People are showing up to the ER and demanding flu shots.

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RustedFox

RustedFox

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Yep. You heard it.

"I didn't wanna wait in line at Walgreens."

This is where we're at, people.

Also, working at an HCA facility now. Meditech has gotten far worse since I was last here several months ago.
If it wasn't total dog$hit then, it is now.
 
RustedFox said:
Yep. You heard it.

"I didn't wanna wait in line at Walgreens."

This is where we're at, people.

Also, working at an HCA facility now. Meditech has gotten far worse since I was last here several months ago.
If it wasn't total dog$hit then, it is now.
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Are your ED wait times really so low that people would actually get their shot in a reasonable period of time? I never see that where I work because those people would be sitting in the waiting room for 1-2 hours before they LWBS.

Also, at the end of my residency training, they made it a policy during my last year there that we didn't give flu shots in the ED ever. If you were getting admitted and needed one, you got it upstairs.
 
BoardingDoc said:
Are your ED wait times really so low that people would actually get their shot in a reasonable period of time? I
Click to expand...

The rival hospital system has billboards with LED displays showing the "current" wait-time; e.g., "Current Wait at Holy Moses ER: 17 Minutes." We put our foot down on that one.

If they are getting people seeking flu shots because of that.... serves them right.
 
Honestly, why is this such a bad thing? I would argue that it saves money in the long term and prevents patients from being checked in down the road, and maybe helps the few that develop severe ARDS and all sorts of other complications. As winter progresses and your waiting room fills up with homeless people, getting people out who have flu symptoms is probably a good thing.That is, of course, assuming the flu shot actually does what it's supposed to do.

I would argue a triage nurse should just be able to give the shot and they can leave without seeing a physician. From a public health standpoint it's probably better for the greater good.

But yeah if a physician has to see them and perform a MSE and document a note, eff that.
 
TheComebacKid said:
Honestly, why is this such a bad thing? I would argue that it saves money in the long term and prevents patients from being checked in down the road, and maybe helps the few that develop severe ARDS and all sorts of other complications. As winter progresses and your waiting room fills up with homeless people, getting people out who have flu symptoms is probably a good thing.That is, of course, assuming the flu shot actually does what it's supposed to do.

I would argue a triage nurse should just be able to give the shot and they can leave without seeing a physician. From a public health standpoint it's probably better for the greater good.

But yeah if a physician has to see them and perform a MSE and document a note, eff that.
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It's a bad thing because we aren't PCPs, and using an ER physician's time and resources to address PCP complaints takes away from resources that can be used to treat patients with medical emergencies.
 
I agree it’s the concept of doing more that what we are trained for in the ED. What the purpose of the ED in our society. If we start giving vaccines and Kleenex then there is literally no reason to go see the PCP.

I bet white coat investor might object, because these people are customers and they pay our salaries, but there has to be some sort of limit on what we do.

Just imagine a family bringing in their child to the ED every year to get their tdap, mmr, and all sorts of other vaccines and boosters shots for their kids. Next we are going to be asked to fill out their vaccine history on their school forms. Probably happens now.

The abuse of the ER has to stop!
 
You both bring up extremely valid and correct points. But it is not in accordance with reality. The fact of the matter remains that people used the ED for dumb stuff routinely. Instead of being drunk at home, they come to the ED drunk. Instead of taking tylenol for their headache at home, they come to the ED for tylenol. The list goes on and on.

I would argue that the flu shot, while a stupid ED intervention, is one of the "better" stupid interventions we have to offer. In fact, it's an intervention that we can do to prevent future unnecessary ED visits.

I agree with you that the PMDs should be taking care of this problem. I agree with you that providing flu shots in the ED sets a bad precedent and will likely encourage patients to come to the ED instead of making an appointment with their primary. But if it comes down to giving you a turkey sandwich, or giving you a flu shot, I think the flu shot is slightly a better option.
 
I used to scribe ED. It’s stuff like this that’s why I will NEVERRRRRRR go into emergency medicine. We had people wait for hours just they could get a free pregnancy test.... that’s all.


Sent from my iPad using Tapatalk
 
thegenius said:
I agree it’s the concept of doing more that what we are trained for in the ED. What the purpose of the ED in our society. If we start giving vaccines and Kleenex then there is literally no reason to go see the PCP.

I bet white coat investor might object, because these people are customers and they pay our salaries, but there has to be some sort of limit on what we do.

Just imagine a family bringing in their child to the ED every year to get their tdap, mmr, and all sorts of other vaccines and boosters shots for their kids. Next we are going to be asked to fill out their vaccine history on their school forms. Probably happens now.

The abuse of the ER has to stop!
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Do they though? I know I’ve seen him say this before, but what percentage of your money actually comes from these BS patient presentations? For my patient population, it’s probably 2-3% at most. I see 2-3 of these patients a shift (when not working at the FSED) who come in with crap that anyone with an ounce of common sense would avoid the ER for. Where I can discharge them without a single order placed. These patients tend to not have insurance to begin with, and I’m clearly not going to bill above a level 1 encounter on them anyways. That’s probably at most $40 made off them. I would gladly take a 2-3% pay cut to never have to see these type of patients again.
 
My medical director's perspective about all this stuff is that we need as many full-note-type pt visits as we can get, no matter how silly or repetitive they are, even if they don't generate revenue for us. That's because bigger ER census numbers help increase our sway with HCA, help us get more resources from them, and prevent HCA from micromanaging our TH group from the top even more than they do now. The more visits we have, the more we justify our existence.

So that's my understanding of the corporate medicine view of this. If the HCA brass really believes this, I'd think they're gonna shoot themselves in the foot eventually by incentivizing all these silly visits that make them lose money.
 
I'm totally OK with people requesting flu shots. We should have a nurse/pharmacist stationed outside the ER with flu shots in hand for all comers. Would be a great public health intervention and a great patient satisfier. If Walgreens can have pharmacists administer flu shots, would it really be that hard to have a pharmacist interview patients in the waiting room and administer the vaccine? With ER visits down around the country and the devastating disease burden of influenza, it seems like this is an issue we can and should deal with.

I'm all for anything that increases vaccination rates, and think of all the annoying flu visits we can avoid later.
 
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I always thought this kind of thing is what the triage nurses were for. How many ED docs are actually giving flu shots or even having a face to face encounter on these people?
 
miacomet said:
I'm totally OK with people requesting flu shots. We should have a nurse/pharmacist stationed outside the ER with flu shots in hand for all comers. Would be a great public health intervention and a great patient satisfier. If Walgreens can have pharmacists administer flu shots, would it really be that hard to have a pharmacist interview patients in the waiting room and administer the vaccine? With ER visits down around the country and the devastating disease burden of influenza, it seems like this is an issue we can and should deal with.

I'm all for anything that increases vaccination rates, and think of all the annoying flu visits we can avoid later.
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Someone, or something, is being charged $1,500 dollars for that flu shot! That’s the problem!!!!! It’s $5 at Walgreens.
 
Stagg737 said:
I always thought this kind of thing is what the triage nurses were for. How many ED docs are actually giving flu shots or even having a face to face encounter on these people?
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100% because they need a medical screening examination, no matter how brief.
 
thegenius said:
100% because they need a medical screening examination, no matter how brief.
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Really? Is that for everyone? Where I rotated for EM the docs definitely did NOT see everyone that came through nurse triage, so how does that work out? I know they had NPs who saw some patients up front, but was unaware if the ED docs actually had to sign off on everyone that came through...
 
Stagg737 said:
Really? Is that for everyone? Where I rotated for EM the docs definitely did NOT see everyone that came through nurse triage, so how does that work out? I know they had NPs who saw some patients up front, but was unaware if the ED docs actually had to sign off on everyone that came through...
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We are getting into issues of EMTALA, don’t know how much you know about that law. Basically a qualified medical personnel must provide a medical screening examination to everyone who comes into the ED, no matter what the complaint. The definition of “qualified medical personnel” and “medical screening examination” are open to interpretation, but it basically involves a doctor or mid-level provider.

I would be very surprised these days if a non-doctor or MLP saw a patient and disposed them in the ED.
 
thegenius said:
Someone, or something, is being charged $1,500 dollars for that flu shot! That’s the problem!!!!! It’s $5 at Walgreens.
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Yes and the ED will get blamed in the press for the high cost, not the person who went to the ED to get a flu shot. You can't go to a five star restaurant, order a hamburger, and then complain it was more expensive than the drive through at McDonalds.
 
thegenius said:
We are getting into issues of EMTALA, don’t know how much you know about that law. Basically a qualified medical personnel must provide a medical screening examination to everyone who comes into the ED, no matter what the complaint. The definition of “qualified medical personnel” and “medical screening examination” are open to interpretation, but it basically involves a doctor or mid-level provider.

I would be very surprised these days if a non-doctor or MLP saw a patient and disposed them in the ED.
Click to expand...

Very familiar with EMTALA. The bolded is what I'm uncertain of, as in would a triage nurse be a "qmp" if the patient's only complaint is "I want a flu shot"? I imagine this would vary from state to state, but Idk.
 
thegenius said:
We are getting into issues of EMTALA, don’t know how much you know about that law. Basically a qualified medical personnel must provide a medical screening examination to everyone who comes into the ED, no matter what the complaint. The definition of “qualified medical personnel” and “medical screening examination” are open to interpretation, but it basically involves a doctor or mid-level provider.

I would be very surprised these days if a non-doctor or MLP saw a patient and disposed them in the ED.
Click to expand...

My understanding is that a qualified medical screening exam is defined by hospital bylaws. In some facilities a nurse can provide a "qualified medical screening exam". This is how a labor and delivery nurse can evaluate a patient and provide a qualified medical screening exam.
 
thegenius said:
Someone, or something, is being charged $1,500 dollars for that flu shot! That’s the problem!!!!! It’s $5 at Walgreens.
Click to expand...

You can have a nurse ask the patient if they want to be admitted, or if they just want a flu shot. If this is really happening that frequently (I haven't seen it happen at my hospital, not once, but our urgent care is extremely convenient and much cheaper, and the pharmacies give flu shots with no wait), there are some easy administrative workarounds. There's no reason a hospital has to charge $1500 for this. That they choose to charge so much is another problem entirely.
 
MechEDoc said:
My understanding is that a qualified medical screening exam is defined by hospital bylaws. In some facilities a nurse can provide a "qualified medical screening exam". This is how a labor and delivery nurse can evaluate a patient and provide a qualified medical screening exam.
Click to expand...

In particular for the ED specifically, while EMTALA doesn't define who is a "qualified medical personel" in terms of performing a MSE and ruling out an emergent medical condition (at which time the EMTALA obligation is over), CMS has clearly said that an evaluation by a triage nurse alone in the ED does not meet the definition of a medical screening exam.
 
gamerEMdoc said:
In particular for the ED specifically, while EMTALA doesn't define who is a "qualified medical personel" in terms of performing a MSE and ruling out an emergent medical condition (at which time the EMTALA obligation is over), CMS has clearly said that an evaluation by a triage nurse alone in the ED does not meet the definition of a medical screening exam.
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I would think that could be gotten around.

"Would you like to see the doctor while you are here or are would you like to decline an exam and just get a flu shot?"
 
gamerEMdoc said:
In particular for the ED specifically, while EMTALA doesn't define who is a "qualified medical personel" in terms of performing a MSE and ruling out an emergent medical condition (at which time the EMTALA obligation is over), CMS has clearly said that an evaluation by a triage nurse alone in the ED does not meet the definition of a medical screening exam.
Click to expand...

So several years ago our hospital discussed implementing MSEs in triage and wanted our ED group to perform these. As I’ve stated in the past I don’t see any real benefit in doing these as an ED group that bills and collects for our work. We declined and actually kicked this one up the chain to med mal attorneys and state nursing boards. A hospital triage nurse can 100% perform the MSE exam (at least in my state) but the hospital has to designate them as being capable of performing the MSE and very few hospitals are willing to give them such authority because the hospital doesn’t want to absorb the liability. We came back to the hospital admin (whom we actually have a great relationship with) and explained that they could authorize their triage nurse to perform the MSE and the issue disappeared pretty quickly.


Sent from my iPhone using SDN mobile
 
Where I trained, we used to give follow up rabies series vaccines in triage with only an RN seeing the patient. I imagine flu would be no different. Honestly, what is the risk of a healthy person with normal vitals showing up just for a vaccine?

I think it's important to redirect the conversation back to the original question of "should we be doing this in the first place?" I say No. Yeah it's a nice public health initiative (maybe) but let these people show an ounce of personal responsibility and either get it from their PMDs or a pharmacy. I don't need my triage nurse tied up triaging this NON-EMERGENCY, then having them or another nurse going through the health screening questions and then administering the vaccine. All of this takes resources (1-2 nurses) and time. We see enough nonsense in the ED, let's not add to it.
 
ER visits are down: https://theshift.usacs.com/emergency-room-visits-fall-sharply-in-dc-maryland/. I'm not concerned about people coming in for flu vaccines. We need to redesign EDs so that Urgent Care is contiguous with the ED and people can be triaged there accordingly should they wish to pay a lower copay. It's hard to get into primary care and some people have unforgiving work schedules.

It's a mystery to me why more facilities don't design their EDs this way. And we shouldn't take it for granted that ED visits will increase forever. 10% is a huge drop, and this is what feeds us.
 
miacomet said:
ER visits are down: https://theshift.usacs.com/emergency-room-visits-fall-sharply-in-dc-maryland/. I'm not concerned about people coming in for flu vaccines. We need to redesign EDs so that Urgent Care is contiguous with the ED and people can be triaged there accordingly should they wish to pay a lower copay. It's hard to get into primary care and some people have unforgiving work schedules.

It's a mystery to me why more facilities don't design their EDs this way. And we shouldn't take it for granted that ED visits will increase forever. 10% is a huge drop, and this is what feeds us.
Click to expand...

- Fear of persecution under EMTALA
- Perverse incentives caused by nonsensical CMS pricing and bundling decisions
 
miacomet said:
ER visits are down: https://theshift.usacs.com/emergency-room-visits-fall-sharply-in-dc-maryland/. I'm not concerned about people coming in for flu vaccines. We need to redesign EDs so that Urgent Care is contiguous with the ED and people can be triaged there accordingly should they wish to pay a lower copay. It's hard to get into primary care and some people have unforgiving work schedules.

It's a mystery to me why more facilities don't design their EDs this way. And we shouldn't take it for granted that ED visits will increase forever. 10% is a huge drop, and this is what feeds us.
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You can't "triage" them - once you make contact, you have to see them in the ED. Then, any advantage of a UC (cost, speed) is lost.

Now, if the UC is in FRONT of the ED, so a prospective pt has to walk by it, before they get to the ED, and decide to walk into the Walk In clinic, that is a different issue.
 
GonnaBeADoc2222 said:
Where I trained, we used to give follow up rabies series vaccines in triage with only an RN seeing the patient. I imagine flu would be no different. Honestly, what is the risk of a healthy person with normal vitals showing up just for a vaccine?
Click to expand...

This is because those patients aren't seen as ED patients. Followup rabies shots are generally done as an outpatient order attached to the initial ED bill.
 
TheComebacKid said:
Honestly, why is this such a bad thing? I would argue that it saves money in the long term and prevents patients from being checked in down the road, and maybe helps the few that develop severe ARDS and all sorts of other complications. As winter progresses and your waiting room fills up with homeless people, getting people out who have flu symptoms is probably a good thing.That is, of course, assuming the flu shot actually does what it's supposed to do.

I would argue a triage nurse should just be able to give the shot and they can leave without seeing a physician. From a public health standpoint it's probably better for the greater good.

But yeah if a physician has to see them and perform a MSE and document a note, eff that.
Click to expand...

I thought we were cool, then you had to go and say a crazy thing like that, lol.
 
TheComebacKid said:
Honestly, why is this such a bad thing? I would argue that it saves money in the long term and prevents patients from being checked in down the road, and maybe helps the few that develop severe ARDS and all sorts of other complications. As winter progresses and your waiting room fills up with homeless people, getting people out who have flu symptoms is probably a good thing.That is, of course, assuming the flu shot actually does what it's supposed to do.

I would argue a triage nurse should just be able to give the shot and they can leave without seeing a physician. From a public health standpoint it's probably better for the greater good.

But yeah if a physician has to see them and perform a MSE and document a note, eff that.
Click to expand...

I thought we were cool, then you had to go and say a crazy thing like that, lol.

BoardingDoc said:
Are your ED wait times really so low that people would actually get their shot in a reasonable period of time? I never see that where I work because those people would be sitting in the waiting room for 1-2 hours before they LWBS.

Also, at the end of my residency training, they made it a policy during my last year there that we didn't give flu shots in the ED ever. If you were getting admitted and needed one, you got it upstairs.
Click to expand...

Lol. At my shop, they’d wait 8 hours and still not leave. I think visiting my shop is a pass time for some people.
 
miacomet said:
It's a mystery to me why more facilities don't design their EDs this way. And we shouldn't take it for granted that ED visits will increase forever. 10% is a huge drop, and this is what feeds us.
Click to expand...

The problem is patients who wait for frivolous medical care that is the exact opposite of emergency care, or potential emergency care, end up waiting, taking up space for more sick patients, then leave remarks on Yelp saying how they had to wait 1.5 hours to get a shot, and the hospital gets all the bad press behind it.

If the hospital wants to dish out flu vaccines as a public health benefit then set up a separate mechanism for doing so and don't go to the ED.

There has to be some sort of distinction between primary care and emergency care, and if ERs are giving out vaccines then we should just oblivate the need for primary care.
 
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