Tracking Patients in the Waiting Room

[gamerEMdoc]

With terrible inpatient staffing causing lengthy beholds now a common occurrence in today's EM world, a lot more testing is being done while patients are waiting in the waiting room on low and moderate risk patients. And probably some high-risk patients in places that are really in bad shape with inpatient staff. Depending on volumes, the number of patients in waiting rooms waiting to be seen, waiting for testing, or waiting for admission, can be significant. People have told me horror stories about 100+ patients in their WR which just seems unfathomable to me.

One of the problems, when the WR gets really backed up, is finding and identifying patients. When radiology comes to find someone for an x-ray, or someone tries to go discharge someone, trying to find them in a sea of people without screaming their name in front of a ton of people is difficult. And if radiology can't find the patient, they just move on to the next person, which then leads to longer delays.

I'm wondering, has anyone's ED utilized any RFI tracking or any other novel systems for tracking where patients are who aren't in a bed, but rather somewhere in the queue that is the modern ED waiting room?

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[CoolDoc1729]

With terrible inpatient staffing causing lengthy beholds now a common occurrence in today's EM world, a lot more testing is being done while patients are waiting in the waiting room on low and moderate risk patients. And probably some high-risk patients in places that are really in bad shape with inpatient staff. Depending on volumes, the number of patients in waiting rooms waiting to be seen, waiting for testing, or waiting for admission, can be significant. People have told me horror stories about 100+ patients in their WR which just seems unfathomable to me.

One of the problems, when the WR gets really backed up, is finding and identifying patients. When radiology comes to find someone for an x-ray, or someone tries to go discharge someone, trying to find them in a sea of people without screaming their name in front of a ton of people is difficult. And if radiology can't find the patient, they just move on to the next person, which then leads to longer delays.

I'm wondering, has anyone's ED utilized any RFI tracking or any other novel systems for tracking where patients are who aren't in a bed, but rather somewhere in the queue that is the modern ED waiting room?

We often have 30-50 in our waiting room. We really just holler their name. A few times people have been missed during roll call because they are deaf, so now we mark in the tracking board if they are deaf, blind, don’t speak English, etc. I’m intrigued by your rfi idea, but I don’t think my hospital would ever spend that kind of $$.
The last time I tried to send a patient to our Big State University Hospital (very few things I have to send out) they had over 200 in their waiting room, of which 50+ were admitted holders!

 

[bky3c]

This reminds me of the dark ages when patients had to write their name and chief complaint on a little slip of paper and put it on the triage desk to check in. The triage nurse kept them in a pile when it was busy, grabbed one at a time, and bellowed the patient's name from the triage desk to have them come up for vitals, etc. This was a big hospital where a lot of patients and staff spoke Spanish. One day there was a non-Spanish speaking male nurse working triage. Big white guy, built like a refrigerator. One of the other nurses had slipped a fake patient check-in form into the stack. On it, he had written (under "name") "Meduele Lasnalgas." So the triage nurse yelled that into the waiting room, and everyone who knew some Spanish (most of them) burst into laughter. "Me duele las nalgas" means, "My butt hurts."

Anyway... seems like restaurants are way ahead of us on this. I guess the problem would be loss/theft, but those little pucks that light up and make noise might help in crowded waiting rooms. I worked in a place that was terrible about this even pre-pandemic, and I always hated having to not only find the right patient (and hope they weren't in the bathroom, hadn't run out to their car to get something, etc.) but then either have a conversation right there or try to find an empty office, closet, or even a bathroom in which to talk. It makes us look terrible, and it's a gigantic waste of time. And of course, every other patient you've already seen out there will also want to pull you aside and ask about what's going on with their labs, when their x-ray will be done, can they get a sandwich, can you explain this to their sister-in-law the vet tech on the phone, etc. I imagine this happens to the rad techs, lab techs, etc. too.

 

[bravotwozero]

This reminds me of the dark ages when patients had to write their name and chief complaint on a little slip of paper and put it on the triage desk to check in. The triage nurse kept them in a pile when it was busy, grabbed one at a time, and bellowed the patient's name from the triage desk to have them come up for vitals, etc. This was a big hospital where a lot of patients and staff spoke Spanish. One day there was a non-Spanish speaking male nurse working triage. Big white guy, built like a refrigerator. One of the other nurses had slipped a fake patient check-in form into the stack. On it, he had written (under "name") "Meduele Lasnalgas." So the triage nurse yelled that into the waiting room, and everyone who knew some Spanish (most of them) burst into laughter. "Me duele las nalgas" means, "My butt hurts."

I laughed at that for 5 minutes. Thanks for the story lol.

Yes I’m immature AF.

 

[CajunMedic]

It makes us look terrible, and it's a gigantic waste of time. And of course, every other patient you've already seen out there will also want to pull you aside and ask about what's going on with their labs, when their x-ray will be done, can they get a sandwich, can you explain this to their sister-in-law the vet tech on the phone, etc. I imagine this happens to the rad techs, lab techs, etc. too.

If you walk past them, they look at you with the "animal shelter" eyes. "Are they coming for me? Is that my doctor? Am I finally getting Dilaudid for my hangnail?." Just needs a Sarah McLachlan song and it feels like an ASPCA commercial.

But seriously, I usually bellow their name in my Drill Sergeant voice, gets their attention and quiets it down for a minute.

 

[BJJVP]

How long until programs realize they can sucker a senior resident into completing a waiting room fellowship?

 

[Apollyon]

We often have 30-50 in our waiting room. We really just holler their name. A few times people have been missed during roll call because they are deaf, so now we mark in the tracking board if they are deaf, blind, don’t speak English, etc. I’m intrigued by your rfi idea, but I don’t think my hospital would ever spend that kind of $$.
The last time I tried to send a patient to our Big State University Hospital (very few things I have to send out) they had over 200 in their waiting room, of which 50+ were admitted holders!

"because they are deaf" - you're too kind. I have a post up from about 20 years ago or so in "Things I Learn From My Patients", about a guy who complained that he didn't get called, despite having normal hearing, being the only one in the waiting room, and being called 3 times.

 

[Rekt]

"How do we normalize waiting room medicine and at the same time increase our liability?"

No thanks. Admin can come down and see the patients themselves.

 

[CoolDoc1729]

"because they are deaf" - you're too kind. I have a post up from about 20 years ago or so in "Things I Learn From My Patients", about a guy who complained that he didn't get called, despite having normal hearing, being the only one in the waiting room, and being called 3 times.

Literally one man was totally deaf and had a stroke so nonambulatory. He just sat in the waiting room watching tv for 35 hours. 15 of those hours he was not on the board because they had taken him out “without completing treatment” because he didn’t answer. To be fair his wife probably should have called after less than 35 hours. Or even been there with him ? Crazy.

 

[JacobMcCandles]

The hospital is more interested in RFI'ing staff to see how long they're in the room, where they're at, etc. way more than they want to RFI patients.

 

[emergentmd]

Why would any doc do waiting room medicine? Admin needs to fix the problem.

I don't see any other specialists seeing pts in the waiting room?

 

[CoolDoc1729]

Why would any doc do waiting room medicine? Admin needs to fix the problem.

I don't see any other specialists seeing pts in the waiting room?

Actually .. ours do. Urology and GI regularly are taking patients straight from wr for scopes, neuro, cards, you name it. We have people boarding in the wr up to 36 hours though so …

I don’t want to do wr medicine, but I can’t do the other thing anymore as our department is always full to ratio of boarders. I have persuaded my night nurses that it works better if we actually do all the meds and tests (that don’t require intensive monitoring) so we can get people in and out, so it runs like the regular ER except patients in chairs and the ratios are thrown out the window. Generally ok for esi 3-5 and better than nothing for esi 2 IMO.

Legally I think we are liable for the patients either way. On a higher level it would probably be better if we refused to do anything for the wr patients so the hospital would be forced to hire more nurses .. except .. that’s how it was in December and January of 2020/1 and we were instructed by CMG not to see anyone in wr and so we just had 40% LNT for that time and nothing changed at all. Plus if I were a patient in the wr I’d want someone to try to help me, instead of “taking a stand” against corporate medicine. I see where the No WR Medicine camp is coming from. There’s no good answer so we have to do what we have to do to sleep after shift.

 

[GonnaBeADoc2222]

Actually .. ours do. Urology and GI regularly are taking patients straight from wr for scopes, neuro, cards, you name it. We have people boarding in the wr up to 36 hours though so …

I don’t want to do wr medicine, but I can’t do the other thing anymore as our department is always full to ratio of boarders. I have persuaded my night nurses that it works better if we actually do all the meds and tests (that don’t require intensive monitoring) so we can get people in and out, so it runs like the regular ER except patients in chairs and the ratios are thrown out the window. Generally ok for esi 3-5 and better than nothing for esi 2 IMO.

Legally I think we are liable for the patients either way. On a higher level it would probably be better if we refused to do anything for the wr patients so the hospital would be forced to hire more nurses .. except .. that’s how it was in December and January of 2020/1 and we were instructed by CMG not to see anyone in wr and so we just had 40% LNT for that time and nothing changed at all. Plus if I were a patient in the wr I’d want someone to try to help me, instead of “taking a stand” against corporate medicine. I see where the No WR Medicine camp is coming from. There’s no good answer so we have to do what we have to do to sleep after shift.

Nah there's really good answers, all of which my hospital refuses to do:

-Patients can line the hallways. You can use those portable dividers for privacy during initial evaluation

-Patients can be doubled up in ER rooms

-Admitted patients can be pulled into hallways

-Inpatient units can have hallway beds


It's always "we have no space." No, we have plenty of space, you just refuse to creatively utilize it.

We don't do waiting room medicine, but they just stay in the WR till it backs up to 40-60 or so and they just leave. They've already been "seen" by a provider in triage so it doesn't count as LWBS and the hospital doesn't care.

 

[CoolDoc1729]

Nah there's really good answers, all of which my hospital refuses to do:

-Patients can line the hallways. You can use those portable dividers for privacy during initial evaluation

-Patients can be doubled up in ER rooms

-Admitted patients can be pulled into hallways

-Inpatient units can have hallway beds


It's always "we have no space." No, we have plenty of space, you just refuse to creatively utilize it.

We don't do waiting room medicine, but they just stay in the WR till it backs up to 40-60 or so and they just leave. They've already been "seen" by a provider in triage so it doesn't count as LWBS and the hospital doesn't care.

My nurses are unionized and they are only allowed to have 4 patients or 2 ICUs. So if I have 18 boarders and 5 nurses, no one can go anywhere besides the wr. Literally if we get a code charge rn goes into assignment and then files a complaint with the union. It’s definitely not a space issue, we usually have 2/3 of the department with the lights off unoccupied. It’s very frustrating !

 

[GonnaBeADoc2222]

My nurses are unionized and they are only allowed to have 4 patients or 2 ICUs. So if I have 18 boarders and 5 nurses, no one can go anywhere besides the wr. Literally if we get a code charge rn goes into assignment and then files a complaint with the union. It’s definitely not a space issue, we usually have 2/3 of the department with the lights off unoccupied. It’s very frustrating !

Heart of a nurse

 

[ScepticSkeksis]

Why would any doc do waiting room medicine? Admin needs to fix the problem.

I don't see any other specialists seeing pts in the waiting room?

I don't think there is a choice. Although I'm relatively fresh, my understanding is that even previously functioning hospitals are doing WR medicine post-COVID.

The worst for me are the abandoned wheelchair patients. Some little old granny sitting in the waiting room all by herself in a wheelchair. She has no way of getting around, and can't walk/move to be seen.

 

[Dr Mantis Toboggan]

I don't think there is a choice. Although I'm relatively fresh, my understanding is that even previously functioning hospitals are doing WR medicine post-COVID.

The worst for me are the abandoned wheelchair patients. Some little old granny sitting in the waiting room all by herself in a wheelchair. She has no way of getting around, and can't walk/move to be seen.

Yup. My community hospital once was a well oiled machine, it was easy to see/dispo 30 pts a shift, no need to transfer except for rare higher level of care issues.

Those days are gone.

 

[emergentmd]

I don't think there is a choice. Although I'm relatively fresh, my understanding is that even previously functioning hospitals are doing WR medicine post-COVID.

The worst for me are the abandoned wheelchair patients. Some little old granny sitting in the waiting room all by herself in a wheelchair. She has no way of getting around, and can't walk/move to be seen.

What a sad state of EM if this becomes the norm. Admin wants patient quality of care and satisfaction, then have pts seen in the waiting room getting a history in the presence of strangers, a subpar physical, and increased liability for the whole system.

I am glad I left precovid and now know why most of my old partners have started to leave the hospital.

I remember doing locums at a place where they had a large room inside the ER, 6 pods, and each pod with 4 chairs. I thought that already was bad medicine and I had a really hard time finding my patients. I could not imagine going into the waiting room and yelling out names for my patients.

EM docs continuing to work in this environment just givens admin the go ahead to continue WR medicine without fixing the ER/back end problems.

 

[Dr Mantis Toboggan]

EM docs continuing to work in this environment just givens admin the go ahead to continue WR medicine without fixing the ER/back end problems.

I’d say rather that we are trying to support our families by doing the best we can for our patients, as opposed to just simping for the admin, but I suppose it’s all in how you look at it.

 

[RustedFox]

What bugs me is the pervasive "just go to the ER" attitude by physicians and admin.

We have a few IM/surg specialists that say to their patients "go to the ER and wait for my PA".

No, bro. We're not your clinic.

Facility physician can't do even basic medicine? Just go to the ER.

Is your widget (tube, whatever) broken? Just go to the ER; forget about keeping one or two around that you can change yourself.

 

[emergentmd]

I’d say rather that we are trying to support our families by doing the best we can for our patients, as opposed to just simping for the admin, but I suppose it’s all in how you look at it.

I get it, we all have worked hard and need to support our family. Its the just the nature of the job and the specialty where if you do not own the pts/facility, you have little say in what happens.

But where does it end? What's next, parking lot medicine where there are numbered slots?

EM has changed a lot and I am one who lets most EM issues not bother me. But WR medicine is just something that would make me quit a job.

 

[Kryptocoin]

This is the symptom of a failed outpatient care system. Improving WR times will only worsen the disease. Because now patients will have an expectation that they should be treated in the WR. When that becomes standard-of-care, lawyers will start scanning local ER waiting rooms to sue for any bad outcome. Right now, they're on shaky legal grounds to do so.

 

[emergentmd]

From my understanding, Covid created alot of "new" ideas to improve flow. Now that covid is dead, we seem to think these new ideas are great. Just like any new program, once you put it in, its hard to take away.

I think we are moving into the ER is the new overflow inpatient facility and the WR is the new ER. If this is what is happening, might as well relabel it so pts don't expect to ever go back to the inpatient overflow area.

 

[GassYous]

From my understanding, Covid created alot of "new" ideas to improve flow. Now that covid is dead, we seem to think these new ideas are great. Just like any new program, once you put it in, its hard to take away.

I think we are moving into the ER is the new overflow inpatient facility and the WR is the new ER. If this is what is happening, might as well relabel it so pts don't expect to ever go back to the inpatient overflow area.

Next thing you know, the parking lot will be the new ER and the waiting room will be the inpatient holds

 

[RuralEDDoc]

Next thing you know, the parking lot will be the new ER and the waiting room will be the inpatient holds

That’s how it is in some places currently.

 

[TrailRun]

Can you, as the physician, be sued for a bad outcome in the waiting room, if you haven’t seen that patient thereby do not have a doctor – patient relationship?

 

[Pudortu]

Can you, as the physician, be sued for a bad outcome in the waiting room, if you haven’t seen that patient thereby do not have a doctor – patient relationship?

Lol you can be sued for anything. Before I arrived at my original job, I heard there was a patient that checked in, and immediately eloped and had a bad outcome. Lawyer went to the hospital website and named every single ER doc listed.

 

[thegenius]

Can you, as the physician, be sued for a bad outcome in the waiting room, if you haven’t seen that patient thereby do not have a doctor – patient relationship?

We have a duty to treat once the patient arrives to the ED asking to be evaluated. That occurs when they step into door. Actually...sometimes that happens within 250 feet of the ER (literally).

So yes.

 

[emergentmd]

Can you, as the physician, be sued for a bad outcome in the waiting room, if you haven’t seen that patient thereby do not have a doctor – patient relationship?

I put my name on the pt chart. I walk out to call the pts name but can't find pt. Pt is found dead in the bathroom. Guess who will be at fault?
I put my name, see the pt, start orders. I see a critical K level of 2.2, rush out and can not find pt. Pt found dead in the cafeteria or waiting in car. Guess who will be at fault?
I am the only doc in the pit, pt dies waiting 2 hrs with complaints of chest pain. Guess who will be named?

There is nothing good with WR medicine.

Staff/docs used to complain that pts in rooms were not undressed, not on monitors. How the heck are you going to monitor WR pts.

 

[CoolDoc1729]

That’s how it is in some places currently.

🙋🏻‍♀️
There’s going to have to be national tort reform on this issue, or there will be no one insurable left to work in the ERs in 10-15 years … yes it is not good medicine but unless every other patient brings a nurse with them what are we supposed to do?

 

[Arcan57]

This WR discussion reminds me of the SDG vs. CMG debates from way back in the day. The same three camps still apply:
1) What is this problem I hear about? The med student/non-EM camp
2) You people are all fools for accepting these conditions and I'm lucky/blessed/superior because I don't have to deal with it. The unicorn job camp
3) How do I make the best of a suboptimal situation because I'm not willing to sever every attachment in my life to grab one of the small percentage of jobs where this isn't an issue. The vast majority camp

We just got done bashing straight hourly pay as a race to the bottom of productivity/effectiveness. If you accept that EM doc compensation commonly involves some form of pay for productivity, it's pretty obvious that for a lot of docs this isn't an academic discussion about medicolegal risk of signing up for WR pts. If you're straight RVU or low base pay+RVUs and you're in a hospital that routinely has more inpatient holds than ED beds, you don't make enough money to support your family if you don't see WR pts. Forgot how quickly you can get to FIRE, can you even make your loan payments if you're only getting paid for the 6-8 new patients that actually got roomed on your shift?

Unless the supply of RNs expands rapidly with a commensurate reduction in their hourly pay, in-patient holds are going to be a permanent fixture of most EDs. If you assume that our job is to provide emergency care, we're going to have to figure out a different model for how to do that under those conditions. It's similar to when the first wave of ED docs created departments rather than a couple of rooms in the basement. We're going to need to figure out how to triage/track/test and get paid for a workflow that doesn't include utilizing any significant RN care in most cases.

 

[Dr Mantis Toboggan]

🙋🏻‍♀️
There’s going to have to be national tort reform on this issue, or there will be no one insurable left to work in the ERs in 10-15 years … yes it is not good medicine but unless every other patient brings a nurse with them what are we supposed to do?

That’s where the endless stream of new grads comes in. Grist for the mill after us old timers are used up and tossed aside.

 

[ScepticSkeksis]

Why not just set up a drive-through window for medical care? That way we don't even have to have a waiting room.

 

[Arcan57]

Why not just set up a drive-through window for medical care? That way we don't even have to have a waiting room.

I think that we'll eventually stratify into 2 models of urgent/emergent care, one of which could be done without a waiting room if you choose.

We've already gotten pretty good at splitting vertical level 3s/4s/5s from gen pop and expediating their workup. As the diagnostics get done quickly but the nursing care lags, patients are becoming more and more used to the idea that an ED will tell you what's wrong but it's not a place to get immediate relief from pain/vomiting/etc. If we can separate the idea of diagnosis from emergent treatment, you can do ED care almost anywhere that has access to diagnostics because you no longer need nurses to deal with patients.

 

[bravotwozero]

With regards to the nursing shortage, one thing that baffles me - why is nobody considering hiring foreign RNs? There’s all kinds of foreign trained docs in America.

Pretty sure nurses from Canada, Phillipines, and other nations where English is widely spoken would be interested in a job that would pay significantly more and raise their standard of living.

 

[Dr Mantis Toboggan]

With regards to the nursing shortage, one thing that baffles me - why is nobody considering hiring foreign RNs? There’s all kinds of foreign trained docs in America.

Pretty sure nurses from Canada, Phillipines, and other nations where English is widely spoken would be interested in a job that would pay significantly more and raise their standard of living.

Oh they are trying.

All the local hospitals around here are trying to import nurses from the Philippines.

Not sure how the logistics of that work, with visas etc.

No doubt they would show up and work hard and get a ton of work done minus the complaining/TikTok viewing etc.

 

[HemorrhagicShock]

Oh they are trying.

All the local hospitals around here are trying to import nurses from the Philippines.

Not sure how the logistics of that work, with visas etc.

No doubt they would show up and work hard and get a ton of work done minus the complaining/TikTok viewing etc.

This is exactly what the various organizations around me are talking about, and they've started to strategize on this idea!

 

[southerndoc]

We have a duty to treat once the patient arrives to the ED asking to be evaluated. That occurs when they step into door. Actually...sometimes that happens within 250 feet of the ER (literally).

So yes.

It's not likely. Most plaintiff attorneys know that if they name an ED doc for a patient that had a bad outcome in the waiting room, it will likely not lead to a settlement and likely will not lead to a judgement against the physician and the hospital. Most jurors will realize that the physician did not have any control over the patient in the waiting room.

Yes, they can name you. No, it's not likely to result in the physician's insurer paying anything.

 

[GassYous]

With regards to the nursing shortage, one thing that baffles me - why is nobody considering hiring foreign RNs? There’s all kinds of foreign trained docs in America.

Pretty sure nurses from Canada, Phillipines, and other nations where English is widely spoken would be interested in a job that would pay significantly more and raise their standard of living.

There are artificial barriers in place by the boards of nursing. For example, in California they require you to take the TOEFL exam if you haven't taken courses in the US and require a speaking score of 26 out of 30 which I'm not sure that I could even get. Meanwhile all of our centers are hurting for staff and paying out the nose for "travelers" who leave as soon as they get a handle of things.

 

[RustedFox]

There are artificial barriers in place by the boards of nursing. For example, in California they require you to take the TOEFL exam if you haven't taken courses in the US and require a speaking score of 26 out of 30 which I'm not sure that I could even get. Meanwhile all of our centers are hurting for staff and paying out the nose for "travelers" who leave as soon as they get a handle of things.

Reading your posts, I would put your level of English proficiency at "native speaker".

 

[PianoMedic]

Reading your posts, I would put your level of English proficiency at "native speaker".

Anything above 25 is considered “advanced” and it doesn’t go any higher for the Toefl speaking section. That’s fluency with minor grammatical errors essentially. So probably about what a native speaker would get on it…

 

[RustedFox]

Anything above 25 is considered “advanced” and it doesn’t go any higher for the Toefl speaking section. That’s fluency with minor grammatical errors essentially. So probably about what a native speaker would get on it…

What kind of strange scoring system is this?

 

[gamerEMdoc]

🙋🏻‍♀️
There’s going to have to be national tort reform on this issue, or there will be no one insurable left to work in the ERs in 10-15 years … yes it is not good medicine but unless every other patient brings a nurse with them what are we supposed to do?

I know multiple organizations sent a letter to the POTUS awhile back basically calling the lack of inpatient staffed beds a national crisis causing us to have no ability to be the safety net of the healthcare system anymore. I honestly think that if this is a longer-term issue, the answer is we have to have some sort of EMTALA related care tort reform. Basically tell EDs to "just do your best under the circumstances, you have blanket protection" and then we just figure it out. During COVID, many states put in temporary tort protection. It's maddening to me that these discussions aren't even being had. The government should probably address that they are federally mandating care when care can't be provided outside of the waiting room in many places. Since the govt can't fix floor nursing staffing quickly, they should probably fix their expectations. But good luck with that happening.

 

[ScepticSkeksis]

I know multiple organizations sent a letter to the POTUS awhile back basically calling the lack of inpatient staffed beds a national crisis causing us to have no ability to be the safety net of the healthcare system anymore. I honestly think that if this is a longer-term issue, the answer is we have to have some sort of EMTALA related care tort reform. Basically tell EDs to "just do your best under the circumstances, you have blanket protection" and then we just figure it out. During COVID, many states put in temporary tort protection. It's maddening to me that these discussions aren't even being had. The government should probably address that they are federally mandating care when care can't be provided outside of the waiting room in many places. Since the govt can't fix floor nursing staffing quickly, they should probably fix their expectations. But good luck with that happening.

It won't happen because the lawyers have the gold AND make the rules.

 

[Arcan57]

I know multiple organizations sent a letter to the POTUS awhile back basically calling the lack of inpatient staffed beds a national crisis causing us to have no ability to be the safety net of the healthcare system anymore. I honestly think that if this is a longer-term issue, the answer is we have to have some sort of EMTALA related care tort reform. Basically tell EDs to "just do your best under the circumstances, you have blanket protection" and then we just figure it out. During COVID, many states put in temporary tort protection. It's maddening to me that these discussions aren't even being had. The government should probably address that they are federally mandating care when care can't be provided outside of the waiting room in many places. Since the govt can't fix floor nursing staffing quickly, they should probably fix their expectations. But good luck with that happening.

Counterpoint, implementing disaster rules tort reform allows a group that bills the government billions and is notorious for disassociating quality from cost to avoid one of the few checks on their pursuit of profit. If you were a hospital that's already shooting for the 10-25% of Truven staffing, what's to keep you from running low enough that you could declare inadequate resources as a defense every day of the week?

Now if you could get tort reform that shielded physicians while still leaving hospitals on the hook for the consequences of their profit chasing, then I think you'd have done some real good. That would require docs en masse to realize 1) they and hospitals aren't on the same side and 2) they need to pony up a lot of their own money to do the lobbying. Number 1 is already happening, I don't see number 2 ever happening.

 

[TooMuchResearch]

This WR discussion reminds me of the SDG vs. CMG debates from way back in the day. The same three camps still apply:
1) What is this problem I hear about? The med student/non-EM camp
2) You people are all fools for accepting these conditions and I'm lucky/blessed/superior because I don't have to deal with it. The unicorn job camp
3) How do I make the best of a suboptimal situation because I'm not willing to sever every attachment in my life to grab one of the small percentage of jobs where this isn't an issue. The vast majority camp

We just got done bashing straight hourly pay as a race to the bottom of productivity/effectiveness. If you accept that EM doc compensation commonly involves some form of pay for productivity, it's pretty obvious that for a lot of docs this isn't an academic discussion about medicolegal risk of signing up for WR pts. If you're straight RVU or low base pay+RVUs and you're in a hospital that routinely has more inpatient holds than ED beds, you don't make enough money to support your family if you don't see WR pts. Forgot how quickly you can get to FIRE, can you even make your loan payments if you're only getting paid for the 6-8 new patients that actually got roomed on your shift?

Unless the supply of RNs expands rapidly with a commensurate reduction in their hourly pay, in-patient holds are going to be a permanent fixture of most EDs. If you assume that our job is to provide emergency care, we're going to have to figure out a different model for how to do that under those conditions. It's similar to when the first wave of ED docs created departments rather than a couple of rooms in the basement. We're going to need to figure out how to triage/track/test and get paid for a workflow that doesn't include utilizing any significant RN care in most cases.

SDG partner here. Can confirm. Have to see WR patients, income is falling because of boarding, decreased collections per patient, increasing admin costs, increasing insurance costs. Might have to merge with another group to keep the wolves at bay. All signs point to doom.

 

[ScepticSkeksis]

SDG partner here. Can confirm. Have to see WR patients, income is falling because of boarding, decreased collections per patient, increasing admin costs, increasing insurance costs. Might have to merge with another group to keep the wolves at bay. All signs point to doom.

As an SDG, what have you done to mitigate WR workups and/or make the process more efficient? From a CMG place, there is virtually no effort on the part of our leadership to make things more palatable.

 

[CoolDoc1729]

As an SDG, what have you done to mitigate WR workups and/or make the process more efficient? From a CMG place, there is virtually no effort on the part of our leadership to make things more palatable.

Our CMG tells us there’s no way there should ever be LWBS because we are way over staffed and that they are losing money on our contract and oh by the way shouldn’t you be billing more CC? Hard to justify if the patient literally is in the wr the whole time they are in our department …

I agree. They (hospital leadership and cmg leadership) are doing nothing to make it better or even acknowledge there’s a problem. Crazy times.

 

[RustedFox]

Our CMG tells us there’s no way there should ever be LWBS because we are way over staffed and that they are losing money on our contract and oh by the way shouldn’t you be billing more CC? Hard to justify if the patient literally is in the wr the whole time they are in our department …

I agree. They (hospital leadership and cmg leadership) are doing nothing to make it better or even acknowledge there’s a problem. Crazy times.

I just had a very similar discussion with our director. What admin/CMG ghouls don't understand is that these patients are anything but straightforward.

"What medications do you take?"
Oh my, oh God, oh dear. Let me see (ruffles thru 10+ pieces of paper, makes 2 phone calls, tries unsuccessfully to log on to CVS on their phone, etc).

"Why are you here?"
Well they said that I might be having an emergency.
"Who are *they*?"
The people I called. I think it was a nurse.
"What number/office/service?"
Oh, I don't remember. Ask my sister. Here, let's call her.

That's the real timesink for me.

 

[BoardingDoc]

I just had a very similar discussion with our director. What admin/CMG ghouls don't understand is that these patients are anything but straightforward.

"What medications do you take?"
Oh my, oh God, oh dear. Let me see (ruffles thru 10+ pieces of paper, makes 2 phone calls, tries unsuccessfully to log on to CVS on their phone, etc).

"Why are you here?"
Well they said that I might be having an emergency.
"Who are *they*?"
The people I called. I think it was a nurse.
"What number/office/service?"
Oh, I don't remember. Ask my sister. Here, let's call her.

That's the real timesink for me.

I just do veternary medicine on these patients. If you cannot provide me with a reasonable history, I will simply treat you as if you were a demented nursing home patient dropped off at our door.

Basic exam. Make sure nothing hurts when I push on it. Look for any obvious signs of trauma. If anyone claims they fell, scan their head/neck. CBC, Chem, UA, EKG. DC if all normal. If they look reasonably well / stably chronically unwell, I honestly don't even care what their chief complaint is. Reassure the muggle that "your tests look good and we're going to send you home now. Call your doctor tomorrow."