the "ideal" ED

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olafa

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Everyone knows and is well aware of the current utilization of the "emergengy room" for non-emmegent medical issues. This is a problem, and continues to be problem.

Are the any good policy ideas that people have to straighten this situation out?
Let's keep them realistic, rather than a way to vent frustion. We obviously can't turn away people on the current medical model, so people keep repeating the same mistake over and over thinking its ok. Sure the policy may take a significant time to really show any turn over, but you have to start somewere?
 
olafa said:
Everyone knows and is well aware of the current utilization of the "emergengy room" for non-emmegent medical issues. This is a problem, and continues to be problem.

Are the any good policy ideas that people have to straighten this situation out?
Let's keep them realistic, rather than a way to vent frustion. We obviously can't turn away people on the current medical model, so people keep repeating the same mistake over and over thinking its ok. Sure the policy may take a significant time to really show any turn over, but you have to start somewere?
Click to expand...

At the next ACEP Scientific Assembly, I saw an ad talking about (?)a hospital that has a physician in triage who can do a quick medical screening and turn people away. Aside from the obvious liability and possible ethical issues, its still interesting to see it being talked about.

CS
 
How about having an urgent care clinic right across the hall from triage and just pointing people over. If the urgent care providers deem them critical they'll come right back over. Seems kind of like fast track but I think this would be a good supplement to fast track.
 
igcgnerd said:
How about having an urgent care clinic right across the hall from triage and just pointing people over. If the urgent care providers deem them critical they'll come right back over. Seems kind of like fast track but I think this would be a good supplement to fast track.
Click to expand...

That's the way it's set up in the hospital where I volunteer. Can't say that it helps much in any way. It's still the busiest ED in the state. And it's busy pretty much 24/7.

Of course, actual docs could certainly speak to this with a greater degree of accuracy than I can. Still, it would be nice if I could come up with a more definitive answer when patients ask (many not very nicely), "Why is this taking so LONG???"
 
drlisa0318 said:
Still, it would be nice if I could come up with a more definitive answer when patients ask (many not very nicely), "Why is this taking so LONG???"
Click to expand...

Well, sir, that's a fascinating question and one I'm glad you asked. You see, reimbursement for in-patient care has dropped dramatically over the past 10-15 years with an unsuprising decrease in the number of available hospital beds.

This is a 50 bed Emergency Department. 25 of those beds are functioning as med/surg beds for admitted patients because there is no room upstairs. That makes this 50 bed ED (which is about 30 beds too small) really a 25 bed ED.

My ED nurses are tied up providing floor care to all of those admitted patients and aren't readily available to draw your blood, give you your pain medicines or that nice warm blanky you would like.

I have nowhere to put those 35 patients hanging out in the waiting room right now waiting to be seen. Like my nurses, I'm also trying to continue caring for those admitted patients in addition to examining, diagnosing and treating all of the new patients who come here for care.

As much as I would love to provide you, and the entire community of people who need/want it the timely and high quality care with a smile and great service that you deserve, I'm unable to because there just aren't enough resources to go around.

But, on the bright side, you health insurance dollars are making some MBAs much wealthier for not providing you any health care.

Thank you so much for asking.

Take care,
Jeff
 
Jeff698 said:
Well, sir, that's a fascinating question and one I'm glad you asked. You see, reimbursement for in-patient care has dropped dramatically over the past 10-15 years with an unsuprising decrease in the number of available hospital beds.

This is a 50 bed Emergency Department. 25 of those beds are functioning as med/surg beds for admitted patients because there is no room upstairs. That makes this 50 bed ED (which is about 30 beds too small) really a 25 bed ED.

My ED nurses are tied up providing floor care to all of those admitted patients and aren't readily available to draw your blood, give you your pain medicines or that nice warm blanky you would like.

I have nowhere to put those 35 patients hanging out in the waiting room right now waiting to be seen. Like my nurses, I'm also trying to continue caring for those admitted patients in addition to examining, diagnosing and treating all of the new patients who come here for care.

As much as I would love to provide you, and the entire community of people who need/want it the timely and high quality care with a smile and great service that you deserve, I'm unable to because there just aren't enough resources to go around.

But, on the bright side, you health insurance dollars are making some MBAs much wealthier for not providing you any health care.

Thank you so much for asking.

Take care,
Jeff
Click to expand...
Wow......well said. 👍
 
so, what the suggestions people have to remedy the problem. We are all too familar with the problem, now what policy action do you suggest that may remedy the situation?? That's the million dollar question!
 
olafa said:
so, what the suggestions people have to remedy the problem. We are all too familar with the problem, now what policy action do you suggest that may remedy the situation?? That's the million dollar question!
Click to expand...
1. Eliminate the malpractice gravytrain and devote those costs back into healthcare.
2. By reforming malpractice and EMTALA I can more effectively triage people out of the ED to a more appropriate level of care.
3. Devote those savings into Medicaid. Change the Medicaid entitlement for indigent to anyone who has a job and their kids.
4. Create a subsistance level of care, similar to the old county system, for the indigent.
 
I have mulled over practical solutions before, but how practical?

With the thinking that misuse of the ED is in part due to PC/FP docs not accessible after hours or lack of their willingness or ability to push a test through...

With the thinking that pts without insurance have no other choice...

I've wondered if moving FP into the hospital as well wouldn't make things smoother, push better coverage (night practice for FP?) and move along those tests. I realize how unpalatable this sounds to some, but medicine is changing over to such a service industry and frankly, people don't care about how it works, just if it works. It does raise other problems, but it does address saving the ED for Emergencies, for these cases at least. IMO the cost would go down because things would get caught sooner. FM, don't throw tomatoes please.
 
olafa said:
so, what the suggestions people have to remedy the problem. We are all too familar with the problem, now what policy action do you suggest that may remedy the situation?? That's the million dollar question!
Click to expand...

The quick answer to ED overcrowding is to move the problem to the people who can fix it. The reason for ED overcrowding isn't in the number of people who come in to see us. It isn't the uninsured (directly). It isn't the PCP dumping on the ED (although it happens and is certainly a problem for other reasons). It's that we can't move patients out of the department once we're done with our workup and admit them.

The quick answer is to make 'em wait in the hallways up on the floor.

When the floors are stacked to the gills with patients, the rest of the hospital will understand the nature of the problem and will work towards a solution.

In the places this has been done, it works. People bitch and moan but that's the point. The people who can do something about the problem feel the pain and are given an incentive to fix it.

The solution to access is another issue altogether. Fortunately for all Americans, there apparently isn't an access issue at all. After all, President Bush says they can just go to the ER.

Take care,
Jeff
 
Agreed, the problem is working with half the beds you are given, the admit delays are what hold thing up- but putting patients in the hallways really doesn't directly address the bureaucratic issues. Patient wait overnight/days in the ED halls sometimes waiting for floor admission, its a horribly frustrating situation and we keep working with it, doing whatever we can do. But, I don't like it. 🙁

---


The quick answer is to make 'em wait in the hallways up on the floor.

When the floors are stacked to the gills with patients, the rest of the hospital will understand the nature of the problem and will work to wards a solution.


Take care,
Jeff[/quote]
 
Having just completed my first month in the Emergency Department as a resident, I have finally gotten some real first hand view of the situation.

I agree that the 'hard' part seems to be getting patients seen/admitted by other services. What bothers me the MOST is to see very junior residents dictating and causing much of the delay. I can call IM on a patient that needs admitted... I tell the IM intern about the patient and mention one small thing (say a VP shunt) and the IM hollars if they have that, NS needs on board. Ok, can't they be consulted on the floor?... No, they need an ED evaluation. So you call some lowly surgery intern covering for NS and are told to get a head to pelvis CT and plain films (i.e. THOUSANDS of dollars). An hour later, there is a call, its ok, call IM.

It bothers me that an intern (like myself) can snap a finger and cost you and I TONS of money without ever laying eyes on a patient or ever talking to a 'grown up doctor' about the issues....All the while, backing up the ED, since now you have to call IM again and they will be down 'in a while'. Another bed is used and someone has to hang out..


If I had attendings from other services telling me you know this patient needs to hang out down here, or we really need such and such test done in the ED as it will dictate are care right now... I am totally cool with that. But when other interns or even more senior residents are doing that, I just disagree...

I love the fact that EM residency seems to be the onle truly supervised residency out there. I know these other residents talk to the 'grown up doctor' about whats going on, but theres just something about actually seeing the patient versus hearing about it.


I can get on my soap box, but alas I have no solution really. Interns/residents and the such have to learn and unfortunately that is at the cost of excessive patient care and backlogs in the ED.... Not to mention extended hospital days due to intern/resident less than stellar marks at efficency...
 
Jeff698 said:
The quick answer to ED overcrowding is to move the problem to the people who can fix it. The reason for ED overcrowding isn't in the number of people who come in to see us. It isn't the uninsured (directly). It isn't the PCP dumping on the ED (although it happens and is certainly a problem for other reasons). It's that we can't move patients out of the department once we're done with our workup and admit them.

The quick answer is to make 'em wait in the hallways up on the floor.

When the floors are stacked to the gills with patients, the rest of the hospital will understand the nature of the problem and will work towards a solution.

In the places this has been done, it works. People bitch and moan but that's the point. The people who can do something about the problem feel the pain and are given an incentive to fix it.

The solution to access is another issue altogether. Fortunately for all Americans, there apparently isn't an access issue at all. After all, President Bush says they can just go to the ER.

Take care,
Jeff
Click to expand...

The problem with ED overcrowding is NOT the presence of low acuity patients that "should have gone to see their PCP". Turning patients away from the ED for ANY reason is bad form and frankly a BAD financial decision. As stated earlier the real problem is the lack of inpatient hospital beds and subspecialist availability to encourage good ED flow. At the hospital I work at there is a 29 min guarantee for patients to be seen in the ED; as long as my admitted patients are quickly getting beds and not tying up my nursing staff everything runs VERY smoothly. Patients don't wait in waiting rooms and it allows me to quickly dispo those patients who have non emergent complaints. In this system I serve as my own "physician at the door", except instead of turning patients away I am able to see them and rapidly send them home. In recent months we have started a system by which we send non-emergent complaints to a PCP style clinic. Let me tell you, it is the ED physician group who is complaining about the policy. Non emergent patients pay well for the amount of actual ED resources they use. Granted non emergent patients are not why we went into EM, they can be frustrating to deal with emotionally but they are great financially.

Boarding patients in the hallways is an interesting system in order to bring ED overcrowding to the attention of the rest of the hospital but likely does not represent a long term solution to our problems. There needs to be hospital wide policies in place so that admitted patients have good flow through their inpatient stay. They must quickly be treated and moved through the system, freeing up more inpatient beds
 
EM_Rebuilder said:
Having just completed my first month in the Emergency Department as a resident, I have finally gotten some real first hand view of the situation.

I tell the IM intern about the patient and mention one small thing (say a VP shunt) and the IM hollars if they have that, NS needs on board. Ok, can't they be consulted on the floor?... No, they need an ED evaluation. So you call some lowly surgery intern covering for NS and are told to get a head to pelvis CT and plain films (i.e. THOUSANDS of dollars). An hour later, there is a call, its ok, call IM.

Im not sure if the IM intern new this, but it actually is a cya reason for having the NS consulted in the ER. Once the patient is admitted, EMTALA does not apply anymore. Hence, if NS is consulted in the ER, the NS that is covering the hospital under federal law (EMTALA) has to consult that pt. If pt is admitted, the NS doesn't necessarly obligated to see the pt under EMTALA. The applies to all consults in the ER and even observation status.
Click to expand...
 
docbooboo said:
EM_Rebuilder said:
Having just completed my first month in the Emergency Department as a resident, I have finally gotten some real first hand view of the situation.

I tell the IM intern about the patient and mention one small thing (say a VP shunt) and the IM hollars if they have that, NS needs on board. Ok, can't they be consulted on the floor?... No, they need an ED evaluation. So you call some lowly surgery intern covering for NS and are told to get a head to pelvis CT and plain films (i.e. THOUSANDS of dollars). An hour later, there is a call, its ok, call IM.

Im not sure if the IM intern new this, but it actually is a cya reason for having the NS consulted in the ER. Once the patient is admitted, EMTALA does not apply anymore. Hence, if NS is consulted in the ER, the NS that is covering the hospital under federal law (EMTALA) has to consult that pt. If pt is admitted, the NS doesn't necessarly obligated to see the pt under EMTALA. The applies to all consults in the ER and even observation status.
Click to expand...


This I did not know. So part of the problem lies with EMTALA.. I just do not think there are any good answers to the whole problem. There are obviously TONS of people much smarter and more tuned to these issues than I, and even they cannot really gather a good solution...
Click to expand...
 
Our set up is an emergency department, peds emergency, urgent care, and the emergency ward. The first 3 are pretty familiar to most people, so I won't go into details. The emrgency ward works as a longer term place to board patients who have been worked up and admitted but have no bed upstairs yet. The EW has hospital like beds, rather than ED stretchers, nursing, etc. It functions like a mini ICU next to the regular ED. I don't know the exact count, but my guess is it's 15 beds or so. I also don't know what sort of physician coverage is there. This system works pretty well (as well as an ED system can work in a busy urban center).
 
docbooboo said:
EM_Rebuilder said:
Having just completed my first month in the Emergency Department as a resident, I have finally gotten some real first hand view of the situation.

I tell the IM intern about the patient and mention one small thing (say a VP shunt) and the IM hollars if they have that, NS needs on board. Ok, can't they be consulted on the floor?... No, they need an ED evaluation. So you call some lowly surgery intern covering for NS and are told to get a head to pelvis CT and plain films (i.e. THOUSANDS of dollars). An hour later, there is a call, its ok, call IM.

Im not sure if the IM intern new this, but it actually is a cya reason for having the NS consulted in the ER. Once the patient is admitted, EMTALA does not apply anymore. Hence, if NS is consulted in the ER, the NS that is covering the hospital under federal law (EMTALA) has to consult that pt. If pt is admitted, the NS doesn't necessarly obligated to see the pt under EMTALA. The applies to all consults in the ER and even observation status.
Click to expand...
I am very aware of this problem and consequently I'm usually ok with calling the on call consultant from the ED. However, I thought that this provision of EMTALA had been changed to avoid the problem of a patient who worsened or developed a new problem while an inpatient. My understanding was that current EMTALA considered the higher level of care to be obligated to take the patient, even an admitted patient, when the patient needed a consult the transferring facility lacked. The sticky problem with this is the question, which is not a new one, is what constitutes "capability." Does it mean having the specialist on staff or on call. Big difference.
Click to expand...
 
docB said:
docbooboo said:
I am very aware of this problem and consequently I'm usually ok with calling the on call consultant from the ED. However, I thought that this provision of EMTALA had been changed to avoid the problem of a patient who worsened or developed a new problem while an inpatient. My understanding was that current EMTALA considered the higher level of care to be obligated to take the patient, even an admitted patient, when the patient needed a consult the transferring facility lacked. The sticky problem with this is the question, which is not a new one, is what constitutes "capability." Does it mean having the specialist on staff or on call. Big difference.
Click to expand...

Thought i knew something, guess not, heres a link that is pretty interesting
check out number ten.

http://www.medlaw.com/healthlaw/EMTALA/education/20-common-practices-that-.shtml
Click to expand...
 
drlisa0318 said:
That's the way it's set up in the hospital where I volunteer. Can't say that it helps much in any way. It's still the busiest ED in the state. And it's busy pretty much 24/7.

Of course, actual docs could certainly speak to this with a greater degree of accuracy than I can. Still, it would be nice if I could come up with a more definitive answer when patients ask (many not very nicely), "Why is this taking so LONG???"
Click to expand...


Same here, and it works very smoothly 😀. I have a rash on my leg, register him for Urgent care!!!
 
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