Emergency Room Manager

In my limited experience as a hospital patient, the nurses always seem like the ones doing ALL the work. The doctors come in for a few minutes and are gone. Do you think the nurses get the respect they deserve, and is there ever hierarchical tension between the doctors and nurses?

Asked by NED almost 13 years ago

We have a great relationship with the ER physicians and nurses here--very respectful and collegial. The physicians trust the care that the nurses give, and rely on the nurses to keep them updated on the patient's condition. ER nurses also have great intuition and sixth sense. Since we are with the patient more, sometimes we will know what is wrong before the doc does. It is true that the nurse does most of the physical work and bedside tasks with the patient. The docs are doing the diagnostic puzzle solving behind the scenes. I think the stereotype you mentioned is continued because of medical TV shows and movies. There may be lack of respect in some ER's, but not mine. When I first started here, I saw a physician give a patient a bedpan and then clean the patient up. I asked her if she had been a nurse before she went to medical school, and sure enough, she had been an ER nurse. Generally, you won't see physicians doing bedpans.....or cleaning up vomit....but I am ok with that.

What's the best time to arrive at an ER to avoid long waits?

Asked by Ginny M. almost 13 years ago

The "slowest" times in our ER are Thursdays all day, and Friday mornings. Mondays are the worst! Our city has an NFL team, and during football season, it is really quiet on Sunday afternoons during the games. So if you can “schedule” your emergency :) .... October generally is a slow month, so maybe the last Thursday morning in October would be good. Summer is full of active people that have hurt themselves doing something. Winter is flu and all kinds of infectious diseases. We’re geared to take care of really sick and dying patients, and we do that very well. If you are really sick, you will be seen quickly. However, if you have a minor illness or injury, the sickest patient will always be seen first. We recently purchased software that will allow a patient with a minor injury or illness to "reserve" a place in line from computer or smart phone. Once we are up and running it will be interesting to see what happens. There is a lot of brainstorming on how we can take faster care of patients with minor illnesses or injuries.

If a patient is uninsured, will he still get treated?

Asked by Tom_1980 almost 13 years ago

YES YES YES!! Emergency Departments are mandated by the federal government to make sure that a patient that comes to the ER is treated for an emergency medical condition. We are not allowed to ask about insurance or ability to pay with the patient when they walk thru the door. That does not mean, however, that the patient will not receive a bill for their treatment afterwards. There is a misconception in this country that "ER care is free." It is not free, and it is extremely expensive, but we cannot ask an ER patient for money or proof of insurance up front. We also cannot give different care in the ER to patients who have insurance over the un-insured or Medicaid patient. The uninsured have difficulty in finding follow-up care and so end up in the ER for their minor illnesses because we cannot demand payment before they are seen. I am confident in our ER that we do not discriminate with our treatment of patients. Right now, our ER alone has over one million dollars in unpaid debt from patients who are unable to pay for their care. Who pays for that? We all do, in higher taxes, higher insurance premiums, and higher prices for those who are able to pay. There is no free lunch.

Have you ever seen violence in the ER?

Asked by Swrv almost 13 years ago

Daily! It is an ongoing issue and causes staff a lot of worry and anxiety. We have a security officer at the front, and all of our doors are locked, however there is no way at this time to stop people, patients or visitors, from bringing weapons into the ER. A couple of the ERs in our area have metal detectors, but we are in a suburban area and it doesn't set a "welcoming" tone. And no one needs to have a weapon to be violent, fists and arms and legs are sufficient to cause injury. I have been pushed and shoved, threatened with death and bodily harm, pinned onto a gurney by an intoxicated huge guy. Most of the violence is due to drugs and alcohol in either patients or their families/visitors. Our state is attempting to pass laws that would make it a felony to assault a health care worker. There is also a tremendous amount of verbal abuse and threats and it is getting worse day by day. We are not even in a high crime area. A lot of times I just want to say, "where is your mother, and who taught you to act like this?"

Are there any instances where an emergency room CAN turn a patient away?

Asked by sayahhh almost 13 years ago

In 1986 Congress passed a law called "EMTALA", the Emergency Medical Treatment and Labor Act, which requires hospitals to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to pay. The actual law is only a couple of pages long, but the interpretation of the law has kept lawyers busy for 25 years. There is a good article in Wikepedia on this very subject. To answer your question--No. Where I work, every employee is highly trained in the EMTALA rules and regs, so I have not seen it here. Hospitals can be fined hundreds of thousands of dollars if an investigation shows that emergency care was refused to anyone. Patients who think this has happened to them have reported this to their various state and federal agencies, and the hospital is investigated. However, not every reason a patient comes to the ER is an emergency medical condition. The law requires that the patient be examined for an emergency medical condition. If the condition is not deemed an emergency medical condition (and there is a whole lot of people trying to interpret what that means), then the ER is not obligated to treat you, however, they must examine you. By the time the ER doc is done examining a person, they end up treating the patient anyway. This law is sometimes called an "unfunded mandate", because there is no funding to go along with the law. The law says we have to do it, but the patient has to pay for it. If the patient can't pay for it, whether through insurance or their own money, then the hospital ends up eating the cost for that care. This is one reason why I believe emergency care is so expensive. That's a whole other topic....

If a celebrity, local government official, or some other person of prominence showed up at your ER, would they be seen faster than a normal patient?

Asked by Scooby over 12 years ago

It depends. Our hospital CEO has been a patient in the ER a couple of times, and initially no one knew who he was and he just went through the system like anyone else. He thought the care was outstanding, and he was treated appropriately. Thank goodness. We have also had a "secret shopper" program to see how patients are treated, we are not doing that any more. The only thing the 'secret shoppers" do anymore is monitor staff handwashing. Several years ago, a patient who had Secret Service protection ( that is all I am going to say) needed to come to the ER. The Secret Service called ahead of time, and we arranged a "back door" entry, and expedited this person's treatment. It was so well managed, that even many of the staff had no idea what was going on. At a previous hospital we treated the mother of a prominent state official, and we expedited her care, and made sure everything was really private, but she was not seen before anyone who was sicker. I always want to have my family or myself treated in the ER that I work in because I know how good of care we give. When I know we have to come to the ER, I usually call ahead to see which doctors and nurses are on, and generally we have that "perk" of asking a specific person to take care of you. Of all of the times me or my family members have been in the ER, however, we have never bumped anyone that was sicker. This is a little off the subject, but one of my jobs is to make sure that no staff look at medical reccords of "famous" people, or unusual patients or accidents, unless they are directly involved in the care of the patient. Since our medical record is electronic and protected, you can easily see when someone is poking around that shouldn't be--it shows when you logged in and from what IP address. That can get you fired in a heartbeat.

How often do nurses go back to school to become doctors?

Asked by sayahhhh almost 13 years ago

I have seen a few, but mostly I see RNs getting advance nursing degrees like nurse practioner, and Masters or Doctorates in nursing. It is a different mind-set, nursing vs physician. There is a different approach to the patient and a different scope of practice. I think being a nurse would help you be a better physician, though, because of the time a nurse spends with the patient, and the interpersonal skills needed.

In a recent Republican debate, Ron Paul was asked whether uninsured patients should be denied ER treatment and he responded that that's what freedom was all about: the choice to take your own risks. The (conservative) audience cheered, although it wasn't clear whether it was merely in approval of individual liberty, or in favor of letting uninsured people die. As a professional healthcare provider in the trenches, how do you feel about it?

Asked by Kyle almost 13 years ago

Individual liberty--feel strongly about it! With great privilege, however, come great responsibilities. Freedom without responsibility is anarachy. Responsibility without freedom is slavery. I think greater people than me said those things before.... As Americans, we have individual liberty, and also responsibility to others. Letting uninsured people die--what kind of question is that? That's kind of like asking the question "when did you stop beating your wife?" I think you can come up with a more thoughtful and informed question than that. Let me help you think about what you are trying to perhaps ask-- Is there a limit to what we, personally and collectively, should spend on keeping people alive? What responsiblity do we (personally and collectively), have to others in terms of their healthcare and financial responsibility? Should people be accountable for the choices or decisions they make that are under their control?--ie, should others pay for uninsured patients that smoke, are overweight, ride a motorcycle without a helmet, etc? Former Colorado governor Richard Lamm said about 30 years ago "the elderly should just die and get out of the way." That is a polarizing statement. Ask me a question that puts some thought into it, because these are the very questions that healthcare professionals and government officials wrestle with every day. I'll try to answer that with my opinion and the opinion of others that are more qualified than me.

How many patients can your ER handle at once and how bad are the wait times?

Asked by katie almost 13 years ago

Our ER has 53 beds, not including the gurneys we put in the halls for the overflows. We are full by 11 AM and stay that way until about 2 AM, then slowly empty out and start all over again. Each nurse cares for about four patients at a time, fewer if the patients are really sick, and more if the illness is minor. We have a good sense of busiest days and times of days. All of the staff, including hospital administration, is very aware of our wait times because it is a marketing and advertising draw. ERs in this area are very competitive and want to make the ER visit for the patient as painless as possible. 85% of our patients are seen by a doctor in 30 minutes or less. If we have an open bed, we take the patient right back into the room, rather than sign them in and tell them to "take a seat" -- this measure has shortened our wait to see a doctor significantly. We have built-in triggers in our computer system that warn us when the waits are getting long, there are too many people lining up out the door (that really happens, it is not a figure of speech!)

Why are ER bathrooms so frequently filthy? I'd think that in hospitals of all places, there would be more concern with germs and therefore more attention to the upkeep.

Asked by Mr Clean almost 13 years ago

They are dirty because they need to be cleaned more! We have three bathrooms for 58 patients, and two public restrooms. They are cleaned once a shift (three times a day), and more if we call them, but it is hard to keep up with them. When the budget trimmers come around, housekeeping is looked at as a non-patient care item, so sometimes the axe falls with those type of departments first. However, a lot of the hospital complaints have to do with cleanliness and I would agree that we don't give that as high of a priority as we should. You can tell a lot about a place by how clean it is/or not. And that is not even taking into account all of the infectious diseases and just plain yuck that you may see. Kind of like a subway platform. Now I digress a little--but follow me here. Any hospital is highly regulated--thousands of pages of rules and regulations that we have to follow to keep our federal funding. The cleaning of blood has different rules, bodily fluids are different, chemicals used to clean are very specific. We can't just wipe off a toilet with a wet wipe like you do at home and call it good. The hospital has a whole department devoted just to making sure that we all follow the rules. The rules and regs are there to protect the patient, and sometimes we spend more time trying to keep the rules than taking care of the patient and keeping them happy and safe.

What draws a registered nurse toward working in an ER as opposed to a 9-to-5 doctor's office? Are there different personality types that are attracted to one vs. the other?

Asked by ayehotpants almost 13 years ago

ER nurses are a special breed! Type A, mavericks, strong personalities who won't take a lot of crap from other nurses. Most of us love the fast-paced environment of the ER--the constantly changing patients, the interesting and strange things that we see on a daily basis. There is a "detective" element to this nurse--what is wrong with this patient? It is a challenge to take a patient who may only say "I don't feel good" and figure out what is wrong and help make them better. Many love the "blood and guts" and we have been called adrenalin junkies. We work very independently, and need to make quick decisions that may have life or death consequences for the patient. Great multi-taskers, we have eyes in the back of our heads, just like mom. The ER is open 24/7, holidays included, so if you want banker's hours, this job is not for you. Most shifts are 12 hours, which can be a killer as you get older (I’m 54). The ER nurses generally are younger and very physically active. The clinic/office nurses are drawn to the more long term nurse/patient relationships and working with the patients in lifestyle changes, education and management of their health problems. The hours are more "regular," and the job is not as physically demanding.

What's the most bizarre thing you have seen? Or perhaps the craziest thing you have seen someone put in a bodily orifice?

Asked by tjspot almost 13 years ago

The creepiest thing I have seen, I wouldn't call it bizarre, but I will never forget it--a patient came in with his arm amputated just above the wrist in a farming accident. When there is a chance to put the part back on, there is always a staff member whose responsibility is to take care of the amputated part. In this case, it was me. I opened the cooler (the patient had been flown in from a rural area), and the arm was just lying there in a plastic bag in a container on ice. It reminded me of "Thing" from the Addams Family. I almost expected the hand to climb out of the cooler by itself. By the way, the surgeons were able to reattach the hand and with a lot of physical therapy, it ended up being a pretty functional hand. Anything you can imagine has been put in a bodily orifice. From the common Lego up the nose, bean in the ear, lost tampon (how do you forget about a tampon?), and you can let your imagination run wild, it has probably happened. There are stories all over ERs about this, but this one was one of my patients--a young man inserted a thin glass chemistry tube about the size of your pinky into his urethra. He had to go to the OR to get that removed. This was not in an orifice, but here is the scenario--I was there. A gentleman had placed a common hex bolt around a certain body part and low and behold it became stuck. It became a medical emergency because the blood flow to the body part was being stopped and it was becoming blue, no blood flow. We had to get a pair of bolt cutters from the hospital engineers, and the physician who happened to be 9 months pregnant, was leaning over the gurney trying to get enough strength to cut that 3/4 inch bolt off before he lost his member. She's nearly in labor, he is screaming and thankfully it worked. After about an hour, he regained blood flow and his pain went away. He said "thanks" and walked out the door. Whatever.... I'm sure there are better stories out there, but I only want to refer to what I've seen or done myself.

What inspired you to go into nursing?

Asked by ShipofFuels almost 13 years ago

I’m afraid I don’t have a wonderfully inspiring story of how I got into the nursing field. I would love to be able to say that the life of Florence Nightingale drew me into nursing, but it was a lot simpler than that. I was originally a music/piano major, and came to the realization that I did not want to practice the piano the rest of my life. At that point I had no idea what I wanted to be when I grew up, but needed a direction. Many of my friends on my dorm room floor were nursing students and I thought “I could do that,” and that’s how it started! Once I got into the classes and clinicals, I loved it!

I went to the ER with a tonsil infection, was looked at by a doctor and given a morphine drip, and sent home later that day without even being admitted. A month later, I got a bill for $14,000 (i am not exaggerating in the slightest: $9,000 hospital bill, $5,000 Doctor's bill). When I filed a complaint, they told me it was so high because I'd been given the most severe non-trauma classification possible (level 5 or something), which apparently I was not even allowed to contest. Who comes up with those absurd valuations?

Asked by tonsils almost 13 years ago

You got a morphine drip for a tonsil infection?  Sweet!!! Seriously—the premise of all emergency visits from the perspective of the physician is that we look for the things that are going to kill you first, and then work down from there.  A severe tonsillitis can cause obstruction in a person’s breathing, or cause an abscess in the tonsil that is a surgical emergency.  A level 5 charge sounds totally appropriate (without reviewing your medical record, of course).  How the ER charges for the care is determined by the federal government.  There are 5 levels, 1 being the least (like stitches being removed), up to a level 5, which are sick people, some who don’t have to be admitted, but come in with a potentially life threatening problem, which yours could have been.  How much the hospital charges for each level is up to the hospital.  In our area, the ER level charges are pretty much the same no matter what hospital you go to. As I mentioned in a couple of previous posts, emergency care is very expensive—one due to it being mandated by the government without funding assistance; everyone pays more to balance out for the people who can’t pay.  Just like auto insurance is high for everyone because of those folks who drive without insurance and then get into an accident…. If you have insurance, the insurance company usually contracts to pay a certain percentage of what the actual bill is.  It is unlikely that the your insurance paid the hospital $9000.  Probably more like $3500.  If you don’t have insurance, most hospitals will negotiate a lower price similar to what the insurance company is paid, and work with a payment plan. I’m glad you are ok, because I have seen patients die with what you had.

Do ER employees eventually get desensitized to morbidity?

Asked by TrimTebow almost 13 years ago

You compartmentalize your life, you have to or you couldn't function day to day. There is a lot of sick humor among staff in the break room. I think that if you don't deal with it as it happens and talk about it honestly with a friend or co-worker, you will eventually burn out or develop self-destructive behaviors. ER nurses are a lot like police officers or firefighters/first responders. There is a lot of substance abuse and depression among us. ER nurses do not come to work impaired (generally), but there is a lot of alcohol use outside of work to deal with what we see on a daily basis.

If someone lands in the ER after overdosing on illegal drugs, are you required to alert the authorities?

Asked by Rx almost 13 years ago

No. The nurses and doctors are not the police, and that is not a part of our job. The medical treatment any patient receives is protected health information and we cannot release that info to anyone unless the patient oks it, or it is subpeonaed in an investigation. Even though some drug use is illegal, substance abuse is considered a medical problem. However, if, in the course of treating a patient, we find that there might be child neglect or domestic abuse or that a crime against another person has happened, we are obligated to report that. Each state has mandatory reporting laws around abuse. But we are reporting the suspected abuse of another person, not the drug use of the patient. If we find illegal drugs or pipes, etc. on a patient, we do call the police and they come and get the stuff, but in our ER I have not seen the police arrest anyone for that after we have called them. They may check for any outstanding warrants, and who knows what that may lead to. We have great relationships with our local law enforcement, but we don't do their job and they don't do ours.

Heh, you guessed exactly what happened > viral tonsillitis that they were concerned would obstruct my airway, and yes: morphine is awesome (i was uninsured and "negotiated" bill down to $3,000). One more Q: is there a bright-line rule as to what constitutes an "emergency" that qualifies for the "cannot-refuse-treatment-even-if-uninsured" mandate? If a patient comes in after discovering a lump in her breast, do you have an obligation to treat her? It may not be an urgent-care scenario but hard to say that it's not "life-or-death" in a broader sense.

Asked by tonsils almost 13 years ago

The question of “what constitutes an emergency” has resulted in reams and reams of interpretations by government and private sector lawyers. Remember Bill Clinton and his statement “it depends on what the definition of ‘is’ is”…. Generally speaking emergency refers to immediate life threatening injury or illness. What does “immediate” mean? Yikes, I’m drowning in paperwork!!! We actually have patients who come into the ER because they have found a lump in their breast. We examine them, they might have a life threatening breast abscess, who knows until you look at it. For someone who has a lump like you may be referring to is sent to their primary care physician for follow-up. There is not an emergency mammogram. If a patient does not have a doctor, we give out referrals to clinics in the area. We also have a full time ER case manager/social worker that can help the person navigate the system. When a person doesn’t have insurance or any money, then we refer to one of the many clinics that have a sliding scale fee schedule—one of our hospital clinics has that. Sometimes it is not easy to get an appointment, and we try to help set that up sooner rather than later. Speaking of cancer, you would not believe the number of patients that come to the ER and we find a first diagnosis of cancer. The ER is not where you first want to hear that you have cancer.

Are there any TV shows that portray an ER accurately?

Asked by Kyle almost 13 years ago

When "ER" first came on the scene, I wouldn't watch it, even though many of my non-medical friends did. I said to a friend one time--"when they starting betting on patients' blood alcohol levels on ER, then I might watch it." About the third or fourth episode, sure enough, that was in the story line. To me, "ER" was the first drama that had the terminology and chaos fairly correct, however, it is the nurses that do all of the work with the patients generally, not the physicians. By the time the ER physicians, who are some of my best friends by the way, give all of the orders, the orders have already been done by the nurses. We know what the docs are going to order before they say it. I don't watch any of the current medical dramas, except I have seen a little of "Nurse Betty" on Showtime, which talks about substance abuse in medical professionals. To finally answer your question, yes, the drama is sensationalized. No one would watch it unless it was. Even though the ER is pretty exciting at times, there is no way that we do that every hour all of the time.

Why aren't there more (and better) food & drink vending services in ER waiting rooms? Folks are waiting for hours, often bored and hungry -- seems like a wasted revenue opportunity when I only see one vending machine filled with snacks from 1974.

Asked by Trooper1 almost 13 years ago

We have one food vending and one drink vending machine in the ER and all of the revenue goes to the vending companies. The can of Coke is $1.50!! If someone needs something more, we direct them to our 24 cafeteria or the cafe in the hospital lobby. A while back, the ER provided free coffee and juice in the waiting room, but it cost about $8000. With budgets being trimmed, that was one of the first things to go. One of the things that frustrate ER staff is a patient who comes in with belly pain and says that they have been vomiting all night and they walk in with a bag of Cheetos or a bunch of food from Taco Bell. That doesn't help your credibility that you have an emergency. Our ER length of stay (how long you are in the ER, including time in the waiting room) averages about 3 hours. Hopefully a person can be without their Coke or Snickers that long.

Does it frustrate you and your staff when people use the ER for non-emergencies?

Asked by funnygirl almost 13 years ago

Yes, sometimes it can be annoying, especially when you see the same patients over and over, and you have given them referrals for clinics and primary care doctors for their follow-up. In the past 6 months, our ER has seen an increasing number of "clinic" type visits vs. true medical emergencies. Most of these patients are un-insured or under-insured. Also, many patients are using Emergency Departments to get controlled substance prescriptions such as oxycodone or hydrocodone who either do not have a primary care physician or are using the ED for their addiction/dependence. We could have a big discussion just about that and how it is affecting the ER. That being said, we may give referrals to patients until the cows come home, but if the primary care doctors are not taking new patients, or not taking Medicaid/Medicare patients, or not seeing uninsured patients, there is not much the ER can do. The ER is mandated by the Federal government to see every patient to determine if they have a emergency medical condtion, but the clinics/primary care doctors have no such mandate.

Now that you're on the business / administrative side, do you miss the hands-on stuff?

Asked by deadwooood almost 13 years ago

I love the administrative and business end of the job! A nurse geek! I worried that I wouldn't be taking care of patients, but I’m in the ER a lot of the time assisting during busy times and talking to patients and families when they have concerns. It is just the right balance for me. When I was involved in direct patient care, I was taking my work home with me (emotionally). I continually wondered if I had given the best care or had made mistakes. Now, if I miss a spreadsheet deadline or am late for a meeting, it is not affecting the patient at that moment.

What types of patients (ethnicity, age, income level, etc.) are the biggest hypochondriacs?

Asked by JustinB almost 13 years ago

I don't know if I have any demographics to give you since the description of a hypochondriac is pretty subjective. These are just my opinions and observations here, to make it clear. I think a lot of people who some would describe as a hypochondriac have undiagnosed depression or anxiety disorder. I have seen patients who are convinced that they have cancer, or some type of serious illness, maybe the "disease of the week" you would see in the news media. Despite all of the diagnostic tests, etc, the person is not convinced they are not sick. I have seen a lot of elderly who seem to be obsessed with their state of health, and sometimes I think they are depressed and lonely. We had one patient who would come to the ER almost weekly with some thing or another that he thought was wrong with him. He actually had significant health problems, like heart disease and emphysema, but the reasons he would come to the ER weren't really related to this. One day he actually said to the staff that he came to the ER because we were the only people he considered his friends. He had no family in the area and lived like a recluse. The ER sees a big number of patients that we would call "frequent flyers". Some of them come to the ER for minor things, some are seeking prescription drugs, some have no social support, some are victims of unrecognized domestic abuse and see the ER as a safe place., many have substance abuse problems. It is easy to get callous with these folks, and roll our eyes and say "here they are again." There is usually a really complicated back story around them, and we don't often get to see it. The demographic is really all over the place--men/women, young/old, poor/wealthy. The most common thing is a really dysfunctional personal life, if we get to find that out in the course of their visit.

Have you ever had nurses on staff that got romantically involved with patients?

Asked by bom-chick-a-wah-wah over 12 years ago

I have never seen that in the ERs that I have worked. However,the staff get hit on by a lot of patients, especially if the patients are intoxicated. Where I am working right now, a patient has been stalking a nurse, showing up at the ER saying he has a date with her and getting really upset if they don't let him in (the ER is a locked unit). She has called the local police but they have said unless he threatens her there is nothing she can do. So she walks out to her car with security and keeps a close eye out. I have seen a lot of involvement between staff, affairs between married employees, sex in a closed office between employees, stuff like that. Two of the staff were having an affair, and one of the spouses would come to the ER trying to find the other spouse, lots of Jerry Springer drama. That is so frustrating as a manager. Be professional, people! I don't want to know who you are sleeping with, especially when it is another employee.

You said ER nurse training helps someone who later becomes an ER doc. Do you think a background as an ER doc would help you be a better ER nurse? Would it annoy you if an ER doc did TOO much of your work, like the one who cleaned a patient and bedpan?

Asked by anemone almost 12 years ago

Honestly, I don't know of any ER doc who left that profession to become a nurse, so I can't really answer that. Or any type of doctor, for that matter. Other than the instance I mentioned in a previous post, I have also never seen an ER doc do the tasks that traditionally fall to the nurses or the techs. I wouldn't get annoyed, but I wonder what was up. We have great professional relationships with the ER docs, but usually they come and get us if a patient needs something, instead of getting it themselves. For example, if a patient asked for a blanket, the doc will go find the nurse, and then he or she will go get the blanket. The patient just wants a blanket for heaven's sake, just go get one.

How much will a trip to the emergency room cost if I get seen by a doctor, given a prescription, and sent home without being admitted? I am uninsured and just want an idea of the range.

Asked by Carolyn almost 12 years ago

That is not an easy question to answer. There are many factors that determine the cost of an ER visit. Each ER has a system to calculate the charge (called the facility level charge). This method of billing comes from the government. A level 1 charge could be something as easy as a medication refill, or stitches being removed, up to a level 5, which is usually a complex medical condition with or without admission. There is also a level of charging called critical care, above a level 5 charge. So for a simple ER visit such as a sore throat, ear ache or cold, which would just require an exam, possiblly a prescription and then discharge, that generally would be a level 2. In our facility, a level 2 charge is about $500. That does not include the bill you would receive from the physician, which could be another $150. If you are uninsured, the hospital will give you a discount of about 40%, bringing the level charge down to about $300. If your chief complaint (why you came to the ER) is more complicated, and you have tests such as lab or x ray done, the level charge will increase according to those factors. Alevel 5 charge in our ER is over $2500 and that does not include the costs of medications, lab or radiology testing that is done. Of course, every hospital has different charges for different levels, so you may be charged more in a different city or state. The government does not set prices. Just an aside, we have patients who come into the ER and they exaggerate why they are coming just in order to bump the line. For example, most folks know that people with heart attack symptoms will be seen faster than those with an ear ache. However, once you say that you are having chest pain (even if you are making that up in order to see a doctor faster), the physician is obligated to make sure that you are not having a life threatening emergency such as a heart attack or a blood clot in the lung, or pneumonia, etc. You will be charged for the complexity of your care and how much it takes for the physician to determine whether you have an emergency medical condition or not. Be honest, tell the physician all of your symptoms and your concerns. If you minimize your symptoms in order to save money, you run the risk of the physician missing something important. If you exaggerate with the express purpose of getting in faster, you will pay with your pocketbook, and might impede the care of someone who is truly ill.

Does your ER encounter a lot of patients with Münchausen syndrome? (e.g. like the moms who abuse their kids in order to get medical attention?) Weirdest disease ever, btw.

Asked by JustinB almost 13 years ago

I have not seen this in my current ER. In a previous ER in the early 90's I remember a patient who was diagnosed with this. She was seen on camera (while she was a patient in the hospital) injecting fecal material under her skin, mostly on her legs. We saw her in the ER for repeated infections. I don't know what eventually happened to her. Moms who make their kids sick is called Munchausen by Proxy. I have only heard about this, and have not personally seen it. So sad

What was it like the first time you "lost" a patient? Were you braced for it? Did it take you a while to recover?

Asked by UIGElol almost 13 years ago

I actually don't remember the first patient that died while I was caring for them. The first one that affected me the most emotionally was the sudden death of a 12-year-old. We were trying to resuscitate him, and we brought the parents into the room with us as we were doing CPR and trying to save him. As a parent myself, it was the most difficult thing to see this mom and dad with their dying child. This was years ago and I still remember the little details like it was yesterday. I guess it still affects me emotionally because I started to tear up while writing this.

I'm a student in the healthcare management program and I was wondering if I could email you a few question my instructor has asked us to ask an ER head. my email is tchmura11@yahoo.com. Please let me know if it's something you can help me with.

Asked by Tracy Chmura almost 12 years ago

Sure, I would be happy to help, I will email you

Do emergency rooms have dentists? If I get a tooth knocked out, is there a limited window in which it can be saved and restored and is there someone in the ER who can do that?

Asked by HEMAN almost 12 years ago

Generally speaking, there are not dentists in the Emergency Department. Some ED's may have dentists on call that they can refer a patient to for a dental emergency, but dentists do not come to the ED, at least in our area. Our ED does have limited on call oral surgeons for dental trauma, but they are not on call every day 24/7. Most of the oral surgeons do not come in to the ED but ask us to send the patient to their office. The ED doc can treat for dental pain with dental blocks (like Novacaine), or infection with antibiotics, but they cannot reimplant teeth. In our ED we have a list of nearby dental clinics that will take uninsured patients on a sliding scale fee schedule that we refer to for general dental problems. In 2012, our ED treated over 800 patients with dental problems, about 1% of our total volume.

What's the most aggravating part of the job?

Asked by brokejoke almost 13 years ago

I would like for our hospital and ER to not have to worry about where the money to care for the public is going to come from. There is not enough money to sustain the health care system as it is. The only way the government will get more money is to either tax the citizens more, or cut down on the healthcare that they pay for. And the insurance companies will have to charge more for their premiums. There is a lot of negative press given to corporations and pharmaceutical companies. But they are the ones that develop the state of the art treatments for cancer, heart disease, etc. Who pays for the development of technology? It is truly between a rock and a hard place. Will the US become like so many other nations who have to ration health care in order to afford it?

If a patient arrives at your ER and you realize their injury or ailment isn't anything even close to an emergency, will you turn them away?

Asked by three one one almost 12 years ago

ER's are prohibited by Federal law to turn anyone away that has an "emergency medical condition." So every person has to be screened by a physician or a PA to determine that, which requires taking a medical history and performing a physical exam. By then, the docs in our ER just treat them. There is a hospital in our metro area that has a clinics attached to the ER, and they will screen non emergencies and send them to their clinic. But in our case since we have no on- site clinics, it is to risky to do that and potentially face Federal fines, or risk a patient's safety.

if you fractured ur foot do u need a cast?

Asked by emily about 11 years ago

It depends on the severity of the fracture--you may not need anything, you may only need a hard soled shoe, you may need a walking boot, or you may need a cast, or even surgery.  Every fracture is different and needs to be evaluated by a physician after an x ray.  The physician will be able to determine the best treatment.

I'm fully ensured, and yet when I visit an ER, I get hit with a bunch of unforeseen charges. Is there anything I can do *during* the actual ER visit to understand what the costs will be, so that there are no surprises later?

Asked by oucharoo almost 12 years ago

That is a simple question that has a very complicated answer. If you get a chance to read Time Magazine's cover story from March 4, 2013, titled "A Bitter Pill," please do. It is a great article about a lot of things in healthcare, however, a great deal of the article is devoted to a hospital's "chargemaster", which is the spreadsheet document that shows what the patient/insurance company is charged for every thing from soup to nuts. What a person is charged for a certain service or procedure is not what you or the insurance company eventually pays. There is a tremendous mark-up for everything in the hospital because generally, the only income a hospital gets is from payment from the patient/insurer for the services it provides. Of course, a hospital can have investments and investment income, but that is not the main source of income for the hospital system I work for, which is non profit. So the money the hospital receives from the patient/insurance companies is what pays all of the bills, salaries for 1500 employees, utilities, work comp insurance, etc, whatever it takes to run the hospital. When our hospital is doing ok (making budget), we generally do so with a 2-3% operating margin at the most. However, in the first two months of 2013, our hospital lost over 1 million dollars. Most of that had to do with what is called the "payor mix." In January and February, a greater percentage of patients had no or minimal insurance, so there was no way to pay for the cost of providing care to patients. So to finally answer your question, you can probably get a ballpark answer of what the charges might be, but that is not what you or your insurance company will end up paying--it is usually a 40-60% discount on the actual charges. Plus there are a lot of charges that make up the bill--the facility charge (the ER room charge, basically), any doctor's charges, which are billed separately, lab charges, x ray charges, pharmacy charges for any medication you may receive, etc. So it is hard to estimate. I can tell you easily what the facility charge would be, but I can't speak to the other charges.

Do most ER's accept volunteer help? Or do I have to be certified in some way?

Asked by Kendall almost 13 years ago

Sorry it has taken such a long time to answer your question Kendall. Our hospital has an active volunteer program for all areas of the hospital. If a volunteer wants to work in the ER, there is a couple of days of training to familiarize them with the procedures and flow of the ER, and to make sure the volunteers (usually younger people) are not violating any Federal privacy laws, etc. They stop in and talk with the patients, bring them water or food if allowed, warm blankets, and some times just keep people company. The hospital has an active pet therapy program, and the volunteers will bring in the dogs to visit with the patients. Since the ER can be a somewhat uncontrolled environment, we are careful with the pets--they only come in if there is relative peace and quiet.

Is Obamacare going to change how ERs work?

Asked by lol_france almost 12 years ago

I would love to know the answer to that question! I could write a book and never have to work again! Really, the truth is that we don't know. This is driving hospital CEOs and CFOs crazy because how can you plan for a future when you don't know what is coming. Personally I think that the workings of the ER won't change day to day. I do believe that we will be a lot busier. Our patient visits for 2013 are already up about 10% from last year. I think hospitals will have to do more with less, which means being extremely efficient with money, nurses, equipment and supplies. I already see the nurses working a lot harder for the same amount of money, the raises get smaller and smaller, and the patients are sicker and sicker. I don't know where the money is going to come from. It has to come from somewhere. The patients don't have it, the government doesn't have it, and insurance premiums don't nearly cover the cost of healthcare, so the insurance companies are going to run out of money. It is a crisis that has come to our country and I sure don't see what the answer is.

My admiration for you and those who do your work knows no bounds...I got hooked on the show "NY Med" this past summer, that follows actual nurses and doctors in the ER in NYC where Dr. Oz works. Did you get a chance to see it? It was riveting!

Asked by TiredTeacher over 12 years ago

I have not seen that particular series. When I was younger I was hooked on St Elsewhere (shows you how old I am!), and then began watching ER a couple of seasons in, then quit watching. I will watch old reruns of "Trauma--Life in the ER",--which I have found to be the most accurate, however after a while I have said--I do this everyday, why do I want to watch it in my free time. I get frustrated watching medical shows on TV, especially shows such as ER, Chicago Hope, Grey's Anatomy, House, etc. They are all just soap operas set in hospitals. I wonder if law enforcement employees get tired of all of the cop shows on TV?

How do the physicians interact with your department?

Asked by Tracy almost 12 years ago

We have a wonderful relationship with the ED physicians. They are a contracted group of ED board certified physicians, we have had the contract with them for over 20 years. The relationships in the department are very collegial and we work well together. The docs and the RNs are in constant communication about the care of the patients. Since the department is so geographically large, everyone carries cell phones so it is easy to contact each other. We also have the ability to communicate with each other electronically on our computer tracking boards.

Should I go to an emergency room if I suspect I may have been exposed to HIV through unprotected sex? Is it true that taking the drugs meant to treat HIV immediately after exposure can actually reduce the chance of infection?

Asked by doodah almost 12 years ago

I would not go to the ED for a rapid HIV test, although you could. This type of testing should be done through your PCP or clinic to ensure adequate followup. If a person has concerns they have been exposed, one negative test only tells you that you are negative right then. The conversion to a positive result may take months, so you may need further testing. An ED is not the place to create an ongoing doctor-patient relationship. As far as treating with the medication, the physician would talk to you about the risks of immediate treatment with these medications. The meds are not without risks or significant side effects, so that would have to be balanced with the chance of developing a positive HIV test. If you know for certain that the other party was HIV positive, that could sway the decision. It also depends on how much exposure you had--long term continuous exposure vs. a one time thing. There are a lot of factors.

"Just go get one for heaven's sake" (a blanket), but then again you'd wonder "what was up" if your ER docs started doing that stuff... Last time I took my son to the ER the doc was good & so nice. Does being nice maybe slow them down?

Asked by anemone almost 12 years ago

I realized after I wrote the stuff about the blanket that I was kind of contradicting myself... Hopefully being nice doesn't slow them down! I believe that it takes no more time to be nice than to be hurried and abrupt, plus the patient will have a better experience, which is what it is all about anyway--the patient. The federal government is beginning to tie reimbursement (the payments the hospital receives) to the patient satisfaction scores that the hospital has on patient surveys. So everyone is going to have to be nice, and take care of the patient from their point of view. I'm glad that your son got good care in the ER.

What tips do you have for negotiating down a high ER bill if you're not insured? How does the hospital gauge how much they think they can get out of a patient, and what fraction of what they originally bill you for for is it realistic to hope to get it down to?

Asked by TeoGF almost 12 years ago

You want to get on the phone with billing start talking to them right away. Generally if you are uninsured, the bill can be lowered to approximately the same contract rate insurer's pay, you can get from 40-60% off. Ask for the patient rep, ask to talk with financial services and don't wait. You can also ask for a payment plan for the negotiated balance. Don't forget to go over your bill for any errors, just that could save you some $. Don't ignore the bill though, start talking to them right away. It's when you ignore it that it starts down that collection road. good luck, and start looking for the insurance exchanges to get coverage for yourself.

if I had a house party with people who didn't have a security license could the people still physically kick someone out

Asked by Aimee over 11 years ago

Wow!  I don't have any expertise in that at all!  I think that is a question for a police officer or security company.

Are ER doctors of higher, lower, or the same quality as non-ER doctors? Guess what I'm trying to get at is, is working as an ER doctor desirable so that the best doctors vie for those positions, or is it a role most would rather avoid?

Asked by Colt42 almost 12 years ago

The Emergency physician is a board certified specialist who enters a 3-4 year program after medical school. They are specifically trained in Emergency Medicine--they need to know how to treat any kind of health issue, including trauma, and medical emergencies for adults and children. They are unlike primary care or family physicians, who treat and have established relationships with their patients. ER physicians generally do not have private practices, they only work in ERs or Urgent care centers. In 2011, about 7% of graduating medical school seniors entered an Emergency Medicine residency program in the US--there are about 100 programs in the US. It is a fairly new specialty, just over 20 years, so it is very popular and can be difficult to enter. A physician who is not board certified in Emergency Medicine can still work in an ER, however, I would want a board certified physician treating me if I had an emergency. In the hospital where I work, all of the physicians are board certified, and you will see that in most ERs. ER physicians are not generally on call--they work their shift and go home, so it can be an attractive area for that reason. The malpractice insurance is higher than some other specialties, but not the highest. You can't really compare ER docs to other specialists, whether one is "better" than the other, it is like comparing apples to oranges. I would want an ER doc to treat me if I had an emergency, and I would want an OB/Gyn doc to take care of me if I was having a baby.

What is the essential function and background of your department?

Asked by Tracy almost 12 years ago

Our ED has 60 beds, we are located in a suburban community non-profit, non-teaching hospital. In 2012 we had over 73,000 ED visits, which makes us the second busiest in our state. We are a designated Level III trauma center. We care for all ages of patients, from newborn to geriatric. We are a certified chest pain center, certified stroke center, and have a large psychiatric population. We also have started a Senior ER, an area within the main ER that focuses on the medical and social needs of patients over the age of 65.

what are the duties of manager of ER, I'm new at this and when one of the nurses don't come in the floor nurse supervisor told me I'm to come in and take that nurse place. If it's my day off or not.

Asked by capri over 11 years ago

That is generally the sad truth about management--you will be called upon to assist in the ED when staffing is short and they can't get an hourly nurse to come in.  Generally managers are exempt from wage and hour laws and are paid a set salary that usually doesn't include overtime.  It shouldn't be a regular, ongoing thing though; if it does, I would be concerned about your staffing.  If there is a problem with the time and attendance of your staff, then that is a different issue that you are going to have to address as a manager.

The plus side about this is that you will get lots of bonus points from your nursing staff; you will be seen as someone that has their back, that understands front line nursing care, and it will keep your skills current.  That will get respect from the nursing staff that will go a long way when you have to implement changes, or institute policies that affect them.

What are crucial challenges this ED has faced in recent years related to patient flow?
n what basis were these challenges identified? Were quantitative data used to identify and confirm the existence of problems, and if so, which types of data?

Asked by Stacey over 10 years ago

The challenges faced by this ED are similar to those all over the country.  The two main concerns that we had identified by patient/staff complaint and national benchmark data are:

1. Inpatient boarding for those patients in the ED waiting for a hospital admission bed

2. Competitive market challenges to decrease the time a patient sees a doctor, and the overall length of stay in the ED

Because we have a robust EMR (electronic medical record), finding this data was easy to extrapolate.  The data was collected for a six month period of time to show the time that the patient came in the door, when they were seen by the doctor, when the decision was made to admit the patient, and when the patient left the department.  From this data, goals for improvement were identified, and Lean processes were implemented to shorten these times.  The "Patient Flow Committee" now evaluates the data on a monthly basis to see if the ED is improving, or if there are new challenges identified.  Now over 90% of the ED patients see a physician within 30 minutes of arrival.

The inpatient boarding times have shown fluctuation due to flu season, staffing challenges, etc, however the committee is able to identify which of the variables are affecting the times and work to adjust that part of the solution.

Great question, thanks!

I have a couple of questions, if you don't mind. Who are the top staff members in your ED and what are they called? Who's the "top doctor" and the "top nurse"?

Does ED use physician assistants? if so, how much oversight does an ED physician provide?

Asked by BBD about 11 years ago

The nursing leader is called the director, and then under that are managers, and then under that are the charge nurses for each shift.  These are all RN positions.  So the top nurse is the nursing director.

The physician who is in charge of all of the physicians is called the medical director.

The ED uses both physician assistants and nurse practioners.  They are directly supervised by the physicians who are on duty, and practice under the physician's direction.  Generally, they provide care to the less seriously ill or injured.  Depending on the experience of the PA or NP, the physician may do their own independent examination, or may just "sign off" on the patient without seeing the patient themselves.

What sort of decisions does an ER doctor need patient or family permission for? Like in the marathon bombings where doctors determine that a patient needs an amputation or he'll die, what if the family says no? What's doctor's legal responsibility?

Asked by Tev over 11 years ago

In any health care emergency setting, the patient is the decision maker.  If the patient is unable to make decisions for themselves, the person that can make decisions next is the medical durable power of attorney.  Hopefully people have that established before an emergency presents itself.

If the patient is unable to give any type of consent, the ER physician uses something called implied emergency consent (laws are different in every states) and will do what needs to be done to save the patient's life.  If someone tries to influence the care of the patient when the patient is unable to consent, they have to have legal proof that they have been designated by the patient to make health care decisions on their behalf.

Every adult needs to designate someone as their health care power of attorney for those situations when the patient can't speak for themselves.  The MPOA needs to know clearly what the patient would want in every kind of health care situation, so you need to know and trust the person that you select., because they might be making life or death decisions for you.  Don't be afraid to discuss things like organ donation, blood transfusion, life support issues, etc.

I am not a lawyer, consult an attorney in the state where you live because laws vary.

Hi! I recently received a position as the Manager of the Emergency Department...but I am not a nurse. Everyone keeps saying I am not qualified for this position, are they right?!

Asked by Tamara C over 11 years ago

Nearly all of the  clinical managers that I know of in the Emergency Department are nurses.  The majority of the staff are nurses and nurse aides/techs, so in order to manage the staff and understand their scope of practice and job responsibilites, a nursing degree as a basis is a necessity.  There are some large Emergency Departments that may have a business manager or operations manager, along with the clinical manager (nurse) that has some type of business or healthcare administration degree, but I have not seen that many out there.  I understand it is a growing field, have you been hired in that capacity?

I work in the VAMC as an ER psychologist. If a patient comes to the ER and discloses over the course of medical treatment that he was in a hit and run a few days ago, are staff required to report to police?

Asked by dimarco almost 12 years ago

The ED staff is considered a mandatory reporter for instances of child abuse, elder abuse, domestic abuse, gunshot wounds so those are no brainers. I am not sure if the staff are required by law to report crimes that someone else tells them about. I would hope ethically that a person would do so, especially crimes against persons. I will check with someone about my pay grade and get back to you. I

i am currently in college working on my pre reqs to enter a bsn program for nursing i plan to do ROTC and go in to the army and pick a specialty , from your experience what do you think is the best specialty for a nurse to go into ?

Asked by Noah over 11 years ago

When I was in nursing school, I was so sure that I wanted to be a pediatric nurse.  Then I started those courses and realized that pediatrics wasn't for me.  Go through your courses, start doing a lot of reading and research about different specialities, and it will come to you.  There is no speciality in nursing that is "better" than another.  Every person is unique and you need to find what fits you best.  If you don't you will burn out fast.  The great thing about nursing in this present day is that there are so many areas to focus on, there is something for everyone.

When you finish school and still aren't sure what area you want to focus in, I recommend getting a solid background in medical/surgical nursing with critical care training.  Every specialty needs that as a basis anyway, and you need to get good at the assessment of patients, and basic nursing care along with critical thinking skills.  Patients are so much more complex than they used to be, and the technology in caring for them changes daily.

Good luck with nursing school and the Army!

I have to get my 1st abscess drained at er & wanted to know can the prescribe me medication to detox me without insurance

Asked by bdog almost 11 years ago

Hello bdog--I guess I am not exactly sure what you mean by "detox me." Treat you with antibiotics for the abscess?  Detox you from what?

Every designated Emergency Department in the US is required to screen every person for a medical emergency.  They will treat people regardless of their insurance, but that doesn't mean you will not get billed for the treatment, which can be very expensive even for a minor ailment.  If you need a prescription they will prescribe medication, but you will need to get it filled at a pharmacy which you will have to pay for.

Some pharmacies such as Walmart (others also) have a low cost prescription program for commonly used medications, so that is an option.  Good luck to you!

 

I've invented a new approach to managing the spread of germs and viruses. The product uses no chemicals and is called a Coughy Cup. Would you mind writing me at CoughyCup@gmail.com so I can ask you a few questions?

Asked by John Delatorre about 11 years ago

Sorry, no products or sales pitches through this site.  Good luck with your invention, and everyone wash your hands!!

I am a producer on the Discovery Fit & Health and TLC series, UNTOLD STORIES OF THE ER. I'd like to contact you about the show. Ahassett@untoldER.com or 626 798-8000

Asked by Ann Hassett almost 11 years ago

Thanks for the question--I have emailed and called with no response.  Please contact again through this site if you are still interested.

Dear emergency room manager????

I do an investigation

The subject = could a victim survive a gun shot wound in the upper forehead by a 50AE Desert eagle gold 24k at 15 feet with very fast and good medical treatment?????
I can not finding any clear evidence so I hope you could answer my question????

https://youtu.be/IZeigwh1270

Asked by Jeffrey over 7 years ago

How much experience in years and education must an ER nurse have to assist in major ER surgeries. And do they work on set trauma teams under the same Doctor each time? What is the chain of command in an ER?

Asked by Rissa almost 10 years ago

Hi, I have heard by the media that most hospitals are full but have also heard this is a total lie and most are not that full. What is it really?

Asked by Dan over 4 years ago

I am an amateur writer and I'm currently working on a car crash scene. Involved in the accident are six 12/13 year old girls, all minor ish injured, one severely. Would they get brought to the ER for stitches and stuff or have it done at ambulance?

Asked by Ellie over 6 years ago

How fast does the ER nurse call family members to notify them that their Dad,Mom... was bought into the ER?

Asked by Bruce almost 8 years ago

On what basis were these challenges identified? Were quantitative data used to identify and confirm the existence of problems, and if so, which types of data?

Asked by Jones over 9 years ago

Did the implemented changes achieve expected outcomes?

Asked by Jones over 9 years ago

Focusing on one of these challenges, what process improvement or reengineering efforts has this ED taken to address the challenge? Did the department follow Lean and/or Six Sigma or other comparable approaches in addressing this?

Asked by jone over 9 years ago

Focusing on one of these challenges, what process improvement or reengineering efforts has this ED taken to address the challenge? Did the department follow Lean and/or Six Sigma or other comparable approaches in addressing this?

Asked by Jones over 9 years ago