Dispatched to the ER Waiting Room?

[AnthonyM83]

Like I said Crotchity, not frequent, but not uncommon. I get that call every few months, personally. That's not counting my coworkers who might get the call instead of me on a given day, plus all the calls that go out on my days off, and that's only in my first-in area of a few mile radius around one hospital basically...there's dozens dozens more in the county.

So not frequent, but not uncommon

[Carl Ashman]

(Shakes his head sadly....) Only in America!

Come on people, this is just abuse of the system. They are already in an EMERGENCY room, full of EMERGENCY nurses and physicians. If they want to get taken elsewhere because of the waiting times then they take a cab. They are not going in my truck. Not that I would even get to see them because dispatch would refuse and ring the ER.

Is it no wonder that healthcare in the US is so broke?

I don´t normally have such strong opinions but this just goes beyond the pail to me....

Carl.

[Richard B the EMT]

A part of the problem is, many people believe that by arriving at an ER by ambulance means they'll be seen sooner than if arriving by cab, car, sitting on a bicycle's handlebars, or walking. We in EMS know better, but we weren't asked.

Another problem I have seen, working as I do in a widely mixed socioeconomic area, the majority of families who do not have a regular doctor use the ER AS their regular doctor. Ask them who their doctor is, for the call report, they will actually say "the 'X' hospital ER".

[Just Plain Ruff]

The reason why patients wait so darn long is many fold but here are some of the major reasons

1. The ed is full and with the inability to add physical beds, patients have to wait.

2. Adding more staff is not the answer as long as you have a good staff to patient ratio. Adding more staff to an already good mix of staff to patients is just throwing money at a problem.

3. The ED's are chock full of non-emergent cases that should be at a doctors office but they are in the er. I'm looking at the census of my client and there are 32 patients with reason for visits that could be addressed in a doctors office. One is for a cough, the other a sore throat, one is for penis pain and the other is for suture removal among others.

4. The doctors offices can only accomodate a certain number of patients per hour without overwhelming the physicians in the office so when the available appointment slots of 15 mins per patient are taken up then those who want to see the doc have to wait till the next available appointment or they are referred to the ER.

5. Ambulances - patient who come in by ambulance almost always get a bed, even if the ER is packed. Triaging the non-emergent patients to the triage/waiting room should be done on a consistent basis.

6. The ED can only go so fast. The consistent bottlenecks in the ED that I have studied have been waiting for lab results, waiting for the physician to complete their documentation especially if they are using electronic charting and then patients waiting for a bed upstairs. These are the three big bottlenecks.

7. And finally, the murphy factor which means that as soon as the ED becomes less busy, a truck load of illegal immigrants crashes on the highway and all need to be seen in the ED. That is the monkey wrench that gets put in the mix.

And yes I have been called to the waiting room of the ER but you know what the funny thing is? This particular ambulance service is run out of the hospital ER and calling 911 would only get the ambulance crew working in the ED to go to the waiting room and talk to the patient. This particular time the patient said they wanted to go to a different hospital and we refused to transport him. We told him that if he left the ED AMA and called 911 for an ambulance, that it would be me and my partner and the only place we transported to was to our ER that he was already at. He did AMA and called a BLS ambulance service to come get him. They did after they called us and we said that they could come in our district and transport him to the er of his choice. AS far as I know, he made it home that night and wasn't admitted to the hospital he ended up going to.

[crotchitymedic1986]

You started a good list, but you missed the most important reason for ER backlog, but thats ok cause its an inside industry secret that will not get published. Those hospitals that have improved ER flow have done so by attacking the problem on the floors and in the ER. In most hospitals, doctors come and make rounds once; they see all their patients, sit in a cubicle for an hour or two, and then dump 12 charts at the nurse's station at one time. When doctors are forced to round at certain times, turn in charts as they complete them, and are forced to take care of potential discharges first, the flow of patients moves much better throughout the facility. The second sacred cow is the OR. Doctors are assigned blocks of time in the ER, and those times are never altered. If Doctor A has OR room one reserved from 9a-12p, no other surgeries occur in that room, even if he has no procedures that day. By forcing the surgeons to use time and rooms efficiently, again flow improves, but no one will touch the sacred surgeons.

There should be a new law passed nationally, if your hospital is on diversion, you should not be allowed to perform elective surgeries until such time that you are off diversion. The Diversion Problem would be solved overnight.

[Dustdevil]

I would insist that my people respond and treat the caller as any other patient. If the ER talks them into staying there, my medics will need to get the patient to sign a witnessed refusal. Period. You cannot make any assumptions about the relationship between the patient and the ER, or the appropriateness of their treatment. The ER may not hold them against their will. And if you would normally transport this patient, then you will also do so in this scenario. You may not refuse them, unless you would be justified refusing the same patient at a scene.

Edited April 19, 2011 by Dustdevil

[Just Plain Ruff]

You started a good list, but you missed the most important reason for ER backlog, but thats ok cause its an inside industry secret that will not get published. Those hospitals that have improved ER flow have done so by attacking the problem on the floors and in the ER. In most hospitals, doctors come and make rounds once; they see all their patients, sit in a cubicle for an hour or two, and then dump 12 charts at the nurse's station at one time. When doctors are forced to round at certain times, turn in charts as they complete them, and are forced to take care of potential discharges first, the flow of patients moves much better throughout the facility. The second sacred cow is the OR. Doctors are assigned blocks of time in the ER, and those times are never altered. If Doctor A has OR room one reserved from 9a-12p, no other surgeries occur in that room, even if he has no procedures that day. By forcing the surgeons to use time and rooms efficiently, again flow improves, but no one will touch the sacred surgeons.

There should be a new law passed nationally, if your hospital is on diversion, you should not be allowed to perform elective surgeries until such time that you are off diversion. The Diversion Problem would be solved overnight.

Can you tell me what the OR has to do with the ER and the doctors in the OR have to do with the ER?

I've worked with physicians in over 30 Emergency departments across the USA and not many of those have doctors who pull double duty in the ER and in the OR.

Doctors that are on the floor are forced to round at certain times because their offices are open at 9am. So they have between 6am and 9am to round and get all their work done and discharge the patients. The doctors on the floor are in no way involved in taking care of th ED patients until they are called for an admit.

So I'm not sure why you are comparing apples to oranges in this. I may not be getting the drift of what you are trying to say.

The OR docs do indeed have specific times for their OR's but how does that affect the ED flow?

If you are saying that the bottleneck in the ER is partly caused by the OR I disagree with you.

Like I said, I have worked with over 30 ED's over the past 10 years and the consistent themes of bottlenecks are the ones I listed. AS a matter of fact I have put into place bottleneck removers for lack of a better term and throughput has improved in a majority of those ED's. Not once did we address the OR or the nursing flow issues. Maybe that's something to look at for my next client which will be in Baltimore maryland.

Edited April 19, 2011 by Ruffems

[FireMedic65]

Small rural hospitals are often understaffed, but this is for good reason. Why pay 4 nurses in the ER when you have maybe 8 patients ALL night. Sure, it could get busy, but you have to suck it up. Nurses in level 1 trauma centres do it all the time. Having more staff doesn't change the fact that there is just no room. Bringing a patient into the ER from the waiting room and having them lay on an extra bed in the hallway pretty much solves nothing.

As for having doctors pulling 2x duty, this does happen but not in instances where the ER doc has to go perform surgery. What happens if he is in there removing a gallbladder and a shooting victim comes into the ER? Now what? It just won't work out. Transfer the patient to a hospital with OR capabilities. Better yet, the EMS crew bringing them in should know better and take them to the appropriate hospital to begin with.

[Richard B the EMT]

When I worked EMD, policy was to advise the caller in the ER waiting room to ask the receptionist to page the on duty "Patient Advocate" person. Their job is to, minimally, calm down the patient/family/friends, and also try to get the patient through the logjam.

The system is far from perfect, but it sure is better than it was, years ago.

[AnthonyM83]

I should add that in my area, the hospitals are so overcrowded, we have had some very legitimate calls to the ER.

One patient was vomiting blood and ignored. Her 911 call was ignored/delayed (forget specifics now). She eventually expired. That made people start taking the calls a little more seriously. But that's the minority of calls.