ER overuse – “the crisis is near”:

The number of Central Florida hospital beds, meanwhile, has grown just 13.7 percent during that time, from 4,278 in 2000 to 4,865 last year. And even if there are empty hospital beds, there are not enough nurses and doctors to treat patients in those beds.

The issue is compounded further by the state’s medical malpractice insurance crisis, which has resulted in fewer high-risk specialty doctors such as neurosurgeons and obstetricians.

Other factors? There’s a growing number of uninsured Floridians who often go to ERs for routine health care, creating a backlog for everyone else; and the number of elderly residents — who tend to be sicker and become ill more often — also is skyrocketing. In addition, some people wind up in emergency rooms because their doctor sent them there, perhaps for a reason as simple as the fact that the doctor’s office lacks X-ray equipment.

I’d say the overuse crisis is already here. I’d also like to add defensive medicine is a leading factor.

For primary care physicians: sending people to the ER during off-hours to cover themselves from the risk of telephone medicine. It is much safer to say, “Go to the ER”, rather than risking giving medical advice over the phone.

For ER physicians: defensive admissions to cover themselves from any possible discharge complications. It is much safer to admit a chest pain, rather than risk missing an MI.

In other words, it’s all about spreading the malpractice risk around.

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  • Anonymous

    If that’s what it is all about, is it working?

  • Flea

    Anonymous,

    It’s not working. Can anyone show me data that defensive admissions are reducing liability?

    It may be a difficult study, but not one that is undoable.

    best,

    Flea

  • Anonymous

    This isn’t scientific, just common sense: If I see 1000 patients with “vague” chest pain, and I admit all 1000, even if the internist upstairs discharges all 1000 without testing (stress test, echo), and misses the One patient with true angina, I will get sued as an “accomplice” for that one patient, but charges against me will be dropped because I practiced the “standard of care” (ASA, maybe Lovenox, admission). A colleague of mine is UNBELIEVABLY CYA and conservative (he admits EVERYONE) and he has not been sued in 20 years of ER. I know “shoot from the hip” ER Docs who have been sued 5 times.

  • Flea

    Anecdotes!!!!

    These are not acceptable!!!

    Show me the data.

    BTW, how do you know your CYA friend has never been sued? That’s not the kind of thing we share in the cafeteria…

    Flea

  • Anonymous

    Dr. Flea:
    How about sharing how you propose to study “defensive” vs “appropriate” admission. IMO this may be a very subjective decision on the part of the ER doc and it may be fairly difficult to differentiate between the two. Frankly I don’t argue with the ER doc about such admissions. But on the other hand they realize that at 03:00 they will be writing the initial orders on such admissions(with my advise).

  • Anonymous

    Couldn’t you simply go back through their billings and with the patient’s chart identify which tests were, in your opinion, medically unnecessary?

  • Anonymous

    “But on the other hand they realize that at 03:00 they will be writing the initial orders on such admissions(with my advise).”

    ACEP (American College of Emergency Physicians) advises ER Docs to refuse to work at any hospital (or refuse to write) that requires “Holding orders”. If I write holding orders, I am legally responsible for the patient till he is seen by another physician. No thanks. Flea, no offense (and no disrespect) but I don’t think you have any idea just how defensive and legally oriented medicine has gotten. It’s pathetic.

  • Anonymous

    “Couldn’t you simply go back through their billings and with the patient’s chart identify which tests were, in your opinion, medically unnecessary?”

    Impossible. What standard do you use? For Example I had a 19 year old with chest pain last week who turned out to have a coronary blockage. Thus every 19 year old in the ENTIRE United States has a Cardiac cause of their chest pain,until proven otherwise, as far as the lawyers and the “standard of care” matters.

    P.S. For those who ? this, She had the occlusion proven by Angio. Her ECG only showed a Left axis Deviation. And true, no way would I have admitted her if I didn’t practice defense 24/7.

  • Anonymous

    What is malpractice?

    “Malpractice is the failure of one rendering professional services (doctors, lawyers, accountants, etc.) to exercise the level of skill commonly possessed by minimally qualified members of the profession in good standing.” (Law in a Flash, Torts, 1999, Emanuel Publishing Co.)

    So it makes sense that minimally qualified physicians, and others perhaps better qualified, SHOULD overuse the ER in order to avoid malpractice risk.

  • Anonymous

    “So it makes sense that minimally qualified physicians, and others perhaps better qualified, SHOULD overuse the ER in order to avoid malpractice risk.”

    That’s fine with me (Job Security) but don’t complain when your’e sitting out in the Waiting Room of my ER for 12 hours with belly pain because i’m seeing the 30 patients sent in from their doctor’s office. The main reason I like working nights is to avoid that crap. Everyone seems to have their “emergency” at about 4 pm on Mondays.

  • Anonymous

    Anon 6:48:
    I am well aware of the ACEP statements on the subject. However, in my hospital we admit upwards of 40 patients to the hospitalist service in a 24 hour period. To expect the hospitalist to run down for every admission (especially “social admissions”) is not reasonable. You tell me should the hospitalist stop managing a septic patient on three pressors to admit a 90 year old for pain control with a compression fracture because ACEP says so? The fact is the hospitalists/ER docs have a symbiotic relationship and there needs to be give/take on both sides or the system will collapse. Both sides have realized this in our hospital. What it means is that we talk about each patient and jointly agree which patients need to be seen and which patients can wait for a period of time with “holding orders”. Just blinding ACEP or ACP statements to please the malpractice attorneys will lead to the whole system falling apart.

  • Anonymous

    That policy will hold up till the first mistake, ie the first time an ER docs orders get carried out for 24 hours, the patient has a bad outcome, and everyone’s looking for “who’s to blame” And as far as I can tell, the entire system is falling apart because we practice at the whim of the malpractice attorney’s.

  • Anonymous

    Anon 1:20:
    I am not trying to be argumentative, but the fact is this system has been in place at our hospital for 10 years (before the term “hospitalist was coined”. The hospitalist’s understand the ER docs need to admit patients even those who would not be admitted in a european country (for CYA reasons). At the same time the ER docs realize the hospitalist’s cannot reasonably see every admission, especially the stable CYA admissions. I am sorry that the CJD’s and Elliot’s of the world have so much power in our system but we still have to do what is best for the patients….period I do agree the system will probably collapse in the next 5-10 years resulting in some sort of nationalized health care. What American’s don’t understand is that when that day happens, the days of ordering every thing under the sun and doing CABG’s on 90 year old’s will also be over. We will be in a rationed system. What the lawyer’s don’t understand is that the present adversial system of malpractice will also be over. We the doctor’s will take a pay cut but we will also work more reasonable hours (or we won’t work).

  • Anonymous

    “I am sorry that the CJD’s and Elliot’s of the world have so much power in our system but we still have to do what is best for the patients”

    The power of lawyers in medicine is vastly overstated.

    “What the lawyer’s don’t understand is that the present adversial system of malpractice will also be over.”

    Sure they do. They all know that.

    “We the doctor’s will take a pay cut but we will also work more reasonable hours (or we won’t work).”

    If physicians are like most people, they can’t afford to take a pay cut. They are living paycheck to paycheck.

  • Anonymous

    “The power of lawyers in medicine is vastly overstated.”

    The ability of lawyers to sue is what is vastly overstated. The few big lottery wins by a few lucky plaintiffs and their lucky lawyers) is what haunts every physician and causes us to nearly bankrupt the system ordering tests.

  • Anonymous

    “The few big lottery wins by a few lucky plaintiffs”

    Why don’t you go tell that to one of them. Somehow I bet that’s not your style.

  • Anonymous

    “Why don’t you go tell that to one of them. Somehow I bet that’s not your style.”

    And somehow I don’t think having a meaningful intelligent conversation on this thread is “your style”. Go take you childish flameballs to another thread.
    twit.

  • Anonymous

    I hate lawyers because they just hurt people. Doctors discharge patients who get too complicated. So guess where the patients wind up. They wind up in the ER!

  • Anonymous

    “Go take your childish flameballs. . . “

    The selectiveness of your outrage undermines its usefulness.

  • Anonymous

    Anon 9:00:
    “The selectiveness of your outrage undermines its usefulness.”

    Did you have something useful to add to this conversation? Did you give your own opinion on how to study defensive admissions and if they reduce liability? How about the role of hospitalists and ER docs with the ACEP guidlines about holding orders? Do you even know what “holding orders” are? No. Just an uninfomed comment about a system which you have little understanding. For the record anon 9:21 is right, there is little correlation with malpractice events and money collection. That is to say most victims of malpractice don’t get their “day in court” and most claims end up in favor of the doctors. In otherwords a “lottery” system which isn’t good for patients or doctors. But hey as long as the lawyers make money who cares.

  • Anonymous

    “There is no way to study it without physicians admitting, under oath, that they’ve committed insurance fraud.”

    Only a lawyer would think that up. Many R/O MI’s are on some level “defensive” admissions (depending on risk factor’s, presentation, lab’s, close followup or lack thereof, etc). Are you now saying we are all committing “insurance fraud”? I actually do agree with Dr. Flea that this would be a difficult (and probably on some level subjective) study which would not be undoable. I guarantee one thing, no doc will touch out when people are throwing around the word “insurance fraud”.

    “A lottery is where you get something for minimal risk or loss. A windfall”

    The definition of lottery (from the dictionary):

    1: A contest in which tokens are distributed or sold, the winning token or tokens being secretly predetermined or ultimately selected in a random drawing.
    2: A selection made by lot from a number of applicants or competitors: The state uses a lottery to assign spaces in the campground.
    3: An activity or event regarded as having an outcome depending on fate: They considered combat duty a lottery

    I will remember to tell my Uncle who “won” the lottery in the 1960′s what a lucky dog he was. His “prize” two years in the US Army, one of those year’s in Vietnam. I will remember to tell him his Purple Heart was a “windfall”.

    I do agree with you on the last paragraph though.

  • Anonymous

    “Are you now saying we are all committing “insurance fraud”? “

    Only if you’re ordering medically unnecessary tests. I’m guessing that the patient’s health insurer would say the same.

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