July, 2008 Archive

July 23, 2016, 2:45 pm

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There is an article in Slate today regarding emergency room care. Lasix 100mg pills $294.00 “Waiting Doom: How Hospitals are Killing E.R. Lasix 100mg pills $294.00 Patients” was written by Dr. Lasix 100mg pills $294.00 Zachary F. Lasix 100mg pills $294.00 Meisel and Dr. Lasix 100mg pills $294.00 Jesse M. Lasix 100mg pills $294.00 Pines. Lasix 100mg pills $294.00 They are emergency department physicians in Pennsylvania. Lasix 100mg pills $294.00 (h/t to Robyn at An Interior Life)

This post is a response to their article. Lasix 100mg pills $294.00 Before you continue, lasix 100mg pills $294.00 please read their article in full, lasix 100mg pills $294.00 as I will be quoting from it and it is important that the quotes are taken in context. Lasix 100mg pills $294.00 It is linked above.


The article begins by summarizing the case of Esmin Green, lasix 100mg pills $294.00 the poor woman who collapsed in a psychiatric ER receiving no help for an hour. Lasix 100mg pills $294.00 As we know, lasix 100mg pills $294.00 by then it was too late. Lasix 100mg pills $294.00 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”, lasix 100mg pills $294.00 meaning, lasix 100mg pills $294.00 if I understand it correctly, lasix 100mg pills $294.00 the risk of pulmonary embolism would be equal. Lasix 100mg pills $294.00 As written:

“But what’s largely missing from this story is the likely cause of Green’s pulmonary embolism. Lasix 100mg pills $294.00 The answer lies in a far more systematic and widespread danger in hospital care: E.R. Lasix 100mg pills $294.00 waits. Lasix 100mg pills $294.00 Why was Green sitting and waiting while blood pooled in her legs?”

I am confused. Lasix 100mg pills $294.00 Did she sit the entire 24 hours? Did she not get up and walk to, lasix 100mg pills $294.00 say, lasix 100mg pills $294.00 the bathroom, lasix 100mg pills $294.00 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. Lasix 100mg pills $294.00 The fact that no one came to her assistance is nauseatingly horrific. Lasix 100mg pills $294.00 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, lasix 100mg pills $294.00 her hospital room/day room?) is ingenious.


I am aware that my impression of emergency care comes from my working in smaller community EDs. Lasix 100mg pills $294.00 I’ve never worked in an inner-city ED, lasix 100mg pills $294.00 so my perceptions may be skewed. Lasix 100mg pills $294.00 But my jaw dropped when I read this: “…hospitals have incentives to keep their E.R. Lasix 100mg pills $294.00 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. Lasix 100mg pills $294.00 I have no issues with this, lasix 100mg pills $294.00 in fact I agree with them.

Let’s get back to those hospital “incentives” regarding ER boarding. Lasix 100mg pills $294.00 The authors state:

What hospital would promote such a practice? Potentially, lasix 100mg pills $294.00 those that profit more from boarding, lasix 100mg pills $294.00 particularly in poorer communities with high numbers of uninsured and Medicaid patients.

The authors believe that because the ER patients are likely poorer, lasix 100mg pills $294.00 the hospital leaves beds open for direct admits and transfers instead, lasix 100mg pills $294.00 as this patient population is more likely to be insured. Lasix 100mg pills $294.00 Ergo:

Do the math: If you fill your hospital with the direct and transfer admissions and maroon the E.R. Lasix 100mg pills $294.00 patients for long periods, lasix 100mg pills $294.00 you make more money….In effect, lasix 100mg pills $294.00 then, lasix 100mg pills $294.00 E.R. Lasix 100mg pills $294.00 boarding allows hospitals to insulate themselves from the burgeoning needs of the poor.

Or, lasix 100mg pills $294.00 if they keep the ER full, lasix 100mg pills $294.00 then the average non-emergent patient will get up and leave, lasix 100mg pills $294.00 saving the hospital money. Lasix 100mg pills $294.00 This has not been my experience.


Rich, lasix 100mg pills $294.00 poor, lasix 100mg pills $294.00 old, lasix 100mg pills $294.00 young, lasix 100mg pills $294.00 drug-seeker, lasix 100mg pills $294.00 homeless, lasix 100mg pills $294.00 insured or not (and we see everything, lasix 100mg pills $294.00 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, lasix 100mg pills $294.00 it’s a sign (usually) that something went wrong. Lasix 100mg pills $294.00 In fact, lasix 100mg pills $294.00 they are constantly working to lower our door-to-disposition time and still maintain a high standard of care.


In all fairness, lasix 100mg pills $294.00 the authors point out other reasons a hospital will keep patients in the ER. Lasix 100mg pills $294.00 Noting there are often strict nurse/patient ratios for the floors:

Sometimes the nursing ratio in the E.R. Lasix 100mg pills $294.00 can be as high as 8-to-1. Lasix 100mg pills $294.00 That’s unacceptable in inpatient units, lasix 100mg pills $294.00 but just stack ’em in the E.R. Lasix 100mg pills $294.00 hallways and suddenly it’s OK.

I have experienced this, lasix 100mg pills $294.00 and usually it’s because there are not enough nurses on the floors to take the new patients. Lasix 100mg pills $294.00 Or the nurse upstairs is overwhelmed and needs more time, lasix 100mg pills $294.00 thinking the next shift is better equipped to admit the patient:

So you tell the E.R. Lasix 100mg pills $294.00 nurse that the bed isn’t ready yet. Lasix 100mg pills $294.00 This practice of “bed-hiding” is more common than you think.

Having not worked the floors in 17 years, lasix 100mg pills $294.00 it’s hard to address this. Lasix 100mg pills $294.00 Sometimes, lasix 100mg pills $294.00 knowing a patient is going to be admitted, lasix 100mg pills $294.00 the hospital will staff UP for the next shift and the patient is held until then. Lasix 100mg pills $294.00 Even so, lasix 100mg pills $294.00 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, lasix 100mg pills $294.00 hoping they will leave, lasix 100mg pills $294.00 or are actually “cherry picking” who gets a regular bed and who stays in the ER, lasix 100mg pills $294.00 or that it’s a conscious decision to deny care to the poor.

On the other hand, lasix 100mg pills $294.00 long ER waits are a fact and there are ways to increase the turn-over in emergency departments, lasix 100mg pills $294.00 so that patients can be seen in a timely manner. Lasix 100mg pills $294.00 It’s good for everyone, lasix 100mg pills $294.00 patients, lasix 100mg pills $294.00 doctors and nurses.

There is nothing wrong with making the case for decreasing ER wait times. Lasix 100mg pills $294.00 While I find their conclusions regarding the intentions of hospitals dubious, lasix 100mg pills $294.00 I agree that decreasing wait times makes for better care.

But, lasix 100mg pills $294.00 blaming the death of Ms. Lasix 100mg pills $294.00 Green, lasix 100mg pills $294.00 an ambulatory patient who had already been evaluated for admission, lasix 100mg pills $294.00 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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July 23, 2016, 8:31 pm

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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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