Monday, May 26, 2014

Urgent Care vs. Emergency Department

How does should a consumer decide if they should go to an ED or an urgent care facility?
This on the surface looks obvious but as usual the “Devil is in the Details.”
Chief complaints, severity of pain, ease of access, time of day or night, insurance mandates, technological needs (cat scan etc.) and the ability of the consumer through the internet to predict complexity of work-up are all factors to consider when deciding.
Emergency Department:
Consider these factors when deciding if an ED visit is necessary:
  •  If there is high complexity of care needed
  • If immediate treatment is needed, what facility will be able to do so
  •  If extensive testing is needed, what facility will be able to do so
  •  Possible admission to hospital
  • Emergent need of specialists
The follow chief complaints are better served initially at an ED:
  • Chest Pain
  • Shortness of Breath
  • Severe Abdominal/Pelvic Pain
  • Pregnancy issues
  • Severe Headaches
  •  Severe back pain with numbness
  •  Tingling
  •  Urinating problems
  • Multiple injuries
  • Head injury with loss of consciousness
  •  Deep lacerations
  •  Fractures with deformity
  •  Children< 3 months old
  •  Elderly patients with multiple medical issues
  • Psychiatry issues

Urgent Care:
Research capability of the urgent care of your choice:
  • Hours
  • X-ray
  • Relationships with local institutions and specialists
Most other complaints can be seen by the urgent care and then referred to a specialist or a hospital for further care.  The urgent care can treat most illnesses that do not need extensive evaluation. The smart consumer will develop a relationship with their local urgent care and call for advice.

A few more things to keep in mind for the consumer: 
  • A significant number of cases are seen first in an UC, and later in an ED. These fall into two categories: a) those that are transferred or referred to the ED for more complete evaluation, and b) those that do not recover or progress as expected and need a more intense workup.
  • Many EDs have, in effect, UCs within their ED environment.  These are usually called, when so embedded, “Fast Track” units.  But sometimes the term UC may be used.  The problem here is that because many EDs are quite full, embedded FT or UC units may receive overflow from the main ED. This impedes the ability of the FT to flow as fast as the off-campus UC, in which hospital limitations are not present. 
  • It is of value to inquire of your personal physician regarding his experience with any local ED or UC, since he may be called if you happen to appear in either site.  At times, he/she may be able to recommend the best approach for various circumstances that may arise for you or your family.

Tuesday, May 20, 2014

Take Me to the Emergency Department? Urgent Care? Free-Standing ED? Hybrid UC?

The average consumer has a lot of confusion on what venue of emergency medical care is available or appropriate for their immediate needs.

An emergency department (ED), also known as accident & emergency (A&E), emergency room (ER), or casualty department is a medical treatment facility specializing in acute care of patients who present without prior appointment, either by their own means or by ambulance.  These are 24 hour venues with full services that are usually attached to a hospital and function under the EMTALA law.  In 1986, Congress enacted the Emergency Medical treatment & Labor Act to ensure public access to emergency services regardless of ability to pay. 

Free-Standing Emergency Department functions as full facility that is not attached to a hospital.  They are also subject to the EMTALA law.  Patients who need hospitalization are transferred to a hospital.

Urgent care is a walk-in clinic focused on the delivery of ambulatory care in a dedicated medical facility outside of a traditional emergency room.  Urgent care centers primarily treat injuries or illnesses requiring immediate care, but not serious enough to require a ER visit or hospitalization.
Urgent care centers are distinguished from similar ambulatory healthcare centers such as emergency departments and convenient care clinics by their scope of conditions and treatment available on-site.  While urgent care centers are not typically open 24-hours a day, 70% open by 8:00am and 95% close after 7:00pm.  They do not fall under the EMTALA law.

Hybrid Urgent Cares are designed to evaluate all levels of patients.  They usually perform ultrasound, cat scan, or x-ray and complex lab tests on-site.  Most are open from 8am to 10pm.  Patients who need hospitalization are transferred.  There is no emergency department facility fee, so the process are lower.  They too are not subject to EMTALA law.

When an individual is ill, where should they go and get the most "bang for the buck"?  This is not an easy decision under stress.  The best method is working with your primary care physician and figuring out, in advance, what level of care and convenience you desire or need.  Insurance companies play a huge role in this as they drive patients toward less expensive platforms of care.

Do your homework!
  1. Pick a hospital system you trust where your primary care physicians operate.
  2. Ask your neighbors/relatives.  They might not recognize quality care, but are aware of attitude, efficiency and caring.
  3. Analyze the capacities of local and hybrid urgent cares -
Good questions are...
  • Level of testing
  • Transfer policies
  • Procedures performed
  • Insurance issues
  • How do they relate to your primary care physician
What to do when you are ill?

If you have time "Google your symptoms" and try to figure how complex a problem is.
  1. High risk illnesses: need a higher level of care.  This list is not inclusive. - chest pain, severe abdominal pain, severe shortness of breath, severe bleeding, syncope (passing out), possible stroke, pregnancy related vaginal bleeding, potential labor, sever infections, acute exacerbations of a chronic illness that leads to hospitalization routinely, pediatric patients under 3 months of age elderly patients with multiple complex illnesses and medications, sever trauma, head injuries, severe fractures that need surgery, and severe lacerations.
  2. Moderate illnesses can probably go to a quality urgent care.  A quick phone call to you primary doctor's office can direct you to the "right place".  The primary care provider can to handle most of these problems, if they can see you immediately.
Bottom line- when in doubt GO TO THE EMERGENCY DEPARTMENT!  If there is time to sort things out, make an informed decision (medical and financial).  A little pre-planning can go a long way.

Wednesday, May 14, 2014

Why I Always Choose the ED

We are fortunate to have a guest blog by Dr. Donald Kamens, MD, FACEP,  FAAEM.  Hope you enjoy!

Suppose you had a broken car and had two fundamental choices to fix it.

1. You could take it to the repair shop down the street.  You've known the mechanic for a long time; and you like him.  He's generally thought to do good work, too, though sometimes his office staff doesn't get things done in time.  The problem you have with choice 1 is finding out what is wrong with the car may take some time.  He'll likely add some oil or give you some other remedy, and tell you to drive it and see how it runs.  But then, if things still aren't working out, he may even look under the hood.  Depending on what he sees there, he may either run a few tests or tell you everything looks good, and you should give it a few more weeks.  After a few weeks or a few tests that are marginal, he will then tell you to see his friend, the engine specialist, to see what he has to say.  It takes three more weeks to get an opening in the specialist's schedule, and that one charges you $700 for parts and labor.  The total cost was about $1,400 between all the parts, materials, and labor.  To say nothing of the time costs when you were not working.

Then we have choice 2- This is the modern garage.  Not only is the place full with every high-tech instrument known, but the mechanic and his crew listen to Car Talk.  You know that if you go in there, it will cost you more than your visit to your choice 1 mechanic.  But you also know your car will get a thorough work over.  Before you leave, you may have 10 fuel tests, 2 auto scans, and an electro-car-o-gram.  However, in a few hours, you will know what's up.  Really, you don't have the time to run all over the place, when you can get it all done with a one shop stop.  So you choose option 2.  They find what's wrong in a hour.  You are done.  The bill is...$1,400.  Wait...wasn't that the same amount you spent chasing the mechanic in plan 1??  No one ever said that comparing a single visit to option 2 was the same as comparing the many visits option 1 would require.

And this folks, is why the ED ought to be the center of the US health care system.  It is already in place.  It knows how to function.  It is effective.  A few tweaks...and it would be the envy of the world.

Go tell Washington. might have to walk!!

Monday, May 5, 2014

Unfunded Mandates

The frustration of physicians of the endless unfunded mandates in an attempt to control health care costs is mounting.  An opinion piece in the Wall Street Journal by a 58 year old orthopedic surgeon is an excellent example of these complaints heard in any medical gathering.  The article a doctor's declaration of independence, elucidates the various complaints.  These include the electronic medical record with all its attendant problems, meaningful use demands for unnecessary clinical data to obtain payment, decrease of face to face time with patients, board recertification, and continual decrease in reimbursements by Medicare and Medicaid.

His suggestion is to stop taking Medicare or any insurance.  The problem is that Medicare and Medicaid pay approximately 30% of the total health care budget.  This is probably a low estimate, but without these funds hospitals would be unable to remain open.

When Medicare started in 1965, physicians and hospitals "hooked their wagons" to the government for higher and consistent reimbursements.  But like any government program, the system is constantly evolving in a negative entropy that appears to be unable to be stopped.  More regulations and more burdens are now the norm.

There is no easy answer for these problems, but physicians need to organize to protect their workplace environments only one of which is financial.  Hating the job is not in the patients' interest.  Their health and care is really the ultimate goal.