The following excerpt from the book "Healthcare Solved-Real Answers, No Politics" by Debra A. Smith, DO
Health classes have failed to teach our citizens what is and is not an emergency. Too many people with urgent or emergent problems wait until their doctor’s office opens or worse yet until the office secretary gives them an appointment. Far too many people, without urgent, let alone real emergencies, go to the emergency room for care. More than once while working in the ER, a person has come in requesting a Band-Aid for a small cut on his finger, insisting that he had a right to treatment. In England, he would have been thrown out; here he will be seen. No country can afford this kind of access.
I will not attempt to go through a list of real emergencies here, but a good rule of thumb is anything that interferes with basic bodily functions, such as airway, breathing, circulation (heart beat/chest pain), for starters, or anything that causes an excessive loss of any bodily fluids from an orifice (natural or man-made), particularly the wrong bodily fluids (other than what would normally be expected), is an emergency.
While covering the emergency room at Deaconess Hospital in Cincinnati, a patient came in via squad with his family in what is referred to as agonal breathing, also known as the death rales or rattles.[3] As the name suggests, it is typical of the type of breathing that occurs close to death; the patient is not conscious of their environment at that point. I asked the patient’s wife how long he had been like this. She answered a few hours. When a person is not breathing well and is not arousable, this should immediately indicate a problem. Our people do not need to be great diagnosticians to learn the basics of what is or is not an emergency. Our schools should be teaching this. Schools should also teach students how to find a family physician, how to make an appointment, and when to use an urgent care center[4] vs. an emergency room. Too many emergency rooms have beds tied up with non-emergency care, such as sinus infections, urinary tract infections, sexually transmitted diseases. In my experience, easily two-thirds of the care is non-emergent.
Access to care and the “lack” of it
So many times in this country we talk about a “lack of access to care.” I do not believe most of those discussing the issue actually understand the true meaning of the phrase. The first week I was in Albania working at ABC Clinic in Tirana, a woman was brought in by her friend, her pastor, a church deacon and her young teenage daughter. She was apparently hemorrhaging and in disseminated intravascular coagulation (DIC). By the time she came into the clinic, she had lost a considerable amount of blood. We immediately ran some labs and started several large-bore IVs. The lab was around the corner and the doctor quickly got us the results. We had to get her to the hospital for care. Since there were no ambulances, the pastor, the deacon, the local Albanian doctor and I got the patient into the deacon’s car, IV in tote, and drove over to the general hospital.
We saw the generalist, who called in the hematologist to look at the patient and go over the labs. They agreed with the diagnosis, but stated that she needed to go to the Women’s Hospital for such problems. They did not handle such cases there. We piled back into the car and headed for the Women’s Hospital. When we spoke to the head doctor at the Women’s Hospital, he refused to admit her. Without examining her, he said she was fine, despite the fact that she could barely stand up on her own. I said the only reason she could even stand at all was because of the IV fluids we were giving her. He and the other doctors stood there laughing at us, as I pleaded with him to examine her, my Albanian colleague earnestly translating my pleadings. This patient would die in the next few hours if nothing was done. When the doctor chuckled and turned to leave, I seized hold of his forearm and told him, “She is going to die, and soon, if nothing is done and it will be on your head. Either help me or tell me where I can get her help.” He tried to get away, but I wasn’t letting go. It was then he looked me in the eye and said “Go to the Maternity Hospital.” I thanked him and returned his arm.
When we got to the Maternity Hospital, the entrance was on the third floor. In the Third World, there is virtually never an elevator; and if there is one, it either hasn’t worked in years, or there is no electricity. This particular hospital had no elevator. The two gentlemen with us carried our patient up three flights of stairs. When we got to the top, the heavy plate glass doors were locked. After beating on the door and waving my arms like a member of the ground crew at JFK bringing a plane into the gate, I finally got the attention of the doctors at the far end of the hall, who came, unlocked the door helped get the patient to an examining room, and took care of her. Now this patient had a lack of access to care on multiple levels.
When Americans refer to a lack of access to care, it is not usually this type of problem. It generally falls into one of three problems. The issue may be a lack of ability to pay for the treatment needed or fear of the lack of money to seek it. It may be that they live far from a local hospital. Unfortunately, on occasion in this country, a person will die in the waiting room of a hospital. It tends to happen when patients come to the ER themselves, rather than call an ambulance. This is due to insensitivity or the inability of the registration and ER staff to triage patients and prioritize care. It comes down to poorly managed resources, rather than a true lack of access to care.
Under the Emergency Medical Treatment and Active Labor Act (EMTALA) [Title 42 of the US Code, Chapter 7, Subchapter 18, Part E, § 1395dd]:
§ 1395dd. Examination and treatment for emergency medical conditions and women in labor
In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1) of this section) exists.
If any individual (whether or not eligible for benefits under this subchapter) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either—
(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or
(B) for transfer of the individual to another medical facility in accordance with subsection (c) of this section.[5]
As long as the patient is willing to consent to treatment, or transfer to a more appropriate facility should the hospital where he initially presented be unable to provide the necessary care, that patient will get emergency medical evaluation, stabilization and treatment. [6] There are well-defined processes and procedures regarding how transfers may take place and under what conditions. If these are not followed, the hospital and emergency room physician may each face civil monetary penalties under the federal law and may be subject to a personal injury suit by the patient under state law.
The Act specifically prohibits discrimination and delays in examining and treating patients due to insurance or the lack of it.
(g) Nondiscrimination
A participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers as identified by the Secretary in regulation) shall not refuse to accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the hospital has the capacity to treat the individual.
A participating hospital may not delay provision of an appropriate medical screening examination required under subsection (a) of this section or further medical examination and treatment required under subsection (b) of this section in order to inquire about the individual’s method of payment or insurance status.
Unlike in virtually every other country in the world, where if you do not have a citizen identity card or a credit card in hand, you cannot receive treatment, we may have made it too easy to receive access to care.
Before you think that last statement preposterous, consider the findings of this study by Weinick, et al.:
For those without a usual primary care provider or who cannot afford their services, the ED [emergency department] provides an attractive option: no one is turned away, no proof of income is required, and often no payment is required at the time services are delivered. In addition, Medicaid patients are more likely to utilize emergency departments in part due to difficulties accessing office-based physicians who are willing to accept Medicaid fees schedules.
A substantial portion of visits to emergency departments are for non-urgent conditions which could be treated in primary care settings. These types of ED visits likely reflect poor primary care accessibility and many limitations of primary care discussed above…Cunningham et al. found that very young children were more likely to use the emergency department for non-urgent care – possibly related to parents’ inability to reach their usual provider after regular office hours. Patients who utilize EDs for ambulatory care were more likely to report non-financial barriers to care, such as an inability to access evening services or get time off work, no timely clinic appointments, and failed attempts to get care elsewhere. One Canadian study reported that, among a largely insured cohort, 55 percent of patients utilized the emergency department for reasons of convenience. This and several other studies suggest that the more traditional hours of primary care physicians are leading patients to seek care when it is convenient for them.
..To better understand this use of EDs, the New York University Center for Health and Public Service Research and the United Hospital Fund of New York have developed and algorithm to profile ED use…Patients in the sample were classified as “Non-emergent” if the initial complaint and vital signs indicated care was not required within 12 hours. Records of “emergent” patients (requiring care within 12 hours) were further examined to assess the resources used in the emergency department. Patients using no resources or resources typically available in a primary care setting were classified as “Emergent—Primary care treatable.”… Computerized ED data was obtained for New York City hospitals for 1994 and 1998,… regarding ED usage in New York City.
· There is significant ED use for conditions that are non-emergent or that are emergent but could be treated in a primary care setting. For children age 0-17, 41.6% of ED use was for non-emergent conditions, with another 36% for emergent but primary care treatable conditions. Only 22.4% of use required ED services, and almost one-third of this use (7.6% of all use) was potentially preventable/avoidable with effective and timely primary care earlier in the episode of illness. For adults similar rates were observed, with 41.7% non-emergent and 32.4% emergent, but primary care treatable.
· The relative rates of non-emergent and primary care use differed by payer. Rates were highest among Medicaid children and lowest among commercial patients, with self pay /uninsured patients falling in between the two.
· Relative rates also differed by race/ethnicity and gender. Black and Hispanic/Latino patients had higher relative rates of use for non-emergent or primary care treatable conditions across all payer classes, and males had higher rates than females.[7]
End the frequent flier programs
Keep the airline programs in place, but let us end the ER frequent fliers. These are the patients who use the ER for primary or urgent care. Some come in as often as once or twice a week. These patients often have one or more chronic conditions that are poorly controlled. This is sometimes because they have a doctor that is hard to get an appointment with, but most of the time it is because they have not refilled their medicines. Now they are coming in with sky-high blood pressure or blood sugar. This is a personal responsibility issue. A follow-up appointment should have been made for them by their doctors’ office before their pills and refills ran out. Or the patient should have done it himself. If ER abuse is a pattern, public and private insurance should at most cover 20% of the visit, and let the patient cover the rest. The insurer’s explanation of benefits statement, which states what has been paid and what the patient owes, should include a list of several in-network primary care and urgent care centers within a given radius of the patient for future reference.
Interestingly, the frequent fliers do not like to fly coach; they almost always fly first class. In healthcare, that means coming by ambulance. (Incidentally, that practice also ties up ambulances from getting to real emergencies.) They know that they will go to the front of the line, ahead of patients in the waiting room, deserved or not, and be put in an ER bay for evaluation. This is often nothing more than a $500 or more taxi ride. We all know the story of the little boy who cried “Wolf!” too often; [8] as a country, we cannot afford this. If it is not due to trauma or the patient is not admitted to the hospital, the bill should be the patient’s responsibility. (A few exceptions may need to be delineated, but I trust you have grasped the point.)
We must teach our citizens how to be wise consumers of healthcare. Find out what services are available at the local urgent care clinics. Most offer x-rays, basic lab tests, electrocardiograms (EKGs), aerosol treatments, etc. Ask family, friends, co-workers and neighbors if they have a doctor they like, with convenient hours.
Further reading of the book "Healthcare Solved-Real Answers, No Politics" can be found at Author's website http://healthcaresolved.net/
[1] Injury or illness requiring immediate (same day) but not emergency care.
[2] Serious injury or illness requiring emergency room care.
[3] Merck Manual Home Edition: When Death is Near http://www.merck.com/mmhe/sec01/ch008/ch008j.html [Accessed 6/20/09]
[4] “Urgent Care Centers are walk-in ambulatory care centers, generally open seven (7) days each week often 13 or more hours each day. No appointment is required for a patient to receive care. These centers have a broad array of diagnostic and therapeutic services, often including x-ray, laboratory testing, on-site pharmacy, procedure rooms for laceration and fracture care, exam rooms, and specialized corporate services for employee health and workers compensation cases.” See http://www.urgentcare.org/FAQs/tabid/135/Default.aspx . [Accessed 6/20/09]
[5]EMTALA http://www.law.cornell.edu/uscode/42/1395dd.html [Accessed 6/20/09]
[6] “(B) The term “stabilized” means, with respect to an emergency medical condition described in paragraph (1)(A), that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or, with respect to an emergency medical condition described in paragraph (1)(B), that the woman has delivered (including the placenta).
(4) The term “transfer” means the movement (including the discharge) of an individual outside a hospital’s facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital, but does not include such a movement of an individual who (A) has been declared dead, or (B) leaves the facility without the permission of any such person [against medical advice].” See EMTALA definitions http://www.law.cornell.edu/uscode/42/1395dd.html [Accessed 6/20/09]
[7] Weinick R, Billing J, Burstin H. What is the role of primary care in emergency department overcrowding? See http://www.kaisernetwork.org/health_cast/uploaded_files/WeinickED.pdf
[8] Aesop’s Fables http://en.wikipedia.org/wiki/The_Boy_Who_Cried_Wolf [Accessed 6/20/09]
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