That Waits That Matter

[MachineGhost]

Those of us who have dedicated our careers to health care must confront the fact that our inability (or, more likely, unwillingness) to reduce the waits and delays that bedevil emergency care is harming and even killing our patients. The Shakespearean warning “Defer no time, delays have dangerous ends”? is an apt precept for the treatment of emergency and urgent conditions which has been underemphasized of late. We fill our hospitals with patients recovering from elective surgery and then run out of hospital beds for the patients in the ED. In other countries, hospitals first take care of all the patients who are in the ED or are waiting as inpatients and then allow the operating room to proceed with elective surgery if beds are still available. A solution to ED boarding may thus be to invert the current paradigm of incentives and reimbursement and reprioritize our scarce health care resources and hospital beds for patients with emergency or urgent conditions, whose immediate medical needs exceed those of patients undergoing elective procedures. But this is not a problem that ED physicians, surgeons, and nurses can solve alone. It is a responsibility we must share with others throughout the hospital and, ultimately, the entire health care system.

http://tinyurl.com/ct3224l

[WiseOne]

This is more than a bit oversimplified, and also leaves the impression that ED doctors and nurses are responsible.  Let me enlighten you all:  medical staff have ZERO control over what goes on in a hospital.  It's hospital administrators that are in charge.  The reasons that patients often wait hours in the ED are due to many problems, not just lack of beds, that all come down to a single cause:  administrators are cutting services dangerously close to the bone to save money. 

First off, in the US in general ERs are overused because patients can't figure out any other way to be seen for urgent problems.  The urgent care clinics that are popping up everywhere, especially in pharmacies, are a great solution if that trend continues.

Getting an ER patient up to a floor bed requires a long chain of events.  First, there has to be an evaluation by an ER physician, who is typically spread too thin because the hospitals are all trying to short staff.  (My sister is an ER doc at a small-ish academic center.  They are short 5 MD positions by her count, and the hospital refuses to hire more.)  Then, if the patient is to be admitted there needs to be a second evaluation by the admitting MD.  Both of these then have extensive electronic documentation requirements that have to be completed before the patient can be moved - and that's enforced by computer fiat.  These requirements, of course, are continually increasing, so expect this to get worse. Meanwhile, any studies that need to be done quickly have to be ordered and completed from the ER, because as soon as the patient is admitted to a floor bed, they go to the back of the line.  Finally, transport has to come and physically move the patient.  At our big NYC teaching hospital, that takes hours because the hospital is understaffed here as well.  Often, transport doesn't happen unless the residents do it, which they often can't because they're also admitting 12 patients and answering numerous pages.  Typically, the whole process takes at least 6 hours after a floor bed has been assigned.

Have I scared all of you away from ERs? 

[MachineGhost]

Have I scared all of you away from ERs?   :(

Is it your opinion this whole mess is because theres too little free enterprise in holding administration accountable to the paying end consumer, or too much political interference and centralization ala the former Sovet Union?  It seems whenever an administration is accused of doing things to save money or to make a profit, it harkens to the former, yet the logistics and sheer incompetence of outcomes surely reeks of the latter.

[Pointedstick]

Have I scared all of you away from ERs?   :(

Is it your opinion this whole mess is because theres too little free enterprise in holding administration accountable to the paying end consumer, or too much political interference and centralization ala the former Sovet Union?  It seems whenever an administration is accused of doing things to save money or to make a profit, it harkens to the former, yet the logistics and sheer incompetence of outcomes surely reeks of the latter.

This guy seems to think it's a combination of too much command-and-control, and the nonsensical, historically accidental rise of insurance for non-insurable costs: http://truecostofhealthcare.org

[Ad Orientem]

Those of us who have dedicated our careers to health care must confront the fact that our inability (or, more likely, unwillingness) to reduce the waits and delays that bedevil emergency care is harming and even killing our patients. The Shakespearean warning “Defer no time, delays have dangerous ends”? is an apt precept for the treatment of emergency and urgent conditions which has been underemphasized of late. We fill our hospitals with patients recovering from elective surgery and then run out of hospital beds for the patients in the ED. In other countries, hospitals first take care of all the patients who are in the ED or are waiting as inpatients and then allow the operating room to proceed with elective surgery if beds are still available. A solution to ED boarding may thus be to invert the current paradigm of incentives and reimbursement and reprioritize our scarce health care resources and hospital beds for patients with emergency or urgent conditions, whose immediate medical needs exceed those of patients undergoing elective procedures. But this is not a problem that ED physicians, surgeons, and nurses can solve alone. It is a responsibility we must share with others throughout the hospital and, ultimately, the entire health care system.

http://tinyurl.com/ct3224l

I think a major factor is the way we ration health care. Your quote notes the difference in approach with most other countries. I believe a major contributing factor to this difference is that in virtually every developed country other than the US health care is rationed on the basis of need, whereas here it is rationed primarily on the basis of ability to pay.

[Pointedstick]

I believe a major contributing factor to this difference is that in virtually every developed country other than the US health care is rationed on the basis of need, whereas here it is rationed primarily on the basis of ability to pay.

Isn't that just another way to define capitalism? In any event, my experience a few years ago being an uninsured person who needed health care and at one point visited an ER did not actually include any ability-to-pay rationing at all. The ER staff saw people roughly in the order of severity of our injuries, and only after they were done with me (fractured wrist) was payment even mentioned.

If you want to know the part that really was criminal about my experience, it's that after making me wait four hours before being seen and charging me $600 for an X-ray and an arm sling that made the pain worse, it was a $2 ACE bandage that eventually did the trick.

[WiseOne]

Have I scared all of you away from ERs? 

Is it your opinion this whole mess is because theres too little free enterprise in holding administration accountable to the paying end consumer, or too much political interference and centralization ala the former Sovet Union?  It seems whenever an administration is accused of doing things to save money or to make a profit, it harkens to the former, yet the logistics and sheer incompetence of outcomes surely reeks of the latter.

For what it's worth, my opinion that is...there are multiple reasons.

First, overuse happens because the ER visit is too inexpensive (i.e. free) if you're a Medicaid patient.  In New York state, 1/4 of the population is on Medicaid.  That's insane.  Someone who is uninsured, on the other hand, gets the jackpot when it comes time to pay the bill.  No one mentioned $$ to you, AO, because it's not possible for normal humans to figure out what each person is going to be charged.

Second, heavy handed control is increasingly becoming the order of the day. I recognize that the medical profession should have done a better job of reducing errors and improving care quality on its own, but imposing this from above is backfiring badly. Being a physician now is less of a profession and more like a factory job.  We're constantly having to choose between satisfying the increasingly onerous regulations and doing right by patients, because you can no longer do both.

Cost-cutting is necessary and if anything we need more of it, but it's being done in the most unintelligent way possible, by people who have the least knowledge of how to do it.  The end result, ironically, is INCREASED costs because no one bothered to stop and think, for example, what it would really mean to impose huge, expensive, poorly designed EHR systems on every medical enterprise in the country.  Or whether it really does save money to to try to get by with an understaffed ER.  Ask a physician how to cut costs and they'll tell you:  #1 insurance companies (>20% overhead right there), #2 most Medicare/federal regulations, and #3 futile end of life care (so ubiquitous I dubbed the medical ICU "God's waiting room").

[MachineGhost]

If you want to know the part that really was criminal about my experience, it's that after making me wait four hours before being seen and charging me $600 for an X-ray and an arm sling that made the pain worse, it was a $2 ACE bandage that eventually did the trick.

The magic words nowadays are "uninsured cash discount" which can be less than even co-pays for the insured.

Back when I was more chicken hawk naive, and had to take a trip to the ER due to cyclical vomiting which consisted of a wait of several hours to be seen, then an IV and a blood panel drawn, it cost me over $1000.  I didn't want to pay the bill.  A few years later, the hopsital went bankrupt to add insult to injury.

[MediumTex]

Here is a really dumb ER story:

Back in the spring my mother was involved in a serious car wreck while visiting my sister in another city.  She was taken to the local hospital by ambulance and diagnosed with a broken shoulder, broken finger and bruising over her whole body (she's in her 70s and those bodies seem to bruise up more than younger ones).  Although it wasn't identified at the time (but probably should have been), she also had a pretty serious concussion that I don't think she has fully recovered from yet.

The doctors at the hospital in the other city told her she could have surgery there or they could stabilize her and she could have surgery when she got home (the shoulder and finger would need to be wired and pinned back together).  Stabilizing her meant giving her strong enough pain medicine to get her through to surgery, I assume.  After receiving the pain medicine (and already having a foggy head because of the concussion) she basically did whatever they seemed to want her to do, which was leave their hospital.  She went home with my sister and my sister drove my mother back to her city and left her at a friend's house to make sure she was okay (my mother's care was totaled in the accident).  Since she was still on the pain medicine and feeling reasonably well it didn't seem like that big a deal.  My mother spent the night at her friend's house.

The next morning my mother woke up and hurt from head to toe and was very disoriented.  She took the medicine the doctors at the other hospital prescribed her, so now you've got a woman in her 70s with a concussion on narcotics with multiple broken bones who looks terrible because she got an air bag in the face the day before and who is disoriented and confused.  Her friend realized that this woman needed to be in the hospital so she called an ambulance.

The ambulance took her to the ER and after waiting for hours the doctors confirmed that she had a broken shoulder, a broken finger, bruises all over her body (but no mention of the concussion or pain management, which was by now becoming almost unbearable).  The concussion-related confusion and disorientation must have made it hard to sort through anything she was being told but at some point they told her she was going to have to leave and there was nothing they could do for her.  As they were wheeling her out to leave her on the sidewalk (they told her she needed to arrange a ride for herself, even though she wasn't thinking clearly at all), she began to cry and ask them why no one would help her since she was in excruciating pain by now and had multiple broken bones (and still no one seemed to have realized she had a severe concussion even though her thinking was obviously way out of whack).  The doctor told her that there was nothing else he could do for her and that she needed to take care of things on her own (i.e., find an orthopedic surgeon to fix her broken bones, find a neurologist to treat her concussion, find herself a physical therapist to help with her recovery, etc.).

As my mother's emotional state went from pain and helplessness to anger, she told the doctor that after she did find someone to help her with her broken bones and pain she was going to have her son, who is an attorney, make the doctor and hospital wish they had treated her a little better and not left her outside the hospital in that condition.

Suddenly the doctor's whole demeanor changed.  Suddenly he was telling her that maybe it would be a better idea to admit her, and that they could get her in a very nice room and the orthopedic surgeon could see her as soon as possible and get that surgery scheduled, and they could have someone do some more tests to make sure there wasn't a more serious head injury, and they could get her on some pain meds that would help her get through until the surgery could take place....

When I got to the hospital that night she barely recognized me and couldn't get out of bed for several days (the broken shoulder and shattered finger were on opposite sides of her body so both arms were basically useless).  From my perspective, she was obviously a person who needed to be in a hospital under constant supervision, considering her overall condition and the fact that the severity of the concussion hadn't even been determined.

She wound up spending 10 days in the hospital before being discharged to go to another hospital for another 10 days to recover from the surgeries.  At some point the doctors realized that she had a severe concussion and monitored that closely.  After the attorney reference she was treated like royalty.

It was pretty bizarre and stupid.

[Liz L.]

Tex, the mistreatment of your mother was horrifying. I wish you would send that hospital a "scary" letter to shake them up. Maybe you already did.

The more I experience and learn about this country's health-care system, the more it seems that what I previously assumed was the result of stupidity is instead a function of sheer greedy evil.

[MediumTex]

Tex, the mistreatment of your mother was horrifying. I wish you would send that hospital a "scary" letter to shake them up. Maybe you already did.

I'm not sure that any letter I wrote would be strong enough to penetrate the layer of stupid that the hospital has covered itself in.

Apparently, that hospital is capable of providing excellent care to some of the people who come into their ER.  My mother apparently just wasn't initially identified as one of the people who would receive that type of care.

I'm just glad she is recovering.

[moda0306]

Tex, the mistreatment of your mother was horrifying. I wish you would send that hospital a "scary" letter to shake them up. Maybe you already did.

The more I experience and learn about this country's health-care system, the more it seems that what I previously assumed was the result of stupidity is instead a function of sheer greedy evil.

Definitely... it's not that any one member of the healthcare apparatus is evil, but there's no aparatus to guarantee continuity of care... nobody can see the forest through the trees, least of all the patient, as it's not in their motivational focus to do so.  This is why I don't see a perfectly free-market solution as any better than gov't run, because it's the disjointedness of the care in the first place that causes so many of the problems, and tell me whether MT's mother would have been a discerning, calculating consumer of healthcare during this whole tragedy.  Everyone has their job, and nobody's in charge of getting the client from point A to point Z in the best possible way... everyone's just in charge of their own individual role in the process, and communication falls apart.  I'm seeing something similar with my Dad now, and it simply wreaks of the same lack of orgazation that will come with any bureaucracy, or even worse, various different bureaucracies with different motivations and information available to them.

[MediumTex]

Tex, the mistreatment of your mother was horrifying. I wish you would send that hospital a "scary" letter to shake them up. Maybe you already did.

The more I experience and learn about this country's health-care system, the more it seems that what I previously assumed was the result of stupidity is instead a function of sheer greedy evil.

Definitely... it's not that any one member of the healthcare apparatus is evil, but there's no aparatus to guarantee continuity of care... nobody can see the forest through the trees, least of all the patient, as it's not in their motivational focus to do so.  This is why I don't see a perfectly free-market solution as any better than gov't run, because it's the disjointedness of the care in the first place that causes so many of the problems, and tell me whether MT's mother would have been a discerning, calculating consumer of healthcare during this whole tragedy.  Everyone has their job, and nobody's in charge of getting the client from point A to point Z in the best possible way... everyone's just in charge of their own individual role in the process, and communication falls apart.  I'm seeing something similar with my Dad now, and it simply wreaks of the same lack of orgazation that will come with any bureaucracy, or even worse, various different bureaucracies with different motivations and information available to them.

Absent a sophisticated and engaged family member or loved one, there is often simply no advocate for the patient.

When my dad was sick I couldn't count the number of times I felt like I was negotiating on behalf of a client to get better care from a provider who was bent on doing the absolute minimum.  Once they figured out that I was going to be with him for the duration of the disease and would fight for the best care every step of the way they started providing what seemed like a much higher level of care.  I don't know if my persistence had anything to do with it, but my dad lived twice as long as the statistics suggested he should have following his diagnosis.

One thing that sort of annoyed me during that process was other family members who felt like I should just sit down and be quiet and let the doctors do whatever they wanted to do without any of us getting involved. I hope if I am ever sick like he was I have an advocate who will engage with the doctors and challenge them to beat the odds rather than just submit to them.

My subjective opinion is that doctors as a group can be fiercely competitve people, but they are often tired, bored, or frustrated and that competitiveness can get dulled when it comes to any particular patient.  In my dad's case I repeatedly had doctors remind me that he was probably going to die no matter what we did, to which I always replied with something like "Yes, I know that.  I just want to make it as hard for death to find him as possible, and I want you to help us with that.  I want your best effort."

When it came time to let him go, I knew we had done all we could and that helped cushion the blow a lot for me.

[WiseOne]

MT, that story about your mother is completely horrifying to me, as well.  I can think of several reasons for an elderly person who was recently in an auto accident to be acutely confused, and some of them are potentially life threatening (thankfully that didn't happen in this case, I gather).  Did she get a head CT at the first hospital, at least?  That is standard procedure for any trauma of this magnitude.  And in no case should such a person be discharged.  The first discharge was inappropriate as well.  If they really wanted her treated closer to home, they should have offered an ER to hospital transfer.  What I can't understand is why that was so much of a consideration.

This is a separate issue from what I was railing about earlier, and there is no excuse for such behavior, but it is related to the change in attitudes by and toward physicians that I referred to.  If you treat a physician like a janitor, they'll start acting that way.  But, I've seen many situations like this in private/community hospitals.  Something like that happened to my own father not too long ago.  My mother brought him in for acute confusion, and the physician looked at some test results from 2 months earlier and said, "Looks good...nothing wrong!"  Didn't even examine him.  I took him to a colleague the next day who immediately arranged the standard workup.  He had an intracranial hemorrhage.  Recovering well, thank goodness.

You should definitely write a very strongly-worded letter, naming names and giving dates & details, and send to Patient Relations (may be called Patient Liaison) at both hospitals.  And let them know you're an attorney.  You do have grounds to sue if you are so inclined, but at the very least you might make it less likely for this to happen to someone else.

[MachineGhost]

You should definitely write a very strongly-worded letter, naming names and giving dates & details, and send to Patient Relations (may be called Patient Liaison) at both hospitals.  And let them know you're an attorney.  You do have grounds to sue if you are so inclined, but at the very least you might make it less likely for this to happen to someone else.

Yeah, MT.  Time to put on your Democratic Trial Laywer hat and sue the bastards!  Defeatism is the root of all evil.

[MediumTex]

You should definitely write a very strongly-worded letter, naming names and giving dates & details, and send to Patient Relations (may be called Patient Liaison) at both hospitals.  And let them know you're an attorney.  You do have grounds to sue if you are so inclined, but at the very least you might make it less likely for this to happen to someone else.

Yeah, MT.  Time to put on your Democratic Trial Laywer hat and sue the bastards!  Defeatism is the root of all evil.

Well, we are already suing the guy who hit her.  He ran a red light going about 20 mph over the speed limit in an old Trans Am and plowed into her as she crossed the intersection.

One lawsuit at a time is my motto.