Posts Tagged ER

The Emergency Room — high cost of care

ER signPeople go the the ER but often do not get admitted to the hospital.  Why does this happen?  Do they think the problem is an emergency or do they just not have access to other health care?  The CDC presented the following data from 2011:
ER_1 ER_2 ER_3

(note respondents could answer yes to multiple items)

The bottom line:  people who go to the ER but do not get admitted do so because they think the problem is serious, but 80% also say they lack access to other providers.

Social factors often force the ER visit:

  • No primary care provider has been established
  • Primary care does not have enough walk-in capacity
  • In rural communities once the few primary care offices close there is no other alternative
  • Work hours force evening or night care for family members
  • ER is closer than other options
  • ER is more willing to see someone without insurance
  • Patients seek continuity of care once they have been seen at the ER — they return.

A not uncommon scenario is when a single parent picks up a child from day care only to find they are sick but doctor’s offices are closed.  And, the parent is expected back at work early in the morning.

Possible solutions:

  • Encourage urgent care or “community ER” clinics.  In many larger cities doctors or hospitals have opened urgent care clinics — they are not intended to provide continuity of care but just service when needed.  In the UK such clinics are often staffed by nurse practitioners.
  • Assign one provider in a primary care office to walk-in duty — thus increasing the capacity for unscheduled visits and allowing the other providers uninterrupted time to see scheduled patients.
  • Locate some primary care clinics with extended hours next to the ER.  The patients can see a primary care provider at a lower cost — but if the problem really is critical the ER is next door.
  • Use the phone more.  Also, use Skype since it is encrypted and should meet HIPPA guidelines.  Cost would be lower for everyone if health care providers made better use of technology.  Accountable care organizations (with less fee for service incentive) should find the lower cost aspect very attractive.
  • Provide more mobile care.  Some enterprising ambulance services provide service on location and don’t actually transport the patient to the ER.  Unfortunately, the overhead cost is rather high — but the same can be said for the ER in general.  It’s like the guy who comes to your driveway to replace a car windshield.  Instead, you might get a laceration sutured in your kitchen!  Or your child with a sore throat could be checked with a strep-screen.

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Critical Communication — SBAR

submarineThe U.S. Navy Submarine Service is attributed with the development of a communication technique for critical situations.  The technique is to standardize a message from one person to another in the order of Situation, Background, Assessment and Recommendation.  For example in a submarine:

  • Situation:  Captain this is #1, we are having difficulty maintaining our speed
  • Background:  We are near a fishing fleet
  • Assessment:  I think we may be entangled in a fishing net
  • Recommendation:  I recommend we surface and cut away the netting

The captain says “make it so” or perhaps he says “no, all stop, send out divers”

 

About 15 years ago the method came to the attention of patient safety experts.  It had several great features:  1) The person on the front line (like an ER doctor or nurse) could make a report quickly  2) the method was easy to learn and was consistent even when emotions were running high  3) It leveled the hierarchy so the person on the front line made a recommendation with situational awareness that the person receiving the message might not have.  In a medical situation SBAR might sound like:

  • Situation:  Doctor this is the ICU nurse, your patient John Doe has become comatose and is breathing very slowly.
  • Background:  He has lung disease and was just admitted 2 hours ago
  • Assessment:  I think he is in respiratory failure
  • Recommendation:  I recommend we intubate as soon as possible.

The critical care doctor says: “Get me a scope and a tube, I will be right there”

 

Those health care professionals who embraced the method found it very helpful and it is still being used at many institutions.  But, the idea has not had universal success for reasons that were not clear at the outset:

  1. Fear.  Recommendations might be rejected.
  2. License:  Some felt their license did not allow an assessment which was the equivalent of a diagnosis.
  3. Semantics:  The word assessment means physical exam to nurses but it means diagnosis to physicians.
  4. Litigation risk:  Some felt if a recommendation was followed and later proved to be an error they would be blamed and possibly sued.

 

Improved communication in critical health care situations is very important to the patient in distress, in fact, poor communication is responsible for many in-hospital errors.  The SBAR technique is more difficult than one might think.  And, implementing it requires more than just saying “wow, this is great, do it”.  Techniques for implementation include some of the following:

  1. Audio or video recordings of the technique in use
  2. Practice sessions including both doctors and nurses.
  3. Role playing — the doctor giving the nurse a report and visa versa.
  4. Explanation of why the technique works
  5. Examples of errors in communication and how patients might suffer
  6. Emphasis on teamwork and not blame.  A single negative comment by a physician or supervisor can take a great deal of effort to correct.
  7. Understand a critical assessment is not a final diagnosis but just a step in the right direction.  The assessment is made at the training level of the person stating it.  Some might say “breathing difficulty” some might say “respiratory failure”.
  8. Continued education and reinforcement.  All new members of a medical team need to be instructed.  This is an ongoing process.

 

Good communication improves patient safety especially when quick action is needed.  SBAR is a framework for communication.  Other methods may do the same thing but the history and success so far suggest it has wide applicability.  Users of the technique express satisfaction (1).  Communication always involves two parties — both must be accepting and well trained to use the technique.  The World Health Organization has included SBAR in some of its publications (2) so wider use of the technique is expected.

References:

Personal experience with SBAR

(1) Beckett, C. D. and Kipnis, G. (2009), Collaborative Communication: Integrating SBAR to Improve Quality/Patient Safety Outcomes. Journal for Healthcare Quality, 31: 19–28. doi: 10.1111/j.1945-1474.2009.00043.x

http://onlinelibrary.wiley.com/doi/10.1111/j.1945-1474.2009.00043.x/abstract

(2) Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Journal on Quality and Patient Safety, 32 (3), 167–175.

http://www.ncbi.nlm.nih.gov/pubmed/16617948

(3) Anonymous (2007) Communication During Patient Hand-Overs.  WHO Collaborating Centre for Patient Safety Solutions,Patient Safety Solutions,volume 1, solution 3, May 2007

http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf

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Clinic of Last Resort — the ER

erdoorDeath can be caused by not having a car.   If a sick person does not have transportation the effects can be serious.  And, lack of insurance makes the problem worse.

A new study reported in Health Affairs  finds closure of inner-city ER facilities causes more deaths.  Poverty, advanced age, immigrant status, and lack of insurance were correlated with the increased mortality.

Poor people count on the ER as the clinic of last resort — our health system is designed that way — call an urgent care clinic and ask what services are available — “it depends on your insurance” is the answer — “you better go to the ER” is the advice if you have Medicaid or don’t have insurance.

Why wait until the last minute?  Because, there is always hope the health problem will get better, the chest pain will subside, the blood in the stool will stop or the arm weakness will vanish.  Once the heart attack hits, the bleeding is worse,  or the whole side of the body is paralyzed  the chances of death are much higher.

If you don’t have money one of the greatest concerns is NOT getting admitted — how do you get home, how do you pay for outpatient medications and how do you pay for the ambulance ride ($1000)?  The logic is simple: wait until you are REALLY sick.

The ambulance-to ER-to-operating-room is usually a very profitable supply-line of patients, so lots of resources have been lavished to make the system work.  If the ambulance-to-ER system brings diabetes, pressure ulcers and urine infections it drains a hospital’s resources, and finally leads to ER closure.

A good health system would provide transportation, guaranteed urgent care, medications and transportation home for a low-cost package price.  The unloading of the ER might actually save the ER, save patients with true emergencies, and save poor patients who get care earlier.  Wow — and what if that urgent care center was right next to the ER so if there really was an emergency it could be handled.

But no, all that would require planning and a health system where hospitalization was an overhead expense, not a profit center.  So, the only viable solution in the US:   include vouchers for ER visits with Cadillac  purchases or golf club memberships.

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Real Life ER Visit — Some Pitfalls

One winter afternoon Mr. C was at his health club  enjoying a workout on the StairMaster. Suddenly, he began to have a nosebleed.    In the past, any nosebleed would go away with some pressure but this was different, the bleeding  just would not stop.  Driving his car was out of the question.  Fortunately, another health club member offered him a ride to the ER.  On the way they passed an urgent care clinic but did not stop.  They were concerned the urgent care clinic might not be able to stop a nosebleed.   The towel he used to catch blood was getting very red and he was a little frightened by the thought of bleeding to death.

Holding his nose with the towel he checked in to the ER and was quickly taken to an ER room.  After 20 minutes a nurse evaluated him and took his blood pressure.  His nose continued to bleed and 30 minutes later a doctor arrived.  He put drops of epinephrine in the nose followed by a nasal pack.  The bleeding stopped, he was given an antibiotic  pill (ciprofloxacin), he  rested a few minutes then his wife took him home.  A few days later his wife removed the packing as directed.  Problem solved — at least the bleeding problem.

He eventually got a statement from his Medicare (MC) supplemental insurance company.  

Item Charges MC Allowed Out-of-Pocket
Facility charges $3,569.05 $310.92 $0
Procedure (30903) $681.00 $139.85 $0
epinephrine 4 drops $204.60 $0 * $204.60
ciprofloxacin 500mg $50.82 $0 * $50.82
TOTAL $4,505.47 $450.77 $255.42

* Medicare would not cover (“allow”) the medication because the medication was categorized as an outpatient charge.  What Medicare does not allow supplemental insurance will not allow either.  So, the patient has to pay.

Wholesale prices of medications are as follows:
epinephrine 1 mg/ml (0.1%) 1 ml ampule $2.55   (charged 80 x cost)
ciprofloxacin 250 mg 2 tablets $0.45                       (charged 110 x cost)

See the reference on nosebleeds (epistaxis).

Could there have been another way?  Less waiting and less cost?  Perhaps.  Consider the following alternative scenario:

A patient had a nose bleed for 5 minutes at which point he called his on-call primary care provider (PCP).  The patient was instructed to go to an urgent care center.  Waiting was minimal since bleeding is a big deal at the urgent care center (at the ER there are bigger things going on).   The treatment at the urgent care center was the same as the ER except a prescription for ciprofloxacin was given to him which he picked up at the 24 hour pharmacy ($0.50).    The charges and out of pocket expenses for the urgent care visit were as follows:

Item Charges MC Allowed Out-of-Pocket
Procedure (30901) $275 $94.32 $0
epinephrine nasal $20 (est) $0 $20.00
ciprofloxacin 500mg $0.50 $0 $0.50
TOTAL $270.50 $94.32 $20.50

It is important to note there is no “facility” charge at the urgent care.  Only hospitals can charge for use of the facility.  Ostensibly, this is to offset the costs of maintaining higher staff levels to be ready for really big emergencies.  In effect, by going to the hospital ER the patients with minor problems subsidize the patients with major problems.

The bottom line:  At your next visit with your PCP discuss how they want you to handle minor and major emergencies.  In general, if you feel you have time, call your PCP’s office (even at night because someone is on call) before going to the emergency room.  Use urgent care centers rather than the ER if possible.  Don’t accept a facility dispensed medication to take at home if there is a nearby 24 hour pharmacy.  If your PCP is aware of an urgent problem they will likely follow up when needed.

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