I feel like we are rapidly reaching jump ship level. My own sister (in her 40s with 4 kids and natural born Texas/US citizen) is actively migrating her family to Canada next year. Her daughter with a clef pallet cost her family 90K last year WITH insurance. Her husband makes $150K a year, so they managed...but Christ! My sister is so serious that she already submitted all her immigration papers and is waiting to hear back.
I work in a clinic. The ER at the hospital I work for has sent critical patients to our clinic because they 1) apparently have no staff that know how to evaluate for a emergency (I say this having 8 years ER experience under my belt). I had a patient go to the ER twice in 24 hours for urinary pain, bleeding 1 week post op. They sent him to the clinic pale AF, orthostatic blood pressure 80/40, bladder scan showed 330 after voiding (ended up being a giant number of clots that I got to try to hand irrigate in the OFFICE!). The ER did a UA at both visits and NOTHING ELSE.
You might want to say this is my institution in particular...however I haven't held a job at 1 institution for more than 3 years. I've traveled. So, yes, there are better and worse.....but they are ALL getting worse. Process improvement usually involve trying to make up care gaps with unlicensed, under educated, unqualified people OR have one qualified person do the work of 3-4 people (both of which create gross care gaps).
I wish I could go with my sister. This has only gotten worse in the 15 years I've been a nurse. I'm not proud of my field.
Specializes in Surgical Specialty Clinic - Ambulatory Care.
TonyaMarie said:
I'm noticing it too as a case manager. Not only is there a nursing shortage but the older docs are retiring and the number of medical school enrollees has declined. APRNs are overworked. PCPs are booked for months because none of the medical students are choosing primary care. Thankfully our ER is not that bad but I have definitely seen a shift in the last few years. These problems existed before COVID. The pandemic made it worse.
Yes, the biggest problems I see (that have always been but are worse now) are there are less people with experience so the infrastructure of the hospital systems are failing. There are literally not enough people who understand what needs to be done and there are practically no people qualified to delegate anything to.
A nurse manager can't run a unit because the staff she has need way more education and preceptorship than she can provide. So there are constantly basic things being missed. The more experienced nurses have an over burden of patients, so they can't help mentor. The younger ones have an over burden of patients and don't even know how much they are missing. Management can't make policy because people don't stay long enough for any policy to adhere. The little policy that remains no longer steam lines the unit, it actually becomes a burden too because it is irrelevant. And because the manager is always chasing their tail to keep enough staff on the unit to at least APPEAR to be staffed appropriately, she has no time to enact a well thought out policy that would actually help.
I have never been a manager, because I can see the over burden. I have no desire to get my master's degree, because I see how much they over burden NPs, managers, and clinical educators. I do not view their compensation adequate for the time they have to pour in to their position to get it done correctly. I do not see the value in moving up in my field. Especially since we see how easy it is for people to die or get diagnosed with a terminal disease....where is the value in getting severely underpaid for a job you will never be able to keep up with unless you sacrifice your personal life, health, and time with your family?
I see nothing but poor care, negligence cause by overwhelm, and stagnation because there aren't enough EXPERIENCED healthcare providers in administration or at the bedside. It's like living Lord of the Flies. Children leading children because there aren't anymore adults. So much is getting lost and once it is gone it has to be relearned instead of taught to the in coming crew. I just want out if this field and quite possibly out of this country.
I haven't read through all the comments yet, but from my perspective as a nurse and as a patient, I have felt our system collapsing for several years as well.
I recently retired from an outpt pediatric clinic after working in PICU/trauma centers and a variety of other Pediatric focused positions with a bit of adult med-surg, totaling 40 plus years. I thought the outpatient clinic would be a nice way of easing into retirement while enjoying caring for mostly healthy children and their families. Guess what? It was one of the most stressful positions I'd ever had. Wonderful providers and staff and yet we worked 4-5 nursing staff positions short. Full staff would have been 8 nurses, we had 4. Our manager and supervisor worked everyday on the floor and could not keep up with their own work. I averaged 50-60 hours a week and was pressured NOT to work OT. THAT only added insult to injury and a whole other discussion. Everyone in the practice, including providers, were heavily overworked and several have left the practice.
I'm sure all of you reading this have story after story of examples like mine and worse.
The CEO of our medical system earned over $11 million dollars last year, but they wouldn't pay a decent wage for staff and most felt it wasn't worth the stress.
Specializes in OR 35 years; crosstrained ER/ICU/PACU.
This is the state of healthcare, thanks to insurance companies who dictate our care, & big Pharma who charge outrages prices for meds. It's sad when we're operating, & a surgeon has to choose a lesser implant, repair method, fixation method, etc based on the patient's insurance! I seriously have had to check the patient's chart mid-surgery for that!! Insurance also pushes patients out the door asap.....there's no "care" anymore, just $$$
This is my story. I worked on the front lines throughout the entire pandemic and saw many things I wish I could erase. That being said, I noticed a trend, and brought it to the attention of management. Older white people with COVID were being admitted to the ICU while younger black people were being left in the ER to die. Management informed me it's because of insurance. White people have insurance, and black people don't. Meanwhile, on the news, they are telling the country that black people are dying from COVID at a higher rate because of genetics. I tried to blow the whistle on the hospital, I contacted the whistleblower hotline, and they told me if I know what's good for me I will keep my mouth shut and leave the profession. I blew the whistle in 2022, and they threatened my life. So I left the healthcare profession. I will repeat this. Because I wanted to blow the whistle that they were allowing black people to die alone in the ER for not having health insurance.
Spiker said:
This is the state of healthcare, thanks to insurance companies who dictate our care, & big Pharma who charge outrages prices for meds. It's sad when we're operating, & a surgeon has to choose a lesser
Specializes in Surgical Specialty Clinic - Ambulatory Care.
Everyone knows, should know, that brown people are worse off in our healthcare system than white people. There are TONS of statistics to prove it. Even more disturbing is those statistics remain true even when people of color have adequate, good insurance.
Black uninsured people dying in ERs of COVID....uh, duh? Not exactly whistleblower unless you are saying your institution admitted white people who had no insurance but not black people that had no insurance. It does not surprise me in the least that an ER would do the bare minimum to stabilize a patient and send them home to die if they had no insurance. Under anti-dumping laws, all hospitals with emergency rooms must treat people who have emergency medical conditions, regardless of their ability to pay. Pay attention, they must TREAT them, they don't have to save them. When a patient has had enough treatment in the ER that they can be determined stable (even if you know it won't last) you can discharge the patient. That is all emergency rooms are required to do. They can also have you transported to a charity hospital of your choice, but they don't have to admit you. So apparently you have no ER or ICU experience and quite possibly no experience in a non-profit hospital.
When a patient has had enough treatment in the ER that they can be determined stable (even if you know it won't last) you can discharge the patient. That is all emergency rooms are required to do.
As far as I know, the above is incorrect.
My understanding is the following: Prior legal cases have brought up the definition of stabilizing care, and this includes the definition of emergency care. My understanding is that the general view, based on prior legal cases, is that if a patient's medical problems are such that deterioration would be expected/likely if they were discharged home from the emergency room, then the patient should be admitted for inpatient care, and a duty of care exists in this regard. In the above situation, the stabilization of the patient concludes when the patient is admitted as an inpatient. The exception is that if the emergency room is unable to provide the type of stabilizing care necessary, they must then transfer the patient to a facility where they can receive the necessary stabilizing care.
Specializes in Surgical Specialty Clinic - Ambulatory Care.
Susie2310 said:
As far as I know, the above is incorrect.
My understanding is the following: Prior legal cases have brought up the definition of stabilizing care, and this includes the definition of emergency care. My understanding is that the general view, based on prior legal cases, is that if a patient's medical problems are such that deterioration would be expected/likely if they were discharged home from the emergency room, then the patient should be admitted for inpatient care, and a duty of care exists in this regard. In the above situation, the stabilization of the patient concludes when the patient is admitted as an inpatient. The exception is that if the emergency room is unable to provide the type of stabilizing care necessary, they must then transfer the patient to a facility where they can receive the necessary stabilizing care.
I would say you are correct except I have seen the definition of stabilizing care mean VERY different levels of stabilization depending on the state you are in. Illinois was very through. Madison County had some of the highest rates of litigation in the state that had been won by the patient. So the care in the ER was more to the spirit that you wrote. Here in Texas, it is the wild wild west. I've worked in 3 ERs since living here and I wouldn't consider any of them emergency capable much less able to recognize when a patient is stable enough to be discharged or transferred. So the law is the law everywhere, but the litigation that has actually occurred because of the law, and the outcome of those cases, greatly affect the definition of the law.
This is the state of healthcare, thanks to insurance companies who dictate our care, & big Pharma who charge outrages prices for meds. It's sad when we're operating, & a surgeon has to choose a lesser implant, repair method, fixation method, etc based on the patient's insurance! I seriously have had to check the patient's chart mid-surgery for that!! Insurance also pushes patients out the door asap.....there's no "care" anymore, just $$$
The assumption you make is that in other markets, like lets say Europe or Canada, that their patients are receiving that better implant, repair method, fixation method, etc. I think the difference here in the U.S. is that the more expensive options are just that, options, whereas in many places the basic option is the only option.
I work in medical devices and have friends who work for companies like Stryker in Europe. For the most part, new fancy devices are launched in the U.S. years before they are even considered to be launched in places like Europe or Canada. When they are launched they are typically only available at the private hospitals and/or are available to those patients with insurance.
P.S.
It isn't insurance pushing patients out of the door, it is the federal government. One of the whole points to moving to a DRG based system by the federal government was to encourage hospitals to push patients out of the door.
I would say you are correct except I have seen the definition of stabilizing care mean VERY different levels of stabilization depending on the state you are in. Illinois was very through. Madison County had some of the highest rates of litigation in the state that had been won by the patient. So the care in the ER was more to the spirit that you wrote. Here in Texas, it is the wild wild west. I've worked in 3 ERs since living here and I wouldn't consider any of them emergency capable much less able to recognize when a patient is stable enough to be discharged or transferred. So the law is the law everywhere, but the litigation that has actually occurred because of the law, and the outcome of those cases, greatly affect the definition of the law.
My understanding is that the litigation has occurred due to various facilities' interpretation of the standard of care required in the emergency dept. setting. As I understand it, the outcome of those cases affects what is defined to be the appropriate standard of care in the emergency dept. Also, as far as I know, the threshold for inpatient admission for Medicare is that the patient requires medical/nursing care for an acute illness that cannot be treated at home and for which the patient is likely to deteriorate/would be expected to deteriorate if they are not admitted as an inpatient.
If anyone really wants to know why healthcare is the way it is today in the United States these publications are a good place to start. We are not where we are by accident. The American healthcare system was overhauled starting in the 1980's with PPS which moved into VBP in the 2000s.
"When PPS was implemented, there were strongly held expectations among promoters and skeptics. Promoters of the policy hoped that payment reductions would be matched by lower levels of spending through reduced lengths of stay (LOS), reduced intensity of care, and more efficient hospital operations. Promoters presumed this could occur without financial collapse or compromises in patient care, as large volumes of "slack" were used up (unproductive resources reallocated, unnecessary ancillaries and days eliminated, and so on). So long as hospitals had been reimbursed their costs, they faced few incentives to provide efficient care. PPS gave hospitals new incentives to operate economically.
But there were also skeptics. If hospitals faced new incentives for efficiency, there were serious questions as to whether they faced just the right incentives. An additional test or day of hospital care became costly under PPS, whether medically justified or not, and the narrow financial incentive was the same in either case to eliminate the added cost. Although hospitals would not necessarily strike the wrong balance between patient well-being and their income statements, there was nothing intrinsic to the PPS structure to guarantee that the right balance would be struck.1 While PPS assumed that hospitals and physicians practiced inefficiently, it also assumed that hospitals and physicians would successfully mediate between conflicting pressures to enhance patient well-being and to contain costs. However, there necessarily were fears that the changes in practice patterns induced by PPS would be harmful—that changes in practice patterns would harm patients or, to the extent that hospitals resisted purely financial incentives and maintained quality care, that hospitals would suffer financially. Without pre-existing slack, PPS might well force a choice between survival of the institution and quality of patient care. Indeed, this choice is at the core of any system of incentive payment for hospitals: the "carrot" of being able to keep surpluses and the "stick" of failing to survive."
Specializes in NICU, PICU, Transport, L&D, Hospice.
Asystole RN said:
The assumption you make is that in other markets, like lets say Europe or Canada, that their patients are receiving that better implant, repair method, fixation method, etc. I think the difference here in the U.S. is that the more expensive options are just that, options, whereas in many places the basic option is the only option.
I work in medical devices and have friends who work for companies like Stryker in Europe. For the most part, new fancy devices are launched in the U.S. years before they are even considered to be launched in places like Europe or Canada. When they are launched they are typically only available at the private hospitals and/or are available to those patients with insurance.
P.S.
It isn't insurance pushing patients out of the door, it is the federal government. One of the whole points to moving to a DRG based system by the federal government was to encourage hospitals to push patients out of the door.
Medical devices contribute to our unsustainable health costs. Insurers benefit from pushing patients out of the hospital nursing units and into outpatient care, they lobby for that power.
Simply review health outcomes to understand that fancy and expensive new devices are not improving our overall health or improving our outcomes. They are a profit generating endeavor.
KalipsoRed21, BSN, RN
495 Posts
Yes, the biggest problems I see (that have always been but are worse now) are there are less people with experience so the infrastructure of the hospital systems are failing. There are literally not enough people who understand what needs to be done and there are practically no people qualified to delegate anything to.
A nurse manager can't run a unit because the staff she has need way more education and preceptorship than she can provide. So there are constantly basic things being missed. The more experienced nurses have an over burden of patients, so they can't help mentor. The younger ones have an over burden of patients and don't even know how much they are missing. Management can't make policy because people don't stay long enough for any policy to adhere. The little policy that remains no longer steam lines the unit, it actually becomes a burden too because it is irrelevant. And because the manager is always chasing their tail to keep enough staff on the unit to at least APPEAR to be staffed appropriately, she has no time to enact a well thought out policy that would actually help.
I have never been a manager, because I can see the over burden. I have no desire to get my master's degree, because I see how much they over burden NPs, managers, and clinical educators. I do not view their compensation adequate for the time they have to pour in to their position to get it done correctly. I do not see the value in moving up in my field. Especially since we see how easy it is for people to die or get diagnosed with a terminal disease....where is the value in getting severely underpaid for a job you will never be able to keep up with unless you sacrifice your personal life, health, and time with your family?
I see nothing but poor care, negligence cause by overwhelm, and stagnation because there aren't enough EXPERIENCED healthcare providers in administration or at the bedside. It's like living Lord of the Flies. Children leading children because there aren't anymore adults. So much is getting lost and once it is gone it has to be relearned instead of taught to the in coming crew. I just want out if this field and quite possibly out of this country.