Wasteful use of Emerg

TCW · Mar 10, 2002

I am still in nursing school, but I work for a health insurance company processing claims. I am amazed at the claims I handle daily from people who could have waited until morning or are too clueless to pick a Primary Care Provider so the entire ER becomes their own little PCP clinic. Some people go to the ER several times a week...which I find ridiculous.

The thing that bothers me is that a lot of folks go to the ER, don't call there PCP to get approval so the claim gets denied (depending on the situation) and eventually the hospital "eats" the cost. Don't get me wrong...I am not taking the side of the insurance companies because believe me, I see a lot of crap...it's just crazy.

babynurselsa, RN · Mar 10, 2002

Fergus, I agree with you 10000%. I used to get so angry with the people who would come in to the ER with the assorted BS c/o. Invariably these losers would be the ones standing in the hall having fits because we just roomed a chest pain or a real SOB when they were there first. Then when you did get them roomed it would be murder to get them off the phone to do an assessment on them. My standard question to the stomach pain x 3wks would be why was it an emergency tonight, no date? or was your cable out?

These folks do not care what an ER visit costs because they have no intention of paying for it anyway, nor do they plan to pay for the ambulance that brought them to the ER.

Charles S. Smith, RN, MS · Mar 10, 2002

There are all kinds of reasons why people hit the ED doors with what, we as healthcare providers, know are not emergencies. But, we are healthcare providers, and the general public think we are there as a walk in clinic for any and all ails. What we define is an emergency is certainly different than what they think an emergency is. By law, our doors are open and we must treat regardless of the symptoms. Sometimes people just need to be reassured that they OK, sometimes they just need someone to listen, sometimes what seems minor turns out not to be. And yes, some use it as the gateway to the healthcare system because they have no insurance and have no where else to turn. We can not judge their motives, only educate them as we go, hoping to help them understand that coming to the ED requires some thought. Once they come through the doors we are duty bound as patient advocate and that means helping them find different avenues for care as we can. The MDs have a role in this too and I am more concerned with inappropriate and extensive medical care that reinforces their belief that the ED is the best place to come. Educate your docs too.

I recently had a conversation with one of our new ED docs who, in addition to writing lots of prescriptions, wanted to send pain meds (narcotics) home with the patient so the patient would not have to go to the pharmacy at nite. My position was, we are not a pharmacy dispensing service and in fact our liability is increased if we give meds to go, they take them on the way home and get in an accident rather than waiting to take the meds at home. If they can get here for minor problems, they can get to a pharmacy.

So educate everyone you can within the scope of your hospital policy and treat them and street them....with dignity intact.

chas

MickeymomRN · Mar 10, 2002

All of you said it all for me. So I'll share this story with you. We had our typical ambulance run come in with a primip labouring teenage patient. While completing our paperwork, resident asked why she took the ambulance in if she wasn't really hurting and she wasn't bleeding (I guess they try to educate them in the clinic at their office visits). I forgot to tell you that her entire room was packed with friends and family. I worked at a family- birthing hospital setting. You know the one where anyone can watch? Anyways, her answer was "My family didn't have room for me in the car." I lost it. I started laughing. Since I can't control what I want to control, I always laugh. The resident was not amused. He "yelled" at her by saying that she should've told them that she's the one who needed to go the hospital and that they should've called a cab. And that hopefully someone wasn't out there fighting for their life but couldn't get help quick enough b/c they were busy cabbing her to the hospital while her family followed in their car. And the looks he drilled into the family. I wasn't laughing by the time he was done. I told him that he did a good job not letting that get by without a response. He said that he too was tired of the indirect wasteful actions of our government funds. Which is surprising to find that people don't realize is coming out of our hard earned paycheck. Hmmm, we're in a way paying ourselves for the work we sweat out.

How come insurances can place a stipulation about calling the PCP first etc,etc. and those on welfare can call ambulances for rides or come into the ER for a cold? And they don't have to pay a dime? They don't have to fight the government to get them to pay the bill? Just some thoughts about the weaknesses in our medicaid system.

fergus51 · Mar 10, 2002

I just find it frustrating, probably particularly because we don't have private health care here so the waste is a VERY serious issue. I wasn't a big fan of the US system because it was so expensive I saw people delaying treatment when it was really needed, but it seems like a lot of Canadians go too far the other way. Just because we don't get a bill for the ER visit, doesn't mean it doesn't cost anything! Our gov't just finishing legislating a contract on RNs and now docs and upping our health care payments because the system is too expensive.

I am really concerned that the new gov't is going to bring in private two-tiered health care because of the public perception that universal health care is impossible. I maintain that our universal health care isn't too expensive, it's MISMANAGED!!! If people don't stop wasting soooo much money for BS like "I was worried about tetorifice after getting a scratch (even though my tetorifice shot is up to date)", this system is going to collapse. My friend said she brought her sister in because it was the only way to get her to stop crying. When I was 14 I didn't get my way and waste a few hundred bucks from the health care system everytime I threw a fit. It's one thing if she thinks she needs to go, but the fact that an adult would take her in just to appease her absolutely infuriates me. I HATE IT SOOOOOO MUCH!

TCW · Mar 10, 2002

How come insurances can place a stipulation about calling the PCP first etc,etc. and those on welfare can call ambulances for rides or come into the ER for a cold? And they don't have to pay a dime? They don't have to fight the government to get them to pay the bill? Just some thoughts about the weaknesses in our medicaid system.

MickeymomRN,

This is a good question. I have worked for both commerical insurance companies and medicaid and the things that get paid under medicaid are astonishing. The fees that are paid to the docs/hospitals are quite low, but the patients who are abusing the system generally don't have to pay a dime.

hogan4736, BSN, RN · Mar 10, 2002

Originally posted by Charles S. Smith, RN, MS
There are all kinds of reasons why people hit the ED doors with what, we as healthcare providers, know are not emergencies. But, we are healthcare providers, and the general public think we are there as a walk in clinic for any and all ails. What we define is an emergency is certainly different than what they think an emergency is. By law, our doors are open and we must treat regardless of the symptoms. Sometimes people just need to be reassured that they OK, sometimes they just need someone to listen, sometimes what seems minor turns out not to be. And yes, some use it as the gateway to the healthcare system because they have no insurance and have no where else to turn. We can not judge their motives, only educate them as we go, hoping to help them understand that coming to the ED requires some thought. Once they come through the doors we are duty bound as patient advocate and that means helping them find different avenues for care as we can. The MDs have a role in this too and I am more concerned with inappropriate and extensive medical care that reinforces their belief that the ED is the best place to come. Educate your docs too.

I recently had a conversation with one of our new ED docs who, in addition to writing lots of prescriptions, wanted to send pain meds (narcotics) home with the patient so the patient would not have to go to the pharmacy at nite. My position was, we are not a pharmacy dispensing service and in fact our liability is increased if we give meds to go, they take them on the way home and get in an accident rather than waiting to take the meds at home. If they can get here for minor problems, they can get to a pharmacy.

So educate everyone you can within the scope of your hospital policy and treat them and street them....with dignity intact.

chas

With all due respect Charles, there is a massive shortage of space in our ERs this winter... I work in Phoenix, AZ and I am absolutely frightened of the state of affairs our ERs are in right now.

That being said, we NEED to judge their motives for coming to the ED.

I work in an all-night walk-in urgent care. At 0230 on Thursday morning, we sent a patient to the ER (by private auto), as he required bloodwork, which we don't provide after 0200. He arrived at the ER, and was told there was a 7 hour wait (I had called a phone patch to the charge nurse prior to his departure)

He then drove back to the urgent care and said "I just want medicine for pain. The wait is 7 hours and I have an appointment at 10 AM" I politely roomed him, and let our doctor know.

10 minutes later I see a fire truck and an ambulance pull up. He scurries out to meet them. I followed, and asked his wife what happened. She said "he wants to see someone NOW!" I remarked (to her) that his action was inappropriate, and let the medics know what had just happened. They glared at him, he confirmed, and they loaded him up for a ride to the ER (2 blocks away, mind you). I call the charge nurse at the ER again, and she tells me that she will boot him to the lobby to wait his turn (for his chronic ailment).

Well, he DRIVES back SEVEN minutes later, wanting to now bee seen for a headache, and asks for my name. I room him and inquire as to his issue w/ me. He implies that I am responsible for his being sent to the waiting room at the ER, and says "you're not the judge and jury. it's none of your business anyway"

I inform him that since I am the only nurse here, an ambulance coming to this clinic IS MY BUSINESS, and I walk away.

Charles, this idiot doesn't need reassurance, he needs to be arrested. As I informed him, he could have been delaying care for an actual sick patient, and HOW DARE HE BAHAVE THIS WAY.

We have an obligation to inform and educate, customer service be damned!!!

Any thoughts anyone?

CEN35 · Mar 10, 2002

hey fergy????? look at the lame awards in off topic...lmao!!!!!!!! :chuckle as much as i despise people like that, hey i need some type of humor at work? :roll :chuckle

me

Charles S. Smith, RN, MS · Mar 10, 2002

Hogon...I too am disturbed about the packed conditions in the ED and yes, they get very unsafe. The person you described is taking advantage of a dysfunctional system that is open to this kind of abuse. I dont judge his motives, they are clear. The fact that he can get what he wants in the manner he wants it is the problem. I deal with these folks night after night and I do take the time to ask a few questions when i can, rather than make assumptions about what is going on with them. And the problem wont be solved with mere education, but with hard data going to our legislators in both our state houses and in Congress. Complaining about the fox that is given the keys to the hen house is futile really for that is what we have done in our abusive healthcare system....

my best

chas

dstout-rn · Mar 10, 2002

When i worked ER we actually had people call and ask if they could make an appointment!!!!!! If we explained we don't take appointments and blah blah blah....call your doctor, their answer was well you guys ARE my doctor and i want to make an appointment. Given these patients and the n/v for two years and now its an emergency at 0100 with a 5 hour wait, but can I have a coke and ham sandwich just blow my mind! The 3 times I have been an ER patient in my 27 years of life, the last thing on my mind was food.

I don't know what the answer is but one needs to be found soon!!

kids · Mar 11, 2002

Here'a wasteful use...perpetuated by the ER, really a case of over treating...

As some of you may know my Mom is a new lung ca and started chemo last week (which she sailed through with her only c/o being the s/e of Compazine).

She calls me last evening at 1930 with c/o HA, body ache and oral temp of 101.4. I go over and assess...she is at baseline except her c/o, Picc site is clear. I call the ONC, he sends her to the ER for a CBC and Chem ONLY and calls the ED to let them know who she is and why she is coming. Bear in mind that Mom is a patient of the Hospitals own cancer center.

We get there @2030- I go to triage and stand in line and tell them she is in the car, is a chemo pt and is possibly immuno suppressed and we are here for a blood draw as instructed by the ONC. No problem, ONC called, all we are there for is a blood draw...right into a room we go, she is assessed and 'red dotted' (emergant). We then get sent out into the waiting room "full wall to wall with coughing & puking people, I asked for a mask for her and was told they didn't have one- I took her back to the car to wait. 1 hour later she is called back, the Nurse seemed 'annoyed' I had to get her out of the car. Into a room we go...she was quickly assessed...Nurse says she needs RT for a 'treatment', lungs are clear, wheezing is from a tumor pressing on the left broncus. Doc comes, orders an in & out urine with C&S, CRX and CBC/chem and blood cultures. Mom c/o HA, asks for Tyl.

IV therepy comes to do the culture from the PICC, insists it must be the source and wants to pull it...we refused (Doc agreed with us, was put in 4 days ago in the cath lab). All blood work is done. Mom c/o HA, wants Tyl...

Nurse comes along and hangs a litre of NS via the PICC 'cuz Mom "looks dry" (Doc had said she looks OK-she's at baseline, is a mouth breather and has cotton mouth). I tell the Nurse Doc wants cath UA and Mom has to pee, Nurse gets BSC (?). Ring bell later 'cuz Mom is done...tech comes...won't empty BSC or remove 'cuz its "chemo urine and its not my hall". Mom c/o HA still no Tyl...

Neuro comes and wants to do LP for 'intractable HA with nausea' Nurse is setting up the LP kit as he speaks...we refuse.

Neuro orders 1-2mg IV Dilaudid for HA (hello?). And IV phenergan for N/V (hello she has none! and never has. ATE before, during and after chemo and is eatting and drinking fine since). Nurse gives 1mg (thank God) and the Phenergan.

2430-Doc comes back, asks us if the UA is done yet (no). Blood is back, chem is dead center on every range, CBC is across the board on the lowest # in the range.

0130...Nurse comes and does the UA...RT shows up to do their bit, Mom now asleep in NAD (dilaudid)...he gets abit 'testy' when we refuse the tx...sets up supplies "just in case she changes her mind". Mom asks for Tyl for HA.

0200-ONC calls the ER...he is PIZZED!...sent her they for a blood draw, NO abx unless cultures grow DO NOT PULL THE PICC LINE FOR ANY REASON and get her out of there before she catches something! I go to 7-11 and buy Tylenol and give her 1000mg.

0230....Urine DIP came back +nitrates.

0330 they hang Cipro 400mg IV---did you call the ONC? No, UA screens pos. for UTI. HA is almost gone, temp 99.1 oral.

0430- I call the ONC at home, on his advice I flush the PICC, get her dressed and am signing her out AMA as the ONC arrives in the ER...

1600 today: all cultures are neg, Mom feels much better...ONC thinks it's viral and a coincidence.

What really sucks is the Docs on the Peds cases staffed by my agency send the kids there for after hours blood draws (licensure issue with the state) on a regular basis with NO problems.

I think they saw a cash cow walk in the door. Mom is Medicare and has private insurance for her part B the blood draw would have been a $10 co-pay, now its a $100 co-pay for an ER visit with no admit. I will be making sure the visit gets pulled for UR.

In addition my Mom was given drugs she didn't really want or need, had specialty consults she didn't want or need and spent 8 hours NOT sleeping in her own bed. And was exposed to God knows what (I didn't mention only the primary Nurse washed her hands-and then only once, her very first trip in the room?).

We have an appointment with the ONC on Wednesday. I am doing her PICC dresings to keep costs down and to avoid her having to go out the week her counts are down I am going to set it up for me to have the supplies to do the blood draws when a situation like this comes up.