Is EM just a bubble?

[jerseytrash]

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Well it also ends up wasting the ED's hospital's money, time, and use of resources to work up primary care complaints, plus lots of people I know going into EM specifically don't want to deal with that stuff... so it's a bit of a conundrum

 

[e30ftw]

despite how fashionable it is to blame ED overcrowding on minor visits, etc, the data doesn't support this.. so imma call SHENANIGANS on yall med studs/non-em residents making fun of the premed for saying most people don't use the ED for true emergencies..

the majority of people who go to the ED have an appropriate reason to be there. good ACEP NEWs article on this a few months ago..


http://www.acepnews.com/news/practice-trends/single-article/most-medicaid-patients-don-t-use-ed-for-routine-care/46380c18c42c25cc7916e5088c240c99.html

http://www.cdc.gov/nchs/data/ahcd/NHAMCS_Factsheet_ED_2009.pdf

the public is held to a prudent layperson standard. someone with CP concerned for MI SHOULD be encouraged to go to the ED even if their w/u reveals non cardiac pathology.

ya'll see a snapshot in time and think you know whats up. Most off service residents rotating in our ED carry 1-2 fast track patients at a time and then go say 'there's no pathology' blah blah while we carry 8+ ESI 2 or 3 pts and a couple level 1s for good measure. honestly on an average shift I admit >50% usually since we have fast track. Just because you spent a little time in the ED and some patients pissed you off (and yes many many of them will do that) doesn't mean they aren't sick.

so show me the data that the majority of ED visits are inappropriate considering prudent layperson standard.

 

[Silent Cool]

Yes, by cut and pasting what I said into segments you can make it look like I called ER docs lazy. But read that again. I said that it is attractive to the lazier students. When did I ever say that I think ER docs are lazy? I even mentioned this later but again people just saw lazy, ER, and decided to get all pissy and focused on certain words.
I don't have to own up to jack. Tell me what part of my statement is wrong? Obviously not all students that go into ER are just looking to be lazy. Ill throw the whole quote in for you from my first post. "It seems to me that almost every person(see how I don't just stop at seems to me)I talk to that wants to go into ER says they just "don't want call"."
As first and second year medical students already trying to pick a specially solely based on call, work hours, and yes I have heard directly "rose petals at my feet", then I call that lazy and glory seeking. They are trying to pick a specialty not based on interest, experience, pathology, ect... just trying to work as little as possible.

Again these are things that I have heard expressed from some people interested in ER. Not my personal feelings about ER docs.

Can't entirely blame people for wanting the path of least resistance or least pain. After all, at the end of the day, it's just a job.

As for the "rose petals" bit, that's weird. And Narcissistic. I would never say that and, anyone who does, is weird.

 

[Textbookversion]

despite how fashionable it is to blame ED overcrowding on minor visits, etc, the data doesn't support this.. so imma call SHENANIGANS on yall med studs/non-em residents making fun of the premed for saying most people don't use the ED for true emergencies..

the majority of people who go to the ED have an appropriate reason to be there. good ACEP NEWs article on this a few months ago..


http://www.acepnews.com/news/practice-trends/single-article/most-medicaid-patients-don-t-use-ed-for-routine-care/46380c18c42c25cc7916e5088c240c99.html

http://www.cdc.gov/nchs/data/ahcd/NHAMCS_Factsheet_ED_2009.pdf

the public is held to a prudent layperson standard. someone with CP concerned for MI SHOULD be encouraged to go to the ED even if their w/u reveals non cardiac pathology.

ya'll see a snapshot in time and think you know whats up. Most off service residents rotating in our ED carry 1-2 fast track patients at a time and then go say 'there's no pathology' blah blah while we carry 8+ ESI 2 or 3 pts and a couple level 1s for good measure. honestly on an average shift I admit >50% usually since we have fast track. Just because you spent a little time in the ED and some patients pissed you off (and yes many many of them will do that) doesn't mean they aren't sick.

so show me the data that the majority of ED visits are inappropriate considering prudent layperson standard.

Your experience is not typical. Most ER's do not admit >50% of patients they see. Go ask around the EM forums. A more realistic number would be 15-25%.

 

[TooMuchResearch]

Your experience is not typical. Most ER's do not admit >50% of patients they see. Go ask around the EM forums. A more realistic number would be 15-25%.

Some are as low as 10%. That said, many EDs have fast track areas during the day where the majority of the "not sick but need something the FM clinic doesn't do" pts are treated. Since students/residents/staff don't often work these areas (supervising doc notwithstanding), our admit rates tend to be much higher.

 

[e30ftw]

Your experience is not typical. Most ER's do not admit >50% of patients they see. Go ask around the EM forums. A more realistic number would be 15-25%.

shenanigans. don't change the subject cause u can't find the data. the post was about % of ED visits that are appropriate, not admission rates.

thanks for clarifying though because as an EM resident I never peruse the EM forums nor do I have any idea regarding admissions in community hospitals.

i'm a resident at a level 1 trauma center with a PA run fast track. we see the sickest patients since we're residents so often my admit rate is >50%. that has little to do with the overall theme of the prior post however as I only mentioned admission rates to contrast the experience of medical students and off-service residents (who see fewer, less sick patients and therefore think ED is all fast track) with EM residents/attendings (who see more/sicker patients)

Read the whole post, read the articles I linked..

you are the one who told the premed he was "dead wrong" regarding appropriate ED usage and I offered current EM literature showing that the majority of (medicaid) visits ARE appropriate per layperson standard. Don't change the subject, either you can find the literature to prove that the majority of ED visits are inappropriate or you can't.

find me the studies..

 

[e30ftw]

Paramedics are pretty clueless btw they are high school graduates who they teach how to ABC someone to the ER in return for some community college credits and maybe a mickey mouse degree.

no idea if you're going into EM or not but if so better check that attitude man.. this smacks of the MD elitism that everyone in the hospital knows and hates.. paramedics are very capable for the most part and you can learn a lot from them during residency (also teach them what you know and later it will help you out.

EM = teamwork. cannot have this attitude towards your EMS/RN/tech staff or you'll go down in flames.

 

[alpinism]

despite how fashionable it is to blame ED overcrowding on minor visits, etc, the data doesn't support this.. so imma call SHENANIGANS on yall med studs/non-em residents making fun of the premed for saying most people don't use the ED for true emergencies..

the majority of people who go to the ED have an appropriate reason to be there. good ACEP NEWs article on this a few months ago..


http://www.acepnews.com/news/practice-trends/single-article/most-medicaid-patients-don-t-use-ed-for-routine-care/46380c18c42c25cc7916e5088c240c99.html

http://www.cdc.gov/nchs/data/ahcd/NHAMCS_Factsheet_ED_2009.pdf

the public is held to a prudent layperson standard. someone with CP concerned for MI SHOULD be encouraged to go to the ED even if their w/u reveals non cardiac pathology.

ya'll see a snapshot in time and think you know whats up. Most off service residents rotating in our ED carry 1-2 fast track patients at a time and then go say 'there's no pathology' blah blah while we carry 8+ ESI 2 or 3 pts and a couple level 1s for good measure. honestly on an average shift I admit >50% usually since we have fast track. Just because you spent a little time in the ED and some patients pissed you off (and yes many many of them will do that) doesn't mean they aren't sick.

so show me the data that the majority of ED visits are inappropriate considering prudent layperson standard.

If you consider CCs of minor fever, back pain, cough, headache, unspecified pain, vomiting, and sore throat to be TRUE emergencies, then yes.

(I'm not even talking about all the BS chest/Ab pain and SOB pts...)

However, >90% of us don't consider those to be emergencies as they could (and should) easily be handled by a PCP.

If you want data look at the CDC factsheet you posted. Appropriate ED patients are those categorized as either 'immediate" or "emergent" which comes out to 12%.

The other 88% (urgent, semiurgent, and nonurgent) could be seen by a PCP or even a PA (like all your fast track pts).

The fast track is part of the ED, not a separate primary care clinic.

 

[e30ftw]

"More than 60% of ED visits made by Medicaid beneficiaries under age 65 years are for symptoms that are considered urgent or semiurgent and that should be evaluated in 2 hours or less, the analysis found. Visits for nonurgent complaints, symptoms that should be addressed within 2-24 hours, accounted for about 10% of ED visits by nonelderly Medicaid beneficiaries in 2008. This compares with 7% among those under age 65 years with private insurance. In addition, the Centers for Disease Control and Prevention figures for 2009 cited only 8% of all ED visits as being for nonurgent conditions."

-ACEP

you're using the hindsight of a medical professional to evaluate what an "emergency" is after the work up and diagnosis has already been obtained.

You have to hold people to a prudent lay person standard. If grandma has new chest pain she should go to the ER. We can't retrospectively analyze her chart and state that because after serial markers, EKG, stress test, she was dx w/ pleurisy it was NOT an emergency. It was an appropriate emergency for her at that time. I'm not sure what about this ya'll don't get.

and yes with the right CC and history fever, cough, headache, pain, vomiting, etc can ALL be emergencies and I have seen patients present with above complaints who all had serious emergent pathology.

sincerely,

<-- someone who works in the ED and sees BS complaints all day every day but also realizes that patients should not be discouraged from using EMS services if they have a real concern, even if it turns out to be non-life threatening.

I see people BIBA for chronic back pain, IV dilaudid use, etc all the time, look I bitch about these people and their abuse of the system all the time in the ED but the facts are that when you consider the symptoms people have at home they can't tell if it's an emergency or not and therefore it is appropriate for them to go to the ED.

 

[e30ftw]

I'll even take it a step farther and state that in my opinion (no data, n=1, etc) the costs associated with people NOT coming to the ED for complaints equal or exceed the costs associated with overusage.

Say Homeless Joe has a toothache and goes to the ED. he gets oral pain meds, a physical exam, and a referral to a free dental clinic. Total cost? not too much..

However how much do we spend on people who don't come to the ED because they don't want to wait, don't want to pay money, don't want to spend time, etc, and end up super sick by delaying?

Take every septic patient you have ever seen. If you started them on IV abx and IVF rescus 24 hours prior to their presentation, would that make a difference in their outcome? yes.

Old people get septic and die. Old people don't like going to hospitals because they know people die in hospitals. So grandpa gets a little sleepy and likes staying in bed for a few days, and grandma thinks he's just tired and doesn't call EMS.

EM attendings, how many times have you heard this? "Oh grandpa hasn't been eating or drinking much for a few days but I think he's just tired."

all the freakin time. This is usually followed by an intubation, central line, aline, $4000 work up and ICU admission for sepsis/severe sepsis/septic shock. They usually stay in the unit for ~2 weeks after which you have the "trach/peg" talk and sometimes grandpa extubates successfully and sometimes he gets trached/pegged and sent to a chronic rehab facility until he gets PNA and goes back to the unit.

How much does that cost? How often does that happen? What are the greatest areas of healthcare costs? last 6 mo of life.

 

[Textbookversion]

no idea if you're going into EM or not but if so better check that attitude man.. this smacks of the MD elitism that everyone in the hospital knows and hates.. paramedics are very capable for the most part and you can learn a lot from them during residency (also teach them what you know and later it will help you out.

EM = teamwork. cannot have this attitude towards your EMS/RN/tech staff or you'll go down in flames.

I worked in EMS before school and I like the people, I just have no illusions about their knowledge base. Some of them were under the impression they were "basically ER doctors" which I found privately hilarious.

As for the EM resident posting, yes ACEP tries to establish intellectual cover. That doesn't change the fact that most of the people coming into the ER could be seen by FM. And yes, the people going through fast track still count as patients coming into the ER. You can't just magically exclude them from the ratio of admitted patients and expect us to take your claims seriously.

Their money is just as good, and as long as they are mainly seen by PA's I have a hard time seeing them as anything more than patients that could be seen the next day by FM.

 

[45408]

despite how fashionable it is to blame ED overcrowding on minor visits, etc, the data doesn't support this.. so imma call SHENANIGANS on yall med studs/non-em residents making fun of the premed for saying most people don't use the ED for true emergencies..

the majority of people who go to the ED have an appropriate reason to be there. good ACEP NEWs article on this a few months ago..

ya'll see a snapshot in time and think you know whats up. Most off service residents rotating in our ED carry 1-2 fast track patients at a time and then go say 'there's no pathology' blah blah while we carry 8+ ESI 2 or 3 pts and a couple level 1s for good measure. honestly on an average shift I admit >50% usually since we have fast track. Just because you spent a little time in the ED and some patients pissed you off (and yes many many of them will do that) doesn't mean they aren't sick.

so show me the data that the majority of ED visits are inappropriate considering prudent layperson standard.

I've rotated through the ED, seeing the same acuity patients as anyone else (no EM residents, no mid-levels, and not the Fast Track), and I spent four years as an EMT. I know what shows up in the ED.

There are issues that need to be addressed in a timely fashion that are still not emergencies. Anything that resembles appendicitis, kidney stones, or biliary colic is fair to evaluate as it arises, but it could easily be seen by an internist, if the patient had access to one when they need it. A CT scan or abdominal ultrasound and a basic panel of labs would give you the answer to those things. Just because 50% of your patients are admitted doesn't mean that they're emergencies. A r/o MI warrants admission, as do a variety of cardiac or pulmonary issues, but they're not emergencies. A real emergency is something that goes to the ICU/cath lab/OR from the ED, and you know those are a minority of the patients who come in.

We should improve access to PCPs and urgent cares, because it's a much cheaper venue. People can be seen within 1-2 hours and have their issue safely addressed.

http://www.cdc.gov/nchs/ahcd.htm
http://hschange.org/CONTENT/1204/1204.pdf

The National Hospital Ambulatory Medical Care Survey uses this information to determine the urgency of a visit, which includes five categories: (1) Immediate (patient needs to be seen immediately; (2) emergent (needs to be seen within 15 minutes upon arrival); (3) urgent (between 15-60 minutes); (4) semiurgent (1-2 hours) and nonurgent (2-24 hours). It is important to note that the immediacy with which a patient should be seen is unknown for about 16 percent of emergency department visits in the NHAMCS data for 2008, in part because some emergency departments either do not triage patients in this way or do not keep records of their triage decisions.

Based on this classification system, 4 percent of emergency department visits in 2008 (a total of 4.6 million visits) were visits in which the patient needed to be seen immediately; 12 percent were considered emergent; 39 percent were considered urgent; and 21 percent were semi-urgent. Only 8 percent of visits - a total of 9.9 million - were classified as nonurgent. Trends in the relative number of nonurgent visits have actually decreased slightly since 2000, when 10.7 percent of visits were classified as nonurgent.

 

[45408]

You have to hold people to a prudent lay person standard. If grandma has new chest pain she should go to the ER. We can't retrospectively analyze her chart and state that because after serial markers, EKG, stress test, she was dx w/ pleurisy it was NOT an emergency. It was an appropriate emergency for her at that time. I'm not sure what about this ya'll don't get.

and yes with the right CC and history fever, cough, headache, pain, vomiting, etc can ALL be emergencies and I have seen patients present with above complaints who all had serious emergent pathology.

And between the hours of 7am and 10pm, most of these people could pass through an urgent care first, at a fraction of the cost.

 

[OCDEMS]

Honestly, no one will take the rest of your thoughts seriously after this.

I don't have a lot of time to refute this argument, and maybe it's my fault for using poor syntax, but what I meant to say was the following:

People are using the ED for true emergencies, not only for true emergencies. Put another way, people are not ignoring their missing hand or chest pain in search of an alternative type of service. So, to clarify, I was saying that individuals with true emergencies use the ED. People with totally survivable ailments ALSO use the ED, in much high percentages. My larger point was that the ED doesn't have any direct competition for seriously sick people, since it is the socially acceptable way to get your medical/trauma disaster fixed. There is no guy driving around in a shady van offering to fix up your AMI.

I'm a paramedic. Trust me, I'm more than well aware that it's mostly non-emergent ailments. Occasionally the complaints are completely fabricated (seekers, etc). Nearly 80-90% of my patients would probably survive if I never showed up. People did, after all, survive for hundreds of years with aches and pains before the advent of modern EM.

I'm not going to dive into the fray with everything else said disparaging EMS. There is such a disparity in the types of EMS systems that every physician or medical student has a different opinion of the profession. Some of them are just dumb and uninformed and I don't have the time, care, or energy to get into an internet forum debate over something that is widely considered an essential service for 300 million Americans.

 

[IMcda]

My (unfortunate) prediction:

-with the influx of the previously uninsured, EM will swell with primary care complaints. With cost a continuing issue, the role of NPs and PAs will unfortunately rise (their propensity to over-order studies will be mitigated in the ER), leaving the Physician with the time-consuming, higher-acuity patients. This will likely lead to less-reimbursement, and thus more hours spent working (40hrs per week and not the prophesied 32...). So EM could essentially become an extremely stressful primary care only with a crappy schedule of rotating nights.

 

[John Lannister]

My (unfortunate) prediction:

-with the influx of the previously uninsured, EM will swell with primary care complaints. With cost a continuing issue, the role of NPs and PAs will unfortunately rise (their propensity to over-order studies will be mitigated in the ER), leaving the Physician with the time-consuming, higher-acuity patients. This will likely lead to less-reimbursement, and thus more hours spent working (40hrs per week and not the prophesied 32...). So EM could essentially become an extremely stressful primary care only with a crappy schedule of rotating nights.

There's nothing unfortunate about this, it's not like it's going to happen.

More patients + more service won't lead to less pay. Maybe the same pay but more work, but likely not less.

When did EMS count as working in the Emergency Department? Do most patients who go to the ED travel by ambulance?😕

 

[DubVille]

My (unfortunate) prediction:

-with the influx of the previously uninsured, EM will swell with primary care complaints. With cost a continuing issue, the role of NPs and PAs will unfortunately rise (their propensity to over-order studies will be mitigated in the ER), leaving the Physician with the time-consuming, higher-acuity patients. This will likely lead to less-reimbursement, and thus more hours spent working (40hrs per week and not the prophesied 32...). So EM could essentially become an extremely stressful primary care only with a crappy schedule of rotating nights.

You forgot the last step......

DNPs pay for a study showing a superior morbidity/mortality rate of their patients without mentioning patient acuity, and pushes for autonomy in the ER at physician reimbursement rates.

I dont think pay will decrease if this scenario pans out. Medicaid may reimburse peanuts, but the collection rate in most EDs is so bad I would assume it will still be an improvement.

 

[e30ftw]

Anything that resembles appendicitis, kidney stones, or biliary colic is fair to evaluate as it arises, but it could easily be seen by an internist, if the patient had access to one when they need it. A CT scan or abdominal ultrasound and a basic panel of labs would give you the answer to those things.

First off I absolutely agree that improved access to primary care is essential to health care going forward.

I can only offer my limited experience to reply to the above comment. I think the number of internists and PCP's willing to work up "dangerous" CCs such as CP/abdpain/HA is dwindling. I routinely get patients sent over by PCP with a script for "LP to r/o meningitis" or "CT abd to r/o appy". Literally the PCP writes the order on the scrip and says, "Go to the ER and they will do this for you." PCPs do not like dangerous CCs for the most part and ship them directly to the ED. Some PCPs may still be willing to schedule outpt stress tests for a 65 y/o M w/ htn/dm/tob who p/w chest discomfort that sounds like typical angina but could be something else but the vast majority will say, "Go directly to ED for evaluation" and I'm not convinced that they're really wrong in this approach.

Of course STEMIs/acuteabd/shock/sepsis/dissection/CVA are true emergencies and these account for less than the majority of ED visits. BUT my question is.. if your 80 y/o gma fell and had a head lac, is it emergent that she get a head CT? she may not be in extremis like an acute dissection but it is still completely appropriate for her to be in the ED and imo better for pt safety to come there for r/o SDH than to go through her PCP (who likely will send her to the ED anyway).

Urgent cares are hit/miss. Some definitely do a good job filtering the fluff, but others are questionable. I've had multiple patients transferred by EMS from urgent cares for "19 y/o F s/p panic attack w/ HTN BP 149/89". no joke.

but these aren't the patients bogging down the system. Like i said above, the real money is spent in end of life care.

 

[45408]

I think the number of internists and PCP's willing to work up "dangerous" CCs such as CP/abdpain/HA is dwindling. I routinely get patients sent over by PCP with a script for "LP to r/o meningitis" or "CT abd to r/o appy". Literally the PCP writes the order on the scrip and says, "Go to the ER and they will do this for you." PCPs do not like dangerous CCs for the most part and ship them directly to the ED. Some PCPs may still be willing to schedule outpt stress tests for a 65 y/o M w/ htn/dm/tob who p/w chest discomfort that sounds like typical angina but could be something else but the vast majority will say, "Go directly to ED for evaluation" and I'm not convinced that they're really wrong in this approach.

I think a one minute evaluation and a set of vital signs is enough for a patient's PCP (who presumably has met the pt before and knows them at least a little) to determine if this is a bona fide emergency that should not be further evaluated in the office or not. Abdominal pain with normal vital signs and no fatal diagnoses high on the differential is not such an emergency that they can't be seen in an office setting. I've had several patients get an abdominal CT by their PCP that showed appendicitis. Probably shaved several grand off their bill by not seeing the ED.

BUT my question is.. if your 80 y/o gma fell and had a head lac, is it emergent that she get a head CT? she may not be in extremis like an acute dissection but it is still completely appropriate for her to be in the ED and imo better for pt safety to come there for r/o SDH than to go through her PCP (who likely will send her to the ED anyway).

Depends on the fall, depends on the 80-year old, depends on anticoagulation status, etc. Many of them are an emergency, and most of them are at least fairly important and shouldn't wait until morning or bother going to their PCP first.

but these aren't the patients bogging down the system. Like i said above, the real money is spent in end of life care.

Agreed, but we're talking about ED utilization, so I posted what I did.

 

[TooMuchResearch]

My (unfortunate) prediction:

-with the influx of the previously uninsured, EM will swell with primary care complaints. With cost a continuing issue, the role of NPs and PAs will unfortunately rise (their propensity to over-order studies will be mitigated in the ER), leaving the Physician with the time-consuming, higher-acuity patients. This will likely lead to less-reimbursement, and thus more hours spent working (40hrs per week and not the prophesied 32...). So EM could essentially become an extremely stressful primary care only with a crappy schedule of rotating nights.

The actually sick make the job worthwhile.

 

[docB]

despite how fashionable it is to blame ED overcrowding on minor visits, etc, the data doesn't support this.. so imma call SHENANIGANS on yall med studs/non-em residents making fun of the premed for saying most people don't use the ED for true emergencies..

the majority of people who go to the ED have an appropriate reason to be there. good ACEP NEWs article on this a few months ago..


http://www.acepnews.com/news/practice-trends/single-article/most-medicaid-patients-don-t-use-ed-for-routine-care/46380c18c42c25cc7916e5088c240c99.html

http://www.cdc.gov/nchs/data/ahcd/NHAMCS_Factsheet_ED_2009.pdf

the public is held to a prudent layperson standard. someone with CP concerned for MI SHOULD be encouraged to go to the ED even if their w/u reveals non cardiac pathology.

ya'll see a snapshot in time and think you know whats up. Most off service residents rotating in our ED carry 1-2 fast track patients at a time and then go say 'there's no pathology' blah blah while we carry 8+ ESI 2 or 3 pts and a couple level 1s for good measure. honestly on an average shift I admit >50% usually since we have fast track. Just because you spent a little time in the ED and some patients pissed you off (and yes many many of them will do that) doesn't mean they aren't sick.

so show me the data that the majority of ED visits are inappropriate considering prudent layperson standard.

You make some good points but on this subject I think ACEP is biased. We all know that the majority of ED visits are not true emergencies the way we all really think of them, where without intervention life or limb will be lost in a matter of minutes or hours. Even if we expand the definition to include those things that might be a serious problem and need a work up we still don't account for most visits.

Most ED visits are the result of poor access of patients to health care, poor access of health care providers to diagnostics, patients who want diagnostics their providers told them were unnecessary, providers who are too busy to manage complex patients, drug seeking and other systems and social issues that are not emergencies.

ACEP has a vested interest in making sure this information does not get out to the general public. If the public begins to think that they are paying for these visits the result will not be to repeal EMTALA and stop the visits, it will be to allow the visits and to refuse payment for them. The whole idea of "the prudent layperson" came out of an effort on the part of private insurers to deny payment for visits that turned out to be non emergent back in the 90s.

This is the same reason EMS providers complain about bogus 911 calls but the agencies and administrators don't. A bogus 911 call for an insured patient pays just the same as a real call. And if the public thinks it's paying for bogus stuff it stops the payments, not the services.

Similarly a bogus ED visit pays the same as a real visit. The dirty little secret of EM is that we stay alive by treating ankle sprains, toothaches and the worried well. All that stuff keeps us open so we can be there for the really sick.