I have thought about the overcrowding in my ED and about ways to solve, or at least mitigate it. As there are several medical visionaries who read this blog (and the rest will probably need an ED someday), so I’m looking for constructive criticism.
First, I propose the ED Lobby Vending Machine™, which will have the following: Hydrocodone, Amoxicillin and Work Excuses. They’ll be in single day packs, the machines will accept all major credit cards. A third of my truly questionable visits would/should use this and be gone. (I need a feature so they can bill it to their ever-present cellphone).
That leaves the remaining crush of patients. I don’t know if you’ve had this experience, but our ED has been wall-to-wall patients, literally. We have patients lining all the hallways, in beds: now, we’re running out of hallway space. Therefore, let’s go up! Stackable Patient Beds™, using those stand-on forklifts see in warehouse stores like Home Depot or Costco. I mean, with a zillion patients in the hall it’s not like anything’s going to happen quickly anyway, and expansion possibilities! The roof’s the limit!
Those are my considered solutions at the moment. I look forward to your constructive criticism.
I used to drive a forklift (and I’m a chick) and those stand-on models are tricksy buggers. Plus? Dangerous. I think you’d wind up with more patients after all the docs, nurses and techs get their feet run over with a half-ton machine.
I love the vending machine idea though, that’s fabulous. I would also suggest that it dispenses “Get out of the nursing home FREE” cards, for all those elderly who come in hoping to be admitted as a break from their evil place of residence.
BotanicalGirl,
Yes, forklift training will indeed be tricky. We can make a fortune selling the little “this isle closed” banners, but labeling them as “Hospital Grade”. Unfortunately, another qual: pstient care forklift operator. Someone is already figuring out how to do travelling training on them.
The nursing-home note is intriguing, and brings on thoughts of other markest for medical lobby vending machines. Nursing home: colace, day-pass, and some alcohol of some sort.
Ooh, I love the idea of the vending machine! Problem would be keeping it stocked…
And the stackable patient beds? Putting patients in a bed implies 1) you think there is something wrong with them, and 2) that something will happen very soon. I prefer to leave the drug seekers/anybody else without a potentially life-threatening emergency (i.e. class I or II – don’t know if you use the same Triage system) in the waiting room so they know that 1) no, you shouldn’t be here, and 2) yes, it will be a while. (read: many, many hours.)
Carsten,
Well, that would presume they’re there for ‘non-emergent’ problems. In my ED the acuity is astonishing, and we’re innundated with really ill patients who do NEED to be there, but we’re out of physical space to see/hold/treat them.
Thanks for the comment!
Yeah, I was talking more about the type of patients that would be using that vending machine :-)
The hospital where I was working last winter could have used the stackable beds. We were holding 20-45 admitted patients in the ED on a daily basis, leaving as few as 5 beds for actual emergency patients. The Dept of Health didn’t like the idea of placing patients in the hallways on inpatient floors, but patients lining the hallways (and waiting room) of the ED is fine. It got so bad one day that chest pain patients were given an EKG/labs drawn/saline well placed, and sent back out to the waiting room if the EKG didn’t look suspicious.
The hospital that we use has done a couple of things that I find frustrating …one, they put the minor emergency care (urgent care, is what some hospitals call it, THEY have it off site and no where near the ER) in the same space as the ER, same waiting room, same staff, same triage unit, same reception etc etc … so … you’re sitting there, and you see people coming in and out and in and out ..and if you don’t understand the difference between ER and Urgent Care … you get ticked off because the 15 year old with the sprained ankle, the 45 year old with the ear ache and the 4 year old with the marble in his nose are seen before you with your 104.9 fever, throwing up & possible seizure. (Personally, I understand what’s going on, but I hear the complaints in the waiting room… I’ve made the mistake of trying to explain that if they go in door A, they are considered urgent care, and are being treated like they would be if the doctor’s office was open, if they’re going in door B, they have need for more intensive care therefore, it’s a longer wait … no good ..they just get mad)
The other screwball thing they’ve done and this is REALLY REALLY screwball … is the triage procedure.
There was a time that if I wasn’t sure if what was going on needed medical care or not, I knew I could go to the ER and the triage would help me decide that. The current hospital policy is to not recommend ANYONE leave for any reason. Of all the times we’ve been in, only 3 times did they say “we can see you, but I think it’d be ok if you waited till Monday to see your doctor” but those 3 times SAVED ME TIME, ENERGY, MONEY & STRESS.
Now, you go through triage and they will not recommend you not be seen.
When I asked the triage nurse checking me in if they thought it was something that needed to be treated or if it could wait she said “our hospital policy does not allow for us to tell you not to take the emergency room services, I cannot tell you if it is a good idea to wait or not”
HELLO?? I thought triage was to decide the importance of care as well as to weed out those that did not need it???????
Consequently … I’ve not gone in when I probably should ….
Oh, top it off ..now, it doesn’t matter what you’re there for ..if you’re admitted to the ER side … you automatically get an IV access & urine test and EKG regardless of what you’re being seen for.
When they gave me an IV last time, I figured it was because of what I was there for, then they didn’t use it. I was not happy, then found out it’s “policy to insert IV to all ER patients just in case it’s needed”
NUH HUH!!!! You’re not putting an IV in me till I’ve seen the doctor!!!!
Turned out, I was going in because I’d been to after hours care and was told ‘you’re severely anemic, if this, this or this gets worse, go to the ER, you’ll need to be admitted” Turned out to be an equipment error and a lupus flare …I was not anemic, and didn’t need anything but prednisone.
I’m on immunosuppressant therapy …you’re not giving me an IV & breaking my skin unless you know WHY you’re doing it!
ARGH! sorry didn’t realize you’d stepped on a sore spot here!
I’ve always thought that if you charged 5 bucks a visit, cash it would cut ER visits by 1/3. What’s that you say, not fair to the poor? True which is why I have this great plan. Each patient gets five bucks on entrance to the waiting room. There are two exits — one that charges $5 for admission to the ED and one that charges $5 for a hot fudge sunday (in Allentown, PA where I trained, I’d make it a Funnel Cake) and puts you back out on the street. My guess is at least 1/3 of the people would take the food and bugger off.
I think you’d be on to a good thing if you could sell this to the NHS in the UK. I think the only major adaptation you’d have to make would be some kind of robot body-guard, whose sole job is to shove people out the door and tell them to see their own GP.
One idea that I think would help ease the mass of people in the waiting room would be to take patients cell phone numbers (if they have one) after they have been triaged. Then, the nurse could call the number when the patient is getting within an hour or so of being called. This would allow the patient to go back home, go run errands or do something other than stare at the walls in the waiting room. In our department where patients can wait for 8 hours for urgent care, this would certainly improve patient satisfaction, decrease the LWOT rate, and not cost much at all. Thoughts?
IMHO, if they’re that stable they don’t need to be ED patients, but that’s just me.
There’s a definite downside to letting someone leave after triage, until their Medical Screening Exam is done. Someone with an unstable condition who goes home to do laundry and finished off their MI isn’t going to be happy, and it’s bad medicine.
I suppose that my suggestion may be unique to the facility that I work in. Here, we see ~ 50 patients a day who are here for refills of meds (HCTZ, dilantin etc.) I certainly agree that in an ideal world these would not be ED patients, but currently, at least here, they are (no easy access to clinics or PMDs in a county system).
I of course would not suggest that we encourage unstable patients to go home and come back later – but I think that our nursing staff is capable of identifying patients that would be eligible for the option of being called by cell phone when their turn is getting close. When we are on an 8 hour wait (a daily occurence) or on a 14 hour wait (not uncommon) it would be nice to have options other than sitting in the waiting room.
The ED is a funny business. What other industry fails to expand or change the way business is run while simultaneously, customers leave by the hundreds (thousands?) because they can’t get service?
Derek, it is a funny business, but the same would be done in any industry where the labor costs are high, the facit]lity costs are high, the customers want Cadillac care on a Yugo budget, or worse.
Great ideas, but:)
1) The vending machines would violate federal rules if they take cash in the ED.
2) OSHA would not allow the forklifts in the ED.
On a serious note (which may violate the spirit of this blog), there may be a solution that will make a significant difference if applied on a large scale. The Urgent Care Association of America (UCAOA) is the national organization, devoted to promoting the development of the urgent care industry in the USA. These freestanding centers provide the much-needed access to medical care for patients who can not wait for a scheduled appointment but do not suffer from a problem with enough acuity to require care in a hospital emergency department (ED).
A recent survey by the CDC suggests that about 40% of patients seen in the ED suffer non-acute or semi-acute problems. Most of these could be better managed in an urgent care clinic. Many managed care organizations (MCOs) charge a copay between the copay of primary care and the copay of the emergency department. This is because they want to encourage routine care by the primary care physician, but the MCOs also recognize the importance of the savings realized by urgent care centers over the cost of treatment in the ED.
UCAOA is encouraging Medicaid to consider pilot studies of plans that provide adequate provider reimbursement to cover the cost of urgent care services but also require a modest patient copay. Since this same CDC study found that the average ED visit lasts 3.2 hours, one can expect that the convenience of an urgent care will be preferred to the long waits in an ED. The same patients, whose use of convenient food access, have made McDonalds and KFC so popular in these underserved neighborhoods are likely to be willing to pay a modest $10-20 copay (~the cost of two supersized meals) to receive a similar convenient access to medical care. An appropriate copay may also reduce abuse of this access.
Although this is a new and bold approach, everyone agrees that the current situation in the ED is unacceptable; and there is reason to believe that it may reduce overall healthcare expenditures while improving access to quality care. Local, community-based trials will be needed to evaluate the effectiveness of this approach.
UC Doc,
Thanks for joining in. Better late than never!
Obviously we agree that ED overcrowding is a problem, and I think we could basically agree that less-acute patients can be adequately cared for in an Urgent Care Center (or similar). The Devil is in the Details.
IMHO, most people who bring their sore throats or runny noses to my ED think they have a Bona fied Medical Emergency, and no other source of care will do (Expensive Care). There are several UCC’s in my city, and they see a good business (I’m guessing, as they don’t go out of business publicly), yet my ED is crammed.
I think some of it’s financial: I’m guessing (and it’s just a guess) that UCC’s don’t take Medicaid, which is a portion of the quick-care of my ED. And, frankly, someone who can pay cash is welcome to wait and be seen in my ED!
There are a lot of reasons for ED overcrowding, but I’ve never fully bought into the ‘they have no other options’ route, we’re just the path of least resistance.
My two cents. Void where prohibited, YMMV, etc.