Just Say No to Fast Track
I hate the concept of Fast Track in the ER.
We've had an interesting discussion about the utility of PAs in these departments, but I have found that by establishing a fast track, we perpetuate the problem of non-emergencies clogging up the ER. If you build it, they will come.
Now I understand the argument that perhaps we should be moving to a new model that embraces our new status as "acute care" facilities rather than EMERGENCY departments. Maybe we should focus on meeting the needs of whiny demanding upper respiratory infection sufferers. Neither primary care physicians nor Urgent Care facilities are easily able to do so (at least in this area) because they are shackled by the same bonds - the inability to bill adequately for these low-level cases without a facility fee. That's why emergency department administrators like these patients - by turning a 99203 into a 99283 plus a several hundred dollar facility fee, level three patients are easy money for ERs which are already open anyway.
But as a strong supporter of the concept of appropriate triage, I don't agree with streamlining the dispositions of the lowest acuity patients in the EMERGENCY department. I'll be happy to see them when I'm done with the sicker patients. If we are appropriately staffed, it probably won't take too long. If the patients with runny noses and sprained ankles are in a hurry, they can go elsewhere. If I'm too busy to see them, I'm too busy to care about them.
I wonder when Americans will see the folly of paying several hundred dollars a visit for non-emergent emergency care. Either directly via their overpriced cost-shifting "self-pay" charges or indirectly through their ever-increasing health insurance rates or their collapsing Medicare system, these patients will eventually be deterred, then another system will evolve.
The concept of Fast Track may seem like a functional solution to our current healthcare needs, but it covers up some ugly problems with our system... like putting a band-aid on a melanoma.
UPDATE: Thanks to Kevin for the link!
UPDATE: The Country Doc has similar concerns (and not only beat me to the punch, but found a couple of good articles on the topic).
We've had an interesting discussion about the utility of PAs in these departments, but I have found that by establishing a fast track, we perpetuate the problem of non-emergencies clogging up the ER. If you build it, they will come.
Now I understand the argument that perhaps we should be moving to a new model that embraces our new status as "acute care" facilities rather than EMERGENCY departments. Maybe we should focus on meeting the needs of whiny demanding upper respiratory infection sufferers. Neither primary care physicians nor Urgent Care facilities are easily able to do so (at least in this area) because they are shackled by the same bonds - the inability to bill adequately for these low-level cases without a facility fee. That's why emergency department administrators like these patients - by turning a 99203 into a 99283 plus a several hundred dollar facility fee, level three patients are easy money for ERs which are already open anyway.
But as a strong supporter of the concept of appropriate triage, I don't agree with streamlining the dispositions of the lowest acuity patients in the EMERGENCY department. I'll be happy to see them when I'm done with the sicker patients. If we are appropriately staffed, it probably won't take too long. If the patients with runny noses and sprained ankles are in a hurry, they can go elsewhere. If I'm too busy to see them, I'm too busy to care about them.
I wonder when Americans will see the folly of paying several hundred dollars a visit for non-emergent emergency care. Either directly via their overpriced cost-shifting "self-pay" charges or indirectly through their ever-increasing health insurance rates or their collapsing Medicare system, these patients will eventually be deterred, then another system will evolve.
The concept of Fast Track may seem like a functional solution to our current healthcare needs, but it covers up some ugly problems with our system... like putting a band-aid on a melanoma.
UPDATE: Thanks to Kevin for the link!
UPDATE: The Country Doc has similar concerns (and not only beat me to the punch, but found a couple of good articles on the topic).
Labels: health care crisis
posted by scalpel at 12:11 PM
18 Comments:
Our hospital implemented a fast track/minor care section in our ER and it has worked wonders. Unlike the one you speak of, we have a full time fam med md seeing patients (4-5 day/wk). Also 2nd year ER residents rotate and work it one day a week and present the case to attending before treatment and discharge.
Do you think perhaps education about the ED and what it should be used for would be helpful? As a well educated person, I still wonder if my trip to the ED for an infected gall bladder was the right thing to do. No one ever advises the public when to use the ED except for MI's and car accidents.
The reality is that the public can't be educated (well at least 90%). Scalpel's ideal is good it just is not reality. It is what it is, and for most localities a Fast Track is just a good idea.
If EMTALA could be repealed and people and medicine actually functioned with normal market characteristics then Scalpel ideal might be achieved.
But it is what it is and for most hospitals a Fast Track is a good idea.
C.
Yes, it is appropriate to come to the ED for an infected gallbladder.
Indeed. Most people just don't understand and they never will. And I'm not just talking about the Welfare-ites who knowingly abuse the system. (I think they may know more than you can ever teach those wonderfully upper-middle class folks with health insurance.)
Ignoring the problem doesn't mean that it'll go away. Kind of like the people who believe in teaching abstinence only education.
Our FT was always a great source of irony to me because a runny nose usually got seen faster than someone with a Real Complaint. Obviously not an Actual Emergency since those tend to be seen immediately, but still, someone who was legitimately sick.
I work in urgent care--I'm perfectly happy to see all the colds, minor injuries, mild belly pains, vag infections, etc.
I DO NOT want to see the chest pains and severe abdominal pains because I do not have a CT or ultrasound or labs and observation capabilities needed for potential MIs/PEs. I'm perfectly happy (it breaks up the day) to do the aspirin, oxygen, EKG, IV, nitro thing and call an ambulance but it's not the best use of healthcare dollars, nor is it the safest way for things to be done.
Why can't we educate the public. I think the ER and urgent care docs of the world should finance public service announcements. Chest pain, severe allergic reaction? Call an ambulance for a ride to the ER. Bad abdominal pain? Make your way to your closest ER. Sinus pain for 2 weeks? To urgent care. Run out of your Flonase? Urgent care can get you a refill until you see your own doc.
From our discussions here it seems that the consensus at least agrees there IS a valuable place for mid-levels in healthcare. I'd like to see Scalpel make a new post detailing how he thinks these practitioners are best used to meet the growing healthcare demand. We've discussed to some length where they aren't best suited; where and in what role/capacity do PA's and NP's benefit the system? And shouldn't we differentiate each (PA vs NP) role?
BTW, in my own experience I've only encountered PA's at an urgent care facility where they were able to meet my expectations. I've only encountered an NP in one setting -- behavioral therapist -- and she failed miserably in her role in treating someone close for a mental health disorder. That being said, I am acutely aware that those limited experiences are not necessarily representative of the professions as a whole.
When my 4 yr old son recently had asthma that I couldn't control at home, I called our primary care clinic which doubles as the urgent care after regular hours. They told me to take him to the ED because the clinic had the same or similar meds/equipment that I had and that the ED would have more resources to deal with the situation.
I took him there and they were able to help. They do not have a Fast Track so I don't know how annoyed they were to deal with my son. If the clinic had what my son needed, we would have been there rather than the ED. Maybe we should staff and stock clinics like they were hospitals? With more meds and respiratory therapists?
Ironically, given your past few posts, his care was overseen by a PA (we must have been turfed to him?) who did not introduce himself as one and I really couldn't get a look at his nametag. I only found out afterward when I read the discharge paperwork.
Well, that sounds nice and all, but, as another poster suggested, until EMTALA is repealed, and everyone has access to primary care and insurance. It is unfortunately, a dream.
I just posted some data that you might be interested in Scalpel. Maybe not, but I've always been person of data and numbers, and you MIGHT find this interesting.
http://physasst.blogspot.com
I think insurance companies should increase their copays for patients triaged to fast track. These are patients that could essentially be seen the following day in an outpatient visit. If they want to be seen sooner, charge them a higher copay.
In general, anyone with a stuffy nose or diarrhea that has lasted less than 2 days should seriously consider their emergency needs. If the nosebleed has stopped, the endpoint has been reached. If the complaint includes the word "months" then the emergent nature of the condition has to be questioned.
I always question the "emergent" nature of many of the complaints presenting in Fast Track. But now, you are touching on a more complex topic, and my personal interest. Access to Care. I am wrapping up an institutional study, that demonstrates that many of our patients with chronicity of symptoms (greater than 72 hours), do NOT have access to primary care, some secondary to insurance or financial concerns. Some because of provider shortages, and many are young, and do not think they need a PCP. This creates a burden of lower acuity complaints presenting to the ED. Fast Tracks, despite your apparent distaste for them, serve a necessary function.
I agree with what you said about the increased co-pay for fast track stuff. However, the problem is that there will always be legitimate cases that are triaged as FT but turn out to have something really bad. People are too uninformed to be able to tell this themselves. We (or the PA) should just evaluate them and say either, "This is serious, come into the main ER" or "This is a minor problem, if you want us to treat it, be prepared to pay a lot of money".
Yep...
ERP is correct. Over the past six months, I have had two patients that were admitted directly to ICU care from fast track. I've seen a sore throat, that also was in DKA, a cough, that was really a STEMI, and a patient who was complaining of pain in his eyes, that actually had a hypertensive ICH. Now, in at least two of these patients, I can definitely fault triage, however, on the others, the initial complaint was rather mundane. However, doing a careful history, and then a good physical exam can change the presentation.
Many people do not have ANY other place to turn for treatment of routine medical complaints. They do not have good access to care. These of course are patients that do not have resources, and many may not have insurance, many may not even pay their bill. Fast Tracks are essential in this country, until, and if the primary care and payor problems are addressed, we will continue to be needed.
I have been reading your blog a while, Scalpel. I'm a nursing student and I hope someday to work in a PEDS ED.
About two weeks ago, my son somehow got the removable black tip of my PDA's stylus shoved up his nose. Try as I might I couldn't retrieve it, and as it was 2030 my only option was the ED. I was fast-tracked, my kid had a quick procedure with a Katz extractor and I was on my way in about an hour.
Tell me, honestly, what would you have folks in my situation do if fast track isn't an option to you? Wait around for hours and hours behind the broken ankles, the dental pains, the diffuse abdominal pain with no single point tenderness, the I-think-I'm-pregnants? I think fast tracks, if utilized properly, are a godsend for people who need simple yet emergent/ acute treatment but have no access to after-hours Pediatrician offices or urgent care facilities.
There has to be a way to have a sort of dual-ED. One side for fast-tracked folks staffed with maybe one doc and a couple of PAs and RNs for all the broken ankles, sutures, pregancy tests, etc, and then another side for true emergencies: the 9/10 RLQ pain, the MVAs, the blunt force trauma, etc, the crushing chest pain radiating down the left arm, etc.
Anyway, though, that's just my second-semester-RN-student's opinion, LOL. I probably have no idea what I'm talking about but to me it seems like a good solution.
Viva La Fast Track!
1) Copays are already routinely waived/refunded for patients who require admission to the hospital.
2) Fast Tracks are by no means essential, nor even desirable. I haven't worked in an ER with a fast track for the past 10 years, and I don't miss it a bit.
"Many people do not have ANY other place to turn for treatment of routine medical complaints. They do not have good access to care....blah blah blah."
Boo fricking hoo. They can wait like everyone else. What do you do without a fast track? You see patients in the order of their acuity, as God intended.
I pity the poor suture removals in your ED.
I try to follow up my own suture removals - I have my laceration patients return to the ER a few minutes before my shift starts and I knock them out quickly. You don't need a fast track for that.
Alternatively, the nurses can just take them out in triage.
They will come whether you build it or not, unfortunately. If you don't run an urgent care (fast track) in your ER then the one down the street will or the freestanding ones will come in. Pretty straightforward business decision. You might actually like it -- it will shield you from the whinies and free you up to see the at least in theory sicker patients.
I worked Thanksgiving day this year. Fast track was empty, I was moderately busy with nothing but sick patients. That is exactly what emergency medicine should be, but we all know it's not and wishing for it to be that way will just make you go crazy.
Where do medicaid patients who want to see the doctor go when they can't get a primary and urgent care clinics ask for gasp money? You can leave them waiting, or you can put in a fast track, staff it with midlevels, keep the patients happier, and make some money off the whole thing. At least until the whole system inevitably collapses.
Scalpel, I love you... in that totally distant, I-only-know-you-from-the-internet kind of way, of course.
My ER established a free-standing Non-Acute Care area about two years ago (just before the institution of the 30-Minute Guarantee). Our volume went up like mad, yadda-yadda-yadda. Now, suddenly, with reimbursement rules changing and our uncertain status with an entire arm of the state's Medicaid, we've begun a Right Care, Right Place initiative. We still have the Non-Acute suite (staffed with midlevel providers), but now, we have a MD/NP/PA evaluating the patient at the point of triage (or very shortly thereafter, within 30 minutes, of course!) with a cursory medical screening exam. If the exam reveals there's no medical emergency, they're sent on their merry way with only a list of providers who would be happy to evaluate their non-emergent complaint. We're still generating a Level I charge on these folks, EMTALA isn't violated, and if they want to be seen in our ER anyway, they can cough up $150 for the privilege. No emergency, no cash, no service (beyond the medical screening exam).
The Non-Acute area is still being used, but not as extensively as it once was. I'm just left wondering why we went to such great lengths to bring in the customers, only to push them away again. I don't think this latest policy is a bad idea, necessarily. Until it's instituted across the board, however, it's not really going to be effective. They'll just hit up another ER for their "free" pregnancy test.
Sure do wish I could blog about this...
::sigh::
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