I don't work at University and wasn't there when this policy was put in place. I do have friends who work there and I have asked them about it. It seems like in some cases the attendings hardly do any MSE's and pretty much ignore the policy. In other cases they can be quite aggressive about it. Even the most aggressive though don't estimate that the patients turned away represent even 10% of the volume. However, given the slow patient turnover at academic centers even that few percent can make a big difference in ED constipation. By the time a completely ridiculous CC is seen by the student, a resident, and an attending a fair amount of time can go by. Plus the added effect of subtly discouraging people from going to Univ. and instead choosing another ER helps decrease volume. That only works as long as the other 7 hospitals in inner city Denver aren't doing the same thing. There in lies part of the problem. Denver Health has instituted a similar practice but to my knowledge no one else has. One inner city hospital has gotten so tired of the uninsured inner city patients that they are closing up shop and moving to the suburbs. I'm sure the increased numbers they saw after Univ's policy wasn't the cause but it didn't help. Even out in the suburbs we saw an increase in uninsured care from Denver and Aurora after the MSE's started
The complicated discourse stems from the fact that Univ doesn't appear to have done a lot to prepare the community for this change in policy. The list of community resources is essentially a list of free or low cost clinics which are already working pretty hard and for the most part can't provide specialty care. When the other ER's started seeing patients turned away from Univ and DH they started talking to the press about the most dramatic examples. The one I remember was some poor guy who got his mandible shattered in a fight. He was apparently told it wasn't actually an emergency and wandered around for a day or two until he eventually wandered into Rose hospital and got it fixed for free. The press was pretty aggressive on that one and Univ was forced to defend itself in the press and although they did a good job of explaining themselves I think the PR damage was already done.
In terms of Univ's glowing report on the outcome of their changes a few things have to be kept in mind. Around the time of these changes a few other things happened. The region instituted a new divert policy which dropped divert hours dramatically everywhere. Essentially they no longer had service specific diverts- ICU divert, CCU divert, Psych divert, OR divert, CT divert!, etc... and put in a you are either taking patients or you're not policy. This gave hospital administrator a lot more incentive to stay off divert if it meant absolutely nothing would come in and you'de be amazed how creative they got in helping to clear out the ER. They also split the area into regions of three hospitals each and if all three hospitals were on divert than it meant that none were on divert and they alternated taking patients. In the old days if all of downtown was on divert they would all stay on divert for fear of getting crushed when they came off. I once took an ambulance patient who drove from way south of town all the way through to the northern suburbs looking for an open ED. He passed 10 hospitals and drove more than 60 miles. University also built a new ER that was both dramatically bigger and I think more efficient. I don't think the new happiness at Univ is all about MSE's
