Woman dies after leaving ER due to long wait time

[Painted]

Milwaukee woman dies after leaving ER due to long wait, family says

The family claims that the hospital later called to check on her, by which point she had already collapsed and was on her way back via ambulance.

www.foxnews.com

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[HoosierdaddyO]

I’m sorry that this women passed away... and without sounding cold and callus how is this a physicians problem. This is purely an operations and logistics issue that C-suite in my opinion takes the brunt of the blame for!!!

 

[betamale]

Shouldve been a straight back based on the complaint or at least an EKG, labs at triage

 

[HoosierdaddyO]

Shouldve been a straight back based on the complaint or at least an EKG, labs at triage

Once again an operations and logistics problem... medical director and C-suites issue. Even tho legally in some messed up bizzaro world, it’ll fall on the ER physicians lap!!!

 

[pkwraith]

she did get ekg and cxr at triage

 

[ShockIndex]

Shouldve been a straight back based on the complaint or at least an EKG, labs at triage

Bring them back to what? Most EDs have no capacity - the hallways are full, nurses are beyond their ratios, and most EDs are boarding admitted patients.

 

[Angus Avagadro]

Many EDs won't close due to overcrowding because of hospital administrators dictates. I've seen this many times. Hope they sue the hospital.

 

[Mad Jack]

I’m sorry that this women passed away... and without sounding cold and callus how is this a physicians problem. This is purely an operations and logistics issue that C-suite in my opinion takes the brunt of the blame for!!!

Oh this patient no doubt never saw a doc. Triage by policies that ended up costing her life

 

[deleted109597]

Oh this patient no doubt never saw a doc. Triage by policies that ended up costing her life

Not necessarily. It is quite possible that she would have died anyway, but there's no way to prove that yet. I agree that they need to investigate it, but lets not pin blame just yet, no matter how obvious it seems. We can't keep everyone alive, and she may have died in the hospital just the same.

 

[Lexdiamondz]

Not necessarily. It is quite possible that she would have died anyway, but there's no way to prove that yet. I agree that they need to investigate it, but lets not pin blame just yet, no matter how obvious it seems. We can't keep everyone alive, and she may have died in the hospital just the same.

True.

Truthfully, in 2 hrs she already had most of her workup done. Seeing an MD maybe would have gotten her an echo or a PE study (just tossing ideas out there) but idk what else would have happened w/o examining her.

More tellingly - she didn't leave and go to another hospital. She left and went home - which makes me wonder how seriously ill she thought she was.

Sad outcome, but idk how we could have 100% avoided this.

Bring them back to what? Most EDs have no capacity - the hallways are full, nurses are beyond their ratios, and most EDs are boarding admitted patients.

This.


I walked onto a shift with 17 boarders today. It's insane.

 

[Brigade4Radiant]

HCA’s policies it completely possible to be “seen” and have nothing done while stating 10 min door to doc times

 

[southerndoc]

Many EDs won't close due to overcrowding because of hospital administrators dictates. I've seen this many times. Hope they sue the hospital.

This just shifts the problem. Hospital A closes and shifts all patients to Hospitals B & C in the metro area. EMS picks up a patient and has to travel greater distances to deliver the patient. This ends up leaving 911 ambulances out of service to be unable to respond to calls. So instead of patients waiting longer after being triaged, it ends up being patients at home not triaged and not getting care dying instead of triaged patients getting care quickly in the ER when they are indeed sick.

This is why there is a movement to eliminate diversion. It ends up causing more harm to patients at the benefit of the hospital on diversion.

 

[Angus Avagadro]

This just shifts the problem. Hospital A closes and shifts all patients to Hospitals B & C in the metro area. EMS picks up a patient and has to travel greater distances to deliver the patient. This ends up leaving 911 ambulances out of service to be unable to respond to calls. So instead of patients waiting longer after being triaged, it ends up being patients at home not triaged and not getting care dying instead of triaged patients getting care quickly in the ER when they are indeed sick.

This is why there is a movement to eliminate diversion. It ends up causing more harm to patients at the benefit of the hospital on diversion.

Sounds like a capacity problem at hospital A,B,and C., and not so much a diversion problem. I can see the downstream effect if one hospital diverts. Better the patient arrest in the waiting room than at home or en route.

 

[AMEHigh]

True.

Truthfully, in 2 hrs she already had most of her workup done. Seeing an MD maybe would have gotten her an echo or a PE study (just tossing ideas out there) but idk what else would have happened w/o examining her.

More tellingly - she didn't leave and go to another hospital. She left and went home - which makes me wonder how seriously ill she thought she was.

Sad outcome, but idk how we could have 100% avoided this.



This.


I walked onto a shift with 17 boarders today. It's insane.

Did you read the story? She left to get care somewhere else. She was planning to go to urgent care.

 

[southerndoc]

Sounds like a capacity problem at hospital A,B,and C., and not so much a diversion problem. I can see the downstream effect if one hospital diverts. Better the patient arrest in the waiting room than at home or en route.

Correct. It is best to arrest in the waiting room than at home where help is >5 (many times >10) minutes away.

 

[RustedFox]

We have an amazing "surge capacity" problem here in the US.
My one job site seriously sends out "EMERGENCY TEXTS!" 2-3x a week to ask all those who are available to come in and help.
Because OMG; the WAIT TIME is over :15 minutes! We need ALL HANDS ON DECK, NOW!
Of course, nobody answers them, because of the cry wolf effect.
They used to offer SURGE PAY to those who came in.
Then they made up rules to deny SURGE PAY to those who came in.... if it was determined retrospectively that the SURGE wasn't really a SURGE!
So, of course, nobody plays their game anymore.

I'm willing to bet that if the excrement really hit the fan, that every doc in here would ruck up and come in to work.
I've done it. I've gotten a 4 AM phone call saying: "Dude; we're overrun from the hurricane. Can you come in?"
Damn right I came in.
Woke up. Kissed my wife. Grabbed my scrubs. Went to work.

lt's just that.... the definition of SURGE is a problem.
HCA thinks its a problem with D-2-D times and discharge times.

A real freaking SURGE is when a busload of hemophiliacs is hit by a drunk driver and turns over.
Not when Martha McGillicutty waits more than :35 minutes to be seen for her medication refill.

The definition of "Emergency Care" needs to change in this country.

 

[deleted480308]

This just shifts the problem. Hospital A closes and shifts all patients to Hospitals B & C in the metro area. EMS picks up a patient and has to travel greater distances to deliver the patient. This ends up leaving 911 ambulances out of service to be unable to respond to calls. So instead of patients waiting longer after being triaged, it ends up being patients at home not triaged and not getting care dying instead of triaged patients getting care quickly in the ER when they are indeed sick.

This is why there is a movement to eliminate diversion. It ends up causing more harm to patients at the benefit of the hospital on diversion.

I consider the whole thing an argument against certificate of need, an area having arguments about how many diversions to allow is likely ripe for another ED

 

[pkwraith]

Wow, are people actually talking about closing hospitals due to overcrowding? I am glad so many people here work in a bubble where overcrowding is not a problem for them, and 25 yo chest pains with normal ekgs can be brought back immediately regardless of what else may be happening in the department. But, it is a huge problem nationally, and there are places where this patient would probably be not be back sometimes for longer, and the majority of their workup would probably take place in the waiting room.
There are many ways to try to fix overcrowding hospitals (and they're not easy), and closing them is probably the absolute worst thing you could do.

 

[d2305]

I wonder what her O2 sat and pulse were?

 

[Angus Avagadro]

They are building a bunch of short stay hospitals near me, with ED's. People requiring intensive treatment/surgery are transferred to the mother ship in a few days if longer stay is needed. Obviously cardiac and neurosurg is shipped out by chopper right away.

 

[NITRAS]

Wow, are people actually talking about closing hospitals due to overcrowding? I am glad so many people here work in a bubble where overcrowding is not a problem for them, and 25 yo chest pains with normal ekgs can be brought back immediately regardless of what else may be happening in the department. But, it is a huge problem nationally, and there are places where this patient would probably be not be back sometimes for longer, and the majority of their workup would probably take place in the waiting room.
There are many ways to try to fix overcrowding hospitals (and they're not easy), and closing them is probably the absolute worst thing you could do.

I’m sick of being so full that we board into the ED. Why in heaven’s name does the ED always have to have a different EMR than the rest of the friggin hospital? Why can’t ED RNs “see” my orders or my contact info? It’s all Epic..but not the same. . .

The first week of the year was miserable. The ED wanted to admit everything. On a good day our admit rate is twice the national average. Outside hospitals wanted to transfer all this bull****. We have lost most of our case managers (I’m sure its one of those cost saving things that measures that saved a couple hundred bucks that only increased our LOS and lost a few million bucks).

Our wait times go up, our pay mix gets worse, our admit rate goes up, our LOS goes up and like 90% of the patient calls to me are “handoffs”.

Sorry for venting. I’m sick of being miserable from a tonsillectomy, but I know this is a big problem for my EM colleagues. It is a problem for us inpatient folks too.

 

[Birdstrike]

Milwaukee woman dies after leaving ER due to long wait, family says

The family claims that the hospital later called to check on her, by which point she had already collapsed and was on her way back via ambulance.

www.foxnews.com

Is it possible she died because administration told all the doctors they had to rush to see all the non-emergency patients in less than 15 minutes or they'd be fired?

From a personal perspective, it's worth asking yourself if seeing the non-emergencies has become more important than people who are sick or dying, so administrators to get bigger bonuses, is it worth making the psychological and personal sacrifices required by a specialty criminally hijacked and held hostage by people who don't care about patients, physicians or nurses?

From a patient care standpoint, it's also worth asking, if that's the state of EM in many emergency departments, what's the solution?

It may help to start by letting the public know that immense pressure is placed on doctors and nurse to see non-emergencies to the extent that it may be endangering the patients who need the ED the most: The sick and dying.

 

[percyeye]

I know n=1, but I was at an urgent care for chest pain, they did an ekg which was abnormal and sent me to the ER. I waited 2 hours until I saw the nurse and had another ekg and then waited another 2 hours before I actually saw the Doc there. It was a scary time for sure.

 

[d2305]

Going to an urgent care for chest pain will only delay your care if it is your heart.

 

[STEMI_voy]

Going to an urgent care for chest pain will only delay your care if it is your heart.

Unfortunately most laypeople don’t understand this or view the ED and UC as equivalents.

 

[Vandalia]

Unfortunately most laypeople don’t understand this or view the ED and UC as equivalents.

That is sort of the issue. Generally healthcare "responsible" people want to hedge their bets.

I am now at the age where such stuff happens. I should know better, but I am also an old man and therefore slightly stupid with respect to healthcare.

Two weeks ago Monday I woke up early in the morning with some chest discomfort, sweating, all the signs we tell people to call "911" for. Plus all the anecdotal of a Monday morning, holiday season, etc. So I got up, went to get the paper, have a little bit to eat, walk around, and eventually it all went away. If they were open there was probably a better chance I would have slipped into one of our urgent cares for an EKG. No way was I going to the ED while I was conscious unless I had absolutely textbook signs.

It isn't so much that people don't know the ED is the place to go for "heart problems", it is that they are not sure they are having a "heart problem" in the first place and want to make sure it is reasonable to go to the ED.

 

[AMEHigh]

That is sort of the issue. Generally healthcare "responsible" people want to hedge their bets.

I am now at the age where such stuff happens. I should know better, but I am also an old man and therefore slightly stupid with respect to healthcare.

Two weeks ago Monday I woke up early in the morning with some chest discomfort, sweating, all the signs we tell people to call "911" for. Plus all the anecdotal of a Monday morning, holiday season, etc. So I got up, went to get the paper, have a little bit to eat, walk around, and eventually it all went away. If they were open there was probably a better chance I would have slipped into one of our urgent cares for an EKG. No way was I going to the ED while I was conscious unless I had absolutely textbook signs.

It isn't so much that people don't know the ED is the place to go for "heart problems", it is that they are not sure they are having a "heart problem" in the first place and want to make sure it is reasonable to go to the ED.

Something similar happened to me recently, except it was late at night.
I actually was about to call 911, but then waited a minute and started to feel better. I then thought if I go to the ED without coming in on an ambulance I'll probably have to wait a couple of hours. Since I started to feel better I just monitored myself at home.

I do think there is something to be said about how to fix the problem of people going to the ED for non-emergencies and how the ED handles them. My outpatient health center is open 365 days of the week and has evening hours M-F as I work in an underserved area so it was designed that way to try to help people from going to the ED. We're certainly not perfect, but I do think we're a good place for care. I saw a patient on Monday for routine care, by Wed she had messaged me because she had knee pain and went to the ED that evening :/ I know people's lives are chaotic and some people really can't access care unless it's the ED, which I have sympathy for, but is there anything to be done to lessen the cost and burden of those ED visits for chronic mild knee pain for example?

 

[GeneralVeers]

There's no good solution for this. In one part of town we have two major hospitals that rotate their ambulance diversion. Both are constantly overcrowded and full. At least at one facility they just started builidng (the hospital is only 3 years old) and will double ED capacity this year, and next year will have twice the inpatient beds. My experience though is that if you build an ED/Hospital bigger it only generates more patient visits and the overcrowding is unchanged.

We really just need to do appropriate triage, and let the dental pains/ankle sprains etc self-assort out the door if they feel they've waited too long to be seen.

 

[d2305]

With my statin, my lipids look good. Something else will probably kill me.

 

[ShockIndex]

There's no good solution for this. In one part of town we have two major hospitals that rotate their ambulance diversion. Both are constantly overcrowded and full. At least at one facility they just started builidng (the hospital is only 3 years old) and will double ED capacity this year, and next year will have twice the inpatient beds. My experience though is that if you build an ED/Hospital bigger it only generates more patient visits and the overcrowding is unchanged.

We really just need to do appropriate triage, and let the dental pains/ankle sprains etc self-assort out the door if they feel they've waited too long to be seen.

There is no solution being proposed because most people don’t understand the problem, and of the few who do, about half of them helped to create it or support policies that will only worsen it.

What is being described as a capacity or boarding problem is really nothing more than a revenue and expense problem. That is to say, a series of policies were implemented about a decade ago that significantly decreased hospital revenues (i.e. Medicare cuts, shifting patients from private insurance to Medicaid or making them functionally uninsured with high out of pocket plans, etc.) and increased expenses (EMR, CMS compliance, etc.). The result was that hospitals that were operating on narrow margins of 3-5% were cut to the red and had to reduce services (ie beds), consolidate to spread expenses, or simply close. Crowding in the ED is simply a byproduct of what happens when hospitals cut expenses and divert resources to revenue generating service lines such as ortho, CV surgery, etc. so that they can stay afloat.

The only way to fix that is to inject liquidity or reduce expenses within the system. I have no reason to believe that those who want to provide “free” healthcare to everyone have the understanding of basic economics to make a positive impact. Everything else is a fart in a hurricane.

 

[NYEMMED]

There's no good solution for this. In one part of town we have two major hospitals that rotate their ambulance diversion. Both are constantly overcrowded and full. At least at one facility they just started builidng (the hospital is only 3 years old) and will double ED capacity this year, and next year will have twice the inpatient beds. My experience though is that if you build an ED/Hospital bigger it only generates more patient visits and the overcrowding is unchanged.

We really just need to do appropriate triage, and let the dental pains/ankle sprains etc self-assort out the door if they feel they've waited too long to be seen.

Gasp.

But then they will LWOT???
That is the ultimate no no. Everybody must get their Motrin prescription for dental pains, and ace wraps for ankle pain.

In reality we all know these don’t need to be in the ED.

However we all work for some Noctor, Nurse, Lawyer, or MBA who feel this is the absolutely worst thing ever, and have no clue on the actual patient care side...

 

[Vandalia]

There is no solution being proposed because most people don’t understand the problem, and of the few who do, about half of them helped to create it or support policies that will only worsen it.

What is being described as a capacity or boarding problem is really nothing more than a revenue and expense problem. That is to say, a series of policies were implemented about a decade ago that significantly decreased hospital revenues (i.e. Medicare cuts, shifting patients from private insurance to Medicaid or making them functionally uninsured with high out of pocket plans, etc.) and increased expenses (EMR, CMS compliance, etc.). The result was that hospitals that were operating on narrow margins of 3-5% were cut to the red and had to reduce services (ie beds), consolidate to spread expenses, or simply close. Crowding in the ED is simply a byproduct of what happens when hospitals cut expenses and divert resources to revenue generating service lines such as ortho, CV surgery, etc. so that they can stay afloat.

The only way to fix that is to inject liquidity or reduce expenses within the system. I have no reason to believe that those who want to provide “free” healthcare to everyone have the understanding of basic economics to make a positive impact. Everything else is a fart in a hurricane.

There have been three new hospitals built within the last ten years in the area. All of them devoted very significant resources (money) to architecture and general lavishness, all the while increasing administrative salaries and "bloat." There is plenty of money there, it is simply a matter of where they want to spend it. A party to unveil a $500K sculpture provides more of a venue to see and be seen than hiring care managers on the floors and staff in the ED.

Again, in many places - but certainly not all, there are most definitely exceptions - it is not a lack of money. It is the same way a couple earning $800K a year can be broke, and a couple that never earned more than $50K a year in their life can leave a couple million in their will.

 

[thegenius]

True.

Truthfully, in 2 hrs she already had most of her workup done. Seeing an MD maybe would have gotten her an echo or a PE study (just tossing ideas out there) but idk what else would have happened w/o examining her.

I read the article. Unless new news came out, nobody knows what she died of. It was probably either a PE or myocarditis, or maybe an arrhythmia.

You can treat PE's but treatment especially in the first several hours doesn't do all that much. Clots can still break off, you can have ongoing RV ischemia with existing clot.

arrhythmias you can obviously treat for the most part

myocarditis? not much you can do besides supportive care.

If she was back though, she would have been (presumably) on a monitor and nurses would be able to see vital sign badness and doctors could have intervened. Very sad, 1 in a million case.

 

[thegenius]

A real freaking SURGE is when a busload of hemophiliacs is hit by a drunk driver and turns over.

LMAO

 

[thegenius]

I’m sick of being so full that we board into the ED. Why in heaven’s name does the ED always have to have a different EMR than the rest of the friggin hospital? Why can’t ED RNs “see” my orders or my contact info? It’s all Epic..but not the same. . .

The first week of the year was miserable. The ED wanted to admit everything. On a good day our admit rate is twice the national average. Outside hospitals wanted to transfer all this bull****. We have lost most of our case managers (I’m sure its one of those cost saving things that measures that saved a couple hundred bucks that only increased our LOS and lost a few million bucks).

Our wait times go up, our pay mix gets worse, our admit rate goes up, our LOS goes up and like 90% of the patient calls to me are “handoffs”.

Sorry for venting. I’m sick of being miserable from a tonsillectomy, but I know this is a big problem for my EM colleagues. It is a problem for us inpatient folks too.

Only going to get worse as our health care costs rise, insurance becomes less affordable, and each year millions more go without insurance. Once you get on Medicaid or some other pointless insurance, health care becomes "free" to the extent that no hospital is going to go after a pt with a $40,000 if they only make $50,000 / year. Not when hospitals have to take care of pts per EMTALA.

Our system is slowly, but perhaps irreparably, swirling down the drain. Its like being sucked into a black hole. Once you are within the event horizon, there ain't no coming back.

 

[thegenius]

I do think there is something to be said about how to fix the problem of people going to the ED for non-emergencies and how the ED handles them.

If hospital admin are willing to back up the doctors, and lose a little bit of money, the answer above is easy.

Just discharge them.

It will piss off a lot of patients, and they will write complaints letters. And hospital admin need to ignore them and defend doctors for summarily discharging knee pain and all the other clearly non-emergent stuff that occurs.

I agree with that Atlantic article from several months ago. Americans are hypochondriacs and they want free health care. Makes for a terrible system.

Once we force people to pay for their own health care, and use insurance only to defend against catastrophic care, many (but not all) of these problems will go away

 

[ShockIndex]

There have been three new hospitals built within the last ten years in the area. All of them devoted very significant resources (money) to architecture and general lavishness, all the while increasing administrative salaries and "bloat." There is plenty of money there, it is simply a matter of where they want to spend it. A party to unveil a $500K sculpture provides more of a venue to see and be seen than hiring care managers on the floors and staff in the ED.

Again, in many places - but certainly not all, there are most definitely exceptions - it is not a lack of money. It is the same way a couple earning $800K a year can be broke, and a couple that never earned more than $50K a year in their life can leave a couple million in their will.

The decline in hospital revenues (largely from a $700B Medicare cut) since 2010 is a fact. The overwhelming trend toward hospital closures and consolidation of entire healthcare systems across the country in response to shrinking revenues is also a fact.

 

[Vandalia]

The decline in hospital revenues (largely from a $700B Medicare cut) since 2010 is a fact. The overwhelming trend toward hospital closures and consolidation of entire healthcare systems across the country in response to shrinking revenues is also a fact.

Except revenues are rising at a rate greater than inflation:

"According to Definitive Healthcare data, average net patient revenue (NPR) at U.S. hospitals has steadily increased from $282.7 million in 2014 to $334.5 million in 2018, with average hospital operating expenses following a similar upward trend. In the same time period, average operating expenses have increased from $264.2 million to $313.9 million per year."

According to CMS, actual hospital revenue has been increasing at a fairly consistent rate of roughly 5% per year every year since 2010. The most recently available data shows that hospital revenue increased by 4.6% in 2017 after an increase of 5.6% in 2016.

 

[ShockIndex]

Except revenues are rising at a rate greater than inflation:

"According to Definitive Healthcare data, average net patient revenue (NPR) at U.S. hospitals has steadily increased from $282.7 million in 2014 to $334.5 million in 2018, with average hospital operating expenses following a similar upward trend. In the same time period, average operating expenses have increased from $264.2 million to $313.9 million per year."

According to CMS, actual hospital revenue has been increasing at a fairly consistent rate of roughly 5% per year every year since 2010. The most recently available data shows that hospital revenue increased by 4.6% in 2017 after an increase of 5.6% in 2016.

Net revenues my friend, not gross; total income minus operating EXPENSES. Read this article on hospital operating margins for public and non-profit institutions:

Operating margins stabilize, but not-for-profit hospitals still vulnerable

Median annual revenue growth rose to 5.1% while expense growth dropped to 5% in 2018, marking the first time revenue has topped expenses since 2015.

www.modernhealthcare.com

Operating margins plummeted from 2010 until just last year and the stabilization was driven by aggressive expense control such as cutting excess capacity. Still, an average 1.7% operating margin is anemic across these institutions that form the backbone of our healthcare system. The main reason why it hasn’t been a disaster is that hospitals have offset operating losses with non-operating income (investments, philanthropy, etc.) Meanwhile, $700B in gross revenue over 10 years was pulled out of Medicare that was largely directed at hospital bottom lines since Medicare beneficiaries are the largest and fastest growing users of acute care services.

This is why hospitals in states that accepted the Medicaid expansion are doing, on average, better than those in states that didn’t...for now.

 

[deleted836128]

Is it possible she died because administration told all the doctors they had to rush to see all the non-emergency patients in less than 15 minutes or they'd be fired?

From a personal perspective, it's worth asking yourself if seeing the non-emergencies has become more important than people who are sick or dying, so administrators to get bigger bonuses, is it worth making the psychological and personal sacrifices required by a specialty criminally hijacked and held hostage by people who don't care about patients, physicians or nurses?

From a patient care standpoint, it's also worth asking, if that's the state of EM in many emergency departments, what's the solution?

It may help to start by letting the public know that immense pressure is placed on doctors and nurse to see non-emergencies to the extent that it may be endangering the patients who need the ED the most: The sick and dying.

Yes, this is exactly what I was thinking.

Here's something that disturbs me. I am a PA heavily involved in the admin side of things (unfortunately) and it seems to me that all the nursing director cares about is discharge length of stay times, and waiting room times. So you know what? She LOVES the patients who come in for sore throats and med refills. "Because they make our times look good!" (Ugh, makes me nauseated) So these guys get to get pulled back right away. One dude is in the waiting room for three hours vomiting into a trash can and watches in horror as the dude who comes in with "need anxiety med refilled" and "scabs on my head for two years" goes back right away! And waves to the vomiting dude on his way out to the parking lot.

The low acuity patients get allllll the attention. They wait less. They are the ones who the charge nurse nags you to see first when the doc or PA has a list of patients to go see (unless there's someone obviously critical, of course). Because the charge nurse wants you to "turn and burn" these patients. Sometimes they'll throw them in a hallway in a chair and yell "PROVIDER TO THE HALLWAY, PLEASE," and you'll have to put aside the patients who are actually sick to see that patient.

I have gotten emails that I am not getting my level 4s and 5s out fast enough. "Make them a priority." "We want them in and out in less than 90 minutes." After so many emails and texts about this it becomes automatic for me to focus on that, and it's to the detriment of the patients who actually need me. The patients who actually need me get less time with me, and one day I will make a terrible error because I was focused on Johnny Anklesprain.

And we are reinforcing this. We are encouraging patients to come to the ER for their stupid urgent care or primary care type issues because "they get me in so fast!" So we are making the problem way worse. The number of patients who come in for non-emergencies is only going to increase if we continue this.

Would not be surprised if that's the kind of crap that was going on in THAT ER.

 

[Vandalia]

Net revenues my friend, not gross; total income minus operating EXPENSES. Read this article on hospital operating margins for public and non-profit institutions:

Operating margins stabilize, but not-for-profit hospitals still vulnerable

Median annual revenue growth rose to 5.1% while expense growth dropped to 5% in 2018, marking the first time revenue has topped expenses since 2015.

www.modernhealthcare.com

There are certainly some truly rural or urban hospitals that are in dire financial danger. However, one need only look at spending patterns to see that most are not. Look at acquisitions, new construction, and executive salaries as proof. As I said our local nonprofit "healthcare systems" are on a massive building spree. The same at my medical alma mater. Banks do not offer loans, or more correctly, investors do not buy bonds if they are concerned about repayment. Now for profit hospitals are a different story. They essentially have to operate with one hand tied behind their back since they need to provide financial metrics that need to compete with different industries.

Those who provide for "undeserved communities" are in trouble. We have seen the recent closure in Philadelphia that had (or was to have) a dire effect on GME. I also would not invest in HCA. However, for large, non-profit health-systems they literally have more money than they know what to do with. I have seen the financials. I know West Virginia University (WVU Medicine) is gobbling up every small hospital in sight, and believe me they do not intend to lose money.

The first rule is that it is impossible to make generic statements about U.S. hospitals. The second rule, is that an accountant can make "operating revenue" be whatever they want it to be. Making the net revenue look high is more difficult and can involve breaking GAAP (if not the law), but it is very easy to minimize "profit" or even show a loss.

 

[Amazingmuzmo]

This just shifts the problem. Hospital A closes and shifts all patients to Hospitals B & C in the metro area. EMS picks up a patient and has to travel greater distances to deliver the patient. This ends up leaving 911 ambulances out of service to be unable to respond to calls. So instead of patients waiting longer after being triaged, it ends up being patients at home not triaged and not getting care dying instead of triaged patients getting care quickly in the ER when they are indeed sick.

This is why there is a movement to eliminate diversion. It ends up causing more harm to patients at the benefit of the hospital on diversion.

This is not a good idea. Just few months ago have worked at busy Level 1 trauma center where diversion was needed. Incredibly unsafe at the time, not enough staff, patient's with 3rd degree HB in hallways because all rooms are taken, most rooms taken up by severe trauma or peri-arrest ICU patients. In what world would taking the ability for this hospital to be on diversion lead to better outcomes? I understand that it will lead to longer times until other patients get triaged or care but this ED literally does not have the capability to care for those patients even if they were brought to the ED.

 

[southerndoc]

This is not a good idea. Just few months ago have worked at busy Level 1 trauma center where diversion was needed. Incredibly unsafe at the time, not enough staff, patient's with 3rd degree HB in hallways because all rooms are taken, most rooms taken up by severe trauma or peri-arrest patients. In what world would taking the ability for this hospital to be on diversion lead to better outcomes? I understand that it will lead to longer times until other patients get triaged or care but this ED literally does not have the capability to care for those patients even if they were brought to the ED.

So that third degree heart block is better off at home waiting for 70 minutes for an EMS response? The cardiac arrest victim waiting 112 minutes for an ambulance to show up (number isn't made up, it happened last year)? The anaphylaxis patient dying because an ambulance took 35 minutes to come from a neighboring county because all the other ambulances in the patient's county were tied up transporting to another hospital because the local hospital was on diversion (not made up, it happened)?

There are consequences beyond just the hospital's convenience.

 

[Amazingmuzmo]

So that third degree heart block is better off at home waiting for 70 minutes for an EMS response? The cardiac arrest victim waiting 112 minutes for an ambulance to show up (number isn't made up, it happened last year)? The anaphylaxis patient dying because an ambulance took 35 minutes to come from a neighboring county because all the other ambulances in the patient's county were tied up transporting to another hospital because the local hospital was on diversion (not made up, it happened)?

There are consequences beyond just the hospital's convenience.

And what are those patients supposed to do when they arrive at an ED that is completely and utterly incapable of treating them at all? Just lay there and die. Or instead should they be transported to a hospital that may actually give them a shot at surviving? I can understand the frustration but in the cases of diversion that I have been a part of, the situation of the ED was such that the capabilities of the ED were already stretched far beyond the patients needs that were ALREADY there, let alone any thought of addition patients being brought in. It's unethical to bring someone to a place where you essentially know they cannot be treat and will likely die as opposed to somewhere that offers them a chance.

I must also note that my experiences are within the greater NYC metropolitan area and 2 hour ambulance rides are largely not occurring given the abundance of hospitals in this area.

 

[southerndoc]

It's simple. You make the lower acuity patients wait. No reason that a sprained ankle needs to be seen that quickly. They will not die if brought to the hospital on "diversion." If they do, it's because either their condition was not amenable to treatment or they did not appropriately triage the other patients.

 

[dpmd]

So that third degree heart block is better off at home waiting for 70 minutes for an EMS response? The cardiac arrest victim waiting 112 minutes for an ambulance to show up (number isn't made up, it happened last year)? The anaphylaxis patient dying because an ambulance took 35 minutes to come from a neighboring county because all the other ambulances in the patient's county were tied up transporting to another hospital because the local hospital was on diversion (not made up, it happened)?

There are consequences beyond just the hospital's convenience.

If the hospital that needed to divert instead got those patients it might have reduced the time the ambulance had to drive if the next available hospital was far, but if the hospital was so packed they couldn't get those ambulance patients into room then the ambulance is still going to be out of service until they can get rid of the patient. 20 to 45 minutes is common and there are instances where it is up to 3 hours. If there was a hospital 10 minutes away they could have taken the patient to instead then it would be better for all parties if the impacted hospital was on diversion. If the nearest hospital is 2 hours away then it would be a different story.

 

[southerndoc]

As an EMS physician, I am well versed in wall times. However, I can tell you that diversion leads to worse outcomes overall. Perhaps in NYC this doesn't make a difference, but when the nearest hospital is 30 minutes away it does. Most of the US doesn't operate like NYC does.

 

[dpmd]

As an EMS physician, I am well versed in wall times. However, I can tell you that diversion leads to worse outcomes overall. Perhaps in NYC this doesn't make a difference, but when the nearest hospital is 30 minutes away it does. Most of the US doesn't operate like NYC does.

Hell I am in a place where the only trauma hospital in the county is in this town but there are 5 other hospitals with ERs that are capable of taking most stuff including some trauma patients during the rare circumstances the trauma center had to go on diversion (and having been there at the time of one such episode I can tell you that the outcomes wouldn't have been any better had the patient still showed up during). Do they do worse than when hospitals don't need to divert, sure. But that isn't what you should be comparing. I am all for penalizing hospitals who use diversion as a crutch so they don't have to deal with surges that should be able to be anticipated, or to avoid having as much staffing, or whatever. I am just arguing that banning it or discouraging it withiut any other changes isn't going to make things better.

 

[deleted109597]

Diversion isn't helpful. Either patients need acute care, or they don't.
Sure, a system where dispatch appropriately sends patients to the closest, most appropriate, least burdened hospital sounds ideal. Most city councils are resistant to this, and most hospitals are as well.
But like southerndoc, I am also aware of multiple patients actually dying due to diversion. Yes, there are stories of people dying in waiting rooms as well. The numbers are much, much lower. They're also classically due to staff ignoring obvious ominous signs.

Diversion should be illegal except in the case of internal disaster. Full stop. Every hospital in the US is operating at near capacity every day. It's not like one going on diversion doesn't cause the dominoes to fall rapidly on the others.

 

[TooMuchResearch]

When we get an unstable patient through triage when we're otherwise overwhelmed, we figure it out and take care of the patient. You know what's better than an unstable patient from triage? One coming by ambulance. We have more warning and they might even have an IV or two. The average patient volume doesn't go up and patients get better care.

Our major hospital is relatively close to multiple other larger facilities. When one of us diverts, the others quickly follow, and the cycle starts over. All it seems to accomplish is we end up with patients who still request transfer to their normal system for continuity of care with their specialists.

When I'm working outside of the city, it's a long ambulance ride for the patient if we divert (and we don't for that reason).

And what are those patients supposed to do when they arrive at an ED that is completely and utterly incapable of treating them at all? Just lay there and die. Or instead should they be transported to a hospital that may actually give them a shot at surviving? I can understand the frustration but in the cases of diversion that I have been a part of, the situation of the ED was such that the capabilities of the ED were already stretched far beyond the patients needs that were ALREADY there, let alone any thought of addition patients being brought in. It's unethical to bring someone to a place where you essentially know they cannot be treat and will likely die as opposed to somewhere that offers them a chance.

I must also note that my experiences are within the greater NYC metropolitan area and 2 hour ambulance rides are largely not occurring given the abundance of hospitals in this area.