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Last year, about one in six Centennial Staters visited an emergency department, despite the fact that more than a third of respondents to a 2019 Colorado Health Institute survey believed the maladies that landed them there could have been treated by a nonemergency doctor. Why is the ED so confusing? We asked local physicians for insight into that question—as well as 10 other queries that routinely pop up when crises arise.
Is This Really an Emergency?
Dr. Eric Hill, the emergency medical services director at the Medical Center of Aurora, outlines a few of the acute complaints that could lead to a visit to an emergency department (most places don’t call themselves “emergency rooms” anymore).
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Shortness of Breath
“This is a potentially life-threatening issue,” says Hill, who recommends defaulting to an ED. His caveat: If the symptoms are consistent with something you’ve experienced before, like asthma, and can reasonably be treated with medication or at an urgent care clinic, you don’t have to hightail it to the hospital.
Numbness
Is the numbness in one side or both sides of the body? “With strokes, we’re most worried when you have unilateral symptoms [affecting one side of the body],” Hill says. Weakness, trouble walking, or speech disturbance can also be signs of a stroke. In that case, call 911 immediately. “There is a time window where we have the ability to do thrombolytic medication to dissolve the clots,” Hill says. Another tool for recognizing (and acting on) stroke symptoms: F.A.S.T. (facial drooping, arm weakness, speech disturbance, time to call 911).
Laceration
“If [the cut] is spurting or a brisk bleed, that’s probably arterial, and that needs to be seen by, preferably, an ED,” Hill says. But if it’s controlled yet continues to ooze after you apply pressure, an urgent care center can probably fix you up. For deep, gaping, or complex facial wounds, a hospital ED is likely the best choice because they have specialists on-site who can minimize scarring when they do the repair.
Where Should I Go?
To help consumers make informed decisions about their care, the Colorado Hospital Association and its member hospitals and medical systems created the Where for Care campaign. The following chart is a condensed version of the initiative’s educational core. (When in doubt, though, doctors say go to the ED.)
Primary Care
Visit for these complaints: Preventive/wellness exam; cold or sinus infection; UTI; immunization; managing chronic conditions
Who provides care: Family or personal doctors, physician assistants, or nurse practitioners
Hours of operation: Business hours, by appointment
Cost: $
Urgent Care
Visit for these complaints: Severe cold, cough, or sore throat; bronchitis; ear infection; limb pain; mild vomiting or diarrhea; minor cut requiring minimal stitches; broken toe or finger; sprain; UTI
Who provides care: Doctors, nurses, physician assistants, or nurse practitioners
Hours of operation: Extended hours for walk-ins; may be closed late nights, early mornings, or weekends
Cost: $$
Emergency Care
Visit for these complaints: Chest pain, trouble breathing, or shortness of breath; a large open wound; a major broken bone (e.g., leg); a major burn; poisoning; severe head or spinal injury; sudden loss of consciousness or vision; dizziness; sudden, severe headache; uncontrollable bleeding
Who provides care: Physicians and nurses trained in emergent medical care, trauma, and life-threatening situations
Hours of operation: All day, every day
Cost: $$$
525
Beds in the ED at Denver Health
First Person: The Patient
Time Matters
About a year and a half ago, I couldn’t make my hand type the simple word “t-o-o.” I tried a few times. Frozen on my right side, I made myself fall backward on the couch and thought, I have one shot. I put my fingers to my mouth and whistled. My husband came running. I said, “I’m having a stroke.”
I could see the wheels turning while he was thinking about calling an ambulance. Instead, he drove me five minutes to Swedish Southwest ER [a freestanding ED in Littleton]. By the time we got there, I couldn’t talk or move much. An intravenous procedure to clear the clot didn’t work, and they loaded me onto a helicopter to Swedish Medical Center.
I was off the helicopter, into the surgery room, and having further brain treatment within eight minutes. The entire time from my symptoms to getting to the remote ED to getting to Swedish was maybe an hour and 20 minutes. If my husband had come down an hour later and thought I was napping, I would have been dead. That made all the difference. Now, I’m 96 percent back to normal. If it’s your heart, you’d want to call the ambulance, because they can start treatment on the way. But my husband knew he could get me to the ED quicker by driving, and when it comes to a stroke, time is brain. —Patrice Thomas, 68, Littleton
Are EDs Only for Bodily Injury?
What constitutes a behavioral health emergency—and what to do about it.
Internal scars can affect emotional and mental well-being and, sometimes, manifest as mental health crises—conditions that may be less visually apparent than a broken arm or respiratory infection but are sometimes just as emergent. Here, Heidi Bode, the manager of crisis assessment at Porter Adventist Hospital in Denver, outlines how to identify those who might be experiencing a behavioral health emergency as well as how to help them.
People Who May Be Having A Mental Health Crisis:
Those with chronic mental illnesses who are having a psychotic episode. “Sometimes,” Bode says, “with that psychosis, there can be hallucination…compelling [people] to do something that could be a danger to themselves or the general population.”
Those who have thoughts or compulsions to hurt or kill themselves. Self-harm has been particularly prevalent in recent years among Colorado’s youth and young adults: In 2021, mental health crisis was the top complaint at the Children’s Hospital Colorado ED.
Those with substance abuse disorders. Frequently, says Bode, these folks tend to have concurrent mental health diagnoses and instead of medicating will lean on alcohol or drugs to bury certain feelings in the moment.
How To Help
Contact Colorado Crisis Services (CCS). The statewide response system is a great starting point to determine next steps; Bode encourages everyone to program its contact info (text “TALK” to 38255 or call 1-844-493-8255) into their phones.
Go to a CCS Walk-In Center. Like urgent cares for mental health, CCS’ nine regional Walk-In Centers (five of which are in metro Denver) are staffed by licensed mental health professionals who will see you on the spot. Click “search locations” on CCS’ website to find the one closest to you.
Call 988. In 2020, the Federal Communications Commission designated 988 as the new national line (akin to 911) for mental health emergencies. It will route you to appropriate location-specific resources, such as CCS.
Visit cdphe.colorado.gov/suicide-prevention for a comprehensive list of resources to address youth mental health emergencies and suicidal ideation.
How Should I Behave?
Do’s and don’ts for your time at the ED.
Do: Have some grace. “Almost all emergency departments in town are experiencing some level of staffing stress,” says Dr. Kelli Lewis, medical director at Intermountain Healthcare Saint Joseph Hospital Northglenn Emergency Department. In fact, a 2021 study projects Colorado to have a deficit of more than 10,000 registered nurses and 54,000 lower-wage health care workers (such as medical and nursing assistants) by 2026. “Currently, wait times are longer than any of us want them to be,” Lewis says, “but it’s not that we’re back there having pizza.”
Don’t: Record and post your experience. “Most hospitals have policies against social media,” Lewis says, because “it makes staff super uncomfortable.” Adds Matt Mendenhall, chief medical officer of Centura’s Littleton Adventist Hospital: “It’s a highly litigious world we work in. You’re going to raise anxiety and stress levels of your doctors, nurses, and teams.”
Do: “Be exceptionally truthful with your physician,” Lewis says. If you omit a certain drug you are taking to combat hair loss, for example, your doctor might prescribe a medication that interacts poorly with it, wreaking even more havoc on your bodily functions. “Plus, a lot of hospitals are on the same chart system,” Lewis says. “So, chances are we’ll find it in your chart even if you don’t tell us.”
Don’t: Bring a fan club. Well-intentioned family can be distracting—dare we say, overbearing?—and add to the stress. “Try to pare it down to one loved one versus two or three,” says Adia Bess, a registered nurse and director of emergency services at North Suburban Medical Center. “Do your best to keep kids at home, though we understand that not everyone can do this.”
Do: “Thank the team that’s taking care of you,” Mendenhall says. “There is a very good chance they’ve not stopped to eat, drink, or use the bathroom in hours.”
Don’t: Eat in the waiting room or wear strong scents or perfumes. “Typically, patients who come in are not feeling well,” Bess says. “People may have headaches, feel dizzy, have GI issues, or might be vomiting.” The last thing they need is a whiff of your Drakkar Noir.
First Person: The Doctor
All Wound Up
I was working in the ED on the night shift. It was 6 o’clock in the morning, I’d been up all night, and I get paged into a room. You always get a little thump in your heart, thinking, What am I going to walk into? And there is a guy with a boa constrictor that has bitten him on his hand and coiled around his arm, and his hand is blue. His roommate’s snake had crawled into his bed because he was warm. The patient is yelling, “Get it off, get it off, get it off!” And I’m standing there, like…OK.
I know a boa constricts—that’s how it kills. They don’t have venom. So I uncoiled the snake, but I couldn’t figure out how to get it to let go of the hand. I called the fire department, which had an animal handler. He said, “What you need to do is pull the snake across the room, grab his tail, and yank hard on it.” It’s probably a six-foot snake. And it’s hissing. The guy keeps yelling, “Cut its head off!” But that’s not fair to the snake. I pulled the snake—I’m yanking and yanking—and it finally let go. I took care of his bite, put the snake in a box, and gave it back to his roommate. —Dr. Diane Barta, emergency medicine physician and medical director at Colorado Health Neighborhoods, Centura
Wasn’t I Here First?
First-come, first-served isn’t the way emergency care works.
It might not seem fair, but ED patients aren’t typically treated in the order they arrive. “We triage based on acuity and needs,” says Matt Mendenhall of Littleton Adventist Hospital. “That’s a constantly changing calculation. Wait times can fluctuate in an instant.” However, UCHealth University of Colorado Hospital in Aurora has garnered acclaim for reimagining front-end workflow to prevent unnecessary waiting. Instead of being assigned a waiting room spot based on how severe their problems are, patients are seen immediately by an attending physician and sent through the appropriate channels based on their needs, so patient flow is never stagnant. The results? The median door-to-provider time at University Hospital is less than seven minutes.
What’s the Deal With Stand-Alone EDs?
Freestanding EDs provide more services than urgent cares—at much higher prices.
Over the past 10 years, the metro area has seen a proliferation of freestanding emergency departments (FSEDs): facilities that are staffed by physicians who offer 24/7 care but are not physically attached to hospitals. The problem is that patients often mistake FSEDs for urgent care centers. “So people were getting hit with these [big] bills when they only needed two stitches in their finger,” says Kelli Christensen, UCHealth’s manager of public and media relations. Critics argue that the confusion isn’t completely unintended.
A 2018 analysis by the Colorado Health Institute shows that FSEDs are clustered in affluent neighborhoods, where residents are more likely to have insurance that pays providers at higher rates than Medicaid. From state health officials’ view, this high concentration of FSEDs meant patients across the board were seeking costlier ED care rather than going to urgent or primary care centers, even though in many cases the latter would be more appropriate and less expensive. And all that was driving up costs for Medicaid and other insurers.
So, that same year, Colorado legislators passed a law requiring FSEDs to post signage explaining their emergency status and fee menus on their websites, along with other disclosures. In 2021, the state went even further by offering incentive payments for hospitals to convert their FSEDs—there were 44 statewide, according to a 2020 study in Western Journal of Emergency Medicine—into other types of facilities, such as primary care or behavioral health clinics. (Some have since converted, though not necessarily due to the incentives, according to the Colorado Hospital Association, which notes that some FSEDs closed during the pandemic when hospitals needed to redirect resources to expand in-hospital capacities for COVID-19 care.) And this past July, Colorado required that FSEDs acquire their own licensure, creating new, independent guidelines.
“There’s a whole lot of political discussions around freestandings,” says Dr. Kelly Bookman, emergency medicine physician and senior medical director of UCHealth Emergency Medicine. “But by definition, go to an ED if you think you have an emergency. As a layperson, I wouldn’t think twice about [which one]. Just get in front of a doctor.”
How Much Will This Cost Me?
A sampling from the FSED fee menu at Sky Ridge South Parker ER, indicating the maximum a patient can be charged for each service. These fees are not necessarily indicative of what a patient will owe once their insurance kicks in and may be more accurate for those who are self-paying or uninsured.
WTF?
You shouldn’t be surprised by your bill.
It seems like everyone’s been there: You slip on an icy sidewalk during the winter and sprain a wrist, so you sprint to your local emergency department. A couple of months later, a bill for $2,000 shows up. What? But I’m insured!
Ah, but did you visit an in-network ED? And even if you did go in-network, you might’ve been hit with “balance billing,” which happens when you’re treated—usually unbeknownst to you—by an out-of-network doctor at an in-network facility. The provider sends you the balance of the bill your insurance doesn’t pay. Voilà, sticker shock. Fortunately, both state and federal legislation have been passed in the last few years to, in theory, prevent surprise billing like this: If you go to an in-network facility, you should now only be charged in-network costs, even if your emergency provider is out-of-network. If you are not insured, ask for a “good faith estimate” before you receive care; if your subsequent bill is more than $400 above that approximation, that is grounds for dispute.
Of course, carve-outs remain. Exhibit A: interfacility ambulance transport. Should you arrive at an FSED but need advanced treatment only available at the main hospital, you may be on the hook for your ambulance transfer if you’re not specifically classified an emergency. Furthermore, the new rules only cover transfers via private ambulances; if you are loaded into a vehicle connected to a city or county government, like a fire department ambulance, the hefty surprise charges can (legally) rain down.
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Isn’t There an Easier Option?
Virtual care isn’t just for primary care anymore.
Some hospital systems offer urgent care via video, though the range of problems that can be treated remotely is limited. Nevertheless, providers say virtual care can be a cost-effective and less time-consuming way to triage cases such as urinary tract infections, pinkeye, or a common cough. “Patients are really good at navigating this,” says Michael Breyer, emergency medicine physician and director of the Adult Urgent Care Center at Denver Health. Plus, virtual features like HealthOne’s online Symptom Checker ask patients a set of questions about their symptoms to determine what avenue of care they should seek.
How Do I Navigate the Maze of Health Care Billing?
Vincent Plymell, assistant commissioner for communications and outreach for the Colorado Division of Insurance (DOI), suggests three ways to be a savvier health care consumer.
1. Do your homework—even before you find yourself in an emergency—by discovering where your plan lives online and how to log in to the website. Find the table of contents and then familiarize yourself with your plan’s emergency care section. “It’s important to know how things are dealt with, even on an in-network basis,” Plymell says. For example, some folks will call him and say, “The bill I just got violates this new no-surprises law.” Says Plymell: “What they don’t realize is that they still have to pay their deductibles.”
2. If something does seem off with your bill, call Colorado’s DOI Consumer Services team at 303-894-7490 or email dora_insurance@state.co.us. The DOI doesn’t regulate all plans—its jurisdiction covers Connect for Health Colorado and small and large group plans. (Check for the “CO-DOI” abbreviation printed on your insurance card.) Even if your insurance isn’t protected by the DOI, though, the agency can provide advice for dealing with your provider. And if the DOI receives an abundance of complaints about the same company, the agency might investigate them: This past spring, a DOI inquiry led to a fine for Bright Health after the insurer repeatedly failed to pay claims correctly and on time.
3. Ask the DOI questions about your situation before going down the rabbit hole of filing a formal complaint about your insurance company with the DOI, which sets off a 20-day reply window that can be frustrating. (The DOI mandates insurers respond to its requests for information within 20 days, which can end up taking so long you forget what you were even upset about.) By asking questions up front, the DOI can help you figure out if there’s a way to solve your problem in days instead of weeks.
$3.1 Million:
Amount the Colorado DOI recovered for health care consumers in fiscal year 2021-’22
First Person: The Transport Team
Air Traffic Jammed
We came in at 6 p.m. for an overnight shift, and the day shift told us it had been pretty quiet. It was kind of foretelling. By 6:20 we got our first call from the southeastern part of the state; I think they had four out of the 12 transfers we did that night. So we’re having to facilitate getting multiple helicopters into that one area and make sure they’re all deconflicting with each other—it’s like musical helicopters.
One request was for a pregnancy transfer. The crew we’d normally send was already responding elsewhere, so we had to get our on-call administrators involved to make sure it was appropriate to send a primary care team versus a high-risk obstetrics team. During all of that, the crew on a separate transport with a patient onboard heard a rattle on its aircraft and had to do an emergency landing. It’s a constant tally list of the highest priority thing we need to do at that moment.
On my drive home the next morning, I was probably about 20 minutes from my house, and I had a serious debate with myself: Should I pull over and take a nap right here? There is a lot of mental fatigue that happens on a shift like that. —Leah Smith, AirLife Denver communications manager, based at the Medical Center of Aurora–North Campus
