Waiting room documentation

[CoolDoc1729]

Curious how others document the patients you are assessing in the waiting room ? At my main place we have done about 80% initial work ups in the waiting room for more than a year.

We are being asked to see them, dictate a full level 5 H&P and MDM, and order appropriate workup.

Depending on the day, sometimes the patients get labs and X-rays done , usually no meds are given, or only PO/non controls, sometimes they get no meds no labs.

At first we were instructed not to order any medications/interventions but we all did anyway so they stopped asking us not to.

Most of us have been putting a disclaimer in our mdm that details the waiting room care system, but now hospital is asking us not to do this, “no one else is doing this “ …?

Thoughts?

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[thegenius]

Why are you putting it in your note?

To indicate to the future jury you are speaking to that you have suboptimal working conditions and have to see people in the waiting room? And to hopefully get some special dispensation because of that?

 

[emergentmd]

Curious how others document the patients you are assessing in the waiting room ? At my main place we have done about 80% initial work ups in the waiting room for more than a year.

We are being asked to see them, dictate a full level 5 H&P and MDM, and order appropriate workup.

Depending on the day, sometimes the patients get labs and X-rays done , usually no meds are given, or only PO/non controls, sometimes they get no meds no labs.

At first we were instructed not to order any medications/interventions but we all did anyway so they stopped asking us not to.

Most of us have been putting a disclaimer in our mdm that details the waiting room care system, but now hospital is asking us not to do this, “no one else is doing this “ …?

Thoughts?

They can hire an APP to do this and watch over them. I for sure would not be seeing pts in the waiting room less ordering stuff/doing a chart.

There are so many pitfalls including wasting my time yelling into the crowded waiting room constantly.

 

[CoolDoc1729]

Why are you putting it in your note?

To indicate to the future jury you are speaking to that you have suboptimal working conditions and have to see people in the waiting room? And to hopefully get some special dispensation because of that?

Basically yes there is some disagreement whether this will help with the future jury or not , so I’m wondering what anyone else is doing in similar circumstances. Will this make us more likely to get sued; more likely to get dropped from the case ; etc and what is the documentation that others would consider standard.
We are insured through hospital so their advice obviously has conflict of interest

 

[RustedFox]

Is anything different between your eval and plan from the WR than it would be in a bed?

I eval and work up WR patients every shift.
If I need to do a more in-depth exam (abdomen, back) then I put them in our single bed designed for that purpose, then bounce them back to the WR.

 

[CoolDoc1729]

Is anything different between your eval and plan from the WR than it would be in a bed?

I eval and work up WR patients every shift.
If I need to do a more in-depth exam (abdomen, back) then I put them in our single bed designed for that purpose, then bounce them back to the WR.

For example, we are not typically able to put chest pain with risk factors on a monitor, we are not able to start antibiotics for (actual) septic patients , the eval and plan are the same but we are not able to implement it .. so the Disclaimer a lot of us have been using basically says the patient has to go back to the wr due to staff shortages and we can’t monitor or Medicate them , will this provide any liability protection, will it make us more a target for lawsuits.
I was just wondering if others practicing “waiting room medicine” are charting anything like this, not asking for legal advice

 

[thegenius]

Basically yes there is some disagreement whether this will help with the future jury or not , so I’m wondering what anyone else is doing in similar circumstances. Will this make us more likely to get sued; more likely to get dropped from the case ; etc and what is the documentation that others would consider standard.
We are insured through hospital so their advice obviously has conflict of interest

You will get sued if you take care of an unreasonable patient who gets pissed off at your care and has a bad outcome. Regardless if you practiced standard of care medicine. Those are the high risk patients.

We love to think lawyers will be nice to us if they read that blurb, but in fact it will probably embolden them to sue even more. They will sue everyone

 

[RustedFox]

For example, we are not typically able to put chest pain with risk factors on a monitor, we are not able to start antibiotics for (actual) septic patients , the eval and plan are the same but we are not able to implement it .. so the Disclaimer a lot of us have been using basically says the patient has to go back to the wr due to staff shortages and we can’t monitor or Medicate them , will this provide any liability protection, will it make us more a target for lawsuits.
I was just wondering if others practicing “waiting room medicine” are charting anything like this, not asking for legal advice

Okay.
I understand better now.

 

[Rekt]

For example, we are not typically able to put chest pain with risk factors on a monitor, we are not able to start antibiotics for (actual) septic patients , the eval and plan are the same but we are not able to implement it .. so the Disclaimer a lot of us have been using basically says the patient has to go back to the wr due to staff shortages and we can’t monitor or Medicate them , will this provide any liability protection, will it make us more a target for lawsuits.
I was just wondering if others practicing “waiting room medicine” are charting anything like this, not asking for legal advice

I would not have my name on these charts.

When they die in the WR or have a poor outcome, FWD the MRN to your admin. Seeing patient's in the waiting room lets admin know you're okay with the set up.

 

[Kryptocoin]

My hospital no longer lets us order labs on pts in the WR unless we physically see and exam them. If the pt elopes before you see them, the hospital can't bill regardless if they've had labs or imaging done. At least that's what we've been told.

 

[emergentmd]

Is anything different between your eval and plan from the WR than it would be in a bed?

I eval and work up WR patients every shift.
If I need to do a more in-depth exam (abdomen, back) then I put them in our single bed designed for that purpose, then bounce them back to the WR.

There are so much wrong with seeing pts in the waiting room and as such I do not want to set precedence for admin to use the Waiting room as Bed #30-100.

Other than the obvious, I do not want my waiting room to have staff constantly yelling names, finding pts, mixing crap up.

I will give you one example. If a pt is in the room, they can click the call bell if they need something and can tell that I am the MD. If they are in the WR and a pt need something, good luck figuring out who the pt is and who the MD is.

 

[CoolDoc1729]

My hospital no longer lets us order labs on pts in the WR unless we physically see and exam them. If the pt elopes before you see them, the hospital can't bill regardless if they've had labs or imaging done. At least that's what we've been told.

Our process is :
We physically go see and examine them in a side area off the waiting room ; our midlevel spends their entire shift doing this and we fill in as needed, our lwbs had been 15-25% and now is under 5
We place orders for labs, rads , medicines, fluids etc
We write a H&P and sign the chart
Labs may or may not get done; rads generally gets done unless they need a preg then it bumps into may or may not under labs ; po meds may be given ; IV meds and fluids probably not
If their tests result and they are still in the wr we pull them into a side area again and go over them
Id estimate 80% of our patients and about 30% of admissions are entirely handled in the wr
I’m not debating this system as I am a friendly weekend midnight grunt with no authority to change any of this and we have 1/3 the staff we had pre covid. I know it is crap care but we have been left with providing crap care or no care and I am geographically stuck due to husbands preferences and my preference to remain married to husband

We are constantly told by admin, cmg, hospital that “this is happening everywhere”

 

[HemeOncHopeful19]

Our process is :
We physically go see and examine them in a side area off the waiting room ; our midlevel spends their entire shift doing this and we fill in as needed, our lwbs had been 15-25% and now is under 5
We place orders for labs, rads , medicines, fluids etc
We write a H&P and sign the chart
Labs may or may not get done; rads generally gets done unless they need a preg then it bumps into may or may not under labs ; po meds may be given ; IV meds and fluids probably not
If their tests result and they are still in the wr we pull them into a side area again and go over them
Id estimate 80% of our patients and about 30% of admissions are entirely handled in the wr
I’m not debating this system as I am a friendly weekend midnight grunt with no authority to change any of this and we have 1/3 the staff we had pre covid. I know it is crap care but we have been left with providing crap care or no care and I am geographically stuck due to husbands preferences and my preference to remain married to husband

We are constantly told by admin, cmg, hospital that “this is happening everywhere”

This sounds like a medicolegal minefield.

In my non-professional opinion the hospital is asking you not to document so that they can throw you under the bus when there is an inevitable lawsuit. I agree it may even make you more likely to get sued, but at least it might drag the hospital down with you if that matters to you I guess?

Alternative nuclear option: refuse to see them, get canned, husband has to re-evaluate geographic preferences

 

[Groove]

No, it's not just you. Hospitals are in the same boat where I'm at. Although we are not being asked directly to go see pt's in the WR, I do it routinely. I take a COW out there and decompress as much as possible and try to speak with and lay hands on anybody that looks high risk so I can notify the charge/triage nurses that this particular pt needs to come back sooner. Your alternative is to just ignore the pt's piling up out there but you and I both know that the triage process is not perfect and there are always a few ticking time bombs. If someone dies in your WR, you're going to get sued if you were the doc on shift. It doesn't mean they would win a suit against you, and you might get dropped after it's shown to be the hospitals fault that they couldn't get them in a room ; initiate care but it's still going to be a gigantic pain in the ass.

All that being said, I totally get why docs revolt against WR medicine and I'm one of the very few in my group that actively roams the WR while I'm on shift. I'm just OCD and can't stand WRs backing up. I'd much rather decompress all the crap that has no reason being there at the beginning of my shift rather than worry about someone having an MI or ruptured AAA. On a positive note, it will make all your metrics look great which is certainly not bad for job security. The fact that I actively work the WR is probably why my LOS is the lowest in the group if I'm being honest.

I use a COVID clause but not a WR one. I think it's dangerous to use a clause that singles out your particular hospital as "at fault" for not providing standard of care. I use a much more general one about resource limitations as a result of the pandemic, etc.. If you single out your hospital, they are going to place you under a microscope and be tempted to find a way to terminate you.

To answer your question about documentation. Yes, if I pick them up then I start a note on them. I will drop MSE orders on others based on their chief complaint but don't necessarily always see them. On those, I usually don't document anything.

 

[CoolDoc1729]

No, it's not just you. Hospitals are in the same boat where I'm at. Although we are not being asked directly to go see pt's in the WR, I do it routinely. I take a COW out there and decompress as much as possible and try to speak with and lay hands on anybody that looks high risk so I can notify the charge/triage nurses that this particular pt needs to come back sooner. Your alternative is to just ignore the pt's piling up out there but you and I both know that the triage process is not perfect and there are always a few ticking time bombs. If someone dies in your WR, you're going to get sued if you were the doc on shift. It doesn't mean they would win a suit against you, and you might get dropped after it's shown to be the hospitals fault that they couldn't get them in a room ; initiate care but it's still going to be a gigantic pain in the ass.

All that being said, I totally get why docs revolt against WR medicine and I'm one of the very few in my group that actively roams the WR while I'm on shift. I'm just OCD and can't stand WRs backing up. I'd much rather decompress all the crap that has no reason being there at the beginning of my shift rather than worry about someone having an MI or ruptured AAA. On a positive note, it will make all your metrics look great which is certainly not bad for job security. The fact that I actively work the WR is probably why my LOS is the lowest in the group if I'm being honest.

I use a COVID clause but not a WR one. I think it's dangerous to use a clause that singles out your particular hospital as "at fault" for not providing standard of care. I use a much more general one about resource limitations as a result of the pandemic, etc.. If you single out your hospital, they are going to place you under a microscope and be tempted to find a way to terminate you.

To answer your question about documentation. Yes, if I pick them up then I start a note on them. I will drop MSE orders on others based on their chief complaint but don't necessarily always see them. On those, I usually don't document anything.

I actually found a contained rupture over 10 cm AAA in the WR several months ago. He did fine 😁

 

[RoyBasch]

For those of you who are "putting your foot down" and refusing to see patients in the waiting room for concern of liability, are you concerned about the liability for a delay in care? Patients are in the waiting room because the ER is full. They may be there for a long time with their undifferentiated illness. That is a setup for a patient to suffer morbidity/mortality from a time critical diagnosis in the waiting room. I do not think if you are a physician on duty in the ER (even if there are multiple) you will be absolved of liability in this situation just because "you haven't seen them yet."

Is seeing patients in the waiting room a liability? Yes.

Is letting people die in the waiting room waiting to be seen a liability? Yes.

Another classic ER lose-lose situation.

 

[EctopicFetus]

What i put in every note taken from Ruben Strayer.

Management decisions made amidst COVID-19 public health emergency; admission vs. discharge standard has necessarily shifted. During the entire duration of direct patient care I wore appropriate PPE. Appropriate hand washing and hand sanitizer use both before and after patient contact.

 

[Janders]

As far as the original question of documentation, I try to document in the most friendly team-player manner when WR care is truly suboptimal that I’ve done my best and notified the appropriate parties. MOST WR care i do not make any special note about.

(1) We have some mini-rooms, fast-track rooms, or vertical-care space adjacent to the WR (pick your favorite terms). Most days we see a significant volume of fast-track style complaints in these rooms, and sometimes those patients then go back to the WR to wait for, say, an X-ray or a rapid strep. I personally have no issue with this, it speeds care, its not super risky, patients actually don’t mind a ton, etc. Granted I’d love double the rooms so everyone gets a room, but If you can peel some fast tracks out of the WR and see them in adjacent space, cool for you. Our PAs and MDs do this. We occasionally don’t have enough RNs to really staff these rooms, so occasionally we do things the RNs would normally do (hand people d/c paperwork, etc). I document NOTHING special on these charts. Our MD/PAs are empower to autonomously grab patients from the WR and see them in these spaces if things are backed up and they have high likelyhood of near immediate discharge based on the triage.

(2) As well, we have a host of med-exec approved triage-RN ordered labs / EKGs / plain films and they are told to be aggressive about ordering basic US or even non-con CT head for anti-coag head trauma from the WR (we speak via secured text, or in person, to order these and confirm we want them; sometimes we see the patient in the triage both for 60s to confirm). Is there theoretical liability with this? Sure. Does it also vastly speed care, and patients seem to like it? yes. Do patients sometimes get all of this done in the WR, and are ready to discharge? Sure. I am happy to go grab them, pull them into one of the vertical care spaces, and do the H&P part, go over the results that the kind triage RN ordered as part of the care team with me to expedite their care, and then explain the results and how I’d like to get them out of here with an Rx or whatever. When you frame it as clearly the system is crumbling but the RN and MD are working hard to get YOU THE PATIENT excellent care as quickly as possible even though you’re sitting in the WR… patients and families LIKE this.

For example, 80yo here with daughter b/c he tripped on the rug, clocked his forehead on the coffee table, has a lump and is on eliquis. He’s acting totally fine, has normal vitals, but they were concerned. Non-con head done from WR, negative, I pull patient and daughter back, confirm history, do neurological exam, then go over the thankfully negative CT scan (which was ordered bc the triage nurse was concerned about him, and talked to me in real time about getting it done ASAP! All the hospitals are SO crowded, we’ve really had to start hot-wiring the system to keep patients safe, you see?), and my recommendations re: concussion, symptoms to return for, etc.

Now, what you’ve noticed here is my WR is actually very high functioning. If Xrays are ordered in the WR? They get done. If labs are ordered? Phlebotomy does them. If CT is ordered? CT tech grabs the patient and does it. Is it always super fast? No the place is on fire! However, we and hospital leadership are 100% on the same page that WR care is sub-optimal, but barring doubling the size of our ED this week its going to happen, so we need to do WR care the best we can.

(3) The ones that I do occasional writing things down about… patients that are ESI 2, have concerning triage complaints, triage RN is begging to get them back, every room/hallway/closet is full, and you can’t get them back. Clearly at this point you’ve already escalated through admin whatever your process is for CODE DISASTER etc etc. I absolutely will go see these people in the WR, preferably pulling them into the triage booth or vertical room, or hallway. I absolutely order labs / imaging. I’ve put my own IVs in these people and drawn my own labs. The issue is if they need meds, does your hospital have nursing capacity to truly admin meds in the WR? I am fine hanging my own liter of NS on an IV poll in the WR. But I can’t pull Zosyn from the PYXIS, so you may need to negotiate with your Triage/resource RN to see if they can give a quick med.

Anyway, in this type of case I have written things like “triage RN alerted me to this patient, concerned about their presentation. Due to severe crowding, hospital on CODE DISASTER, every room/chair/hallway currently occupied and they could not be pulled out of the WR. As such I did go immediately and see the patient in the WR/triage booth; to expedite their care I have ordered labs, imaging, and medications for them. Patient understands the initial care plan. D/W triage and resource RN care plan.”

Usually we are good enough that once another 30-60min pass, if the diagnostics are looking bad, we can get them into a hallway chair at least. But when you are ordered a CT for likely perforated viscus in the WR and it shows free air… who knows what the “best” thing to write in the chart is? I figure the truth, without laying blame, and showing the care team is trying its best and did recognize the patient and did NOT “ignore” them in the WR is a reasonable thing to chart. I think the tone and context is important, and if you chose to write this type of context you should be collaborative and not finger pointing.

Have I literally run code strokes in the WR and pushed the patient to CT myself? Yes. Believe me no one in the WR complained about their wait for the rest of the shift…

 

[Janders]

To better summarize, I think Rule #1 applies (Rule #1 is DO WHAT IS BEST FOR THE PATIENT).

If you were a patient in the WR, would you want your tests ordered and done while you wait? YES.
If the MD/PA could come see you, even briefly, to help expedite your workup and give you better care, would you want that? YES.

I do wonder if people’s opinions on this topic change if they are FFS (where a 10% LWBS hurts their bottom line, but cherry picking 5 fast tracks out of the WR and handling them rapidly gets them cash) versus largely salaried/hourly and thus only care about the WR due to a general sense of duty…

 

[bravotwozero]

The other issue is if you get paid based off rvus. If you don’t see patients in the WR and your colleagues are, your rvus will certainly take a hit.

 

[Rekt]

No, it's not just you. Hospitals are in the same boat where I'm at. Although we are not being asked directly to go see pt's in the WR, I do it routinely. I take a COW out there and decompress as much as possible and try to speak with and lay hands on anybody that looks high risk so I can notify the charge/triage nurses that this particular pt needs to come back sooner. Your alternative is to just ignore the pt's piling up out there but you and I both know that the triage process is not perfect and there are always a few ticking time bombs. If someone dies in your WR, you're going to get sued if you were the doc on shift. It doesn't mean they would win a suit against you, and you might get dropped after it's shown to be the hospitals fault that they couldn't get them in a room ; initiate care but it's still going to be a gigantic pain in the ass.

All that being said, I totally get why docs revolt against WR medicine and I'm one of the very few in my group that actively roams the WR while I'm on shift. I'm just OCD and can't stand WRs backing up. I'd much rather decompress all the crap that has no reason being there at the beginning of my shift rather than worry about someone having an MI or ruptured AAA. On a positive note, it will make all your metrics look great which is certainly not bad for job security. The fact that I actively work the WR is probably why my LOS is the lowest in the group if I'm being honest.

I use a COVID clause but not a WR one. I think it's dangerous to use a clause that singles out your particular hospital as "at fault" for not providing standard of care. I use a much more general one about resource limitations as a result of the pandemic, etc.. If you single out your hospital, they are going to place you under a microscope and be tempted to find a way to terminate you.

To answer your question about documentation. Yes, if I pick them up then I start a note on them. I will drop MSE orders on others based on their chief complaint but don't necessarily always see them. On those, I usually don't document anything.

Any proof of this? How many times on SDN "You're going to get sued!" but provide zero proof and it's all just conjecture and guessing. 40 patients in the WR and 5 docs and 3 MLPs on shift or whatever number. We all get sued? I find this very hard to believe actually happening. Hospital getting sued? Yeah definitely. I have the lowest LOS and most PPH my group and see a total of zero ever in the WR with the exception throwing them on a gurney because they're a drop off arrest/OD/trauma.

WR medicine is inappropriate, substandard, bastardized care, and patients suffer for it while your admins and CMG collect your check without the liability.

 

[RustedFox]

What i put in every note taken from Ruben Strayer.

Management decisions made amidst COVID-19 public health emergency; admission vs. discharge standard has necessarily shifted. During the entire duration of direct patient care I wore appropriate PPE. Appropriate hand washing and hand sanitizer use both before and after patient contact.

Can we have ol' Rube whip one of these up for ****ty admins? Or, in my case: hurricane and overburdened healthcare system??

 

[xaelia]

Brutal to see this thread and all the disincentives to do the right thing – which is, in theory, help as many folks as possible. Won't get paid for it. Might have liability. Lack of privacy. All the things.

My time at Kaiser definitely did an "initial eval in a private triage room", labs, EKG, PO (some IM) meds, back to the WR – sorry, "continuing care area" – with a little puke bag and aromatherapy bead. Even when the ED was empty, that's how we did it – probably managed 60% of folks out there, including chest pain with risk factors as long as they were pain free. I'd even put equivocal minor neuro back out there to await MRI – more than one stroke diagnosed out there.

Trying to replicate more of that in our ED in NZ, but the space/resources at triage aren't quite as robust.

 

[TooMuchResearch]

Why are you putting it in your note?

To indicate to the future jury you are speaking to that you have suboptimal working conditions and have to see people in the waiting room? And to hopefully get some special dispensation because of that?

Yes, it's to hope the plaintiff decides the hospital is at fault for the inevitable terrible outcome.

 

[TooMuchResearch]

I would not have my name on these charts.

When they die in the WR or have a poor outcome, FWD the MRN to your admin. Seeing patient's in the waiting room lets admin know you're okay with the set up.

And if I don't see them in the waiting room, our group loses a large amount of revenue and the patients get no care.

 

[Groove]

Any proof of this? How many times on SDN "You're going to get sued!" but provide zero proof and it's all just conjecture and guessing. 40 patients in the WR and 5 docs and 3 MLPs on shift or whatever number. We all get sued? I find this very hard to believe actually happening. Hospital getting sued? Yeah definitely. I have the lowest LOS and most PPH my group and see a total of zero ever in the WR with the exception throwing them on a gurney because they're a drop off arrest/OD/trauma.

WR medicine is inappropriate, substandard, bastardized care, and patients suffer for it while your admins and CMG collect your check without the liability.

Rekt...I have not personally been sued in a case like that but as far as I'm concerned it doesn't take captain obvious for a plaintiff attorney to see the logic in naming the ED physician, triage nurse, hospital and anybody else they can think of to maximize a potential payout. I'm not lazy, so I don't mind getting out there to help patients, exhausted triage nurses and find creative solutions to the ubiquitous healthcare barriers everybody is facing including staffing shortages, lack of beds, overwhelmed EDs, etc.. I don't like it, but it's better than sitting with a thumb up my butt watching the WR explode and waiting for a code blue. We've had a couple of sentinel events in the WR this past year. Would you want me to sit on my ass if it was your mom or dad out there?

 

[Kryptocoin]

Rekt...I have not personally been sued in a case like that but as far as I'm concerned it doesn't take captain obvious for a plaintiff attorney to see the logic in naming the ED physician, triage nurse, hospital and anybody else they can think of to maximize a potential payout. I'm not lazy, so I don't mind getting out there to help patients, exhausted triage nurses and find creative solutions to the ubiquitous healthcare barriers everybody is facing including staffing shortages, lack of beds, overwhelmed EDs, etc.. I don't like it, but it's better than sitting with a thumb up my butt watching the WR explode and waiting for a code blue. We've had a couple of sentinel events in the WR this past year. Would you want me to sit on my ass if it was your mom or dad out there?

In America, you can sue for anything, but that would be one of the most useless lawsuits ever. What's the standard of care for treating patients in the waiting room? There's none.

 

[TrailRun]

If you are lowering the standard of care based on the environment in which you see the patient that’s probably a problem. I would see them in the waiting room but order everything I would typically order which perhaps will be legally protective, Although legally I don’t know if ordering a medicine that isn’t given gets you off the hook

 

[HemeOncHopeful19]

Brutal to see this thread and all the disincentives to do the right thing – which is, in theory, help as many folks as possible. Won't get paid for it. Might have liability. Lack of privacy. All the things.

I would say from the sound of this thread (“we are still at 1/3 of our pre-COVID staffing levels”) the problem is less about doctors being disincentivized to do the right thing and more about administration being incentivized to understaff their hospital and convince the docs to practice substandard care.

 

[evert1de101]

Zero problem with waiting room care. Seen patients in parking lot before. Sooner is better and I'm liable regardless. It's called EMTALA and it's called being the only doctor in the building that actually gets off his/her ass to treat patients. So long as they show up on the EMR so I can document. Even if they end up refusing care, demand a chart be made so you can document document document.

Big no-no happened to me once at a HCA shop - nurse told me to cancel a tele order because patient is in waiting room. Never went back there again.

 

[thegenius]

No, it's not just you. Hospitals are in the same boat where I'm at. Although we are not being asked directly to go see pt's in the WR, I do it routinely. I take a COW out there and decompress as much as possible and try to speak with and lay hands on anybody that looks high risk so I can notify the charge/triage nurses that this particular pt needs to come back sooner. Your alternative is to just ignore the pt's piling up out there but you and I both know that the triage process is not perfect and there are always a few ticking time bombs. If someone dies in your WR, you're going to get sued if you were the doc on shift. It doesn't mean they would win a suit against you, and you might get dropped after it's shown to be the hospitals fault that they couldn't get them in a room ; initiate care but it's still going to be a gigantic pain in the ass.

All that being said, I totally get why docs revolt against WR medicine and I'm one of the very few in my group that actively roams the WR while I'm on shift. I'm just OCD and can't stand WRs backing up. I'd much rather decompress all the crap that has no reason being there at the beginning of my shift rather than worry about someone having an MI or ruptured AAA. On a positive note, it will make all your metrics look great which is certainly not bad for job security. The fact that I actively work the WR is probably why my LOS is the lowest in the group if I'm being honest.

I use a COVID clause but not a WR one. I think it's dangerous to use a clause that singles out your particular hospital as "at fault" for not providing standard of care. I use a much more general one about resource limitations as a result of the pandemic, etc.. If you single out your hospital, they are going to place you under a microscope and be tempted to find a way to terminate you.

To answer your question about documentation. Yes, if I pick them up then I start a note on them. I will drop MSE orders on others based on their chief complaint but don't necessarily always see them. On those, I usually don't document anything.

Very reasonable and truthful response to this topic. I practice the same way. There are ideals...and then there are realities of the job we do. The reality is we are understaffed and our hospital has well known financial difficulties...so I do my best.

The reality is the hospital will find docs to practice the way the hospital sees fit. I want to continue to make my 400-500k/year, so it is not the most egregious request.

 

[thegenius]

For those of you who are "putting your foot down" and refusing to see patients in the waiting room for concern of liability, are you concerned about the liability for a delay in care? Patients are in the waiting room because the ER is full. They may be there for a long time with their undifferentiated illness. That is a setup for a patient to suffer morbidity/mortality from a time critical diagnosis in the waiting room. I do not think if you are a physician on duty in the ER (even if there are multiple) you will be absolved of liability in this situation just because "you haven't seen them yet."

Is seeing patients in the waiting room a liability? Yes.

Is letting people die in the waiting room waiting to be seen a liability? Yes.

Another classic ER lose-lose situation.

Yea someone wrote a few years ago about an EMTALA violation. It basically went like this: a young guy goes to an ER for abdominal pain. Waited 4-5 hours in the waiting room, LWBS or eloped (in this case doesn't really matter) and went to another hospital. Diagnosed with acute appendicitis and pt did well. First hospital cited for an EMTALA violation for failing to recognize and stabilize a patient with an emergency diagnosis.

The only thing we can do as ER docs is to summarily discharge all people without emergencies. Like immediately. Kind of need the support from the hospital though because they will get lots of nasty Yelp reviews and patient complaints. But 1/3 to 1/2 of all patients can be discharged after getting their 1-2 minute MSE and a short 2 minute talk. Entire process is 4-5 minutes. They can be handed a piece of paper outlining all of the regional clinics and urgent cares where they can seek alternate care.

 

[thegenius]

The other issue is if you get paid based off rvus. If you don’t see patients in the WR and your colleagues are, your rvus will certainly take a hit.

yea this part is obvious, surprised it took 25 responses for someone to bring this up.

 

[RoyBasch]

Yea someone wrote a few years ago about an EMTALA violation. It basically went like this: a young guy goes to an ER for abdominal pain. Waited 4-5 hours in the waiting room, LWBS or eloped (in this case doesn't really matter) and went to another hospital. Diagnosed with acute appendicitis and pt did well. First hospital cited for an EMTALA violation for failing to recognize and stabilize a patient with an emergency diagnosis.

The only thing we can do as ER docs is to summarily discharge all people without emergencies. Like immediately. Kind of need the support from the hospital though because they will get lots of nasty Yelp reviews and patient complaints. But 1/3 to 1/2 of all patients can be discharged after getting their 1-2 minute MSE and a short 2 minute talk. Entire process is 4-5 minutes. They can be handed a piece of paper outlining all of the regional clinics and urgent cares where they can seek alternate care.

If the appy patient had not done well it could be malpractice, but it is not an EMTALA violation as the hospital and physicians were not failing to offer the patient an MSE and stabilizing care. The patient simply decided to leave out of their own volition.

 

[alpinism]

There's a huge difference between seeing patients in the waiting room in a disaster situation under disaster standards of care when there are literally no beds or nurses anywhere in the entire hospital and what's currently happening in hospitals.

No matter how you attempt to justify things in your head the bottom line is that leadership is choosing to provide substandard care to patients because the main focus of leadership is on their profit margins.

 

[turkeyjerky]

If the appy patient had not done well it could be malpractice, but it is not an EMTALA violation as the hospital and physicians were not failing to offer the patient an MSE and stabilizing care. The patient simply decided to leave out of their own volition.

Interesting interpretation. If the hospital had defined their triage nurse as qualified to perform an MSE than it would not have been. However, most hospitals refuse to do so. So, in that case, it's easily argued that 4-5 hours of waiting for a potential surgical emergency is not 'timely', as is required by emtala.

 

[thegenius]

If the appy patient had not done well it could be malpractice, but it is not an EMTALA violation as the hospital and physicians were not failing to offer the patient an MSE and stabilizing care. The patient simply decided to leave out of their own volition.

That's not the way it was adjudicated. He presented to an ER and waited upwards to 6 hours. He didn't receive an MSE. The first hospital was fined. I wish I knew how to access the case. Southerdoc would know (he may have even recounted it).

 

[Rekt]

The corollary between who is RVU based and who is pro WR medicine vs. not would tell the tale completely instead of hiding under the guise of "it's still best for patients!".

 

[alpinism]

Let's be honest if people really cared about patient safety they'd bring them back and make them sit on the floor in the emergency department.
That's how many emergency department patients are treated in third world countries when there are no beds on busy days.

 

[RoyBasch]

That's not the way it was adjudicated. He presented to an ER and waited upwards to 6 hours. He didn't receive an MSE. The first hospital was fined. I wish I knew how to access the case. Southerdoc would know (he may have even recounted it).

I’m not trying to antagonize I’m just trying to understand.

Like I get that EMTALA is applied unevenly and in somewhat contradictory ways, but by this standard literally any patient who LWBS is a potential EMTALA violation. Does it matter the wait was long? I mean long waits are pretty common around the country. If a 6 hour wait is considered “dissuading a patient from seeking care” then does that mean the hospital is racking up one violation after the next once wait times get long. What can a hospital do? Refuse to let more people check in once the wait time gets long—because that actually WOULD be a violation.

 

[southerndoc]

That's not the way it was adjudicated. He presented to an ER and waited upwards to 6 hours. He didn't receive an MSE. The first hospital was fined. I wish I knew how to access the case. Southerdoc would know (he may have even recounted it).

From my database:

2014-06-05
Olive View - UCLA Medical Center - a county hospital in Sylmar, CA - entered into a settlement agreement with the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services, effective May 23, 2014. The $40,750 settlement resolves allegations that Olive View violated the Emergency Medical Treatment and Labor Act, (EMTALA), by failing to provide an individual with an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department in order to determine whether he had an emergency medical condition.

Specifically, the individual presented to the Olive View emergency department with signs of appendicitis and severe abdominal pain that he rated at a 10 on a 10-point scale. Despite his severe pain and symptoms, he was forced to wait for several hours to receive an MSE. After waiting for 6.5 hours, he left to seek medical screening and treatment at another hospital, where he was diagnosed with acute appendicitis with a large peritoneal abscess and had to undergo an immediate laparoscopic appendectomy. According to EMTALA, if an individual comes to a hospital emergency department and a request is made on his/her behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate MSE within the capability of the emergency department to determine whether or not an emergency medical condition exists. OIG was represented by Associate Counsel Odies Williams, IV. Olive View was represented by Brandi M. Moore of the Los Angeles County Counsel's Office.

EDIT: Please note that is the summary released by OIG and not my summary. "Forced to wait" is a common language they use to describe EMTALA violations.

 

[emergentmd]

I am surprised with some comments agreeable with WR medicine. I am all for helping when there are unusual circumstances that necessitates WR medicine or whatever they want to set up like tents but this should never be the norm. Not only is it bad and potentially dangerous medicine (say what you want but its a poor environment for good care) but it sets precedence. Here are things I had to deal with and admin figured it out bc our SDG did not back down. If we accepted this, admin would not have found the appropriate solutions.

1. ER docs being the inpatient central line doc - they found PICC nurses, and other inpatient services to deal with
2. ER docs being the overnight OB first responder so OB can sleep at home - they hired an overnight OB
3. ER doc being the trauma team back up - they found trauma coverage
4. ER docs being triage nurses to click pt to provider times - they hired an NP

Yeah it costs them money and that is their job to figure out. Now if they wanted to pay the ER doc $$$ for the above coverage, then sure a discussion can be had. But in no way should be free labor so they dont have to fix their systemic issues. They do stipends, bonuses all the time to find specialist coverage so why would be add extra duty for free?

But hey, do what you want and if you want to to start being WR docs then be prepared to be Tent docs and whatever admin wants.

And the reason that it is best for pt care if totally misguided. If the ER is that busy and rooms are not avail, then they need to hire an NP to do MSE and send the non emergent off to clinics or hire an NP to do WR medicine for all I care. But My education and time is way to valuable to be WR docs.

 

[pkwraith]

Maybe you guys have sicker waiting rooms. But most of the time when I look at at my giant waiting rooms and their chief complaints, vitals, and triage notes of the patients, I have zero motivation to decompress them and hope they elope. On most days, the vast majority are BS, non emergencies, or soul-sucking Press-Ganey bombs. We have PIT APPs at our major hospital that shuttle through the actual acute patients who does the waiting room medicine, and they hate it, but actual sick patients get identified and move back pretty fast.

 

[emergentmd]

I worked at a Locums place that paid well so no room for complaints. They had this large room prob 50x50' that probably was built to be some type of CDU or storage area. Well, they decided it was a great idea to section it off into 4 pods with 4-6 chairs each so could carry 20+ pts. Talk about a miserable area. Every time you walk in, you had no idea who it was. You yelled out their name. You go do a useless exam, and you try quietly whisper as to not create some HIPPA issues, and then its the nurses turn to figure out who the pts were. Could never find the correct charts/labs, could not find the pt half the time to discharge/reevaluate. Just terrible care.

An open waiting room would be 10x worse with 10x the amount of pts. Anyone who wants to do WR medicine is just foolish.

 

[GonnaBeADoc2222]

I am neither paid on RVUs, nor am I the only doc on shift ever. No motivation to clear the WR.

 

[DeadCactus]

Patient requires further evaluation to exclude emergent medical conditions. No rooms are currently available in the emergency department, patient sent back to waiting room.

 

[southerndoc]

I worked at a Locums place that paid well so no room for complaints. They had this large room prob 50x50' that probably was built to be some type of CDU or storage area. Well, they decided it was a great idea to section it off into 4 pods with 4-6 chairs each so could carry 20+ pts. Talk about a miserable area. Every time you walk in, you had no idea who it was. You yelled out their name. You go do a useless exam, and you try quietly whisper as to not create some HIPPA issues, and then its the nurses turn to figure out who the pts were. Could never find the correct charts/labs, could not find the pt half the time to discharge/reevaluate. Just terrible care.

An open waiting room would be 10x worse with 10x the amount of pts. Anyone who wants to do WR medicine is just foolish.

If it's a HIPAA violation, you are not liable. The hospital would be held liable for having you see the patient in non-ideal places (unless you physically put the patient in that location).

 

[emergentmd]

If it's a HIPAA violation, you are not liable. The hospital would be held liable for having you see the patient in non-ideal places (unless you physically put the patient in that location).

That sounds great and all but I rather not spend any extra unpaid time dealing with said issues.

 

[RoyBasch]

From my database:

2014-06-05
Olive View - UCLA Medical Center - a county hospital in Sylmar, CA - entered into a settlement agreement with the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services, effective May 23, 2014. The $40,750 settlement resolves allegations that Olive View violated the Emergency Medical Treatment and Labor Act, (EMTALA), by failing to provide an individual with an appropriate medical screening examination (MSE) within the capability of the hospital's emergency department in order to determine whether he had an emergency medical condition.

Specifically, the individual presented to the Olive View emergency department with signs of appendicitis and severe abdominal pain that he rated at a 10 on a 10-point scale. Despite his severe pain and symptoms, he was forced to wait for several hours to receive an MSE. After waiting for 6.5 hours, he left to seek medical screening and treatment at another hospital, where he was diagnosed with acute appendicitis with a large peritoneal abscess and had to undergo an immediate laparoscopic appendectomy. According to EMTALA, if an individual comes to a hospital emergency department and a request is made on his/her behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate MSE within the capability of the emergency department to determine whether or not an emergency medical condition exists. OIG was represented by Associate Counsel Odies Williams, IV. Olive View was represented by Brandi M. Moore of the Los Angeles County Counsel's Office.

EDIT: Please note that is the summary released by OIG and not my summary. "Forced to wait" is a common language they use to describe EMTALA violations.

For a young patient with normal vitals and a complaint of abdominal pain going to a busy ER I don't know that I would consider 6.5 hour wait unreasonable. Is it long--yes. Is it a bummer for the patient--yes. Is it ideal--no. But is this probably the norm at many hospitals in the country right now? Does the OIG think anybody with verbalized "10 out of 10" pain needs to come back immediately? A very large number of ER patients describe their pain as "10 out of 10" when asked at triage which then gets faithfully documented (even people with stubbed toes, tension headaches, superficial lacerations, etc.)

Again I am aware that YOU personally do not necessarily agree with the decisions of CMS and the OIG in these cases, but I'm just trying to understand by asking you an EMTALA expert what are the realistic solutions to these potential EMTALA pitfalls.

 

[Apollyon]

A very large number of ER patients describe their pain as "10 out of 10" when asked at triage which then gets faithfully documented (even people with stubbed toes, tension headaches, superficial lacerations, etc.)

That brings to mind something from my career. Any pt with an amputation reported their pain to be a 6 or a 7. Bar none, that was the pain scale. "5th Vital Sign", my a**.