Primary Care in the ER?

Original article at: http://tinyurl.com/washpost071309 See my points/comments in bold/blue

A Critical Situation For Area Hospitals
Primary-Care Needs Spill Over Into ERs

This title is inaccurate: it implies patients are seeking "primary care" in the ED. This is false. Primary care (pap smears/breast exams, colonoscopies, diabetes managment etc) is not done in the ED, rather it's people who no longer have a PCP coming to the ED for their acute problems that would otherwise have gone to their PCP's office.

By Yamiche Alcindor

Washington Post Staff Writer Monday, July 13, 2009

Hospital emergency departments across the region are overflowing with patients who have been battered by the recession and are increasingly using hospitals as their primary source of health care, according to local and national health officials.

What national officals? This article mentions none.

At the District's Providence Hospital, emergency room visits increased by 13 percent in the past year. In Montgomery County, the number of patients seeking free care at community clinics designed to divert people from emergency rooms rose by 43 percent, many of them referred by hospitals.

The community clinics are not focused on providing ACUTE care, they are there for chronic, preventative and primary care purposes. They provide a different service line than the ED. That 43% increase are the people that have no PCP and are going there for their ongoing, primary medical services.

... A national debate is underway about how to reduce health-care costs and provide medical coverage to everyone. Diverting people from emergency rooms -- which are an inefficient and expensive way of delivering basic health care -- is a central issue, said Larry Gage, president of the National Association of Public Hospitals and Health Systems.

Don't forget dwindling reimbursements for emergency care are also to blame. Trauma funding is often inadequate as well. Lack of on call specialists, lack of qualified attending MD's and Nurses as well. Also patient "boarding" and psychiatric/mental health patient "holds" ....ALL these things are contributing in addition to people merely lacking a primary MD.

"The absolute number of people using emergency rooms has gone up as much as 20 to 30 percent in the last six to eight months due to the recession and people losing their jobs," he said. "The only option in their minds is going to the hospital."

...also, it's the only thing they KNOW. In my personal experience, quite a few of the folks I've had to refer to community clinics or free clinics had no idea they even existed. (Now here's an opportunity for public education!)

Last year, Providence and the D.C. Primary Care Association launched the ED Diversion Project, which places community health workers in waiting areas to help patients obtain primary-care doctors and sign up for Medicaid and Medicare coverage.

Now this is a GREAT idea! However, don't the hospitals have social workers and medicare/medicaid workers already? Can't the ED care team give these people the information to make a phone call the next day or give them directions to these people's offices? Why do the taxpayers (again!) have to fund this "diversion project" when we already have health care workers who can make the referrals?

Zoila Alvarez, who arrived in the United States three years ago from El Salvador, has been a patient at Mary's Center for a year. Before she found the clinic, she sought prenatal care and treatment for depression at hospital emergency rooms, she said.

Interesting, here is a lady (I'll assume a legal immigrant) who comes to the US (no mention of husband or family) to have her baby who "becomes" a US citizen upon birth....

...Albertha Boone, 55, of Southeast Washington, can relate. Her last visit to a primary-care doctor was in 1989, she said, even though she has asthma and high blood pressure and needs to have major knee surgery.

She said she has a monthly income of $1,400: $1,000 from a disability check and $400 from a part-time job as a clerical assistant. After she pays rent -- $800 -- she uses the remaining $600 to pay for utilities and buy groceries. She said that she has Medicare coverage but that it won't pay for regular doctor visits or for the knee surgery a doctor has told her she should have. So when she needs care, she will continue to go to an emergency room for treatment.

WHAT????? Medicare not paying for doctor visits? I don't believe this statement. However, if you tell me that she can't find a PCP who will TAKE medicare, then I can swallow that a bit more. We need more information here because this doesn't make sense to me.

"Moving forward, we need to do more so that people are aware of clinics in their neighborhoods," said Pierre Vigilance, director of the D.C. Department of Health. "We have to make sure that these clinics are available to people when they need them."

I agree, get the word out, run a campaign or a public education incentive. However, I postulate that the root cause of a lot of this (economy aside) from the provider's standpoint is the whole EMTALA (http://tinyurl.com/emtala) issue. Those of you in the "biz" you know what I'm talking about...the whole legislated principle of ED's not "turning" people away as well as ED's doing WAY MORE than they were designed to do beyond providing the legally mandated "Emergency Medical Screening" assessment/exam.

Emergency Department Overuse - Austin Tx

In a recent article posted in the online version of the Austin American Statesman Newspaper, Ms. Mary Roser (a staff writer) comments on a recent release of information that shows that one ED in Austin Texas log over 2678 patient visits from just nine individual patients. These astounding numbers were released by a nonprofit group in central Texas which provides care for uninsured and low income patients.

The author goes on to discuss some specific numbers in situations which paralleled that of the current state of our EDs nationwide. The problem of ED overcrowding is not new, nor is the problem of overuse of our nations emergency departments.

In her article Ms. Roser reports that between the years 2003 in 2008 there were 9 patients who accounted for 2678 merged department visits in that time. In particular, one of these patients spent 145 days in the ED during the last year alone.

Ms.Roser further discusses in her article, some considerations for possible causes of these apparently excessive uses of the emergency department. From her article it seems that one of the main causes is that these patients have no place else to receive their health care. Which, interestingly, echoes back former Pres. George W. Bush's statement about our nation's health care. Mr. Bush, when asked about the lack of primary health care in America, stated that people do have access to health care through the emergency department.

The article also attempts to explain some things are being done to appropriately manage these recurring patients. One of the doctors interviewed for the article stated that their primary focus is to assess and stabilize any medical emergencies but the problem becomes when they must decide where and how inappropriate discharge plan would be undertaken for the patient. The problem becomes that some patients still don't have access to basic health care needs, and they find that they have nowhere to turn other than emergency departments for their care.

In particular I have seen similar problems firsthand during my times working in the ER. The problem, as Ms. Roser discusses in her article, is not unique nor inherent to any one particular region, community, or facility. That being said, the solution to this ever growing problem is not an easy one to solve. A situation such as this, would require cooperation and collaboration between the health care facility, community organizations, local, state, and federal legislators.

Several readers of this article have left their comments on the newspaper website. I would like to take a few minutes and reply to some of those comments directly on this blog.

One poster (chukalukabus): seems to have the opinion that the overuse of their ED is mostly due to a problem with illegal aliens. As we are talking about a hospital in Austin Texas, I can understand this posters position and concern. It stands to good reason that in this person's region, there are many undocumented illegals residing. These same people, again I would logically assume, do not have a third-party health-insurance, and, are for the most part unfamiliar with public or free community resources for health care needs. I also believe that this poster does not realize that the problem of ED overuse is not a regional one but of national scope. Because it is a bigger problem than just locally, more than likely there are other factors at play here than just illegal aliens using the ED for healthcare.

Another poster (dterbush): remarks that if there were more affordable primary or urgent care type clinics that the emergency departments would not be as affected as much with overuse. This is a good thought. And this may be a potential solution which we are currently watching unfold. There is a growing trend nationwide towards establishing retail health care clinics to meet some primary care needs. Some of the largest venues for these are found in places such as Wal-Mart and the CVS pharmacies. These walk-in clinics, while not a substitute for primary care, are quite capable of treating a large host of maladies which typically bring people to the ED. However, the retail health clinic system, is in its early stages of establishing itself in building its unique niche in the health care industry.

Other posters who have applied to this article have indicated that "Universal Health care" might be the answer as well. We don't know this yet, if it would be beneficial or not. Additionally, as we hear more about universal health care daily, our understanding of just what universal health care is might become different than what we perceive it to be.

I suggest that any solution for this problem is still years away, multifaceted, and will have profound political and social implications to strictly address.


You can refer to the original article here:

The Economy and Specialty (CEN) Certification...?

So I was sitting down tonight watching President Obama's first press conference (8:00 pm EST ????)....Anyways, as he was explaining his take on the pulse of our current economy and how he has seen "first hand" the effects of it on places like Elkhart IN that saw it's jobless rate nearly triple in the last 3 months, and how people are out of work and loosing jobs; I was considering what relevance this state of affairs has to achieving specialty board certification for nurses.

Mr. Obama was explaining his take on principles of economy that decreased consumer credit causes people to spend less, companies to produce less and companies to have to reduce their costs on such things as payrolls and numbers of employees. He went on to talk some about the hardships faced by "Main st" while on the unemployment dole and I got to thinking about nurses...Specifically my brethren Emergency Nurses.

Through many online and in person conversations, one of the recurring themes as to why more ER nurses don't pursue specialty certification (CEN) is their "lack of interest or motivation". Some people I've talked to have even said the extraordinary lengths their employers will go through to support and encourage certifications. At some facilities, the nurses actually risk NOTHING at all due to employer compensations - and they (the nurses) still aren't motivated to pursue certification.

Although we hear about a nursing shortage (and I'm not here to tell you there isn't one) we know that in hospitals, the payroll is THE SINGLE LARGEST line item and it is a direct reflection of the current numbers on the employee payroll. So if a company is going to start "downsizing" to control it's costs, don't you think the choice of who stays and who goes will factor in things like credentials or qualifications.

Like myself, ALL RN's came on board with only a generic entry-level license (AKA right to practice) in a general setting. No RN comes out of nursing school with a competency or credential to practice ER nursing. It is through the on-the-job-training, experience, mentoring and good 'ole 'elbow grease' that many RNs working in an ER setting claim the title "Emergency Nurse".

Until those same nurses acquire a professionally recognized and verifiable credential as the CEN (Certified Emergency Nurse), they technically remain just a generalist in nature.

Now, don't get me wrong, there are THOUSANDS of RNs working in our nation's ERs who probably have the experience and knowledge commensurate with that of the CEN credential, however, they have not been recognized in that manner...yet.

Once the ER RN decides to prepare for and sit for the CEN exam, and then PASS it - then they can truly call themselves an "Emergency Nurse".

In today's health care arena we are already seeing a shift in our Emergency Medicine Doctors in that more and more hospitals and practice groups are mandating Board Certification in Emergency Medicine. The days are slipping by where once a Family Practice trained MD could take a job in an ER and practice as an "Emergency Physician". The credentialing, accrediting and regulatory groups are more and more looking to set the bar "higher" for the attainment of an elevated, verified skill, knowledge and practice level. And like the RN's -this does NOT mean that there aren't some FP's out there that are not EM boarded, practicing at an equivalent high level as their boarded peers; on the contrary, there are assuredly MANY who are.

But as we see this push and shift from non EM boarded MD's to EM boarded one's, undoubtedly natural progression will dictate at some point that it is desirable for the RNs as well as it denotes a verified specialty locus of practice.

So as we see our nation's economy stumbling, the workforce dwindling and health care crumbling, it becomes more concerning for the Emergency RN who wants to secure their place in teh workforce to attain certification in their speciality.

Some call it pride,
Others call it professionalism,
Others still call it accountability,
I say it is more and more likely that someday not too far off, it will be mandatory....

LINKS for more information:
-The BCEN (who adminsters the CEN)
-The Emergency Nurses Association (ENA)
-CEN exam preparation continuing education