Symptoms requiring immediate emergency department attention:
Spurting blood, massive bleeding
Vomiting blood (often a black coffee ground-like substance), passing black
stool, coughing blood
Blue lips, face, or nail beds
Heart stopped or faint pulse
Extensive burns, especially if skin is white or charred
Eye injuries, or acids or other strong solutions in the eye
Obvious alteration in consciousness resulting from head injury or without
Insect stings, if patient is known to have allergy
Seizure or convulsions
Severe pains in chest, upper abdomen, or down arm plus shortness of breath
Suspected poisoning or overdose
Sudden, severe abdominal pain not attributed to indigestion
Suicidal thoughts or any violent behavior
Patient simply appears to be very sick
Call patients doctor for advice. If you cant promptly reach the doctor,
go to an ER.
Our ratings of area hospital emergency departments will help you decide
where to go. Note that your optimal hospital choice may be different depending
on whether the patient needs simple care, complex care, or you dont know
Go to a primary care doctor. If you need care outside your doctors office
hours, go to an urgent care clinic. Dont use a hospital emergency department.
Click here for patient ratings of primary care doctors.
Youre not a doctor. (And, no, you dont play one on TV.) But chances are
that at some point youll be forced to make emergency medical judgments
for others or yourself. Is it a bump on the head or a concussion? Is it
heartburn caused by eating too much fried food or a heart attack? Will
the cut heal on its own or does it require stitches? You need to know whom
to call, what to say, and where the patient should go. We provide advice
on what to do, and, if emergency medical care is needed, much information
on the quality of care offered at area hospitals.
When first confronted with an illness or injury, you must quickly decide
whether the case is life-threateningwhether theres a risk of death or
permanent disability if the patient does not receive immediate care (within
30 minutes). If you are faced with what you are sure is a heart attack,
your decision is easy; in other cases, you may not be so sure. The rule
to live by: If you think the case may require immediate care, assume it
does. Making the right decision can be a matter of life and death. In treating
heart attacks and serious injuries, even a few minutes can dramatically
improve survival rates.
If a case may be life-threatening, call 911: Thats the best way to get
treatment started fast.
It will likely take longer to get the patient into a car than to wait for
an ambulance. In most parts of the area, the average time between calling
for an ambulance and the ambulances arrival is less than 10 minutes.
Using an ambulance is also safer: The risk of shock is minimized by allowing
the patient to lie down, and an EMS crew can often extricate and transport
an injured person without adding to injuries.
Ambulance crews can begin treating patients during transport to hospitals:
In communication with hospital staff, they can start IVs and administer
drugs and other treatment. And because ambulance crews communicate with
hospital staff during transport, the emergency department can prepare to
treat the patient immediately upon arrival.
Perhaps the greatest virtue of calling an ambulance is that it relieves
the frequently panicky patientand those assisting the patientof virtually
all responsibilities. The ambulance crew decides on preliminary treatment,
drives the vehicle, chooses the hospital, calls ahead for instructions.
In life-threateningor potentially life-threateningcases, ambulances take
patients to the closest appropriate hospital, given each patients specific
In cases where injuries or illness are not immediately life-threatening,
most ambulances routinely transport patients to the closest hospital. That
practice might be one disadvantage of calling an ambulance: The patient
might not be able to choose the best available hospital. But in many areas,
ambulance squads will honor a patients request to go to a more distant
hospital if the additional travel time will not endanger the patientor
other patients by depleting the areas ambulance coverage.
On balance, we recommend calling an ambulance, even if doing so limits
your choice of hospital. You can be reasonably sure that the hospital emergency
department staff at the hospital chosen by the ambulance squad can provide
at least the relatively basic treatment needed immediately to stabilize
a life-threatening caseopening a blocked breathing passage, stopping massive
bleeding, restoring blood loss. When stabilized, the patient can be transferred
to a more sophisticated facility.
When you call the ambulance, be calm and clear with the person who answers
your call. State the address or location carefully, and ask the operator
to repeat itespecially if you are using a cell phone. Easily made errors
have produced some tragic outcomes.
After you have called an ambulance, administer what first aid you can to
the patient, follow any directions the 911 operator gives you, and call
the patients doctor, if he or she has one. Calling the doctor is important
because the doctor might come to the emergency department to work with
the staff (although very few do this anymore); the doctor might call and
instruct the emergency department staff to bring in a particular specialist
whom the doctor trusts; or the doctor might alert the emergency department
staff to important facts about the patients history.
The most difficult decisions involve cases in which you feel safe waiting
30 minutes or more to receive care, but still require treatment at a hospital,
rather than at an urgent care clinic or doctors office. In these cases,
you can generally do without an ambulance; a car or taxi will suffice.
But you may prefer an ambulance if
The patient and those assisting him or her are too upset to drive; using
an ambulance is comparatively easy.
Medical skill may be needed to move the patient (for example, if there
is a possible fracture).
On the other hand, there are good reasons not to use an ambulance
By providing your own transportation, you control the choice of hospital.
In an ambulance, even if the ambulance squad considers a patients preference,
hospital choices likely will be limited to the two or three closest hospitals.
You ensure that the emergency department will not turn you away. Concerns
about legal liability make it difficult for hospitals to turn individuals
away at the door. In contrast, ambulances are easily turned away. The emergency
department simply claims to be overcrowded and asks that ambulances be
put on reroute. Thus, in an ambulance you may be shunted to a more distant
hospital, which has a more responsible policy on keeping its emergency
department open but is equally overburdened.
Ambulances often charge fees. Even if you have insurance coverage, you
might have to pay all or a portion of the fee.
Assuming you do provide your own transportation, or your ambulance service
allows you to choose a hospital, you have the opportunityand the burdenof
making that choice. A good strategy is to have the patients doctor choose
for you. There is usually time to call the doctor, who probably has a general
sense of the medical capabilities of different emergency departments and
knows which are easiest to communicate with on follow-up.
A call to the patients doctor also makes sense for other reasons:
The doctor will be able to tell you whether to call an ambulance and what
first aid to administer.
The doctor may call the emergency department and smooth the way for your
arrival. This may eliminate a lot of red tape because tests can be ordered
right away, without having to wait to see an emergency department physician.
The doctor may also specify conditions under which a specialist should
be called inand perhaps who that specialist should be.
The patients doctor may be able to tell you not to bother with the emergency
departmentto wait for a regular office visit or to visit an urgent care
If you cant reach the patients doctor, or he or she doesnt have one,
or if you want to have a role along with the doctor in emergency department
selection, our Ratings Tables provides information that will help.
The right choice in an urgent but not life-threatening case depends mainly
on the complexity of the case. Let us (somewhat arbitrarily) divide cases
into three categories:
Simple cases. You know what is wrong and know that the treatment is simplefor
instance, a laceration that may require stitches (other than on the face).
Complex cases. You know what is wrong and know that treatment will require
considerable skillfor instance, severely crushed fingers or a badly lacerated
Cases in which you dont know. You arent sure what is wrong or how complex
the problem isfor instance, an unusual abdominal pain that has become
increasingly severe over a period of a few hours, or the patient experiencing
shortness of breath following several days with a cold.
The fact that a case is simple does not mean it cant be very uncomfortable.
And choosing the wrong hospital (or the right hospital on the wrong day)
can make the experience miserable. Your major considerations for these
cases are convenience and pleasantness.
Other patients are an excellent source of guidance when choosing an emergency
department for simple cases. Our Ratings Tables show how area consumers
(primarily CHECKBOOK and Consumer Reports subscribers) rated hospital emergency
departments they had used on the following criteria: overall quality of
care, speed of service, staff pleasantness, effort to relieve patients
discomfort and anxiety, listening to/communicating with patient, and
helpfulness in arranging follow-up care. Click here for more information on our customer survey and other research methods.
Our Ratings Tables also report results of a survey in which physicians
told us which hospital emergency departments they considered most desirable
and which they considered least desirable for emergency treatment of
minor injuries. The Ratings Tables show, among the physicians who
mentioned each hospital, what percentage considered it most desirable.
If your case is simple, you want to obtain treatment and go home as quickly
as possible. In addition to the ratings from patients on speed of service,
our Ratings Tables report data on hospital emergency departments from
the federal governments Hospital Compare website, which includes six
measures related to the speed of service:
Average number of minutes patients waited to be seen by a healthcare professional
Average number of minutes patients spent in ER before decision was made
to admit them
Average number of minutes patients waited to get to their rooms after decision
to admit was made
Average number of minutes it took ER to treat patients and send them home,
if not admitted
Average number of minutes patients with broken bones waited to receive
Percent of hospitals patients who left the ER without being seen
For simple cases, you can call various emergency departments to ask about
wait times before making a choice. Some hospitals now post average wait
times on their websites. Keep in mind the estimates provided on websites
usually take into account how long patients wait to see a doctor, physicians
assistant, or nurse who provides care, but usually dont indicate how long
it will take the hospital to treat you and get you out the door.
Your best choice of facility might be quite different in cases that require
An Overall Quality Indicator
Our Ratings Tables show results from our surveys of area physicians
who were asked which area hospitals they considered most desirable and
which they considered least desirable for emergency treatment of major
injuries. We believe this is a useful overall measure.
Although in complex cases youre likely to get most of your care from a
specialist who will be called in, the emergency department staff itself
is also important. The emergency department doctors who see you first will
be the ones who decide, or advise you, whether a specialist is needed.
Also, they can sometimes influence which specific specialist is called
in, and are likely to begin diagnostic procedures, preparation, and treatment.
In addition, they can do a lot to make you more comfortable while you wait
for a specialist.
One indicator of quality is always having on duty a physician who is board-certified
in emergency medicinesomeone who has completed training and passed exams
to become certified in the field. Treating a large volume of cases also
suggests that the hospital is serious about maintaining a major emergency
service capability. These data are reported on our Ratings Tables for
Another indicator of an emergency departments capabilities is the trauma
care designation it has achieved. California has adopted guidelines based
on recommendations of the American College of Surgeons (ACS) that designate
hospitals as Level I, II, III, or IV trauma centers. These designations
guide EMS crews in deciding to which hospital they should take a patient,
and determine how the hospitals will work together to manage trauma care.
Patients with complex or severe injuries either are taken by an EMS crew
directly to the hospital that has staffing and facilities appropriate for
the case, or are taken to a hospital that will stabilize the patient and
then transfer him or her to a facility with proper capabilities.
Level I trauma facilities can provide comprehensive care for any type of
injury. These facilities are expected to conduct trauma research and be
the trauma systems leaders in education, prevention, and outreach.
Like Level I trauma facilities, Level II facilities must also be able to
provide comprehensive care for any type of injury. But Level II facilities
are usually smaller than their Level I counterparts and arent required
to be research or teaching centers.
Facilities with Level III trauma designations have to be able to at least
treat initially any type of injury, but patients with severe traumas are
usually stabilized and then transferred to a Level I or Level II center.
Level IV trauma facilities are usually rural clinics that usually stabilize
severe traumas and then transfer these patients to a Level I or Level II
facility for further treatment.
Our Ratings Tables report the trauma designation, if any, each hospital
has achieved with the ACS.
How Often Hospitals Followed Best Treatment Guidelines for Stroke and Heart
On our Ratings Tables, we report the overall percentage of instances
in which the hospitals performed the proper tests or procedures for stroke
and heart attack cases. These scores are derived from data published on
the federal governments Hospital Compare website.
To collect these data, the federal government examined patient records
for each hospital and assessed how often hospitals performed recommended
tests or treatments known to produce the best results for patients with
certain medical conditions. This analysis examines, for example, how often
hospitals gave heart-attack patients aspirin upon arrival and how often
hospitals gave stroke patients medicine to break up blood clots within
Our Ratings Tables list aggregate scores calculated across all measures
for heart attack and stroke. (In other words, we added up all of the instances
where a given hospital performed the proper tests and/or treatments across
all reported measures, and then divided that total by the number of times
the hospital had an opportunity to perform the proper tests and/or treatments.)
One limitation in these data is that the recommended care may not always
be the best treatment for everyone. For example, someone who has recently
had a heart attack should be given aspirin as soon as possible upon arrival
at the hospitalbut not, of course, if that patient is allergic to aspirin.
Unfortunately, the federally reported data do not always take into account
patients who should not have received generally recommended care.
Quality of the Backup Services
Since theres a good chance in a complex case that youll need a range
of services from the hospital, and that youll be admitted to the hospital
as an inpatient, you want a hospital that has high-quality backup servicessuch
as laboratory and imaging servicesand that provides high-quality care
to its inpatients. Our ratings of more than 4,000 acute-care hospitals
in the U.S. for inpatient care includes a trove of data related to the
care patients receive during overnight stays. Our Ratings Tables for
area hospital emergency departments also reports some key measures of inpatient
care for each hospital:
Whether the hospital received our top rating for inpatient hospital care.
Hospitals that received our top rating scored high on an overall score
calculated across a range of measures.
Adjusted death rates. For relatively high-risk cases, these are the percentages
of each hospitals patients who died within 90 days of hospital admission.
The adjusted death rates are based on analysis of records of hospital stays
of Medicare patients admitted to hospitals during a three-year period (fiscal
years 201012) for medical cases and a four-year period (fiscal years 200912)
for surgical cases. These rates are adjustedto the extent possiblefor
differences in how sick and frail each hospitals patients were.
Patients overall ratings for inpatient care. These ratings come from federally
sponsored surveys, using a standardized questionnaire and survey procedure.
The survey asked a random sample of recently discharged patients about
important aspects of their hospital experience.
Doctors ratings for high-risk surgery. These are the percentages of physicians
who rated each hospital very good or excellent for surgery on adults
in cases where the risk of complications is high in our surveys of area
doctors. We also show the number of doctors who rated each hospital on
The Leapfrog Group , an
organization that tracks and encourages hospitals efforts to improve patient
safety, calculates its Hospital Safety Score for more than 2,500 hospitals
in the U.S.; scores shown on our Ratings Table were reported by Leapfrog
in August 2015. The Leapfrog Hospital Safety Score program grades hospitals
on their overall performance in keeping patients safe from preventable
harm and medical errors. For more information, visit www.hospitalsafetyscore.org
Selecting the right emergency department is most important when you dont
know what is wrong or what treatment will be requiredfor instance, in
a case of severe abdominal pain. Such pain might result from any of many
causesincluding an aneurysm, which is immediately life-threatening and
requires sophisticated treatment; appendicitis, for which the treatment
is much less complex; or gastroenteritis, which can often be treated with
In such undiagnosed cases, the relevant indicators of quality are the same
as in complex cases where you do know whats wrong. But in undiagnosed
cases, the emphasis is different: Youll want to put somewhat more weight
on the expertise of the frontline emergency department staff as opposed
to the hospitals inpatient backup capabilities.
Using an emergency department with a strong staff of its own is important
because its emergency department physicians will be able to make many diagnoses
and provide successful treatment on their own. A good emergency department
physician might, for instance, spot an unusual strain of pneumonia that
a less capable physician (or resident) might never recognize and never
bring to the attention of specialists.
In undiagnosed cases, the availability of in-house physicians is also relatively
important. In-house physicians are likely to be consulted in diagnosing
your case. While an emergency department physician might be quite reluctant
to ask an on-call physician to come to the hospital just to consult on
a diagnosis, asking an in-house specialist to come to the emergency department
On the other hand, relying on in-house specialists has some disadvantages.
Since they are usually residents still in training, they have less diagnostic
experience than top-quality on-call attending physicians might have. They
also have less treatment experience. Yet there is a chance one will end
up operating on you or providing whatever other treatment you require.
You can offset this disadvantage by insisting that an attending physician
be called in if you are not entirely satisfied with the soundness of a
residents diagnosis, or if you require anything other than the most straightforward
In general, we have found that the top-scoring emergency departments for
complex cases also tend to get top scores for dealing with cases in which
patients dont know what is wrong.
Many cases are not urgent, of course. These cases could await a visit to
an urgent care clinic or a family doctor during regular hours. They include
small lacerations, sore backs, mild sore throats, painful bruises, and
chronic complaints. They constitute a large portion of all cases handled
at many hospital emergency departments.
If you feel confident your case is not urgent, avoid an emergency department.
Use a family doctor; if you dont have a family doctor, take this opportunity
to try one out. Click here for patient ratings of area primary care doctors.
The main reason to use a family doctor rather than an emergency department,
or even an urgent care clinic, is that the family doctor will provide better
continuity of care. Doctors often say about 80 percent of diagnosis is
in the patients history, but the emergency department wont know you and
your medical history as well as your doctor does. An emergency department
might, for instance, diagnose acute appendicitis when your doctor would
tie stomach pains to a previously diagnosed disorder. Also, since emergency
departments ordinarily dont schedule follow-up visits, when you visit
your own doctor for follow-up he or she will not have first-hand knowledge
of what symptoms you had at the time of the emergency visit, what treatment
was given, or what assumptions were made about aftercare.
Another reason to consult a family doctor in non-urgent cases is cost.
Emergency departments must maintain staff even at hours when there are
no patientssimply to be prepared. Patients pay for that staff. Similarly,
emergency services must maintain sophisticated equipmentfor instance,
to resuscitate heart attack victims. Patients help pay for that. It all
adds up to much higher fees at emergency departmentssometimes five times
higherthan at doctors offices.
Not only is the base price more, but an emergency department will also
impose additional special charges. It will perform lab tests and X-rays
because it must find out in one visit everything a family doctor knows
from past visits or could expect to find out on a future visit. All these
tests are important to the diagnosis and protect the emergency department
doctor against malpractice suits.
And extra costs dont end at the time of the emergency visit. When you
go to your doctor for a follow-up visit after being treated in the emergency
department, the doctor will have to remove dressings, duplicate tests,
and waste time on the phone getting reports on the emergency departments
studies. This is expensive.
Of course, this higher cost factor makes no difference to you if your insurance
policy pays for ER visits. But deductibles and other obstacles force many
patients to bear the full cost of either an emergency department or doctors
office visit, and you may feel a social responsibility to keep medical
costs downeven if the charges dont come out of your own pocket.
Ask your doctor to call the hospital.
Make sure to mention your doctors name if the doctor practices at the
Before treatment begins, explain that you want all records sent to your
If you dont have a doctor to call for you, if possible call ahead yourself
to inform the staff you are coming and what your problem is; this will
help them prepare the equipment and assemble needed staff. If the case
is not life-threatening, ask if the facility is unusually crowded. If it
is, go somewhere else.
Ask whether the physician treating you is a resident. If so, and if you
have any doubts about the diagnosis or treatment plan, ask to discuss your
case with the attending physician along with the resident.
Show evidence of ability to pay. An insurance card is ideal, but dont
worry if you have no insurance: Any hospital will treat an emergency first
and worry about payment later.
Be polite; it relieves staff tension and helps you communicate your medical
If you did not call your doctor before visiting the emergency department,
make sure your doctor is informed as soon as possible about your emergency
Check with your health insurance plan as soon as possible to determine
all requirements for plan notifications and pre-approvals.