"ERs are very busy places, and we really are the safety net for the broken health care system we have in our nation," said AnnMarie Papa, DNP, a clinical nurse specialist at the University of Pennsylvania and president of the Emergency Nurses Association (ENA).
Research indicates that today, more Americans than ever — both insured and uninsured — use that net.
Why the increase? Not only does the emergency department provide medical care for the uninsured, but it also offers one of the only options for evening and weekend care for insured patients who can't see their physician during normal working hours. This uptick means that waiting rooms are often crowded places. Add the busy hospital environment to the anxiety and pain of illness or injury — and you have a recipe for stress, confusion and vulnerability. Knowing who you will likely encounter during an ER visit may help you get the best care at a time when you may be feeling anxious and afraid.
While You Wait
When Ashley Finley, 37, a higher education curriculum consultant, crashed onto the pavement from her bike after braking to avoid a pedestrian, she landed on her head and her chin was bleeding profusely. She and her partner, Goldie Pyka, took a cab to a nearby ER in the District.
Pyka was relieved at the short wait time in the ER; but what she didn't expect were the numerous encounters, with often-anonymous hospital workers, which she and Finley experienced.
The first people Pyka and Finley met weren't medical personnel, but administrative registration clerks. These staff members take your name, date of birth and other personal details, and then they collect your insurance provider information.
Once you're checked in, the next person you'll often see is the triage nurse. Originating in wartime, the term triage refers to a system of organizing the injured according to how much and how soon they need care.
"The triage nurse is responsible for determining the severity of the patient's complaints, how sick they are and setting priorities for who goes back to be seen first," says emergency nurse Papa. Care in the ER is not first-come, first-served; if you arrive at the ER in an ambulance, unconscious or unresponsive, or if you have symptoms that might indicate a heart attack or stroke, the triage process puts you at the top of the list, ensuring you get care before someone with a sprained ankle.
During triage, the nurse typically records blood pressure, temperature, oxygen levels and assesses your pain levels. This role should be filled by a registered nurse, Papa says. As part of the triage process, nurses classify patients based on how quickly they need care, ranging from immediate care needed to no care necessary.
Once the nurse has determined the urgency of your problem, he or she will either take you directly to the treatment area or direct you to the waiting area. Patients who feel any changes in their condition while they're waiting should inform the triage nurse, Papa said.
Patients usually have no way of knowing how long they will have to wait, although some ERs are working to let patients know periodically how soon they can expect to receive care. (See Box "Emerging ED Trends")
Though ER wait time depends on a variety of factors, certain times are busier than others, such as weekends. According to the National Center for Health Statistics, two-thirds of people who visit the emergency room arrive during non-business hours—after 5 p.m. and before 8 a.m. Monday through Friday, and also on weekends.
The Treatment Team
Once you move to the treatment area, you will be cared for by the primary emergency department nurse. This type of registered nurse has a degree in nursing, and the training and experience to manage and assist with a variety of emergency situations, from complaints about broken bones and sprained ankles to cardiac arrest.
"That primary nurse is really the jack-of-all-trades," Papa said. A primary emergency department nurse may clean wounds and burns, suction an airway, administer intravenous fluids, aid in neurological evaluations, field family member's concerns and arrange for transportation to another floor of the hospital.
Some emergency departments also have a charge nurse, an experienced nurse responsible for overseeing the flow and dynamics of the entire nursing department and managing complex patient cases. In the first half hour you're being treated in the ER, the charge nurse may be one of several nurses assisting your primary emergency department nurse in providing preliminary care and interventions.
Next in the treatment lineup: your physician. Nearly 87 percent of ER patients see an attending physician, or faculty physician in charge of care. Attending physicians have completed medical school and residency and are medical doctors (MDs), or doctors of osteopathic medicine (DOs). Though traditionally ER doctors may have had backgrounds in internal medicine, family medicine or surgery, "more recently physicians are specifically trained in emergency medicine. ERs now are most often staffed by people who practice emergency medicine full time," said Charissa Pacella, M.D., chief of emergency services at UPMC Presbyterian Hospital in Pittsburgh.
Specialist physicians with more training in orthopedics, cardiology, surgery, neurology and other medical specialties also consult with attending physicians and treat patients in the ER.
Often people arrive at the ER requiring the immediate care of a specialist. Depending on the size of the hospital and the nature of the problem, a specialist physician with training in orthopedics, cardiology or surgery may be available onsite to aid in the treatment. In other hospitals, specialists, especially plastic surgeons or neurologists, must be called to the hospital to deliver needed care.
In many emergency departments, patients only see the attending physician. But at ERs with a university teaching affiliation, you might encounter both medical students and resident physicians, or physicians in training, who are participating in your care. Medical students are participating in a four-year program, but they aren't doctors yet. "During their medical school education they spend some time in clinical areas and participate with care, but typically they are learning to take histories, perform examinations and make treatment decisions," Dr. Pacella said. Medical students may assist, but not direct, your care in the ER.
In addition to physicians and nurses, ERs employ physician assistants (PAs), persons qualified to practice medicine under the direction of a physician, and nurse practitioners (NPs), nurses with advanced training and master's degrees, to treat patients in the ER. Though PAs and NPs perform many of the same duties as a doctor, the attending physician will be supervising your ER care.
Most ERs also use the services of other medical assistants. "Those might be called a nursing assistant, medical assistant or patient care technician. Many times they were trained as a graduate nurse or a paramedic. The people who fill those roles might help with IV catheters, drawing blood, getting electrocardiograms and transporting patients," Pacella says.
Today's ERs often include staff technicians to perform X-rays, CT scans and other tests on patients. These members of the ER or hospital staff perform one or more types of medical testing, but they cannot answer your questions about test results or patient care.
Injured or critically ill patients transported to the ER by ambulance or helicopter also encounter emergency medical technicians (EMTs) or paramedics. Both of these medical pros monitor vital signs, gather medical history and provide emergency care such as CPR during transport; paramedics have additional training that allows them to administer medications, interpret imaging tests and perform more complicated medical procedures. At the hospital, EMTs and paramedics move patients to the ER and provide a detailed report on the patient's condition to ER nurses and physicians.
Patients who've experienced severe injury or trauma require a group of ER personnel — a trauma team — that includes an attending physician, surgeon, one or more residents, a specially trained nurse, and possibly a pharmacist and paramedics, to administer care. Emergency departments and trauma teams may also include a social worker or hospital chaplain; these individuals provide support to family members and can relay questions to the medical team.
Some ERs also use forensic nurses, or sexual assault nurse examiners. These registered nurses are specially trained to collect forensic evidence and treat patients who are victims of violence, Papa said.
Finally, you need a way to get from place to place. Inside the hospital, transporters, or escorts, move you from the ER to another area of the hospital for inpatient admission or testing. Outside the hospital, the transport team includes paramedics, physicians and nurses who provide care to critically ill or injured patients en route to the hospital via ambulance or helicopter.
For patients watching the parade of scrub-wearing people participating in their care, keeping it all straight can quickly become confusing. How do these people know how to treat you? Nurses, physicians and other health care staff communicate with one another and note details about your care in your medical record, which the nurse creates for you during the triage process. Though some ERs use paper-based charts, many ERs have switched to computerized medical records. Your nurse or doctor logs in to a computer in each treatment area to access your chart and makes note about your condition, diagnosis, assessment and treatment.
Who Can Help Me?
So, with all of these players in the game, patients and family members may wonder: Who can answer my questions?
The primary nurse, who is assigned to several patient units or "rooms," is usually the most accessible staff member to ER patients and can discuss many aspects of your treatment plan, as well as help you learn about your condition or symptoms. Many of the questions could be answered by more than one person, though, so it's fine to ask the physician how long he or she expects things to take or what kind of test you're having, Dr. Pacella says.
Other common questions to ask include: When will my pain be reduced? Will I be admitted? Who else will examine me? Pyka said that if she had Finley's ER experience to do again, she'd ask each person who treated Finley what their role was in her care and what to expect next.
Keep in mind, though, that if you or your loved one is acutely ill, the answers you receive from medical staff may be delayed. "Our focus is on trying to identify life- or limb-threatening injuries and to try to get them resolved quickly, because time is our enemy in those circumstances," said R. Lawrence Reed, M.D., director of trauma services at Clarian Methodist Hospital in Indianapolis. In critical care situations, even though physicians and nurses may not give you an immediate answer to your question or concern, you should continue to ask until you receive an answer, he said.
Trauma team members don't have consistent rules about the presence of family members in the patient's room, and instead take it on a case-by-case basis, Reed said. "When there's time and it appears that the family member can help alleviate anxiety, by all means we have them there," Reed said. But if a patient needs multiple or life-saving procedures, there may not be enough room for family members or they may be easily overwhelmed, Reed said. Most visits end with a patient being discharged and handed an explicit written set of instructions. These instructions may provide information about their health problem or specific symptom, recommend what to do at home and identify restrictions on diet or activity. They may also include instructions on symptoms or problems to look for or when the patients should come back to the ER or call a physician. Patients may also receive instructions about recommended follow-up visits, a referral to a new specialist, prescriptions for medication, devices or equipment that may be needed or work release forms.
"Patients are part of our life for such a short time, but we're part of their life forever in the stories they tell about the hospital," says ER nurse Papa. "I've had patients that have had tragic things happen, and they come back a year or two later and say, 'I remember you,' and they'll repeat your words back to you. Every word we say is important. Patients know and trust that we really want to do the best we can for them, and we want to partner with them to make their experience the best they can be."
A final note on follow-up: When it comes to telling their own stories, many patients aren't aware that it's often left up to them to let their own primary care physicians know that they were treated in the ER and why. If you ever land in the ER, make sure to pass that information on to your health care team.
* Note: Goldie Pyka is the communications manager for the Center for Advancing Health, of which the Health Behavior News Service is a part.
Emerging ED Trends
Wait Time 411
Need to go to the ED but worried about long wait times? Some hospitals provide updated wait times via the Web, text, roadside billboards and even smartphone applications such as iTriage. However, not all emergency departments use these services, and this information is subject to change at a moment's notice.
Stanford Hospital and Clinics experimented with a drive-through ED in 2009, where nurses triaged patients and doctors evaluated them inside their vehicles or on nearby cots. The drive-through experience reduced wait times by an hour and half, compared to what patients would undergo in the ER, and eliminated the need for a wait inside the hospital, researchers said, and could prove especially useful in case of a pandemic or terrorist attack to prevent the spread of disease.
Robotics engineers at Vanderbilt University announced in December 2010 that they're building a prototype robot assistant called "TriageBot" that registers ED patients, takes initial medical histories and alerts staff to critical symptoms such as chest pain. The robots also notify patients of wait times and provide directions to the waiting room. Other robots may check waiting-room patients' blood pressure, pulse and other vital signs and monitor changes in pain level, notifying staff if serious changes occur.
EDs and Urgent Care Centers: What's the Difference?
Like emergency departments, urgent care centers provide nighttime and weekend medical care without an appointment, and if your local emergency department is prone to long wait times, an urgent care center may provide more rapid, less costly treatment. However, the National Association for Ambulatory Care cautions that consumers should know the difference between these two types of emergency facilities.
Urgent care centers provide 24-hour care for medical problems that aren't life threatening, such as burns, cuts, sprained ankles, fevers, coughs or broken bones. Most urgent care centers are staffed by family physicians, not emergency medicine specialists, as well as nurse practitioners and physician's assistants. Some imaging and laboratory services, such as X-rays and urinalysis, are provided onsite. However, patients with critical conditions such as breathing problems, chest pain, bleeding or head trauma or loss of consciousness should go to the ER for evaluation and treatment.
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