A little Rant on needless ER visits

OK, I’ve been trying to be really positive today, but I wanted to share 3 cases that didn’t need to come to the ER today.

1)  12 year old with a sore throat.  The school nurse said, “Go to the Emergency Room”

2)  An 80ish year old lady who was IN her doctor’s office, had a Normal EKG taken, lab panels drawn, outpatient scripts written for a heart monitor and some vascular studies. She passed out when her blood was drawn.  So the doctors office sent her to the ER.  Umm…so you’ve already got her EKG, her labs, she’s scheduled for some great outpatient tests, and then she had a vagal reaction IN your office WHILE DRAWING BLOOD.  Umm…what do you want me to do exactly?

For the record, I had to draw more blood since I had no access to the PCP offices bloodwork…and she passed out again.  When she woke up I sent her home.   I did nothing for her except give her a “check up”.  Isn’t the doctors office for “check ups”?

A 60ish year old guy with DVTs (blood clots in his legs) on Coumadin, a blood thinner.  The coumadin was not therapeutic.  So his PCP sent him to the Emergency Room to get a shot of Lovenox and some prescriptions for lovenox.  Sigh.  The PCP can WRITE her own prescriptions for the Lovenox and send a home health nurse to the house to help teach him to administer them.

For anyone who doesn’t understand why the above scenarios are needless ER visits… the Emergency room includes ALL of the following, none of them are optional:

1)  Registration for demographic & insurance information & creating a  permanent written record of the patient’s care

2)  Evaluation by a triage nurse, including initial vital signs and coordinating getting the patient to the right part of the ER as timely as possible

3)  An evaluation by the patient’s assigned nurse

4)  A physician’s evaluation.

Between numbers 2, 3 & 4, we are required by federal mandate to ascertain that no emergency medical condition exists.  This means that every single patient who shows up at the ER is seen by at least 2 practitioners (nurse and physician).  If a patient is on the hospital premises and requests an evalation, I am personally responsible for that patient, even if I never actually see him for whatever odd reasons.

Add to the above any medically recommended blood tests, imaging & other testing to help diagnose the said emergency medical condition, and then obviously to treat any conditions that exist.

So in the case of a patient who has already been seen & examined by his physician and needs only a prescription for Lovenox, the ER doctor’s involvement only complicates the patient’s care, exposes the ER to further liability, is a waste of money for the patient and/or his insurance company and/or you and I in the form of increased premiums to cover this visit.

In the case of the patient who was at her physician’s office,  and had a vaso-vagal reaction to drawing blood…Well, the trip to the ER was just to appease the daughter.  It was a “really bad fainting spell” according ot the nurse practictioner who saw her in the office.  OK, when you faint, you faint.  Blood flow to the head is decreased when you have a vaso-vagal reaction, you pass out, blood flow returns ot your head and you wake up.  During this process you are goofy or unconscious.  Some people have “myclonic” jerks which are small muscle twitches like the ones you have as you are about to fall asleep at night.  A vaso-vagal fainting episode is not a siezure, and any practictioner who has ever seen either knows the difference.

Since the patient arrived in my ER, I was obligated to ensure that no emergency medical condition existed, for example, a severe anemia that would limit the patient’s abilty to respond to a vaso-vagal reaction … all of this had been checked at the PCP’s office, but I had no access to teh data so it all had to be performed again, resulting in a 2nd identical episode.

What really aggrevated me is that after this entire episode, the patient tells me, “Oh, I always faint when my blood is drawn.”

Wouldn’t it have been funny if we needed to admit the patient and watched her faint every morning at 6AM when labs were drawn?

And the 12 year old?  Well if a school nurse can’t tell the difference between a student that needs to go to teh ER and a student that just needs to stay home from school for a day…she might need to take a little nursing refresher.

OK, rant over, only positive stuff for awhile.

  8 comments for “A little Rant on needless ER visits

  1. October 13, 2007 at 4:41 pm

    I can definitely sympathize with your annoyance. Being at a teaching hospital, we have an even longer process to clear such minor cases including: 4a) Evaluation by a med student or intern. 4b) Evaluation by a senior resident. 4c) Evaluation by an attending physician. Things like the above can easily clog a bed for 2-4 hours, particularly if something more acute comes in.

    The other day, I had a worker from an auto factory come in by EMS on high-flow oxygen. She was sent in by an “occupational” nurse at her workplace for a blood pressure of 145/90– and was entirely asymptomatic. I think my attending’s BP was well over that from just hearing about it.

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  3. white cap nurse
    October 14, 2007 at 4:24 am

    We had a patient come to the ER last week to have her routine INR drawn despite having had her other labs drawn already that day. She decided the INR should be drawn at the ER and whoever was drawing the blood thought that was OK! (It was at a therapeutic level.)

  4. October 14, 2007 at 11:01 pm

    Fair, logical, reasonable thoughts on a really frustrating topic. Great post!

  5. Jared
    October 15, 2007 at 6:16 pm

    There are projects with groups like firefighters and police officers for “how to stay out of X-group’s way”.

    Why has no one developed one for ER’s?

  6. October 15, 2007 at 7:42 pm

    This is a familiar topic for our audience of healthcare executives — reducing non-emergent use of the ER. Change will be slow, but as more health plans and hospitals put caseworkers in the ER to educate patients about proper ER use, raise co-pays for ER visits and enforce the idea of medical homes for all, some potential patients may just decide to stay home.

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