Dispatched to the ER Waiting Room?

[JakeEMTP]

We were dispatched to the waiting room for CP once. We were in the EMS workroom so it wasn't to far

to go. Anyway, the folks around here know how to get a emergency response. It;s either CP or respiratory distress. However, we treat everyone the same. Turn out to be a STEMI and we wheeled the pt. right through triage and into the ED, stopped long enough for the Attending to confirm our findings and continued straight to the Cath lab. The pt. did have a positive outcome.

So yeah, not all pt.'s who call from the ED waiting room are self centered and full of shit. Do your job and treat the pt. appropriately. That is what we are here for.

One other time we explained to the pt. what the word "triage" meant. After doing our assessment we advised her that she would not be seen any sooner if we took her through the back door and would "loose her spot in line" if she left. However, we did not refuse to take her stating it was her choice to come with us or not, but also informed her that she was most likely going to be "triaged" back to the waiting room.

[Doczilla]

This is a hot button issue in areas where there is a lot of competition between hospitals and a lot of advertising.

This has nothing to do with EMTALA. EMTALA, as someone already mentioned, was written to prevent hospitals from transferring patients away or refusing to see them because of their ability to pay. As much as patients love to crow that their long wait time is because they are uninsured, or minorities, or because they've tried to sue the hospital before, it really doesn't factor in. Triage protocols are developed and externally validated, and deviating from them for personal or financial reasons is highly unethical. They are designed to detect severe underlying illness, and nurses undergo continuing training as well as QA processes to further hone their accuracy. Also, with regards to the "medical screening exam", triage by a nurse does not meet this requirement. Though we haven't defined it well in writing, it is interpreted to require an exam by some sort of provider: physician, PA, or NP.

ERs have the capability to see pediatric patients. They may not be able to admit them to the hospital, but all must have the equipment and training. Nobody can argue that a specialty pediatric hospital wouldn't do a better job of it, although through RSV season our pediatric hospital has some of the longest wait times in the city.

Contrary to an earlier statement here, hospitals do add staff at peak times, much as high volume EMS agencies do, to improve performance at the busy times and reduce cost at the slow ones. Having a rigid staff contingent when most presentations to the ER are elective and typically peak during certain hours is not really seeing the big picture. Trouble is, there are unexpected peaks and valleys in ER volume, and even astute managers who look at trends and apply formulas cannot predict when those are going to occur. It's disheartening to everyone in the ER when 30 or 40 or 50 patients walk through the door in one hour, as sometimes happens in my ER. But it is tough to say exactly when that's going to happen. You may as well say the same thing about EMS when every ambulance is out the door and calls are stacking up. Sure, if they staff more trucks, those peaks will be easier to handle, but at what cost?

A patient calling EMS from the ER waiting room does not constitute an emergency. They already have access to the emergency medical system. They have a right to be seen, and will be seen. It may just not happen in the amount of time they would prefer. Worse, you are removing the patient from an environment where there is a higher level of care. If the patient decompensates enroute, you've taken them away from somewhere that has extensive resources and personnel into an austere field environment. Now, voluntarily calling 911 to take you somewhere else does not constitute an EMTALA violation or inappropriate transfer. It is "left without being seen", and would be the same if the patient walked out of the ER and got in a cab.

We can all cite or envision cases where a patient was mistriaged and had a graver medical problem than immediately evident. But these are the exception to the rule. Circumventing the system jacks up the patient flow. If every patient had a choice, they would page a resuscitation team at triage for every one, and they would get seen instantly, labs and xrays would be expedited, and the disposition done lightning fast. Which is essentially what we are trying to do, but the reality of emergency care in this day and age is that we can't do it. So we have to rely on triage protocols. But this does not mean we should abandon the triage system, and further burden the EMS system with additional call volume. The truth is that very few of these cases are about a medical emergency. It is far more about unrealistic expectations on the part of the patient (as evidenced by the fact that they would call 911 to haul them elsewhere). The patient believes that by setting a destination of the hospital, they can utilize free transport by EMS, and that's just not so.

Don't get me started on the patients unhappy that we didn't prescribe them percocet or refill their xanax. That's clear abuse, and our medics call the police, as do we.

Crochity, I'm assuming you were talking about OR blocks, not surgeons getting blocks of time in the ER.

Keep in mind that EMS operates at a loss; you cannot adequately equip and staff an ambulance to make decent response times unless you are subsidizing the emergency care with paid scheduled nonemergency transports (which are highly efficient use of resources) or with external funding, such as through taxes or hospital revenue. This means that every transport not only costs the patient, but costs the system. The EMS system, as much as we train on customer service and satisfaction, is providing a potentially lifesaving service to those in the field, or to effect transfer to a higher level of care when it is determined that specialized services are needed. It is not there to cart the patient around town at will. It is a safety net for those who cannot get to the hospital by other means, and who require immediate stabilization even before hospital arrival. This service comes at a substantial cost, a fact that all too many cities are aware of with shrinking budgets. To utilize it solely for customer preference reduces the capability of the EMS system by one ambulance, and lengthens response times to those who need it. This margin of safety gets narrower every year as cities and companies try to do more with less. ERs suffer the same issue. You cannot recuperate the costs you incur in providing emergency medical care. Hospitals eat it because the ER is the front door for their admissions.

ER overcrowding is a national problem, not just a problem of one facility. Despite the fact that ER admissions have been steadily and rapidly climbing for the last 2 decades, the number of ER beds and inpatient beds has been declining. So we are doing more with less. Add in physician shortages in emergency medicine and internal medicine, and you have an insufficiently robust physician workforce to handle these admissions. Care now has become more complex. Gone are the days when you could simply admit every chest pain. Now you have to use complex testing algorithms and serial enzymes to arrive at a safe disposition while using as few inpatient beds as possible. And the number of primary care physicians is well short of what is needed. This is not simply an issue of payer source, since insured patients use the ER as much as uninsured patients. Massachusetts passed a law for universal health coverage, and ER visits went up, not down. Hospitals are creating committees to address the issues, and with buy in from the inpatient floors, discharge planners, skilled nursing facilities, nurses, managers, housekeeping, and just about everyone else, the problem can be attenuated, but will always be there, and will get worse.

This issue is ENTIRELY about customer service. The customer is unhappy, and wishes to go elsewhere. The problem is, now you're spending other people's money (the taxpayer's) to do it.

'zilla

[Just Plain Ruff]

Zilla I got to agree 100% for your response.

The answer is not adding hundreds more beds.

The answer partly lies in patient throughput, and fully on patient satisfaction.

Hospitals do eat their ED costs above and beyond what medicare/medicaid/insurance/selfpay pay out to them.

As to front door of the hospital

For the past 7 hospitals I have been involved with in the transforming and automating their ED's the admission from the ER rates break down this way

Hospital 1 - 57% of admissions come from the ER

Hospital 2 - 79

Hospital 3 - 64%

Hospital 4 - 93%

Hospital 5 - 48%

Hospital 6 - 76%

Hospital 7 - 83%

Don't ask for the hospital names as I won't give them but just to understand their size, several are level 1 trauma centers wiht all the fixins for cardiac, stroke, trauma, peds and pregnancy care.

2 or three were general hospitals that did not specialize in anything like the above ones.

And one was a hospital that had 7 different ER's each ER on the campus catered to a different subset of patients.

Hospitals are forced to work more with less resources and all the protocols, formulas and odds/ends out there cannot fully address the 60 people who walked in to the ER in the last hour and the 60-100 that will walk in the next hour and each subesequent hour. ER's do a great job getting patients in and out but it's a tough job.

I'm looking at my computer screen right now and I see over 100 people waiting to be seen in my current clients ER and they have all been triaged to the waiting room. I see an additional 20 or so that have come in and are waiting to even be triaged.

There are not enough beds in this ED to accomodate all the patients that walk in. This ER also gets about 20 ambulances an hour. they are the only hospital in the city.

120 people walking in and 20 more coming in by ambulance - this ER only has around 100 physical beds. Where are those people supposed to go? they go right to the waiting room and sit because there's just no room in the INN.

If you build it they will come and that seems like a fine idea and a solution to the problem but seriously, this is NOT the answer.

Edited April 20, 2011 by Ruffems

[Prmedc]

We had a call a couple of years ago to the local ED for "Male Patient, abdominal pain, requests transport to Big City ED" (about one hundred miles away). We arrived to find one of our local "cruisers" sitting outside the ED door in his electric wheelchair. Apparently the patient had been placed on antibiotics, didn't feel that was sufficient treatment (aka no pain meds), signed AMA and called us. The ED staff side of the story included the patient ripping out his IV and trailing the saline bag out the door. Patient refused to sign Hospital Bypass or ABN form, so we wheeled him back to his room (much to the dismay of the assembled nurses). We did obtain a refusal of care.

Of course, in the rural setting we don't have the consistent waiting room waits, and it's rare to wait for a room if you come in by ambulance.

Prmedc

[crotchitymedic1986]

I know it sounds crazy but the OR does have an influence on the whole hospital. The OR is the cash cow for the hospital, no matter where it is. Although the ER often gets overwhelmed by the volume of patients who present to the ER, the other end of the problem is when the ER can not move admitted patients to the floors because rooms are not available or ready. In hospitals that have drastically improved diversion, they have done so by expediting elective surgeries and room turn around times on the floor. You have to improve flow throughout the whole facility to solve the diversion issue

p.S. Another mind blower, consutants in the industry are now promoting that ERs do away with the triage process and see everyone as they appear, to avoid logjams. Sounds crazy but it is true.

Edited April 22, 2011 by crotchitymedic1986

[Just Plain Ruff]

I know it sounds crazy but the OR does have an influence on the whole hospital. The OR is the cash cow for the hospital, no matter where it is. Although the ER often gets overwhelmed by the volume of patients who present to the ER, the other end of the problem is when the ER can not move admitted patients to the floors because rooms are not available or ready. In hospitals that have drastically improved diversion, they have done so by expediting elective surgeries and room turn around times on the floor. You have to improve flow throughout the whole facility to solve the diversion issue

p.S. Another mind blower, consutants in the industry are now promoting that ERs do away with the triage process and see everyone as they appear, to avoid logjams. Sounds crazy but it is true.

Addressing both your points

I think that the OR issue is a small part of the issue. Patients needing surgery are a small part of the ED population. I know that at some of the facilities I've been involved in and also worked as a paramedic at may go 8-12 hours between a single patient needing surgery. To cease elective surgeries or require them to be cut down when the ED is overcrowded would result in a marked decrease in elective surgeries at a specific hospital thus causing the surgeons to go to a hospital which will accomodate them.

Yes the OR Is a cash cow but so it physical therapy and also outpatient procedures departments.

The OR truly does not have a big impact on throughput thru the ER.

AS for addressing your 2nd point, I am in the industry that computerizes the ED's and I have not heard of this gaining much traction and I don't think it will. If you see patients as they appear would cause untold problems the least of which would be the non-emergent patients getting beds and then not having beds for the truly sick people. I am going to discuss this with some of my colleagues who also work in the automation of the ED's and ask them if they have heard of this. I think this is NOT a good idea to do away with Triage alltogether.

[Richard B the EMT]

Has anyone noted, as I have, that when we have the first real warming days after the cold of winter, that call-type "Sick" seems to jump up, and cause some backlog in the ERs? Same thing when we get the first cold snap of the fall?

[FireMedicChick164]

Just a random thought:

If you are sitting in the waiting room...have you been triaged yet? Sometimes there is a wait to even be triaged and if you are just waiting for them to triage you no chart has been initiated so technically you'd just be in the hospital not registered yet in the ER.

Also I have heard of ambulances being dispatched for calls outside of hospitals but never to an ER.

[Richard B the EMT]

If you are sitting in the waiting room...have you been triaged yet? Sometimes there is a wait to even be triaged and if you are just waiting for them to triage you no chart has been initiated so technically you'd just be in the hospital not registered yet in the ER.

When I bring a patient into an ER, while not known if legally binding, my patient is supposedly under care by the ER crew. When the designated person in the ER signs my call report, that makes it legally binding. The Triage Nurse tells me to put my patient into what specific examining bed, or a seat in the waiting areas, but I do not "D&R" any patients. That translates to "Dump & Run", which is illegal, or should be if it is not already. There's no continuation of care, even if you've just been misused as a taxi service.

As for my patients whom the Triage Nurse advises me to place in the waiting areas, they only get placed there after my partner and I give a brief presentation of the patient. They will get the full ER triaging, just slightly delayed, but they wouldn't be going to the waiting area if the Triage Nurse didn't feel, from our presentation, that they were stable enough to do so.

[xselerate]

Im really surprised this has generated such varied response. In NYC it's so simple, if your in an ER there's no rma, no patient assessment, no patient period. The assignments an 'unfounded' and closed out. I don't see the need for any any other argument. If the caller don't like it, well... tough. There's someone else out there we could provide real help to. Have a nice day.

Obtaining rma's? Actually giving into these drains on the system and transporting? No thanks. They are in an er already. Done.