Local ER now has Appointment Times!!! wtf

[Meursault]

Look at it this way: if you're a hospital administrator, well people are great. They still get billed for the evaluation, they're out of there quickly, and you don't have to find them a bed.
Therefore, you do anything you can to encourage non-sick people with private insurance to come to the ED. Presenting your ED as a fast 24-hour alternative to standalone urgent care or making a PCP appointment is a good way to draw in these patients.
Appointments are a logical extension of this; going to the ED is not nearly as attractive if you have to worry about waiting for two hours with the unwashed masses.

 

[ffemt8978]

Very unfortunate the Emergency Medicine has come to taking appointments.

This can't help things.................


cnsnews.com/news/article/64034

Given that the Patient Protection and Affordable Care Act has been ruled unconstitutional because of the individual mandate, this may change. Of course, it's going to depend upon what the Supreme Court finally decides once it reaches them.

 

[Veneficus]

Look at it this way: if you're a hospital administrator, well people are great. They still get billed for the evaluation, they're out of there quickly, and you don't have to find them a bed.
Therefore, you do anything you can to encourage non-sick people with private insurance to come to the ED. Presenting your ED as a fast 24-hour alternative to standalone urgent care or making a PCP appointment is a good way to draw in these patients.
Appointments are a logical extension of this; going to the ED is not nearly as attractive if you have to worry about waiting for two hours with the unwashed masses.

Two hours would be nothing.

I have seen facilities with an average wait of 12-14 hours for non urgent cases. (in the US exclusively)

But I think a variety of factors come into play.

For example, most PCPs aren't available in a reasonable amount of time. The average appt. in the US, i read in NEJM last year was 40 days.

Some of my friends who are EM docs tell me the largest patient population in the ED are insured people who cannot take a day off work to go see a doctor during business hours.

I think that is the general failure of trying to industrialize medical care. If medicine is not available when people need without further disrupting their lives, then it simply works better for providers than for patients.

Some forget that patients drive medical need, not providers.

 

[sbp7993]

This makes sense to me. If you are in serious danger, then you would call 911 instead of driving to the ER yourself, and you would be seen immediately. If it can wait a few minutes, then why not schedule it, and be seen in a timely manner?

 

[Aidey]

Two hours would be nothing.

I have seen facilities with an average wait of 12-14 hours for non urgent cases. (in the US exclusively)

But I think a variety of factors come into play.

For example, most PCPs aren't available in a reasonable amount of time. The average appt. in the US, i read in NEJM last year was 40 days.

Some of my friends who are EM docs tell me the largest patient population in the ED are insured people who cannot take a day off work to go see a doctor during business hours.

I think that is the general failure of trying to industrialize medical care. If medicine is not available when people need without further disrupting their lives, then it simply works better for providers than for patients.

Some forget that patients drive medical need, not providers.

One would think that after hours urgent care centers would be more common then, targeting that population with claims that they are more efficient and less expensive than the ER. I agree that health care needs to serve people after work/school hours, however using the ED for that isn't a sustainable model.

It isn't just the convenience of seeing the MD at the ER, it is also the tests and results people are after. I once transported a lady to the ER in the middle of the night because she wanted the results to the out patient MRI she had the day before. She was upset she didn't get the results immediately, and she was of the opinion that the ER would either get those results for her, or do a new MRI.

Maybe it is just the area of the US I am in, but there also seems to be low level paranoia when it comes to taking time off work for a doctors appointment. People seem to think that gives their employer the right to see why they were at the doctor. There is also the slightly more realistic low level paranoia that any show of weakness to an employer will result in job loss.

 

[Veneficus]

One would think that after hours urgent care centers would be more common then, targeting that population with claims that they are more efficient and less expensive than the ER. I agree that health care needs to serve people after work/school hours, however using the ED for that isn't a sustainable model.

There is more to it than just "using the ER."

For people who are underinsured or outright uninsured poor, the ER usally sends a bill. An urgent care clinic very often demand cash up front.

Urgent care centers are found in population centers where the volume of patients can support its services. So what do patients in populations that cannot sustain them do?

Easy, they go to the ED where there is a federal mandate to help them. Which brings up the problem of over saturated EDs.

So having an urgent care area of center at the ED has a few advantages.

The indigent billing system and financial counciling is already in place.

The medical devices and lab are already available.

The pt can be triaged to either the ED or urgent care depending on presentation and properly cared for without delay.

Urgent care or ED human resources can be redirected based on need.

The attached urgent care can reschedule appointments and followup with a common record, especially useful if the patient was admitted to the same hospital or have had past surgery.

There is also the benefit of having many in house specialists in EDs attached to hospitals. Even if those specialists are only in house during certain hours. (makes that ED appointment that much better) That way you don't have patients taking up a bed in the ED all night long who are doing nothing more than waiting for a specialist consult in the morning.

I think it is important that people don't have the idea the ED is "just for emergencies." Because true life threatening emergencies are not treated by the ED. They are just stabilzed until those services can be activated. Without the "not real emergencies" there would be so little need of EDs they would be closing en mass and a lot of EM docs would be struggling for work.

As with all of life, there is evolution over time. The 19th century definition of an emergency is long past it's use.

US medicine right now is facing a very complex set of problems. The old ideas and system has failed to the point of catastrophe. From initial education to end of life care, every aspect of the system needs revamped. It is past time for small fixes and bandaides.

What people choose to have as a system is irrelavent to me. If they want pay to play, fine. If they want a complete government run system, fine. There are several system designs that are shown to work. It is only specific interests who stand to lose if they are implemented.

But I am giving up trying to reason with or show facts to grossly ignorant people whos source of education is partisan media. It is like curing stupid, it can't be done so why try?

 

[Aidey]

Vene, I wasn't talking about the uninsured and/or poor, I was specifically talking about the employed, insured who find it inconvenient to take time off work.

I also got the impression from the news article that these appointments were for the ED proper, not an urgent care center attached to the ED. Frankly, I think that is a different situation than people making appointments for the ER. I think we are all aware of House and his love for Clinic time. A clinic like that, attached to an ED would be a reasonable place to make an appointment. The main ER....not so much.

Did you happen to see the study done on ER wait times for Asthma patients? (I have no idea what it was published in, one of the MDs left it lying around and I was reading it while waiting for paperwork). It was about ERs that had special asthma/respiratory sub sections, where those patients were shipped directly to when they arrived. It reduced wait times by something like 4 hours on average for patients having an asthma attack.

Look at what happened with L&D, Peds, and Psych; They have often branched off, seeing their own patients while bypassing the main ED. I see that being the way of the new ER, a main Emergency Room, with a number of sub sections for certain types of patients. Respiratory, urgent care, etc. Patients over or under triaged can be transferred to the appropriate section. There could be a step down area, for patients who need infusions or to be monitored for a few hours, but don't require admission or the full services of an ED.

I think rather than redefining "emergency" or "emergent" the EDs need to do a better job of sorting patients so that those true emergent cases that come in don't get lost in the shuffle. This also would help prevent non-urgent cases from waiting for hours because an urgent case came in.

 

[Veneficus]

Vene, I wasn't talking about the uninsured and/or poor, I was specifically talking about the employed, insured who find it inconvenient to take time off work.

Unfortunately, that is a majority of underinsured. It is not a convenience to take off of work. They barely make enough to live to start. When they take off work to go to the doctor not only do they have to pay sizable deductables because they often cannot afford plans with lesser deductables, they also lose wages that cause them to be late or not pay other bills. The insurance is usually only enough to cover catastrophic illness one time.

What many insured don't realize, is they are only 1 catastrophe away from the same because as soon as they lose their job from temporary or permanant disability they lose their insurance too. Which is why it is so maddening for me to listen to people who have a job and insurance think they are somehow superior or better off. The truth is much more frightening.

I also got the impression from the news article that these appointments were for the ED proper, not an urgent care center attached to the ED. Frankly, I think that is a different situation than people making appointments for the ER. I think we are all aware of House and his love for Clinic time. A clinic like that, attached to an ED would be a reasonable place to make an appointment. The main ER....not so much.

Yes I understand that. But short of building a new ED, in many existing hospitals the "urgent care" is a few beds or a partition of the ED proper.

These "fast moving" beds, if you will, ensure that the beds for more emergent or critical patients are maintained. That way you do not have nonacute care taking up all the emergent beds. As well, it takes considerably more staff time to deal with critical patients. So by having a dedicated "urgent care" doc or nurse, it keeps the waiting room flowing as well. That way you don't have 10 hour waits because the ED is slammed with emergencies.

It is great when facilities can actually physically seperate the two services but that is not always economically possible.

Think of the dual fast food places under one roof as how it works.

Did you happen to see the study done on ER wait times for Asthma patients? (I have no idea what it was published in, one of the MDs left it lying around and I was reading it while waiting for paperwork). It was about ERs that had special asthma/respiratory sub sections, where those patients were shipped directly to when they arrived. It reduced wait times by something like 4 hours on average for patients having an asthma attack..

If we are talking about the same study that dates back to the 70's. EDs early as the 80's had these areas. However it was often a set of chairs rather than beds. One of the criteria was you had to be able to sit up on your own in order to qualify. I do not know why they were done away with, but I am sure there is something regulatory involved in some manner or another.

Again, if you can build a seperate space, that is great. But not always possible.

Look at what happened with L&D, Peds, and Psych; They have often branched off, seeing their own patients while bypassing the main ED. I see that being the way of the new ER, a main Emergency Room, with a number of sub sections for certain types of patients. Respiratory, urgent care, etc. Patients over or under triaged can be transferred to the appropriate section. There could be a step down area, for patients who need infusions or to be monitored for a few hours, but don't require admission or the full services of an ED.

The trouble I see with that is how do you justify the costs of the respective specialties to be there 24/7? L&D and peds require specialized knowledge and specialized equipment. Sure pulmonology is specialized knowledge and equipment, but long term therapy and follow up doesn't have to be taken care of emergently. It would be much easier to just change physician working hours. (good luck with that)

I think rather than redefining "emergency" or "emergent" the EDs need to do a better job of sorting patients so that those true emergent cases that come in don't get lost in the shuffle. This also would help prevent non-urgent cases from waiting for hours because an urgent case came in.

But emergency has been redifined over the course of the last 20 years. It has been redefined by the people who use and pay for service. (even if pay for means a federal poverty program)

Not losing the patients in the shuffle is the eternal problem. Unfortunately no matter how good a system is designed somebody will always fall through the cracks. As the system shrinks or becomes inaccessable, those cracks get bigger and more fall through. Untill the whole system is changed, the ED problems cannot be truly addressed. Only more temporary fixes can be implemented.

 

[looker]

Given that the Patient Protection and Affordable Care Act has been ruled unconstitutional because of the individual mandate, this may change. Of course, it's going to depend upon what the Supreme Court finally decides once it reaches them.

Assuming it do not get repealed prior to getting to us supreme court. It's very likely to be found partially unconstitutional with the rest of the bill being left as valid.

 

[rescue99]

I have a niece that works in a "step-down unit" of the ED. The "step-down unit" sees the non-critical pts., sore throats, coughs, etc. (Sounds like a Urgent Care) but, they also take care of the pt. that need to be observed. These are the pt. that started out in the regular ED, and that don't need to be admitted to the hospital, they will stay less than 24 hours. They also watch the pt. that need IV fluid or antibiotics, that take hours to run in.
I thought it was kind of a neat idea. If it is quiet on the "step-down" side the RN's go and help out in the ED.

Step downs have been around for 10-15 years here. A number of our hospitals created them to curb the nonemergant flow into the main ER area.

 

[mycrofft]

They need to sit down and play "Man From Mars"

What makes sense here to meet the mission, if we throw out historic and political considerations?
"Emergency Rooms" were originally to divert walk or drive-in admission without appointments who needed immediate care away from the Admissions area. Now they are the predominant admission department for many hospitals, and the biggest unprofitable "drain" of resources and admission mode for nonpaying patients. Keep them physically small, stressful and inefficient to encourage patients to walk away.

Also, the "ER" can be a good place to attribute cost overruns from other parts of the hospital (i.e., make the ER charge for IV SNS exhorbitant; when it doesn't get paid back, use the difference in loss above actual cost as camouflage for such things as wasted or stolen sterile supplies, executive shower rooms, or ineffective materieles control in the OR's, etc.)
Get rid of the Emergency Department, just have a good triage function at Admissions and prompt diversion to Urgent Care, "Emergency Stabilization" or some such, and/or clinic referral facilitated by physical layout and datakeeping. Stop keyholing emergent presentations, accomodate them.

 

[cmetalbend]

Here's my appointment date....... <13/<32/>2010