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Hospital Emergency Departments (From CHECKBOOK, Fall 2012/Winter 2013)
 
Go to Ratings of 67 Bay Area Hospital Emergency Departments
Whom to Call, Where to Go 

If You Believe the Case May Be an Immediate Threat to Life or Future Ability to Function (Must Be Treated Within 30 Minutes or Less), IMMEDIATELY CALL 911. Give Dispatcher the Facts: 

  • Address, including nearby cross streets 
  • How many patients are involved (so more than one ambulance will be sent, if necessary) 
  • The age and gender of the patient 
  • Your phone number (so the dispatcher can call back if more information is needed) 
  • Briefly what happened and what is wrong—a car accident, a fall, is the patient breathing, bleeding, unconscious (so appropriate personnel and equipment are dispatched and they know what to expect) 
  • Whether the patient is indoors or outdoors 
  • Call the patient’s doctor 

Symptoms Requiring Immediate Emergency Department Attention: 

  • Spurting blood, massive bleeding 
  • Vomiting blood (often a black coffee-ground-like substance), passing black stool, coughing blood 
  • Breathing stopped 
  • Breathing difficult 
  • 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 
  • Paralysis 
  • Unequal-size pupils 
  • Obvious alteration in consciousness as result of head injury or without attributable cause 
  • Insect stings if patient is known to have allergic reaction 
  • Seizure or convulsions 
  • Severe pains in chest, upper abdomen, or down arm, and shortness of breath 
  • Suspected poisoning or overdose 
  • Sudden, severe abdominal pain not attributed to indigestion 
  • Suicidal thoughts or any violent behavior 
  • Patient simply appears very sick 

If You Believe the Case Is “Urgent” (Can Wait 30 Minutes or More, but Not Until Regular Doctor’s Hours), Call Patient’s Doctor for Advice or Do the Following:

If you know needed treatment is complex, or if you don’t know what is wrong, GO TO: 

  • Alta Bates Summit Medical Center–Alta Bates Campus 
  • Alta Bates Summit Medical Center–Summit Campus 
  • California Pacific Medical Center–Pacific Campus 
  • Children’s Hospital & Research Center Oakland 
  • Eden Medical Center 
  • John Muir Medical Center–Concord Campus 
  • John Muir Medical Center–Walnut Creek Campus 
  • Kaiser Permanente San Francisco Medical Center 
  • Kaiser Permanente Santa Clara Medical Center 
  • Mills-Peninsula Medical Center 
  • Queen of the Valley Medical Center 
  • San Francisco General Hospital & Trauma Center 
  • Santa Clara Valley Medical Center 
  • Santa Rosa Memorial Hospital 
  • Sequoia Hospital 
  • Stanford University Medical Center 
  • UCSF Medical Center at Parnassus 

If you know needed treatment is simple, GO TO: 

  • Alta Bates Summit Medical Center–Summit Campus 
  • California Pacific Medical Center–Pacific Campus 
  • Children’s Hospital & Research Center Oakland 
  • El Camino Hospital 
  • John Muir Medical Center–Concord Campus 
  • John Muir Medical Center–Walnut Creek Campus 
  • Kaiser Permanente Antioch Medical Center 
  • Kaiser Permanente Redwood City Medical Center 
  • Kaiser Permanente San Francisco Medical Center 
  • Kaiser Permanente San Jose Medical Center 
  • Kaiser Permanente Santa Clara Medical Center 
  • Kaiser Permanente Santa Rosa Medical Center 
  • Kaiser Permanente Walnut Creek Medical Center 
  • Mills-Peninsula Medical Center 
  • Novato Community Hospital 
  • Queen of the Valley Medical Center 
  • Sequoia Hospital 

If the Case Is Not Urgent (Can Wait Until Regular Doctor’s Hours) 

Go to a regular doctor or urgent care clinic. Don’t use a hospital emergency department. 

Bad stuff happens. Kids get injured. Friends and coworkers suddenly get sick. Perfectly healthy people—for no apparent reason—pass out. 

At some point chances are you’ll be forced to make medical judgments for others during a medical emergency. When this happens, you’ll need to know whom to call, what to say, and where the patient should go. 

Above we’ve summarized the decisions you’ll have to make and the steps to take. In the following article, we give you the reasons behind this advice. In making the necessary decisions, you can’t avoid making medical judgments. You must decide how urgently care is needed and how complex or sophisticated that care should be. 

If There Is Immediate Danger to Life or Ability to Function 

When first confronted with an illness or injury, you must quickly decide whether the case is life threatening—whether there’s a risk of death or permanent disability if the patient does not receive immediate care (within 30 minutes or less). 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 is this: 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 the treatment of heart attack and serious injury cases, even a few minutes can dramatically improve survival rates. 

If a case may be life threatening, call 911. 

That’s the best way to get treatment started fast. In most parts of the area, the average time between a call for an ambulance and the ambulance’s arrival on the scene is less than 10 minutes. In a life-threatening emergency, using an ambulance is almost certain to be better than using a car. 

First of all, it may take longer to get the patient into a car than to wait for an ambulance. It takes time for someone who is upset to find the car keys, bring the car to a convenient loading place, and get a sick or injured person inside. An ambulance crew with a gurney is often much faster. Second, using an ambulance is 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. Third, 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. Finally, because ambulance crews communicate with hospital staff during transport, if necessary the emergency department can be prepared to treat the patient immediately upon arrival. 

Perhaps the greatest virtue of calling an ambulance is that it relieves the frequently panicky patient and those assisting the patient of virtually all responsibilities. The ambulance crew decides on preliminary treatment, does the driving, chooses the hospital, calls ahead. 

In life-threatening—or potentially life-threatening—cases, ambulance squads will take patients to the closest appropriate hospital, given each patient’s specific condition. 

In cases where injuries or illness are not immediately life threatening, most ambulance squads routinely transport patients to the closest hospital. That practice might contribute to a disadvantage of calling an ambulance: you might not be given the choice of going to the best available hospital. But in many areas, ambulance squads will honor a patient’s request to go to a more distant hospital if the additional travel time will not add risk for the patient or add risk for other potential patients by depleting the area’s ambulance coverage. 

On balance, we strongly recommend an ambulance, even if doing so will limit your choice of hospital. You can be reasonably sure that the hospital emergency department staff at the hospital the ambulance squad chooses will be able to give at least the relatively elementary treatment needed immediately to stabilize a life-threatening case—opening 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, try to be calm and clear with the person who receives your call. Give the address or location carefully and ask to have it repeated back, especially if you are using a cell phone. Easily made errors have been responsible for some tragic outcomes. If your address is not easy to find, it’s a good idea to post next to your phones a set of written directions for getting to your home from one or more well-known intersections. That will make it faster for you to communicate in a time of stress and will be especially important if a visitor who is not familiar with the area has to call for an ambulance. 

After you have called an ambulance, you have only to give what first aid you can to the patient, follow any directions the 911 operator gives you, and call the patient’s doctor, if there is 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 whose ability the doctor knows; or the doctor might alert the emergency department staff to important facts about the patient’s history. 

If the Case Is Urgent But Not Life-Threatening 

The most difficult decisions come in cases that are “urgent” but not immediately threatening to life or the patient’s future ability to function. This might include a laceration that appears to need stitches or a high fever. These are cases in which you feel the patient can’t wait to see a doctor during regular office hours but in which you feel safe in waiting 30 minutes or more to reach the hospital. 

In these “urgent” 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 the patient are too upset to drive; using an ambulance is comparatively easy. 
  • Medical skill may be required to move the patient, although this problem is infrequent in “urgent” cases except where 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 and avoid giving the ambulance squad the option of simply choosing the closest one capable of handling the case. In an ambulance, even if the ambulance squad will consider a patient’s preference, the choice is likely to be limited to the two or three closest hospitals. 
  • By providing transportation yourself, you assure 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.” Ambulances respect this closing down and go to the nearest open emergency department, although the closed hospitals might be closed simply because they don’t want to deal with excessive crowds or don’t want any more low-income, nonpaying patients who might have to be admitted for inpatient care. 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 a fee. 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 that your ambulance service allows you a choice of hospital, you have the opportunity—and the burden—of making that choice. A good way to choose is to have the patient’s doctor do it for you. In an urgent case, there is usually time to call the doctor before deciding where to go. The doctor will probably have a general sense of the medical capabilities of different emergency departments and will know which he or she finds easiest to communicate with on follow-up. The doctor might also have a feel for which are usually most pleasant and least crowded—although we have found that doctors’ opinions on those aspects of emergency department service don’t correlate very well with patients’ reported experiences. 

A call to the patient’s doctor makes sense for other reasons also— 

  • The doctor will be able to tell you whether to call an ambulance and what first aid to give. 
  • The doctor may call the emergency department and smooth the way for your arrival. This may cut 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 under what conditions a specialist should be called in—and perhaps who that specialist should be. 
  • The patient’s doctor may be able to tell you not to bother with the emergency department—just to wait for a regular office visit. 

If you can’t reach the patient’s doctor or the patient doesn’t have one, or if you want to have a role along with the doctor in emergency department selection, our Ratings Tables give information that should be helpful. 

The right choice in an urgent but not life-threatening case depends mainly on how complex the case is. Let us, somewhat arbitrarily, divide cases into three categories: 

  • Simple cases—where you know what is wrong and know that the treatment is simple—for instance, a small laceration that may require stitches (other than on the face). 
  • Complex cases—where you know what is wrong and know that treatment will require considerable skill—for instance, severely crushed fingers or a badly lacerated face. 
  • Cases where you don’t know—where you aren’t sure what is wrong or how complex the problem is—for instance, an unusual abdominal pain that has become increasingly severe over a period of a few hours or shortness of breath following several days of having a cold. 

Simple Cases 

Your major considerations in a simple case can be convenience and pleasantness. 

The fact that a case is simple does not mean, of course, that it is not very uncomfortable. And choosing the wrong hospital (or even the right hospital on the wrong day) can make the experience miserable. 

Other patients are an excellent source of guidance when choosing an emergency department for a simple case. Our Ratings Tables show what we found when we asked area consumers (primarily CHECKBOOK and Consumer Reports subscribers) to rate hospital emergency departments they had used “good,” “very good,” or “excellent” (as opposed to “fair” or “poor”) on the following criteria: “overall quality of care,” “speed of service,” “staff pleasantness,” “effort to relieve patient’s discomfort and anxiety,” “listening to/communicating with patient,” and “helpfulness in arranging follow-up care.” (For more information on our customer survey and other research methods, click here.) 

As a way to give you a little more information on good hospital choices for simple cases, our Ratings Tables also report results of a survey of physicians we conducted in 2010, in which we asked the physicians to tell 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.” 

While patient and doctor ratings of facilities are important, you also will want to consider other factors. For example, everything else being equal, you are probably better off even for a simple case to use a facility that sees a substantial number of emergency cases each year and that has a nurse in the operating room 24 hours per day. Our Ratings Tables give you information on these and other matters for each listed emergency facility. 

If your case is simple, you also want to get treatment and get home as fast as possible. Many hospitals now post average emergency department wait times on their websites. These estimates are usually the amount of time it takes to see the doctor, physician’s assistant, or nurse who provides care, and don’t tell you how long it will take the hospital to treat you and get you out the door. But, since some information is better than none, it’s probably worth a check on wait times before you set out. 

Complex Cases 

Your best choice of facility might be quite different in cases in which you know you need complex treatment. 

An Overall Quality Indicator 

The Ratings Tables show results from our 2010 survey of physicians. We asked the physicians 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. 

Front-Line Capabilities 

Although you’re likely to get most of your care in a complex case 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 they are likely the ones who will begin diagnostic procedures, preparation, and treatment. In addition, they can do a lot to make you more comfortable if you need to wait for a specialist. 

One indicator of quality is having on duty 24 hours per day a physician who is board-certified in the specialty of emergency medicine—someone who has completed training and passed exams to become certified in the field. A large volume of cases and the presence of a nurse in the hospital’s operating room 24 hours per day also suggest that the hospital is serious about maintaining a major emergency service capability. 

Another indicator of an emergency department’s capabilities is the trauma care designation it has achieved. In most states, emergency departments work together as members of a regional system that has adopted guidelines that determine how trauma care is managed. 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. 

In California, the state 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 help guide EMS crews in deciding to which hospital they should take a patient, and determine how the hospitals will work together. 

Level I trauma facilities can provide comprehensive care for any type of injury. Each year, these facilities must treat at least 1,200 patients with traumas, and at least 20 percent of these traumas must be severe trauma cases. Level I trauma facilities must have available at all times in-house attending surgeons on duty. Level I facilities are expected to conduct trauma research and be the trauma system’s 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. Level II facilities are usually smaller than their Level I counterparts, and Level II facilities aren’t required to be research or teaching centers. Attending surgeons don’t have to be available in-house at all times, but must be able to be called in on short notice. 

Facilities with Level III trauma designations have to be able at least to 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 III trauma facilities must have general surgeons available on short notice, either in-house or on-call. 

Level IV trauma facilities are usually rural clinics, and usually stabilize severe traumas and then transfer these patients to a Level I or Level II facility for further treatment. Level IV facilities must be staffed by at least one physician at all times. 

The Ratings Tables report the trauma designation, if any, each hospital has achieved with the state. Note that many area hospitals have not yet received a trauma center designation by the state, but still participate in their county’s trauma system. 

Quality of the Doctors 

Emergency department physicians almost always call in specialists in complex cases. What you want is the emergency department most likely to call in a high-quality specialist. If the patient’s face is badly lacerated, you want a top-flight plastic surgeon. If the patient’s fingers are crushed, you want an orthopedic or plastic surgeon with special skill in the treatment of hands. 

We could not evaluate the skills of the specialists on each hospital’s roster of on-call and in-house physicians. But a clue to the quality of physician you’ll get is whether a hospital is a teaching hospital. Our Ratings Tables show which hospitals have residency programs—post-medical school training programs in which doctors spend from two to seven years getting practical, clinical experience in a specialty. The residents get their training from other doctors in the hospital. 

The advantage of going to a hospital that has a range of residency training programs is that physicians who have chosen to associate themselves with these facilities are likely to be above average in knowledge and skill. Their commitment to teach residents suggests that they are making an effort to keep up-to-date on developments in their fields. 

The disadvantage of these hospitals is that an inexperienced resident might treat you. In their favor, residents’ training is fresh and residents know that any treatment given will later be reviewed and have to be defended before the teaching program’s faculty. However, a resident is not yet fully trained and does not have the years of practical experience an on-call physician might bring. 

In short, a hospital with a teaching program in the specialty area you require is a good bet except for the risk that you will be treated by a relatively inexperienced resident. 

Quality of the Backup Services 

Since there’s a good chance in a complex case that you’ll need a range of services from the hospital and that you’ll be admitted to the hospital as an inpatient, you want a hospital that has high-quality backup services—such as laboratory, x-ray, and pathology services—and that provides good-quality care to its inpatients. In our ratings of hospitals for inpatient care in our Guide to Hospitals section, we report a trove of data related to the care patients receive during overnight stays. For this article, we also report for each hospital some key measures on inpatient care: 

  • Whether the hospital receives our top rating for inpatient hospital care. Hospitals that receive our top rating rate high on an overall score we calculated across a range of measures. 
  • Doctors’ ratings for inpatient care. These are the percentages of physicians who rated each hospital “very good” or “excellent” for “surgery on an adult 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 this question. 
  • Adjusted death rates. For relatively high-risk cases, these are the percentages of each hospital’s patients, for a two-year period, who died within 30 days of the time they were admitted to the hospital. These rates are adjusted—to the extent we were able—for differences in how sick and frail each hospital’s patients were. Rates were calculated by analyzing selected, relatively high-risk cases in three categories: medical cases, surgical cases, and a combination of medical and surgical cases. 
  • How often the hospital followed “best treatment” guidelines. For specific types of cases (heart attack, heart failure, pneumonia, and surgical infection prevention), this shows the percentage of these cases in which the hospital gave the test or treatment that would be called for by evidence-based guidelines—for example, gave heart-attack patients aspirin upon arrival or gave proper antibiotics to prevent surgical infections. We report a percentage for all these case types combined. The scores shown are based on data from the U.S. Department of Health and Human Services (HHS) and are the aggregate percentages calculated across all cases of the case types included. 

Comforts 

Though medical quality is the key consideration in complex cases, the patient’s comfort is important, too. The customer survey results on the Ratings Tables, which are our main guideposts in choosing a hospital for a simple case, are relevant here as well. Also relevant are how patients rated the hospitals overall for inpatient care. The Ratings Tables show results from federally-sponsored surveys of patients who had recent hospital stays. We show the percentage of patients who gave the hospital an overall rating of 9 or 10 on a 0-to-10 scale. 

When You Don’t Know What’s Wrong or How Complex It Is 

Selecting the right emergency department is most important when you don’t know what is wrong or what treatment will be required—for instance, in a case of severe abdominal pain. Such pain might result from any of many causes, including an aneurysm, which would require rather sophisticated treatment; appendicitis, for which the treatment is much less complex; or gastroenteritis, which can often be treated with medication. 

In such undiagnosed cases, the relevant indicators of quality are the same as in complex cases where you do know what’s wrong. But in undiagnosed cases, the emphasis is different: you’ll want to put somewhat more weight on the expertise of the front-line emergency department staff as opposed to on-call staff and hospital inpatient backup capabilities. 

Using an emergency department with a strong staff of its own is important because the 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 might never think to 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 is easy. 

On the other hand, there are disadvantages connected with this reliance on in-house specialists. Since they are usually residents still in training, they have less diagnostic experience than a top-quality on-call attending physician 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. But 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 resident’s diagnosis or if you require anything other than the most straightforward treatment. 

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 you don’t know what is wrong. 

Cases that Are Not Urgent 

Many cases are not even urgent, of course. These cases could await a visit to a clinic or a family doctor during regular hours. They include 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 don’t have a family doctor, take this opportunity to try one out. 

The main reason to use a family doctor rather than an emergency department or even an urgent care clinic is that you will get better “continuity of care.” Doctors often say about 80 percent of diagnosis is in the patient’s history, but the emergency department won’t 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 don’t 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 prefer a family doctor in non-urgent cases is cost. The emergency department must maintain staff even at hours when there are no patients—simply to be prepared. You pay for that staff. Similarly, the emergency service must have sophisticated equipment—for instance, to resuscitate heart attack victims. You help pay for that. It all adds up to much higher fees at emergency departments—sometimes five times higher—than at doctors’ offices. 

Not only is the base price more, but also the emergency department will have additional special charges. It will give lab tests and x-rays simply because it must find out in one visit everything a family doctor knows from past visits or can expect to find out on a future visit. All these tests are important to the diagnosis and are security for the emergency department doctor against malpractice suits. 

And the extra cost doesn’t 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 department’s studies. This is expensive. 

Of course, this higher cost factor may make no difference to you if your insurance policy pays for a visit to a hospital emergency department—especially if it pays less for a doctor’s office visit. But deductibles and other obstacles cause many people to bear the full cost of either an emergency department or a doctor’s office visit, and you may have a sense of social responsibility to keep medical costs down—even if the charges aren’t paid from your own pocket. 

How to Deal with an Emergency Department 

  • Ask your doctor to call the hospital before you arrive. At least be sure to mention your doctor’s name if the doctor practices at the hospital. 
  • Before treatment begins, explain that you want all records saved for your doctor. 
  • If you don’t have a doctor to call for you, 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, you can ask if the facility is unusually crowded. If it is, you might go somewhere else instead. 
  • If you go to a hospital that our Ratings Tables show has some residency programs, 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 talk over your case with the attending physician along with the resident. 
  • Show evidence of ability to pay; an insurance card is ideal. But if you have no insurance, don’t worry; you can expect any hospital to treat an emergency first and worry about payment later. 
  • Be polite; it helps relieve the staff’s tension and helps you communicate your medical needs. 
  • If you did not call your doctor before going to the emergency department, be sure your doctor is informed as soon as possible about your emergency department visit. 
  • Check with your health insurance plan as soon as possible to find out about all requirements for plan notifications and for pre-approvals. 


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