Let’s start with the “GOLDEN HOUR.”
“The golden hour is a window of opportunity in which rapid medical intervention can save a patient’s life or make a significant difference in the level of impairment a patient experiences after recovering from a medical emergency. People often use this term in the context of trauma medicine, where many members of the lay public are aware that rapid transport to a trauma center can make the difference between life and death, but it is also important for treatment of strokes, heart attacks, and other medical issues.” (1)
For stroke patients “… treatment within the golden hour is more successful because patients are candidates for the powerful clot-busting drug known as tPA (short for tissue plasminogen activator), which must be given within the first few hours after a stroke.” (2)
For heart attack patients the “…Golden Hour is a critical time because the heart muscle starts to die within 80-90 minutes after it stops getting blood, and within six hours, almost all the affected parts of the heart could be irreversibly damaged. So, the faster normal blood flow is re-established, the lesser would be the damage to the heart.” (3)
So it is important to get immediately to the right ER rather than always be taken to, or going to the nearest ER. A stop at the wrong ER for trauma, stroke or a heart attack, then a transfer to the right ER, can pierce the golden hour.
Some states have multiple levels of Stroke Center with different capabilities. New Jersey has two: Primary and Comprehensive. (4)
Some hospitals have been awarded Chest Pain Center accreditation by the Joint Commission. (5) Cardiac Centers should have interventional cardiac catheterization laboratories; an excellent standard is in-house interventional cardiologists 24/7.
It is worth knowing that some hospitals have separate psych and pediatric ERs. And there are now some separate geriatric ERs and obstetrical ERs.
Next you should know the training of the physicians who staff an ER. The Gold Standard is board certified Emergency Medicine trained physicians 24/7.
“Emergency medicine focuses on the immediate decision making and action necessary to prevent death or any further disability both in the pre-hospital setting by directing emergency medical technicians and in the emergency department. The emergency physician provides immediate recognition, evaluation, care, stabilization, and disposition of a generally diversified population of adult and pediatric patients in response to acute illness and injury. A high-pressure, fast-paced, and diverse specialty, emergency medicine requires a broad base of medical knowledge and a variety of well-honed clinical and technical skills.” (6)
Beware of ERs staffed by “moonlighter” from other specialties and/or “on-call” specialty consultants who bill fee-for-service. And while an ER might be in-network for the hospital charges, it is possible (though unconscionable) that the ER physicians and specialty consultants are out-of-network and will not accept what your insurance pays them, leading to “balance billing.”
Just because you think you have been admitted doesn’t mean you have actually been admitted. You may be “Under Observation.” “You’re an inpatient starting when you’re formally admitted to a hospital with a doctor’s order. The day before you’re discharged is your last inpatient day. You’re an outpatient if you’re getting emergency department services, observation services, outpatient surgery, lab tests, X-rays, or any other hospital services, and the doctor hasn’t written an order to admit you to a hospital as an inpatient. In these cases, you’re an outpatient even if you spend the night at the hospital. (7)
Like me you may have seen highway billboards “clicking” nearby ER waiting time. While Waiting times are important all ERs triage patients so seriously ill get to the head of the line
For a serious, undiagnosed problem UrgiCare Centers are not alternatives to ERs. UrgiCenters are appropriate alternatives to the ER for situations where you normally go to a doctor’s office or health center. (8)
The Emergency Room is a new hospital “front door” as protocol driven medicine channels only the sickest patients to hospitals. Hospitals take this “high risk” role very seriously and monitor ER quality diligently. But all ERs are not the same and an educated consumer approach is necessary as you consider emergency health care decisions.
Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.
Jonathan M. Metsch, Dr.P.H.
Clinical Professor, Preventive Medicine, Icahn School of Medicine at Mount Sinai
Adjunct Professor, Zicklin School of Business, Baruch College, C.U.N.Y.
Adjunct Professor, Rutgers Schools of Public Health & Public Affairs and Administration