Trouble on the EM Horizon

Won't overall compensation go up? Won't some of the garbage that we see in the ED be removed? I'm having trouble finding negatives, other than this perceived increase in "patient anger levels....therefore leading to an increased risk of liability." It's not like we're in a high risk specialty already......oh wait, we are.

This just shows how "bottom line" driven medicine has become. It bothers me to see MBA's running the show and thinking about patients as dollar signs and doctors as human capital to be exploited!

Uncle Rico said:

Won't overall compensation go up? Won't some of the garbage that we see in the ED be removed? I'm having trouble finding negatives, other than this perceived increase in "patient anger levels....therefore leading to an increased risk of liability." It's not like we're in a high risk specialty already......oh wait, we are.

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I agree. This sounds like a good change.

I had a patient this weekend, with no insurance. He was accidently hit on the head at work 2 days earlier. He came with non-specific complaints and a scratch on the bridge of his nose. After wasting my time (and wasting taxpayer money) he eventually revealed his motive for coming in. He wanted a medical excuse to get out of work for a few days.

It seems like this policy is already in effect to some degree. Someone is triaged with a nonsense complaint. They are seen by a doctor (probably not immediately as in DocB's scenario) and determined to be stable, and they are sent out with outpatient follow up.

The difficulty with the EMTALA medical screening exam is trying to determine what is exactly an emergent condition requiring stabilization. A sore throat, for example, could be an emergent condition requiring appropriate antibiotic therapy to prevent rheumatic fever, abscess, or epiglotitis.

Don't get me wrong. I'd really be in favor of method to screen out nonsense complaints and shunt them to urgent care centers or their PCP. But the whole conundrum is trying to determine exactly who has a nonsense condition and who doesn't. Hence the need for diagnostic testing/observation/examination.

I think differentiating emergent from nonsense complaints is considerably more difficult in an uninsured population, where they may present with more advanced/unusual disease states, and follow up is nil.

If hospitals are pressuring EM docs to certify patients as stable and not use labs/imaging, then that could be a real problem, and possibly a violation of the spirit, if not the letter EMTALA.

margaritaboy said:

It seems like this policy is already in effect to some degree. Someone is triaged with a nonsense complaint. They are seen by a doctor (probably not immediately as in DocB's scenario) and determined to be stable, and they are sent out with outpatient follow up.

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Agree... I don't see this as being a big change. There are other free clinics where patients can be seen free-of-charge for non-medical emergencies. The ED should be reserved for the true emergencies.

"the overall number of pts this will apply to is low."

if by low you mean 10-15% I would agree. if you mean < 10% I would not. in a busy er there are lots of basically bogus pts, including some who call 911. as a pa I probably see more of these folks than those of you who are docs because of how the pts are triaged. in any given day I would say upwards of 15-20% of the pts I see could see their pcp in a week( or not at all and use otc products) without any danger of a worsening of their conditions.
for instance consider these chief complaints:
runny nose since this morning, has not tried otc
yellow toenails x 6 months
my scalp always itches( brought in by als ambulance)
I burp a lot when I eat
I have another yeast infection from using antibiotics
I need a back to work note
I need you to extend my disability status from my back injury in 1982
I have chapped lips
I am out of hemorrhoid cream and if you write an rx the state will pay
etc...etc....etc.....
this is the kind of crap that comes into many er's. most of these folks don't ever pay for evaluation of these nonemergent problems. if the hospitals were starving for pts then by all means let's see all comers, but these folks in the waiting room just delay care for those with fractures, lacerations, and other legitimate urgent and emergent problems. hopefully a good triage nurse will catch on that shoulder pain in a 65 yr old diabetic without trauma needs eval before all these folks but not always. it is a fairly frequent occurence that I find pts with truly emergent conditions accidentally sent to fast track and forced to wait hours behind all the abovementioned bogus pts.
I am all for screening out the nonemergent pts to pcp's and clinics so we can see sick folks.

I'm not too knowledgeable in this subject, but doesn't the person doing triage essentially do what is being proposed (screening pts)? Aren't most EDs following a prioritizing strategy (if 2 people walk in at the same time, the one with the more urgent condition is seen first? At the hospital I volunteer at, triage takes place and the patients are brought back based on the urgency of their condition.

Why not make people who have non-emergent concerns wait in the waiting room until there is time/space to accomodate them?

I'd love to hear some feedback.

Thanks

iatrosB said:

This just shows how "bottom line" driven medicine has become. It bothers me to see MBA's running the show and thinking about patients as dollar signs and doctors as human capital to be exploited!

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I totally agree that this is a sad state. When businessmen run a hospital and not the doctors, that has led the the healthcare problems we currently are having ie malpractice, uninsured, etc.
The hospital where I work is doing something very similar and we definitely have seen an increase in angry patients but then again we do see the critical patients much more quickly. I don't know what is better.

It seems to me that this causes two negatives for EM physicians. First, by evaluating a pt and then send ing them to urgent care or a PCP that in those few cases of a hidden emergent condition that doc is wide open for a lawsuit. Second if the doc has to do a H&P on every pt to decide on keeping them or kicking them doesn't that take up just about the same time it would to see them? And if they are sent away you just took a billable procedure and gave it away (if they want to get all $$ about this).

Future Doc B said:

I'm not too knowledgeable in this subject, but doesn't the person doing triage essentially do what is being proposed (screening pts)? Aren't most EDs following a prioritizing strategy (if 2 people walk in at the same time, the one with the more urgent condition is seen first? At the hospital I volunteer at, triage takes place and the patients are brought back based on the urgency of their condition.

Why not make people who have non-emergent concerns wait in the waiting room until there is time/space to accomodate them?

I'd love to hear some feedback.

Thanks

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EMTALA is a law that mandates that patients presenting to the ER be given a medical screening exam (MSE) to determine whether they have an emergent condition requiring intervention and stabilization, or whether they are already stable. The MSE can specifically NOT be preformed by a triage nurse. Triage only serves to prioritize patients in the ED, or send them to an appropriate venue in the ED(monitored critical care, vs. unmonitored bed).

As it is set up now, people with nonsense complaints are made to wait in the waiting room until they can be accommodated. Sometimes, people self triage themselves right out of the ED and go home, because whatever nonsense complaint they have isn't worse than waiting 14 hours in the ED to be seen. But...since many people have no other health care alternative (the uninsured poor), many very low acuity complaints still get through. Someone mentioned free community clinics, but in my community there are no such clinics, at least not enough to serve the uninsured population. The ED has become that free clinic.

Referring back to DocB's original post: since a MSE must be done for each patient I am not sure where the great time savings comes in, nor where we are spared from the nonsense complaints. We would still have to do a MSE on everyone. So the policy seems a little weird.

On the other hand, if there were a way to shunt low acuity complaints away from the ED before they arrived, then we'd be really be getting somewhere.

On a thread earlier this year, I had asked a question about why hospitals don't set up a 24/7 "clinic" adjacent to the emergency dept. where these non-urgent cases can be sent to see NP's and FP's, and set up appointments for follow-up care/patient education. The responses were really interesting, and of course, had a lot to do with the issue of death/lawsuit resulting from a seemingly non-urgent set of symptoms.
Do you think any of the liability with this sort of a system would be lessened if it were the PATIENT's choice to enter the "clinic" and be seen more quickly, or the ED and wait forever?

(This, of course, coming from a mother on vacation out-of-state whose insurance company told her to take her kids to the emergency room to get antibiotics. You'll be happy to know that I didn't....$270.00 out of pocket at an URGENT care center, instead of $1000.00 in the ED paid in full by insurance. I may be poorer, but at least I didn't have to feel like a hypocritical idiot while waiting in chairs However, if the "urgent care" center had been affiliated with the hospital, the hospital would have billed my insurance (the private urgent care centers will not)

To switch the subject just slightly....

Where I come from (Rochester, NY) all ambulances are triaged. The truly bogus pts. who arrive by EMS are triaged to chairs. Semi-bogus complaints get triaged to a fast-track area, etc.

My EM rotations so far have been in Ohio and PA. At these places, all ambulances are asigned beds prior to arrival, no matter how stupid the complaint sounds. Doesn't this practice encourage people to call ambulances for bull****? I can't figure out why these places do this.

iatrosB said:

This just shows how "bottom line" driven medicine has become. It bothers me to see MBA's running the show and thinking about patients as dollar signs and doctors as human capital to be exploited!

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It bothers me when physicians (or medical students) think that money grows on trees. Without getting paid, we wouldn't survive. We waste valuable resources on patients that cannot pay. We waste almost the same amount of resources on patients that do not need to be there in the first place. Many of these patients now view the ED as a primary care clinic.

I was employed as a paramedic for a hospital that instituted this policy in 1997. We did exactly as you describe, and if I'm not mistaken, this was copied throughout an entire health system. This has worked well in that hospital and is, in fact, still in place today. The number of unnecessary ED visits has decreased dramatically.

Funny enough, the hospital accepts all major credit cards.

margaritaboy said:

A sore throat, for example, could be an emergent condition requiring appropriate antibiotic therapy to prevent rheumatic fever, abscess, or epiglotitis.

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There is <1% chance of developing rheumatic fever with strep. There is a 100% chance of mortality just by being born. Perhaps we should provide medical treatment for everyone simply because they are alive and run the risk of dying in the future.

(OK, I'll quit being sarcastic here.)

This policy IS already big in Texas. But as far as I know the MSE is performed by a nurse practioner (or PA), not by the attending!
If the attending has to do the H&P, I really don't see how there can be any time saved! Depending on how the coverage is where you work, you will be busy with acute patients and the MSE pts will be waiting forever, just as before...

DOrk said:

To switch the subject just slightly.... Where I come from (Rochester, NY) all ambulances are triaged. The truly bogus pts. who arrive by EMS are triaged to chairs. ... [At] my EM rotations so far ... all ambulances are asigned beds prior to arrival, no matter how stupid the complaint sounds. Doesn't this practice encourage people to call ambulances for bull****? I can't figure out why these places do this.

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Good point. Where I work, every now and then (especially if a pt is a known customer) they will send an ambulance to Triage. The truck arrives, the doc does a quick eyeballing there at the back doors... and the medics roll the pt out to Triage to start at square one. All the way past all the cubicles and out to the front.

The look on the face of a truly FOS patient, realizing the ploy did not work, is priceless.

southerndoc said:

There is <1% chance of developing rheumatic fever with strep. There is a 100% chance of mortality just by being born. Perhaps we should provide medical treatment for everyone simply because they are alive and run the risk of dying in the future.

(OK, I'll quit being sarcastic here.)

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An MSE must be done on every patient to demonstrate that their condition is either: a) stable or b) unstable.

The reason we are mandated by EMTALA to do a MSE is exactly because an unstable patient runs the risk of permanent injury or death. By definition, they have an emergent condition requiring stabilization.

We saw two immunocmpetent adults with acute epiglotitis within 3 months, and they spent a couple of days in the hospital with the cric tray by their bed. Also saw a retropharyngeal abscess that later turned into Ludwig's Angina and mediastienitis in that same time frame. Perhaps these patients bypass your ED and come to ours.....

Sarcasm aside, the point was that it can be difficult to weed out nonsense chief complaints (even if they seem straight forward) in the ED without doing the required MSE. That said, and again referring back to DocB's original post, the policy mentioned wouldn't really save us much grief.

how would doing this for every person that comes in affect the time per patient you would typically spend?

does this add to liability issues since you are basically giving a dx right there on the spot?

you are not actually moving out any patients, you are just prioritizing them correct?

Margarita, we've all had our share of extreme cases (sore throat being a retropharyngeal abscess, etc.). However, the minority is not the rule.

Where I used to work, every patient received a brief exam by the physician. Did it save the physician work? Yes and no. Yes he had to do the H&P, but he didn't have to worry about other things (labs, etc.). The hospital receives the greatest benefit, which in turn can be translated to the physician. With hospitals not receiving as many FOS patients, they do not need additional nursing or physician staffing. This turns into more profit for the hospital, which hopefully, will turn into higher pay for nurses/physicians and more technology being purchased.

Likewise, the frequent flyers who come in once per week will be less likely to come in. When the general public in the community get word of what's going on in the ED, then less stupid stuff will present to your doors. We saw our "FOS volume" cut in half within a period of 6 months.

I first heard about this at UC and it sounded like a great idea. Screen out the BS. The problem is, as someone already mentioned, by the time you truly screen out the BS you are 90% ready to discharge. You don't have to treat nonemergent conditions as it is, so just discharge them and be done with it.
If someone's nose has been running for six months with clear lungs and VSS, give them their walking papers and tell them to get OTC cold medicine, FU w/PMD or local clinic.

It doesn't help the docs, it helps the admin people not having to register the patient and the nurses/PCAs not having to prepare a bed. This will probably improve flow but leaves more room to miss true pathology as you don't have any observation period while the patient meanders through the registration process.

The only advantage is that it may discourage your regulars who are looking for a bed, a work note, a meal or a shoulder to yell at. Then again, they'll probably just all start shouting chest pain to avoid this problem, which will create another level of nightmare difficulty. At least now anyone who comes to the ER gets in the door so BS chest pain isn't that common.

The true BS that's difficult to deal with are the patients with multiple comorbidities that have enough of what I call 'medical welfare money' to buy a workup. Patients with DM, HTN, ESRD can pretty much say anything and at least get a basic met or EKG to evaluate their K, and any chest pain buys an admission. Many of these people have chronic pains and true chronic which may easily mask acute disease.

I can see the value of screening out the nonemergent and directing them elsewhere. I just hope this only happens when there are adequate resources for those pts who truly do need care but just not necessarily in the ED, right now.

How would you feel to be in margarita boy's area where he says these resources don't exist, and turn away someone who needs care but doesn't meet the criteria, all the while knowing they have no other option for treatment? "Yes, Mr. Jones, that is a terrible case of toe fungus. You will need an prescription-strength med to treat that. Yes, I am a doctor and I have the authority to write that prescription but I'm not going to. You have no money? There are no free clinics? I'm sorry, you'll have to figure that one out on your own. Good bye now, I need to see the next person." Sure, this hypothetical Jones is unlikely to die any time soon of that fungus, but to deny care to those who are too poor to pay up front and who have no other viable routes for care contradicts the values that brought me into the medical profession.

There were Medicaid clinics where I am from, but they were overflowing, and pts often could not be seen in a timely manner. I remember picking up a school-aged boy who had a sore throat and fever, and had been sent home by the school nurse. The mother called the clinic but couldn't get an appt for several days. They waited until evening, and when the boy felt worse she called 911. There was no need for an ALS transport, but her desire to go to the ED was understandable, considering her choices were keep the boy home with OTCs for 4 days, or get him seen ASAP and hopefully back to school sooner. It is with these people in mind that I would hesitate to back such a plan.

Ehh, soon enough the regulars will learn "Chest pain and a suffy nose" and be in the door again for care of their URTI and a free snack.

southerndoc said:

Margarita, we've all had our share of extreme cases (sore throat being a retropharyngeal abscess, etc.). However, the minority is not the rule.

Where I used to work, every patient received a brief exam by the physician. Did it save the physician work? Yes and no. Yes he had to do the H&P, but he didn't have to worry about other things (labs, etc.). The hospital receives the greatest benefit, which in turn can be translated to the physician. With hospitals not receiving as many FOS patients, they do not need additional nursing or physician staffing. This turns into more profit for the hospital, which hopefully, will turn into higher pay for nurses/physicians and more technology being purchased.

Likewise, the frequent flyers who come in once per week will be less likely to come in. When the general public in the community get word of what's going on in the ED, then less stupid stuff will present to your doors. We saw our "FOS volume" cut in half within a period of 6 months.

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I guess I must really be missing the boat here. It sounds like you agree with me that every patient must recieve a MSE. But it also sounds like you are saying a sore throat is a trivial complaint that can be immediatly shunted away from the ED without a MSE to community free clinics or primary docs for those that can afford them. Is that right?

margaritaboy said:

I guess I must really be missing the boat here. It sounds like you agree with me that every patient must recieve a MSE. But it also sounds like you are saying a sore throat is a trivial complaint that can be immediatly shunted away from the ED without a MSE to community free clinics or primary docs for those that can afford them. Is that right?

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No, it doesn't take a minute to do a physical on someone c/o of sore throat. So a MSE is warranted. Sorry I was misreading your posts.

I have several problems with this process. First, it is another example of a 'great ' solution to a problem that doesn't actually address the problem.

Proponents say it decreases waiting times and increases the percentage of paying patients by turning away all of those deadbeats that use the ED for primary care.

First, it turns out the ED isn't actually full of deadbeats without health insurance (Weber EJ, Showstack JA, Hunt KA, Colby DC, Callaham ML. Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? Results of a national population-based study.Ann Emerg Med. 2005 Jan;45(1):4-12.)

The idea, therefore, that you'll end up with a higher ratio of paying patients doesn't make sense.

As for the waiting times, this problem is frequently a symptom of departmental constipation. The real cause of the problem is often found outside of the ED. Anything you do in the ED, short of not admitting anyone regardless of need, isn't likely to help problems occuring after admission.

I have no doubt that this policy will decrease ED volume. I'm just not sure this is really a great idea.

I'm sure it makes lots of sense to the hospital, though. It's a policy that certainly seems to be taking dramatic action to fix a problem. Strong work, hospital administrator! As an added bonus, the hospital will realize the cost savings while transfering the liability to the physician.

This seems to be yet another example of fixing the symptoms and not the problem. Just like EMTALA itself 'fixed' limited access to care by the uninsured.

If we truly wanted to fix this problem, we'd develop a system of universal individually owned (not employer) health insurace that make it financially rewarding for PCPs to actually see their patients in a timely manner.

Take care,
Jeff

T-43.5 hours (not that I'm counting)

Do you guys ever engage in "patient education" to try to reduce the number of bogus visits or to get this patient population to an urgent care clinic (if available)? Or is that considered to be poor form or a waste of breath? I think I'd have a tough time keeping my opinion to myself with some of the cases used as examples.

I would think it is safe to say that most patients don't want to be educated, they want their problem fixed, even if they are the problem. For the most part people just don't care. All they want is a fix (magic pill, ect) to the problem. Urgent care costs money, the ER is "free." You could give your opinion but it'll probably be ignored.

Jambi said:

I would think it is safe to say that most patients don't want to be educated, they want their problem fixed, even if they are the problem. For the most part people just don't care. All they want is a fix (magic pill, ect) to the problem. Urgent care costs money, the ER is "free." You could give your opinion but it'll probably be ignored.

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I wouldn't do it if it didn't help...it's obviously not the solution.

Sweet link to the DecoStop! We are doing our hypoxic training right now and I haven't seen that site before.

NeuroSync said:

Sweet link to the DecoStop! We are doing our hypoxic training right now and I haven't seen that site before.

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Glad you liked the link. Good luck with your training. Nothing like diving. Can't be paged at 100 FSW

Jambi said:

Glad you liked the link. Good luck with your training. Nothing like diving. Can't be paged at 100 FSW

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Don't want to be paged. . . ever. Gotta love shift work (for the most part)! Diving up here in the Northwest is Great...cold and deep, but great! I'd love to check out the Channel Islands, though. We'll have to make a trip down this fall.

Cheers.

docB said:

Exactly, I'm still doing the same amont of work on the same stupid complaints that I always did. It's just that now the people leave angrier. The hospital saves money on this plan, not the docs (the way that I see it done). Now don't get me wrong. I absolutely believe that the doctor patient relationship should be a quid pro quo and that the non-pays are dragging the system down. I just think that the real fix would be to reform EMTALA. Not for hospitals to create policies where the liability for EMTALA and an increased risk of med mal suit is placed on the docs.

I think triaging ambi pts to the lobby is a great idea. It doesn't get done enough where I am. One of the other problems with people that come in by ambi for ridiculous crap is the inevitible "I want a cab voucher." discussion.

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Great dialogue. This policy is most certainly inclusive of several states. Whether "MBA's run hospitals" or not matters little to the current difficulties facing emergency medicine. The fact remains that few places provide patients with 24 hour physician availability and climate control. Patients will not stop coming to the ED. Overcrowding by the infirm and the drug-seeking is a present reality. Neither cash nor money grow on trees. The practice of placing a physician in the triage area is a clever way to put a band-aid on a hemorrhaging lac. Many hospitals in Florida, regardless of their public/private status, are forced to accomodate increasing patient volumes with fewer providers and beds. I can't posit one simple solution, but having physicians triage patients to other destinations (chairs, lobby areas, or PCPs) satisfies requirements under EMTALA and routes patients appropriately.

It seems that the ED functions as this nation's default "safety net" system for patients without insurance or a personal physician. Perhaps money might be better spent in the construction of an after-care area? In our hospital system, the fast-track/minor care areas are constantly busy during their hours of operation. Lines begin to form prior to the clinic's opening. With NPs and PAs, it is possible to extend physician availability and even extract some reimbursement from Medicaid/Medicare. This strategy accomodates the real need for reliable "after hours" care. With liability and health care delivery costs on the rise, the nation's primary care doctors are in legitimate need of assistance. In Florida, for example, many local PCP's utilize hospitalists to manage their in-patients. Patients that have a complaint with any possibility of admission are therefore directed to the emergency department. Though these particular patients are not in need of an EP's services, they take time and resources away from people more critically ill... Broward County recently opened a centrally located 24 hour urgent care clinic that is freestanding, tax-assisted, and staffed by emergency and primary care specialists. The patient's accomodated by this "AftER Care" place are therefore routed AWAY from the ED and into a system more suited to the management of simple complaints. It seems reasonable to have a PA/MD/ARNP/DO tackle a pharyngitis in the clinic rather than divert desperately needed hospital resources to the evaluation of a non urgent problem. I dunno. I can't see this issue disappearing in the next decade.

-PuSh

The problem in Canada is somewhat of the opposite. Everyone is of course medically insured here, so we don't have that problem. The problem we do have is people coming to the ED with runny noses, sore throats, blisters, etc., that then cost the system ~$250 whereas if they had gone to a family clinic it would have only been about $25.

leviathan said:

The problem in Canada is somewhat of the opposite. Everyone is of course medically insured here, so we don't have that problem. The problem we do have is people coming to the ED with runny noses, sore throats, blisters, etc., that then cost the system ~$250 whereas if they had gone to a family clinic it would have only been about $25.

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We don't have that problem here in the States.

(I really wish.)

docB said:

This screening out policy really sucks. I had a 70 yo F who is in between insurances and is going to run out of her htn meds next week. She called her primary and he refused to see her because she doesn’t have insurance so she came here. Because she doesn’t have an emergent medical condition I’m obligated by hospital policy to refill her meds only if she goes through registration and pays cash up front. She didn’t have the cash so she left with a list of local indigent clinics. I guess I’ll be allowed to treat her when she comes back with an ICB.

By the same token I’m in an incredibly bad mood today because I have this 20ish yo F troll who really just has a pharyngitis but is complaining of severe HA, dizziness, neck pain, pleuritic CP, AP, vag bleed, vag dc, N/V, fever chills and generalized weakness. She looks fine but all this other crap is all over the nurse’s chart. She’s a smoker and a drinker and I think she’s likely a prostitute so my $20,000 work up will be, CT head and LP, CT chest, CT abdomen, pelvic with cultures, blood work, IVF, drugs and many, many, many hours of wasted time. Late tonight, at the end of my shift, I plan to dc her with a massive, negative work up and a script for PCN. God I hate defensive medicine. If I didn’t have to be worried about being sued her heels would have been on the sidewalk 2 hours ago.

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That's a bummer as far as the litigious thing goes. I was talking with one of our EM2's about, when I'm in practice, judiciously asking the patients if 1mg of Dilaudid or a turkey sandwich is what they want. I had a guy that I thought was dialysis disequilibrium, but resolved, and wasn't impressed. When I told him he was leaving, he just wanted to make sure I gave him oxycodone.