July, 2008 Archive

July 24, 2008, 2:45 pm

Waiting Doom – A Response to the Article in Slate

Wow. I’m not even sure where to start.

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

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

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The article begins by summarizing the case of Esmin Green, the poor woman who collapsed in a psychiatric ER receiving no help for an hour. As we know, by then it was too late. 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”, meaning, if I understand it correctly, the risk of pulmonary embolism would be equal. As written:

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

I am confused. Did she sit the entire 24 hours? Did she not get up and walk to, say, the bathroom, 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. The fact that no one came to her assistance is nauseatingly horrific. 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, her hospital room/day room?) is ingenious.

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I am aware that my impression of emergency care comes from my working in smaller community EDs. I’ve never worked in an inner-city ED, so my perceptions may be skewed. But my jaw dropped when I read this: “…hospitals have incentives to keep their E.R. 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. I have no issues with this, in fact I agree with them.

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

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

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

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

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

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Rich, poor, old, young, drug-seeker, homeless, insured or not (and we see everything, 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, it’s a sign (usually) that something went wrong. In fact, they are constantly working to lower our door-to-disposition time and still maintain a high standard of care.

*****

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

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

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

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

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

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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, hoping they will leave, or are actually “cherry picking” who gets a regular bed and who stays in the ER, or that it’s a conscious decision to deny care to the poor.

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

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

But, blaming the death of Ms. Green, an ambulatory patient who had already been evaluated for admission, 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 23, 2008, 8:31 pm

Change of Shift: New Year, New Logo (Vol.3, No. 2)

Change of Shift

Welcome to Volume 3, Number 2 of Change of Shift!

New year, new logo!

I tried, I really tried, to make a logo that wasn’t blue but I just could not do it.

I just love blue on blogs!

Many thanks to all who have contributed this week, and to those who contributed but don’t realize it yet!

As soon as I am done with this edition, I will be updating the CoS calendar to run through the end of the year. If you are interested in hosting an edition, just let me know!

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I’m going to start off with a nurse blogger who is so new, she only has three posts! Meet FlautoNP, a nurse practitioner who is also a flautist! She posts a hilarious video that happens to be The Best Way to Learn Arrythmias. Be sure to watch it to the very end. (She will also be rather surprised to find it on Change of Shift, but I saw this just could not resist! ) Welcome to the blogosphere!

Our Mother Jones tells us the conclusion of her recent work predicament in It’s Always the Nurse’s Fault, Part II at Nurse Ratched’s Place. (For those who missed it: Part I) Alas, no Las Vegas for her. (I can’t even think of Las Vegas without that atrocious “Viva Viagra!” commercial popping into my head! Ugh!)

I don’t know about you, but nursing has done a number on my back! A long time contributor to Change of Shift, Dean Moyer of The Back Pain Blog shares information about Aquatic Therapy for Back Pain. Be sure to check out the cartoon at the end – and make sure you have swallowed all beverages before you do! : D

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Miss Elaine gets her first patient with an acetaminophen OD in Acetaminophen: Good for Headaches, Bad For Liver. Don’t forget to send congrats her way as she has passed all tests and is officially an RN! You can find her blog at Miss-Elaine-ious,RN.

Jen Carroll was voted Valedictorian of her nursing class and presents a great post on Writing a Valedictory Speech. What is amazing, is much of what she wrote can work for any speech or even writing for your blog! The speech itself gave me goosebumps and took me back to my own pinning ceremony. Well done Jen, and congratulations. Her entry can be found on mendelbrot!.

Have a patient who is going to be laid up for awhile, or ever find yourself in that position? Just thinking about puts 10 pounds on me. In Forced to Rest? Watch your Weight!, Heather Johnson goes over some tips that can help your patients avoid weight gain associated with enforced rest. She also wrote a post on Relaxation Tips for Nurses at Stuffed Nurse. I’m not sure what a “stuffed nurse” is, but it’s pretty much how I feel after a pot luck.

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Over at NurseLinkUp there is an article by Keith entitled: Measles, Mumps and Rubella, Oh My! A great overview of vaccines for healthcare workers, It hit close to home as I just had all my titers checked. I’ve had measles, mumps, rubella, varicella – it’s a wonder we nurses-of-a-certain-age made it through childhood!

Katie Bee links to a story about overworked (and penalized) social workers as she wonders Could We Switch the Word Nurse for Social Worker? posted at Young and Restless Nurse. Sounds like they need mandated ratios.

The Nurse Came With the Room is a thought provoking post by Nurse Kathy at NurseConnect wondering just who will be held responsible for preventing the hospital-acquired conditions that will no longer be covered by Medicare/Medicaid. Weigh in with your opinion in the comments section. Then check out Kathy’s take on Nurses and the Media. Have we made any progress?

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What makes a nurse a “Professional”? Nurse Laura at Nurse Connect has some ideas in Professionalism: Is it Different in Our World? Are we different? Should we be different? Join in the conversation at Laura’s blog.

With an aging population, we will be caring for larger groups of older patients. Alvaro at SharpBrains looks Computerized Cognitive Assessments: Opportunities and Concerns. You’ll be surprised at who is using computerized cognitive assessments and why!

Okay, it’s official get-out-your-kleenex time. New nurse RNTed paints a vivid picture of critical care and connecting with her patient in Interventions and Outcomes posted at Vertical & Ventilating. Beautiful post

Oh man, Beka at Medscape Nurses read my mind when she penned Are You Ready to Quit Nursing? Surveys reveal that unbelievable numbers of us are ready to at least leave our current jobs. Find out what the survey said and discuss the state of your workplace!

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And that’s it for this edition of Change of Shift! Our next edition will be on August 7th right here at Emergiblog. Be sure to check out the schedule once it is up for future editions and hosts!

Thanks for reading!

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July 22, 2008, 7:19 am

Grand Rounds, Grand Announcements!

funny pictures

The only thing missing from this picture is the coffee cup!

Our one-and-only Grunt Doc takes on hosting duties for Grand Rounds for the sixth time (and yes, the April Fool’s edition counted!).

This marks the 200th edition!

Be sure to read from the bottom up. My post is the last one in the list.

(I have no shame…)

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Change of Shift is Thursday, and right now I have a lot of submissions from….people who are not nurses!

Now, I’ve been reading and I know you all have a post you are just dying to submit, so take a moment and shoot me a link in an email! Right up top – the “Contact” button and Blog Carnival are just waiting to ferry your submission across the sea of cyberspace.

You can’t hide, I know where you blog!

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Congratulations are in order for nurse blogger colleague Keith Carlson of Digital Doorway! Keith has won the ValueCare, ValueNurses Nurse Blogger Scholarship! I’ll let Keith describe what he’ll be doing with his new award:

Basically, I was chosen as the one nurse blogger in the United States who will receive a generous stipend to blog several times each month on issues salient to healthcare reform and the current crisis in healthcare as we prepare for the presidential election. It is a very big task and I’m still preparing mentally for the challenge. I would appreciate any guidance or advice, as well as links to articles or websites that might be fodder for my writing process.

I’ve been a fan of Keith and his writing for a long time, and if anyone can make sense of our health care issues as we go into this election, he’s da man! And trust me, there is lots of fodder out here , so be sure to send Keith any information you think he can use!

As if this weren’t enough, Keith is working with a new nursing community entitled “NurseLinkUp”. I just checked it out, head on over and say hi!

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Congratulations are also due to nursing community Nurse Connect as they celebrate their first year of bringing nurses together.

I’ve had the pleasure of watching the site grow over the last 12 months and I appreciate the support they have given to Emergiblog.

Happy Birthday guys!

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You may have noticed a new addition to the Emergiblog sidebar.

I’d like to welcome Nursezone.com to Emergiblog and encourage you to check out their nursing resources.

My favorite section is the rotating articles on the main page, one of which deals with a focus how to handle hospital bullies.

Bullies? In hospitals? Aren’t we all adults?

Yes, yes and one would hope!

Read how “bullying” tactics are affecting health care.

Wait until you see who is behind the initiative to promote an emotionally healthy workplace! I may have to eat some crow…

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Original post from www.emergiblog.com.

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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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