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Intrahospital Transfer
Bjorn, Pret trauma-list@trauma.orgTue, 21 Jan 2003 15:57:41 -0500
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Andrew,
Pret,
Thanks for your input also. True I did bring up the issue of
legality/billing as it does play a factor. True the most important thing is
patient care, no argument there.
You're right, there's no argument.
Distressing, then, how you insist on arguing with me.
But, I was looking at everything. Is it common practice to transfer an
inpatient to the ED at the same physical facility, is it legal, will we get
paid for the service we will provide (if we don't then if this continues
there is no ED to take care of in or outpatients)?
You've gone beyond thoroughness and ventured into hyperbole and hogwash.
Is this scenario common? As if that's a test of what your ED should accept
and refuse?
Is it legal? THINK, man! What could possibly be illegal about sending an
overdose to an Emergency Department? You're worried somebody might sue you?
Spare me.
Will we get paid? For cold sores, you worry about the insurance.
Toothaches. Back pain, sometimes. Even then, you do an appropriate
screening exam and prove there's no emergency. It's not like there's no
precedent here.
Go check: what's your rate of reimbursement for off-the-street overdoses?
Wow. That low? Perhaps you should just stop treating them, before you have
to start laying people off. Keep out the gunshot wounds while you're at it;
and the teenage pregnancies, and all those high-cost Medicare slackers.
Work this right, your ED will be laughing all the way to the bank. You
depress me.
All factors that come in to play. Sure give me the OD off the street (Mom
or otherwise, but if it is my Mom she gets a kick in the butt first) because
the ED is the best. But already a well established inpatient, with an open
ICU??? Come on, do the right thing and transfer to ICU and make the
appropriate consults.
Spoken like a true, proud, stultifyingly myopic ED nurse.
I claim the right to say that, 'cause I am, too.
News for you, Andrew: the ICU is not staffed, equipped, or trained for a
fresh OD. Back to your mother again: clock's ticking. You want Hortense in
the Unit to take her? Hortense also has that quad you sent down yesterday,
and his pressures have been soft this shift. Plus, the intensivists won't
be rounding until seven thirty, and the resident doesn't know jack about
overdoses; he's off looking for his Harriet Lane. Lab and x-ray have been
running behind all day, and pray Mom doesn't need meds any time soon,
because they're still waiting for the nine-o'clock run from the pharmacy.
About the only good news is that the ICU's only available room has a primo
view from the sixth floor. But then, Mom's here for a suicide attempt,
isn't she?
With your argument, anybody who takes a turn for the worse in the hospital,
and becomes an "emergency" should go back to square one (the ED) and start
all over because it takes too long to call the right consult and transfer
the patient to ICU or telemetry.
Don't pretend this is a hip replacement with chest pain. This patient
turned from a psych patient (who goes to Group t.i.d. and has a pass for
dinner with her husband tomorrow, and is thoroughly unknown to any promptly
available practitioner of physical medicine) into a gutful of unspecified
pills with intent to self-harm. There's no unit in a typical hospital
qualified to manage her on short notice--except the ED.
Wow, how overcrowded is your ER right now, mine cannot take that added
proposed influx. I have to do with the outpatients that are waiting for 4-5
hours to be seen the first time let alone go upstairs and come back again a
few days later because their doctor was lazy.
When did this go from a transfer to an influx? Take a breath, Andrew.
Enjoy a refreshing soft drink.
Our ED is busy mostly because our hospital is busy. Go spend a shift in
your ICU before you start actually believing your ED is the center of the
physical universe. Be prepared, when need arises, to screw your
outpatients. Better still, take a close look at your temptation to refuse
an overdose for their satisfaction and convenience. Just what kind of a
nurse have you become?
But if it makes you more comfortable, go ahead and paint the doctor as lazy.
Makes it easier to deny that he might have been doing right by his patient.
Andrew J. Bowman, RN, CEN, CCRN, NREMT-P
Patient Care Coordinator
Education Coordinator (Trauma & Emergency Cardiovascular Care)
Emergency Department
Home Hospital Campus
Greater Lafayette Health Services, Inc.
2400 South Street
Lafayette, Indiana 47904
USA
Andrew,
Legality? Billing? Horseshit. It's a sad reflection on the trauma-list
membership that nobody's defending what's in the best interest of the
patient.
Imagine for a moment that this is your mother who's OD'd in a medical psych
ward which shares a campus with a perfectly good ED, staffed by a qualified
overdose expert and experienced overdose nurses, equipped with
state-of-the-art monitoring, and stocked with all the activated charcoal she
can drink. Now throw in a handful of obstructive backseat whiners, fussing
about clinically indefensible turf issues and obsessing about medicolegal
apocrypha while the tricyclics digest.
Ask her psychiatrist his plan for the proper management of a fresh
psychotropic overdose. Then trot over to the ICU and see how soon they can
find a bed for an untreated OD patient who's sufficiently psychotic to
require a locked unit. Experience for yourself the vacant stares and the
predictable ridicule, then ask where you really want to send Mom.
Last I heard, there's nothing illegal about referring an emergency medical
condition to an Emergency Department. Surely EMTALA has no application
here--except to the extent that if you're deferring treatment of any patient
based on their ability to pay, you're as pathetic as you are screwed.
You find a better disposition, great. Write a policy, educate your
practitioners, and implement the process Until then, treat the patient and
shut up.
I may be alone here, but I think you and all those who are cheering you on
should be ashamed of yourselves.
Pret Bjorn
Trauma Coordinator
EMMC Trauma Program
489 State Street
Bangor, ME 04401
207.973.7260 (office)
207.973.7673 (fax)
207.941.5085 (voice pager)
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<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=630523119-21012003>Andrew,</SPAN></FONT></DIV>
<BLOCKQUOTE dir=ltr style="MARGIN-RIGHT: 0px">
<DIV><STRONG><FONT face=Tahoma size=2>Pret,</FONT></STRONG></DIV>
<DIV><STRONG><FONT face=Tahoma size=2></FONT></STRONG> </DIV>
<DIV><FONT size=2><FONT face=Tahoma><STRONG>Thanks for your input also.
True I did bring up the issue of legality/billing as it does play a
factor. True the most important thing is patient care, no argument
there.</STRONG><FONT color=#800000 face=Arial><SPAN
class=630523119-21012003> </SPAN></FONT></FONT></FONT></DIV></BLOCKQUOTE>
<DIV><FONT color=#800000 face=Arial size=2><SPAN class=630523119-21012003>You're
right, there's no argument. </SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=630523119-21012003></SPAN></FONT> </DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=630523119-21012003>Distressing, then, how you insist on arguing with
me. </SPAN></FONT></DIV>
<BLOCKQUOTE dir=ltr style="MARGIN-RIGHT: 0px">
<DIV><FONT face=Tahoma size=2><STRONG>But, I was looking at everything.
Is it common practice to transfer an inpatient to the ED at the same physical
facility, is it legal, will we get paid for the service we will provide (if we
don't then if this continues there is no ED to take care of in or
outpatients)?</STRONG></FONT></DIV></BLOCKQUOTE>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003>You've gone beyond thoroughness and ventured into
hyperbole and hogwash. </SPAN></FONT></FONT></FONT></DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003></SPAN></FONT></FONT></FONT> </DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003>Is this scenario <EM>common</EM>? As if that's a
test of what your ED should accept and refuse?
</SPAN></FONT></FONT></FONT></DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003></SPAN></FONT></FONT></FONT> </DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003>Is it <EM>legal</EM>? THINK, man! What
could <EM>possibly </EM>be illegal about sending an overdose to an Emergency
Department? You're worried somebody might <EM>sue </EM>you? Spare
me.</SPAN></FONT></FONT></FONT></DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003></SPAN></FONT></FONT></FONT><FONT size=2><FONT
color=#800000><FONT face=Arial><SPAN
class=630523119-21012003></SPAN></FONT></FONT></FONT> </DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003>Will we get <EM>paid</EM>? For cold sores, you
worry about the insurance. Toothaches. Back pain, sometimes.
Even then, you do an appropriate screening exam and prove there's no
emergency. It's not like there's no precedent
here.</SPAN></FONT></FONT></FONT></DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003></SPAN></FONT></FONT></FONT> </DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003>Go check: what's your rate of reimbursement for
off-the-street overdoses? Wow. That low? Perhaps you
should just stop treating them, before you have to start laying people
off. Keep out the gunshot wounds while you're at it; and the teenage
pregnancies, and all those high-cost Medicare slackers. Work this right,
your ED will be laughing all the way to the bank. You depress
me.</SPAN></FONT></FONT></FONT></DIV>
<BLOCKQUOTE dir=ltr style="MARGIN-RIGHT: 0px">
<DIV><STRONG><FONT face=Tahoma size=2>All factors that come in to play.
Sure give me the OD off the street (Mom or otherwise, but if it is my Mom she
gets a kick in the butt first) because the ED is the best. But already a
well established inpatient, with an open ICU??? Come on, do the right
thing and transfer to ICU and make the appropriate
consults.</FONT></STRONG></DIV></BLOCKQUOTE>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003>Spoken like a true, proud, stultifyingly myopic ED
nurse. </SPAN></FONT></FONT></FONT></DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003></SPAN></FONT></FONT></FONT> </DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003>I claim the right to say that, 'cause I am,
too.</SPAN></FONT></FONT></FONT></DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003></SPAN></FONT></FONT></FONT> </DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003>News for you, Andrew: the ICU is not staffed, equipped,
or trained for a fresh OD. Back to your mother again: clock's
ticking. You want Hortense in the Unit to take her?
Hortense also has that quad you sent down yesterday, and his pressures have
been soft this shift. Plus, the intensivists won't be rounding until seven
thirty, and the resident doesn't know jack about overdoses; he's off looking for
his Harriet Lane. Lab and x-ray have been running behind all day, and pray
Mom doesn't need meds any time soon, because they're still waiting for the
nine-o'clock run from the pharmacy. </SPAN></FONT></FONT></FONT></DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003></SPAN></FONT></FONT></FONT> </DIV>
<DIV><FONT size=2><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003>About the only <EM>good </EM>news is that the ICU's
only available room has a primo view from the sixth floor. But then, Mom's
here for a <EM>suicide attempt</EM>, isn't
she?</SPAN></FONT></FONT></FONT></DIV>
<DIV><FONT color=#800000><FONT face=Arial><SPAN
class=630523119-21012003></SPAN></FONT></FONT><FONT size=2><FONT
face=Tahoma><SPAN class=630523119-21012003><FONT color=#800000
face=Arial> </FONT></SPAN></FONT></FONT></DIV>
<DIV><FONT size=2><FONT face=Tahoma><SPAN
class=630523119-21012003> </SPAN><STRONG>With your argument, anybody who
takes a turn for the worse in the hospital, and becomes an "emergency" should go
back to square one (the ED) and start all over because it takes too long to call
the right consult and transfer the patient to ICU or
telemetry.</STRONG></FONT><FONT color=#800000 face=Arial><SPAN
class=630523119-21012003> </SPAN></FONT></FONT><FONT size=2><FONT
color=#800000 face=Arial><SPAN
class=630523119-21012003> </SPAN></FONT></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2> </FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN class=630523119-21012003>Don't
pretend this is a hip replacement with chest pain. This patient turned
from a psych patient (who goes to Group t.i.d. and has a pass for dinner with
her husband tomorrow, and is thoroughly unknown to any promptly available
practitioner of physical medicine) into a gutful of unspecified pills with
intent to self-harm. There's no unit in a typical
hospital qualified to manage her on short notice--except the ED.
</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=630523119-21012003></SPAN></FONT> </DIV>
<DIV><STRONG><FONT face=Tahoma size=2>Wow, how overcrowded is your ER right now,
mine cannot take that added proposed influx. I have to do with the
outpatients that are waiting for 4-5 hours to be seen the first time let alone
go upstairs and come back again a few days later because their doctor was
lazy.</FONT></STRONG></DIV>
<DIV><STRONG></STRONG><FONT color=#800000 face=Arial size=2> </FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN class=630523119-21012003>When
did this go from a transfer to an <EM>influx</EM>? Take a breath,
Andrew. Enjoy a refreshing soft drink.</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=630523119-21012003></SPAN></FONT> </DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN class=630523119-21012003>Our ED
is busy mostly because our hospital is busy. Go spend a shift in your ICU
before you start actually believing your ED is the center of the physical
universe. Be prepared, when need arises, to screw your outpatients.
Better still, take a close look at your temptation to refuse an overdose
for their satisfaction and convenience. Just what kind of a nurse have you
become?</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=630523119-21012003></SPAN></FONT> </DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN class=630523119-21012003>But if
it makes you more comfortable, go ahead and paint the doctor as lazy.
Makes it easier to deny that he might have been doing right by his
patient.</SPAN></FONT></DIV>
<BLOCKQUOTE dir=ltr style="MARGIN-RIGHT: 0px">
<DIV><STRONG><FONT face=Tahoma size=2>Andrew J. Bowman, RN, CEN, CCRN,
NREMT-P<BR>Patient Care Coordinator<BR>Education Coordinator (Trauma &
Emergency Cardiovascular Care)<BR>Emergency Department<BR>Home Hospital
Campus<BR>Greater Lafayette Health Services, Inc.<BR>2400 South
Street<BR>Lafayette, Indiana 47904 <BR>USA</FONT></STRONG></DIV>
<BLOCKQUOTE dir=ltr
style="BORDER-LEFT: #000000 2px solid; MARGIN-LEFT: 5px; MARGIN-RIGHT: 0px; PADDING-LEFT: 5px; PADDING-RIGHT: 0px">
<DIV style="FONT: 10pt arial"><FONT size=2><FONT face=Tahoma><FONT
color=#800000 face=Arial><SPAN
class=700525517-21012003></SPAN></FONT></FONT></FONT> </DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=700525517-21012003>Andrew,</SPAN></FONT></DIV>
<DIV> </DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=700525517-21012003><EM>Legality? Billing?
</EM>Horseshit. It's a sad reflection on the trauma-list membership
that nobody's defending what's in the best interest of the patient.
</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=700525517-21012003></SPAN></FONT> </DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=700525517-21012003>Imagine for a moment that this is <EM>your mother
</EM>who's OD'd in a medical psych ward which shares a campus with a
perfectly good ED, staffed by a qualified overdose expert and experienced
overdose nurses, equipped with state-of-the-art monitoring, and stocked
with all the activated charcoal she can drink. </SPAN></FONT><FONT
color=#800000 face=Arial size=2><SPAN class=700525517-21012003>Now throw in
a handful of obstructive backseat whiners, fussing about clinically
indefensible turf issues and obsessing about medicolegal apocrypha while the
tricyclics digest. </SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=700525517-21012003></SPAN></FONT> </DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=700525517-21012003>Ask her psychiatrist his plan for the proper
management of a fresh psychotropic overdose. Then trot over to the ICU
and see how soon they can find a bed for an untreated OD patient who's
sufficiently psychotic to require a locked unit. Experience for
yourself the vacant stares and the predictable ridicule, then ask where you
really want to send Mom.</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=700525517-21012003></SPAN></FONT> </DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=700525517-21012003>Last I heard, there's nothing illegal about
referring an emergency medical condition to an Emergency Department.
Surely EMTALA has no application here--except to the extent that if you're
deferring treatment of any patient based on their ability to pay, you're as
pathetic as you are screwed.</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=700525517-21012003></SPAN></FONT> </DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=700525517-21012003>You find a better disposition, great. Write a
policy, educate your practitioners, and implement the process Until
then, treat the patient and shut up.</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=700525517-21012003></SPAN></FONT> </DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN class=700525517-21012003>I
may be alone here, but I think you and all those who are cheering you on
should be ashamed of yourselves.</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=700525517-21012003></SPAN></FONT> </DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN class=700525517-21012003>
<DIV><FONT color=#800000 face=Arial size=2>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=030133519-19052000>Pret Bjorn</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=030133519-19052000>Trauma Coordinator</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=030133519-19052000>EMMC Trauma Program</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=030133519-19052000>489 State Street</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=030133519-19052000>Bangor, ME 04401</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=030133519-19052000></SPAN></FONT> </DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=030133519-19052000>207.973.7260 (office)</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=030133519-19052000>207.973.7673 (fax)</SPAN></FONT></DIV>
<DIV><FONT color=#800000 face=Arial size=2><SPAN
class=030133519-19052000>207.941.5085 (voice
pager)</SPAN></FONT></DIV></FONT></DIV></SPAN></FONT></DIV></BLOCKQUOTE></BLOCKQUOTE></BODY></HTML>
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