Family, friends, and I have been patients in emergency rooms (ER’s) many times. I work in Quality and Patient Safety in a large hospital, and my office overlooks the ER parking lot. My recent experience in a French ER for a dislocated finger has allowed me to reflect on how all ER’s can treat patients better – and the patients’ responsibilities to optimize their treatment. Granted, France has single-payer and the US has a mixture of government insurance/private insurance/self-pay, but these issues cut across cultures and payment modalities.

• An ER is an ER, regardless of location. Folks are in bad shape. There may be hysterical family members, biohazards, and the occasional police officer. There is bureaucracy to deal with, including the “billfold biopsy” for proof of insurance. People who’ve had heart attacks, gunshot wounds, or strokes get first priority for care (as they should); the rest wait for a break in the action to be seen. It could take hours. The waiting room has all the charm of a Department of Motor Vehicles office–with less comfortable chairs.
• Language barriers are frustrating for both provider and patient. Even with a translator present, the nurse or doctor taking the history may not get the full picture. Culture may also play a role in the loss in translation. Patients may not get a description of their condition or how to take care of themselves after discharge. I can speak/understand French, but I did not get more than a prescription and an order for a follow-up X-ray in five days. I heard no mention of how long I need to keep my finger taped up until I called a physician friend in Seattle.
• Hand hygiene (and hygiene on the whole) may be spotty. In my experience, the nurses are most likely to wash/gel in and out of a room, interns and residents less so, and senior physicians are least likely. In the French ER waiting room, a child spilled some soda on the floor. This could have been a hazardous situation for anyone. If hospital staff saw the spill, they didn’t seem to be concerned about it. Fortunately, my partner got some paper towels from the restroom and cleaned up the mess himself.
• Identifying who’s who can be difficult. In the French hospital, I had to squint at the nametag stickers to see who was a nurse or intern. The senior ER physician wore no identification, just a SAMU (Service d’Aide Médicale Urgente, which is easily translated once you know the acronym) T-shirt and cargo pants. Nobody wore ID badges, as is common in US hospitals. And nobody entered my exam room and identified him/herself.

What can be done to improve the patient experience in ER’s and allow staff to give the best possible care?

• These units should only be used for emergencies. For the flu or simple urinary tract infection (UTI), a free-standing urgent care clinic in the US will treat minor conditions without a long wait – and at lower cost. When I had an adverse reaction to the high doses of ibuprofen and naproxen I was taking for the finger, I went to a pharmacy in Aix-en-Provence and asked the pharmacist what to take. (Note: Most French pharmacies, like Costco’s in the US, are closed on Sundays.)
• Cleanliness is essential to prevent the spread of hospital-acquired infections. The Centers for Medicare and Medicaid Services penalize hospitals that have high levels of hospital acquired pneumonia and catheter-related bloodstream or UTI’s. Gelling or washing one’s hands when entering and exiting a room is just the beginning. Computer keyboards are notorious pathogen-catchers. Providers should gel after typing in the patient’s history and before examining him or her.
• As a provider gels in when entering an exam room for the first time, he/she should identify him/herself to the patient. The provider should double-check the patient’s identity, utilizing date of birth.
• If a translator is needed, one should be provided. Family members often get pressed into this service, which can be awkward – especially if the family member is a minor and the ER visit is for a touchy reason. Most hospitals in the US have onsite or video translation services.
• Patients need to tell the nurse and physician everything they take: Prescription and over-the-counter medications, recreational drugs, dietary supplements, alcohol, and tobacco. They should also fess up about any sensitive topics, such as travel to areas with current infectious disease outbreaks (e.g., Zika).
• No patient should go home from the ER (or hospital) without a complete explanation of the condition and treatment. Referrals should be made for follow-up visits before the patient leaves, especially for conditions such as diabetes and heart failure. Providers should not rely on the honor system or a patient’s iffy memory to assure continuity of care.

Regardless of location, the ER is a place best avoided unless there is a real health issue. It can be difficult to achieve optimal care and outcomes in this environment without effort by both patients and providers.