State of Emergency Care

Emergency Medicine in Westchester has come a long way in the past decade.

You wake up with chest pains in the middle of the night—it’s a no-brainer to call 911. But what if you begin to vomit one evening, or your child develops a sudden fever on the Fourth of July? Do you try to reach your regular doctor, find an urgent care center, or call 911? And, except for obviously extreme life-or-death symptoms, how do you know whether the ER or urgent care is more appropriate? What’s the difference? And, anyway, does it really matter? 

“Emergency medicine covers all specialties: adults, pediatrics, obstetrics, orthopedics, surgery, psychiatry, dermatology, trauma, even infectious disease,” says Emil Nigro, MD, director of Emergency Medicine at Phelps Memorial Hospital Center. “We are trained in all fields and are especially skilled in life-threatening emergencies and in resuscitation such as CPR, intubation, and central lines. And we are trained not just to perform these sophisticated procedures but to perform them rapidly.” 

Emergency care in Westchester has changed dramatically over the years. New developments and technology, as well as better education for emergency personnel, help ER staff use time and resources wisely to save lives, balancing speed with efficiency, and focusing on a medical-team approach. 

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“Coordination of care has improved tremendously,” says Rafael E. Torres, MD, director of Emergency Medicine at White Plains Hospital. “From EMT dispatches to discharge-planning, we’re talking to each other.”

 

Detectives at the Door

“Emergency physicians and the emergency department serve as the safety net for the rest of the health system and are often referred to as the ‘front door’ of the hospital,” says Jim Dwyer, MD, FACEP, chief of Emergency Services at Northern Westchester Hospital, who notes that, according to a 2013 study, 80 percent of unscheduled hospital admissions nationwide are from patients who’ve visited the ER. 

From here, emergency physicians must act decisively and swiftly. “You have to be a medical detective,” says Nigro. “A cross between Sherlock Holmes and Marcus Welby.” 

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From the Get-Go

“We spend our whole day preparing for worst-case scenarios,” says Evan Cohen, MD, assistant medical director of Emergency Medicine at NewYork-Presbyterian/Hudson Valley Hospital. “So when we have even three minutes of notice, we consider that very lucky. When a need for balloon catheter or a CT scan is anticipated, staff can activate medical teams and assemble the needed resources, down to monitors and IV poles.”

Today, through an app called LIFENET, first-responders can take an EKG and text the results to the ER before a patient arrives, so staff can quickly spring into action to find the appropriate equipment, meds, and team members. In a heart-attack patient, this can mean the difference between life and death.

Ertha Small-Nicolas, RN, nurse manager of White Plains Hospital’s Emergency Department, cites White Plains’ handheld translator phones, which connect patients with interpreters for any language and dialect, as an example of time-saving technology. “Instead of Googling and trying to translate, we have more efficiency and clarity,” she says. And thanks to secure Internet connections between different hospitals, patient X-rays and CT scans can be sent to ER staff, saving the cost and hassle of repeating tests.  

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When It Can’t Wait

The advent of the “no-wait emergency room” means that patients are seen and assessed right away, funneled into areas of care by nurse managers who stay by their side. NewYork-Presbyterian/Hudson Valley Hospital is certainly no stranger to this system; its  no-wait emergency room has just marked its 10-year anniversary.

“The traditional model of an ER is checking in at registration, then sitting in a crowded waiting room. The nurse brings you back to a triage booth, you return to the waiting room, the nurse brings you to a room, and, finally, the doctor sees you,” says Cohen. “The model we’ve shifted to is a quick registration: We get your name, demographic, and chief complaint, then we bring you back to a room for a team-oriented approach to triage and assessment by nurses and doctors. You’re cutting out the middle process; it allows physicians to see patients sooner—in some cases, immediately.” 

Those critical assessments create “quicker door-to-doctor time and better patient experiences,” Cohen says. “Especially in cases of stroke or heart attack, you want the doctor to interact with the patient as quickly as possible.” 

Cohen recalls seeing a patient who felt chest pains while hiking. “He hiked down the mountain right into our ER, but he looked pretty good,” Cohen remembers. “The nurse brought him to the treatment area within a minute, and, within 30 seconds, we realized he had fatal arrhythmia. We were able to give him an electric shock to the heart within three minutes of him walking through our door.” 

Ivan Miller, MD, FACEP, medical director of the Emergency Department at Westchester Medical Center, says that emergency-medicine professionals are laser-focused on “efficiency and speed,” with painstaking metrics and robust analysis of them. “Door-to-bed time, door-to-balloon time, door-to-doctor time—we’re always measuring and trying to improve upon these,” he says. “You want patients to move quickly through the system, but also safely. It’s like air travel. At airports, you’re frustrated by delays, but you don’t want the pilots to rush things. We’re trying to strike that balance.”

 

…And Don’t Come Back!

As an extension of the team approach, many emergency departments keep case managers and social workers close at hand. “We are focused on getting patients the right level of services for any condition they might have, in any environment they live in and will return to,” Torres says. “So anyone we’re sending home who may be at risk of coming back—whether because they’re not able to take meds, care for themselves, or go to follow-up appointments—we partner with a case manager and social worker to create a safer discharge and head off problems that at one time we didn’t have the resources for.”

 

The Future Is “Upstream”

Remote technologies, including telemedicine, create what Torres calls an “upstream of care, to bring the right level of resources to the right patient at the right time.” He foresees “specialists being able to evaluate patients at the bedside,” he says. 

Through a live feed transmitted by a medical device, doctors can treat a patient who lives too far to visit the ER, without taking a risk. “Telemedicine provides an even higher level of care in these situations,” he says. 

 

Urgent Care vs. Emergency Care

A recent study from Excellus BlueCross BlueShield shows that, throughout New York State, nine out of 10 ER visits could have been avoided or treated elsewhere, such as urgent care centers. In 2013, that amounted to 2 million visits, for common conditions such as sprains and sinus infections, which cost New Yorkers $1.3 billion. 

However, a counter-statement issued by the American College of Emergency Physicians contends that this finding used misleading data that was based on final diagnoses, not presenting symptoms, and that the conditions studied included symptoms that could have led to more serious illness, justifying the visits to the ER. 

“The rule of thumb is: You go to the ER for a life-threatening emergency: chest pain, sudden sharp pain, heart palpitations, shortness of breath, fainting,” says Small-Nicolas. “If you wake up with flu-like symptoms or a sore throat, ear pain, or a sprain, go to urgent care.” Of course, these are just guidelines, and every situation is different. For example, a sore throat can signify a life-threatening collection of pus that needs to be drained in an operating room. How is a patient to know?

Some hospitals are tackling this disconnect by opening lines of communication between urgent care centers and emergency rooms. White Plains Hospital Medical & Wellness in Armonk operates an urgent care center that is staffed with emergency providers who can make immediate decisions on whether patients should remain there or go to the hospital. 

Others say not to heap the stress of
decision-making upon an already fraught situation.

“Most people do genuinely believe they have an emergency when they come to the ER,” says Miller. “They don’t know if their ankle is fractured. They don’t know if their chest pains are coming from their heart. Our job is to evaluate and manage, to admit or release the patient, and to follow up with their doctors to make a plan going forward. Yes, sometimes people feel, in retrospect, as though they shouldn’t have come. But until we saw that patient and made sure that was the case, nobody would have known. We can provide that reassurance. We can also expedite a complicated medical evaluation that might take weeks as an outpatient. That saves time and also anxiety.”

Key differences between urgent care and emergency care include the level of training of the clinicians. “In our ER, you will always be treated by board-certified physicians, magnet nurses, and staff who are trained in emergency medicine,” says Ronald Nutovits, MD, chairman of Emergency Services at NewYork-Presbyterian/Hudson Valley Hospital. 

In addition, he adds, “We will never turn away a patient here. Regardless of their ability to pay, we render the same care.” 

What about wait time? “There is a fallacy out there that ‘If I go to urgent care, I will be seen faster,’” says Nutovits. But the “no-wait ER” has whittled down wait times so
that patients begin their care within minutes of arrival. 

 

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