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Patients Use Express Lane to Access Emergency Department Care.

Posted Dec 23 2008 9:14pm
E mergency departments (EDs) are busy places these days and with the winter cold and flu season fast approaching the work load is likely to pick up. Despite that the kids are back in school and colleges are in session, and people are back from their annual trek to what ever vacation spot they went to this summer, EDs are still seeing large volumes of patients. There are still waiting rooms filled with any number of patients with minor injuries, kids with broken bones from sports, and the usual ills that seem to target the elderly all year long without any sort of abatement.

Patient's tolerances for waiting to be seen by an emergency department physician have also not changed, and in all honesty will never change. In fact as time goes on patients with non-emergent medical problems will likely not tolerate waiting times of any sort as our society becomes used to having things done in the now time frame.

Savvy patients that use local emergency departments for their primary care have learned however to bypass the normal triage and registration processes when they seek care. Waiting in line is not an option for these folks. Instead, many times these patients will come to the ED by using the local 911 rescue service that are typically provided at the behest of the local fire department. While many emergency medical services (EMS) cost several hundreds of dollars plus mileage, there seems to be little concern for spending or should I say squandering precious healthcare dollars on an ambulance ride for a laceration (cut) on one's leg or hand. The goal here is to get into the ED by way of EMS and bypass the waiting room for many patients.

Several times I have heard patients who are in the ED waiting areas say: "I should have taken an ambulance here." "I would have gotten in sooner." Despite healthcare's best efforts it would seem that most people do not understand that emergency medicine is not about who came first. It is about acuity. How sick or injured are you? The closer you are to dying, the sooner you get seen. Perhaps a blunt measure, but it makes the point.

Other than the added cost of a $500 taxi ride in the back of an ambulance for minor injuries and illness where patients could have used alternate transportation to get to the hospital, there are several other issues here. Inappropriate use of EMS ties these very finite resources up when they could be available for other more appropriate reasons. In some cases municipal EMS vehicles will not be available due to high demand volumes for minor medical problems and someone who is suffering a cardiac arrest will have to wait until another ambulance becomes available, or one is dispatched from a neighboring town using a program called mutual aid. In both instances there are delayed response times. Seconds and minutes count when a life hangs in the balance.

Secondly when patients use EMS services for minor problems it only compounds the already problematic issue of emergency department crowding. To help solve some of this, ED managers and nursing staff will send patients who are not seriously ill that present to the ED by ambulance out to triage to be processed as if they came in through the ED front door. On several occasions I have seen this and done this myself and many patients become indignant when they find out they are not going to an ED bed right away. Again it is about acuity.

Furthermore, there is an increased risk of injury for EMS workers and the general public when ambulances are responding to a 911 call. When these resources are used inappropriately again, the cost can be very high. While many of these people [EMS workers] have advanced driving skills, bad things still happen when other motorists are not paying attention.

Patients that are entangled with local law enforcement and those patients that are requesting detox from addiction have also learned to say the magic words that put them close to if not at the head of the line in the ED, or get them out of a holding cell for a while. "I am having chest pain." "It is going to my arm." "I am a little short of breath."

Once again the ED is misused by the more savvy and less savory patients causing back ups, longer waiting times, and adding unnecessary cost, and misusing EMS services. In time my hope would be that EDs will be able to turn away patients that misuse services or at least if that scenario carries too much liability for risk managers to sleep at night than some sort of financial penalty could be levied against them.
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