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Their CEO is an RN and did it citing "less-costly care". As if anybody but her pockets will feel the savings.
Edwards Hospital in Naperville Replaces 14 ER Docs with APRNs
- Thread starter Ronin786
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Their CEO is an RN and did it citing "less-costly care". As if anybody but her pockets will feel the savings.
Naperville, like the rest of Chicago area, is bleeding. They're losing companies, they're losing growth, and taxes are going up up up thanks to Governor Prickster.
Down the drain they go, but rather than lose money at the top, they'll gut patient care for a few years to get a nice juicy bonus check, then they'll cut and run with a promotion in a different hospital.
Down the drain they go, but rather than lose money at the top, they'll gut patient care for a few years to get a nice juicy bonus check, then they'll cut and run with a promotion in a different hospital.
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deleted171991
That's because most mid-career physicians think: they are not MY replacements. They are the future generations'. So why would I fight THEIR war? Sad, but true.
It's a jungle out there... and it's the two-legged animals I am really afraid of.
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Two physicians are on the board and they clearly Ok'ed the move. And these NPs are reporting to two other ED docs that get to keep their jobs. Folks always say they'd rather leave than do certain supervision ratios, but it's a different story when your friends just got the boot and you're next in line.
The problem is these hospitals still have contracts with anesthesiologists, surgical groups, hospitalist groups, cardiologists, ICU docs all privately negotiated. None of these heads have the wherewithal to realize that if the ER docs can be tossed this easily so can they the next time around. I hate unions, but some sort of united stand would go a long way.
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Warning. This is a true story from Edward's for delay in care. Brother in law's father went to Edwards in the recent past. Chest pain, ekg changes, shooting painto middle of the back. They obtained an untimely CT non con after 2 hours into admission. Missed an ascending aortic dissection repeated CT with contrast with pericardial fluid. Why get another scan. Late consult with CT surgery and he died in the hallway on the way to the OR!!! I was on the phone and asked the ER to see if anyone did a POC TTE, labs, where is CT surgery. Response was no qualified people present for scans, lines, no a line no pressure control, etc so hes getting a second scan. That's why he was delayed because they got two CT scans. What a disaster situation.
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Sue their ass.
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deleted171991
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Very sensitive subject happened in the past 2 months.
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deleted171991
I would at least request the medical records.
If there was a clear mistake due to incompetence (the kind that stares you in the face), you'll want to sue in order to prevent the person/hospital from harming others. Nobody is perfect, but there are mistakes and Mistakes. One doesn't futz around with an unremitting typical chest pain for 2 hours.
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Soooooo I don't get it.
Instead of replacing their ED physician with NPs, why can't they just reimburse the ED Physician less for every low-acuity case they see, so that way they can be available when **** hits the fan but not gut the wallets of idiots who decided to use an ED for such a low acuity thing?
Ooorrr just fire 3 ED Physicians and bring on 3-4 NPs who can manage the low level ****? 14 seems drastic
Instead of replacing their ED physician with NPs, why can't they just reimburse the ED Physician less for every low-acuity case they see, so that way they can be available when **** hits the fan but not gut the wallets of idiots who decided to use an ED for such a low acuity thing?
Ooorrr just fire 3 ED Physicians and bring on 3-4 NPs who can manage the low level ****? 14 seems drastic
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deleted171991
Probably because they have a bad business model, and their "Immediate Care" is just glorified primary care. So they only need a paper monkey to sign the charts.
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Should post this in the Emergency Medicine forum so that they know its not only anesthesiologists keeping midlevels in check EMed needs to get this under control.
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I am sorry for your family. We all know odds were not good. But 2 scan in 2 hours?
I hope you guys find some peace.
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Sorry to hear that.
The problem is this country has made a calculus that sub-standard care is acceptable in the name of increased system profits. Corporate physicians and nursing unions/lobbies are complicit in this calculus. They should be demonized and their crimes should be made public.
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I honestly didn't really know him, but def sad for my brother in law. Yeah he presented to the ED at 4 am. First scan at 6 am. I get a call at 7 am from sister in law saying something about a Aortic Dissection. She is actually a RN and had no idea if it was type B type A. So I call the ER as we started to get ready to rush to the hospital, randomly I was visiting Chicago that weekend. The ED contact person tells me that he is getting ready for a second scan with contrast - and I asked why? and they said the first one was without contrast. So I asked does he have an aline, does he have dP/Dt meds, does he have visceral involvement, what about pericardial, coronaries etc, the ED person on the phone was clearly out of their depth. Does he have AI, does he have MR. Since I have taken care of so many dissections I know that AI is bad, but AI and then MR and then Pulmonary edema is a harbinger of death. So I asked how much o2 he's on and shortness of breath he was experiencing. And he was on 6L and coughing.
Anyways, I told them he needs to go to the OR immediately and they said he was going for the second scan. Anyways, its now 8 am when he gets back from second scan and lo and behold arrests in the ER on the way to surgery, they do CPR thing, which is not really ideal with a dissection. Either the second scan was a stall tactic from the private practice CT surgery group or the ED had no idea what to do.
Im actually going to get the medical records now. Thats a great idea. I was going to stay out of it but now I am interested in poking the bear.
DrGasPasser
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OK, time to play a little Devil’s Advocate here. I did a some research and it appears that the Elmhurst Immediate Care facilities are urgent cares, not emergency departments. If this is the case, then the CEO is probably correct to staff it with mid levels. Every hospital urgent care that I’ve ever worked at has been run by PAs and NPs primarily.
As for the aortic dissection case, it’s hard to comment on a case with incomplete information. Perhaps the patient presented in an atypical fashion with flank or back pain and the doctor got the initial non-contrasted scan looking for a stone. Up to 1/3 of patients with AAD suffer a delay in diagnosis due to atypical presentations. I’m not going to criticize another doctor or hospital without some more facts.
As for the aortic dissection case, it’s hard to comment on a case with incomplete information. Perhaps the patient presented in an atypical fashion with flank or back pain and the doctor got the initial non-contrasted scan looking for a stone. Up to 1/3 of patients with AAD suffer a delay in diagnosis due to atypical presentations. I’m not going to criticize another doctor or hospital without some more facts.
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deleted171991
Which part was atypical and wouldn't require at least an immediate bedside TTE and/or CXR (if the CT couldn't happen)?
Otherwise, I agree. That's why I said s/he should get the medical records (and read the story).Modanq said:
DrGasPasser
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I don’t know because I wasn’t there and don’t have access to the chart. My point was that it is common for AAD to have atypical presentations resulting in diagnostic delays. It is possible that this patient initially had atypical symptoms and the more classic features did not manifest until later.
Also, a 2 hour wait for chest pain is pretty standard in a busy EDs across the country. Patients routinely get an ECG in triage within 10 min of arrival and get sent back to the waiting room if there is no STEMI. It is also pretty common for busy EDs to have PAs in triage who order labs and imaging on patients in the waiting room to speed their throughput. Non-contrasted CT studies are generally ordered since waiting room patients can’t have IVs. At my shop it is very possible that this patient would have gotten a non-contrasted study for sudden flank or back pain order by the PA in triage if they were not thinking dissection.
As for a CXR, I’d be a little surprised if one wasn’t done. On the other hand, I would not be surprised at all if it was non-diagnostic since the sensitivity is about 65% for AAD. As for a bedside TTE, it is not standard of care to get one on every patient with acute chest pain in the ED. They are most useful and typically performed on patients with undifferentiated chest pain / SOB and shock to guide downstream diagnostics and therapeutics. If the patient was not hypotensive and a CTA was already ordered, then a TTE is unlikely to add much and will only serve to delay the more definitive test.
Bottom line, there is a lot more to this case that I would need to see before I’m pointing fingers. When reviewing the chart I’d try to ask 2 questions:
1) When should a competent provider have reasonably suspected AAD and was there an unreasonable delay?
2) Once they suspected AAD, did the provider make reasonable efforts to expedite care including lowering shear forces, confirming the diagnosis, and arranging expert consultation? That means starting treatment, obtaining the CTA, and giving the surgeon a heads-up in parallel, not series.
A negative response to either question is a problem...
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deleted171991
If the presentation was as typical as described, the answer to 1 is IMMEDIATELY.
If the delay was due to improper triage by a nurse or midlevel, even more reason to sue.
Regardless, I would get the medical records, and go from there. And no, I wouldn't just sue some poor overworked EM physician who missed an improbable diagnosis (IF that's the case). The hospital is a different story.
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deleted50478
It’s a stretch to compare giving flu shots and testing for Strep at an urgent care center to other services.
DrGasPasser
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Y
You might be surprised at how many of these are mismanaged and result in sudden cardiac death while on the way to the OR. I’ve been an expert witness on 2 in the past 2 years where the diagnosis was unreasonably delayed by more than 6 hours...one at a top tier institution according to US News. The pattern is pretty typical - a less than ideal test such as a TTE or non-con CT has suggestive but non-diagnostic findings such as a dilated aortic root +/- pericardial effusion. The radiologist or cardiologist does not verbally relay that information to the bedside doc or it’s significance is somehow missed in the report. Once, the bedside doc begins to suspect dissection, there are more delays instituting medical and surgical management. In both cases, multiple doctors were named. It’s the passing a pencil through a block of Swiss Cheese analogy - all the holes line up for a bad outcome.
You might be surprised at how many of these are mismanaged and result in sudden cardiac death while on the way to the OR. I’ve been an expert witness on 2 in the past 2 years where the diagnosis was unreasonably delayed by more than 6 hours...one at a top tier institution according to US News. The pattern is pretty typical - a less than ideal test such as a TTE or non-con CT has suggestive but non-diagnostic findings such as a dilated aortic root +/- pericardial effusion. The radiologist or cardiologist does not verbally relay that information to the bedside doc or it’s significance is somehow missed in the report. Once, the bedside doc begins to suspect dissection, there are more delays instituting medical and surgical management. In both cases, multiple doctors were named. It’s the passing a pencil through a block of Swiss Cheese analogy - all the holes line up for a bad outcome.
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Agree with that AAD can have atypical presentation. and I’ve seen them as cath lab cases where a coronary was suspected, or as back pain msk work up, etc....but I would have to say when I got the phone call between scan 1 and 2 it sounded like a more on the delay side and at that point they knew it was a dissection.
I mulled over the case at the time and do think it’s hard to bring the full force of deep medical training even to this ER. I’m pretty sure the CT surgeons there prob do 2 or 3 asc hemi arch or elephant trunks a year so his save would have been a long shot.
I don’t want to hijack this thread but in my opinion we need to be extremely cautious about allowing mid levels into autonomous or in a supervised work setting. The line will be blurred.
I am refusing to train them.
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Have you read the other posts in the thread? It's clearly not always just a flu shot or strep testing. It's the erosion of the standard of care of practice in this country. This isn't midlevels practicing under supervision of physicians. This is midlevels managing all the immediate care centers with two doctors available in case they need a phone call. This model is pervasive across multiple systems.
I can name numerous examples of large systems purchasing smaller hospitals, jettisoning their physicians and staffing with midlevels. These midlevels then have somebody available by phone as a consultant, but they're left to do whatever they please. It's not limited to urgent care clinics. EDs, inpatient wards, ICUs, all of it. And the only cost-benefit is for the CEOs and administrators.
So the public should be aware. Don’t bother going to urgent care. Might as well wait to am to see primary care if weekday. If truly feeling bad. To to ED. At least u have a better chance to see an MD if they are gonna to start with arnp in urgent care only.
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deleted50478
Urgent care is primary care that is open late and doesn’t require an appointment. It’s for minor issues. It’s not an emergency room equivalent and doesn’t require high end staff. The mid levels just need to know enough to transfer anything that doesn’t look quite right to a real ER.
Yes, the public should know, but there’s no monied interest to promote ER over urgent care. The hospital benefits by losing less money in the ED by having patients go to urgent care instead and they profit by catching some appys and choles that might otherwise end up in a different hospital system. They aren’t about to promote ER care. The government should be on the side of an informed public, but they of course actually work for the hospital and insurance lobbies, not the public.
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deleted126335
Except the out of pocket cost to going to ER as opposed to urgent care is significant. The patient that wants an antibiotic off hours for kids OM or Their UTI or just doesn’t want to take off work to see the pcp is well served by going to urgent care.
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I hate to burst your bubble but most primary care offices now staff at least 50% of their FTEs with mid-levels. That is why all of the websites have links to the “providers” instead of doctors. The same can be said for my wife’s OB/GYN and dermotology “provider.”
Americans want someone to provide a pill to fix their ailments - not your expert opinion. Hence the term “providers”....
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Nowadays you can just see a virtual doc online for that.
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I'm going to need proof of that statement.
I'm a PCP working for a large hospital and we're averaging probably 1 mid-level for every 4-6 MDs.
My office is 3-2, and only because we lost 2 MDs in the last 2 years (both retired). My wife's office is 4-1, my uncle's is 5-1. The largest IM group is 8-1.
Everywhere I've been in my home state of SC it's around 3/4-1 in employed offices. The private groups are either all MD or 50% mid-level as you've noted.
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As for the over all thread: I'd love to say UC needs MDs. But I did a year of full time urgent care a few years back. It was the worst year of my life. My wife even said that I seemed happier in residency.
So let the midlevels have it.
So let the midlevels have it.
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Does this mean your group hired midlevels instead of docs to replace the last two retiring physicians? Because that would suggest the ratios will change very quickly in favor of the midlevels. It also implies the midlevels are functioning at the same level as the retiring docs - unless they were part-time/slowing down, or you’re shifting the more complex patients to the remaining docs.
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What you’re seeing does not reflect the country because NPs do not have independent practice in SC. Keep in mind some practices in 22 states are independent NPs - no physicians. Here are the numbers.
There are roughly 210,000 PCPs in America:
U.S. Primary Care Doctor Supply Has Improved But Not Everywhere
The nation’s supply of primary care physicians is helping Americans live longer but “per capita supply” is a worrisome trend for population health, a report in JAMA Internal Medicine shows.
www.forbes.com
There are roughly 190,000 NPs and 90% provide primary care
Nurse Practitioners in Primary Care
Millions of Americans choose a nurse practitioner (NP) as their primary care provider. NPs are advanced practice registered nurses (APRNs) who are prepared at the master’s or doctoral level to provide primary, acute, chronic and specialty care to patients of all ages and backgrounds. As clinicians…
www.aanp.org
There are 120,000 PAs and roughly 50% provide primary care.
So, 170,000 NPs and 60,000 PAs total 230,000 mid-levels providing primary care compared to 210,000 physicians.
While physicians tend to be faster and more efficient than mid-levels, the proportion of patient encounters tend reflect these numbers because physicians often have more non-clinical duties.
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Oh brother....
www.aapa.org
Title Change
Updating the PA title will ensure patients understand the role of PAs in healthcare delivery. Learn more about the change.
www.aapa.org
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No, it means those 2 retired and did not get replaced.
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You didn't read that well. It's 90% of NPs are prepared for primary care but only just over 75% are actually doing primary care (FNPs aren't required to do it).What you’re seeing does not reflect the country because NPs do not have independent practice in SC. Keep in mind some practices in 22 states are independent NPs - no physicians. Here are the numbers.
There are roughly 210,000 PCPs in America:
U.S. Primary Care Doctor Supply Has Improved But Not Everywhere
The nation’s supply of primary care physicians is helping Americans live longer but “per capita supply” is a worrisome trend for population health, a report in JAMA Internal Medicine shows.
There are roughly 190,000 NPs and 90% provide primary care
Nurse Practitioners in Primary Care
Millions of Americans choose a nurse practitioner (NP) as their primary care provider. NPs are advanced practice registered nurses (APRNs) who are prepared at the master’s or doctoral level to provide primary, acute, chronic and specialty care to patients of all ages and backgrounds. As clinicians…
There are 120,000 PAs and roughly 50% provide primary care.
So, 170,000 NPs and 60,000 PAs total 230,000 mid-levels providing primary care compared to 210,000 physicians.
While physicians tend to be faster and more efficient than mid-levels, the proportion of patient encounters tend reflect these numbers because physicians often have more non-clinical duties.
Beyond that, those are some odd sources.
I'm getting more like 230k doctors: https://www.google.com/url?sa=t&sou...Vaw1EY6FQ1scV-TDo_ngqfqQW&cshid=1574677901093
And more like 56k NPs and 30k PAs: The Number of Nurse Practitioners and Physician Assistants Practicing Primary Care in the United States
Now that data is 9 years old, but the article you cited is 6 years old. I find it difficult to believe that it went from 56k to 150k in 3 years.
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I don’t know man. This is taken off the AANP’s “fact page” from last year:
NP Fact Sheet
There are more than 385,000 nurse practitioners (NPs) licensed in the U.S. 1 More than 39,000 new NPs completed their academic programs in 2021-2022. 2 88.0% of NPs are certified in an area of primary care, and 70.3% of all NPs deliver primary care. 3 83.2% of full-time NPs are seeing Medicare…
www.aanp.org
They now describe 270,000 NPs in 2018, of which 73% (190,000) provide primary care. Now, I double dog dare you to call up the AANP and tell them that their “facts” are wrong - you might come down with a severe case of suicide just like Epstein... 😉
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I don’t know man. This is taken off the AANP’s “fact page” from last year:
NP Fact Sheet
There are more than 385,000 nurse practitioners (NPs) licensed in the U.S. 1 More than 39,000 new NPs completed their academic programs in 2021-2022. 2 88.0% of NPs are certified in an area of primary care, and 70.3% of all NPs deliver primary care. 3 83.2% of full-time NPs are seeing Medicare…
They now describe 270,000 NPs in 2018, of which 73% (190,000) provide primary care. Now, I double dog dare you to call up the AANP and tell them that their “facts” are wrong - you might come down with a severe case of suicide just like Epstein... 😉
I wouldn't trust the AANP to tell me water is wet. Their fact sheet doesn't offer much in the way of details, but I'd wager a very large number of that 190k (if true) is CVS minute clinics and urgent care.
That aside, the rapid expansion of NPs is causing problems - for them. Our hospital got bought out last year. The new group has offered our existing midlevels significantly worse contracts than they had previously. When some of them complained, they were told "We get 20 applications for each opening we have for NPs, you don't like it you're welcome to leave. We'll have you replaced by the end of the week."
NPs going back to regular nursing is becoming a very common sight these days because they can't find jobs as NPs.
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I wouldn't trust the AANP to tell me water is wet. Their fact sheet doesn't offer much in the way of details, but I'd wager a very large number of that 190k (if true) is CVS minute clinics and urgent care.
That aside, the rapid expansion of NPs is causing problems - for them. Our hospital got bought out last year. The new group has offered our existing midlevels significantly worse contracts than they had previously. When some of them complained, they were told "We get 20 applications for each opening we have for NPs, you don't like it you're welcome to leave. We'll have you replaced by the end of the week."
NPs going back to regular nursing is becoming a very common sight these days because they can't find jobs as NPs.
I have noticed this also. I have interacted with several nurses who are NPs but continue to work as bedside nurses for various reasons.
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deleted941485
Wow what a travesty. I remember when NPs were the only compassionate souls willing to practice medicine-in those poor underserved rural areas that those greedy evil doctors would never go...Yeah Naperville the emblem of the underserved. Haha.
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That is so bizarre...I’m coincidentally applying for privileges there next month! It seems like it says the changes impact just the urgent care...I feel like APNs under minimal supervision could safely run an urgent care.
If I misread it and it’s actually the ED then I’m nervous I’m going to be getting a lot of pointless consults when I’m on call.
If I misread it and it’s actually the ED then I’m nervous I’m going to be getting a lot of pointless consults when I’m on call.
They're just preparing for the future when 90% of businesses and highly educated residents flee JB Prickter's Utopia, and Naperville turns into yet another post-Democrat hellhole.
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Contact Us | Edward-Elmhurst Health
Fill out this form to contact Edward-Elmhurst Health for general inquires and comments.
we should all be contacting them on their website to let them know what an idiotic decision this is. Some of my colleagues and I already have started.
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I think someone should make a website where the staffing practices are made clear for all to see. Transparency.
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You think pts will look at it and change their medical shopping habits?
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Virtually every ED, urgent care, and physician group in America has a website where people can go and click to “Meet Their Providers.”
Again, I’m not seeing where this hospital is doing anything different than what is being done in urgent cares across America, regardless of hospital affiliation. It seems like people got up in arms because it’s a nurse CEO using NPs. Would they feel differently when it’s a physician CEO making decisions about PAs or an anesthesiologist deciding on CRNAs? Our society has decided that it wants care that is fast and cheap, and mid-levels provide those 2 legs of the system’s 3-leg stool. The third leg, quality, must take a back seat.
