stay (say, difficulty ambulating with no other obvious medical issues). To qualify for SNF care, that pt would have to be admitted IP (not observation) for 3 days before Medicare would pay for a SNF. I have heard of situations where a person is admitted, even if they don't meet IP criteria, so that Medicare will pay for a SNF. Even though the person actually does need skilled nursing, this would be fraudulent based on the rules the government has established. For individuals with a Medicare Part C plan, rules are different, and the insurance company managing the pt's Medicare can authorize SNF care even with no IP stay.

I have an extensive case management background so I am very familiar with the process and guidelines. However, I can count on exactly how many people I have placed in skilled nursing willing to cash pay: Zero.

However, that isn't the question I answered. I didn't say anything about committing insurance fraud. A fractured hip meets inpatient criteria typically based on PT/OT evaluation.

If a hospital makes it a regular practice to place patients in inpatient status when they don't meet the criteria, failing too many RAC audits will put your whole organization at risk.

Ihave seen this before it is the insurance which will cover being seen in ER,and all the tests, but in an office.Sometimes Cobra insurance was like this.

I understand your frustration but the ER is the only choice many have. Many doctors offices will not see you without insurance or cash in hand. The American system is broken.