Should Emergency Rooms Turn Away Nonurgent Patients?

TIME Healthland:

How can we reconcile the two extremes: emergency-physician groups advocating for patients who want convenient medical care, and policymakers and insurers who see ED visits as expensive and mostly unnecessary?

Read the whole story: TIME Healthland

Comments

[butternut1]

06:01 PM on 04/13/2011

I have worked for over 25 years in Emergency Medicine both in the US and in "developed" nations. There is nothing inherently inefficient or costly with regard to EDs that require proposed cost containment proposals to limit their use but rather an investment in management strategies to optimize the facilities and their resources. I have learned that a "non-emergency" does not present itself by an anxious new mom at 2am or by a street person after it rains. There is an old phrase about Emeregncy Medicine--"The ED is where the failure of society and the failure of medicine meet". We need to enhance the front line of medicine because it is nearing a breaking point and manage our weaknesses to minimize the

[rtx47]

08:14 PM on 04/12/2011

ERs are exellent centers to manage true medical emergenices. Yet, ERs are inefficient, expensive and provide poor quality care for non-emergencies.

Much of medical care - routine or otherwise, is NOT a one-time service. Data reports that 75% of illnesses are chronic illness with intermittent acute episodes. Thus generally, medical care is a continuity of care before and after the management of the acute problem at hand.

Vast majority of illness leading to visits to a PCP (primary care doctor) are for a self-healing illness, which settle without need for major intervention, over varying duration. During this period a doctor's role is to help the healing process and monitor the situation to assure progress is satisfactory; and actively intervene only if and when necessary.

ERs do not lend itself to that continuity of care and monitoring of the chronic-acute-chronic disease process. Thus ER doctors in their first and often only one-time encounter with the patient have to play it safe. They are forced to aggressively investigate and actively manage the acute illness and are unable to provide continuity of care. This is both costly and poor medical care to the patient.

[rtx47]

08:33 PM on 04/12/2011

So how do we solve it? Every patient should have a PCP or a "Medical Home". And there should be incentives and disincentives for the patient and PCP to be savvy consumers of healthcare. Patients and Medical Homes should have access to social services and nurses who can monitor their patients to assure that an acute episode is forstalled and another visit to the ER avoided. Likely Obamacare which provides coverage, improves access and (computer) monitors individual's care through electronic medical records will solve the abuses in healthcare.

[pphhrogg]

08:08 PM on 04/12/2011

Having worked for years in ER (as an RN).....I know that some of the people who seek help in the ER could wait and go to their MD the next day.....but the LAW says every person who walks (or is carried) into an ER must be seen. Because most ER's use triage these days, the ones who have minor injuries or are not seriously ill will have to wait until last to be seen anyway. The vast majority of the patients that we saw were real emergencies, and I'd never want to turn anyone away and then find out later that they became worse or died!

[mmm pecan pie]

01:07 AM on 04/12/2011

A lot of doctors won't see you if you don't have insurance. They even look at you funny if you say you have cash. The ER has to treat you, by law. I suppose people could just wait until they were too sick to stand, call 911 and then go to the ER in an ambulance.. But, that option will not be cheaper.

That said, my husband's appendix burst while he waited in an ER because so many were in there with sore throats and dizzy spells.

[alongst]

01:39 PM on 04/12/2011

Most doctors are happy to accept cash, usually with a discount. It means they don't have to fight with an insurance company to get paid. Keep looking around.

[eyelashviper]

06:48 PM on 04/11/2011

It would seem sensible that ER's would belong to a network of health services, and refer non emergency patients, through triage, to urgent care centers if available. In smaller communities, there may not be other options, and during the evenings, weekends, etc., when Doctor's offices are unavailable, people might not have other options.
Having an adequate team to assess patient needs in the ER is essential.

[onionboy]

07:02 PM on 04/11/2011

Current laws (ie, EMTALA) as they are written make that concept problematic...though I agree with you. The hospital I recently worked for had a physician doing triage right inside the door. It the was the first person you'd see. There were even separate waiting rooms, depending on your urgency status. The law says that you have to be allowed to have a physician examination if you go into an ER, so that's the only way to triage with any measure of federal compliance. But once you've gotten to that point, it's hard to tell a patient they'll need to go elsewhere for the treatment. Sometimes it's faster to just write the scrip, do the stitches, etc.

The whole system needs to overhaul, so that there is a financial disincentive to send people away from the ER (which is what EMTALA was written to prevent), other than just fear of fines or shut down.

[HBHB]

06:46 PM on 04/11/2011

I went to the emergency room full of blood with a broken nose and got second place to a woman who wanted antibiotics for her cold because she was going on vacation later that week.

[onionboy]

07:03 PM on 04/11/2011

Yeah, but...where was she going?

Sorry. Kidding. And sorry about your nose.

[alongst]

06:18 PM on 04/11/2011

Would you give your credit card to a welfare queen or drug addict and tell them to use the ER for any ol' problem and send you the bill ?
You already are- but it's the government that gives them a Medicaid card and then sends you the bill !
I work in an ER and the abuse of it is staggering ! 80% of the people I see don't need to be here and most have been here in the last 2 weeks . Some come in 2-3 times a week ! Many have doctors but don't bother because they'd have to make an appointment and keep it. H#ll yes, screen out the drug seekers faking toothaches, congested babies, etc...

[onionboy]

07:06 PM on 04/11/2011

How about the drug seekers claiming "abdominal pain"? How many diagnostics need to be done to rule out an actual problem...just so there's no lawsuit down the road when they eventually give up and leave because they realize they're not getting anywhere.

[alongst]

01:38 PM on 04/12/2011

And no matter how many times they cry "wolf", eventually one day they will have a real problem and if you miss it, they'll be the first to sue.
We need personal responsibility in this country.
And don't even get me started on how many nursing home patients get sent to the ER everyday for falls and other problems caused BY the nursing homes.

[fozzi58]

10:39 AM on 04/12/2011

There's abude everywhere in every system. I think your points are taken well and we understand what you deal with. However, a majority of society won't head to the ER for a typical issue. I for one, fortunately, have never been for myself, but we took my 3yo when she fell down a flight of steps. Although she was probably OK and crying more from the shock, we wanted to be sure she didn't have any internal injuries, a concussion, or fractures.

Could we have waited until the next day? In hindsight, probably.

The needs to reflect the repeat offenders being marked as turned away. We should employ the "3 strike rule" for the wolf criers and this would open up ERs for more serious needs. However, I am injecting logic into the mix now and that doesn't work when you talk to politicians and HMOs.

[alongst]

01:32 PM on 04/12/2011

It's a well known fact that 10 % of the population uses 90% of the medical resources. The same applies to criminal justice, etc... We need real community health clinics but most have closed due to low reimbursement from the government.
And government regulations like EMTALA make it almost impossible to sort out this mess. Even if the person has been to the ER 50 times this year already, we still have to go thru the entire process each time.
As you said, the majority of society wouldn't do this, but the ones that do have destroyed the system. Many have no problem calling an ambulance for a sore finger or toothache ( yes, I saw both yesterday , really). We are having more and more difficulty even recruiting new ER doctors and we are stretched so thin, I'm about to quit. 70 hour weeks are common and we are more packed everyday.
Please don't think Obamacare will cure this- it will provide coverage but not access, and people will still go to the ER for minor problems.

[TheBlondeRaven]

04:57 PM on 04/11/2011

If you know you don't have an urgent condition, then don't go to the ER.

[trishinpitt]

05:48 PM on 04/11/2011

It really should be that simple.

[alongst]

01:41 PM on 04/12/2011

But " common sense ain't so common"
-Will Rogers

[gregory57]

04:54 PM on 04/11/2011

Don't you think that a blanket answer to this question is kind of like giving everyone who shows up at the ER the same treatment.

Some emergency rooms are well staffed, relative to patient load and can handle the kind of walk-in traffic that isn't considered an "emergency". Others need to triage some patients away from the ER to other types of care.

[onionboy]

07:08 PM on 04/11/2011

You're right. The logistics and regulations are what make it a little more difficult in practice.

Healthcare overhaul!

[demilieu]

03:02 PM on 04/11/2011

Many serious illnesses initially present with vague or unextrodinary symptoms.

[alongst]

01:34 PM on 04/12/2011

"I need the wax cleaned out of my ears "- a patient complaint in our ER yesterday. Really.

[stape45]

02:42 PM on 04/11/2011

What kind of panels are we talking about here??

[VA Jill]

02:29 PM on 04/11/2011

NO. They should have a decent "fast track" for non-urgent cases and proper triage and re-evaluation in case what they initially thought was non-urgent turns out to be urgent after all. This can happen, especially with children.

[gregory57]

04:57 PM on 04/11/2011

Yeah, I have seen quite a few kids bounce back after being sent home from the ER.

Bottom line, is that medicine is still an art, and Triage is just another aspect of the art of medicine.

[WaimeaWidow]

02:26 PM on 04/11/2011

But, Dubya said that the uninsured always had the option of the emergency room ... you mean, he was wrong?

[gregory57]

04:59 PM on 04/11/2011

You could tell when Dubya was wrong, the same way you could tell when he was lying,

His lips were moving.

[alongst]

01:34 PM on 04/12/2011

And Obama claimed health insurance costs would drop and everyone would have coverage. His lips moved too.