A recently-released Emergency Department Pulse Report by Press Ganey Associates provides some very helpful insights on the state of EDs nationally, as well as in various regions of the country. It is a report based on survey results from patients who have been treated and released from EDs and were given the opportunity to provide feedback about their stay. It is used by EDs nationally to monitor and improve the quality of their service and the care they deliver.
Among other findings, the report shows that: (1) patient satisfaction rose in 2008, following a five-year trend of improvement; (2) average wait time decreased over the previous year, but only by a few minutes; and (3) patients spent an average of just over four hours in the ED in 2008. Frankly, this is quite impressive, especially given that the period for the 2009 report included the first three quarters of the current recession, which only has added to the demands of EDs as more people lacking health insurance may turn to the ED as their only source for various kinds of medical care.
While the report offers some suggestions to hospitals for how to improve overall patient satisfaction, my own observation and experience after dozens of trips to the ED in three states over the last six years or so, suggests that patients, themselves, and/or their family members and caregivers can do more to improve significantly their overall ED experience than they realize. The key is to understand how the ED works, where it fits in the scheme of your loved one’s medical care options, and how to optimize those things over which you do have considerable control. At that point, you can empower yourself with a strategy for ED visits that will maximize the likelihood that your loved one will get the best of what your local ED can provide.
Here is the way that I break down the issues and decisions into chronological steps (please note: this is an illustration of what works for me based on years of ED visits, and is not intended as a specific recommendation or advice for anyone else):
Step 1: When to go to the ED
This can be easy or difficult to answer depending on the circumstances. Assume that an ED visit IS going to wipe out a good four hours, expose you and/or your loved one to others who may have contagious illnesses, and recognize that there is always some wear and tear in just the ordeal of it. And even if the visit is covered by insurance, there may be a co-pay or deductible. So, assume there will be some cost involved.
What you need to do is apply some basic home assessment based on your own knowledge (e.g., known symptoms, patterns, treatments, etc.), prior conversations with doctors (if it’s a known illness and you are told what signs/symptoms to watch for), and your own comfort level.
- The simple answer: when you have run out of other options for a medical situation that is urgent and requires immediate assistance — for example, it’s late in the evening, the doctor’s office or pharmacy is closed (but find out where the closest 24-hour pharmacy is located), you don’t have the necessary medicine/knowledge/skill to get through the night until the doctor’s office is open. This should be a no-brainer. You shouldn’t be spending more than a couple of minutes getting to the decision.
- The more difficult answer: The factors above just aren’t that obvious. Maybe you don’t really know how serious/urgent the situation is, or the symptoms aren’t familiar to you. You actually may have the “tools” — medications at home, necessary knowledge and skill about how to administer — but you’re not sure if they will help in this situation, or how to use them (specific medications, dosages, etc.). Get a quick expert opinion: if you think you have the time, try to call the patient’s doctor or the doctor on-call for the regular doctor to advise you. But remember that what that person tells you is only advice. YOU are there at the scene perceiving what the doctor can’t except through your description or explanation. I’ve had doctors tell me that they thought I probably could wait until morning, and I knew pretty quickly afterwards that I couldn’t. Other times, a doctor (or a neighbor who is a critical care nurse) has confirmed my suspicion that I had better get my loved one to the ED. If it’s still not clear, then go. That’s what the ED is there for; they are the experts with the knowledge, skill, and tools.
Step 2: How to get there
Some people still seem to have a cultural stigma about calling 911 and having rescue vehicles show up at their house. But this isn’t a time to worry about anything other than a person’s life and the need for medical attention.
- When to drive yourself — if someone can comfortably get into the car and withstand the trip, then maybe it’s okay to drive them. Factor in the possibility of getting stuck in traffic or otherwise delayed in a way that vehicles with red lights and siren usually aren’t in terms of additional delay in getting them medical assistance.
- When to call 911 — Just about any other time. Remember that most ambulances today are like mini-EDs, with highly trained EMTs/paramedics who have a LOT of training, knowledge and skill. Bringing that training, knowledge and skill, and “tools” — oxygen, breathing treatments, IVs, and various drugs that they can administer — to where the person needing assistance is, rather than wasting valuable time driving the ill or injured person to a hospital, can make a big difference in the outcome.
- TIP #1: The ED staff usually triages patients arriving by professional first-responders more highly than someone who drives in themselves (or by family or friends). This means usually by-passing the waiting room and exposure to others there who may be contagiously ill.
- TIP #2: The rescue squad knows whether any hospitals in your area may be “closed” — a situation where a hospital is at full-capacity and accepting no new patients. You would never know that if you decided to drive yourself, and so could be further delayed in getting your loved one medical attention quickly.
Step 3: What to bring
- Essentials: Patient’s insurance card, photo ID and medication list. Everything else is optional.
- Leave at home: anything of value (jewelry, purses, expensive shoes/jackets), food, extra people — bringing the whole family or friends is going to be more hindrance than help in most cases.
- TIP: Get the medication list immediately after you call 911; the EMTs/paramedics will need it once they arrive.
Step 4: What to say/ask
Either the patient or the caregiver needs to be able to describe to first responders and/or ED staff, if possible:
- symptoms — time of onset, what led up to them, how they manifested
- circumstances — anything the patient said or any behavior that seemed unusual OR similar to some known pattern associated with some health condition, even if not directly related to what you think are their symptoms
- recent medical history/issues
- known allergies (especially to medications)
- whatever else the EMT, triage nurse or treating doctor asks — note: this may include the patient’s wishes in the event that resuscitation might be needed and to do whatever is necessary (”full code”) versus do not resuscitate (”DNR”), as may be specified by the patient in an advance directive.
A caregiver needs to stay actively engaged with the ED staff by asking:
- for whatever the patient seems to need, especially if the patient can’t ask themselves or needs assistance
- about any needed tests, when they will happen, in what order, and next steps
- about any medications (pills, IV, injections) to be administered to the patient — what they’re for, any side effects to watch for, etc.
- whether the patient will be admitted as an in-patient, what the criteria are for that, and when a bed might be ready
- depending on the patient’s state of consciousness/awareness, to be allowed to accompany the patient wherever he/she might be taken — for tests, to another floor, etc.
Step 5: What you can do to help
EDs can be very busy places, and you are an extra pair of hands, eyes, ears, and legs that might actually be able to help move things along or monitor your loved one’s status; first, you get points with ED staff for asking how you can help rather than demanding their immediate attention for every little thing; second, you make yourself part of the extended ED team, which helps you feel useful rather than helpless and also lets your loved one know that you personally are assisting in their care. It also puts you in the mindset of learning what IS helpful, building your own knowledge. Of course, you also have to be prepared to hear the response, “Just please stay out of our way,” and not take it personally, knowing that is helping your loved one, too.
Step 6: What kind of care to expect
It’s important to understand the purpose of the ED in terms of its strategy for delivering care in order to set your expectations appropriately. One of my favorite ED physicians explains it this way:
[Y]ou will be evaluated for any number of EMERGENT conditions and after that, diagnostic interventions and procedures are limited. You may not receive a diagnosis or specific treatment because we operate in a world of “ruling out the worst case scenario.” For instance, if you have chest pain, we will do every test necessary in order to establish that your pain is not being caused by any number of life-threatening conditions (heart attack, pneumothorax, pneumonia, etc). If these tests are negative, we may let you leave without a final diagnosis (only “chest pain”). That does not mean there is nothing wrong. It only means we cannot find a cause that needs immediate attention or admission. It does help us to know if there is an agenda that the patient or family has (”just want to get an xray to make sure I didn’t break my back” or “worried I have breast cancer”). Sometimes, these concerns can be addressed directly rather than confounding the picture with a bunch of useless and expensive studies.
So, the ED is part of a continuum of care. Patients with serious problems that cannot be quickly resolved may be admitted to the hospital. Those who are discharged from the ED without a clear or final diagnosis typically will be advised to seek specific follow-up care (e.g., with their primary care physician) as soon as reasonably possible for further diagnosis and treatment.
Step 7: Who to know and acknowledge
Get to know the names of treating nurses and doctors, at least. First, you’ll then know who to ask for when that person disappears and you don’t see them around for a long period. Second, it begins to build rapport and personalize your interactions; after a couple of hours of seeing the same faces, you want to be able to walk up to the busy nurse working on a chart (but only if you need to) and say, “Jennifer, I know you’re awfully busy, but did the doctor okay my wife having some water? If so, I’ll get it if you show me where it is.” You’ve thereby done several things: made it personal (which it sure is for you and your loved one!), acknowledged your awareness that the place is busy and getting water for a patient isn’t all that high on their priority list compared to other things going on, shown you understand that allowing beverage or food is a matter of a doctor’s order in the ED, not the nurse’s discretion, and offered to be the nurse’s surrogate or proxy (part of the team) by getting it yourself. Chances are you’ll get a very positive reaction.
Depending on what happens during that ED visit, you may feel compelled to write a letter later to a staff member or supervisor — hopefully of praise for extraordinary patient care rather than complaint for neglect or error. Remember, you may need to come back to that ED in the future. So, don’t burn any bridges, unless you really have to — hasn’t happened to me yet.
Overall, the more time I spend in EDs, the more impressed, amazed and in-awe I am of the work those nurses and doctors do under some of the most challenging circumstances when people often are at their worst. And, anytime I do need to be in the ED, I am honored when I am treated like part of their extended team.
Copyright © 2009 Joseph Kornowski


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