The future role of the Emergency Room

this is scary considering how many people do not have access to any other healthcare when they get sick.

http://www.herald-democrat.com/articles/2007/04/18/local_news/news01.txt

Wilson N. Jones began a policy April 5 that greets those who come into the emergency room with an admissions screening team. The triage team consists of a registered nurse and a physician’s assistant. Those who need the high-level services of the emergency room are admitted there. Those whose conditions are not truly emergencies or urgent get a list of five area clinics they can visit. This screening process allows the emergency department staff to focus their efforts on the urgent, emergent and trauma patients, WNJ said in a press release earlier this month.

“Many do not realize the number of patients who access the emergency room for non-urgent, primary care services,” said WNJ President and CEO Pat Flynn.

“This is the most expensive location to receive primary medical care. We hope by directing these patients to a local medical clinic, they will be able to be seen more quickly and at a lower cost to the patient.”

Other hospitals, including Bonham’s Red River Regional Hospital and Baylor Medical Center in Dallas, already enforce this policy, said Cathy Black, WNJ’s community outreach coordinator.

In a telephone interview, Donna Upchurch, director of WNJ’s Emergency Department, explained, “We use the concept of team triage, where we have a qualified registered nurse as well as a physician’s assistant or physician in there who are screening the patients who come into the emergency room. Sometimes, majority of the time, some patients have actually been seen, treated and sent home from our triage area, so they don’t ever have to get to the back, which is very satisfying for those patients.”

made and deaths will undoubtedly result. It is sad it has come to this when our system has been so obviously broken for so long.

But it is inevitable when one screens this many people with the overt intent of limiting admission to the ER, that mistakes will be made.

She was indigent, third trip to the ER for a severe headache.
After getting blown off the first two trips, she came back in tears.
Ended up having bacterial meningitis. Of course the healthworkers all had to be treated prophylactically, but how many patients in her 3 visits did she potentially infect? What about her children? Her coworkers?
She would have been triaged out--just like she was at our facility. Ultimately she would have died.

Thankfully she did get treatment ultimately, but yes, it is doubtful PH could ever identify effectively all who should have received prophylaxis at that point. I'm assuming it was Neisseria meningitidis? (implications for further spread would have been a bit less with Strep pneumo or Hib)

But the kicker is...sorry to say...the ONLY reason she got the further treatment is because the physician wanted to teach her a lesson about coming to the ER with a headache.
When her CSF showed almost 1000 wbc's (normal range 0-30)--I can guarantee you that he uttered the same words I did. OH SHIT.

; however, they also have signs up that NO ONE is denied medical care.

before seeing the ER doc in all facilities...The difference in this, is that the triage is determining if the patients that present are sick enough to be seen. If not, they are referred to a clinic.

for routine procedures on the weekend because she didn't want to take time off from work. I don't know why she chose to do this -- if her manager was a snit when she asked for time off or if she didn't have time available to take off, but it seemed like an abuse of the system to me. The company provided 2 weeks vacation & 6 days of sick time.

and basically fall through the cracks.
When they are ill...and cannot go any longer without attention, they will be redirected to a clinic that they would have gone to in the first place IF they had the money to go.
Nobody wants to use the ER.
Some people HAVE to.

Cuz I know alot of our facility's visits come in the middle of the night when the patient's symptoms/illness has exacerbated to the point of needing to be admitted...and if they are in an emergency state from thos symptoms, the hospital cannot just shoo them off to a clinic that won't be open til 8 am the next day.
And I guaranty the population that will be "redirected" are the one's without insurance.
My facility admits ANYone who shows up. Can't tell you how many "near syncope" admissions we get. Syncope meaning "dizzy"...soooo these people are not actually dizzy, they are "almost dizzy" per the diagnosis. Hell I get that way if I stand up to quickly but I don't go to the local ER!
But we admit them, soak Medicare/insurance for a three day neuro/cardiac workup (MRI, CT scan, carotid doppler tests, stress tests, multiple sets of labwork).
Guess we'll be seeing more of these folks since we are down the street from a Dallas area Baylor hospital.

It's a fancy way to dump, wouldn't you say?

faint.

and it actually works fairly well. A few years ago I was very broke and without health insurance and sought out the ER for an ankle injury. My vitals were taken, I was questioned by a triage worker, and then in was recommended I return later that night to the adult walk-in clinic at the hospital. I was also given the option of sitting in the ER until they were able to see me there, but I know it would have been untold hours due to the level of truly critical patients that needed to be seen.

I returned that night, got my ankle x-rayed (serious sprain, no break), had my ankle taped up, got some extra strength Tylenol and an anelgesic balm for my ankle.

Cost? Nothing. And probably cheaper for the hospital that seeing me in the ER.

After that introduction to SF General, I used their clinics for my primary care for three years. The care I got was excellent, some of the best I have ever received. If I needed meds/a test/an x-ray, I got them. And because of my financial situation, it was all free. Yes, I received socialized medicine!!!! :D

Triage is a good way to determine just who needs critical care and who can be seen at a clinic, and, in the case of SFGH, it allows a hospital to clear the ER of uneccessary patient and saves money so that resources can be spreadout to cover more people.

This is basically rural Texas.
There aren't free clinics...this is just a way for the ER to turf you out, hoping you will go to someone else's ER and not cost them any money.

but you are glossing over a lot of significant points. In your original post you say, correctly, "this is scary considering how many people do not have access to any other health care when they get sick."

Have you also considered how scary it is to er staff when a cardiac arrest or horrid automobile accident patient(s) arrives and every bed in er in full with ear aches, minor cuts, insect bites, not to mention frequent-flyer drug seekers?

It may be that this hospital is trying to implement a policy that will allow them to save lives of critically ill patients. I'm willing to give some benefit of a doubt here.

I live in a rural area too with a small er where my sister is rn in er. They are often overwhelmed with minor illnesses while truly critical care patients are arriving. There are no free clinics here, and no one is sent away. But often the place is overflowing, and people with minor problems get irate and make big issues because they are slow being seen. They don't appreciate that the person next door could die if their own little wound is stitched up first.

Instead of trashing er policy, we need to try to find solutions. I have no insurance, but I also know that I cannot afford er treatment for minor problems.

We need universal health care 1st, and more government support for walk-in clinics. We cannot expect emergency rooms to immediately treat everyone that walks in the door. It can't be done without compromising the treatment for critical patients.

whether I want to be or not. The hazards of being cross-trained in a small hospital.
We leave 4 trauma rooms open--never fill them except in a true emergency. In emergencies, we know who can wait and who cannot and deal accordingly. I have NEVER seen a trauma or critical patient shortchanged. In 3 min, we can get an EKG, monitor, IV started and blood drawn even at full capacity. We can even get someone in the cath lab in 30 minutes at full capacity. When a code rolls in the backdoor, everything stops and we all basically know what to do. Not to mention, in a trauma/code, we have communication with the paramedics in the field and have an ETA to clear out if we need to and have everything in place when it actually rolls through the backdoor.
Saying that minor stuff clogs down an ER so that traumas wait are just management talking points to convince everyone that it cannot be done...when it can. It doesn't leave downtime, that is for sure. But it can be done.
No ER worth it's salt or certification fills every bed with minor stuff. That can get you in trouble very quickly.

the sooner we get a health system that is free at the point of use for EVERYONE and that the cost comes out of your salary check. The poor don't pay the rich pay more and we get rid of private insurance.

What then? I'll put up my doctorate and bachelor's against anybody else's.

I've had to go to the ER with uncontrollable vomiting and dehydration due to a sinus infection and drainage, and no insurance. I also had an ovarian cyst that busted unexpectedly and I went to the hospital with no insurance, in severe pain, and barfing my guts out then too.

They do NOT have to accept you if you do not have the funds to pay.
Is the ER overutilized? Of course it is.
However, there really isn't a better option at this point in time for people who are uninsured but still require care.

The after hours clinic is open in the evening and on the weekends. People without emergency symptoms can get care there while the emergency room is freed up for emergencies. If the patient coming to the after hours clinic is actually having an emergency, they can quickly be referred to the ER.