Article on PIT

[turkeyjerky]

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Came across this article about Physicians in Triage.

Curious what others think. I tend to agree with the author. These systems can serve as a stopgap in an overwhelmed ED, but as a primary throughput strategy I find they fail, and have really grown to dislike them.

 

[GonnaBeADoc2222]

Would posit that there is a huge difference between a physician in triage and a "provider" in triage. In the former you have an emergency physician making what I would imagine mostly good decisions and pushing sick people directly into the department.

In the latter you have potentially someone posing as a physician shotgunning labs and radiology and potentially missing real pathology

 

[alpinism]

Completely agree with the article.

Essentially its just a method of shifting resources to low acuity patients to prevent them from leaving the waiting room.

 

[thegenius]

It was implemented at my hospital initially, and purely, as a way to reduce door-to-doc times, but it also allows us to bill for things we couldn't do before. Like we order labs, you get them from the waiting room and then they LWBS. I think the hospital still gets to bill for those labs.

I think patients like it too.

I haven't read the article above and I'll see if I can do it.


EDIT:
I read it, good article and I generally agree with everything as well. Wish there was more hard data in it, and the last paragraph really gives no substantial suggestion on how to fix it. Until we start charging people to come to the ER, or hospitals support us just discharging people without any workup and without any reprisal from the PR department, or just get rid of the liability component of EMTALA, people are going to continue to increase going to the ER. It's free!!!

 

[GeneralVeers]

It was implemented at my hospital initially, and purely, as a way to reduce door-to-doc times, but it also allows us to bill for things we couldn't do before. Like we order labs, you get them from the waiting room and then they LWBS. I think the hospital still gets to bill for those labs.

I think patients like it too.

I haven't read the article above and I'll see if I can do it.


EDIT:
I read it, good article and I generally agree with everything as well. Wish there was more hard data in it, and the last paragraph really gives no substantial suggestion on how to fix it. Until we start charging people to come to the ER, or hospitals support us just discharging people without any workup and without any reprisal from the PR department, or just get rid of the liability component of EMTALA, people are going to continue to increase going to the ER. It's free!!!

They technically aren't LWBS as they have been "seen" which is why hospitals like it. If they've been seen and one of us can generate a chart, that means they can bill for the visit and labs even if the person didn't stay.

 

[RoyBasch]

They technically aren't LWBS as they have been "seen" which is why hospitals like it. If they've been seen and one of us can generate a chart, that means they can bill for the visit and labs even if the person didn't stay.

Exactly, they are technically now 'LWTR' rather than 'LWBS/LPMSE,' which has significant billing implications.

One hospital I work at uses 'PITs.' I would say only 25% (or less) of cases is it 'helpful' from a throughpoint of view. I.e. by the time I see the patient all the necessary workup is back and patient can immediately be dispo'd on my initial visit/conversation with the patient.

75% of the time I either need to order additional workup or they have ordered stuff I wish they hadn't that now needs additional follow up testing (e.g. d dimer on a pt who was PERC negative) resulting in a longer length of stay.

For the most part it's purely about gaming metrics (door to doc time, door to pain med time, door to first order time, etc.) but I don't think it really helps the ER flow that much better.

 

[Apollyon]

What is LWTR?

LPMSE - left prior to medical screening exam?

 

[Siggy]

75% of the time I either need to order additional workup or they have ordered stuff I wish they hadn't that now needs additional follow up testing (e.g. d dimer on a pt who was PERC negative) resulting in a longer length of stay.

Isn't the entire point of low risk Wells, PERC negative to avoid spinning the D-dimer roulette wheel? If they're not low risk Wells, then there's no point in doing PERC.

 

[GatorCHOMPions]

Couldn’t agree more about the point on moral injury and degrading our profession. PIT truly brings to life the concept that we are “glorified triage nurses”. We have it in our ED and is pretty much universally disliked by all physicians except the ones who enjoy shutting their brains off for several hours or admin who use some of the shift time to attend meetings. Although I guess those two groups of people are somewhat synonymous.

And to add insult to injury my shop is hospital employed RVU based (about 40-50% compensation) so these shifts are money losers for the individual doc.

 

[RoyBasch]

Isn't the entire point of low risk Wells, PERC negative to avoid spinning the D-dimer roulette wheel? If they're not low risk Wells, then there's no point in doing PERC.

Exactly. This is why its a problem when PIT orders one.

 

[RoyBasch]

What is LWTR?

LPMSE - left prior to medical screening exam?

LWTR is left without therapeutic reason, i.e. after Medical Screen Exam is done (but not signed out AMA). For the hospital they are still sending bills for a provider encounter and testing peformed. LPMSE is Left Prior to Medical Screen Exam, which I don't think they can generate any charges for.

 

[BoardingDoc]

LWTR is left without therapeutic reason, i.e. after Medical Screen Exam is done (but not signed out AMA). For the hospital they are still sending bills for a provider encounter and testing peformed. LPMSE is Left Prior to Medical Screen Exam, which I don't think they can generate any charges for.

It's spelled "eloped." Your LWTR is just eloping. LPMSE is just LWBS. I understand that these new terms probably allow for some more granular data mining, but unless you had explained it, I would have literally no idea what "left without therapeutic reason" is meant to convey.

 

[thegenius]

Yea...you either
LWBS - left without being seen - you are registered but not seen by a provider. Like you register your name and your chief complaint, told to sit in the waiting room, get tired of waiting and just leave.
Eloped - you are seen by a provider and are in the middle of a workup. Then you leave

I do understand there might be some confusion if you as a pt go through PIT. I guess technically if you are PITted, then leave, it's probably elopement even though you were seen for 30 seconds.

The intended difference between LWBS and Eloped, at least theoretically, is that one designates usage of ER resources (nurses, doctors, lab techs, and other services) that should be billed for, and the other does not.

All the more reason why we really just need to charge people to use the ER. No matter what their complaint is. You register your name and pay $50 bucks. If you are LWBS, you can get your money back. If you elope at any time during the process, you forfeit your $50. Hospitals need to grow some PR balls and charge people for using the hospital. And doctors need to say "ADIOS" if you can't pay and don't have an emergency. Everyone is so scared of the PR ramifications and social media.

 

[martvubo]

Yea...you either
LWBS - left without being seen - you are registered but not seen by a provider. Like you register your name and your chief complaint, told to sit in the waiting room, get tired of waiting and just leave.
Eloped - you are seen by a provider and are in the middle of a workup. Then you leave

I do understand there might be some confusion if you as a pt go through PIT. I guess technically if you are PITted, then leave, it's probably elopement even though you were seen for 30 seconds.

The intended difference between LWBS and Eloped, at least theoretically, is that one designates usage of ER resources (nurses, doctors, lab techs, and other services) that should be billed for, and the other does not.

All the more reason why we really just need to charge people to use the ER. No matter what their complaint is. You register your name and pay $50 bucks. If you are LWBS, you can get your money back. If you elope at any time during the process, you forfeit your $50. Hospitals need to grow some PR balls and charge people for using the hospital. And doctors need to say "ADIOS" if you can't pay and don't have an emergency. Everyone is so scared of the PR ramifications and social media.

I don't think it's a PR issue, I think it's a "huge EMTALA fines will far outweigh any revenue from charging up front" issue

 

[thegenius]

EMTALA does not prevent you from charging patients. It just can't delay an emergency medical screening examination and stabilization of an EMC. Because most pts sit in the ED for 2-4 hours while they wait for tests, once the MD sees the patient and order tests, it should be fine to charge them.

 

[deleted836128]

We did provider in triage at my ER a few years back. We had the PAs and NPs do this shift. I did it a handful of times, and it was horrendous. It was so busy that we had ONE shot to figure out what to order on the patient. We had to somehow take a brief history, do a brief physical, order the labs/imaging we thought would be helpful to the docs on, and put a little chart in ("I have examined this patient and ordered labs/imaging with the expectation that they will later be seen by an MD in the main department. At this time the vital signs are stable...blah blah...") all while the bossy triage nurse was leading most of the encounter. By the time she got through her questions she would be pulling another patient back (literally, gave me no time...this was winter so patients were constantly trickling in) so I would have maybe 45 seconds to check out the patient and figure out what to do. By the time the next patient was being questioned I would be putting in orders and my note for the previous patient. It was AWFUL. Firstly, it was awful because of liability - I saw this patient, and now they are going back to the lobby. What if they aren't okay to go back out to the lobby? The triage nurse doesn't care because she doesn't have rooms available. What happens if labs or imaging comes back abnormal and the patient leaves, and I DON'T KNOW they leave because I can't keep track of the zillions of patients I briefly saw, and now there's an abnormal test floating out there with my name on it? What if the provider who EVENTUALLY sees the patient does a crappy job, and I get named because I ordered the tests to start with and I "saw" the patient first? What if the provider who sees the patient fails to notify the patient about an abnormal finding on a test I ordered, such as a lung nodule that turns into cancer and I am on the hook for THAT? And the flip side is, sometimes providers in triage would order tests that the docs in back would not order, and then they would get stuck knowing what to do with it (i.e. D-Dimers... an EKG with questionable ischemic changes that shouldn't have been ordered in the first place... etc.). Luckily my group saw that it was not cost efficient to have a provider in triage so we nixed the idea. Really, nursing protocols take care of a lot. Except why they don't get pregnancy tests on 29 year old females with belly pain is a mystery to me...

 

[USCDiver]

EMTALA does not prevent you from charging patients. It just can't delay an emergency medical screening examination and stabilization of an EMC. Because most pts sit in the ED for 2-4 hours while they wait for tests, once the MD sees the patient and order tests, it should be fine to charge them.

So once you see them in Triage and order a work up have you stabilized the as yet unidentified EMC? Nope, so you can’t ask for money until you have completed their workup.
If you don’t order any workup for a fast track patient, like maybe a simple lac repair, then theoretically you could ask for copay then but that’s too confusing for patients, registration, cashiers, etc.

 

[Groove]

We used to have physician triage shifts at one of my old gigs and as effective as it might be on metrics, etc.. it was a truly miserable shift. Nobody wanted to work them and the only reason a few of us did is because we quickly figured out that it would boost RVU/hr significantly. Still....I hated those shifts.

 

[BoardingDoc]

So once you see them in Triage and order a work up have you stabilized the as yet unidentified EMC? Nope, so you can’t ask for money until you have completed their workup.
If you don’t order any workup for a fast track patient, like maybe a simple lac repair, then theoretically you could ask for copay then but that’s too confusing for patients, registration, cashiers, etc.

If you have a doc in triage who orders tests on a patient, you can absolutely bill them. That is identical to seeing a patient in the ED who goes into a room, sees a doc and then leaves. They still get a bill. The fact that the workup isn't complete is irrelevant to whether or not you bill them. The only likely difference is that it's probably going to be only a level 2 or 3 chart instead of a potential lvl 4 or 5 as there won't be any complex MDM/imaging/etc.

 

[martvubo]

If you have a doc in triage who orders tests on a patient, you can absolutely bill them. That is identical to seeing a patient in the ED who goes into a room, sees a doc and then leaves. They still get a bill. The fact that the workup isn't complete is irrelevant to whether or not you bill them. The only likely difference is that it's probably going to be only a level 2 or 3 chart instead of a potential lvl 4 or 5 as there won't be any complex MDM/imaging/etc.

I was under the impression that thegenius was saying secure payment before any of that because "You register your name and pay $50 bucks. If you are LWBS, you can get your money back. If you elope at any time during the process, you forfeit your $50." very strongly implies that there is a period of time after giving $50 but before being seen by a provider (because LWBS becomes impossible otherwise).

 

[thegenius]

So once you see them in Triage and order a work up have you stabilized the as yet unidentified EMC? Nope, so you can’t ask for money until you have completed their workup.
If you don’t order any workup for a fast track patient, like maybe a simple lac repair, then theoretically you could ask for copay then but that’s too confusing for patients, registration, cashiers, etc.

I don’t think it’s resolution of an EMC, it’s delay. You can’t ask for money, like a co-pay, if it delays seeing or stabilizing the patient.

1395dd (f):
(h)No delay in examination or treatment
A participating hospital may not delay provision of anappropriate medical screening examination required under subsection (a) or further medical examination and treatment required under subsection (b) in order to inquire about theindividual’s method of payment or insurance status.

EMTALA Law

 

[deleted109597]

You can absolutely tell them what their charges may be before their EMC is completely stabilized.

 

[thegenius]

I was under the impression that thegenius was saying secure payment before any of that because "You register your name and pay $50 bucks. If you are LWBS, you can get your money back. If you elope at any time during the process, you forfeit your $50." very strongly implies that there is a period of time after giving $50 but before being seen by a provider (because LWBS becomes impossible otherwise).

Well, technically I don’t know if it’s legal to ask for money up front prior to seeing a doctor. Part of it is interpreting what an emergency medical condition is and whether delay of evaluating and treating that medical condition will result in serious jeopardy. I think we can all agree that there are a sizable number of health complaints that can wait in perpetuity for evaluation without any risk of serious health jeopardy.

I think most hospitals want to avoid this by just asking for payment after you’ve seen a doctor. Whether that is at completion of eval and treatment of the EMC or during eval of it depends on the hospital.

At Kaiser where I work, we ask patients to pay after we discharge them.

The problem with asking for payment though is that the hospital needs to follow up on delinquent accounts if patients don’t pay, and that can be overtly burdensome.

 

[thegenius]

You can absolutely tell them what their charges may be before their EMC is completely stabilized.

Not only that, but request payment. EMTALA doesn’t forbid a hospital for charging patients. You can request payment in the middle of an eval for a EMC.

Someone comes in with chest pain and you determine that they need 4 hr obs, serial EKGs and serial trops to determine if they are having a heart attack. They should have their evaluation commence as soon as possible. If you at the 1 hr mark ask for $100 facility copay, that is legal.

Now, if they refuse to pay, you can’t discharge them because you haven’t completed your 4 hr obs with serial EKGs and serial trops. That would violate the federal statute.