July, 2008 Archive

August 26, 2016, 2:45 pm

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There is an article in Slate today regarding emergency room care. Zithromax 500mg pills $114.00 “Waiting Doom: How Hospitals are Killing E.R. Zithromax 500mg pills $114.00 Patients” was written by Dr. Zithromax 500mg pills $114.00 Zachary F. Zithromax 500mg pills $114.00 Meisel and Dr. Zithromax 500mg pills $114.00 Jesse M. Zithromax 500mg pills $114.00 Pines. Zithromax 500mg pills $114.00 They are emergency department physicians in Pennsylvania. Zithromax 500mg pills $114.00 (h/t to Robyn at An Interior Life)

This post is a response to their article. Zithromax 500mg pills $114.00 Before you continue, zithromax 500mg pills $114.00 please read their article in full, zithromax 500mg pills $114.00 as I will be quoting from it and it is important that the quotes are taken in context. Zithromax 500mg pills $114.00 It is linked above.


The article begins by summarizing the case of Esmin Green, zithromax 500mg pills $114.00 the poor woman who collapsed in a psychiatric ER receiving no help for an hour. Zithromax 500mg pills $114.00 As we know, zithromax 500mg pills $114.00 by then it was too late. Zithromax 500mg pills $114.00 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”, zithromax 500mg pills $114.00 meaning, zithromax 500mg pills $114.00 if I understand it correctly, zithromax 500mg pills $114.00 the risk of pulmonary embolism would be equal. Zithromax 500mg pills $114.00 As written:

“But what’s largely missing from this story is the likely cause of Green’s pulmonary embolism. Zithromax 500mg pills $114.00 The answer lies in a far more systematic and widespread danger in hospital care: E.R. Zithromax 500mg pills $114.00 waits. Zithromax 500mg pills $114.00 Why was Green sitting and waiting while blood pooled in her legs?”

I am confused. Zithromax 500mg pills $114.00 Did she sit the entire 24 hours? Did she not get up and walk to, zithromax 500mg pills $114.00 say, zithromax 500mg pills $114.00 the bathroom, zithromax 500mg pills $114.00 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. Zithromax 500mg pills $114.00 The fact that no one came to her assistance is nauseatingly horrific. Zithromax 500mg pills $114.00 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, zithromax 500mg pills $114.00 her hospital room/day room?) is ingenious.


I am aware that my impression of emergency care comes from my working in smaller community EDs. Zithromax 500mg pills $114.00 I’ve never worked in an inner-city ED, zithromax 500mg pills $114.00 so my perceptions may be skewed. Zithromax 500mg pills $114.00 But my jaw dropped when I read this: “…hospitals have incentives to keep their E.R. Zithromax 500mg pills $114.00 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. Zithromax 500mg pills $114.00 I have no issues with this, zithromax 500mg pills $114.00 in fact I agree with them.

Let’s get back to those hospital “incentives” regarding ER boarding. Zithromax 500mg pills $114.00 The authors state:

What hospital would promote such a practice? Potentially, zithromax 500mg pills $114.00 those that profit more from boarding, zithromax 500mg pills $114.00 particularly in poorer communities with high numbers of uninsured and Medicaid patients.

The authors believe that because the ER patients are likely poorer, zithromax 500mg pills $114.00 the hospital leaves beds open for direct admits and transfers instead, zithromax 500mg pills $114.00 as this patient population is more likely to be insured. Zithromax 500mg pills $114.00 Ergo:

Do the math: If you fill your hospital with the direct and transfer admissions and maroon the E.R. Zithromax 500mg pills $114.00 patients for long periods, zithromax 500mg pills $114.00 you make more money….In effect, zithromax 500mg pills $114.00 then, zithromax 500mg pills $114.00 E.R. Zithromax 500mg pills $114.00 boarding allows hospitals to insulate themselves from the burgeoning needs of the poor.

Or, zithromax 500mg pills $114.00 if they keep the ER full, zithromax 500mg pills $114.00 then the average non-emergent patient will get up and leave, zithromax 500mg pills $114.00 saving the hospital money. Zithromax 500mg pills $114.00 This has not been my experience.


Rich, zithromax 500mg pills $114.00 poor, zithromax 500mg pills $114.00 old, zithromax 500mg pills $114.00 young, zithromax 500mg pills $114.00 drug-seeker, zithromax 500mg pills $114.00 homeless, zithromax 500mg pills $114.00 insured or not (and we see everything, zithromax 500mg pills $114.00 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, zithromax 500mg pills $114.00 it’s a sign (usually) that something went wrong. Zithromax 500mg pills $114.00 In fact, zithromax 500mg pills $114.00 they are constantly working to lower our door-to-disposition time and still maintain a high standard of care.


In all fairness, zithromax 500mg pills $114.00 the authors point out other reasons a hospital will keep patients in the ER. Zithromax 500mg pills $114.00 Noting there are often strict nurse/patient ratios for the floors:

Sometimes the nursing ratio in the E.R. Zithromax 500mg pills $114.00 can be as high as 8-to-1. Zithromax 500mg pills $114.00 That’s unacceptable in inpatient units, zithromax 500mg pills $114.00 but just stack ’em in the E.R. Zithromax 500mg pills $114.00 hallways and suddenly it’s OK.

I have experienced this, zithromax 500mg pills $114.00 and usually it’s because there are not enough nurses on the floors to take the new patients. Zithromax 500mg pills $114.00 Or the nurse upstairs is overwhelmed and needs more time, zithromax 500mg pills $114.00 thinking the next shift is better equipped to admit the patient:

So you tell the E.R. Zithromax 500mg pills $114.00 nurse that the bed isn’t ready yet. Zithromax 500mg pills $114.00 This practice of “bed-hiding” is more common than you think.

Having not worked the floors in 17 years, zithromax 500mg pills $114.00 it’s hard to address this. Zithromax 500mg pills $114.00 Sometimes, zithromax 500mg pills $114.00 knowing a patient is going to be admitted, zithromax 500mg pills $114.00 the hospital will staff UP for the next shift and the patient is held until then. Zithromax 500mg pills $114.00 Even so, zithromax 500mg pills $114.00 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, zithromax 500mg pills $114.00 hoping they will leave, zithromax 500mg pills $114.00 or are actually “cherry picking” who gets a regular bed and who stays in the ER, zithromax 500mg pills $114.00 or that it’s a conscious decision to deny care to the poor.

On the other hand, zithromax 500mg pills $114.00 long ER waits are a fact and there are ways to increase the turn-over in emergency departments, zithromax 500mg pills $114.00 so that patients can be seen in a timely manner. Zithromax 500mg pills $114.00 It’s good for everyone, zithromax 500mg pills $114.00 patients, zithromax 500mg pills $114.00 doctors and nurses.

There is nothing wrong with making the case for decreasing ER wait times. Zithromax 500mg pills $114.00 While I find their conclusions regarding the intentions of hospitals dubious, zithromax 500mg pills $114.00 I agree that decreasing wait times makes for better care.

But, zithromax 500mg pills $114.00 blaming the death of Ms. Zithromax 500mg pills $114.00 Green, zithromax 500mg pills $114.00 an ambulatory patient who had already been evaluated for admission, zithromax 500mg pills $114.00 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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August 26, 2016, 8:31 pm

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Thanks for reading!

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August 26, 2016, 7:19 am

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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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