Down with the EMERGENCY DEPARTMENT

[mycrofft]

Make an "Intake Department" ("Marcus Welby Wing) for everyone except pre-triaged patients with time critical trauma/illness.

Carve out an "Intensivist Area" (the Gregory House Memorial Pavilion) as the direct area to receive ambulance admits, or patients triaged from the general intake.

Rotate duties throughout this wing , no one is a trauma cowboy, everyone can identify croup and tetanus as well as dissecting descending aortal aneurism.

Have diagnostics and lab next door (the Leonard McCoy hall), including MRI. Basic OR on the other side (Benjamin Franklin Pierce suite.

And an express elevator stopping at ICU, postop, preop.

Cut the ego cultivation, get people in and out or up ASAP instead of keyholing.


What say?

 

[Tigger]

One of the two Level IIs in town already does this. The ED is broken down into four care units. Care unit one has three resus rooms and maybe 12 more beds with a lower patient/RN ratio. Two has probably 20 beds for your "average" ED patient, three is fast-track, and four is psych. The ED staff rotates through each except for the charge RN who stays in unit one and coordinates incoming ambulances and waiting room admits with a direct line to triage. The trauma surgeon is also likely to be found there. Specialty services are down the hall, the ICU is directly above accessed by it's own elevator that also goes to the helipad.

 

[mycrofft]

Are staff rotated between the exciting and the important parts?

 

[MonkeyArrow]

As novel as this sounds to us, we know that the people making the decisions aren't always as receptive to our ideas. The problem I foresee with that setup is what happen during off hours (non-peak times). Do you shut down one "wing" of the ER or what? And for what it's worth, I would prefer to keep psych separated from the ER as much as possible and not have everyone and their mother rotating through psych except for psychologists, psychiatrists, therapists, etc. The issue with having triage and special areas for specially triaged pts. is that how can you be sure patient A with triage B goes to area C for treatment. Pt. A needing care area C could just walk into area B and then what?

My 2 cents, we should reformat the ER to have a three winged structure with a central area. Central area will be the only place incoming pts. go where they will be immediately triaged/admited. From there, they will be sent to wait in wing 1- fast track (urgent care clinic type setting), wing 2- typical ER room for tx, or wing 3- trauma bays/resus. rooms. Psych will be at a different facility and all incoming ambulances will be directed to transport directly to psych facility. All incoming psych pts. get IFT to said psych facility. The fast track center is just like your regular doctor's office. Your ER has places for fast tx/dx where they will wither discharged or sent back to central pavilion for admission. Trauma bay will be directly under the OR which will be directly under the ICU. These three wings have their own express elevator with helipad access. The trauma bay has its own MRI/CT dedicated to trauma pts. with, ideally, a Lodox and iStat for all primary labs and imaging purposes.

Edit: Staff remain in their own wing and do not rotate, except for med students/residents needing to for their education. I think each should specialize in their own trade. A trauma surgeon should be a trauma cowboy just as a family medicine doc should be able to identify poison ivy from chicken pox. A jack of all trades is a master of none.

 

[medicsb]

Make an "Intake Department" ("Marcus Welby Wing) for everyone except pre-triaged patients with time critical trauma/illness.

Carve out an "Intensivist Area" (the Gregory House Memorial Pavilion) as the direct area to receive ambulance admits, or patients triaged from the general intake.

Rotate duties throughout this wing , no one is a trauma cowboy, everyone can identify croup and tetanus as well as dissecting descending aortal aneurism.

Have diagnostics and lab next door (the Leonard McCoy hall), including MRI. Basic OR on the other side (Benjamin Franklin Pierce suite.

And an express elevator stopping at ICU, postop, preop.

Cut the ego cultivation, get people in and out or up ASAP instead of keyholing.


What say?

Have you missed some aricept doses? What you're describing, generally exists in many EDs. Triage, fast-track, and areas with different names (e.g. "zones", "pods", "cores", etc.) for intermediate and high-acuity patients. Most EDs have dedicated resuscitation bays and some now have critical care areas. Radiology on the same floor, or even as a wing of an ED exists in many places. Even in major trauma centers, an OR in the ED or next to the ED is not necessary as most surgical patients do not need to be taken to the OR expeditiously enough that a ride down a hall up and elevator and down another hall makes any difference.

Also, most ED docs would love to get patients "in and out or up ASAP", but the rate limiting factor is rarely the ED. There are no hospitalists standing around on the floors twiddling their thumbs, wondering when the patient from the ED will arrive.

 

[NomadicMedic]

I think when a view on how to shape the focus of Emerency medicine was current 20 years ago, you just have to take it with a grain of salt.

 

[MonkeyArrow]

So DEmedic, what is your revolutionary new idea to reshape the idea of emergency medicine (no sarcasm intended)?

 

[NomadicMedic]

I don't have an idea to reshape the intake, treatment and eventual dispo of hospital patients. I'm a paramedic. Not an emergency department consultant or hospital admin.

But nothing that the OP suggested was anything new. Every major ED, that is not a community hospital, has a central intake area, separate pods for trauma and fast track, CT and radiography in the department, a lab that can run stat blood work in minutes and is committed to getting patients in or up and out ASAP. The same way it's been done for the last 20 or so years....

 

[MonkeyArrow]

What's your opinion on ER's actually going back to (I don't know if they ever were originally like this anyways) being for EMERGENCIES only. You know, it's in the name and everything. I think that after triageing the patient, the hospital staff should be able to decide whether they want to see a pt or not. Why are we dedicating resources in the fast track to a frequent flier with c/c of a stubbed toe at 3 AM in a busy metropolitan level 1 where we could be using those resources to treat the real emergencies and decease the 5 hour ER waiting room times. Yes, I understand that ERs triage patients and that's why certain people have to wait as long but a kid with strep throat to the point where he cannot drink and is persistently painful should not have to wait in a waiting room for hours until someone can get around to him (personal experience).

I guess what I'm trying to say is why can't we as EDs and EMS systems eliminate the fast track and refuse to treat non-emergent pt. referring them to their PCP. Most, if not all, EMS systems are forced to transport if the pt. requests it even if they have a unreasonable c/c. So why can't we refuse and eliminate the fast track referring them to their PCP since that is what fast track is anyways.

 

[NomadicMedic]

Does EMS abuse bother me? Sure. However, EDs have been plagued by non emergent patients since they first opened. (In fact, I think Hippocrates first ED patient was foot pain x 3 weeks)

However, in the end, I don't really care. If the patient needs a paramedic, I transport them and start treatment. If they don't, I triage them to BLS and they get transported to the ED to seek treatment. Obviously they felt that the hospital was where they need to be and the hospital continue to see them... So, there you go.

My service doesn't bill at all, paramedic service is fully supported by the state and county. It matters not one bit to me if I see stubbed toes or CHF.

So, really... You're asking the wrong questions to the wrong person.

For me, it's clear that each ED has allowed themselves to become an all encompassing endpoint for everyone needing medical care, from sniffles to cardiac arrest. Fix that problem, by having hospitals refuse treatment or give us alternative transport and/or treatment options and you'll see the prehospital stuff will take care of itself.

 

[Tigger]

What's your opinion on ER's actually going back to (I don't know if they ever were originally like this anyways) being for EMERGENCIES only. You know, it's in the name and everything. I think that after triageing the patient, the hospital staff should be able to decide whether they want to see a pt or not. Why are we dedicating resources in the fast track to a frequent flier with c/c of a stubbed toe at 3 AM in a busy metropolitan level 1 where we could be using those resources to treat the real emergencies and decease the 5 hour ER waiting room times. Yes, I understand that ERs triage patients and that's why certain people have to wait as long but a kid with strep throat to the point where he cannot drink and is persistently painful should not have to wait in a waiting room for hours until someone can get around to him (personal experience).

I guess what I'm trying to say is why can't we as EDs and EMS systems eliminate the fast track and refuse to treat non-emergent pt. referring them to their PCP. Most, if not all, EMS systems are forced to transport if the pt. requests it even if they have a unreasonable c/c. So why can't we refuse and eliminate the fast track referring them to their PCP since that is what fast track is anyways.

Emergency rooms were never just for emergencies. Not to mention that fast-track units allow hospitals to milk the urgent care cash cow as well. Get em in get em out and if you're lucky they're on good insurance. If they aren't, well at least you got them out quick. It isn't like fast track units somehow greatly detract from actual emergency services. Any ER worth it's salt understands that triage doesn't end at intake. Serious patients get procedures and labwork done quicker. Some sub acute units (our local ones for example) probably increase the quality of care for other areas by being self contained which prevents those other areas from losing resources when the fast track unit is busy.

As for the second part. EMS in it's current form cannot move out of the transport everyone mentality until education standards are improved and billing requirements revamped. The end.

 

[mycrofft]

placebo effect of the "E.R.".

One local hospital tried setting up doc in a boxes (freestanding emergency clinics) near their hospitals, and actually bought out one small chain of them (MEDCENTER Medical Group, now defunct). The clinics lost their agility under the paperwork, the patients stopped coming and went to the ERs (making the problem worse).

Recently they tried posting Nurse Practitioners at a chain of pharmacies but the facilities were too spartan to hold patient trust and they mainly told people they were fine, or sent them to their parent hospital.

They also tried apportioning some neighboring space in the hospital as an acute/not urgent/triage area. If incoming triage sent them there, cases were dealt with, or sent back as "urgent".

BOTTOM LINE:
Patients wanted to be seen at the "ER" and considered any diversion or a place not in the hospital building as "bogus".

 

[medicGee]

What's your opinion on ER's actually going back to (I don't know if they ever were originally like this anyways) being for EMERGENCIES only. You know, it's in the name and everything. I think that after triageing the patient, the hospital staff should be able to decide whether they want to see a pt or not. Why are we dedicating resources in the fast track to a frequent flier with c/c of a stubbed toe at 3 AM in a busy metropolitan level 1 where we could be using those resources to treat the real emergencies and decease the 5 hour ER waiting room times. Yes, I understand that ERs triage patients and that's why certain people have to wait as long but a kid with strep throat to the point where he cannot drink and is persistently painful should not have to wait in a waiting room for hours until someone can get around to him (personal experience).

I guess what I'm trying to say is why can't we as EDs and EMS systems eliminate the fast track and refuse to treat non-emergent pt. referring them to their PCP. Most, if not all, EMS systems are forced to transport if the pt. requests it even if they have a unreasonable c/c. So why can't we refuse and eliminate the fast track referring them to their PCP since that is what fast track is anyways.

Well alot of people in a major urban enviroment, or where most trauma centers are located do not have insurance. So the ER beceomes the PCP. It's inevitable nowadays. To fight this would be to fight an unwinnable battle. Plus with the new Obamacare, I wouldnt be suprised to even see more of an increase in pt wait time for the ER. The deductibles are unreal....

 

[mycrofft]

Delayed response to MonkeyArrow

Originally Posted by MonkeyArrow

"What's your opinion on ER's actually going back to (I don't know if they ever were originally like this anyways) being for EMERGENCIES only".

I think the concept of the ER (or ED) is creating trouble in how "emergency" staff relate to patients and the rest of the hospital. Using triage, as you said, to send patients to appropriate level of care is the thing to do; however, in my limited experience (limited because of the time period I worked in the field) hospitals use a tiny triage function to "keyhole" services. That's like Walmart on Saturday afternoon with one checkout counter open. The mentality is like looking out the gun slits at The Alamo.

Here's how we used to have an "emergency room" (and it was basically one room): one triage nurse; one MD; three RNs including the lead RN; two LVNs; two clerks at the waiting room. No dedicated parking, had to use regular lot. Anything not emergency we would maybe hand out a sample tell them to see their family physician...which most of them didn't have.

Try this: six triage RNs with standardized procedures, three MD's, three RN's PLUS a lead RN to act as manager, and three LVNs. Four clerks. Just run it as an effective clinic (like a doc in the box), but be able to swing into critical cases immediately.

Historically the emergency ROOM was invented to keep the bloody dirty dead and screaming away from the rest of the real paying customers. After WWII they started to amass specialized or dedicated equipment.

 

[triemal04]

One local hospital tried setting up doc in a boxes (freestanding emergency clinics) near their hospitals, and actually bought out one small chain of them (MEDCENTER Medical Group, now defunct). The clinics lost their agility under the paperwork, the patients stopped coming and went to the ERs (making the problem worse).

Recently they tried posting Nurse Practitioners at a chain of pharmacies but the facilities were too spartan to hold patient trust and they mainly told people they were fine, or sent them to their parent hospital.

They also tried apportioning some neighboring space in the hospital as an acute/not urgent/triage area. If incoming triage sent them there, cases were dealt with, or sent back as "urgent".

BOTTOM LINE:
Patients wanted to be seen at the "ER" and considered any diversion or a place not in the hospital building as "bogus".

Stand-alone ER's still exist. I'm not going to say that they are prevalent nationally, but they are far from unheard of. And the ones that I've seen manage to stay quite busy.

 

[medicsb]

Yes, I understand that ERs triage patients and that's why certain people have to wait as long but a kid with strep throat to the point where he cannot drink and is persistently painful should not have to wait in a waiting room for hours until someone can get around to him (personal experience).

Strep throat is not an emergency. So, why did you go the ED? Based on what you have said, you should have been turned away and referred to your kids pediatrician.

I guess what I'm trying to say is why can't we as EDs and EMS systems eliminate the fast track and refuse to treat non-emergent pt. referring them to their PCP.

Lawyers, the fact that many people do not have PCPs, and the fact that it is difficult to determine "emergent" or "in need of hospitalization" without a good work-up.

 

[mycrofft]

Strep throat is not an emergency. So, why did you go the ED? Based on what you have said, you should have been turned away and referred to your kids pediatrician.



Lawyers, the fact that many people do not have PCPs, and the fact that it is difficult to determine "emergent" or "in need of hospitalization" without a good work-up.

Or we just make it faster and easier to be seen for anything. Hire enough people and the right mix to do it.

Was talking to a nurse today in my class. She works a large local ED and they have over sixty beds (more than the local military hospital did!). The ED MDs basically triage and refer, and the appropriate specialists just appear.
And yet, waiting times of two, four and even twelve hours are not unheard of.

 

[medicsb]

Or we just make it faster and easier to be seen for anything. Hire enough people and the right mix to do it.

Was talking to a nurse today in my class. She works a large local ED and they have over sixty beds (more than the local military hospital did!). The ED MDs basically triage and refer, and the appropriate specialists just appear.
And yet, waiting times of two, four and even twelve hours are not unheard of.

You figured it all out. Now make it happen.

 

[mycrofft]

You figured it all out. Now make it happen.

OK, OK, right after I perfect that new athelet's foot remedy!

 

[Rialaigh]

Get rid of ER physicians, staff ER's with hospitalist that can admit and an Intensivist to manage actual emergencies. The same physician can see the patient, write admission orders, and get the patient out of the ER.


Without changing the broad idea of seeing everyone in the ER this is the fastest most efficient way to improve throughput.