Ambulance vs Walk-in

[Guest partyrock]

There have been plenty of studies celebrating the significantly improved time from arrival to treatment of serious patients when they arrive by ambulance rather than walking in. Hospitals have done a lot over the years to reduce that disparity and in the last report I saw for American hospitals had the time to triage down to medically acceptably times for stroke, CVA, AMI, and pneumonia. My question is what about everything else. Unless you hit one of those four categories or are a trauma candidate you still wait a disturbingly long time for triage. I've always suspected this but got the chance to experience it first hand a couple of weeks ago. I was nearing the end of another EMS rotation when I was called by my mother saying she was taking my father to emergency room with severe acute abdominal pain. Since there is not much I can do I finish up and head over to check on the old codger. He's been there for over an hour and he still hadn't been triaged. There were no more than 12 other patients in the waiting room and no real evidence of progress. I give him a quick head to toe and find he's a little warm, generalized abdominal pain with severe tenderness in the right lower quad immediately above the pelvis. He'd been experiencing abdominal discomfort for 2 days but wrote it off to "something he ate". He has a history of hyperlipidemia and hypertension both controlled with diet and exercise. No meds. No allergies. Anyone want to take a crack at whats wrong with him? If he had come in by ambulance he would have gotten a stretcher and a quick visit from the attending. I managed to get in toch with a nurse explained who I was and what I had found and was informed that I should understand why he's waiting and that they would be with him as soon as possible. I ducked into the ER grabbed a medic who was there with a patient, explained everything and he hooked me up with the people to talk to. Long story short I snuck him past a now very pissed off nurse and he was on the first OR table in the morning. Luckily he is back to his old pestering self.

The whole point of this dragged out story is that it makes sense to call for an ambulance for every ache and pain. EMT's and Paramedics handle assessment and provide the triage staff and shortened detailed history that allows for faster and more accurate triage while the humps who walked in are treated as burdens to the system. Until that half of the system is fixed there is no reason for people to stop abusing the system.

[GAW6 66]

I agree. I had almost the same story. Last year my husband went to his MD because he wasn't feeling well; the MD sent him to the ER because "something wasn't right". I met my husband there (we are both EMTs who go in to this ER regularly on calls), he looked like s***. He was burning up with fever, I got a nurse who told me she "would see what she could do". When the triage nurse finally called him in, his temp was 104.8. She handed him 3 Tylenol and told him to go back in to the waiting room!! He waited in there almost 3 hours before he was seen by an MD. Turned out he had a severe case of cellulitis and was hospitalized for 10 days.

I got to the point where I was going to call for our ambulance to pick him up outside the ER and bring him in!!

[ONEEYEDMIC 68]

Just call an ambulance you might get one or you might not. ZING Seriously I wouldn't call an ambulance for anything that wasn't life threatening. I know that you will prob get seen faster if you do call an ambulance I just don't want to take one out of service.

[Guest feraldan]

I got to the point where I was going to call for our ambulance to pick him up outside the ER and bring him in!!

That lady who died in a California ER a few months back tried that one... she called 9-1-1 and they told her they couldn't do anything because she was already in the ER.

[emtpjimd 1]

On the other hand, I stress to patients that going by ambulance WON'T mean you get in quicker unless you are really quite sick..any "minor ache or pain" gets sent by the charge nurse to the waiting room to start the process as a walk in. Whether it's the father who called the ambulance for his 7 year old with a fever instead of getting the script he was given by his MD filled, or the cough for a week, or basically anything that's not in need of an immediate MD assessment, the ambulance won't save you a lot of time here.

[Guest feraldan]

I think that actually depends on the hospital. I've seen quite a few people with non-emergency conditions get bumped ahead of walk-ins at more than one hospital just because they were bused in.

I wish all hospitals did it like emtjimpd said.

[firemoose827 324]

Interesting topic....I have seen both sides of the spectrum here too. But I have also seen people who were bused in given a quick once over and sent to the waiting room where they still waited for an hour or more. Some times, our pt is put on a guerney in the HALL and are forced to wait there for an hour or more, right next to the nurses station! Our local hospital ( first aid station ) is an equal opportunity triager...you get screwed either way unless your a critical pt!!

But sometimes, as in partyrocks situation, someone slips through the triage system and gets mis-triaged. I brought in a 86 year old FM from a side impact MVA. The impact was on the drivers side and, da DA, she was the driver! She complained of abdominal pain, abdm was tender, she was confused and starting to black out, weak thready pulse, almost no BP, medic started two lines, we tx to the ED, gave the report, and they put her in THE HALLWAY!!! We were there for 45 minutes cleaning rig, restocking after a big MVA, and she was finaly seen by doc after my captain finaly said something to the doc. She was in the exam room for 5 minutes and was suddenly rushed to trauma in full code. She had a AAA. Mis-Triaged...and she was brought in by ambulance, lights and sirens with medic on board. (No chopper available, medic wanted tx to nearest facility)

So either way, something needs to be done with our ED triaging system, I agree.

[Guest feraldan]

I hope that lady pulled through and if she did pull through, I hope she has a good lawyer to sue the hell out of the hospital.

[Guest partyrock]

Maybe I wasn't clear, this isn't about being seen by the doc. I'm just looking for fast and effective triage. If they're working up a couple of MI's and and a trauma I can understand waiting. That night the ER was quite crowded so I could understand having to a few hours. Waiting over an hour just to be triaged is a problem. He was there for an hour and they had no idea what was wrong with him outside of his chief complaint. EMD requires more info. You're mode of transport to the hospital should not affect the speed with which you are treated.

[Guest mediconpatrol]

I agree a fast triage system is definately needed in all facilities. Unfortunately though with any system people do fall through the cracks. The stinky thing is that in this profession that could be the difference between life and death.

I have seen just as many people who come in by ambulance be triage to waiting room based on the EMT/medic report. So I am not sure coming in by ambulance in the right answer to quicker service, though I realize that wasn't the point of the posting.

Also, sometimes we do give medication (tylenol) in triage and then the patient waits to see the doctor because seeing if the fever comes down with medication is an evaluation tool.

[ny10570 745]

damn, I have almost the same story with my father at White Plains Hospital. I bring people to the ER who don't even need a doctor all the time, but I have to because they called for an ambulance. At most hospitals they are appropriately sent off to the waiting room, AFTER BEING TRIAGED. Abdominal pain or injury are not necessarily tickets straight to a bed in the ER. At times due to crowding patients are going to have to be seen in the hallway, as was my father. These are not desired situations, but they are necessary. What is unacceptable is waiting longer to be triaged because you came in by private means. Just as it is unacceptable to be treated faster just because you came by ambulance.

[E58RET 24]

As a retired firefighter/paramedic and present day RN who has spent 20 plus years in Emergency Dept's, yes is great to blame triage nurses and the system, but this is what we have to work with,a three level triage system of Emergent/Acute/Non Emergent. When you throw into this mix pt's who come to the ED because they can't see thier MD right away or "cant wait for a couple of hours until thier appt" and the usual mix of semi urgent pt's and EMS arrivals then you can see why the system bogs down. I feel sorry for those who seem to fall thru the cracks , but ER's today have become the last hope for medical care and or an outpost for MD's offices

[ny10570 745]

As a retired firefighter/paramedic and present day RN who has spent 20 plus years in Emergency Dept's, yes is great to blame triage nurses and the system, but this is what we have to work with,a three level triage system of Emergent/Acute/Non Emergent. When you throw into this mix pt's who come to the ED because they can't see thier MD right away or "cant wait for a couple of hours until thier appt" and the usual mix of semi urgent pt's and EMS arrivals then you can see why the system bogs down. I feel sorry for those who seem to fall thru the cracks , but ER's today have become the last hope for medical care and or an outpost for MD's offices

All these things are true, but how does that explain why it takes an hour to be triaged as emergent, acute, non emergent. triage takes what, 5 minutes? The fact of the matter is the people on the other side of the counter seem to have been conditioned to think that if you really are sick you would have called an ambulance.

[Oswegowind 17]

Personally, I believe it begins with the ambulance crew. If you properly triage your own patient and conclude that the waiting area is sufficient than so be it. We did this all the time. Some people call the ambulance cause they have the idea it means they are going straight to a bed or don't have money for a cab. Pay attention, examine/triage your patient and make the right choice. If you have a question, talk to the nurse. Even the VAC's have to learn this, this is EMS and everyone has to be on the same level.

FYI: A few of our Westchester Hospitals have begun programs called, Rapid Admission. These protocols follow patients that have already gone to the private doctor and it has been determined that they qualify and need admission. These persons will most likely be brought straight in to a special area of the ER to wait for their bed to become ready on the floor, while the private MD sends in his orders to the ER staff. St. John's is one of these facilities. Just make sure your doc can admit there first!

[E58RET 24]

I agree with the last post about MD's admitting Pts thru the ED,It clutters up an ED with multiple work ups , when if you are going to direct admit a pt send them in with orders rather than have an E.D md have to do the work up.This procedure also ties up triage when pts come in stating "my doctor sent me in to be admitted and you have to go thru the entire history,meds etc before they are seen