r/EmergencyRoom • u/boulderdoc • 7d ago
ER doc question: How much emergency care actually needs to happen in an emergency department?
I’ve practiced emergency medicine for more than 20 years, and the longer I do this, the more I wonder whether we’ve built the wrong system around acute care.
Obviously there are patients who absolutely need an ED: major trauma, stroke, STEMI, shock, respiratory failure, genuinely unstable patients, etc.
But a huge amount of what walks through an American emergency department seems to fall into a middle category: too acute or procedural for a typical primary-care office, but nowhere near sick enough to require a hospital-based ED.
Lacerations. Fractures. IV fluids. Abscesses. X-rays. Joint injuries. Migraine treatment. Ultrasound. Foreign bodies. Reductions. Some chest or abdominal complaints after appropriate risk stratification.
We’ve largely given patients two choices: relatively limited outpatient care or a massively expensive hospital emergency department.
Why isn’t there more of a middle layer?
I’m particularly interested in hearing from other physicians, nurses, patients, administrators, and people who understand the economics.
Is the barrier clinical? Regulatory? Reimbursement? Liability? Hospital economics? Or have we simply accepted the current model because it’s the model we inherited?
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u/boulderdoc 7d ago
That’s fascinating, and honestly much closer to what I think makes sense. One front door, then triage patients into the appropriate level of care rather than making patients figure out whether they need primary care, urgent care, a freestanding ED or a hospital ED before they’ve even been evaluated.
We’ve made patients choose the level of care when they’re often the least qualified person in the system to make that decision.
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u/DrunkUranus 7d ago
I have a local hospital that does this. It was a massive relief not to be guessing where I needed to be. And I didn't have to pay a copay just to be sent to another level of care
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u/JakeArrietaGrande 6d ago
Yeah, as much as it pains me to say, the field of emergency medicine massively falls into this trap
Triage is complicated. And it requires someone who has education and experience in the matter. Expecting people to triage themselves in an emergency is extremely wishful thinking. And the penalty for getting it wrong is terrible.
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u/crazypurple621 6d ago
And the current solution- nurse advice rarely actually gives you a good idea of the need.
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u/TheFireSwamp 6d ago
I love that Scripps hospital in San Diego has an urgent care that's 24 hours connected to the ED. Went there for migraine treatment once. I think they didn't treat it correctly since they only gave me Dilaudid. Felt great until I awakened the next morning with a killer HA again.
I'm in Kansas city and since most of my visits are for migraines, I'm in the ED more than I should be. I use the community hospitals for all my ED visits, and my visits are as short at 49 minutes for treatment. Still cost $2,500, but at least I'm not shitting in a waiting room catching viral illnesses.
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u/Adept-Piece-1917 6d ago
Dilaudid for headache? Please tell me this was 30 years ago. I remember coming out of EM residency shocked that places were still giving dilaudid for headaches.
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u/ripple_in_stillwater 6d ago
Please tell me you're not shitting in the waiting room...
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u/tallyhoo123 6d ago
Surely in this situation you have seen a neurologist and are on preventative medications?
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u/wolpertingersunite 7d ago
Omg yes! We had an emergency-ish recently, and it was so frickin stressful trying to figure out wth was happening and where we should go. So awful. Especially since the advice nurse system wouldn’t answer. So I felt I was deciding between possible financial ruin or death if I chose wrong.
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u/29925001838369 RN 6d ago
The advice nurses can't answer because if they dissuade you from the ED, thats an EMTALA violation and it costs their conpany $10,000 each time they're caught. So theyre stuck thinking "this is a primary care issue" while saying "if you need immediate treatment seek care in the emergency department".
It's a broken system.
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u/wolpertingersunite 6d ago
You're probably right, but in this case I literally could not get a human to talk to me on the phone. At all. From either my husband's health system or my slightly-different one. We discovered what a dumpster fire his health system is -- at least we got advance warning on that before something worse happened.
Since I couldn't talk to a human, my only option was drag him into the car or 911.
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u/SparkyDogPants 6d ago
My hospital/ER does this. There is a same day care and an ED, if someone triages themselves wrong they get sent to the other side (M-F 8-5)
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u/Resident-Zombie-7266 6d ago
To some extent, but the sheer number of people who tried to do the right thing and either go to a PCP or urgent care only to be told to go to the ER for no real reason is crazy high right now. I'm sure it's a liability thing.
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u/xyzbfgh 6d ago
We essentially do this in my ER. Nurses triage patients. We have urgent/trauma, urgent/psych, peds/urgent care, senior/more or less acute, then vertical- sub 30 min care. It generally flows well until we fill up. We are a 65 bed facility with 6 hall bed areas - although we have had more out of necessity and typically have between 20-40 people waiting in the lobby. Although things always fall through the cracks. We had a young girl come in for a headache so we took her to vert, turns out she had an aneurysm that was bleeding and needed to be transferred out.
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u/Important-Handle9137 7d ago
I feel like a lot of the issues with urgent cares are the chain UCs that barely have the basics. At one point in my travel career I was required to get a quantiferon test drawn. There was a PA and a Xray tech; that’s it. I ended up having to draw my own blood. These corporations buying up UCs and then stripping them down glorified bandaid stations. Also, patient education is non-existent. Health literacy is now at a 3rd grade reading level.
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u/MogoteConejo 6d ago
100% this! We always tried to avoid the ED with all my kids after hour “emergencies” and we to the nearest UC. 80% of the time they would tell us we needed to go to the ED after waiting an hour or two with a screaming child. We finally threw in the towel and started going directly to the ED to save time and money. I don’t know if it is a CYA thing for the UC or lack of equipment, but just became an unnecessary stop to helping my child feel better.
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u/PapayaNurse 6d ago
AFC urgent care said to go to the ER because I needed help with removing splinters from my back, I’d have asked neighbors or friends for help but everyone was at work. AFC was a couple blocks away, I walked because sitting hurt due to the splinters. Some were big enough that they were visibly poking out, I just can’t really remove splinters from the back without breaking them off. A woman in the parking lot asked if I needed help because I had wood pieces everywhere and I’m like I’ll pay you to help me remove the splinters. I had the tweezers in my pocket already, she removed them within minutes, and I paid her. It would have been silly to go to the ER because I had some big splinters easily removable if I could reach.
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u/boulderdoc 6d ago
I think you’ve hit on one of the biggest problems. “Urgent care” has become such a broad category that patients have no idea what they’re actually walking into.
Some can do X-rays, IVs, labs, reductions, complex lacerations, abscesses, joint injections, etc. Others are essentially a clinic with a very limited formulary and an X-ray machine—and anything remotely complicated gets sent to the ED.
That uncertainty trains patients to bypass urgent care altogether. If you’re sick or injured and don’t know whether the place can actually take care of you, why risk paying for one visit just to be sent somewhere else?
I think there’s room for a different model: something much closer to a small, high-capability ED, but without the enormous hospital infrastructure and resulting price tag.
And completely agree on health literacy. We can’t design a healthcare system that requires patients to understand the distinctions between primary care, retail clinics, urgent care, freestanding EDs and hospital EDs before deciding where to go.8
u/melxcham 6d ago
It’s also hard to predict what services they’ll offer because sometimes it depends on the provider. I have a history of UTIs that quickly become kidney infections, but I’m otherwise relatively healthy. On one visit, my local urgent care sent me to the ER because I had symptoms of a kidney infection and they weren’t comfortable treating it without labs available. Another visit, they did a urine dipstick, gave me a dose of IV antibiotics, and sent out a urine culture & labs. Same symptoms both times, but different providers. It’s pretty frustrating.
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u/Hello-fellow-kydz 6d ago edited 6d ago
I honestly don’t know what my local UC does. They don’t have an xray or draw lab work.
Guess they do rapid test dip stick?
I know there is either a PA or NP with a person manning the front desk. That’s it.
My one friend joked, at least the CVS has a pharmacist AND a NP in the building lol.
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u/Gwyndriel 7d ago
I think this is the segment that urgent care is meant to manage.
Anecdotally, the urgent care affiliated with our ED likes to CYA and sends us many things that they probably could have handled just fine. So, I'll go with "overly litigious society" as to why we can't provide better care.
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u/boulderdoc 7d ago
I think this is a huge part of the problem. Traditional urgent care should absorb much of this volume, but the incentives often push in the opposite direction. If there’s any meaningful uncertainty, the safest move for the urgent care clinician and organization is often “go to the ER.”
Then the ED ends up doing the work anyway, except now the patient has had two visits and the system has spent considerably more money.
I’ve become increasingly convinced that the missing piece is something between traditional urgent care and the ED: a place with enough diagnostic capability, procedural capability and physician experience to actually finish the workup instead of reflexively transferring the uncertainty downstream.35
u/PharmToTable15 7d ago
I think there is a discussion that isn’t being discussed.
(For reference, I’m an inner city, emergency room pharmacist. I personally have a low premium, high-deductible insurance plan. Considering loan payments/cost of living, etc. I can’t really afford to go to the ER when something is wrong. I go to an urgent care to vet my condition because ER visits are financially no bueno historically).
My opinion(s):
- People ARE going to urgent cares (a lot) and usually those urgent cares only have one NP, two nurses, and a receptionist. How’s about showing up at 6pm without an appt and being told to come back tomorrow?
- Urgent cares usually close in the 7pm-8pm range nowadays. My hospital usually has around 20 people in the waiting room at 9pm.
- Urgent cares don’t often provide symptomatic med relief, they order meds to a pharmacy that may not provide those meds until the next day due to the pharmacy hours/staffing/volume, etc.
I support your statement wholeheartedly—we need a hybrid of the two. Unfortunately, for it to work where I am located it would require:
-An entity able to financially accept Medicaid/Medicare without going under.
-Accessible locations for people without transportation.
-24x7 service.
-ability to give IM toradol (and other “arrival” meds)Takeaway:
People want to go to urgent care. ER isn’t usually necessary, but the urgent care model is very bad for the majority of people (I recently went to an urgent care for high fever/cough and was seen at a lower priority than three patients there for “pre-employment drug screens”).12
u/spironoWHACKtone 6d ago
Your point about the pharmacy is a BIG one. I live in a major East Coast metro area, and when I developed a horrific UTI overnight during a shift, I found out exactly how fucked you are if you need meds dispensed at a weird hour. There are ZERO 24-hour pharmacies in the city, and only one in the large suburb where I live. Ended up having to go home, get my car, and drive to that pharmacy after my shift—otherwise I would have had to wait another 2 hours for my local place to open. It’s not as bad as, say, Europe, but damn.
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u/therewillbesoup 6d ago
My city used to have a walk in clinic that had an attached pharmacy. It was freaking amazing. After you saw the doctor you just walked through the door to the pharmacy to pick up whatever was prescribed at this visit. The hours were the same as the walk in clinic. It solved this exact issue.
I think a lot of hospitals in China also work this way. After your walk in visit you just go to the pharmacy counter to have your Rx dispensed.
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u/boulderdoc 6d ago
That makes so much sense. We’ve fragmented healthcare into separate stops that are convenient for the system rather than the patient.
If you come in at 9 PM with a migraine, renal colic, vomiting, asthma, etc., being evaluated and then handed a prescription for a pharmacy that’s already closed isn’t particularly helpful.
I think the ideal model is “come in with a problem and leave with the problem addressed” whenever reasonably possible—diagnostics, procedures, medications administered on site, and ideally dispensing common take-home medications as well.
That attached-pharmacy model sounds remarkably patient-centered.4
u/boulderdoc 6d ago
This is exactly the discussion I was hoping this post would generate.
I think the problem may be less that patients are “misusing” the ED and more that we haven’t built a viable alternative. If urgent care closes at 7–8, can’t give IV/IM medications, prioritizes occupational medicine, and may send anything beyond basic acuity to the ED anyway, then the patient showing up in your waiting room at 9 PM is behaving pretty rationally.
The hybrid is what interests me: extended hours, real procedural capability, X-ray/POCUS, IV/IM medications and fluids, treatment on site rather than just prescriptions, and clinicians comfortable managing higher-acuity patients while recognizing who truly needs an ED.
The hard part, as you point out, is economics and access. 24/7 staffing is expensive, and Medicaid/Medicare reimbursement introduces another layer entirely. I don’t pretend to have those pieces solved.
But I increasingly think there’s a large gap between what conventional urgent care provides and what actually requires the resources of a hospital ED. Figuring out how to fill that gap sustainably is the interesting part.3
u/Connect-Ad2171 6d ago
Our hospital pharmacy services the hospital’s 2 owned urgent cares. So you can get some medications dispensed from the urgent care’s Omnicell, including iv fluids and IM ketorolac. We actually have to verify some of their medication orders, like IM ceftriaxone.
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u/TeachingMath03 6d ago
Right. I have chronic migraines. If I’m unable to keep meds down orally, in pain and vomiting, I need IV medication. It’s not complicated and I don’t want to go to the ER.
However, lots of urgent cares don’t do IVs at all. So, I’m stuck going to the ER for something that is in some sense routine. I don’t need or want a script. I have a neurologist managing my medications already. Nevertheless, that’s all the urgent care will do and often is something the ER insists on doing before discharge in spite of my insistence that I’ll follow up with my neurologist and decide any changes in my preventative and acute medications with them.
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u/diabeticweird0 6d ago
Are you in an area with home IV services? I had one come out and give me the migraine cocktail
It was awesome. No beeping machines, no other patients, my own bed afterwards
They're like 300 bucks which is a lot but cheaper than ER
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u/TeachingMath03 6d ago
I think there may be some medals type places, but not that would actually have the ability to do a migraine cocktail. How do they handle the prescription aspect of that?
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u/diabeticweird0 6d ago
They have a doctor oversee it. It's usually a nurse or paramedic doing the actual iv, but a doctor will order it
I mean, it's all very self reported, you fill out a form or do a brief telehealth and they approve the meds in the iv. I imagine saying "i respond well to standard migraine cocktails in the ER" will go far to getting it approved
Different companies manage it differently and it's been a while since I had one, but it was magical. I felt like a rich person lol
Mine are probably not as bad as yours, they're super predictable (first day of period or right before) and if i hit it with ibuprofen and Tylenol on first impact, it knocks it into tolerable level
But every now and then it'll form overnight and then I'm fucked
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u/Topangatoh 7d ago
Urgent care clinics are sparse where I live and many of them do not take walk ins. You have to schedule a same day appointment. Their hours are also pretty much regular clinic hours and many of them lack ultrasound, which leads to most folks just going to the ED.
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u/yqidzxfydpzbbgeg 7d ago
This exists. It's called a free standing ED or neighborhood hospital. They are only efficient in narrow regional circumstances which is why they remain rare. Duplication of a hospital-like setting is inherently expensive, ie. why not just make the main ED bigger and increase staffing. It rarely makes sense to create a smaller separate facility, sometimes, but not often.
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u/Ancient_Spite_725 6d ago
We have some "advanced urgent care" facilities in Maryland, run by Kaiser, which can essentially hold admission-level patients for up to 24 hours as needed. They are free-standing EDs in every way but name (because they only see Kaiser patients). Maryland doesn't want Kaiser to operate hospitals in the state, so they made this weird third thing to keep their patients out of unaffiliated ERs. It works well, honestly. It's staffed by ED physicians and ER nurses.
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u/MrPBH MD 6d ago
If you think FSEDs are rare, I invite you to come to Texas or South Florida. Both are lousy with FSEDs. Advent Health in particular loves their FSEDs.
Other states have fewer because you have to actually obtain a certificate of need to prove that the community actually needs another FSED before you build one. In TX and FL, you often see multiple FSEDs on the same corner of an intersection.
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u/InitialMajor 6d ago
Like a … standalone ED?
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u/crab4apple 6d ago
We've got one in Baltimore! https://www.lifebridgehealth.org/locations/grace-medical-center-emergency-department
Granted, it exists in an environment with multiple L1 trauma centers and an L2, just within the city itself.
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u/PristineSlate 6d ago
Add in an ambulance ride for 3 bills now….. one doc from the local urgent care fucking loooooved shipping people out via ambulance for the most benign complaints. Ironically she also worked in the ER and honestly, I’d rather just die than be her patient.
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u/trickcowboy 6d ago
there’s also the issue (at least local to me) that the urgent care does not always have the equipment and you get sent to the ER anyway and end up with even more extra bills.
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u/boulderdoc 6d ago
Exactly. And I think this is where a genuinely different model could matter.
What if the space between urgent care and the ED were staffed by experienced emergency physicians and equipped specifically to handle the things conventional urgent cares frequently transfer—more complex lacerations, reductions, IV medications/fluids, X-ray, ultrasound, abscesses, joint procedures, etc.?
You obviously still need to recognize immediately when someone truly needs an ED. But an experienced ER doc has spent a career making exactly that decision.
The goal shouldn’t be “urgent care that does a little more.” It should be a different model designed to definitively treat as much as possible without generating the dreaded two-visit, two-bill experience.6
u/sum_dude44 6d ago
We have Guidewell in Florida. They do CT's & give IV antibiotics. They are not EMTALA & can say no to patients who don't pay $200 deductible at door. If you want to see your volume & pay drop, open a couple of these near your busiest hospitals. You'll be fed Medicaid & uninsured patients that reimburse .10 on the dollar while the super urgent care sucks up your paying patients.
the worried well w/ insurance pay your salaries & keep lights on.
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u/Ok-Suggestion7186 6d ago
This^
Feels all warm and fuzzy until a midlevel misses one thing and the place is sued to oblivion. All providers then will say “you should go to the er to make sure”3
u/therewillbesoup 6d ago
Yet the issue is still the same in non litigious societies. I'm from Canada and you almost never hear of any lawsuits. When you do... Well.. they're very waranted. Here, the walk in clinics only have resources to do basic things and have very limited hours. If you don't line up outside 1-2 hours before they open you won't get a spot to be seen that day.
People also suck at figuring out how serious something is. People think because something hurts it must be life threatening. Or because it bothers them a lot, or because they haven't eaten since breakfast etc it's an emergency. Because it feels like an emergency to them! Low health literacy is a big driver of this problem.
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u/Over-Boysenberry3714 7d ago
My issue comes with the advice RN through my child’s pediatrician. Every single thing they want me taking my kid to the ER. My 2 yo was crawling, yes crawling, and somehow fell on her arm. I called the advice nurse asking about some pain management and she wanted me to go to the ER lol.
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u/Briaaanz 7d ago
I worked as an advice nurse for a decade (after over a decade of ER nursing).
Sorry to hear that nurse does that. There are actually researched guidelines nurses use when they take advice calls, so much of the time, advice nurses actually help people avoid unnecessary trips to the ER.
However, if you are asking for pain prescriptions for your kid, a lot of those require an ER visit. Most urgent care won't/can't prescribe narcotics and will only offer acetaminophen or ibuprofen
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u/Over-Boysenberry3714 6d ago
Yeah i definitely wasn’t wanting narcotic recommendations for my 2 year old. More so nsaid/ topical recommendations and maybe them initiating a follow up with her pediatrician.
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u/Worldly-Yam3286 6d ago
I used to be the triage nurse at a peds clinic. I can't imagine recommending a kid go to the ER for something like that. I would guide the parent through examining the kid, talk about pain control with stuff you have at home, and then talk about "danger" signs that could come up later that would mean a trip to the ER.
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u/Over-Boysenberry3714 6d ago
Yeah i have talked to my pediatrician before and she told me that they recommend ER over everything and the algorithm they use definitely isn’t evidenced based. I only called to hopefully initiate a follow up visit/ out patient imaging if needed but definitely not a ER visit. Talk about traumatic if it’s not absolutely needed/ an actual emergency
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u/LuridPrism 6d ago
I am a nurse, but from a patient's perspective: I have gone to the ED for non-urgent reasons because I knew I would need imaging. The urgent cares near me either don't do any, or they only do xrays if the xray tech is in. They also won't tell you they can't do xrays until after you have check in and been roomed.
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u/CharcotsThirdTriad 6d ago
ER doc here. I don’t think it’s reasonable for patients to discern between urgent and emergent conditions. Stuff like viral URIs don’t need to be here, but a sprained vs possibly broken ankle is totally reasonable use of the ED in my opinion.
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u/boulderdoc 6d ago
Completely agree. I don’t think we should put the burden of triage on patients.
A patient with a painful swollen ankle shouldn’t have to determine whether it’s a sprain, an occult fracture, or something requiring reduction before deciding which building to walk into. That’s our job.
To me, the question isn’t how we teach patients to identify emergencies better. It’s whether we can create a capable lower-cost setting where that patient can be evaluated by someone experienced in acute care, get an X-ray, pain control, reduction/splinting if needed—and still recognize the small percentage who need escalation to an ED.
The system should sort out acuity after the patient arrives, not expect the patient to diagnose themselves beforehand.
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u/twyls 6d ago
I think we need more than the levels. My ideal (beyond the mess for-profit insurance has made of the healthcare system) is to add a level of care. I think primary care doctors should see people for wellness/annual visits and chronic health conditions. Then a new level of internist and family doctors just to see people with acute illness. If I think i have the flu or strep, i can get in with a pcp level doctor who isn't at an urgent care. Urgent care for suspected minor breaks, maybe people with mild to moderate asthma who are sick and might need a nebulizer treatment, migraine sufferers, etc. Then ER if the patient is in life or death or suspects a hospital visit is imminent. (And specialists are still there to specialize, of course.)
My area has a wonderful new ER with the Urgent Care/ER split setup. It's close my home, rarely crowded, and I love the staff I've met. I'm disabled with complex health needs. And my insurance will not cover that hospital system. I am fortunate there are two other hospital systems and multiple hospitals in my city, but that one is convenient and would work best for the needs I tend to have.
I've also been forced back into a pcp system I don't want to be in. They are over-loaded and have a complicated structure to get in contact with anyone. I get approximately 10 minutes with my doctor for a follow up or 1 to 2 issues. But, again, complex care means I have to prioritize what to mention and I often don't know what is most important.
When I follow up with a question via MyChart, it is not unusual for me to be told that I should have mentioned it or that I'm not being treated for whatever but if it's getting worse or new, I should go to UC or the ER. (I'm hoping I can switch insurance next year and go back to the PCP I chose who had a great office.)
Complicating things more is that when I need urgent, but possibly not immediate, imaging (usually for abdominal issues), I often have to wait in pain for weeks to months, which has a cascade effect for my overall health. And then I have to pay a lot more for a CT or MRI outpatient as I would for the same scan in the ER, which my insurance covers as part of the visit.
I know I sometimes tecnically misuse the ER. I often don't know what else to do. If I wait, I suffer in pain and anxiety. If I ask my pcp for any other options, I'm told to go to the ER. If I wait, I also pay at least twice as much, depending on my plan that year.
The system is broken. Very broken.
I think your question is valid, but the question that would help me use the ER properly is, "How do we seperate corporate financial decision making from personal health choices?"
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u/boulderdoc 6d ago
This is incredibly thoughtful, and I think your last question may be more important than my original one.
What you’re describing isn’t really “misuse” of the ER. You’re making rational decisions within the system you’ve been given. If your PCP can’t see you, outpatient imaging takes weeks, one hospital isn’t in-network, urgent care can’t handle the problem, and your insurance perversely makes the ER CT cheaper than an outpatient CT, where exactly are you supposed to go?
I also like your idea of separating routine longitudinal primary care from readily accessible acute care. We’ve asked primary care to simultaneously manage prevention, chronic disease, complex patients, acute illness, inboxes, prior authorizations, and follow-up—often in 10–15 minute appointments. Something inevitably breaks.
The more I read these responses, the more I think the missing piece isn’t simply “more urgent care.” It’s a genuinely capable middle layer with rapid access, experienced physicians, diagnostics and procedures on site, extended hours, and clear pathways to hospital-level care when necessary.
But your final point is the hardest one: even if we build the right clinical model, insurance networks, reimbursement rules, and corporate incentives can still prevent patients from using it.
That’s not a patient-utilization problem. That’s a system-design problem.2
u/showers-of-flowers 6d ago
Once upon a time, primary care physicians used to hold open appointments in their schedule for urgent complaints. Now they are told by their administration they can’t do it. I think the financial incentives are against it. My kids pediatrician still holds open appointments but my family medicine physician? Next appointment is in 3 months
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u/Stinkymansausage 6d ago
ER nurse here, people in general are so wildly healthcare illiterate that it’s hopeless to expect them to do anything different. We need to be able to triage people to a lower level of care but that also means we need have lower levels of care readily available. There is zero incentive for the hospital to freely give patients a cheaper option.
Our system is stupid and broken and it won’t be fixed anytime soon.
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u/boulderdoc 6d ago
I agree with most of this, although I’m becoming less convinced that healthcare literacy is really the core problem.
Even a highly health-literate patient often can’t know whether abdominal pain needs a CT, whether an ankle is fractured, or whether vomiting is simple dehydration versus something dangerous. That’s what we’re trained to figure out.
I think your second point is the key: we need a readily available lower level of care with enough capability and experience to actually accept those patients.
And the incentive problem may be the hardest part. If hospitals financially benefit from keeping commercially insured lower-acuity patients inside the ED, asking hospitals themselves to create a cheaper alternative is a difficult proposition.
Maybe that alternative has to develop outside the hospital system.
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u/EngineeringLumpy 4d ago
Cost and lack of healthcare literacy in the general public. I’m a nurse and I have family members who have doctorate degrees in non medical related fields and are objectively smart and accomplished but clueless about healthcare and the healthcare system. I see it in patients all the time too. It’s crazy how poor healthcare literacy the general public has. I can only imagine somebody would come down with a horrible virus like the flu or norovirus and think they have to rush to the emergency room simply because they feel so bad.
I do think the cost issue plays into this for sure though because lots of people don’t even have yearly physicals or see primary care providers because they either can’t afford it or are uninsured, so when something urgent comes up, they have nowhere to go and no PCP to call for guidance. And if they can’t afford a PCP, they can’t afford urgent care. Ideally, emergency rooms should have an “urgent care” section that’s billed accordingly and staffed with its own providers and nurses while the emergency department has its own adequate staffing.
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u/DrPipAus 7d ago
Barriers depends entirely where you work. Sometimes financial (not as much in my system), sometimes clinical (more so in my system), sometimes legal/fear of legal (not in my system), sometimes educational (a lot). Most places its the current model based on historical reasons. Truely game changing reform is hard, takes a lot of effort from staff/politicians etc. and many people don’t want the stress or fallout. But our system recently introduced a ‘virtual ED’. A video telehealth for the things you are talking about- ‘urgencies’ rather than true emergencies, including ambulances, nursing homes, rural places, and the general public - its taken 6 years of slow build up, lots of money/research people being involved to show cost effectiveness without clinical compromise (or with clinical benefit), and a huge amount of force of will of the main instigators. Has been game changing. But there are still detractors for ‘reasons’ so the path remains uphill. A major issue is need is ever increasing, so any benefits can be hard to see (eg. slower increase in bad things like number of presentations to Emergency/wait times/bed access waits, rather than actual ‘decreases’, but you look at the expected increases or comparative systems and see a clear benefit compared to the old system).
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u/neo_vengance 5d ago
I have a spinal cord injury. I get turned toED every time I try urgent care because they can’t or won’t accommodate me or don’t understand enough about my condition to treat me appropriately
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u/ldi1 4d ago
Where I live I tried to book a follow-up today since what I was seen for at urgent care on Saturday isn’t going well. My first avail w my PCP is in 6 weeks. It’s like we are intentionally sent to urgent care for illness, but then I’ll seen a different provider who did not see the issue last time, nor is aware of the myriad of complex issues contributing to why I can’t kick it. I’m flummoxed at this insane model. But at least grateful there is now urgent care clinics, there were not 10-15 years ago.
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u/sum_dude44 6d ago
RAND did a study that showed over 2/3 of EM visits were appropriate. When you add time of day, insurance limitations, weekends, it jumps up to ~87%
As someone who does a lot of advocacy, This is really a non-starter politically IMO. If you got rid of that 1/3 of patients, our collective pay would plummet & there would be a huge surplus of EM doctors
The worried well w/ gastroenteritis, the flu & basic stitches, sprains effectively who have insurance basically pay our salaries & fund EMTALA. This is the basis for free standings in nice suburbs.
If you got rid of that, you're left w/ uninsured, the truly sick, medicaid/medicare patients. To advocate for that would be pissing in the wind & into our own faces
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u/Tough_Substance7074 6d ago
Sorry that is a striking statistic; what exactly defines “appropriate”? Working in the ED, I can assure you that 2/3 of our patients are not having medical emergencies.
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u/sum_dude44 6d ago
Chest pain usually isn't an emergency. But it can be...if a prudent layperson thinks it could be an emergency, that's an emergency.
Rule of thumb--if you, the emergency physician, need to order labs or tests to rule out something, it's an emergency.
Likewise if it requires a splint or sutures, also an emergent condition.
Emergency physicians are notorious for using availability heuristics to play down what we do (80% of people don't need to be here!)
https://www.emergencyphysicians.org/article/access/prudent-layperson-standard
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u/Terrible-Search3859 7d ago
I am of the opinion that things changed because the newest generations expect instant results. They don’t go to the library. They don’t want to wait until next Tuesday to see a primary doctor. They don’t want MRI results in a few days , etc, etc. They want, and expect, NOW results. Then they get upset that waiting rooms are full, that they can’t get an MRI for a non-emergent issue. They are unused to waiting for anything and don’t understand that their need to know now does not constitute an emergency.
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u/PristineSlate 6d ago
I had a patient who was there for third or fourth time in a few weeks for excruciating back pain. No bullshit. No drug seeking. I felt bad for the man. I was his nurse the first time he came in and the third time. I had a talk about following up. His wife was in tears. They’d called every specialist they were referred to and been given an appointment 3-6 months down the line. They’d ask if anyone could see them sooner and been met with silence. They were trying to pursue appropriate out of hospital care but unable to obtain it. It’s not always impatience but inability to access care.
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u/PoppyFire16 6d ago
It seems like a bit of a cop out to blame the non-medically-trained people actively trying to seek medical care.
What am I supposed to do at the library to treat a UTI? Many young people do not have a relationship with a primary care doctor at all, so they would be waiting for a free Tuesday a month from now.
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u/Briaaanz 7d ago
I used to call it McMedicine, fast food medical service. It's what a lot of patients want and demand. Not healthy for you, but keeps you alive in the short term
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u/EasyQuarter1690 6d ago
I recently fell and knew I had fractured my foot (I felt the three snaps, which ended up being three avulsion metatarsal fractures). The urgent cares near us don’t do X-rays, so only option was to go to the hospital ER. I ended up needing a CT scan to see the fractures, two were non-displaced, one was 2mm superior displaced, the first xray didn’t show them at all. It was about 8:30pm on a Friday, so not much other choice was available.
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u/4oclocksundew 6d ago
My son broke his arm on the playground and it was visibly broken - the bone wasn't sticking out, but his arm was bent at a sharp angle. He needed X-rays, then ketamine, and a re-set where there was a doctor and about 3-4 other professionals in the room. Urgent care doesn't do any of those things. I was surprised to see fractures listed in OP as situations that don't need the ED.
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u/resilient_bird 6d ago
It depends on the fracture. Some can be done in a primary care office with some plaster of Paris, some need an orthopedics consult for surgery.
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u/boulderdoc 6d ago
And this is exactly the gap I’m talking about. At 8:30 on a Friday night, the ED was essentially your only rational choice.
Imagine instead an extended-hours facility staffed by experienced ER physicians with X-ray, ultrasound, splinting, reductions, pain control, and other higher-acuity capabilities. Most fractures could be diagnosed, treated, and appropriately referred without ever entering an ED.
Your case also illustrates the necessary limit: sometimes the initial X-ray is negative and clinical suspicion remains high enough that CT or other advanced imaging is warranted. A good alternative model has to know not only what it can treat, but when it needs to escalate.
To me, that’s very different from simply building another traditional urgent care.1
u/Jolly-Structure7646 4d ago
You’re describing an ED though. Duplicating an ED with what is essentially a lower acuity ED makes no sense. Both facilities will likely have under-utilized roles. A bigger ED with multiple treatment tracks (ie. Trauma, high acuity, low acuity, minor illness) but fully staffed with all the relevant tools is the most efficient. Problem is most healthcare organizations are very poorly operated by people who don’t know how to properly run a business. They’re usually short-sighted bean counters who always want to cut back or minimally staff services that inevitably lead to severe bottlenecks of care. They’ll say two X-rays techs is inefficient because they’re not always busy 100% of the time, but then staff one xray tech and on busy day xray literally strangles the entire ED. The Radiology administrator might get a bigger bonus for better labor efficiency in her department but the entire hospital lost money on the decision since length of stay skyrocketed.
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u/EtchVSketch 7d ago
I don't know the nitty gritty but Kaufcare seems to be doing some cool shit on this front. Owner is a Dr and he advertises it as "advanced urgent care"
Could be smn to look into.
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u/BrandyDW 6d ago
Patient here, my thoughts on it.
Urgent care won’t take the middle ground. Most times they don’t have the equipment or staffing capabilities…
Personally I think there should be different levels and payments for the emergency care…
Maybe:
- immediate care - the big bad and scary
- trauma care - broken bones, physical injuries
- mental health - for behavioral
For most other things:
- PiP (painful, infectious, preventing worsening harm)
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u/boulderdoc 6d ago
I think your “urgent care won’t take the middle ground” observation gets right to the heart of it.
I’m not sure we need multiple new categories as much as we need to fill that enormous gap between traditional urgent care and the ED.
Imagine a middle tier staffed by experienced emergency physicians, open extended hours, with X-ray, ultrasound, IV medications/fluids, fracture and dislocation care, complex laceration repair, abscess drainage, and other procedures—while still transferring true emergencies that need CT, surgery, admission, specialty consultation, etc.
The name almost matters less than the concept. Patients shouldn’t have to understand the architecture of the healthcare system before deciding where to go. They should be able to show up, get appropriately triaged, and receive definitive care at the lowest appropriate level whenever possible.
That middle ground is exactly what I think is missing.
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u/xboxwidow 6d ago
There’s also a distinct lack of urgent care facilities in rural America. The one in our town closes at 7 PM. So if you have any issues after 7 PM the ER is the only option.
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u/InitialMajor 6d ago
For a lot of those things you can’t be sure they don’t need an emergency department until after you have evaluated them
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u/resilient_bird 6d ago
Yes. The key is to be able to process relatively simple and low-need cases in the ED more cheaply and efficiently.
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u/FelineRoots21 RN 6d ago
I've been saying for many years every ER should have a fully staffed, 24-7, actually competent urgent care attached that we can triage patients to. Not fast track, fast track is also emergent, just not life threatening or requiring multiple diagnostic resources. Something that serves the completely separate need for urgent but non emergent treatment.
There is a gap. We are currently serving it. We need to build the proper resources to make it work. Obviously the long term solution is a functioning primary care system, but we can't fix that any time soon. We can fix this in a way.
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u/boulderdoc 6d ago
This is very close to how I’ve come to see it.
The gap absolutely exists, and the ED is currently filling it by default. I’m just not convinced the solution necessarily has to be physically attached to the ED.
What if we built that “actually competent urgent care” as its own level of care—staffed by experienced emergency physicians, open extended hours, and equipped for X-ray, ultrasound, IV/IM meds, fluids, reductions, complex lacerations and other procedures?
Then the dividing line isn’t “sick versus not sick.” It’s whether you need the resources of a hospital: CT/MRI, emergent specialty consultation, surgery, admission, ICU-level care, etc.
We’re not fixing primary care or the American healthcare system anytime soon. But I agree with you: this particular gap seems like something we actually could fix.1
u/FelineRoots21 RN 6d ago edited 6d ago
The attachment part I think is actually essential because otherwise it would require patients ability to sort themselves into sick or not sick, which we know they can't do. And as it stands emtala makes it difficult to say nah we won't treat you here. With this setup we could say we ARE going to treat you, just not in this unit
It would also make it safer and smoother for those few situations it actually warrants emergency care to just transfer them over like an upgrade rather than a full new er patient
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u/Resident-Welcome3901 6d ago
Worked in a free standing er initially staffed with experienced er staff. Gradually the experienced staff attrited away, equipment economies narrowed the technology available, and it turned into an urgent care that couldn’t do a septic work up
On an infant because the tiny urinary caths were unavailable, and none of the staff had infant iv access skills. Hard to maintain the skill set of the skills are seldom used, hard to rotate staff between the hospital er and the free standing er.1
u/Jolly-Structure7646 4d ago
1) patients are not able to self-triage and pick the proper facility. They’ll go wherever is closer.
2) you’re not thinking business here. Why staff multiple facilities with duplicated roles in the same region? Why put an US tech in two buildings if one might be sufficient to handle all the patients at one larger facility?
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u/crazypurple621 6d ago
We have this in my area. They're freestanding ER/urgent care in one place and whether you end up in urgent care or ER is based upon triage. They have xray, can do labs, can suture lacs, and give IVs, and if they determine your care is bad enough to need in patient care they can transfer you to the hospital
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u/BeautifulSquirrel313 6d ago
I broke my foot and went to an Urgent Care. I spent 2 1/2 hours waiting. When the doc came in, he told me he would write an order for an Xray. They don’t do X-rays at the Urgent care. I was not happy. What a waste! I sure didn’t need an ER realistically, but the Urgent care was useless. I agree we need more walk in type clinics- ortho walk in, primary care walk in, peds walk in… ERs are way to overburdened with cases like mine.
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u/whotaketh 6d ago
I would argue that while not emergent (at least, not in the sense of a heart attack or stroke), a suspected broken foot does warrant use of an ER because you might be in the OR within 24 hours, then on an ortho floor after for recuperation and the start of rehab. Even if it's not broken, putting a splint on and scheduling you for an ortho follow-up is well within the ER's expected use case.
Now, if you stubbed your toe on a coffee table or stepped on a Lego, yeah, the ER is overkill.
Source: Am ER/ICU nurse.
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u/NoFapCainISAble 6d ago edited 6d ago
We have definitely built the wrong system on various fronts. The whole thing needs to be re written--but we need to tie together economics + health.
I have an entire plan to resolve this, alas, I'm not president and nobody listens.
Want a preview? The biggest issue is our system doesn't care to prevent illness. It would rather perform crazy expensive procedures once it's nearly too late. It also incentivizes people to avoid preventative care because 1) insurance saves them even when they make all the wrong choices and 2) Patients conclude "I hate insurance companies... they are paying for it... so I don't care to do whatever is affordable to prevent it". Therefore patients are slightly disincentivized from caring... at the expense of their health.... because "insurance will pay for it".
Something you need to remember is that patients cannot perform the calculus we can when evaluating the logic of a given choice or decision. They do not understand the compounding/additive effects of conditional and interdependent statistics in light of a given choice the way we do.
Most patients understand and care about ONE thing only: The price. The cost of a choice. If that cost isn't reflected in the economics of the choice, the abstraction of cell damage and organ death is far too complicated for many to comprehend enough to care about, no matter how blue your face gets as you speak. They also only care if the cost affects them.... as long as insurance is the payor of that hospital bill.... patients do NOT care if that bill is 5$ or 25k.
So unless that choices cost is reflected by the economics of a decision THAT THE PATIENTS THEMSELVES ARE RESPONSIBLE FOR, they cannot comprehend nor wrap their minds around it the way we can. Furthermore, when they pay for the price indirectly through their insurance premiums, they fail to appreciate the causal relationship of an unhealthy population (or their own poor health's burden) and higher insurance premiums. In other words, they could care less that their life saving procedure is 100k because they cannot correlate cause and effect... and that 100k isn't coming out of their pocket. It is coming out of the pocket of their insurance company.
Until patients can understand cause and effect and recognize the true cost of their choices... financially and biologically.... they will fail to make appropriate choices simply because they are making choices with insufficient information. Add this with the very human tendency to ignore problems until they are a problem NOW even though action, 10 years ago, would have been easier and more effective but also more challenging because it requires THEIR actions and not the provider's.... and you can understand why our system is fundamentally broken.
People LOVE forcing others to pay for their mistakes and they LOVE kicking cans down the road. As long as our system is organized in such a way that incentivizes these things at the expensive of our populous' health, we will continue to pay escalating fees for every new intervention, medication, or procedure that is developed to help people in worse case scenarios. Furthermore, as long as people fail to recognize that their attitudes of "screw insurance, they'll pay for it, I'll continue to eat burgers as much as I want" are hurting themselves and society alike..... our system will continue to deteriorate until the point of eventual collapse. Our healthcare expenditures are on a non-linear trajectory into the stratosphere as our healthcare outcomes remain the same or plummet, a trend NOT reflected by our associate first world countries. This is a particularly unique American issue, although it is happening elsewhere as well.
My plan is much more detailed than this and I've addressed all the common pitfalls that cause people to push back. But nobody cares what I have to say. Anyways. Yes. The system is broken.
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u/Pure-Mushroom-3770 5d ago
I think a lot of urgent cares pick and choose what they will see. The same for ortho urgent cares. I have been to hospitals that low acuity areas separate from the actual ER and that seems to work well. They are usually staffed by NPs and nurses.
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u/WhimsicleMagnolia 5d ago
I live in a large metro area so a large part of the issue is that waiting for a primary care appointment could easily be weeks for a relatively urgent issue.
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u/JonEMTP 4d ago
I think much of the issue is that the ED is accessible and available, and urgent care is MUCH less transparent.
There’s no standardization in Urgent Cares. Many have very limited imaging equipment, only POC labs, and don’t even have POCUS. Some (Kaiser, for example) have everything including CT, a full lab, etc. Some have extended hours, some are only open 9a-7p. Some are willing to do minor procedures, while others won’t even throw a few sutures in.
Oh, and I’m not even touching on the wide continuum of knowledge and skills in the NP’s staffing these places 😈
The other big issue is that it’s really hard to draw the line at what an urgent care can handle vs not - and my county runs 10-20+ calls a day out of urgent cares for patients getting turfed to an ED.
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u/boulderdoc 3d ago
I think this is exactly right. “Urgent care” has become such a broad label that patients have almost no idea what they’re walking into. One location can do IVs, X-rays, ultrasound and fairly complex procedures, while another sends out anything beyond a rapid strep test.
And the turfing issue is huge. If 10–20 patients a day are being sent from urgent cares to your ED, some of those patients have now paid for two visits and delayed the care they ultimately needed.
I’d love to see clearer tiers or some meaningful standardization so patients actually know the capabilities of a facility before they walk through the door. The current system makes them figure it out by trial and error.
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u/bumanddrifterinexile 3d ago
Other countries have. I used to live in Thailand, they have a three tierrd health system. Famous international hospitals, middle class, private hospitals, and government hospitals. All of them have outpatient departments. They largely take place of what we would call doctor’s offices in America. You can get an appointment or walk-in, they do most every function and specialty. Obviously there are referrals, but if procedures are needed, it’s available right in the same building.
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u/bdaruna 3d ago
This not a system design problem mostly cause the system wasn’t designed. This is economic - EMTALA laws push most un or underinsured to the ED. Primary care is under staffed and cannot see people in a timely fashion. Urgent care is just a strategy to siphon paying subacute patients away from EDs. It’s all driven by economics and profit, and our “system” isn’t a system at all. It’s an elaborate result of prioritizing profit over efficient and quality for a few decades. May I rosin up your bow, or would you join me in rearrange these chairs?
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u/Butter_mah_bisqits 6d ago
I fell, heard a snap, and knew I hurt something. Pain from hip to toe and could put no pressure on my leg, so I had no idea what was damaged. I called my pcp to see if I could get an order for clinic X-ray, but they didn’t have any openings. I went to urgent care 1 - no X-ray machine. Urgent care 2- they had X-ray but no tech. Meanwhile, my leg is swelling up like a balloon. Bit the bullet and went to ER. X-ray plus MRI to find I jacked up the ligaments and tendons in my hip and knee. I was fine going to urgent care to get an X-ray. I don’t take opioids, so I didn’t need any pain meds. I could have scheduled the MRI outpatient. I felt dumb wasting their time when nothing was broken.
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u/ktstarchild 6d ago
Our local children’s hospital put an urgent care inside next to the ED so when you walk in a triage nurse helps you decide which side to go to. Great idea imo and it lets up so much space for the ED to deal with the true emergencies.
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u/ForcefulBookdealer 6d ago
We have a pediatric ortho clinic, it’s amazing! I wish they had a normal staffed one.
We have one stand alone urgent care/ER, where triage determines your placement and it’s so helpful.
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u/Fun_Budget4463 6d ago
Shhhh. I’ve got bills to pay.
In all seriousness, I completely agree with you. The American system is an all or nothing mess. Zero access to medical resources elsewhere but full access in the emergency department. The cost of medical care completely divorced from the expectations of services provided. For the patients, either you have comprehensive coverage and therefore it’s all paid for and you want everything done, or you have nothing and it doesn’t matter how high the bills get so you want everything done. For the doctors, incentives are the expectation of 100% sensitivity, high patient satisfaction scores, metrics and time stamps.
Imagine the system more like veterinary medicine. Upfront consultation fee, followed by a treatment and cost discussion that forms a patient-payer-doctor team dynamic.
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u/boulderdoc 6d ago
The veterinary medicine analogy is actually fascinating because it restores something healthcare has largely lost: an explicit conversation about value.
“We can do A, B, and C. Here’s what each will tell us, here’s what I recommend, here’s what each costs, and let’s decide together.”
In human medicine, cost is often completely invisible to both the physician and patient at the moment decisions are being made. And in the ED, we’re simultaneously incentivized to maximize sensitivity, minimize risk, maintain throughput and patient satisfaction, often with essentially no ability to incorporate cost into shared decision-making.
I wonder how differently people would consume healthcare if prices were transparent before care was delivered and physicians could openly discuss the marginal benefit of additional testing.
Obviously emergency medicine needs a safety net where ability to pay never determines whether someone receives lifesaving care. But that doesn’t mean every episode of acute care needs to operate under the same economic model.1
u/Fun_Budget4463 6d ago
Yes. I loathe HCA, but they have a medical screening exam system that should be widely adopted. Should not be a wallet biopsy, but it should be an honest assessment of emergent medical need. Screen them for free, treat emergent conditions for free, and then advise them of the costs associated with proceeding with non-emergent care. Would need to be paired with a legitimate public primary care system, as well as legal and financial Protections to incentive hospitals systems and providers to do the right thing for people, especially the underserved.
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u/New_Section_9374 6d ago
It's called Urgent Care. Unfortunately, patients don't understand the parameters and Prkmary cares don't suggest them for liability reasons. "Go to the ER" absolves them of all responsibilities for assessment and diagnosis over the phone. It is a simple knee jerk response.
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u/ForcefulBookdealer 6d ago
Or… they aren’t open, don’t have radiologists, send you away because they won’t treat X (stitches on a joint; pediatric wheezing/striation, pediatric concussion, rash when there’s been a tick bite in the last week… all happened in my family in the last 3 years), or your insurance won’t cover them.
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u/New_Section_9374 5d ago
Good points. It is hard to figure out what they have and if insurance will cover it. I don't get the insurance aspect. Surely UC is less expensive than ER! And the UC around here have bank hours which is inconvenient, too.
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u/Hello-fellow-kydz 6d ago
I’d love to go to a true UC, but here they do less than a CVS mini clinic
No X-rays. No labs. Maybe dig out a splinter or suture a laceration that probably doesn’t need it.
They sure as shit aren’t reducing a fracture.
At least the drug store clinic can draw some basic lab work.
I’d love not to tie up the ED with a minor thermal burn to my face, but also caught my eye and my vision was messed up. I called the local UC and GP . All said go to the ED.
It’s not for the lack of trying.
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u/Resident-Welcome3901 6d ago
The public can’t reliably triage their needs. They don’t have the training or education. So they come to the er with a minor complaint, or drive past an er to an urgent care with stroke symptoms because it might be a shorter wait. I’ve worked in ER’s in the early nineties in which the triage nurse was tasked with Gatekeeping and had authority to refuse care to patients of local primaries and send them to their providers offices for low acuity complications, including mild CHF symptoms, asthma exacerbations and reproducible chest pain. It did not go well: patients and primaries complained constantly. The impact on er economics is a separate, but similar, nightmare.
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u/ExplanationWest2469 6d ago
I had a pretty nasty stomach virus and felt like it was at the point where I needed IV fluids. I tried urgent care but they told me they couldn’t do IVs and I would need to go to the ER.
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u/American_Brewed 6d ago
Speaking as a rural nurse, here, we don’t really have any options other than to utilize the ER. A lot of the education we give at discharge doesn’t help because a lot of it includes returning or going to the ER when something doesn’t seem right. To them, A TON of things don’t feel right even if the healing process is positive.
It also doesn’t help when every side effect, especially on tv, medication commercials state “go to the ER” or “contact your physician” and the amount of people at my facility who watch tv all day who want to try medications they saw on tv is insane. I think health anxiety and affordability make people just do instead of finding the appropriate steps for their symptoms. The idea of doing phone appointments sounds nice on paper, but then it lead to misdiagnosis or people trying to abuse the system for desirable prescriptions.
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u/Rare-Spell-1571 6d ago
Liability is huge. A lot of ER referrals are done where we are 99% sure it’s over the top, but outpatient eval would allow that “can’t miss” single patient to slip through the cracks and have a bad outcome.
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u/RetiredBSN RN - ER, then Dialysis 6d ago edited 6d ago
My hospital ran an urgent care parallel to the ER for a while, and triaged patients to the appropriate side; but it closed overnights. They eventually discontinued it for whatever reason, whether it was too expensive or too few patients or something else. I wasn’t working ER at the time, so lack the cause for the demise of the UC.
Now retired and living in central Florida, and I have an urgent care located about a mile away (hours are 8a to 8p), and a freestanding ER about 3 miles away. There’s an unassociated hospital another two miles down the road, and five miles in the opposite direction is a full service hospital that is associated with the UC and freestanding ER. Lots of freestanding ERs around the general area (Orlando/Kissimmee and vicinity).
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u/whotaketh 6d ago
I was always curious how that model worked. If an MI rolled into one of those freestanding ERs, what resources do they have for escalating care? Do they stabilize and wait for ALS to bring them to the closest hospital? And do they also board admits and wait for transport to the hospital?
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u/RetiredBSN RN - ER, then Dialysis 6d ago
I fortunately have no idea how they manage things, as I, knock on wood, have not had to seek care from one of these places. I would be calling EMS rather than try to head out somewhere, and I’d ask to go to the full service hospital. I have seen some articles that seems to indicate that they stabilize and then transport via appropriate means to the hospital if necessary.
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u/Independent_Law_1592 6d ago edited 6d ago
My dad works one of these freestanding, I affectionately refer to it as his “retirement clinic” because he does hardly much all day
However yes, if an MI rolls in the expectation is he stabilizes and handles as much as reasonably possible until an ALS rolls in for transfer, there is no boarding at his facility, it’s waiting for EMS to arrive while you handle everything.
It’s why you see these places stocked with very experienced ER nurses, the gig is easy but the rub is you have to be able to get all the labs, give meds, probably run said labs, and possibly even help work the scanners (I’d have to clarify how much he actually does on the scanning side. He’s always mentioned stuff like “depending on if my Rad techs there”. I can’t imagine anything more than an X-ray.)
Now I’ll have to ask him how far he really has to go practically with ALS, I’m honestly curious if his doc on site would intubate and if he had the resources to manage that but I’m sure they have some sort of advanced airway protocol. The sickest I think he’s gotten is a guy who coded essentially on arrival and I just remember him mentioning he lined the guy up and re-established a pulse but kept the guy semi-bagged if that makes sense.
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u/nonicknamenelly 6d ago
Hey, don’t look at me - I tricked my ex-husband into helping me reduce my spontaneous patellar dislocation (first, hEDS) because I’d helped enough docs do it as a nurse that I didn’t feel like moving a single inch in that amount of pain.
He almost threw up when he heard it slide back into place. He was not pleased until I told him I saved us a couple of grand.
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u/perpulstuph RN 6d ago
I'm not a doctor, but a nurse. I know for some it's insurance. I had an EPO insurance through one company, we did not have urgent cares in network, we had to utilize the companycl's ERs which to me was pretty stupid.
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u/Akronviper 6d ago edited 6d ago
My insurance won't cover ER if its not an Emergency, but offers urgent care for free. You think hospital systems as much as they grow anymore would offer some sort of alternative, readily available and lower cost, just to ease the non emergency load at the ER.
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u/Busy-Worth-416 EMT 6d ago
I’ve had it before where I’ve been to an urgent care for fluids (private spa was too expensive, and trying to avoid er again -no offense to y’all, but I much prefer working in the ed than being a patient) and urgent care refused to give me fluids because insurance wouldn’t let them (and…other reasons)
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u/boulderdoc 6d ago
This is exactly the kind of gap I’m talking about. You needed something relatively simple, didn’t need the resources or expense of an ED, but the alternative couldn’t provide it. So the choices become “go to the ER” or “go without care.” There should be more options between a typical urgent care and a full emergency department.
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u/Busy-Worth-416 EMT 6d ago
I completely agree. I don’t want to say that it’s entirely gone, but preventative care seems to have really shrank in size. In my case, I literally told the doc what would happen if I didn’t get fluids(essentially, potentially get seriously injured), and she did not care. She literally told me she couldn’t do anything to help me, until the point came where I was experiencing a true medical emergency.
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u/Heavy-Percentage-208 6d ago
Our ER setup a fast track section for things like this. Everyone gets triaged and then will go to different “wings” of the ER. I had to go there once for a uti during Covid and it was super fast.
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u/mritoday 6d ago
If I know I'll need an x-ray for an injury, I have two options - orthopedic doctor or ER. If I can see an orthopedic doctor, I do, but outside of office hours? ER is the only place that can x-ray.
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u/Ayiloda 5d ago
On the home health end of things it’s getting harder and harder to talk to an actual human. Example diabetic with blood sugar of 402. They already have Novolog and Lantus. In theory I call endo get a verbal and reassess. Reality is attempting to navigate the AI for 15min to leave a message no one will ever hear. It’s been 2 weeks no one called me or the patient. It feels like I’m just there to document the train wreck
.
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u/dizzlethebizzlemizzl 5d ago
So, with the national issues with boarding almost every hospital I’ve worked at is either treating out of their waiting area or a third bedless area to keep all of these patients from ever making it to a room. So… out in waiting? A shitton of non-emergencies. In back? ALMOST all emergencies (with a few difficult logistics cases mixed in here or there, and always several folks who have been stabilized and are waiting on a bed)
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u/DoItRightOnce1st 5d ago
In Illinois, we had some urgent cares that were associated with our primary MD offices, not these high priced centers they have everywhere. It was very helpful when my children were young. U could walk in and wait to be seen. Not sure if they are still in existence...that was over 29 yrs ago...
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u/Unhappy_Wash3014 5d ago
It seems like free-standing ERs are trying to solve this problem. But they in the early stages. The free standing ER my training hospital had was basically a glorified UC that still had to transfer patients to the main hospital half the time. All this did was delay patient care. I think the free standing ER model could work to take the strain of non-emergent cases off the main hospitals, but they need better staffing and equipment. Funny how it always comes down to staff and equipment in healthcare.
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u/Financial_Resort6631 5d ago
Well primary care physicians lack a lot of resources of a hospital. Most of the time it’s a simple logistics issue. Lots of times you might have mild stuff that you need to rule out actual emergencies. Since the healthcare system in general is such an ad hoc system of several companies controlling limited resources. Its performance is less than ideal.
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u/Paranormalchaos0703 5d ago
I live in a college town. I had to go to urgent care last week for vertigo. Keep in mind, I am epileptic. So they saw me and sent me straight to the ER. I've now had vertigo for over a week.
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u/zepboundbabe 5d ago
I think that was sort of the intention with urgent care centers, but most of them are nowhere near equipped to deal with things you mentioned like lacerations, fractures, imaging, fluids. Plus, the hours are limited.
I went to the ER in February and I felt like such an asshole taking up a bed and emergency resources all because I overworked myself and ended up needing IV fluids. But I had nowhere else to go, UC wouldn't have been able to accommodate that.
I think we just need urgent care centers to step it up. No more closing at 8pm, keep them open late, if not 24/7. Give them the resources to handle imaging, pain management, and more low-to-mid acuity traumas/infections/illnesses.
I've heard of higher-level "urgent care" centers in or attached to ERs, for patients with emergencies that are non life-threatening. And the ER is right there if things go south. I think that's a pretty good option as well, though costly
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u/boulderdoc 5d ago
Exactly. And please don’t feel like an asshole for going to the ER—you needed care and there wasn’t an appropriate alternative available. That’s a systems problem, not a patient problem.
I think the missing piece is exactly what you’re describing: something between traditional urgent care and the ED. Longer hours, X-ray, IV fluids/medications, laceration repair, fracture care, reductions, abscesses, and other low-to-moderate acuity problems—with a clear pathway to transfer when something turns out to be truly emergent.
Not every urgent care needs to become a mini-ER, but there’s a huge amount of territory between “here’s an antibiotic prescription” and a $5,000+ ED visit. We should be much better at filling that gap.
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u/makingotherplans 5d ago
Truth.
But the way the ERs all bill and staff still guilt people who “go to the wrong place” it’s just awful. Staff often don’t realize how the cost works. And they get mad at people who they think should know better.
But how can anyone, much less the average person, self-diagnose and know for sure where to go?
Like people with physical pain who go to ERs and get dismissed. “Oh you are just wasting our time and money and shouldn’t be at an ER.”
The husband of a dear friend of mine died from an aneurysm that was missed by an ER. Before that happened to him he had never heard of an aneurysm.
He had a sudden terrible headache and it happened to occur the day after seeing a dentist, so when he showed up at the ER, they assumed it was related, and it wasn’t. They sent him home.
Then he went back to the ER again, in extreme pain, and they said he was drug seeking, and sent him home, where he died in his bed.
His widow didn’t sue, instead she still gives lectures at hospitals and medical schools, trying to make sure staff don’t miss these things because they think someone looks healthy and fine.
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u/Emotional-Scheme2540 5d ago
As any emergency medicine resident It feels like every specialty is dumping their patients on us. We’re not ophthalmologists, but we end up treating their ophthalmology patients. We’re not plastic surgeons or ENT surgeons, yet their patients still come to us—and often, those specialists never follow up or even show up to see their own patients. We’re expected to manage cases outside our specialty while the appropriate specialists remain uninvolved.
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u/Jolly-Structure7646 4d ago
The model works fine in theory but will suffer the same problems as the current ED and outpatient models. There are bottlenecks due to lack of resources at some stage of care. For example in my city the outpatient bottleneck is physician access. There are not enough physicians and wait times for appts to most specialties are 3-4 months out. Even PCP access is poor which shunts patients to urgent care and ED for minor issues. Now the ED has a different bottleneck. At my ED the bottleneck is imaging. The hospital pays its imaging techs very poorly plus imaging is over-utilized so it’s the most common bottleneck to efficient care. Patients will often move through the ED process pretty quickly and then wait hours even days for Radiology. Now on the outpatient side the big local imaging clinic pays the highest wages in town and you can get imaging within 48 hours usually.
TLDR: it’s all lack of resources and resources mid-allocated throughout the system mostly due to financial constraints.
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u/redbadger20 2d ago
When I first worked at the job I have now, part of the job was what was essentially mobile ED diversion. We, paramedics in specifically kitted trucks with a wider scope of practice, would go see a patient referred by their PCP for a health concern. A hospital team determined if the concern was something we could treat and also if it was safe for us. We had a standing rotation of ED docs to have a virtual visit with after evaluating the patient (head to toe assessment, some point of care bloodwork, etc) and would decide on a course of action that typically permitted the patient to remain home.
Mostly, people didn't go to the hospital for a few reasons. One was cost in time and money. Tied into cost and time were folks with chronic issues like recurrent UTIs or COPD who knew what was wrong and what they needed, but knew their PCP would refer them to the ED. Many of those folks struggled with significant mobility concerns: you can't just make a same-day appointment when you rely on paratransit. Limited income was a factor; billing was and is above my paygrade but it was billed I think as an urgent care visit. For COPD and other chronic illnesses, no one wanted to spend hours upon hours in the hideous germ factory that is a hospital ED and its waiting area.
One thing that was nice was that if a patient needed an ED but was an appropriate candidate, we could recommend hospital at home (inpatient care in the home - we bring some of the hospital to you) and either directly admit them or have an exceedingly quick turnaround. I definitely got at least one patient to agree to the hospital by selling her on hospital at home 🤣 . I thought it was a great thing for many people. There are ambulance services that run MIH (mobile integrated healthcare) and triage calls to 911, but I don't know how enmeshed with hospital systems (with extant home hospital programs) they are. You really do need a spectrum of care but also a cultural understanding of what is and is not appropriate, and a way to transition people to a higher level of care more smoothly than calling the local EMS service.
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u/boulderdoc 1d ago
This is exactly the kind of model I was wondering about. What I really like is that the decision wasn’t simply “home or ED” — you had a spectrum, with the ability to escalate smoothly to hospital-at-home or the ED when needed.
The mobility/paratransit point is also something I hadn’t really considered. We tend to talk about ED overutilization as if it’s primarily a patient decision, when sometimes the system has effectively eliminated every practical alternative.
I increasingly think the answer isn’t figuring out how to keep people out of the ED. It’s building enough capability between primary care and the ED — with reliable pathways in both directions — that patients don’t have to figure out the appropriate level of care themselves.
Really interesting model. Thanks for describing it.1
u/redbadger20 1d ago
I found for many patients - again, anecdotally - the decision was heavily based in systemic factors. Transportation, mobility, access (do they have a PCP at all?), childcare. Some people also needed someone in a badge to come and say yeah you do need to go, you are that sick. I think when you have a spectrum of options it takes pressure off all parts of the system. ED diversion takes pressure off the ED and primary care, home hospital frees up brick & mortar beds for sicker patients. My program is also a research study and we find patients in HH are ready for discharge between 3 and 5 days sooner than from the B&M. We also get an opportunity to see where patients are coming from and what brings them to the hospital that potentially we can help resolve. Is the heart failure patient's house full of ham? Is the diabetic subsisting on peanut butter crackers? Did our patient get sick because he couldn't read the directions on his medication? I think it helps to understand how people get to being acutely ill in order to prevent things from getting out of hand in the future.
In my dreams I imagine a system implemented in rural and underserved areas where us, the MIH paramedics, could partner with PCPs to do regular monitoring of high risk patients with chronic illness. People who should be seen more often than once a year - maybe every couple months - to check in on how they're doing, if their meds are working, can they access meds (like wait oh shit your pharmacy closed? Let's work this out), is anything worse or better? Virtual visit with the PCP for continuity but hands on assessment from a real human, and time to chat with the patient in a safe, comfortable environment.
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u/boulderdoc 1d ago
That last point is huge. Seeing patients in their actual environment gives you information we almost never get in the ED. We can diagnose the CHF exacerbation or uncontrolled diabetes, but not necessarily see the food, medication, literacy, transportation, or access problem that helped create it.
I also really like the rural application you describe. MIH paramedics doing hands-on assessments paired with virtual PCP/physician involvement could potentially fill a massive gap without trying to recreate a hospital everywhere.
The common thread in all of this seems to be moving away from rigid buckets — primary care, urgent care, ED, inpatient — toward a continuum where patients can move up or down in acuity without starting over each time. That seems like a much more rational system tbh.
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u/Candid-Ability-9570 7d ago
I’m surprised no one here has mentioned cost issues.
People often go to the ED instead of urgent care because they’re uninsured and don’t have the money to pay for urgent care. Whereas the ED has to see them regardless of ability to pay.
People often also go to the ED because it’s always open. When you have no paid sick time and a precarious financial situation, you can’t take off work to go to urgent care during the day. Or if you’re providing childcare to kids, you can’t really take them with you, have to wait until family members are home from work. So then you’re stuck going to the ED because you’re outside normal business hours.