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Some Finding No Room at the ER

Discussion in 'Emergency Medicine' started by terpgirl, Apr 28, 2004.

  1. terpgirl

    terpgirl Senior Member
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    Some Finding No Room at the ER
    Screening Out Non-Urgent Cases Stirs Controversy
    By Ceci Connolly
    Washington Post Staff Writer
    Monday, April 26, 2004; Page A01


    DENVER -- It's not the heart attacks or stabbings that alarm Norman Paradis. It's the minor maladies, the daily deluge of coughs, colds, toothaches and even hangnails that clog his emergency room.

    As the provider of last resort, hospital emergency departments across America have for decades accepted thousands of truly non-urgent cases and swallowed the cost. For the most part, the patients have nowhere else to go, no insurance and no money.

    That is starting to change. University of Colorado Hospital, where Paradis works, is leading the way on a controversial solution -- weeding out the people with bumps and scrapes so it can devote more time and resources to serious, life-threatening traumas and, also, to paying customers.

    Officials here say its 15-month-old system of medical screening, or "triaging out," could go a long way in easing the financial strains that have forced hundreds of emergency departments to shut down in the last decade. But many in the health care profession call it a callous, greedy and shortsighted maneuver that puts a greater burden on neighboring clinics and hospitals -- all at the ultimate expense of the working poor.

    Under the new policy, University hospital demands partial payment up front from non-emergency patients who seek treatment in the ER. For some, including Medicare and Medicaid beneficiaries, the fee is a small cash co-payment; insurance pays the rest. For the uninsured, however, the charge can be a few hundred dollars -- money many don't have. So they leave, toting a list of low-cost clinics in the area.

    Rather than being a remedy, many argue, medical screening is a symptom of much of what ails America's health system.

    "It's an incredibly mean, nasty time to be in medicine," said Mark Earnest, a general internist at University and vice president of the Colorado Coalition for the Medically Underserved. "There is not a consensus on how we are going to take care of people, and the result is everybody having to worry about their own survival."

    The experiment at the Denver hospital and similar efforts in Indianapolis and Houston cut to the core of some of the thorniest problems in health care today. With about 44 million uninsured Americans, a record number of patients are flooding emergency rooms, a trend experts say is unwise from both a medical and economic perspective. ER care is both the most costly and least effective at treating the sort of chronic problems that claim the greatest number of lives each year.

    In 2002, U.S. hospitals provided $22.3 billion in uncompensated care, up from $18.5 billion in 1997, according to the most recent data from the American Hospital Association. In the past, hospitals have made up some of the deficit by charging insured patients higher fees, a cost-shifting trick that in medical circles is dubbed the Robin Hood model. But that money is disappearing, too.

    "We can't do everything for everyone, so what are we not going to do?" asked Paradis, who, as head of University's emergency department, implemented the screening policy in the fall of 2002. Other hospitals, clinics and private physicians find ways to limit care covertly, Paradis contends, while "we are overt. It's rational rationing."

    Stop at the Financial Desk

    On a recent gray Monday morning, a slow trickle of patients passed through the 11th Avenue emergency entrance of the University of Colorado Hospital. Among them were Molly Turner and Debbie, a 45-year-old woman who asked that her last name not be published because her insurer might object to her ER visit.

    Both women had endured a miserable weekend: Turner afflicted with a cough, sore throat and slight wheeze, Debbie with painful hives she feared might be chickenpox. Both women were seen by the top doctor on duty, Norman Paradis. And both cases, he ruled, were "non-emergent" -- not serious enough to require immediate care.

    Under the new policy, he explained to each, the next stop was the financial desk, where patients may pay to stay for treatment or leave and get a much smaller bill in the mail for the screening. From there, the two women took different paths.

    Turner, 27, a mother of three who sells sod at a local farm, dropped her health insurance when the price hit $390 a month. Informed she would have to pay the hospital $250, she opted to go home and tough out what Paradis said were seasonal allergies.

    "You get what you pay for," she said with a shrug afterward. "If I wanted to pay $250 I'd have had the full-blown workup. But he's telling me it's not necessary, so I'm comfortable with that."

    Still, Turner was unsettled that Paradis reached his conclusion after just a brief chat and a listen through the stethoscope. "I wanted to say, 'Are you sure? You don't want to do any tests?' " she said. "But he's the doctor."

    For her half-hour visit, Turner would get a $50 bill and a list of primary care clinics in the area.

    The health insurance provided through the employer of Debbie's husband requires a straight 20 percent co-payment with no deductibles or up-front charges. Because she doesn't have a primary care physician, she decided to stay -- and was pleased with the service.

    "I've been to emergency rooms where there are crying babies and the whole drama," she said, seated on an exam table. "I'm amazed how quiet it is."

    On average, one-third of the care provided in U.S. emergency departments is "inappropriate," several studies have found. At Houston's Memorial Hermann Healthcare System, the stubbed toes, twisted ankles, leg pains, earaches and abscesses account for nearly 120,000 of the 345,000 visits each year to its eight acute care hospitals, said Tom Flanagan, vice president for emergency services. In an attempt to deal with the crowding, the hospitals instituted a triage system similar to Denver's University hospital, though there is no charge for the initial screening.

    "The resources for caring for those patients are very limited," said Brent King, chairman of the emergency medicine department at the University of Texas at Houston Medical School, which is affiliated with Memorial Hermann. "Under the current market conditions, no one can stay in business if they don't somehow limit this load of patients."

    At University, Debbie's rash and Turner's allergies are precisely the sort of cases that used to jam the emergency department. In the past six months, ambulances have delivered three hangnail cases to the ER; another person made 165 visits in one year, Paradis said.

    "That kind of behavior wrecks the system," he said, and used to force the hospital to divert ambulances to other hospitals hundreds of times each month. Since beginning the screening, emergency room visits have dropped 20 percent, and diversions have been almost nonexistent, Paradis said.

    But the desire to redirect minor cases to more appropriate treatment facilities only goes so far. In a perversion of the system, insured patients such as Debbie are welcome to stay, no matter how trivial the problem.

    "Because of her insurance, our institution will make money on her visit," Paradis said. "The charges on those cases help us treat the indigent cases."

    A Doctor Comes Around

    When University began screening ER patients, Kristen Nordenholz was "one of the most recalcitrant and angry" professionals on staff, as she put it. After working five years for the Indian Health Service, which provides comprehensive care for all, she found that ER triaging was "the opposite of what we are trained to do as physicians."

    Yet Nordenholz has come around, in large measure because University has given doctors wide latitude in the screening process.

    "Many people come just to have their fears alleviated, and they don't understand how expensive emergency medicine is," she said. Now, ER patients "are getting to see a senior doctor, usually within 20 minutes. That's not bad care."
     
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  3. terpgirl

    terpgirl Senior Member
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    Nurse Jeanie Murray has also come to see walk-ins in a different light. She recalled one young man who showed up for treatment of a sexually transmitted disease. Murray tried to explain that a local clinic would be better suited for his ongoing care, but the man liked the ER's round-the-clock hours.

    "It made me mad," she said. "We're not here for his convenience. We're here to treat emergency medical problems."

    Often, the patients Murray triages out are people who need a bit of advice about how to treat sunburn or assurance that an over-the-counter syrup should do the trick for their cough. But until those patients have alternatives, physicians elsewhere say it is risky to not give them a thorough workup.

    "If we tell people don't come to the emergency department unless you're dying, that's exactly what they'll do," said Arthur Kellermann, a professor at Emory University School of Medicine and chairman of the emergency medicine department at Grady Memorial Hospital in Atlanta. "If no one else is willing to take care of that diabetic, then we are very unwise to turn that person away," because chronic conditions tend to worsen if left untreated.

    "We found it offensive," said Dennis Beck, co-president of CarePoint, the physician group that staffs seven free-standing HealthOne emergency departments in the Denver area.

    He and partner Stephen Hoffenberg accuse University of steering patients to neighboring hospitals, potentially violating the federal law requiring hospitals to treat every emergency regardless of ability to pay. As examples, they described cases that were turned away from University involving a man with a broken jaw, a student with an infected ear and a patient who fell down a flight of stairs and had neck pain and tingling in one arm. The pair say they are aware of more egregious cases but cannot disclose the details because of privacy laws.

    The Emergency Medical Treatment and Active Labor Act, or EMTALA, leaves plenty of room for interpretation, especially on terms such as "emergency" and "treat." Cancer may be a killer, for instance, but a cancerous lump in the breast is not, by law, an emergency. Furthermore, EMTALA requires only that the patient be stabilized.

    Federal and state regulators say in the past 15 months they have investigated only a few complaints against University and found one EMTALA violation, due to a billing dispute and missing paperwork, said Sharon Haney, program manager for the hospital section at the state Department of Public Health and Environment.

    Shirking Responsibility?

    Even if medical screening meets the letter of the law, many say that University hospital, which received nearly $28 million in federal assistance last year, is shirking its larger societal responsibilities.

    "University shutting down their emergency room says to these people, 'Go somewhere else.' But the somewhere-elses are already overloaded," said Kraig Burleson, chief executive of the Inner City Health Center, a low-cost clinic.

    Many in the community say they would not have an issue with triaging patients out of the ER if University could make them appointments at a more appropriate facility, as the city-funded Denver Health does.

    "We do over-utilize our emergency rooms, " said Lorez Meinhold, executive director of the Colorado Consumer Health Initiative. "But a piece of paper" listing local clinics "is not access to care."

    At St. Anthony's Hospital, just a short drive from University, the uncompensated care tab has nearly doubled in just two years, said Jay Picerno, chief operating officer of parent company Centura Health. Though he does not have hard statistics, doctors and nurses say part of the increase is due to the change in policy at University.

    Picerno believes its ER problems stem from poor financial management, rather than too many "walking wounded," as he put it. "What are they doing with these [government] funds?"

    State Rep. Debbie Stafford, Republican vice chairman of the legislature's health committee, said she has heard numerous complaints from other area hospitals and is examining ways to redistribute some of the federal money University receives to other hospitals.

    The doctors and nurses at University do not argue with many of the complaints. They say they were confronted with a nearly impossible situation as uncompensated care costs rose from $31 million in 2001 to $65 million last year.

    "In the ideal world, you would not want to do medical screening," Paradis said. "But when the core mission is at risk, this is an acceptable tradeoff."
     
  4. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD
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    This is completely in compliance with EMTALA. I have been wondering how long it would be before we would begin to do this. I don't think its a bad idea at all. You don't need to do a full work-up every time to rule out a particular complaint as being non-emergent. At that point, there is no legal reason we cannot send someone to "the financial desk."
     
  5. DrQuinn

    DrQuinn My name is Neo
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    s'actly. They're getting their "medical screening exam."

    Doubt it will happen in the majority fo places, but hey maybe it will start spreading. Sooner rather than later.

    Q, DO
     
  6. beyond all hope

    beyond all hope Senior Member
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    I wish they would do this everywhere. The ER is so often abused by people who know they don?t have emergencies but are too lazy to make an appointment at a clinic. The true emergencies should get all of our time and energy. Fast track is nice but it still promotes the idea that any time you need a doctor, just go to the ER.

    It?s bad for patients, who don?t get good continous care, and it?s bad for us ER docs.

    Make em pay if they want us to remove a hangnail or treat a URI in the ER. That way true emergencies won?t wait 4 hours...
     
  7. Creamfly

    Creamfly Creamfly
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    I hate to say it, but it's not just patients who abuse it. It is also alot of other physicians and other "phone-in" triage systems.

    "If you have any concerns got to the ER."

    I really do not see it getting much better in the near future.
     
  8. EMT036

    EMT036 MS-III/AEMT/Rescue Diver
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    I actually did my thesis (undergrad) studying ED overcrowding. One hospital ED in California successfully implemented a system where patients with non-urgent conditions would be triaged out into primary care settings. Guidelines were set by the nursing and medical staff as to which conditions were emergent and required immediate care and those that were not urgent and could be redirected to a primary care setting. The next step was to establish links with primary care clinics in the community. This ensures that patients who are triaged out will receive appointments for treatment of their condition. Once a source of alternate care for the patient is identified and an appointment is made, the patient must sign an agreement with the arrangements. Transportation and financial concerns are discussed to make sure that the patient will actually have a way to get to the appointment and pay for it. This way a higher degree of compliance is experienced. This program was highly successful. The percentage of inappropriate visits was reduced from 30% to 6%. Patients also reported higher satisfaction, as 74% of patients elected for a definate appointment time in 48-72 hours, rather than waiting for 18+ hours in the ED.

    Private physicians triaging non-urgent patients to the ER because they are too lazy to deal with them is another story, however...
     
  9. docB

    docB Chronically painful
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    Creamfly is EXACTLY right. About a third of my patients tell the same story.
    Pt: "My doctor told me to come to the ER."
    Me: "You talked to your doc and he said to come in here?"
    Pt: "Well it was actually his nurse."
    Me: "Was it his nurse or was it just the person who answered the phone?"
    Pt: "Yeah, I guess it was probably the receptionist."
    Me: "I see. And why did they tell you to come to the EMERGENCY room. What's your EMERGENCY?"
    Pt: Well I felt sick. So I called for an appointment. Then they told me they couldn't see me until 6 years from now. So I told them I'm really, REALLY sick and then they told me to come here."
     
  10. roja

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    The hospital where I went to medical school had a system like this where there was an acute care clinic where nurses screened people into. There was also a lot of advertising in the community to help explain WHAT was an emergency. It was one floor above the ER so if there was something that slipped through triage, it could reroute to the ER.

    Where I am in residency, we have a fast track area for this kind of stuff. Of course after hours, we still get the stuff.
     
  11. beriberi

    beriberi Senior Member
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    There was recently an interesting program done with headstart parents, trying to get them not to see the clinic/ER as the first stop when they have a medical concern. They gave a very easy to understand book to the parents and helped them learn how to use it. For example, when the kid has a fever, the first step is to take a temperature and try OTCs to see if the fever goes down. If the kid has a cough, try cough syrup. If the kid doesn't get better, call your clinic for an appoitment. If x or y is true, then go to the emergency department

    The results were very good. Clinic visits and ER visit dropped dramatically in the trained group. They will soon be expanding this program (I think they did 200 parents, now they will do 2000).

    Like the above article said, many people come to the ER for assurance that nothing serious is going on. It would serve all of us well if patients had other ways of figuring that out.
     
  12. Andy Kahn

    Andy Kahn Senior Member
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    I agree with the point about pt education mentioned in the previous 2 posts. Public education is important so that pts know when an ED visit is not necessary, but it is also important to get others to come to the ED before the window of opportunity closes, like those with an ischemic stroke for tPA.

    -ak
     
  13. ERMudPhud

    ERMudPhud Back for a visit
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    It's interesting that University and Denver Health's trial of aggressive interpretation of EMTALA is starting to get some nationwide exposure. I suspect if it works for them it will become more widespread but the potential for problems is huge. All it will take is one mistake-a person sent out as nonemergent who subsequently dies- for the press, the legislators, and the lawyers to come down hard on the ED's in a way that might make EMTALA look benign. Don't forget that EMTALA was created to stop ED's from dumping uninsured patients. I've already seen or heard about a few local problems with the new MSE and street'em practices. A pregnant women apparently presented to one of the two ED's mentioned above and someone (not a physician) determined that medicaid had assigned her pregnancy care to a hospital across town. She was sent out and collapsed in the parking lot, a police officer picked her up and drove her across town to her assigned ED. A friend of mine was on in the ED and described a very upset police officer carrying in an unconcious patient with both of them covered in blood. With aggressive resuscitation and an emergent c-section everybody did ok but the outcome could have been worse. It was unclear to me whether the patient ever received an MSE at the first institution or if she was bleeding on presentation. I also have to say that referring non-emergent patient to low cost clinics is essentially a joke. I've tried myself to get patients into these clinics and it is pretty near impossible. You may be following the letter of the law in terms of what EMTALA requires you to do but I think the university physicians are fooling themselves if they think the patients they send out are actually getting care. The low cost clinics are few in number, over worked, underfunded, overwhelmed, and generally lacking in specialty care. What isn't obvious in the article is that along with limiting ED access University hospital has cut off or severely limited access to specialty care. Just try getting care for a fracture, a sz disorder, or a chronic ophtho condition to name a few in this town if you don't have insurance. University hospital used to be called Colorado General and it had a mandate to provide quality care (to insured and uninsured alike), teaching, and research. It appears one of those mandates is going away. I realize that the system couldn't continue as it is without bankrupting University and DG but closing the doors just pushes the problem on to someone else without fixing it. In the end the problem of the uninsured won't go away if you close your doors.

    Another factor which would limit the abillity of other ED's to adopt the same tough policy is liabillity. As state and city employees, the docs at DG and I believe University are subject to very severe caps on damages. I believe I was once told something in the range of 250-500K per incident (economic and noneconomic). If you can't be sued its a lot easier to spend 5 minutes with someone tell them there is nothing wrong and send them home.
     
  14. docB

    docB Chronically painful
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    ERMudPhud is correct. This is a liability driven business and 1 anectdote about a poor patient outcome will unite public opinion against us. My system tried for a while to aggressively triage ambulance patients to the waiting room so that people wouldn't abuse ambulances just to bypass the wait. The story got around that someone had sued so we're back to only sending the clearly abusive ambi call to the lobby.
     
  15. 12R34Y

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    Preface: this is not meant as inflammatory just a valid (maybe) concern.

    Beyond all Hope,

    YOu say that this is a great idea and that all of the throngs of people who are non-emergency should go elsewhere and the true emergencies should be what you are working on.

    If the only patients an ED doc sees in most communities (suburb, rural, midsize towns) are "true" emergencies you will be treating very very few patients.

    is it possible that there would not be a need for that many EM docs if all ED's were for just "true" emergencies?

    I've worked in several suburban ED's and urban ones as well and you can go weeks without seeing a good MI or a nice trauma or a AAA, or a critical OD etc....

    many of the patients are URI's, gyn, ankle sprains, lacs etc... ( you all know this).

    My question is that if you carry this plan of "triaging out non-emergencies" to its extreme and truly just had ED's taking care of emergencies then you'd need about a billionth of the amount of EM docs out there wouldn't you?

    I mean censuses at some ED's are 100,000 plus........if you got rid of all of the non-emergencies it'd probably be around 20,000.

    obviously, there wouldn't need to be that many ED docs to staff that place would there?

    i'm rambling, but i'm in the middle of board studying.....sorry.

    later
     
  16. docB

    docB Chronically painful
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    You are absolutely correct. However, EDs are bursting at the seams all over the country. People that are actually sick are waiting in the waiting room. If we drop the census there will still be ample business for all of us.

    Another thing is that as an ER doc I'm a terrible primary care doc. That's why IM and FP do residencies in those fields, to get good at nonemergent stuff. When a PMD sees a URI they think "How can I best treat this person?" When I see a URI I think "How can I prove that this is not a PE?"
    People are often upset because they came to the ER for primary care, they just want a hand nold and a prescription and they get a zillion dollar work up. Primary care should be done by primary docs. They are better at it than I am and it frustrates me when I have to see those patients.
     

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