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Tuesday, February 11 2014

1. “Patience will get you nowhere.”

Nobody likes a visit to the emergency room. Babies are crying. People are wheezing or moaning in pain. And there’s little relief in watching the worst cases being rushed to an operating room. Nonetheless, more people step into ERs every year, with visits hitting 130 million in 2010, up 34% from 97 million in 1995, according to the Centers for Disease Control. Meanwhile, the number of emergency departments is down about 11% over that same time period.

As a result, people are waiting longer to see a doctor: A 2009 report from the Government Accountability Office found that patients whose condition indicated they should have been seen in 1 to 14 minutes, according to Emergency Nurses Association guidelines, waited 37 minutes on average to see a physician. Even worse, those who were supposed to be seen in less than 1 minute were left waiting for about 28 minutes. Crowding can be worse during the holidays, when some hospitals see an uptick in visits from patients suffering from heart disease or from excess alcohol consumption.

Hospitals are addressing the crowding by assigning more responsibilities to physician assistants and nurse practitioners and treating some patients without assigning them to a bed. Some hospitals are treating patients more quickly by using a team approach where patients are attended to by a doctor, nurse and registration worker at once who can immediately order needed tests and procedures as well as quickly treat patients with simple cases, says Alex Rosenau, president of the American College of Emergency Physicians, or ACEP, a trade group for emergency physicians.

The urgency of a patient’s condition is determined when he or she first walks into the ER and is seen by a nurse in a process known as triage, which is designed to get the sickest and most seriously injured patients in front of a doctor first. But because sudden changes in a person’s condition can go unnoticed amid the commotion in crowded emergency rooms, it’s important for patients or their advocates to speak up if they begin to feel much worse or if they think doctors or nurses are misunderstanding their symptoms, says Rosenau.

2. “But shorter wait times aren’t always better.”

More hospitals are advertising their wait times—on their websites, on Twitter and even on billboards—in an effort to set themselves apart from competitors. And lowering wait times could also protect their bottom lines: Because of a pay-for-performance system created by the Affordable Care Act, Medicare payments to hospitals are partly based on patient satisfaction. 

The advertised wait times might help patients make smarter decisions about where to go for non-urgent conditions, doctors say, but some providers are concerned that this recent focus on the clock could end up hurting patients. “You can move people through quicker, but if you are taking short cuts, there is a cost,” says Drew Fuller, an emergency medicine physician in Maryland and director of safety innovation for Emergency Medicine Associates, a physician group. For instance, if hospitals interrupt care in an effort to move some less-urgent patients through the system, they may be putting high-risk patients in danger, according to an informational paper on wait times by ACEP. And patients who avoid the emergency room because they’re worried about long wait times could be putting themselves at risk, doctors say.

Another issue with publicized wait times: They’re not reliable. Many hospitals measure wait times differently, making it difficult for patients to interpret them. Some hospitals stop the clock at the point when a patient is first greeted, others when a patient is first examined and others when a patient is moved to a room, ACEP points out in its report. And unusually high wait times can occur with little or no notice, doctors say, rending predicted waits inaccurate. “I could advertise my wait time as 20 minutes but then a school bus of children comes in and it’s now an hour and a half,” says Rosenau.

3. “Our riskiest procedure doesn’t involve needles or scalpels.”

Some doctors say the most dangerous procedure that happens in the emergency room doesn’t take place anywhere near the operating table: It’s the handoff that happens between doctors and nurses changing shifts or when patients are transferred to another department. If doctors don’t communicate well when they’re changing shifts, insiders say, the most important information about the patient can get lost amid the list of figures and status updates in the patient’s chart, making it difficult for the doctor taking on the patient to know what to prioritize. An estimated 80% of serious medical errors are due to miscommunications between medical providers handing off or transferring patients, according to the Joint Commission, a nonprofit organization which accredits health care organizations in the U.S.

“The fact is that we have no standards out there for how physicians do this critical thing,” says Fuller. Fuller is among the doctors calling for a standardized approach known as “Safer Sign Out.” The process asks doctors and nurses to fill out a form highlighting their biggest concerns about a patient and to meet briefly when they’re transferring shifts to discuss those concerns and introduce the incoming doctor to the patient. Some hospitals are overlapping the first hour of the incoming doctor’s shift with the last hour of the outgoing doctor’s shift in order to give doctors time to do all this, says Rosenau.

4. “We constantly forget to wash our hands.”

Three ways for patients to protect themselves from a potentially deadly medical mistake or hospital infection.

If you’re worried about catching something from the person sneezing next to you in the waiting room, just imagine the germs surrounding the doctor or nurse treating you, say health experts. Health-care workers who don’t wash their hands are putting their patients at risk for urinary tract infections, pneumonia, and blood infections, among other serious complications, doctors say. And emergency room physicians, moving frequently from one urgent patient to another, have more opportunities to forget to wash their hands, says Jason Sanders, a Ph.D. student at the University of Pittsburgh studying epidemiology, or how diseases spread within populations. While health-care workers agree that hand washing can help reduce a patient’s risk of infection, many hospitals are battling low compliance rates. A 2009 analysis of 20 hospital-based studies on hand hygiene by the World Health Organization’s World Alliance for Patient Safety found that hand hygiene often improved when hospitals introduced new guidelines, hand-sanitizer stations and awareness posters, but many health-care workers still washed their hands less than half as often as they were supposed to.

Hospitals are showing patients videos and brochures that encourage them to ask doctors if they’ve washed their hands, but many patients are too intimidated to challenge their doctors. According to a study published in September in the journal Infection Control and Hospital Epidemiology, one third of patients surveyed by the University of Pittsburgh Medical Center said they didn’t see their doctors wash their hands, but two-thirds of that group said nothing to the doctor about it. Some hospitals are posting hand-washing rates around the hospital in an effort to get health-care workers to recognize when they may be forgetting to wash, says Rosenau. Others are watching workers more closely. After North Shore University Hospital in Manhasset, N.Y. began using video surveillance to monitor hand washing in 2008, the share of health-care workers complying with hand-hygiene policies increased from less than 10% to more than 80%, according to the hospital.

5. “Electronic records? It might be safer to stick with our messy handwriting.”

More hospitals are using computers to order prescriptions and to keep electronic records. The hope is that this will help doctors keep better track of a patient’s current condition and medical history and help to prevent errors. Indeed, the digital approach can make it easier for doctors to spot allergies and potentially dangerous drug interactions, but some critics say they can also have unintended consequences. Doctors using computers to order prescriptions might easily order medication for the wrong patient or enter medical information under the wrong name, says Heather Farley, assistant chair of the department of emergency medicine for the Christiana Care Health System, a network of hospitals based in Delaware, and the lead author of a 2013 report on the quality and safety implications of emergency-department information systems. The risk is greater in fast-paced emergency rooms where doctors are juggling multiple critically ill patients who they are often meeting for the first time, she says. Critics of electronic systems also worry that some doctors can suffer from “alert fatigue” when they receive too many status updates and messages regarding a patient, increasing the chance that they will overlook a test result that is important to the patient’s condition, says Fuller. Another common concern among health pros is that the time doctors spend entering and scanning medical records takes away from time that could be spent with a patient.

To be sure, many of the mistakes doctors make when using electronic records are in line with the errors they might make using paper records, but the errors can pile up since doctors are often able to enter orders remotely without revisiting a patient or communicating properly with other doctors, says Farley. Many hospitals also have no formal procedure in place for doctors to use to alert each other about possible glitches or safety issues they notice when using electronic records, says Farley. Some hospitals are taking steps though to prevent potential patient mix-ups, such as including the patient’s room number or photo in their file, she says. And Rosenau of the American College of Emergency Physicians says many hospitals using digital records meet regularly to discuss possible glitches and to make recommendations to vendors on ways to make programs more helpful for doctors.

6. “Hope you like being prodded and probed.”

It’s no surprise that a visit to the emergency room isn’t cheap, but bills are often inflated by tests and procedures some doctors say aren’t really needed. Sometimes the tests are requested by overly cautious patients, but often, they are added by doctors making sure they’re covered if they end up in court. Indeed, some 48% of doctors surveyed by ACEP in 2011 said the biggest cost on their patients’ emergency room bills were diagnostic-testing charges, and 54% of doctors polled said the main reason they conduct as many tests as they do is because they’re afraid of getting sued. “Physicians are concerned about being wrong even once a year, because if you’re wrong once a year, you get a multimillion-dollar lawsuit,” says Rosenau.

Some hospitals are working to lower those costs by cutting down on the use of CT scans, which are relatively pricey and expose patients to potentially harmful amounts of radiation, and by finding new uses for less expensive technology like ultrasounds. In October, ACEP released a list of five tests and procedures it says patients often do not need and suggested alternatives that can be more cost effective and come with fewer complications. In the guidelines issued, the organization argued that most patients coming in with minor head injuries don’t have conditions requiring CT scans, which are mainly needed to diagnose skull fractures or brain bleeding. The guidance calls for cutting back on the use of antibiotics for wound cleaning, catheters for stable patients and IV fluids for patients who can drink fluids by mouth. Doctors first abide by the Hippocratic oath of doing no harm, says Rosenau. “Then beyond that, do the test that will give you the best answer for the cheapest cost and that is quickest too.”

7. “Don’t expect us to cure you.”

Sure, some cases can be resolved before a patient leaves the ER: A person with an infection gets put on antibiotics, a gash needs stitching and a broken arm needs a cast. But there’s a good chance you’ll leave the emergency room just as confused about your condition as you were when you got there. Many conditions discovered in the emergency room require more monitoring and care than can be provided in the emergency room. “We want to cure whatever we can,” says Rosenau. “And we put people on a pathway for the rest.”

Indeed, more than 60% of ER patients are referred to an outside physician or clinic for further treatment, according to a 2010 report by the CDC. For instance, when Catherine McCarthy, a 28-year-old public relations consultant in Washington, D.C., went to the emergency room to treat a severely sprained ankle, doctors wrapped her foot in a cast, gave her crutches and instructed her to keep her weight off the injured leg, but they also referred her to a podiatrist for longer-term treatment.

8. “That huge bill is just a bluff.”

Emergency departments are required to care for patients whether or not they are able to pay. That means any questions about insurance and payment might not come until after a patient is in the clear. When the bill does come, it may very well be alarmingly large. But it shouldn’t be seen as the final price tag, says Linda Adler, chief executive of Pathfinders Medical Advocacy & Consulting, a company that helps patients negotiate medical bills. “Think of it as just a starting point,” says Adler, who estimates that disputing the bill typically leads to breaks of 10% to 25%. If no break is offered, many patients are at least put on a payment plan that buys them more time to pay—and avoids the high interest charges that can hit consumers who put the bill on a credit card. Indeed, many hospitals will put patients in touch with financial counselors who can set them up with financial assistance, payment plans or reduce what they owe, says Rosenau.

Patients should ask hospitals for an itemized bill that lists the specific services they’re being charged for, and then ask hospitals to dismiss or reduce some of the charges, billing pros say. About eight in 10 medical bills contain errors, estimates Pat Palmer, founder of Medical Billing Advocates of America, a group that helps patients lower their medical bills. Emergency rooms will often charge a premium for routine medical supplies like Tylenol, gloves and bandages, says Palmer, adding that many patients can get such charges removed from their bills. It’s not clear yet how the Affordable Care Act will impact how much patients spend on hospital visits, but some patients could see lower bills in the coming years as hospitals transition to a system where they are paid more for successful outcomes rather than for specific services performed, says Palmer.

Danielle Davis, an actress and musician in Chicago, went to the emergency room after she fell off her bike and broke her collar bone in August, just weeks after her 26th birthday—and just weeks after being booted off her parents’ insurance plan. When she received her bill, it included markups, such as a $50 charge for two generic pain pills she could have purchased for roughly 20 cents each at a pharmacy. “I just thought it was ridiculous that I had to pay that much,” says Davis. After she called the hospital to explain that she no longer had insurance, they shaved about 5% off her bill and put her on a monthly payment plan for the biggest portion of the $2,500 balance.

9. “Oh, and there’s a cheaper option down the street.”

An emergency department will never turn you away, but the hospital staff also won’t necessarily fill you in on your cheaper options. There could be a clinic or urgent-care center down the street that is better equipped to treat your condition, meaning shorter wait times and a smaller bill. “Right now a lot of people just end up at the wrong place,” says Peter Hudson, an emergency physician and co-founder of iTriage, an app that helps people sort through nearby medical providers based on their symptoms. “They go to the ER for something that’s minor.” Emergency departments can charge $200 to $600 more than urgent care centers for treating the same medical issues, according to the Urgent Care Association of America, a trade group for professionals working at urgent-care centers.

Emergency rooms often need to charge higher rates because they must be open 24/7, serve riskier patients and have higher overhead and staffing costs. Certain less severe injuries and conditions, such as the flu, fever, rashes and minor cuts and bone fractures, can be treated at urgent-care centers, according to ACEP. Some less urgent conditions like bronchitis and ear infections can also be treated at other places like a walk-in clinic at a local pharmacy, says Hudson. But people with serious illnesses or injuries, such as severe abdominal or chest pain, which could possibly require surgery, should still go to their closest emergency department, says Hudson.

10. “Good luck seeing a specialist.”

Emergency room doctors work around the clock, but they don’t always have the expertise to treat patients with unique conditions—such as complicated brain injuries, serious burns, or rare heart conditions. The nationwide shortage of non-primary care specialty physicians is expected to grow to 64,800 by 2025, up from a projected shortage of 33,100 by 2015, according to the Association of American Medical Colleges. And for patients who need specialty care in the emergency room, the dearth of specialists who are available on an on-call basis could force hospitals to delay care or to transfer patients to another hospital, according to a study on specialists by ACEP.

Such shortages are more likely to occur in rural areas. But many specialists are reluctant to work in hospital emergency rooms anywhere, because they may be less likely to be paid for care they provide to uninsured or underinsured patients, according to ACEP. Some hospitals are addressing the shortages by having specialists examine patients virtually. For instance, some hospitals are having patients video-chat with a psychiatrist at another hospital so they can still receive a psychological evaluation even if that hospital doesn’t have a psychiatrist on staff, says Rosenau. The “telemedicine” approach also work well for hospitals that don’t have intensive care doctors or who need burn specialists to examine a wound and recommend a form of treatment, says Rosenau.

Marte, Jonnelle. "10 things emergency rooms won't tell you." MarketWatch. Wall Street Journal., 08 Dec. 2013. Web. 10 Dec 2013.

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