29 June 2007

Pissed off PCPs

It seems my last post pissed off the primary care docs, based on the comments left. Not really my intent, but hey, it won't be the first or last time I'll unintentionally piss off a whole class of practitioners.

Every ER doc has had to deal with the patients who come in with the "positive suitcase sign," meaning that their presentation is not only not an emergency but that they took the time to pack the suitcase before coming in (more than occasionally by ambulance). It's no fun to try to turn that into a satisfying patient experience when you are going to have to deny their initial expectation of hospital admission. Sometimes it's due to a 'patient issue," which is to say that either they just decided that they are not going home, or they willfully misinterpreted what another doctor told them. Nothing we'll ever do about that. But often, they come with the maddening statement "my doctor told me I was being admitted," when no such arrangements have been made. That's much more frustrating for all parties, and easily preventable.

Both the ER and the PCPs can play a role in mitigating this problem, I think. For the PCP's, I would ask the following:

  1. If you are sending a patient to the ER, please call us in advance and tell us what it is you want. We're all about customer service, we just have to know what it is you want us to do.
  2. Don't send a patient to the ER if they do not need to be seen in the ER. Seriously, if they are stable, make them a direct admission. It saves everybody time and money.
  3. Make sure the patient is clear on the expectation. Don't tell them they need to be admitted unless you are the decision-maker regarding the admission (in which case, see #2). If they are being sent for a work up, please make sure that is clear to the patient.
In our ED, we keep a phone log of every patient referral we receive, including the referring doc's expectations (i.e "just deal with it" vs "admit" vs "do X and call me back"). Every ER should do this. It works great, and even better, the phone log gets mated with and imported into the permanent medical record (Ibex/Picis). So if a referring doc wants a patient admitted, there's a record of that, too. All you have to do is pick up the phone and give us a call.

Somewhere out there, Flea is smiling.


  1. I tend to always call ahead if I'm sending someone to emerg. To me it's just like any other consult I ask for, and I'd never send someone to a consultant without a letter or a call. I think it's courteous and in the interest of good patient care. Usually I send along a note and a meds list with the ambulance crew to try to make the job easier once the patient arrives in emerg.

    That being said, I've been yelled at by people in emerg many times when making those calls (yes, I know they are stressed out too), and often told to send the patient to a different and more distant emerg, because the big hospital is too busy...so I can understand how some family docs get turned off of calling ahead...you can only volunteer to have your ass chewed off so many times...

  2. If I had a dollar for everytime a patient was sent to the ER but could have been a direct admit, I'd be able to buy that million dollar beach house I was admiring. There is a contingent of PCP's who abuse the ER in just this way.

  3. Everyone in healthcare needs to be ashamed at this occuring. Instead of constantly whining on all your blogs..collectively get togehter and CHANGE THINGS. We are dying out here.

    County officials express dismay at the events surrounding the recent controversial death at King-Harbor hospital. One nurse has resigned.
    By Charles Ornstein, Times Staff Writer
    May 20, 2007

    In the emergency room at Martin Luther King Jr.-Harbor Hospital, Edith Isabel Rodriguez was seen as a complainer.

    "Thanks a lot, officers," an emergency room nurse told Los Angeles County police who brought in Rodriguez early May 9 after finding her in front of the Willowbrook hospital yelling for help. "This is her third time here."

    The 43-year-old mother of three had been released from the emergency room hours earlier, her third visit in three days for abdominal pain. She'd been given prescription medication and a doctor's appointment.

    Turning to Rodriguez, the nurse said, "You have already been seen, and there is nothing we can do," according to a report by the county office of public safety, which provides security at the hospital.

    Parked in the emergency room lobby in a wheelchair after police left, she fell to the floor. She lay on the linoleum, writhing in pain, for 45 minutes, as staffers worked at their desks and numerous patients looked on.

    Aside from one patient who briefly checked on her condition, no one helped her. A janitor cleaned the floor around her as if she were a piece of furniture. A closed-circuit camera captured everyone's apparent indifference.

    Arriving to find Rodriguez on the floor, her boyfriend unsuccessfully tried to enlist help from the medical staff and county police — even a 911 dispatcher, who balked at sending rescuers to a hospital.

    Alerted to the "disturbance" in the lobby, police stepped in — by running Rodriguez's record. They found an outstanding warrant and prepared to take her to jail. She died before she could be put into a squad car.

    How Rodriguez came to die at a public hospital, without help from the many people around her, is now the subject of much public hand-wringing. The county chief administrative office has launched an investigation, as has the Sheriff's Department homicide division and state and federal health regulators.

    The triage nurse involved has resigned, and the emergency room supervisor has been reassigned. Additional disciplinary actions could come this week.

    The incident has brought renewed attention to King-Harbor, a long-troubled hospital formerly known as King/Drew.

    The Times reconstructed the last 90 minutes of Rodriguez's life based on accounts by three people who have seen the confidential videotape, a detailed police report, interviews with relatives and an account of the boyfriend's 911 call.

    "I am completely dumbfounded," said county Supervisor Zev Yaroslavsky, who has seen the video recording.

    "It's an indictment of everybody," he said. "If this woman was in pain, which she appears to be, if she was writhing in pain, which she appears to be, why did nobody bother … to take the most minimal interest in her, in her welfare? It's just shocking. It really is."

    The story of Rodriguez's demise began at 12:34 a.m. when two county police officers received a radio call of a "female down" and yelling for help near the front entrance of King-Harbor, according to the police report.

    When they approached Rodriguez to ask what was wrong, she responded in a "loud and belligerent voice that her stomach was hurting," the report states. She said she had 10 gallstones and that one of them had burst.

    A staff member summoned by the police arrived with a wheelchair and rolled her into the emergency room. Among her belongings, one officer found her latest discharge slip from the hospital, which instructed her to "return to ER if nausea, vomit, more pain or any worse."

    When the officers talked to the emergency room nurse, she "did not show any concern" for Rodriguez, the police report said. The report identifies the nurse as Linda Witland, but county officials confirmed that her name is Linda Ruttlen, who began working for the county in July 1992.

    Ruttlen could not be reached for comment.

    During that initial discussion with Ruttlen, Rodriguez slipped off her wheelchair onto the floor and curled into a fetal position, screaming in pain, the report said.

    Ruttlen told her to "get off the floor and onto a chair," the police report said. Two officers and a different nurse helped her back to the wheelchair and brought her close to the reception counter, where a staff member asked her to remain seated.

    The officers left and Rodriguez again pitched forward onto the floor, apparently unable to get up, according to people who saw the videotape and spoke on the condition of anonymity.

    Because the tape does not have sound, it is not possible to determine whether Rodriguez was screaming or what she was saying, the viewers said. Because of the camera's angle, in most scenes, she is but a grainy blob, sometimes obstructed, moving around on the floor.

    When Rodriguez's boyfriend, Jose Prado, returned to the hospital after an errand and saw her on the floor, he alerted nurses and then called 911.

    According to Sheriff's Capt. Ray Peavy, the dispatcher said, "Look, sir, it indicates you're already in a hospital setting. We cannot send emergency equipment out there to take you to a hospital you're already at."

    Prado then knocked on the door of the county police, near the emergency room, and said, "My girlfriend needs help and they don't want to help her," according to the police report. A sergeant told him to consult the medical staff, the report said. Minutes later, Prado came back to the sergeant and said, "They don't want to help her." Again, he was told to see the medical staff.

    Within minutes, police began taking Rodriguez into custody. When they told Prado that there was a warrant for Rodriguez's arrest, he asked if she would get medical care wherever she was taken. They assured him that she would. He then kissed her and left, the police report said.

    She was wheeled to the patrol vehicle and the door was opened so that she could get into the back. When officers asked her to get up, she did not respond. An officer tried to revive her with an ammonia inhalant, then checked for a pulse and found none. She died in the emergency room after resuscitation efforts failed.

    According to preliminary coroner's findings, the cause was a perforated large bowel, which caused an infection. Experts say the condition can bring about death fairly suddenly.

    Hours after her death, county Department of Health Services spokesman Michael Wilson sent a note informing county supervisors' offices about the incident but saying that that police had been called because Rodriguez's boyfriend became disruptive.

    Health services Director Dr. Bruce Chernof said Friday that subsequent information showed Prado was not, in fact, disruptive. Chernof otherwise refused to comment, citing the open investigation, patient privacy and "other issues."

    Peavy, who supervises the sheriff's homicide unit, said that although his investigation is not complete, "the county police did absolutely, absolutely nothing wrong as far as we're concerned."

    The coroner's office may relay its final findings to the district attorney's office for consideration of criminal charges against hospital staff members, Peavy said.

    "I can't speak for the coroner and I can't speak for the D.A., but that is certainly a possibility," he added.

    Marcela Sanchez, Rodriguez's sister, said she has been making tamales and selling them to raise money for her sister's funeral and burial. Her family has been called by attorneys seeking to represent them, but they do not know whom to trust.

    She said the latest revelations, which she learned from The Times, are very troubling.

    "Wow," she said. "If she was on the floor for that long, how in the heck did nobody help her then?

    "Where was their heart? Where was their humanity? … When Jose came in, everybody was just sitting, looking. Where were they?"

    Sanchez said her sister was a giving person who always took an interest in people in need, unlike those who watched her suffer. "She would have taken her shoes to give to somebody with no shoes," she said. Rodriguez, a California native, performed odd jobs and lived alternately with different relatives.

    David Janssen, the county's chief administrative officer, said the incident is being taken very seriously. In a rare move, his office took over control of the inquiry from the county health department and the office of public safety.

    "There's no excuse — and I don't think anybody believes that there is," Janssen said.

    Over the last 3 1/2 years, King-Harbor has reeled from crisis to crisis.

    Based on serious patient-care lapses, it has lost its national accreditation and federal funding. Hundreds of staff members have been disciplined and services cut.

    Janssen said he was concerned that the incident would divert attention from preparing the hospital for a crucial review in six weeks that is to determine whether it can regain federal funding.

    If the hospital fails, it could be forced to close.

    "It certainly isn't going to help," Janssen said.

    At the same time, he said, the preliminary investigation suggests that the fault primarily rests with the nurse who resigned. "I think it's a tragic, tragic incident, but it's not a systemic one."

    Supervisor Gloria Molina, who hadn't seen the videotape, said she wasn't sure the hospital had reformed.

    "What's so discouraging and disappointing for me is that it seems that this hospital at this point in time hasn't really transformed itself — and I'm worried about it," she said.

    Supervisor Mike Antonovich said he believed care had improved at the hospital overall, but added, "It's unconscionable that anyone would ignore a patient in obvious distress."

    Rodriguez's son, Edmundo, 25, said he still couldn't understand why his mother died. "It's more than negligence. I can't even think of the word."

    His 24-year-old sister, Christina, said, "It just makes it so much harder to grieve. It's so painful."



    Times staff writers Stuart Pfeifer and Susannah Rosenblatt contributed to this report.


  4. "If I had a dollar for everytime a patient was sent to the ER but could have been a direct admit, I'd be able to buy that million dollar beach house I was admiring."

    You've obviously have not worked on the floor/ICU in a long time. In every hospital STAT resources are focused on the ER, not a complaint just the way it is. Having a pt who may (or may not) have been evaluated elsewhere while nonstat resources are used in the initial work up is a prescription for disaster. You really need to get out of that box called the ER.

    PS: And so do you moderator.

  5. the point is not the use of STAT resources...the patient's that should be direct admits are the ones that have already been worked up, already have a plan, and someone sends them on to the ER just b/c it's easier. It's also more expensive (all those STAT tests the admitting team will want from me cost $$$, and don't forget the charge for the ED visit), and takes up ED resources that may be used on sicker, unstable patients. If you send a direct admit to the floor, yeah, some things take a bit longer, but does that really make a difference? Do they all have to be "stat?"

    this is part of the problem with our medical system...once you realize things CAN happen STAT, you want them ALL that way...

  6. hibgia:
    Since you only spent a few months on the floor in your EM residency I will cut you some slack for not knowing what are talking about.

    1: Every lab I have ever seen from every hospital's ER (and I have worked in a lot of hospitals) is STAT. I am not begrudging the system and I understandthe need to "move the meat", but the fact is the floor/ICU issues take second to the ER (unless phone calls are made to emphasize it is an acute issue). That is the fact and any disagreement on your part just shows your lack of understanding on the subject.

    2: If you really think the only pt's who should be "direct admits" are those that already have been worked up, well you don't know much about hospitals. I regularly direct admit, if the pt is stable and does not need a stat eval. In fact if I and my cohorts dumped these pt's on the ER, we would be increasing your work by 10-20% of admits (or more).

    3; You might complain about STAT, but do you realize the ER is by far the worst offender? Again, I don't blame the ER with the move the meat mentality but the fact is you can't have it both ways.

    May I suggest you spend a little moretime out of the ER to see how the other half lives.

  7. Iam a Housekeeper for a Hospital and what really Burn's My Ass is when the E.R Nurses try using intimidation and threats, then stand there laughing infront of Dr's and other nurses like they are proud of belittleing another fellow co-worker.
    Iam not referring to any of you on this site, but am referring to rude nurses at the hospital where I work.
    Today I wa cleaning E.R and out of the blue the charge nurses asked another nurse if a room was cleaned yet? And the nurse said "she is working on it now" the charge nurse's reply was: "WHAT! We dont have to wait for an hour to get a room cleaned?" she stood there with her arms crossed lughing infront of the Dr's.
    I came back in there later to deliver linens an charge nurse made a remark "Wonder if room 225B is cleaned yet we asked for it an hour ago? to another nurse she asked about this room. The Dr said "Call housekeeping a see if it got cleaned yet"
    The charge nurse laughed and said "Call Housekeeping?" Im not calling Housekeeping they dont clean anything, Im calling my boss!"
    She didnt call her boss she stood there laughing standing behind the Dr's staring at me.
    I know Im complaining but Iam responsible for cleaning E.R and I was cleaning that room she was complaining about, and w have one girl on the MED SURG floor that handled room 225B hours before her complaint. To me if she was so worried about that room being cleaned she should have made that call to MED SURG to find out or to the other housekeeper.

  8. I too work in the same hospital she does and its true the rudeness towards Housekeeping is sad!
    The nurses are suppose to change out the sheets, blankets,draw sheets, pillow cases every morning for theyre patients, " Well at this hospital the nurses leave the dirty linens on the floors and make housekeeping pick it up, and if that isnt bad the nurses will leave a toilet plugged up all night long wth feisces and urine in it overflowing on a patients floor, they call security to unplug it they refus to so they wait for housekeeping to clock in and then they force housekeeping to do the plunging of the toilets which they should hve called House Superviser or reported it to maintenance.
    So the bad treatmet is there and it is rediculous, so if anyone has any info on what to do please tell us. Thanks


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