Heresy
Sometimes, an answer is so simple that nobody thinks of it. It takes a really simple-minded person like me to come up with the solution.
It is obvious that our ERs are overcrowded. Patients wait too long to be evaluated and even longer to finally get admitted to a room upstairs. A few have even died in our waiting rooms. Some people suggest that the biggest contributor to this problem is the lack of available inpatient/ICU beds upstairs which causes admitted patients to tie up our ER rooms and our nurses. I'm going to suggest another important cause.
Often when I start my shift, 9 of my 12 rooms are filled with patients who are waiting for admission. Sure, I can try to fast track a few patients in triage, but many patients are not good candidates for the "fast track" approach, and without a dedicated nurse to do all the stuff that I order, even simple patients are not easily managed in this fashion. And often when I need something done for one of my three patients, their nurse is busy managing an "admitted" patient.
So what can we ER docs do about it? Complain to management? Write a letter to our congressman? Wait for ACEP to fix everything?
How about not admitting so many patients (gasp!):
We want to see acute patients in the ER, not manage already admitted patients who are waiting for a bed upstairs or twiddle our thumbs while patients wait in triage. If we stop admitting so many soft cases, the ones who REALLY need to be admitted won't have to wait so long to get a room and maybe the patients in the waiting room won't have to wait so long to be evaluated.
The success of this plan will depend on several factors:
Maybe if we were able to crank through a few more patients per shift, the extra income would be incentive enough. You try it first, and let me know how it works; my balls are a little gun shy right now.
It is obvious that our ERs are overcrowded. Patients wait too long to be evaluated and even longer to finally get admitted to a room upstairs. A few have even died in our waiting rooms. Some people suggest that the biggest contributor to this problem is the lack of available inpatient/ICU beds upstairs which causes admitted patients to tie up our ER rooms and our nurses. I'm going to suggest another important cause.
Often when I start my shift, 9 of my 12 rooms are filled with patients who are waiting for admission. Sure, I can try to fast track a few patients in triage, but many patients are not good candidates for the "fast track" approach, and without a dedicated nurse to do all the stuff that I order, even simple patients are not easily managed in this fashion. And often when I need something done for one of my three patients, their nurse is busy managing an "admitted" patient.
So what can we ER docs do about it? Complain to management? Write a letter to our congressman? Wait for ACEP to fix everything?
How about not admitting so many patients (gasp!):
- Chest pain with normal ECG and negative enzymes and maybe a CT angio? Follow up with your Cardiologist, or I'll find one for you.
- End stage renal disease and short of breath early on a Monday morning? We'll knock your blood pressure down a bit and you can keep your regularly scheduled dialysis appointment. Usually you'll get dialyzed sooner there anyway. Potassium a little high too? We'll work on that for a bit then give you a swig of Kayexalate for the road.
- Pyelonephritis with vomiting? Have a shot of Rocephin and a Zofran. If you are still vomiting tomorrow, come back and see us. Otherwise oral meds will probably work just fine.
- Gastroenteritis? We probably admit more gastroenteritis patients than any other country in the world. There is an old-timey treatment known as "oral rehydration solution." Use it.
- Diverticulitis? No abscess = no admission.
- Cellulitis? Have a dose of IV antibiotics in the ER and complete the course with oral meds. See your doctor in the next day or two to be re-evaluated.
- Weak and dizzy? If your tests are negative, you can see your doctor tomorrow. Besides, you really aren't that weak anyway. Or that dizzy. Loneliness isn't a reason to admit a patient.
- Diabetes out of control? We'll aggressively manage it in the ER, and you can see your doctor in the morning. By the time a bed becomes available, I've probably already fixed you anyway.
- Suicidal? Really, or do you just want a comfy place to stay for a while?
We want to see acute patients in the ER, not manage already admitted patients who are waiting for a bed upstairs or twiddle our thumbs while patients wait in triage. If we stop admitting so many soft cases, the ones who REALLY need to be admitted won't have to wait so long to get a room and maybe the patients in the waiting room won't have to wait so long to be evaluated.
The success of this plan will depend on several factors:
- Patients and their families will need to be willing to provide some of their own care at home.
- Reimbursement for outpatient medicine will need to be increased, so PCPs will be willing and able to share some of the load.
- The provision of adequate home health services will probably need to be improved in some areas.
- Of course appropriate tort reform legislation is a must.
- But the most important factor is that some of us ER docs will have to start growing some balls.
Maybe if we were able to crank through a few more patients per shift, the extra income would be incentive enough. You try it first, and let me know how it works; my balls are a little gun shy right now.
Labels: ER, health care crisis, rants
posted by scalpel at 1:03 PM
35 Comments:
Our hospital is doing a study for the feasibility of ER-based CT angios for "low risk" chest paineurs. Maybe it's cardiac, but it's most likely not. You get CT angio in the ER and if it's okay, you are sent home. Bada bing bada boom. They stay in the ER longer waiting to meet all the parameters to have the CT angio (mainly a low enough heart rate), but they are discharged from the hospital earlier. I guess even with the CT angio, the patients save money, and the invasive angio is avoided.
We're trying man, we're trying.
in my neck of the woods....
chest pain longer than 6 hrs?
minimal risk factors?
1 set of enzymes and a neg stress test in the e.d.: start an asa/day and see your doc in the morning...
goodbye
Local hospitals here advertise their ERs like mad, which leads me to believe that they're making money in some way from people choosing their ER and coming in.
Is the money primarily made from ER services themselves, or from admitting people from the ER for further care or something?
Hate to be a wet blanket on your great idea....but the desire for people to accept responsibility for their illness is long gone. The personality/thinking process of the modern day American is completely different then the self reliant people of old.
We have created a "helpless" society. We have generated several generations of "stupid" people. The commen sense quagmire we have our selves in these days, is a hinderance to your tremendous idea.
At some point there will be a tremendous backlash to what I term "the fruits of the 60's". That is what we are experiencing right now; all that free love, free thinking, free living life style that has pushed us to this point. Nobody has ANY idea of self control. Nobody has ANY idea that their actions do affect other people. Nobody has has ANY idea of personal self restraint.
Sigh....sorry about pointing out what I feel is so obvious. Now if only I could come up with that million dollar idea on how to affect a change.
Steve
scalpel = jerry maguire
Help me help you.
I'm sure this is a dumb question, but why do people wait for hours in the ER for a bed? Is it that hard to find someone to drive them upstairs? Is the hospital really full?
The hospital can be effectively full if there aren't enough staff to run every ward. Occasionally at shift change, beds magically appear in bunches.
There are a fixed number of ICU and telemetry beds in any given hospital, so the specific type of bed that is appropriate for the higher level of care required by sicker or more unstable patients is often unavailable. Sometimes we'll place patients in a lower acuity type of room than we would prefer, hoping that their condition doesn't deteriorate. But most of the time we just hold them in the ER until a bed becomes available, which can take 24-48 hours in some cases.
Transferring patients to other hospitals is also difficult because (among other reasons) they are often full too.
I used to watch ER on the television and seem to remember the motto was
Treat 'em aand Street 'em
Quite a controversial post! As the recipient of many "soft" admissions I thank you for putting some of my thoughts into words. The rumor going around our hospital is that the ED physicians get a bonus for every admission.
I can't tell you how any admissions I get from the Emergency Department that wind up taking up a bed and staying just 24 to 48 hours.
This is the most pathetic set of complainers I've ever seen.
Patients not wanting to take responsibility for their own illnesses? This is bullshit. You've been watching too much tv.
There are most definitely a lot of people in the US (group #1) who go to ERs because they are uneducated, do not have insurance and feel they have no other place to go. Granted.
There are also just as many intelligent patients (group #2) who take ALL the responsibility for their health and well-being -- who show their doctors their OWN internet research (and I don't mean WebMD - I mean real research) and who travel to the ends of the earth seeing specialists, consultants... and that's, of course, when their not fighting with their insurance companies.
No one wants to be in an ER. It's unpleasant, slow and generally an unsatisfying experience. You would all be wise to learn to discriminate between group #1 and group #2 and show some respect for your fellow intelligent human beings in the latter group.
Unless you would just generally like to be despised and prefer to act like arrogant assholes. In which case: carry on!
Oh, and - love all the anonymous posts from doctors and nurses. If you feel so strongly, why not leave your name? Like I said: assholes.
Great post. I can't help myself. I must reply to one of your commenters...
To Stephanie from New York:
Boy, did you spew a lot of garbage in your comment! So much to reply to. But I think that I'll focus simply on one item....
Are you really telling doctors and nurses that they should discriminate against ignorant and underinsured patients who have no place else to go for healthcare (Stephanie's group 1), and give preferencial treatment to intelligent, insured people (Stephanie's group 2)????
You did. Wow.
This comment sure said a lot about the kind of person you are.
Linda, also known as Lou. I'm a former Los Angeles based Emergency Department nurse who is probably very glad that you never showed up at my hospital...
You might want to consider doing a stint as a volunteer in the nearest big city hospital ED. You might think twice before you you speak with such authority about something you clearly know very little about.
Heres an idea for chest pains. if the EKG and enzymes are normal, give them a dose of nexium and a GI cocktail and get them on their way. Then when they go home and have that massive heart attack, you will get your ass sued off. How can you be an ER Doc and still not know that EKGs and enzymes are not an all clear for an MI in the making?
Hey, folks, how 'bout let's tone done the comments a bit? Scalpel has some good points to make. Remember, in a narrow sense, ER docs are always better off admitting the patient because that is a direct hand-off of the patient to another doctor. I personally am glad Scalpel recognizes that isn't always in the patient's best interest, nore good medical practice.
Recall that ER docs don't get to see all the responsible people who don't use their ERs, because, well, THEY DON'T USE THEIR ERs! Likewise, my partner and I joke that at any given time, some of our sickest patients look bad enough to be admitted on the spot (But we try our best to keep them out of the ER); these are patients the ER staff also don't see. When I'm on call and get paged by the Nursing Home about such and such a patient (usually, quite old, demented and yes a Do-Not-Resuscitate) I try my damndest to keep that person out of the ER (have even been know to prescribe antibiotics over the phone, on occasion). So, I do thank many are doing their part to help this problem. Probably there needs to be more cooperation and collaboration between the admitting doctors and the ER staff.
And to anonymous who asks about the wait for a hospital bed:
yes, many hospitals really are completely full.
If the hospital is not full, the available bed and room have to be cleaned, and there has to be a nurse available to care for the patient that will fill that bed. This is also a problem, given the nursing shortage.
It sounds like you (S orS) just want patients and docs to behave responsibly...Reasonable request.
What kind of car do you drive?
Sure hate to blame "the system" for irresponsible behavior, but it truly is at the top of my list...If you look carefully at your list of things that need to happen there are lots of incentives otherwise, so expecting people to behave contrary to how they are incentivized might be a bit much.
I try to appeal to their better natures when I think they are being irresponsible. It's harder for me to do this with colleagues than with patients.
http://poemd.blogspot.com/2007/10/fast-redi-quick.html
Scalpel,
What a great post. I'm in a smaller ER so I think we are less of a patient factory compared to the giant ER's I was a part of in residency. I think this leads to greater personal responsibility when it comes to putting a patient up for admission -- instead of just dropping a chart off in a room full of internists I explain my rationale to the admitting doc for every patient I put up for admission.
My default is to try to manage stuff as an outpatient, or if I'm on the fence about an admission explain things to the patient/family and let them take an active role in the decision. Maybe I'll look back in 10 years and feel stupid for the way I did things, but for now I feel good about the way I'm practicing medicine.
In the end, though, just like you said the generic ER doc is always going to look for a way to admit since that's where all the incentive is. Nothing will change until there is incentive to discharge.
Maybe we will see more and more 23hr ER Obs units spring up -- no fights with admitting docs, financial incentives, and it gives patients a day to prove they're not headed south.
UH,
Almost none of of those patient scenarios get admitted at my hospital.
If you are correct about that, then your hospital would be unusual in my experience. There are certainly specific physicians at every hospital who refuse almost all borderline admissions (usually they are the ones who haven't been sued yet) and there are certain ER docs who discharge all borderline cases (ditto), but most facilities have a mixture of overcautious and overconfident docs.
Assuming you are correct, however, I wonder if my theory is supported... that perhaps your ER and admission processes function more efficiently given that you only admit the sickest patients.
Or is the ER clogged up with bouncebacks who have gotten sicker, and are the wards filled with patients who have longer lengths of stay because of delays in effective initial treatment. Those are caveats I wonder about.
While that post articulates some simple solutions in specific instances, I'm afraid the problem is much more complex. Un- or underinsured patients, immigrants, an aging population, a decrease in beds and ED's, a significant nursing shortage, all of these things are contributing factors to the crowding problem. And while a vast majority of the patients seen following the criteria in this post would do well, the insurance folks and the risk management people would have a cow.
You could treat several hundred people using this approach and everything might be fine, but when the 33 year-old male comes in with chest pain and gets stuck waiting because others more likely to be having a MI are being seen by the limited staff available and then he drops dead (Olive View anyone?), you better have a good lawyer.
Hi, two questions.
1) are people being admitted for cellulitis? really?
2) couldn't part of the meta-protocol be:
a) treat whatever, as you said
b) pt goes home now
c) in case of issue, call 911 and specify [magicpassword].
d) treatment resumes, with vital new information.
Like with every other medical condition, there is a broad spectrum of severity with cellulitis.
Not many of us would admit a 6 year old with a mosquito bite that was starting to get a little red around it, but few of us would send home a 400 pound diabetic whose massive pannus was infected and starting to break down underneath their fat roll while sporting a fever of 104 and a white count of 25K.
Between those extremes are where the judgment calls occur, some of whom do indeed get admitted for one reason or another.
Scalpel wins!
Good post Scalpel.
No arguments there, I think a lot of really simple cases come through the emergency department to get away from the dizzyingly long queues in the clinics.
You’re good, Scalpel. Maybe you can be our next Surgeon General.
MJ
"Reimbursement for outpatient medicine will need to be increased, so PCPs will be willing and able to share some of the load."
Scalpel, could you please elaborate on this? Not sure I understand this point, and it strikes me as an important one.
It's easier to discharge a borderline patient if we can be sure that their own doctor will be willing and able to see them within the next couple of days.
Medicaid patients already can't get appointments because their visits are reimbursed so poorly. Medicare patients are already getting squeezed, because they have the next worst reimbursement and their numbers are increasing so rapidly. They are going to have more and more difficulty getting appointments at all, much less on short notice. As PCPs limit their practices or retire and are not replaced in adequate numbers, access will eventually be limited for everyone.
Oh dear lord; that's scary.
Did you know that IV therapy for dehydration was invented BEFORE oral rehydration salts? So, technically, IV therapy is more "old-timey" than oral rehydration.
Way to go, scalpel. I agree wholeheartedly.
While admissions (or no admission) has been mentioned, what about obs? EDs go on divert all the time not only because of a backup in bed space in the floors above, but because of the patients in beds in the ED being observed for x amount of time. These patients are usually sitting there because the obs section is full of other patients being observed. Maybe redefining obs criteria is also called for.
That's an interesting post. I thought this was what ERs have been doing, attempting to treat what they can and only admit what needs admitting. Certainly, that's what they've done where I've worked.
They only chuck cases that could otherwise go home to the services when they are swamped (in which case the internist, surgeon, psychiatrist, whatever usually starts a treatment plan and shows the patient the door whenever possible). It's considered un-kosher to not help out when the ED is (more) swamped (than usual).
I got a flyer in mail a few months ago from a nearby ER. They're doing the fast-track "30 minutes" thing and, hand to God, the ad said, "See a doctor in 30 minutes or get a voucher for a free meal." I can just see the ensuing pandemonium--patients walking up to the triage desk asking, "I get a free meal where? The sh*tty cafeteria or somewhere nice, like McDonalds?"
Also--I know I should just mix up a batch and see, but I can't bring myself to do it--it seems like the official WHO oral rehydration solution would taste (to put it bluntly) like ass. Is this the case?
Oh Linda (Lou) -
What is interesting is your interpretation of my comment. What is it about what I said that led you to believe that I favor giving preferential treatment to knowledgeable patients who take responsibility for themselves? If you read my post again - and you are darn right that I'm angry - perhaps you would see that I was actually trying to give this blogger a pass by reflecting my understanding that patients in "group 1" must, without question, be frustrating to try to help (those that leave and don't come back, or rant and rave over nothing - the "helpless" society, to which one of the other comments refers) but that, under no circumstances - even when dealing with knuckleheads - do doctors and nurses have the right to disparage patients on a blog or anywhere else.
That's what I find disgusting and repugnant. I could not care less who the patient is - could be the richest or the poorest, the most knowledgeable or the biggest alarmist - my disgust is with medical professionals such as yourself (unless you would care to share your last name, which I would then be delighted to share with your employer, etc.) hiding behind a shroud of anonymity and insulting the very people they took an oath to serve.
And fyi, no one knows more about how an ER works than a family caretaker who is in and out of multiple ERs, in multiple cities in the world over a period of years. Los Angeles? Who cares. I could tell you about 20 cities. And I could do it from THIS side of that little glass window - not your side.
Perhaps you are the one who needs to experience the medical system from a patient's point of view: not the other way around.
I used to work at the local University hospital and as an EMT on the streets, and I wholeheartedly agree with you, on one hand.
On the other hand, I'm the partner of a person who was seen in the ER for sudden exacerbation of back pain then sent home and was back in the ER a day later with paralysis and incontinence due to the huge ruptured disk that the doc refused to even consider.
So I can see the reasons behind sending people home and also for admitting them and doing more extensive tests.
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