Wanted to get the ER opinion

[BlahtoThis]

Hey everybody,

I'm an IM resident now but wanted to get the opinion of some ER pepz about this. I know that in this day and age, there's a lot more stress on ER docs in terms of moving patients because there are just so many people who use the ER inappropriately as a primary care service or for problems that would be best treated as an outpatient. However, where I'm at there's a policy that if there's more than a certain number of patients in the waiting room, everything goes into a kind of "go faster mode" for a set period of several hrs in which they try to push the docs to just admit patients quickly who seem like they *most likely* should be admitted anyway rather than working them up further. Obviously, there are a lot of cases in which you will have an idea of who will most likely be admitted and who will most likely be able to leave straight from the ER.

That's the background. My question is do you think this is a good policy for an ER to have? I've worked down there and I really don't like it because sometimes I feel uncomfortable admitting a patient who I'm being pushed to admit because they're kind of borderline (and these patients' stay on the floor usually ranges from 2 hrs to an overnight stay in which there wasn't even bloodwork taken or an iv placed). Being on the other side of things, I've had patients during these "go faster" periods admitted to a floor service in DKA or in shock with no access because their labs weren't followed up or they weren't appropriately worked up.

I wonder if this is the policy in a lot of places and how you feel this would impact your work situation? I went to med school in an inner city area and of course that was totally different with average wait times in the ER being LOOOOOONG (like more than 12-15 hrs).

(By the way, I'm not trying to be critical of EM docs in anyway but of this sort of policy ... it's really a different world in terms of the ER versus being on the hospital floors, but I think policies like this force the docs on the floors to question admissions from the ER since the degree of work-up becomes not just physician-dependent (which would be appropriate) but dependent on some arbitrary policy that forces the ER docs to turnover patients faster.)

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[DrQuinn]

Hey everybody,

I'm an IM resident now but wanted to get the opinion of some ER pepz about this. I know that in this day and age, there's a lot more stress on ER docs in terms of moving patients because there are just so many people who use the ER inappropriately as a primary care service or for problems that would be best treated as an outpatient. However, where I'm at there's a policy that if there's more than a certain number of patients in the waiting room, everything goes into a kind of "go faster mode" for a set period of several hrs in which they try to push the docs to just admit patients quickly who seem like they *most likely* should be admitted anyway rather than working them up further. Obviously, there are a lot of cases in which you will have an idea of who will most likely be admitted and who will most likely be able to leave straight from the ER.

That's the background. My question is do you think this is a good policy for an ER to have? I've worked down there and I really don't like it because sometimes I feel uncomfortable admitting a patient who I'm being pushed to admit because they're kind of borderline (and these patients' stay on the floor usually ranges from 2 hrs to an overnight stay in which there wasn't even bloodwork taken or an iv placed). Being on the other side of things, I've had patients during these "go faster" periods admitted to a floor service in DKA or in shock with no access because their labs weren't followed up or they weren't appropriately worked up.

I wonder if this is the policy in a lot of places and how you feel this would impact your work situation? I went to med school in an inner city area and of course that was totally different with average wait times in the ER being LOOOOOONG (like more than 12-15 hrs).

(By the way, I'm not trying to be critical of EM docs in anyway but of this sort of policy ... it's really a different world in terms of the ER versus being on the hospital floors, but I think policies like this force the docs on the floors to question admissions from the ER since the degree of work-up becomes not just physician-dependent (which would be appropriate) but dependent on some arbitrary policy that forces the ER docs to turnover patients faster.)

Where I'm at (inner city, Level 1 academic center), we recently have been so backed up, we had 40 waiting for beds, with 50 in the waiting room. There was ONE bed available in the ED to see new patients in. We even had patients admitted (who were stable and didn't need monitoring), using the waiting room chairs.

This left us with ONE bed in case EMS had to bring in a new patient, unresponsive, MI, shock, trauma, whatever you want.

Not good patient care. We need to get our ED ready for emergencies, not boarded patients. I know what it was like to be a medicine resident, I did 6 months of medicine/med subspecialty call during residency, and know what is admitted and what isn't. But we need the ED to be open 24 hours a day with the ability to handle what comes through teh doors.

Imagine what would happen if L&D were full and wasn't allowed to bring in a patient crowning, or with a prolapsed cord.

Q

 

[Apollyon]

One of the med-psych residents where I was at was there before the EM residency started, and he said that it was "night and day" between then and now, as far as patient care went. In the "old days", it was IM on one side, and surgery on the other. Whatever train wreck you got, you got.

In June, he said to me that, with the EM residents now, there's nothing left to do - no lines, no orders, no procedures, no thinking. I know of a now-IM3 resident that, to the end of his IM2 year, had never done an LP. Not one.

You seem to want it both ways - patients that don't need to be admitted, but, the ones that do, aren't worked up. That's part of the continuum - when you're involved, YOU put the line in. YOU manage the patient, from an earlier point than usual.

And, the final option is available (that was used where I was prelim-IM) - if you don't agree with a patient being admitted, have the IM attending discharge the patient from the ED (there was an IM attending in-house available for this, among other things).

 

[waterski232002]

Although unfortunate for all involved, obviously the overcrowding issue is a big problem. And I think it's a much bigger problem than most IM, Surgery, and subspecialty services really realize. As DrQuinn touched on, we really do need the beds for the inevitable crashing patient that EMS brings in, the GSW that walks through the door, or the angioedema that needs rapid attention... all interspersed between your black box of 70 yo's c/o CP or hemiplegia. Although these are only about 25% of what we see, these patients can NOT wait in the waiting room. So it is better to admit the boarderline patient (in his best interest) and take care of the more sick patient (in his respective best interest as well).

I will agree, that it is unexceptable to send a patient to the floor without an IV, labs, or work-up. You won't know what service the patient should be admitted to, or what type of monitoring he will need until he is properly worked up and labs are back.

The dilemma I find myself in, is that some IM residents/attendings want to continue the workup in the ER after the main diagnosis or systemic problem has been established. It is appropriate to continue the work up in the ER if a lab/imaging study will change the service the patient is admitted to, or level of monitoring required (i.e. 70 yo F c/o SOB and being treated for COPD... the IM service would like a CT chest to r/o PE b/c if it's positive they will need a telemetry bed). On the other hand, I find it inappropriate to keep the same patient in the ER for a CT chest to evaluate a questionable lung nodule).

 

[mikecwru]

Although unfortunate for all involved, obviously the overcrowding issue is a big problem. And I think it's a much bigger problem than most IM, Surgery, and subspecialty services really realize. As DrQuinn touched on, we really do need the beds for the inevitable crashing patient that EMS brings in, the GSW that walks through the door, or the angioedema that needs rapid attention... all interspersed between your black box of 70 yo's c/o CP or hemiplegia. Although these are only about 25% of what we see, these patients can NOT wait in the waiting room. So it is better to admit the boarderline patient (in his best interest) and take care of the more sick patient (in his respective best interest as well).

I will agree, that it is unexceptable to send a patient to the floor without an IV, labs, or work-up. You won't know what service the patient should be admitted to, or what type of monitoring he will need until he is properly worked up and labs are back.

The dilemma I find myself in, is that some IM residents/attendings want to continue the workup in the ER after the main diagnosis or systemic problem has been established. It is appropriate to continue the work up in the ER if a lab/imaging study will change the service the patient is admitted to, or level of monitoring required (i.e. 70 yo F c/o SOB and being treated for COPD... the IM service would like a CT chest to r/o PE b/c if it's positive they will need a telemetry bed). On the other hand, I find it inappropriate to keep the same patient in the ER for a CT chest to evaluate a questionable lung nodule).

What the hell do you need to put a PE on a tele floor for? A stable PE usually gets me a downgrade (from tele to floor) since a strong alternative diagnosis has been established.

mike

 

[beyond all hope]

Is the ED.

We take all comers. As a result, we are abused. As a result, we are overcrowded and unable to take care of true emergencies.

A good ER doc will rapidly DC the ones with nonemergent complaints and rapidly admit stable patients requiring inpatient treatment in order to free up our resources to take care of sick people.

When it's busy and I know a stable patient is coming in, I let the docs know about it after I've gotten the critical tests (EKG for CP, etc), and while they're getting the story, all of the other labs and studies will come in.

Specialists and primary docs have different thresholds on what they consider an appropriate ED workup before admission. Some docs refuse to even hear about a pneumonia before getting a WBC (which is absurd). Others are willing to hear the H&P from the ED doc and run with it from there.

When we have more time, we like to be nice to our admitting services and do nonemergent studies and labs from the ED. Last night it was so light I didn't call anyone until my diagnostic workup was complete, and then I waited until 5:30 so they could get a few hours of sleep.

 

[waterski232002]

What the hell do you need to put a PE on a tele floor for? A stable PE usually gets me a downgrade (from tele to floor) since a strong alternative diagnosis has been established.

mike

At our hospital it is protocol that PE patients are put on tele... Not sayin that I agree with the protocol, It's just an example or a test which will actually make a difference in where the patient will go in our hospital, so I think it's warranted in the ER.

 

[southerndoc]

We have orange and red zones. It's a complicated system that the ED charge nurses activate based on the number of admitted patients waiting on beds, the total number of patients in the department, and the number of patients waiting in the waiting room.

It basically makes the upstairs people work faster cleaning beds, taking reports, and moving patients (transporters have priority to move admitted patients instead of shuttling other patients on the floors to diagnostic tests and such).

Patients can be "rocketed" upstairs with incomplete workups. However, they are NEVER sent up without IV's and without a clue as to what is going on. Examples of patients that are sent up: pneumonia (may go up with a lactic acid pending; BP, HR, RR are not indicative of an ICU admission); ROMI's (may go up with a troponin pending if low-risk and CPK/MB are negative); PE (may go up with CT pending if high- or moderate-risk and heparin has already been initiated; if heparin is being held for the study, then the patient remains for diagnostic imaging), etc.

Patients are NOT admitted prior to at least a working diagnosis. Patients are simply admitted because the ED is overwhelmed with patients. It's more of a process to get patients upstairs quicker once the decision has been made to admit the patient.

I think we're in red zone maybe 5% of the time. It's not very often that we are in red zone.

 

[FoughtFyr]

Hey everybody,

I'm an IM resident now but wanted to get the opinion of some ER pepz about this. I know that in this day and age, there's a lot more stress on ER docs in terms of moving patients because there are just so many people who use the ER inappropriately as a primary care service or for problems that would be best treated as an outpatient. However, where I'm at there's a policy that if there's more than a certain number of patients in the waiting room, everything goes into a kind of "go faster mode" for a set period of several hrs in which they try to push the docs to just admit patients quickly who seem like they *most likely* should be admitted anyway rather than working them up further. Obviously, there are a lot of cases in which you will have an idea of who will most likely be admitted and who will most likely be able to leave straight from the ER.

That's the background. My question is do you think this is a good policy for an ER to have? I've worked down there and I really don't like it because sometimes I feel uncomfortable admitting a patient who I'm being pushed to admit because they're kind of borderline (and these patients' stay on the floor usually ranges from 2 hrs to an overnight stay in which there wasn't even bloodwork taken or an iv placed). Being on the other side of things, I've had patients during these "go faster" periods admitted to a floor service in DKA or in shock with no access because their labs weren't followed up or they weren't appropriately worked up.

I wonder if this is the policy in a lot of places and how you feel this would impact your work situation? I went to med school in an inner city area and of course that was totally different with average wait times in the ER being LOOOOOONG (like more than 12-15 hrs).

(By the way, I'm not trying to be critical of EM docs in anyway but of this sort of policy ... it's really a different world in terms of the ER versus being on the hospital floors, but I think policies like this force the docs on the floors to question admissions from the ER since the degree of work-up becomes not just physician-dependent (which would be appropriate) but dependent on some arbitrary policy that forces the ER docs to turnover patients faster.)

Given that you and I are at the same institution, I would say you have a very skewed view of the process. There are two "overcrowding" iniatives. The only was that is a "hurry up" within the department is an internal disaster mode. In that mode, yes, we will send folks to the floor with incomplete work-ups. In that mode all seniors on the "admitting" services are notified that we are essentially "moving the ED upstairs". The attending staff (we call them "consultants") are also called in from home. We fully expect that several of those patients will not stay long. The last time I saw this mode activated was a bus crash where we were set to be the recieving hospital for 10-15 "red" high-school aged trauma patients and expected to handle at least that number in "yellows". Needless to say, we "cleared" the ED rapidly, and having a process in place to do that is good for overall patient care. That said, such a mode is entered into an average of 1.5/yr in the 4 years since it's creation.

The "mode" I think you are referring to has nothing to do with EM operations. When the ED reaches a certain point of overcrowding, three things happen. First, additional technical staff (RTs, Rad techs, and lab techs) are called in from home. As we have a dedicated ED lab and many more radiology suites than we can use, this drops the time to get the needed tests for a complete work-up. Second, the charge nurse meets with the attending staff and assesses which patients are waiting on consults from which services. Those services are then paged directly and their attending staff are often called from home to assist if needed. Lastly, additional ED staff +/- PAs are called in to "open up" beds in our observation unit as additional ED beds.

The idea behind all these moves to to open up the "backdoor" of the ED recognizing that we have no control over the front door. The idea is to "speed up" the evaluation by making the information available to the EP as quickly as possible, not to shorten the critical thinking nor abreviate the normal work-up. I have never been pressured to dispo my patients with less than complete work-ups (except in disasters as above), and I'd venture to say I've spent far more time in our ED than you. If you have concrete examples where you feel the work-up was improper or truncated, go the ETU page on the intranet and submit the M&M, or just PM me the clinic numbers. It will be dealt with.

That said, the biggest problem with off-service rotators we have is expanding their work-up to the level of an EP. While they will gather very complete H&Ps on every patient, the critical thinking usually stops at the door. Probably because, as an IM resident upstairs, you present your H&P and your senior provides the diagnosis and treatment. Not down here. You actually have to think here. So I could see an IM resident using the "overcrowding" mode as an excuse to truncate things. If you don't have the guts to put your money where your mouth is and let me follow-up on these "incomplete workups", at least look for yourslf and see what program the resident caring for the patient was in. I'll bet you it was not EM (and if it was, PM the resident's name and clinic number - please!).

For the rest of the folks here - our "overcrowding" mode is SWEET! We get everything we need, double time. I can get labs, CTs, and x-rays all read and verified in 15 minutes. I'm barely done charting and I can dispo even the real sick folks. If you can't close the front door, make the back door bigger! (But I can't even imagine how much it costs the institution).

BTW - Southern, our system sounds like yours. We use yellow and red "lights". The red light is the "disaster" but it could, in theory, occur from overcrowding too.

- H

 

[Jeff698]

First, I'm jealous of institutions that have a programatic way of announcing that the ED is overwhelmed and needs help.

Second, I think in most places the biggest reasons for overcrowding have little to do with the ED. In any ED where a significant number of ED beds are occupied with admitted patients waiting on admitting teams to come down and do their H&Ps or for a floor bed to open up, the source of the overcrowding problem ain't in the ED!

For the rest of the folks here - our "overcrowding" mode is SWEET! We get everything we need, double time. I can get labs, CTs, and x-rays all read and verified in 15 minutes.

It sure sounds sweet. The concept of labs back in 15 minutes boggles my poor little brain. We can get our bedside labs in that time (lactate, troponin, egroup) but nothing else. Hell, urine takes at least an hour. God help you if you need an HCG (of course, we'd never need one of those!).

Kudos to the places that have thought this out and implemented plans, even if they're not perfect, for dealing with this problem.

Take care,
Jeff

 

[BlahtoThis]

reply to foughtfyr:

wow ... i really didn't mean to start a tirade about it, and i wasn't ever questioning anybody's ability. i do take offense to your comment about the im intern not having to think since we don't just rely on our seniors to do everything for us, though i may be misinterpreting your comment. i'm not trying to question the er itself, i'm questioning the systems aspect of it, and if it's residents from other departments who are making the system malfunction, then maybe they shouldn't be allowed in an er setting because they aren't well suited for it.

 

[Apollyon]

if it's residents from other departments who are making the system malfunction, then maybe they shouldn't be allowed in an er setting because they aren't well suited for it.

The problem is that most "primary" residencies require time in the ED (IM, Peds, Ob/Gyn, surgery, ?FM, ?Psych (as psych ED)), so that has to be done one way or another.

 

[Hercules]

Second, I think in most places the biggest reasons for overcrowding have little to do with the ED. In any ED where a significant number of ED beds are occupied with admitted patients waiting on admitting teams to come down and do their H&Ps or for a floor bed to open up, the source of the overcrowding problem ain't in the ED!

The IOM report would agree with you on this.

 

[Daiphon]

reply to foughtfyr:

wow ... i really didn't mean to start a tirade about it, and i wasn't ever questioning anybody's ability. i do take offense to your comment about the im intern not having to think since we don't just rely on our seniors to do everything for us, though i may be misinterpreting your comment. i'm not trying to question the er itself, i'm questioning the systems aspect of it, and if it's residents from other departments who are making the system malfunction, then maybe they shouldn't be allowed in an er setting because they aren't well suited for it.

well, even if they're not "well suited for it," methinks it's a good idea for the primary care specialties to spend time in the ED. sure, they sometimes feel like fish out of water; and yes, we EM peeps can sometimes get annoyed... but having the services spend some off-service time "down in the trenches" is good because, anectdotally, by the end of their rotation they 1) realize how much crap we put up with and (hopefully) realize that we don't admit patients just to take them away from the call room, 2) have better working relationships with many of the ED staff (which facilitates admissions/consults/etc), and 3) oftentimes get experience with procedures such as lines/tubes/etc that they will need in the units - at least in the ED, there's upper-level residents & attendings to back them up, as opposed to overnight call in the units which is often only residents.

obviously most off-service rotators aren't meant for EM, or else they would've migrated over to our little OCD/ADHD/In-n-Out corner of medicine; however, having them in the ED, while occasionally befuddling to the parties involved, is probably a good thing.

just my $0.02,
-t

 

[kungfufishing]

How do you guys handle off service rotators and workload expectations? Occasionally we have rotators who have a work ethic but more often they like to sit. I dont really need the help, but I think that if they are going to understand how EM works they should actually do something.

Obviously, I dont want them carrying many patients at a time which would be self defeating.

 

[mikecwru]

How do you guys handle off service rotators and workload expectations? Occasionally we have rotators who have a work ethic but more often they like to sit. I dont really need the help, but I think that if they are going to understand how EM works they should actually do something.

Obviously, I dont want them carrying many patients at a time which would be self defeating.

I openly discuss my expectations with them, a reasonable pace would be a little slower than an EM intern, although there are plenty of good IM residents (I'm just using the term IM, we have rotators from IM, FP, psych, gyn, anesthesia, and others intermittently). If I see them surfing the internet while there are charts in the rack, I turn off their computer and hand them a chart.


This is not an IM bashing response. Most people do well. I rarely have to bust balls about seeing patients. Usually, if there's any problems, it's more with follow up and efficiency, not actual enthusiasm or work ethic.

mike

 

[FoughtFyr]

wow ... i really didn't mean to start a tirade about it, and i wasn't ever questioning anybody's ability.

Hmm, let's see...

I've had patients during these "go faster" periods admitted to a floor service in DKA or in shock with no access because their labs weren't followed up or they weren't appropriately worked up.

Nope, not questioning ability at all. BTW - where are the clinic numbers or M&M submission. "The needs of the patient are the only needs to be considered". Given that our ED screws up because of this hurry-up mode so often, aren't you obligated to follow-up and insure these errors don't happen again?

i do take offense to your comment about the im intern not having to think since we don't just rely on our seniors to do everything for us, though i may be misinterpreting your comment.

Take offense all you'd like. Much as your question is based on your experiences, my statement is based on mine. I have rotated through many departments in IM during my residency, and this "I'll get an H&P and let the senior and consultant tell me what is wrong with the patient" was pervasive of the interns in all of them.

i'm not trying to question the er itself, i'm questioning the systems aspect of it, and if it's residents from other departments who are making the system malfunction, then maybe they shouldn't be allowed in an er setting because they aren't well suited for it.

Well that would be nice, excepting that it is required by the FP RRC and in our institution (you do realize we are at the same place don't you Blahto?), IM, OB/GYN, psych, derm (WTF?), and ENT are all required to rotate, required not by the ED but by their programs. And that leaves aside the question of "did the system malfunction"? You have yet to back up your examples, but most of the cases I've heard of of ED "misses" are more pontification by the IM folks. I.e., we treated a CHF exacerbation with abx because of a mild WBC elevation and soft CXR findings and the IM people disagreed (after rounding for 12 hours), or even better we "failed" to get blood cultures in that patient...

- H

 

[RuralMedicine]

And, the final option is available (that was used where I was prelim-IM) - if you don't agree with a patient being admitted, have the IM attending discharge the patient from the ED (there was an IM attending in-house available for this, among other things).

I think this is probably an option everywhere (or it should be). The irony in it for me was I never invoked it until my third year as a resident for a patient with altered mental status and fever that somehow the ED attending forgot to workup. After working up the patient we felt comfortable discharging. The ED attending involved generally is very on top of things and I think honestly was overwhelmed not sloppy. [I later learned he flagged his own chart for review] It actually kind of worked out neatly, I asked the ED attending to order the head CT and antibioitics when he called to admit, he held the admission (at the time over the phone I was agreeing that the patient needed to be admitted I wasn't sure a floor bed was suitable so we held to reassess level of care), ordered blood and urine cultures. I came down 30 minutes later (I had just intubated another patient in the ICU before the phone call I was dealing with that and a few other ICU patients) saw the CT and did the LP. The CT was negative. LP had no cells (although the patient wouldn't let my stellar sub-I do the tap which made her less of a fan) urine toxicology came back positive for cocaine(hyperpyrexia rather than fever? we went with it). Mental status improved. My stellar sub-I managed to contact the patient's daughter who gave us some of her mental health history and very key for disposition volunteered to drive up and take her back to her home until she could follow up with her psychiatrist.

Disposition: Home
[Door to Discharge Time: 6 hours (but only 2 hours after medicine got involved so you could argue workup time wasn't excessive--although perhaps it took the four hours of the patient coming down off her drugs for me to consider she could possibly go. I didn't see her when she came in at 3am, I would have probably had a different perspective on the whole situation]