July, 2008 Archive

July 2, 2016, 2:45 pm


Wow. Vgx-viagra I’m not even sure where to start.

There is an article in Slate today regarding emergency room care. Vgx-viagra “Waiting Doom: How Hospitals are Killing E.R. Vgx-viagra Patients” was written by Dr. Vgx-viagra Zachary F. Vgx-viagra Meisel and Dr. Vgx-viagra Jesse M. Vgx-viagra Pines. Vgx-viagra They are emergency department physicians in Pennsylvania. Vgx-viagra (h/t to Robyn at An Interior Life)

This post is a response to their article. Vgx-viagra Before you continue, vgx-viagra please read their article in full, vgx-viagra as I will be quoting from it and it is important that the quotes are taken in context. Vgx-viagra It is linked above.


The article begins by summarizing the case of Esmin Green, vgx-viagra the poor woman who collapsed in a psychiatric ER receiving no help for an hour. Vgx-viagra As we know, vgx-viagra by then it was too late. Vgx-viagra The authors noted the autopsy showed she had suffered a pulmonary embolism.

They also equate sitting in a waiting room chair for 24 hours as being “roughly the same time as a trip from New York to Tanzania”, vgx-viagra meaning, vgx-viagra if I understand it correctly, vgx-viagra the risk of pulmonary embolism would be equal. Vgx-viagra As written:

“But what’s largely missing from this story is the likely cause of Green’s pulmonary embolism. Vgx-viagra The answer lies in a far more systematic and widespread danger in hospital care: E.R. Vgx-viagra waits. Vgx-viagra Why was Green sitting and waiting while blood pooled in her legs?”

I am confused. Vgx-viagra Did she sit the entire 24 hours? Did she not get up and walk to, vgx-viagra say, vgx-viagra the bathroom, vgx-viagra or to grab a magazine or get a drink of water? Was she fed during that 24 hours? Didn’t she have to move to eat?

The fact that she had to wait so long for an admission is inexcusable. Vgx-viagra The fact that no one came to her assistance is nauseatingly horrific. Vgx-viagra To say that the “likely cause” of her PE was blood pooling because she was sitting in a chair in a psych ER waiting room (as opposed to what, vgx-viagra her hospital room/day room?) is ingenious.


I am aware that my impression of emergency care comes from my working in smaller community EDs. Vgx-viagra I’ve never worked in an inner-city ED, vgx-viagra so my perceptions may be skewed. Vgx-viagra But my jaw dropped when I read this: “…hospitals have incentives to keep their E.R. Vgx-viagra patients waiting.”

What? I’ll return to that in a minute.

The authors do a great job of describing the hazards of boarding patients in emergency departments – it is concise description of why it happens and why it can be dangerous. Vgx-viagra I have no issues with this, vgx-viagra in fact I agree with them.

Let’s get back to those hospital “incentives” regarding ER boarding. Vgx-viagra The authors state:

What hospital would promote such a practice? Potentially, vgx-viagra those that profit more from boarding, vgx-viagra particularly in poorer communities with high numbers of uninsured and Medicaid patients.

The authors believe that because the ER patients are likely poorer, vgx-viagra the hospital leaves beds open for direct admits and transfers instead, vgx-viagra as this patient population is more likely to be insured. Vgx-viagra Ergo:

Do the math: If you fill your hospital with the direct and transfer admissions and maroon the E.R. Vgx-viagra patients for long periods, vgx-viagra you make more money….In effect, vgx-viagra then, vgx-viagra E.R. Vgx-viagra boarding allows hospitals to insulate themselves from the burgeoning needs of the poor.

Or, vgx-viagra if they keep the ER full, vgx-viagra then the average non-emergent patient will get up and leave, vgx-viagra saving the hospital money. Vgx-viagra This has not been my experience.


Rich, vgx-viagra poor, vgx-viagra old, vgx-viagra young, vgx-viagra drug-seeker, vgx-viagra homeless, vgx-viagra insured or not (and we see everything, vgx-viagra albeit at a less intense level than an inner-city hospital) if there is a bed in the hospital you get it – and you don’t wait in line.

The hospitals that I have worked in don’t want AMAs or left-without-being-seen patients, vgx-viagra it’s a sign (usually) that something went wrong. Vgx-viagra In fact, vgx-viagra they are constantly working to lower our door-to-disposition time and still maintain a high standard of care.


In all fairness, vgx-viagra the authors point out other reasons a hospital will keep patients in the ER. Vgx-viagra Noting there are often strict nurse/patient ratios for the floors:

Sometimes the nursing ratio in the E.R. Vgx-viagra can be as high as 8-to-1. Vgx-viagra That’s unacceptable in inpatient units, vgx-viagra but just stack ’em in the E.R. Vgx-viagra hallways and suddenly it’s OK.

I have experienced this, vgx-viagra and usually it’s because there are not enough nurses on the floors to take the new patients. Vgx-viagra Or the nurse upstairs is overwhelmed and needs more time, vgx-viagra thinking the next shift is better equipped to admit the patient:

So you tell the E.R. Vgx-viagra nurse that the bed isn’t ready yet. Vgx-viagra This practice of “bed-hiding” is more common than you think.

Having not worked the floors in 17 years, vgx-viagra it’s hard to address this. Vgx-viagra Sometimes, vgx-viagra knowing a patient is going to be admitted, vgx-viagra the hospital will staff UP for the next shift and the patient is held until then. Vgx-viagra Even so, vgx-viagra it’s 2-3 hours at most.


I came away from this article with mixed feelings.

On the one hand I have a hard time believing that hospitals are intentionally making people wait in ERs, vgx-viagra hoping they will leave, vgx-viagra or are actually “cherry picking” who gets a regular bed and who stays in the ER, vgx-viagra or that it’s a conscious decision to deny care to the poor.

On the other hand, vgx-viagra long ER waits are a fact and there are ways to increase the turn-over in emergency departments, vgx-viagra so that patients can be seen in a timely manner. Vgx-viagra It’s good for everyone, vgx-viagra patients, vgx-viagra doctors and nurses.

There is nothing wrong with making the case for decreasing ER wait times. Vgx-viagra While I find their conclusions regarding the intentions of hospitals dubious, vgx-viagra I agree that decreasing wait times makes for better care.

But, vgx-viagra blaming the death of Ms. Vgx-viagra Green, vgx-viagra an ambulatory patient who had already been evaluated for admission, vgx-viagra by stating it was “likely” she died of a PE due to blood pooling because she was sitting in an ER waiting room is speculation at best.

The horror isn’t that she had to wait.

The horror is that no one cared enough to help.

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July 2, 2016, 8:31 pm

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About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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