Denying care in the ED?

[iliacus]

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There were many many times when people would present with the flu and when they contacted their FP were told to go to the emergency department. This always happened on the weekend or a holiday. I got into the habit of telling them how long the wait would be (4+) hours and usually that desperate emergency turned into a trip to an urgent care facility the next day.

So, should people be turned away? Sessamoid, docB, febrifuge?

 

[Sessamoid]

There were many many times when people would present with the flu and when they contacted their FP were told to go to the emergency department. This always happened on the weekend or a holiday. I got into the habit of telling them how long the wait would be (4+) hours and usually that desperate emergency turned into a trip to an urgent care facility the next day.

So, should people be turned away? Sessamoid, docB, febrifuge?

I don't know. Do they have insurance? It's amazing how much more crap I'm willing to put up with if I'm actually getting paid to put up with it. An uninsured patient who's belligerent and demanding about non-emergent visits gets no sympathy at all from me, though.

 

[Febrifuge]

So, should people be turned away? Sessamoid, docB, febrifuge?

I had a really long response written, but the essence is yes, with a huge caveat. The problem is how the heck do you identify people who should be turned away, at the moment you do so, with 100% accuracy. Under EMTALA there is no way to not have abuse of the system, and without it there is no system I can think of that doesn't involve at least some unavoidable mortality and morbidity as byproducts.

"Paging Dr. Rock; Dr. Hardplace is on line 1."

 

[docB]

So, should people be turned away? Sessamoid, docB, febrifuge?

Yes. It should have nothing to do with insurance (and remember that I'm the local right wing extremist). If someone has a primary care complaint such as a minor illness or a chronic condition we need a mechanism to divert them to a PMD. I have said many times that an EP is an expensive, poor quality PMD. Now the particulars of financing and liability will sink any attempt to really do this.

 

[Apollyon]

I have said many times that an EP is an expensive, poor quality PMD.

I have appropriated this, and am liberally spreading it around, without attribution, sucka!

I'm tellin' you, dude, from what you post, it sounds like the real metro is like they show on CSI and "Las Vegas". You rock!

 

[k's mom]

Ok, the responses to my original question about a combined clinic/ED were about what I expected, issues with malpractice and cost. If anyone has personal experience with Denver's model, I would love to hear about them. However, I want to clarify a few points:
1. I did not intend for this to be a money-making venture. It just seems that if so few federal and state dollars (including Medicaid/care) are available, and these people will have to be given services regardless, that sharing the cost of the overhead (housekeeping, maintenance, lease, utilities, billing, auxillary staff and services) would make sense and stretch those dollars further. It could simultaneously take the strain off of ED staff, and discourage people from waiting until a simple health issue becomes an expensive crisis.

2. How many malpractice suits are instigated because patients are pissed? HOw many of those same patients/family members are pissed because they felt they were not listened to/had to wait too long/were not given the right information/felt they were ignored/ etc.....? As I said before, ( again, pardon my ignorance if I have made too many assumptions,) educating patients, and being an ear for their complaints, are NOT an EP's first, second, or even third-tier responsibilities. (or at least they shouldn't be) The same is true (again, I assume), for ED nurses and PA staff. They are, however, fundamental responsibilities of FP's and clinic staff. Given a little more time with medical personel, a little more attention, (even assuming their injury/complaint is not even worthy of a phone call, let alone a trip to the emergency room), I wonder how many of these "bad outcomes" would pursue litigation?

Just wonderin'

 

[docB]

2. How many malpractice suits are instigated because patients are pissed? HOw many of those same patients/family members are pissed because they felt they were not listened to/had to wait too long/were not given the right information/felt they were ignored/ etc.....?

You are exactly right. The majority of suits are brought by pts and families for these reasons. That is certainly something that could be helped by a clinic setting. The down sides are that pts don't like being told that they don't actually have an emergency and practically every primary care setting now has to see ~6 pts/ hr to make ends meet.

Just a little perspective on how hard it will be to triage out the silly stuff so it doesn?t clog the ER. My group is going to be staffing a new hospital and the docs have been having an ongoing email discussion about how to handle drunks. Some of us are of the county med center mentality and are willing to just let them sober up, reevaluate and d/c. Others are of the community mindset which figures that any altered person needs labs and a head scan or by the time they sober up they could die. They also assert that if a drunk should pop up seizing from hyponatremia or have any other bad outcome in the future the ED doc will be held liable because he won?t be able to prove that it wasn?t happening when he saw him (clearly defensive medicine but that?s reality).

So even with something a simple as a drunk the ?Can they be triaged out?? question is pretty murky and riddled with liability. The sore throat could always be a PTA and the cough could always be pneumonia. I want these primary care cases out of the ED as much as anyone but there?s really not an easy fix.

 

[Sessamoid]

Some of us are of the county med center mentality and are willing to just let them sober up, reevaluate and d/c. Others are of the community mindset which figures that any altered person needs labs and a head scan or by the time they sober up they could die.

I'm curious whether all of these guys are residency-trained in EM. All the physicians I know who were EM residency-trained would fall into the "county med center mentality." Obviously, if there's a suspicion for fall or head trauma that's a different matter, but I'm fine with letting them lie around until they either sober up sufficiently or I can find a responsible family member to take them home.

I'm not saying it has to be a money-making venture, but it can't be a money losing venture (any more than emergency care already is). You can't effectively triage these patients to a clinic without doing most of the evaluation and testing from an emergency standpoint first. So what you propose is hiring another nurse and an FP to manage their HTN and educate them as well. I'm saying that you can't just mandate such a thing and expect the hospital and physicians to provide even more free care. Either take money from another program, borrow more, or tax more to pay for it. It's a nice idea, but I don't think it's practical for most of the country.

 

[docB]

I'm curious whether all of these guys are residency-trained in EM. All the physicians I know who were EM residency-trained would fall into the "county med center mentality."

Yeah, they are. But, just like every other area of medicine the defensive attitude rules. You don't think in terms of "most likely" you think in terms of "worst possible" and do your workup from there.

 

[Sessamoid]

Yeah, they are. But, just like every other area of medicine the defensive attitude rules. You don't think in terms of "most likely" you think in terms of "worst possible" and do your workup from there.

Just curious: what is your level of comfort re: obviously intoxicated decreased mental status patients? Myself, if the guy is even a little arousable and maintaining his own airway, as long as there's no evidence or reasonable suspicion for trauma, I'll just let them sit with IV fluids and a pulse ox until they sober up.

 

[spyderdoc]

Just curious: what is your level of comfort re: obviously intoxicated decreased mental status patients? Myself, if the guy is even a little arousable and maintaining his own airway, as long as there's no evidence or reasonable suspicion for trauma, I'll just let them sit with IV fluids and a pulse ox until they sober up.

I fully agree. I breathalyze them, and that's about it. I often times won't even start an IV...Just watch them and let them sober up until they are "clinically sober" and then boot them right out the door...If it is 3AM and they are sober, out they go...I am not the nice guy that "keeps them til the morning"....Takes up space, encourages future visits, and if they stay too long, they will start withdrawing....Can't have that now...

 

[ERMudPhud]

Myself, if the guy is even a little arousable and maintaining his own airway, as long as there's no evidence or reasonable suspicion for trauma, I'll just let them sit with IV fluids and a pulse ox until they sober up.

Thats usually been my approach

 

[docB]

Just curious: what is your level of comfort re: obviously intoxicated decreased mental status patients? Myself, if the guy is even a little arousable and maintaining his own airway, as long as there's no evidence or reasonable suspicion for trauma, I'll just let them sit with IV fluids and a pulse ox until they sober up.

That's how I used to do it too but the older guys in the group are telling me I'm nuts. I've started getting labs on most of these guys now and if they don't wake up enough to talk to me I scan them.