To Go to the Emergency Room—or Not

Reader Comments
Back to blog

When encountering a personal Emergency first, take a deep breath and count to 7 seven before slowly releasing over 8 eight seconds, remain calm and remember practical solutions such as direct pressure and elevation in this case requiring stitches.
Responding to "Emergency Room or Not". If a diabetic loses or runs out of medicine, or someone needs antibiotics they could suffer or die without an emergency source. I have seen asthmatics wait to long and lose their life waiting for care...Emergency Departments around this country provide the very safety net that is holding the deteriorating fabric of our health care in this nation together.
If communities and insurers could staff and provide enough other resources to support stand alone emergency centers and 24 hour or extended hour walk in urgent care centers, the communities could benefit, and emergency department over crowding could be relieved. Also the public could be more informed on self triage and the insurers have available 24 hour live nurse lines with top nurses in emergency triage (almost like a 911 intake personnel). While the American Heart Association has done by emphasizing what to do with chest pain - call 911! Respond fast! The public knows less about "brain attacks" (strokes or impending strokes) which are equally disabling and fail to articulate to Emergency Medical Services or Emergency nurses and physicians their symptoms.
Surf the web, or watch shows like ER or others that show surgeries or conditions and learn about our bodies to better nurture and support our personal health. Work with your insurer; join advocacy groups to improve your insurance's coverage and services on behalf of individual's and communities. Support your local ER and health organizations in your communities and make change from the inside out one person and family at a time.

Laura Maire, MD Emegency Physician of HI 8:28PM June 27, 2008

The percentage of visits to an emergency department that are "not emergencies" varies widely depending on your definition. Studies which use the final diagnosis would consider chest pain in a 55 yo man to not be an emergency if the final diagnosis is "gastritis" or gastroesophageal reflux disease (GERD), even if the patient spent several hours in the ED having tests to exclude heart disease. From the perspective of the healthcare provider seeing the patient in real-time, this patient (with a final diagnosis of GERD) would be just as much of an emergency as a similar patient who after the same evaluation was found to have unstable angina.
For those of us who work in the ED, patients who present with signs and/or symptoms of a potentially serious condition, especially if they have risk factors that make a serious condition more likely, require the same emergency evaluation whether they "rule-in" for the serious condition or "rule-out".
There are certainly conditions which most of us would agree do not constitute an emergency (simple rashes, mild upper respiratory infection, and minor trauma), but these are not commonly seen in most of our nations EDs, and when they are, it is my experience that the patient has tried and failed to get a timely appointment to be seen elsewhere.
Finally, for those millions of people without insurance and without much money, Urgent Care Centers do provide care for less, but they charge and you often have to pay for care, whereas the emrgency department has a legal obligation to evaluate anyone who shows up, regardless of their ability to pay. This subsidized care contributes to the overall expense of everyone's ED visit.

Lawrence M. Lewis of MO 4:47PM June 27, 2008

No creditable source, except perhaps the most pessimistic, has ever estimated that over half of Emergency Department (ED) visits could be cared for in an Urgent Care Center, and if that were true, there aren't enough Urgent Care Centers in the country to handle half of the 116 million ED visits annually!
Actual overall estimates for non-emergent/non-urgent Emergency Department visits have ranged from 15-25%, with the following breakdown:
1. For the Commercially Insured population, approximately 10-12%. This is often for very rational reasons - e.g. do I take my sick child to the ED now, or wait until tomorrow, hoping they don't get worse overnight, and then hope that my Pediatrician or Family Doctor can squeeze them in without significant delay (like the following day after that!), and then have to miss work and lose earnings or take time off to keep that appointment?
2. For Medicare members 3-5%. The elderly do not go to the ED because they have nothing better to do; they'd rather be at home, and more often delay in heading to the ED. You'd better be darn sure you've ruled out ALL potentially significant disease before sending a Medicare patient home from the ED!
3. For the indigent on Medicaid 25-33%. Contrary to common current political rhetoric, this is NOT people using the ED inappropriately for Primary Care type services; rather, society has not provided our indigent with adequate alternatives to the ED. Inadequate charity level reimbursement has ensured that there are inadequate private office appointments available, and there are also insufficient numbers of tax subsidized Federally Qualified Health Care Centers (FQHC) to timely handle routine visits, much less urgent care. There is significant revenue loss with each Medicaid visit, regardless of the Provider - Hospital ED, Urgent Care Center, or Private Office; fortunately, most Providers do still provide at least some charity care. Where else does the government depend on personal charity to provide essential public services? Could we buy F14s or build highways and schools for 60 cents on the dollar?

David E. Wilcox, MD, FACEP of CT 3:47PM June 27, 2008

Nice article, there is a lot of good information there.
I do, however, have 1 issue which I disagree with: Over half of Emergency Department visits could be handled at an urgent care center!!?? Where did you find this information? I can't imagine it's true.
I am an emergency physician practicing just outside Washington DC. We see over 90,000 patients per year, most of them need a work-up that an Urgent Care Center cannot adequately provide.
Urgent Care Centers can handle sore throats, sprains, minor fractures, lacerations, and a variety of other problems. They often have x-rays, some basic lab tests, basic medications, and they can do some basic procedures. Urgent Care Centers provide a valuable service to society for minor problems, but often lack adequate resources to provide the comprehensive care that an Emergency Department is equipped to handle.
Urgent Care Centers usually do not have CT scans, ultrasounds, extensive lab capabilities, and many cannot do blood work, though some can. These patients require an Emergency Department with appropriate resources and physicians with an appropriate skillset. Most patients with chest pain, abdominal pain, headaches, difficulty breathing, motor vehicle accidents, and many more conditions usually require a more complex evaluation than an Urgent Care Center can handle.
Again, I think this is a great article, but most of the patients I see in the Emergency Department cannot be adequately treated in an Urgent Care Center.

Neal Chawla, MD of VA 2:36PM June 27, 2008

A lot of those “evaluations” that the emergency could be taken care of in an urgent care setting are made retrospectively, after the patient was screened and examined. That is Monday morning quarterbacking. Conversely, if it turns out to be a more severe disease than symptoms initially suggest, this patient could be at risk of becoming sicker. The insurance company doesn’t know what the patient has when they enter the ED and the patient often does not know either.
Let’s take the case of urticaria after a bee sting in summer. Yes is could just be itching and a “little bee sting” but what if this develops into a major case of anaphylaxis.
What if the person who cut his finger severed his tendon?
Additionally, there are not enough “urgent care” access even for the insured patients and many patients end up in the ED because they could not reach their own physician, or their physician referred them to the emergency department.
Patients should not be diagnosing themselves or waiting for the insurance company to sign off on going to the emergency department. Precious minutes may be lost. A stomach ache could turn out to be a heart attack, and an urgent care clinic is not going to be able to help you with that. In my experience, when a patient thinks it's an emergency, it almost always is an emergency.
I have practiced in Europe and primary care access in the United States is more limited here than in Europe. In the European system, patients and physicians have more continuity of in their patient-physician relationship and physicians. And even in Europe, an emergency is still an emergency and requires an emergency department to be treated.
Dr. Tareg Bey

Dr. Tareg Bey of CA 2:31PM June 27, 2008

A lot of those “evaluations” that the emergency could be taken care of in an urgent care setting are made retrospectively, after the patient was screened and examined. That is Monday morning quarterbacking. Conversely, if it turns out to be a more severe disease than symptoms initially suggest, this patient could be at risk of becoming sicker. The insurance company doesn’t know what the patient has when they enter the ED and the patient often does not know either.
Let’s take the case of urticaria after a bee sting in summer. Yes is could just be itching and a “little bee sting” but what if this develops into a major case of anaphylaxis.
What if the person who cut his finger severed his tendon?
Additionally, there are not enough “urgent care” access even for the insured patients and many patients end up in the ED because they could not reach their own physician, or their physician referred them to the emergency department.
Patients should not be diagnosing themselves or waiting for the insurance company to sign off on going to the emergency department. Precious minutes may be lost. A stomach ache could turn out to be a heart attack, and an urgent care clinic is not going to be able to help you with that. In my experience, when a patient thinks it's an emergency, it almost always is an emergency.
I have practiced in Europe and primary care access in the United States ismore limited here than in Europe. In the European system, patients and physicians have more continuity of in their patient-physician relationship and physicians. And even in Europe, an emergency is still an emergency and requires an emergency department to be treated.
Dr. Tareg Bey

Dr. Tareg Bey of CA 2:27PM June 27, 2008

Your statement that over 50% of visits to ER's could be handled in an urgent care center is a gross overestimation of the truth. As there is no source quoted, it is difficult to know the entire context of that statement.
While some patients that we treat do present with chronic medical problems, this is because they have trouble getting into see their own primary doctor. Having diagnosed not only cancer but metastatic cancer on several patients who presented with vague, yes chronic, abdominal pain, I was the catalyst to expediting their complex treatment and integration of consultants. This would not occur in an urgent care. These are the same patients who could not get an appointment with their already overbooked primary care doctor. Perhaps not a patient who would die that same day from the disease process, yet a good example of the safety net that Emergency Departments serve. Certainly if this were you or your family member, you would consider this diagnosis an "emergency: and want help with what to do next, treatment options available, and so forth.
The issue, Ms. Andrews, is not the number of patients coming into the front entrance of the Emergency Departments across the country, regardless of their reason why they do so. Rather, it is having admitted patients wait for a day or more for a bed.
The issue is not having a primary doctor for our patients to contact to follow-up on abnormal tests.
The issue is not having on-call specialists to come to our ED's to care for challenging cases and having to spend hours on the phone trying to find appropriate care at other facilities.
The issue is diversion of ambulances from one hospital to another because there is no stretcher available for a patient because of overcrowding.
We as Emergency Physicians can handle the volume of patients coming into the front doors of our departments. Where the problem lies is in the outflow--admitted patients must get beds, outpatient clinics must have timely appointments for follow-up, and we need available on-call specialists such as plastic surgeons to assist with the more complex patients to allow us to care for the new patients.

Melissa Barton MD of MI 2:03PM June 27, 2008

It's really quite easy to figure out what's an emergency. Go to an emergency room and get a diagnosis. If it wasn't serious, then you know it wasn't an emergency.
One of our residents studied patients arriving for a prescription refill, which represented 1 percent of visits. He found that 30 percent of the patients needed admission because of complications of not taking their medication. Insomnia, particularly early AM awakening, can be a sign of serious depression. Fever is not necessary to the diagnosis of pneumonia or other serious infection. A sore throat might be a peritonsillar or retropharyngeal abscess. We see "bug bites" all the time, along with "minor rashes" which turn out to be Lyme's disease. On occasion, we even see chronic conditions which have been misdiagnosed and turn out to be quite serious.
My point is not that everyone with a symptom needs to rush off to an emergency department. Rather, it's quite easy in retrospect, after the diagnosis is known, to conclude that the visit was unnecessary. Extensive research has shown that a patient's perception of whether something is minor, or an emergency, is highly inaccurate. Given the lack of advanced training of the general population in health care and differential diagnosis, this finding should not be seen as a particular surprise. It is for this very reason that there are rather extensive public educational efforts regarding heart attacks and strokes. It's rather paradoxical that, while we complain about patients with minor infections, there's an international effort to reduce mortality in patients with advanced infection, whose sin was to wait too long to come to an emergency department. (By the way, logically, if you really don't need the ED, you probably don't need the urgent care center either.)
I suspect that what really drives this commentary is the fact that we work in a high-stress, high-volume environment. Part of that stress relief is to blame the patients who were determined to not have an emergency for coming at all, and to blame the patients with the true emergencies for not coming earlier.
However one wants to spin this, given our current dysfunctional system of care, if you have a medical problem and need an answer, there are few other places to go. At our place, we're more than happy to be of help.

Peter Viccellio of NY 12:53PM June 27, 2008

In your recent article on emergency department care, it is stated, "It's estimated that more than half of visits to emergency rooms could be handled at an urgent care center." As a physician for 46 years, an emergency physician for 33 years, having worked in 25+ different emergency departments, with faculty affiliations in emergency medicine in 6 different medical school, as well as having served as an oral examiner for the American Board of Emergency Medicine for the past 20+ years.I believe that I have had the experience to countermand that statement.
Many larger ED's have diverted patients who are thought not criticial at triage to a Fast Track, a sort of in-hospital Urgent Care Center. Urgent Care Centers are competitors, not substitutes. There is no question that the emergency system in this country needs to be fixed. What needs fixed, though, are the resources to handle the crisis, the catastrophe. It's broken! It would be wise to mend our heath care system, starting with emergency medical care, so that care would be available to all in a timely manner.

Hubert S. Mickel, MD of MD 12:21PM June 27, 2008

I am the medical director of a large community hospital in Montclair, NJ. While it may seem to insurance companies, that half of all ER visits could be handled elsewhere, that is an "after the fact" estimate. Your own injury was a perfect example of this erroneous thinking. Neither you nor most people know at the time they suffer an unexpected injury or illness just how serious the change in their usual state of health might be. Whether or not the person seeking care assumes that the numbness in their arm is a pinched nerve vs. a stroke can be the determining factor in deciding where to seek care, the doctors office or urgent care vs. the local emergency department. It's fine for insurance companies to say that half the people seeking emergency care turned out to have a less severe problem AFTER an ER evaluation. But there is something called the prudent layperson standard, which essentially means that it's ok for patients to assume the worst when seeking emergency care. This prevents insurance comapnies from denying claim payments to purchasers of their plans who believe theri chest pain is a heart attack, but turn out to have heartburn.

Dr Mark Melrose of NY 11:42AM June 27, 2008