Are there FSEDs that actually see high acuity?

[alpinism]

So I'm in academics right now and I've noticed that many groups are requiring new grads to work at multiple sites which often includes single coverage FSEDs affiliated with local hospital systems. For obvious reasons I think we can agree that its best for new grads to not work at these kinds of sites especially since most usually see very low acuity patients compared to regular hospital EDs. This is supported by the multiple studies including one a couple years ago which showed that on average they only admitted 4% of patients which equates to 0.4% patients requiring critical care.

To put that in perspective that's 1 in 250 patients seen in your average FSED based on the studies.

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[EctopicFetus]

So I'm in academics right now and I've noticed that many groups are requiring new grads to work at multiple sites which often includes single coverage FSEDs affiliated with local hospital systems. For obvious reasons I think we can agree that its best for new grads to not work at these kinds of sites especially since most usually see very low acuity patients compared to regular hospital EDs. This is supported by the multiple studies including one a couple years ago which showed that on average they only admitted 4% of patients which equates to 0.4% patients requiring critical care.

To put that in perspective that's 1 in 250 patients seen in your average FSED based on the studies.

I agree with everything but your admit to critical care deal makes no sense. General rule of thumb is about 20-30% of admits are critical care. Depends on your billing of level 5%.

 

[RuralEDDoc]

What does “best for new grads” mean? Best for their growth and learning? Residency is over 🤷‍♂️

 

[RustedFox]

This is gonna get snarled, quickly.

Ectopic: I don't think OP is talking about how we code the chart. I think he's talking about *actual* critical care. AFib-RVR and NSTEMI don't really count.

RuralEDDoc: I think we can all agree that the first year out has a significant learning curve, especially now that the newly minted physician isn't at a site even anywhere close to an academic mothership anymore in most cases.

 

[thegenius]

I agree with everything but your admit to critical care deal makes no sense. General rule of thumb is about 20-30% of admits are critical care. Depends on your billing of level 5%.

Where do you get this from?

 

[RuralEDDoc]

RuralEDDoc: I think we can all agree that the first year out has a significant learning curve, especially now that the newly minted physician isn't at a site even anywhere close to an academic mothership anymore in most cases.

For sure. My reply was a bit tongue in cheek, but represented a real perspective. Staffing and managing departments isn’t an easy job in many cases. As a scheduler, I might not have the luxury of worrying about a new grads growth at a relatively low acuity free standing site.

 

[turkeyjerky]

For sure. My reply was a bit tongue in cheek, but represented a real perspective. Staffing and managing departments isn’t an easy job in many cases. As a scheduler, I might not have the luxury of worrying about a new grads growth at a relatively low acuity free standing site.

Sorry, but that’s BS.

The groups that do this, do it in a very intentional way. It’s not about filling holes in the schedule, it’s about creating a group of 2nd class citizens in the group, or shafting new members w/ the lower paying shifts at the ****ty hospital an hour out if town.

Also, if you’re the scheduler and are just filling holes, then you have far more power than you acknowledge. Been there, done that.

 

[EctopicFetus]

Where do you get this from?

There is a formula used by RCM companies which weighs your % of 99285 and admit % and spits out an expected Critical care %. Generally it is 20-30% of your admits

 

[EctopicFetus]

What does “best for new grads” mean? Best for their growth and learning? Residency is over 🤷‍♂️

I think when residency is over it doesnt mean your growth is over nor your learning. Ive been out 10+ years and things change. If I immediately went to work at a low volume low acuity ED my skills I learned would have withered. My group staffs a site that averages 1 intubation PER YEAR (not A typo). While residency is over anyone who finished it can attest to the growth during the first few years in particular. Learning how to run a department, learning how to be truly efficient etc.

 

[EctopicFetus]

Sorry, but that’s BS.

The groups that do this, do it in a very intentional way. It’s not about filling holes in the schedule, it’s about creating a group of 2nd class citizens in the group, or shafting new members w/ the lower paying shifts at the ****ty hospital an hour out if town.

Also, if you’re the scheduler and are just filling holes, then you have far more power than you acknowledge. Been there, done that.

Agreed. Simply as the number of residency grads grows and the sites that train them get sketchier and sketchier “residency is over” might mean we are better than an NP but seemingly fewer will be ready to be a real doctor.

Sticking the new grads at low acuity/low volume sites is a kiss of death for their careers especially in what will become an incredibly competitive job market.

 

[southerndoc]

There is a formula used by RCM companies which weighs your % of 99285 and admit % and spits out an expected Critical care %. Generally it is 20-30% of your admits

20-30% of admissions should be critical care?

 

[Janders]

Free standing ERs aren’t all the same.

I’ve worked at one where certainly it wasn’t tertiary center insanity, but I admitted a couple people per shift, and had critically ill patients (Acute stroke, STEMI, intubation, Sepsis on pressors, trauma needing blood and transfer) at least half of my shifts.

Perhaps being full time there might not be best for a new grad, but doing 20-40% of your shifts there? No issue in my mind.

Now if the admit rate at the FSED is 2% and they haven’t cracked their code cart 8 months… thats an urgent care. And again, as a PORTION of your shifts, no bigggie… but all of them? Meh.

 

[alpinism]

I agree with everything but your admit to critical care deal makes no sense. General rule of thumb is about 20-30% of admits are critical care. Depends on your billing of level 5%.

Sorry to clarify I mean percentage of patients admitted to a full ICU bed (not receiving any critical care time)

Generally speaking everywhere I've worked its been around 10% of admits (20% admissions = 2% ICU admissions)

 

[bravotwozero]

It also depends on whether your FSED accepts EMS traffic. The ones that do are definitely higher acuity.

 

[alpinism]

This is gonna get snarled, quickly.

Ectopic: I don't think OP is talking about how we code the chart. I think he's talking about *actual* critical care. AFib-RVR and NSTEMI don't really count.

RuralEDDoc: I think we can all agree that the first year out has a significant learning curve, especially now that the newly minted physician isn't at a site even anywhere close to an academic mothership anymore in most cases.

Yeah I know it can be a testy subject for many people.

Its crazy though how many groups are basically requiring people to work in their FSEDs to even get any hospital shifts. There's places where literally every job in town requires its new hires to do 25% or even 50% of shifts at them as part of the contract. Then maybe after a few years when there's an opening you'll get the privilege of being able to do more hospital shifts. For all the experienced docs it's not a huge problem however for new grads that's a huge recipe for disaster as they won't get a chance to develop the skills needed to care for critical patients.

 

[RustedFox]

Yeah I know it can be a testy subject for many people.

Its crazy though how many groups are basically requiring people to work in their FSEDs to even get any hospital shifts. There's places where literally every job in town requires its new hires to do 25% or even 50% of shifts at them as part of the contract. Then maybe after a few years when there's an opening you'll get the privilege of being able to do more hospital shifts. For all the experienced docs it's not a huge problem however for new grads that's a huge recipe for disaster as they won't get a chance to develop the skills needed to care for critical patients.

I wanna know where you're finding all these SDGs or quasi-SDGs that can make staffing decisions like this.
HCA and the like just DGAF. You wanna work a FSED straight from residency to death? Sounds like a win for them.

 

[thegenius]

20-30% of admissions should be critical care?

Seems way to high for me

 

[Arcan57]

20-30% of admissions should be critical care?

20% admit rate, 20% of them are crit care - that's a 4% CC rate which seems pretty reasonable. 30% admit rate with 30% of them being crit care is still only 9% critical care.

I think the nature of medicine is changing regarding who staffs where. Hospitals want FSEDs or micro hospitals (MHs) with minimal specialty coverage to shuttle patients from well-insured suburban enclaves to the mothership. Staffing these (relatively) low acuity settings is for many groups a requirement in order to keep the contract. If you've got a large collection of EM docs looking to wind down their careers, then staffing these FSED/MHs takes care of itself for a while. But if you don't have that large collection of senior docs, that means recruiting new docs. So you can piss off the docs that are used to working at the mothership by booting them to the FSEDs to let the newbies develop in a high acuity setting. Or you can keep most of your existing docs who already play well with the mothership's staff at the main ED and recruit new docs to work in a low acuity setting where it's harder to mess up. Most directors are going to pick option 2.

 

[CoolDoc1729]

20% admit rate, 20% of them are crit care - that's a 4% CC rate which seems pretty reasonable. 30% admit rate with 30% of them being crit care is still only 9% critical care.

I think the nature of medicine is changing regarding who staffs where. Hospitals want FSEDs or micro hospitals (MHs) with minimal specialty coverage to shuttle patients from well-insured suburban enclaves to the mothership. Staffing these (relatively) low acuity settings is for many groups a requirement in order to keep the contract. If you've got a large collection of EM docs looking to wind down their careers, then staffing these FSED/MHs takes care of itself for a while. But if you don't have that large collection of senior docs, that means recruiting new docs. So you can piss off the docs that are used to working at the mothership by booting them to the FSEDs to let the newbies develop in a high acuity setting. Or you can keep most of your existing docs who already play well with the mothership's staff at the main ED and recruit new docs to work in a low acuity setting where it's harder to mess up. Most directors are going to pick option 2.

It is too bad, though. My group over hired right before covid so they ended up giving the 6 newbies 1-2 shifts a month at the main place, and half time hours at the brand new FSED. All straight out of residency. 2 years later out of the 6 of them (2) are decent (both of these have given notice) (2) are terrible, the place falls apart when they work and (2) quit soon enough that I don’t know if they can run a dept yet. I learned so much and benefited so much from having someone to run things by for the first at least a year. I pointed this out to the higher powers and was told that “it would be fine” and that was the end of that. They just don’t care if they end up with well trained docs because of it doesn’t work out they’ll just get a different one, and they can still bill if people die (hey maybe get critical care out of it 🙄) It’s very degrading.

Sorry for the rant .. 13 midnights in 17 days talking ..

 

[turkeyjerky]

Or you can keep most of your existing docs who already play well with the mothership's staff at the main ED and recruit new docs to work in a low acuity setting where it's harder to mess up. Most directors are going to pick option 2.

And that's a huge problem. In addition to being shortsighted, it's literally ****ing over your colleagues' careers.

We are definitely headed towards a future where a substantial portion of EM grads end up shafted into an underclass of glorified urgent care docs.

 

[beebermd]

I have personal experience with this.....used to work 12/mth in very difficult high acuity shop. fell in love with easier FSED work so transitioned into part time (4/month) at my normal shop. After about 4-5 yrs I got out of the FSED completely and returned back to 12/mth. I was absolutley blown away with how my skills had deteriorated. It happened so slowly that I didn't even realize it. I probably never would have if I didnt return to a normal ER environment. keep in mind, its not just the docs. You have a whole staff of nurses and techs that suffer the same atrophy. Patient with a O2 in the mid 80s? My normal ER wouldn't blink twice. My FSED would be in crisis mode.......because they forgot what its like to see this 10x day. Older docs who wanna transition out......go for it. But we had some younger docs who decided to go this route right out of residency full time for money and lifestyle reasons......and havent seen a real ER in 5-7 years. Just seems like a waste to me. As a side note, I was the director of the ER when the FSED market crashed in texas and all off a sudden there was a sudden oversupply of docs looking for jobs. My group would not even interview docs who had not practiced in a traditional ER in the last 2 years. Additionally, Some of the FSED docs volunteered to help out the hospitals during covid, and the general feed back was that these guys were shells of what they used to be before they left. I would like to note, that this is referring to FSED that do not take EMS traffic. FSED that have traditional hospital affiliations and accept EMS traffic are a different story and less likely to suffer from the above.

 

[RuralEDDoc]

We are definitely headed towards a future where a substantial portion of EM grads end up shafted into an underclass of glorified urgent care docs.

Agreed. New grads should only be allowed to work high acuity shifts with triple coverage, just in case they have a challenging case and need a little help. Directors should also monitor graduate milestones and procedure logs for at least two years and give frequent feedback in the form of formal M&Ms and case conferences.

But seriously, it’s not detrimental to someone’s career to ask them to work a minority of shifts in a lower acuity area. No one gets upset about new docs taking their share of fast track shifts. We don’t accuse others of screwing careers when a fellowship director allows someone to do a two year fellowship where they work half the number of shifts they would have worked in the community. Predatory scheduling from bad groups is real and shouldn’t happen, but that’s not necessarily what we’re taking about.

Back to the OPs main question - I am unaware of any truly high acuity free standings. The free standing business model depends on relatively low acuity. I’m sure there are exceptions.

 

[EctopicFetus]

20-30% of admissions should be critical care?

A typical Ed will admit 20-30% of patients. So let’s call it a 100 patients. You admit 20-30 people. Of those 20-30% would be critical care. So 4-9%. That’s a broad range. Higher acuity places will be at the top of that and others at the bottom. Most billing companies can get you a more accurate number for your site. The Ed’s I have worked at we have been told 7-9% would be expected.

 

[EctopicFetus]

Sorry to clarify I mean percentage of patients admitted to a full ICU bed (not receiving any critical care time)

Generally speaking everywhere I've worked its been around 10% of admits (20% admissions = 2% ICU admissions)

I’m talking billing 99291. Agreed with 10% of admits going to the icu as a rough guess.

 

[thegenius]

There is a formula used by RCM companies which weighs your % of 99285 and admit % and spits out an expected Critical care %. Generally it is 20-30% of your admits

99285 is level 5
do you mean 99291? that is critical care first 30 mins.

 

[EctopicFetus]

The formula of expected critical care depends on % of level 5 and admits. I can’t remember the exact number but brault (rcm company) had one.

 

[southerndoc]

A typical Ed will admit 20-30% of patients. So let’s call it a 100 patients. You admit 20-30 people. Of those 20-30% would be critical care. So 4-9%. That’s a broad range. Higher acuity places will be at the top of that and others at the bottom. Most billing companies can get you a more accurate number for your site. The Ed’s I have worked at we have been told 7-9% would be expected.

Guess I never thought of it like that. I bill about 10% critical care for all patients.

 

[benem]

I think acuity also depends highly on exactly what type of FSED we’re talking about. There’s a FSED in my system that sees around 30k a year located at a former hospital that closed. It’s actually a pretty high acuity shop because it sees all of the typical presentations to a hospital based ED. I know there are freestandings out there that see 50k or more, especially in Certificate of Need states where hospital beds are highly limited. On the other hand there are FSEDs that patients wouldn’t visit for a true emergency. It’s not like a chest pain patient is going to stop at the dinky strip mall “ER” when a hospital is five minutes down the road.

 

[oldtown]

I think acuity also depends highly on exactly what type of FSED we’re talking about. There’s a FSED in my system that sees around 30k a year located at a former hospital that closed. It’s actually a pretty high acuity shop because it sees all of the typical presentations to a hospital based ED. I know there are freestandings out there that see 50k or more, especially in Certificate of Need states where hospital beds are highly limited. On the other hand there are FSEDs that patients wouldn’t visit for a true emergency. It’s not like a chest pain patient is going to stop at the dinky strip mall “ER” when a hospital is five minutes down the road.

You don’t know how wrong you are. I’m an owner of a FSED-ish facility (physician owned, unaffiliated, no OR/cath lab/procedure suite/icu/L&D)- just an ER and a small inpatient unit. Does not accept EMS traffic or CMS.

We’ve had active labor, horrible angioedema, STEmI’s and NSTEMI’s, brain bleeds, ischemic strokes, drop off overdoses, stabbing, GSW’s, falls > 15 feet with multisystem trauma, anaphylaxis- off the top of my head. All walkins.

Patients with 911 worthy complaints can and do go to the “dinky strip mall ED’s” all the time.

 

[RuralEDDoc]

Was thinking the same thing. Chest pain goes to urgent care all day. Why wouldn’t they go to a freestanding ED? Patients know very little about what each facility is and isn’t able to handle.

 

[Rekt]

You don’t know how wrong you are. I’m an owner of a FSED-ish facility (physician owned, unaffiliated, no OR/cath lab/procedure suite/icu/L&D)- just an ER and a small inpatient unit. Does not accept EMS traffic or CMS.

We’ve had active labor, horrible angioedema, STEmI’s and NSTEMI’s, brain bleeds, ischemic strokes, drop off overdoses, stabbing, GSW’s, falls > 15 feet with multisystem trauma, anaphylaxis- off the top of my head. All walkins.

Patients with 911 worthy complaints can and do go to the “dinky strip mall ED’s” all the time.

Really poor counterargument. If you're around long enough you'll see that stuff. But it's not going to be even close the acuity volume of a regular hospital.

As someone who just went through the job finding process. FSED new grad abuse is incredibly rampant and disgusting. Not to mention you're stuck working 12s which is terrible. I disagree that all residents are same and not ready for working without backup. My hospital sees about 100k/yr with one other irrelevant residency and we consulted consultants as a last line after we tried everything.

But I do 100% agree going to a FSED as a new grad is a terrible decision. Or even if a majority of your shifts are there.

 

[oldtown]

Really poor counterargument. If you're around long enough you'll see that stuff. But it's not going to be even close the acuity volume of a regular hospital.

As someone who just went through the job finding process. FSED new grad abuse is incredibly rampant and disgusting. Not to mention you're stuck working 12s which is terrible. I disagree that all residents are same and not ready for working without backup. My hospital sees about 100k/yr with one other irrelevant residency and we consulted consultants as a last line after we tried everything.

But I do 100% agree going to a FSED as a ne w grad is a terrible decision. Or even if a majority of your shifts are there.

I wasn’t saying that an FSED like ours would have adequate acuity for a new grad. I agree with most here that it is not.

The poster I responded to said “It’s not like a chest pain patient would go to a dinky FSED in a strip mall when there’s a hospital 5 minutes down the road”.

I was merely pointing out that they, and other patients who should have picked up the phone and dialed 911, do it all...the...time.

(In fairness, I bolded the portion of the post I was responding to, which may not have been apparent, so I can see how my reply could have been construed as responding to the post as a whole)

 

[emergentmd]

FSERs comes in two typical shapes and both are roundly disliked by the Old ER guards.
Show FSERs = easy shift = less money
Busy FSERs = single coverage + can get really bad + Typically poorly staffed = same or less $$$ than mothership

So when a new FSER needs coverage, or an outlier less favorable hospital site it get given to the new hire or the newer docs. New grads who wants to be in a sought after site with FSERs will have to pay the dues before going to the mother ship.

I worked at hospital ERs x 20 yrs, super efficient, top 3 highest RVU doc in my group. Worked mostly tertiary sites and some really difficult sites doing high rate locums. Intubation and central lines in 2-3 pts/shift not uncommon. I have put in 3 central lines, intubation in an hr. Been doing FSERs only x 4 yrs and my skill have atrophied. I am sure I could go back to the hospital but would take about a month to get sharp again. I would never recommend doing FSEDs predominately coming out of residency or you will be like a FM doc working in the ER.

 

[Restart13]

Agree with all that is said. I think depending on where you work, all night shifts (currently do it) can equal the same thing. I do less procedures than my colleagues during the day, granted we have other problems (less consultants awake and calling back at night). You can also say for academic docs working in high acuity shops but so isolated from procedures that they can’t work anywhere independently anymore.

 

[EctopicFetus]

Guess I never thought of it like that. I bill about 10% critical care for all patients.

Right. And I’m guessing you rarely critical care a discharged patient. There is a much more specific formula that frankly I’m too lazy to look up but it took into account your 99285s and admit % and gave a very tight range of critical care expected.

 

[southerndoc]

Right. And I’m guessing you rarely critical care a discharged patient. There is a much more specific formula that frankly I’m too lazy to look up but it took into account your 99285s and admit % and gave a very tight range of critical care expected.

Anaphylaxis, SVT, AF/RVR are about the only ones I do critical care for and discharge. SVT rarely exceeds the 30-min mark though.

 

[PianoMedic]

Anaphylaxis, SVT, AF/RVR are about the only ones I do critical care for and discharge. SVT rarely exceeds the 30-min mark though.

Do you critical care anaphylaxis if you don’t give epi? The hives and vomiting or diarrhea technically meets criteria for it but doesn’t really require epi imo. I have a hard time billing critical care time for it without giving epi personally but wasn’t sure how other people practiced.

 

[Zebra Hunter]

Do you critical care anaphylaxis if you don’t give epi? The hives and vomiting or diarrhea technically meets criteria for it but doesn’t really require epi imo. I have a hard time billing critical care time for it without giving epi personally but wasn’t sure how other people practiced.

Why are you not giving epi if they meet criteria for anaphylaxis is the better question. I don’t give epi for the anxious people who claim their throat is swollen and they are itchy but have no objective evidence of rash, wheezing, stridor, voice changes, or pharyngeal swelling…but I also don’t diagnose them with anaphylaxis.

 

[Apollyon]

Anaphylaxis, SVT, AF/RVR are about the only ones I do critical care for and discharge. SVT rarely exceeds the 30-min mark though.

What about asthma?

 

[PianoMedic]

Why are you not giving epi if they meet criteria for anaphylaxis is the better question. I don’t give epi for the anxious people who claim their throat is swollen and they are itchy but have no objective evidence of rash, wheezing, stridor, voice changes, or pharyngeal swelling…but I also don’t diagnose them with anaphylaxis.

Normal vital signs, have urticaria and diarrhea. No angioedema or other airway compromise, no wheezing, not hypotensive or lightheaded or severely orthostatic. They meet technical criteria for anaphylaxis and I discharge them with an epi pen, but I don’t epi them because they don’t have anything life threatening at this time. Sure boards is gonna tell me I should epi them every time since they have anaphylaxis. I will consider it if Benadryl, fluids, solumedrol, Pepcid doesn’t fix them. I don’t see the epi fixing any of the symptoms they’re having any better than the other meds I’m already giving. I then have to watch them for longer (I usually watch about 90-120 minutes without epi, push it to 3-4 hours if I gave epi) and if they have undiagnosed CAD and I give them epi, well I might also be diagnosing their CAD too. If you’re dying or could be soon from anaphylaxis = epi. I have put people with life threatening anaphylaxis on epi drips, had to intubate before their airway closed, etc. So when I see someone who isn’t dying and won’t die from their symptoms, I don’t give them epi. Maybe I’m an idiot about this, but that’s how I have seen it practiced in the community as a med student and then where I trained for residency (different states and several different hospitals).

If anyone else on here practices this way, do you bill critical care time if no epi given?

 

[southerndoc]

What about asthma?

Rarely, but sometimes.

 

[thegenius]

Normal vital signs, have urticaria and diarrhea. No angioedema or other airway compromise, no wheezing, not hypotensive or lightheaded or severely orthostatic. They meet technical criteria for anaphylaxis and I discharge them with an epi pen, but I don’t epi them because they don’t have anything life threatening at this time. Sure boards is gonna tell me I should epi them every time since they have anaphylaxis. I will consider it if Benadryl, fluids, solumedrol, Pepcid doesn’t fix them. I don’t see the epi fixing any of the symptoms they’re having any better than the other meds I’m already giving. I then have to watch them for longer (I usually watch about 90-120 minutes without epi, push it to 3-4 hours if I gave epi) and if they have undiagnosed CAD and I give them epi, well I might also be diagnosing their CAD too. If you’re dying or could be soon from anaphylaxis = epi. I have put people with life threatening anaphylaxis on epi drips, had to intubate before their airway closed, etc. So when I see someone who isn’t dying and won’t die from their symptoms, I don’t give them epi. Maybe I’m an idiot about this, but that’s how I have seen it practiced in the community as a med student and then where I trained for residency (different states and several different hospitals).

If anyone else on here practices this way, do you bill critical care time if no epi given?

I probably would..but I see anaphylaxis about once/year. so I don't remember

 

[BoardingDoc]

My crit care discharges are similar to @southerndoc. As for asthma, if they are sick enough that I'm actually checking in on them several times and giving them mag, yes. Otherwise, no. I probably do one crit care asthma per year.

As to the above question about anaphylaxis: I give epi, I bill CC. I don't, I don't. I also don't document it as being anaphylaxis in the latter case. One, because it's semi wishy washy. Two: if anything bad happens later (biphasic reaction, whatever) I don't want to justify not giving them epi when they were still in the dept. I gain nothing with that dx (assuming you're not billing CC) and I likely open myself up to unnecessary liability.

 

[BoardingDoc]

Anaphylaxis, SVT, AF/RVR are about the only ones I do critical care for and discharge. SVT rarely exceeds the 30-min mark though.

I think I do 30 min cc on all my SVTs. My argument is that I'm spending at least that much time ordering meds, being in the room when adenosine is pushed, charting, writing the dc papers etc. I agree it's close, but if you count all that time I think it's reasonable.

 

[Jabbed]

What about asthma?

I don’t see how you could critical care-discharge an asthmatic as all of the critical care indicators (NIPPV, >2 nebulizer therapies, hypoxia) would warrant at least observation admission. If you want to keep them downstairs for 6-8 hours and then discharge them, then maybe.

 

[BoardingDoc]

... 2 nebulizer therapies ... would warrant at least observation admission.

Disagree. This is certainly the criteria that a lot of people use to justify cc time (and for which I've seen total BS asthma cc time written) but I certainly don't think multiple nebs = admit/obs.

That said, the rare asthmatic I do cc time on and DC is generally in the dept for 3+ hours.

 

[Apollyon]

I don’t see how you could critical care-discharge an asthmatic as all of the critical care indicators (NIPPV, >2 nebulizer therapies, hypoxia) would warrant at least observation admission. If you want to keep them downstairs for 6-8 hours and then discharge them, then maybe.

Just those rare ones that look like badness coming in, but turn around quickly. Wasn't ever even often for me, but, rarity.

 

[alpinism]

It would be interesting to see if FSEDs that accept EMS patients see higher acuity but I sincerely doubt it would make a huge difference.

From everything I've read most are deliberately opened in the richest parts of town next to tertiary care hospitals and often can't accept things like STEMIs, CVAs, or Traumas for obvious reasons. That's pretty much a perfect recipe for having a low acuity emergency department that sees primarily urgent care type complaints. While I'm sure they do see the occasional sick patient you'd expect that it would be much less common than what's seen at your typical community hospital emergency department.