Comments on: ER Overcrowding: View from the Outside

By: V

Thu, 12 Oct 2006 00:48:47 +0000

As someone who trained in the mid-80′s, just in time for the DRGs & that new pesky disease, AIDS, I’ve had expeience with the joys of hall beds. I’ve coded folks in hall beds. I’ve seen hall bed folks trying to use the commode. This is NOT something you’d want for your near & dear.

I now work out of a hospital where you can no longer direct-admit a patient, due to the paucity of beds. If I suspect that the person may need admission, I must send them to the ER. It has been years since I can pick up the phone & direct-admit a sickie from my office. They opened a whole new wing, with all those lovely new beds. Strangely, the admission process hasn’t eased one iota. But then, they’ve closed several hospitals in town. Gee, do you think there may be a connection?

By: TheNewGuy

TheNewGuy — Mon, 09 Oct 2006 12:08:30 +0000

Look… specialties that require longer training, entail higher risks and sicker patients should be reimbursed at a higher rate. There has to be some return for the added education, stress, and liability, and in our current system that reward is financial. I don’t know too many people who would disagree with that.

However, physician pay is only a very small part of the healthcare pie, but it makes a nifty class-warfare and envy issue for people with political agendas. It’s the flip side of that old soak-the-rich coin that gets played over and over and over…

By: Sid Schwab

Sid Schwab — Mon, 09 Oct 2006 00:08:43 +0000

There has always been stress around the relative income of specialists vs primary care. Who works harder, who took longer to get there etc ad nauseum. Whereas I don’t disagree with the idea of increasing reimbursement to primary care docs, I have a hard time agreeing that it must in some way be hand in had with reductions to specialists. Surgery reimbursement, for example, is already at much less than half of what it was a few years ago. Cutting doctor pay has been about the only consistent method of healthcare cost control, and the turnip has pretty much been bled dry. And, at the risk of offending my primary care colleagues, there’s no way I can be convinced that their work is as hard or as time-consuming — as all consuming — as mine was. Perhaps we’ll agree at some point, when there’s no money left as the current deficits become incurable, that the only health care that’s cost effective is preventative, and we’ll get rid of surgeons altogether. It would have less impact on the health of our country than if we got rid of refuse removers. But until a decision like that is made, you’ll never see enough people choosing certain specialties — especially surgical ones — if the work isn’t reimbursed at a higher rate than that of primary care. I think it’s safe to say that’s a truism, right or not.

By: Goatwhacker

Goatwhacker — Sun, 08 Oct 2006 23:47:01 +0000

The mega workup the hospitalists request prior to admission is definitely one of the factors that clogs up our ER. “Get the CT scan and call me back.” Three hours later….yes, indeed, it really is diverticulitis.

This topic was discussed at length at Dr. Tony’s blog several months ago. I think both ED docs and hospitalists have a point, and both tend to push the envelope (in opposite directions) of what constitutes an adequate workup, especially if they’re busy.

On a different topic, I do primary care now and it drives me nuts when patients go the ED for non-emergent problems when I’m in my office. It’s a heck of a lot cheaper for them to come to see me plus the wait is almost always much less.

By: doctor J

doctor J — Sun, 08 Oct 2006 02:49:47 +0000

I am a board certified ER doc, and recently left full time ED practice and started working in a high end urgent care. What a difference! The good ED patient come to the urgent care and actually are happy and pay their bills. It is a beautiful thing!I diagnosed a women’s son with Lyme disease last week and she brought me a rum cake a few days later(got a headache after that shift). There is currently no health care system just a fragmented buch of hospitals and clinics leaving patients without a clue of how to get the best care, hoping to get a good primary care physician to guide them along. Our specialty of Emergency Medicine highlights most of American Medicine’s problems of today and I do not see much light at the end of this tunnel at this time, especially concerning out liaility crisis.

By: EMT to Doc

EMT to Doc — Sat, 07 Oct 2006 19:03:05 +0000

I often wonder though, what would happen if wishes were granted and patients started going to their PCP, or to urgent care centers instead of the ED.
Someone is going to get the bright idea of “Look at all of the wasted space in the ED. We could put offices there!”
And you’re back to over crowded with the ability to treat less patients because the cash flow is what’s most important (right or wrong).

By: scalpel

scalpel — Sat, 07 Oct 2006 14:09:48 +0000

By: Greg P

Greg P — Sat, 07 Oct 2006 13:49:32 +0000

This is a multifaceted problem, and therefore requires a multifaceted solution. And there isn’t (right now) the mechanism(s) to deal with it.

1. There is the problem of patients in the ED who don’t need the ED. They could go to a late hours clinic, many could wait to see their primary MD. The challenge is sifting them out, and saying, “Go someplace else.”

2. In many cases patients cannot get into the hospital because there is no concerted effort to get others out. Patients stay in the ICU because there are no monitored beds in a step-down unit, those patients stay there because there are no beds on the regular floors. Or because the attendings can’t handle their own anxieties. I always find it a little schizophrenic when doctors insist on patients staying on a monitored unit until some magical time when suddenly they go home! One moment, “We’re so worried you need to stay fully monitored,” then next, “Ok, you can go home now.”
Many patients stay in the hospital because there is no option for close outpatient followup — being seen daily or every other day — even though that could save a LOT of money all around.

3. In the ED, there are patients who need to be admitted, it’s obvious, but we have to do this ungodly complete workup BEFORE they can be admitted to the floor. I’ve overheard hospitalists getting upset with the ED doc when the entire workup for a problem wasn’t almost completely done before the patient left the ED.

4. Yes, there are a lot of patients in the ED without insurance, but for others, the ED is BIG business — premium prices on everything (if you can pay).

In the end, there is no concerted effort to work on these multiple facets of the problem, which really requires MDs to be in charge and doing something about these issues, not high-school graduate clerks as “discharge planners” or social workers or non-MD hospital administrators or some elderly semi-retired physician working bankers hours attending some meetings and shuffling papers around.

By: Chris Bartus

Chris Bartus — Sat, 07 Oct 2006 07:53:19 +0000

I’ve seen two groups up here that make me think you’re right. There are several free standing ED’s up here. They are basically level 2 ED’s with nothing else. They do a lot of primary type care. Lotsa physician time used. They’re not what takes up bedspace though. You get them in and out fairly quickly. The problem is bed space in the hospitals. It’s like the old saying that the fastest way to make planes run on time in Austin is to build another runway at O’Hare in Chicago, since everything runs through Chicago. More wards/floors/ICU’s would reduce ED strain. Maybe not ED physician strain (you still gotta see ‘em), but system strain because the patients could get out.

By: impactEDnurse

impactEDnurse — Fri, 06 Oct 2006 23:32:59 +0000

Thank you Dr grunt.
Your comments ring so true and come as our own department battles new lows of overcrowding, access block and all the accompanying erosions of our doctors ability to deliver quality emergency medicine.
Even my own solution seems slightly less than satisfactory.(http://impactednurse.com/?p=148)
And with our own cities population rapidly ageing, it is only going to get worse.