Thursday, June 18, 2015

How to Pick the Right Emergency Department

Regardless of age or gender, all patients will inevitably need emergency care at one point in their life or another.  I am often asked by friends and family members how to pick an Emergency Department (ED).  I usually give them my response and they sometimes will say:  “the wait time is too long”… “the ED physician did not give [a relative] enough attention last time”…  “the seats at [local hospital] are so uncomfortable”… “can you believe that [so and so] was sent home without pain medication?”… etc.  Although these explanations are certainly valid, this article is meant to point out that there is more strategy to an ED visit than a wait time, an uncomfortable chair, and sedative medications. 

Your Preferred Local Emergency Department

Most experts would recommend using the Emergency Department at your preferred local hospital (see “How to Choose a Hospital”).  This choice allows you to establish a relationship not only with the hospital but also the ED physicians, the admitting physicians, the consulting physicians, and the hospital staff.   It is also important to consider which ED your primary care physician or specialists admit patients to or have a relationship with.  Patients and families often establish this type of relationship with a hospital in order to be more comfortable in the future when trying to make difficult split-second decisions.   Just so I am clear let me reiterate- a patient’s preferred local hospital is likely to be the correct choice for the vast majority of patients.  

However, there are instances in which you might want to make a different choice of ED.  As a disclaimer, there are a myriad of situations that will not be covered in this article and not all recommendations will be suitable for all patients.  Patients who live in large cities will have many more options than those in small communities, and different locales will have different options based on the medical landscape.  The suggestions below are meant to be a guide and reference not the absolute truth.   The resounding theme will be to:  do your homework about your surrounding hospitals and EDs prior to actually needing to go to the hospital.  

911/Severe Illness

Patients who call 911 and are taken to the ED by ambulance can have a significant medical condition that will require immediate attention whether it be a trauma, heart attack, stroke, or other condition.  In these situations, you will most likely need to be taken to the closest emergency department as long as they offer the necessary services.  Emergency medical technicians (EMTs) are trained to make this choice and can be a great resource for you if you are incapable of or undecided on the choice of ED.  (As a side note, be aware that some hospitals incentivize EMTs to bring them patients and this will bias their recommendation).  If you are at risk for a serious illness like heart attack or stroke based on your risk factors and family history, you should research your available options and pre-specify the ED you prefer to your familiy members.  

Most hospitals in medium to large sized cities will have full-service medical staffs that offer comprehensive medical care.  However, patients should be aware that certain EDs will not be capable of caring for all types of emergencies.   For instance, small EDs are not usually equipped to handle traumas or major injuries.  Other “major” hospitals may not have a staff of neurologists to care for stroke patients.  Despite the prevalence of heart disease in our country, certain hospitals will not have cardiologists or catheterization lab services to take care of heart attack patients.   DoctorRated can aid you in determining which hospitals have the appropriate and needed services.  

Minor Illness

One of the only times that I recommend going to an Emergency Room known for having the shortest wait time or the worst reputation is when you have a minor illness like a broken finger, a small cut/laceration, or to obtain a prescription and then go home (i.e. antibiotic, blood pressure medication refill, pain medication, etc.).  Even then, one must be very careful about this decision.  My friends often tell me that they take their children to an adult specialty hospital (see below for details) for broken bones and cuts/lacerations.  They find that the wait time is much shorter than at a major hospital and the ED physicians are the same as in the bigger hospitals.   I think this is a pretty insightful and savvy way of seeking ED care.  Other friends tell me that they will only go to an Emergency Room with an urgent care or fast-track clinic, which has a different set of physicians who treat minor illnesses and do it more quickly than regular EDs.  The bottom line is that if you have a minor illness, you might do well to go to an urgent care or lower volume/quality ED in order to save time.  

Unknown Illness

I often have been told after the fact by a patient that they chose to go to the local heart hospital with upper abdominal pain or shoulder pain that they thought was heart related.  They tell me this woefully after they were found to have a ruptured gallbladder or other emergency that could not be taken care of at that ED.  In these situations, I think it is important for the patient to be aware of the possible need for specialty and subspecialty care which might not be available at all hospitals.  Too often, a patient will make a poor choice of ED and then regret it because they will either not be treated aggressively or will have to be transferred to another ED for care.  

The other situations that often require a full complement of physicians include severe infections/sepsis, severe respiratory disorders that require ventilators, traumas, neurological and neurosurgical illnesses, and multi-organ (kidney, liver, lung, heart) system failures.   Do your homework on DoctorRated prior to becoming ill so that you will be prepared for these situations.  

Wait Times

One of the most common complaints that I hear from patients about ED visits has to do with wait times.  Busy EDs can often have extremely long wait times especially around the time that the doctors and nurses change shifts (there are now web apps that will tell you this schedule and also give you real-time wait times).  Although time is an important factor to consider when determining which ED is right for you, wait times should never be a major determinant of which ED you choose.  

I use the same philosophy regarding wait times when choosing a physician.   Emergency departments like physician’s offices function based on volume.  A busy office or ED is often busy because the community considers that place to be of good quality.   Full chairs at a local MD office or ED should not be a reason to necessarily go to the next option.  Usually the wait time is a function of quality, however occasionally it is a function of a major trauma or other circumstance which is binding up the patient flow.  

One final comment on wait times:  if you do your homework about EDs and determine that two centers are equal in quality and function, wait times then become important especially if you have a serious illness that requires immediate attention.  

Specialty Services and Hospitals

The environment and makeup of a hospital physician staff has changed over time and continues to evolve.  Hospitalists are admitting more patients than primary care physicians in most areas.  Specialists are consulting more and admitting less.  Large groups of specialists are becoming employees of hospital systems and thus can be limited to a single hospital due to this.   The integration of physicians with hospitals can force some hospitals not to have coverage for certain subspecialty areas.  All of the above factors can impact your choice of ED.  

For instance, if you have severe lung disease and see a pulmonologist, you need to ask that physician which hospital he/she prefers so that you can factor that into your next ED decision.  
In addition, do not assume that your favored metropolitan ED will have a spine surgeon available when you rupture your lumbar disc the next time.   Finally, be aware that going to an ED and hospital known for a specific type of specialty can be detrimental when you turn out to have multiple medical issues for which the hospital is not able to treat.  

Specialty hospitals, as mentioned above, are springing up around the country and generally service heart, orthopedic, and surgical patients.  Be aware of this type of hospital and ED and research it benefits and risks.  


Most of this article has excluded the field of pediatrics, but I think this specialty requires comment.  Most major cities and areas now have a “Children’s Hospital” for all pediatric care.  If pregnant or you have young children, I would begin to research your different options for pediatric care in the area and then choose the best fit for you.  One great way to get an opinion on which hospital to choose for your child is to ask your pediatrician.  


Location, location, location is an often used phrase for choosing real estate, however this can be perilous when choosing a hospital and emergency department.  For instance, if your primary care physician does not admit patients at the hospital closest to you but at one a few miles farther away, you might choose the one that is less convenient but more preferred for your doctor.  Alternatively, you might change your choice of doctor if you have a strong preference for a local hospital especially if you feel that the quality of hospital supersedes the quality of or connection with your physician.  

One other major mistake that I have seen patients make in the past especially in rural areas is to choose an ER based on proximity to home only to be dissatisfied with its care.  This often happens when patients go into their rural EDs and must be transferred to a larger hospital for specialty care.  They often choose the hospital that is closer even when the better hospital is less than an hour’s drive more.  

The bottomline is that in an emergency situation, you will be thrust into an uncomfortable decision making process.  If you have done your homework, you will be able to make informed decisions about which ED to choose, which one to avoid, and (if you need specialty care) which one to be transferred to urgently.  

Board Certified Emergency Physicians

Trust me when I tell you that you do not want to find out after you have been seen at an Emergency Department that some or all of the ED physicians are not board certified.   This might seem obvious, but certain states allow non-board certified doctors to work in EDs either due to necessity or other circumstances.   Once again, do your homework and allow yourself to be taken care of by the best ED doctors available.  

Insurance Details

As with most of the above narrative, little details can often make a big difference in your decision about choosing an ER.  One detail that is often overlooked in an emergency is whether the hospital/ED actually accepts your insurance.  In most cases, emergency care is considered covered by all insurance plans.  However, remember that most visits end up with admission to the hospital and introduction and establishment of patient-doctor relationships.  The salient point about insurance occurs when you choose one ED in an emergency and then have to change to all new doctors after that hospitalization due to insurance issues.   


The above article was written as an overview of a patient’s choices and decisions concerning “How to Choose an Emergency Department.”  As I stated, this commentary could not cover all of the necessary points or possible scenarios.  Below is a list of the top five points to remember when choosing an ED: 

1.  A patient’s preferred local hospital is likely to be the correct choice for the vast majority of patients.

2.  In the setting of a major medical emergency, you will likely be taken to the closest emergency department as long as it offers the necessary services.

3.  If you have a minor illness, you might do well to go to an urgent care or lower volume/quality ED in order to save time.  

4.  Wait times should almost never be a major determinant of which ED you choose.  

5.  Research all of your area’s hospitals and EDs by asking your doctors/friends/family and review ratings on DoctorRated and other websites.  Know which ones offer the most comprehensive care and which ones offer care that is not offered at other area hospitals.  

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