EMERGENCY ROOMS are not all created equal!

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.

(1) http://www.wisegeek.com/in-medicine-what-is-the-golden-hour.htm#didyouknowout

(2) https://www.caring.com/questions/golden-hour-stroke

(3) http://apollolife.com/HealthTopics/Heart/GoldenHourforHeartAttackPatients.aspx

(4) http://www.thenecc.org/images/Mammo.Gizzy.pdf

(5) http://www.jointcommission.org/chest_pain_certification_process/

(6) https://www.aamc.org/cim/specialty/list/us/336838/emergency_medicine.html

(7) https://www.medicare.gov/Pubs/pdf/11435.pdf

(8) http://www.usatoday.com/story/money/personalfinance/2015/12/30/primary-care-urgent-care-er-all-depends-what-ails-you/76979284/

 

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.

To get a once weekly post by email subscribe (free) at http://doctordidyouwashyourhands.com/

Jonathan M. Metsch, Dr.P.H.

http://icahn.mssm.edu/profiles/jonathan-m-metsch

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

 

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How to find the best doctor?

A great way to find out who the best doctors are is to learn who respected doctors themselves see and send their families to see. But this is not so easy unless you are an ”insider” like me having worked as a hospital executive with physician colleagues to ask.

So here is a suggested strategy:

1. Find a well qualified primary care physician (PCP). Usually a physician in family practice, internal medicine, obstetrics/gynecology, or pediatrics who is a patient’s first contact for routine, outpatient health care. (Start with personal recommendations than use Google to get more information.)

2. “Best Doctor” lists are useful but learn to differentiate between lists which are independent publications from ones where physicians can “pay to play.” (can usually be found in an appendix.)

3. Your PCP should be Board Certified. Many specialties now require periodic Maintenance of Certification, beyond initial certification.

4. Look for a PCP who has admitting privileges at a nearby community hospital and a regional teaching hospital. Better yet a physician with a medical school faculty appointment who teaches medical students and residents.

5. Ask if your PCP will participate in managing your care if you are admitted to the hospital, or transfer your care off to a “hospitalist.”

6. Takes your insurance and is not “out-of-network.” And has a an in-network panel for specialist referrals.

7. Uses your preferred medical decision making style – e.g., physician led, shared patient/ doctor discussion.

8. Has convenient office hours and off-hours phone/ email availability or back-up.

9. Listens to you and does not appear to be preoccupied or rushed. And does not continually get interrupted or take phone calls during your visit.

10. Answers your questions clearly in an evidenced-based way.

11. Uses an Electronic Medical Record to share information with your other clinicians, and with a patient portal so you can easily access your medical record.

12. Orders diagnostic test thoughtfully (not defensively) and prescribes antibiotics carefully (and not simply because you ask).

13. Washes his or her hands in front of you every time and is not insulted if you ask “Doctor, Did You Wash Your Hands? ™”

 

To get one weekly post by email subscribe (free) at http://doctordidyouwashyourhands.com/

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.

http://icahn.mssm.edu/profiles/jonathan-m-metsch

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

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