I started today with 12 patients.
That's fine with me. Unfortunately, the more money I spend caring for barely sick granny, the less money there is when you come in with septic shock. As we've seen in the last few weeks hospitals are closing because the money isn't there to pay them and to keep up with unfunded mandates. ED's are already closing nation wide due to the unfunded EMTALA mandates. I suppose one way to decrease costs is to decrease access. If I can tell a patient up front that their condition will not be paid for, they have a choice to pay cash up front or go home and deal with the non urgent medical issue like many generations before them did. The hospital is not a magic force field of health. It is a building full of death and disease. You should want to avoid the hospital, not embrace it.
So here's my list of conditions that don't ever need to be in the hospital.
Since November 1st, 2007 I have discharged approximately 450 people from the hospital. A full 25% of those people were discharged from observation stays. Observation stays are considered outpatient. That's a lot of money just to observe.
The hospital is also the largest cost to our health care pie. I just gave you 17 reasons why.
- I discharged ten of them
- Of the ten discharges, seven of them were discharged as an observation stay
That's fine with me. Unfortunately, the more money I spend caring for barely sick granny, the less money there is when you come in with septic shock. As we've seen in the last few weeks hospitals are closing because the money isn't there to pay them and to keep up with unfunded mandates. ED's are already closing nation wide due to the unfunded EMTALA mandates. I suppose one way to decrease costs is to decrease access. If I can tell a patient up front that their condition will not be paid for, they have a choice to pay cash up front or go home and deal with the non urgent medical issue like many generations before them did. The hospital is not a magic force field of health. It is a building full of death and disease. You should want to avoid the hospital, not embrace it.
So here's my list of conditions that don't ever need to be in the hospital.
- Acute Back Pain without red flags. I don't care how much it hurts, you can hurt just as much at home as you can in the hospital. Time, Time, Time.
- Alcohol Intoxication. I work at a hospital, not a drunk tank. Throw 'em in jail for the night, for all I care.
- Loneliness. I'm not kidding. I had a patient tell me she couldn't be alone and was happy to be in the hospital.
- Headache without red flags. Again, you can hurt just as much at home as you can in the hospital.
- Chronic Abdominal Pain of Any Cause, but specifically chronic pancreatitis If you have 24 admissions for abdominal pain, the 25th isn't going to be productive
- Acting Out. I'm sure this falls more in the pediatric realm, but I work down in the EDs when out of control kids come in and their parents want them admitted. We are not your babysitters
- Cellulitis without a trial of outpatient antibiotics. This is not all inclusive, but you know when you see the "go home" cases and "call me in a week" if it isn't better
- Shortness of breath. The classic morbidly obese smoker on 4 liters of oxygen all the time who complains of "can't catch my breath". And normal oxygen saturations. Go home, exercise, quit smoking, and if your oxygen levels take a dive, call me. I'd be happy to help.
- Narcotic withdrawal. I do not run a detox service. People do not die from narcotic withdrawal. It's going to be painful. That's the way it works.
- Chest pain with a negative stress test a week ago, a normal EKG and negative cardiac enzymes, AND a negative d-dimer, CTA chest and leg dopplers. You just did my entire hospital work up. It's time to go home.
- Anorexia. I can't cure you in the hospital.
- Weight loss. Again, I'm more a one stop shop of convenience. Weight loss deserves an outpatient work up.
- Hemocult positive blood in a bed bound nursing home patient. Don't ever check a hemocult in a bed bound nursing home patient.
- Dizziness. Way to much dizziness going around. My experience with inpatient dizziness is very unproductive.
- Chronic hyponatremia. If they're walking and talking, they'll be fine. I've had VA patients who baseline sodium was 115. It's not the number that matters, it's how quickly it changes.
- Rash. Doesn't matter how scary it looks, if there aren't red flags, time is on your side.
- The SOCIAL ADMIT. Grandma needs a nursing home (which Medicare won't pay for) but granny has 100 days of paid skilled Medicare nursing days available and the only way to get grandma into the nursing home for her skilled days is to admit her for three midnights in a hospital and qualify her based on the rules of the game that Medicare built.
Since November 1st, 2007 I have discharged approximately 450 people from the hospital. A full 25% of those people were discharged from observation stays. Observation stays are considered outpatient. That's a lot of money just to observe.
The hospital is also the largest cost to our health care pie. I just gave you 17 reasons why.
whitecap nurse says:
ReplyDeleteDr. Happy will you come & work at my hospital, PLEASE! We are always admitting very weak CP with negative work-up or L arm tingling (which is probably cervical nerve pain) etc., etc. small quibble- I think you meant hemoccult pos. STOOL not BLOOD. One question, if granny really does need a nsg. home placement & 3 days of hospitalization are required to get it, what do you suggest?
Shortness of breath. - Some dire conditions, smoking related or not, can have desaturation only on exertion at first and be normal at rest. How do you rule those out?
ReplyDeleteHmmm. You've been spammed. This is the third time I've seen a drug add pop up in the comments section of a med blog in the last two days.
ReplyDeleteWhen Grandma needs a nursing home, the family needs to place her in a nursing home. They need to step up and take care of Grandma, even if that means they need to pay out of pocket. The 100 days at the nursing home are SKILLED days, also paid by medicare for those people who can recover and go home to independence. It is not a 'free' 100 days in the nursing home paid for by medicare.
ReplyDeletethis list should be forwarded to many er's. put it over the threshold between the ed and the doorway/elevator to the regular floors!
ReplyDelete