Kevin, M.D. - Medical Weblog

Several hours only???

At my community hospital is southern CA 24 hours of boarding is fairly routine, 2 days is not uncommon, and my record for a psychiatric patient is 5 days.. Can't wait for Avian flu.
 

AT the community hospital I work at the "Boarder" problem is so bad that last year a psych patient (uninsured of course) stayed in the ER for 10 Days. Somehow a bright nurse figured him out; Turned out he was using a fake name, and was hiding in our ER because the police were looking for him, he was a child rapist.
 

The boarding problem is so bad that if you can manage to walk and talk then don't even think you are sick enough to be admitted.
 

Definately we have more people admitted than we have beds to put them in.

Question: Why it is any worse for the patient to be in the ER than a medical or surgical bed upstairs? The ER is a great place to be if you have an emergency!
 

"Question: Why it is any worse for the patient to be in the ER than a medical or surgical bed upstairs? The ER is a great place to be if you have an emergency!"

The answer is obvious if you ever bother to walk around the hospital beyond the little box you work in called the ER. Because there are NO BEDS period. Maybe you should take a long look at WHO you are admitting and see if they truly need to be inpatient. I regularly deal with ER doc's CYA (ie "bronchitis" and "COPD" admits with normal room air sats and no resp distress but the ER doc is just "not comfortable" sending them home and much much more). I don't argue about it but I have very little tolerence for the ER complaints after successive days of CYA admits that leave the hospital overburdened and pt's sitting in the ER beds for 24-48 hours at a time. Personally I would rather have a med-surg or ICU nurse taking care of these patients than an ER nurse who has no clue as to patient management. But hey that's life, deal with it.
 

anon 1127

Yeah, Yeah, Yeah. I hear the whine all the time from the inpatient docs of how we do too many unneccessary admisions. All the time these "unneccessary admisions" end up staying in the hospital for weeks at a time, end up with CABG's, etc. Somehow those problems would not have had to be dealt with if they were just magically "sent home from the ER" If the patient has proved that he is doing fine then all you have to do is DISCHARGE THE PATIENT when you see them. But in real life I see that your balls are no bigger than mine and your insurance is no better than mine.

I do agree with you that the patient should go upstairs and be cared for on the floor and in the unit. There is nothing special about ER hallways. Hallways upstairs could work just as well.
 

I read on EMED-L about a hospital where the head of medicine was complaining at a medical staff meeting about the number of unnecessary CYA admissions from the ER. The medical director of the ER returned a month later with the information that not a single patient admitted from the ER was discharged within 6 hours of admission. He asked the head of medicine why his docs had not immediately discharged all of the unnecessary admissions. No further complaints about this.

At every hospital where I have worked as an ER doc the situation has been the same. The ER doc doesn't admit any patients. All patients are admitted by attending physicians. If they feel the admission is not warranted, all they have to do is send the patient home from the ER. I can count on one hand the number of times this has been done by anyone other than the hospitalist and I cannot think of a single time it has been done between 12 and 6 am.

Those who don't work in the ER don't appreciate that fact that an ER doc only gets one shot to get it right. There is no "call me tomorrow" option. Many of the patients that a PMD might send home from the office would get admitted from the ER because of the uncertainty of follow-up.

I especially agree with the comment that the hallways upstairs are just as good as the hallways in the ER.

Yesterday I started a shift in the ER at 1200. We had three patients come in to the ER as direct admits, not because the hospital had no beds, but because the administration wanted to keep a ward closed.
 

Here is a circular argument I play with the pediatricians all the time at our hospital since it does not have a pediatric ICU.

I get a kid who needs to be admitted, but stable for a ward. The Pediatrician over the phone somehow can tell that the child does not need to be admitted. When I will not comply, the same kid suddenly (again over the phone) is so sick that I should transfer them to a hospital with a PICU. When I refuse, the kid is suddenly again ok for me to send home. Huh??? In many cases I have learned that specialist consultant is someone who has learned how to give bad advice over the phone with confidence.
 

I am frank with the admitting doctor. "This is a CYA admission, discharge them anytime you like". They may moan and groan but the admitting doctor ALWAYS admits. Over the years I have seen a few with balls lose their balls making a poor judgement making the rash discharge. In the current culture there is no personal award financially, professionally, or legally to try and save the system any money.