Know Where to Go: Immediate Care or the ER?

 

When you need care right away, knowing where to go can make all the difference. In this episode of On Call with Southern NH Health, Dr. Brett Sweeney, medical director of Southern New Hampshire Medical Center’s emergency department, and Sue Hills, director of operations for Southern New Hampshire Health Immediate Care, discuss the Know Where to Go campaign and explain when to choose Immediate Care, when to go to the emergency department, and how staying within the Southern New Hampshire Health system helps connect patients to the right care quickly.

Complete Transcript: 

Keith Baldi: Welcome to On Call with Southern NH Health. I'm your host. Keith Baldi. On Call delivers the latest health care news and updates, along with insights into the latest medical innovations and technologies. Southern New Hampshire Health is a nonprofit system serving the communities in greater Nashua, New Hampshire, and northern Massachusetts. The health system includes a 188-bed hospital, one of southern New Hampshire's most comprehensive teams of primary and specialty care providers, and five walk-in Immediate Care locations open seven days a week for urgent needs. Southern New Hampshire Health. Expert care close to home.  

Thanks for joining us for this episode of On Call. Today, we are in the business of educating our patients about when to go to an Immediate Care location or urgent care, as many people call them, and when to go to the emergency department at the hospital. We have two guests to talk about this, and we're even going to play a little game at the end to give our listeners a way to absorb what we're discussing. Joining me today are Dr. Brett Sweeney, medical director at Southern New Hampshire Medical Center's emergency department, and Sue Hills, director of operations for Southern New Hampshire Health and Immediate Care. Thanks for being here. 

Dr. Brett Sweeney: Thanks for having us. 

Keith: So, before we start, we always like to get to know people a little bit. You both have interesting jobs as far as I'm concerned. I've always been impressed by doctors, nurses, and clinicians who work in emergency medicine. As a former news person, you know, I know how hectic and intense things get. And what I did wasn't even close to what you guys do. So, you know, that pressure and everything, but everyone has a story about why they got into things. Dr. Sweeney, let's start with you. Why did you decide to become an ER doctor? And what is it that you like about the job? 

Dr. Sweeney: Sure. I think I always knew I wanted to be in medicine. I went to the Army right out of high school and was a medic in the Army, then went to college and medical school. I think I chose emergency medicine because one, I don't think my attention span is great for any other specialty. And second, I like dealing with everything. You know, there was no one medical specialty that jumped out at me that I said, I want to do this for the rest of my life. I just liked being involved in a little bit of everything. And that's what emergency medicine offers. 

Keith: Yeah, and it can get intense. It sure can. Sue, you're the director of Immediate Care, but you're also a physician assistant. So, you see patients as well. What got you going into this type of medicine? 

Sue Hills: Yeah, so when I was in high school, we had a health occupation program at my high school, and I started realizing that I loved that kind of biology, chemistry sort of stuff. And then once I started doing that, I realized healthcare was definitely something I wanted to go into. So, I started a very basic medical assistant position. I went to college for biochemistry initially had a pre-med focus, and then I heard about the PA program when I was in Boston. And it really drew me to be able to still have a career but also be a working mom. So I felt like it really gave me that balance, allowed me to start my career earlier than if I went to medical school.  

I originally started in primary care, loved it, and then when I found out about the opportunity in Immediate Care in 2011, I loved the ability to work shift work, but also work in the community and be able to take care of just patients from as Brett said, from, you know, birth all the way to a hundred years old, but also just seeing the variety of different complaints. As Brett said, I wanted the variety. I didn't want to just do physicals all day. I love the fact that you can go from dermatology to cardiac to pulmonary to GI, and you just really are allowed to take care of a multitude of different complaints, which is great. 

Keith: Well, I'm sure what I'm going to say here reflects what a lot of people think. It's impressive what you both do and thank you. Because when you need good, you know, emergency urgent care, you need people to be on the ball and dedicated to it. And I know you both are. So that's amazing. But it must be it must be fun in a way to have your brain move from thing to thing. I like that too. I like to do something different, but the same. That makes sense. 

Dr. Sweeney: Yeah. Ton of fun. 

Keith: All right. So, you know, we've heard about this Know Where to Go campaign. A lot of health care systems have these campaigns just so patients know when you need medical care immediately. You know, there are two options. There's Immediate Care. And in the hospital emergency department. Dr. Sweeney, why is it so important to know where to go when you're a patient and you're having that need? 

Dr. Sweeney: I think there are a few reasons. One, I think we want you to get the best care that you can get, and we want to get it to you as quickly as we can. Right? So, if you have a life-threatening emergency, we want you to be at the emergency room. We have a full suite emergency department to take care of you. But if you have something that's a little bit more minor, it can be taken care of at Immediate Care. We want you to go there because they're able to take care of you there. And it's often a lot quicker. It's often a lot more efficient to go to Immediate Care as opposed to the emergency department. 

Keith: Sure. So going to the right place can really make a difference for a patient's health, too. Right? I mean, let's face it, there's convenience as well. As Dr. Sweeney just said, you may not have to wait as long. 

Sue: Yeah, I think it's convenient. It's the throughput of being able to get patients seen efficiently, not kind of overburdening our emergency departments so that they are able to see the higher acuity. I also think it's affordable, as we all know, there are large deductibles. A lot of us are paying for our care, and we have that cost. And I think it's just important to make sure that we're going to the right avenue so that we can see as many patients as efficiently as possible. 

Keith: Yeah, that makes sense. I mean, why overburden the system when we have these for a reason? And there's also an aspect to this about connecting patients to care, right? We know many patients are going to need follow-up after they go to the emergency room, or they go to an Immediate Care. If they're already a patient in our system, you already have that important information when it comes to one of our sites. Dr. Sweeney, why do you think it's important to have people in the system, you know, have their records? They have maybe they've seen a primary care provider in our health system, right? 

Dr. Sweeney: I mean, I think it's all kind of rooted in the word system. I mean, it's kind of we have a full-scale health system that we can take care of you in every aspect of that, you know, whether it's primary care, taking care of you, keeping you healthy or taking care of you when you're sick. And we can do that in various different offices, locations depending on your needs. We really have kind of every modality to take care of, every need that the patient may have. 

Keith: Yeah. That's important. So can you talk about the whole ecosystem of care as well? When you go to a primary care, you're in the system. And then maybe it's a Saturday, and your doctor's not around, but you come to our Immediate Care, and they kind of already know you in a way. 

Sue: 100%. I think the value around it is that I can look into your chart. I can see, for example, if you're on blood pressure medications, I know those things. So, when I'm prescribing you a medication, I'm taking those into consideration. I can see your most recent lab so I can know if I need to adjust a medication's dose based on those things. The other benefit to it is that you can see images that the patient may have had, or you can connect to care. So, one of the things that Immediate Care started about two years ago is that we started being able to directly book with some of our specialists. So, if you came into Immediate Care with a fracture, I could get you in with orthopedics. So, I see you on Saturday, I can splint you and I can get you in with our orthopedic department on Monday. Same thing with our general surgery department, our pulmonology department, and our foot and ankle department. So, we have a bunch of connected care within our organization.  

In addition, if you don't have a primary care, we do have a system set up that we can get you in with a primary care. And if you have an established primary care, and we see something that, you know, you're not too sick to have to go see Brett and his team, but you're kind of in a higher risk category. We can get you set up with your primary care provider next week to prevent hospitalization. 

Keith: It's so important to have that communication, you know, Dr. Sweeney, that you can also reach out to a doctor. I mean, we're just talking about someone coming in on a Saturday. But, you know, maybe someone comes in on a Tuesday morning and they're in the ED and, you know, they have something serious happening. If they have a primary care or a specialist within our system, you can have that real-time communication. 

Dr. Sweeney: We can always have that real-time communication. Not to oversimplify it, but you think about right now at home I'm having hardwood floors redone. Right? So I asked all my friends. Hey, who does a great job with hardwood floors, right? If you need an electrician or a plumber, you ask around. I mean, being in a health system, that's exactly what we do, right? If I need to send someone to a podiatrist, I know that, right? I can say, hey, this person's a great guy.  

You know, we have a process now for Immediate Care, where if a patient comes to an Immediate Care and then they need to be referred on to the emergency department, we have a process in place where Sue's team will reach out to the emergency department. They put a note right in the computer, and that patient gets expedited through the emergency department. So they're not having to wait. And that's the benefit of staying within the system. 

Keith: And that's huge because, as I said, you know, at the beginning of this, there's a real aspect to your health and well-being. And then there's a convenience aspect to this. It's just the way people are and the way life is. Right? I mean, you know, you might have to pick up your son from school later in the day, and you need care now, but you don't want to be lost. You know, you want to be in a system where you can get that follow-up. 

Dr. Sweeney: Yeah, and I think you want to make it as easy as possible. Right? Often, when people are going to Immediate Care or coming to the emergency department, for a lot of people, it's the worst day of their life, right? So, you want that to be as easy as possible. You don't want to have the added burden of going somewhere you don't know, seeing people you don't know, trying to navigate a new or different health system. 

Keith: Yeah, absolutely. And so we're talking about the different, you know, areas of our health system, primary care specialists, emergency care. What is the message to people about seeing a primary care provider? So maybe they don't get to the point where they need Immediate Care, or they need emergency care. Obviously, that's always going to be there. But when you have that first contact as a primary care provider. 

Sue: Yeah, I mean, primary care providers are very, very important in our ecosystem. You know, really, it's preventative medicine. Right? So, you want to make sure that you're having your annual physical with your primary care provider. But the other big things around calling your primary care first, especially Monday through Friday, is those are the providers that know you best. I mean, Brett's team, my team do a great job, but nobody knows you better than your primary care provider.  

So we have provider care teams that work really well and efficiently to get their patients through. So, I think it's important to call them. See if they have accessibility. But the good thing is that within our health system, we are all in Epic. So, if you do come see me or you come see Brett's team, we can see those things as we discussed before. So, we can really provide collaborative care. Those providers can then see our office notes, see our testing that we did, and where we want follow-up. So, we do a really good job at kind of collaborating that care together, even if you're not seeing your primary. 

Keith: Oh, absolutely. Dr. Sweeney, you have to see people on the ED, obviously, and they have conditions that might have deteriorated over time. So sometimes they can be caught earlier by a primary care provider. To Sue's point. 

Dr. Sweeney: Yes, absolutely. I mean, the primary care provider's job is to keep you out of the emergency department, to keep you healthy. Certainly, they can take care of you as well when you’re sick, but their primary focus, not to be redundant, is to keep you healthy and keep you out of the emergency department. I don't think anybody ever wants to end up in Immediate Care or the emergency department. 

Keith: Yeah, those things happen, right? And that's part of life, right? We want to when you have an accident or something that happens. That's the point. 

Dr. Sweeney: But I frequently tell my patients, if you're lucky, you'll never see me again, you know. 

Keith: Not good to see. 

Dr. Sweeney: If you're lucky, you'll never see me again. 

Keith: Right. 

Dr. Sweeney: It's the nature of my business. 

Keith: Absolutely. And the nature of both of your businesses is. Let's face it, primary care providers can't work 24 hours a day, seven days a week. And so when people, you know, when these things come up, Dr. Sweeney, talk a little bit about cases where patients come into the ED, maybe they don't need to, but you can't turn anyone away. Right? This is just the nature of emergency medicine as well. And this is why it's important to have those other parts of the system.  

Dr. Sweeney: I mean, we will see everybody, right? One, because we're happy to see everybody, and two, because it's law. You walk into the emergency department and you have the right to be seen, and we're happy to do that. But there are certainly patients that show up to the emergency department that could be handled in Immediate Care. And I think that's why forums like this are super important to get the word out there so that people know where to go. Sometimes people just don't know where to go. Sometimes they can't get to Immediate Care. You know, they live downtown and the hospital is within walking distance. But, you know, informing people, you know where to go, when to go. I think that's why we're here today. 

Keith: Absolutely. So what is the message to people? What are some of the most common reasons to go to an Immediate Care? Not an ED? 

Sue: Yeah, so most common things we see are rashes and urinary tract infections. Obviously during cold and flu season we're seeing things like strep throat, flu, COVID, and RSV in children.  

I think a big thing to note about our Immediate Care locations is that we do see a lot of orthopedic things, and I think those are things that sometimes people assume that an urgent care can't take care of or don't take care of. So things like fractures, as long as it is not, 'I fell down a flight of stairs', it's more like I tripped over the couch, and I hit and rolled my ankle. You know, those are great areas to come to Immediate Care. We do splinting right there in the clinic.  

Another thing that urgent cares do is laceration repair. We can also perform procedures like incisions and drainages. So those are kind of like the basic things.  

But we also offer higher-level things. We can do nebulizer treatments. So, if you're having a COPD or asthma exacerbation again, not to the point where you can't take three steps without getting out of breath. I mean, those are more of the emergency room. But your very basic, I mean, asthmatic and COPD patients know when they're starting to exacerbate. Again, getting in early so that we can take care of those outside of an emergency room setting.  

IV hydration. So, you have a really bad GI bug, or you're in your first trimester of pregnancy. Those are things that we can perform in Immediate Care.  

Simple, more basic cellulitis. You know, something that has just begun in the very early stages. You know, oral antibiotics are definitely appropriate. Again, sometimes you start in Immediate Care, and I have to call Brett's team and say, " Hey, you know, this person might need a more advanced IV antibiotic.” But I always say to people, if you're kind of in that unsure position, but you know that you need to be seen, you can always start at urgent care. So we will always direct you in the right direction. If you need Brett's team, you know, again, as Brett spoke, we have a great red carpet kind of system that we have between our two departments. I work very collaboratively and those patients get really great care because we have that connection. They're not going from one system. And then Brett's team sees them. They have no idea what I've done, what workup I've performed. Brett's team knows. And when they get there, they're immediately triaged, which is wonderful. 

Keith: Which is great. Yeah. It's, in that sense, a triage to make sure. If you can't treat them at that level, then you move on. I'm going to ask you what the reasons are to go to the ED. But when we play this game it might be a little redundant. But tell me, what are the big ones? 

Dr. Sweeney: Yeah. Even before I tell you that, I would say circle back just to the primary care for a second. You know, I think it's important if you don't have the luxury of listening to this podcast, you can always call your primary care physician, and your primary care physician can say you can be treated at Immediate Care, or you should go directly to the emergency department.  

So, if there are questions, I think there's always that foundation of the primary care to reach out. And they'll tell you what they think is best. Perfect. But I think when you're thinking of the emergency department, I mean, our goal is to treat life-threatening emergencies. So if you think you're having a heart attack, if you have the worst headache of your life and you think that you're having a brain bleed, or you think you or your family member is having a stroke, those are the reasons to go to the emergency department. Certainly major traumatic events. I think the emergency department is appropriate place, right? 

Keith: Yeah, and you think of the car crash, and maybe if you're up and walking around and whatever, you want to see it, you know, Immediate Care. But if when you're in a car crash and something serious, I mean, that's what emergency rooms are there for. Correct. You know, I mean, more than that. But, you know, my point is that those traumatic things are when you have an accident doing work on your house, something that's very serious.  

So, okay, let's have a little fun. Let's play a quiz. I know whether it's going to be fun for you or me, but. Yeah. Perfect. I know you guys are very good like that, so I'm going to give you a condition. And whoever wants to claim that patient for their location, you do that and tell me why. All right?  

Chest pain or pressure, shortness of breath, and pain radiating to the arm. 

Dr. Sweeney: So that's going to be us in the emergency department. And the reason for that is, you know, that certainly could be a life-threatening event. But even if it's not a life-threatening event, it's something that's going to require advanced diagnostic testing, and that's going to be done in the emergency department. 

Keith: That could be a heart attack, obviously. 

Dr. Sweeney: Yeah, it could be a heart attack. And it's often depending on your age and risk factors, you're often going to require admission to the hospital because there's oftentimes, we can't rule that out just in the emergency department. And obviously, being in the emergency department, we have the hospital above us where patients can be admitted. 

Keith: Right. Which is super important. You know, there are freestanding ERs that are now in New Hampshire, and another one is being built. But our emergency department is full-service, and it's connected to the actual hospital. So, to your point, observation, additional testing, all those things, medication, you just take them upstairs, in essence. 

Dr. Sweeney: It's an elevator ride versus ambulance ride, right. 

Keith: Good point. Okay. Next one. You hurt your ankle. There's swelling and redness on a bone or joint. 

Sue: That's me. Okay, so as I spoke to earlier, I mean, we have X-ray right in the office. We can do any sort of splinting that will be needed. Crutches, knee immobilizers. I mean, I know we talked to ankle, but kind of any joint we're able to take care of.  

There are cases where we do need our orthopedic department, or sometimes it's a surgical repair. But as we spoke about earlier, we have a very great connected system with our orthopedic department. And they will get them in. The biggest things around sprains and fracture concerns are when it's a trip and fall, and it's a short distance. And there's a mechanism where if you fell down a flight of stairs, Brett is your place. If you have pain because you were in a motor vehicle accident and there's multiple areas of trauma, those are the things that we really want the emergency room for. 

Keith: Makes sense. Okay, here's another loss of balance. Vision changes, face drooping arm weakness, speech difficulty. 

Dr. Sweeney: That's going to be the emergency department for all of the same reasons we mentioned before. But those are all signs and symptoms of potential stroke, right? And that's going to be best handled in the emergency department one, because we have the CT scanners and diagnostic studies. We also have the availability of neurologists and experts. And we also have the medications to treat stroke. 

Keith: Absolutely. And I know stroke is another one like heart attack where every minute really matters. Right? So going to the right place. 

Dr. Sweeney: Time is brain. 

Keith: That's interesting. Yeah. That makes sense. The longer you don't get treated. Why is that? 

Dr. Sweeney: Because when we think of a stroke, it means a stroke is a part of your brain is not getting oxygen. So, every minute that part of your brain doesn't get oxygen, there's the potential that more of those brain cells are dying off. 

Keith: Yeah. It's not great. No, no, not good at all. But again, that's the reason we do these things to educate people so they know if that's the case, go straight there or call an ambulance. Right? Okay.  

This one seems pretty common. Fever, chills, nausea, fatigue for a day or two. 

Sue: That's me. So, as I have spoken to you, you know, we have the strep testing, flu, COVID testing, RSV testing, most upper respiratory infections, you know, just need some viral education around them. But we do rule out other things like ear infections, sinus infections, and pneumonia, all things that we can treat within the Immediate Care setting. 

Keith: That's great. Red, itchy bump. Pretty irritated. Maybe I got stung by a bee, or maybe I got bitten by a mosquito. 

Sue: So that's me again. 

Keith: Tick? 

Sue: Ticks are huge at this time of year. But one of the things we will talk about because we are heading into our fun spring season is that if you do get stung by a bee, and you are starting to feel like your throat is swelling or you're wheezing, that's an immediate 911 call. Not, let me get in the car and head over to Immediate Care. We do obviously have patients that come in in those situations. But ideally, you know, EMS is the is the best in those situations, but a very simple bite. Yep. That is what we are here for.  

And that's another space to use our virtual program as well. So, we have something we call Skip the Trip for virtual care with an Immediate Care. So, what's great is you can literally do it from your couch. You don't even have to leave your house if you have a rash. You call up our phone number, you book an appointment, we see you virtually, and we can send those prescriptions right into your pharmacy without you ever leaving home, which is great if you have a family or kids. 

Keith: Oh, absolutely. 

Sue: Or just even work to be able to have that appointment. 

Keith: Same professionals, just a different way to talk to them. Exactly. That's amazing. Yeah. Okay.  

Last one here a burn. But here's how the patient would describe it. Larger than about three inches. Looks white, charred, leathery, maybe deep brown. 

Dr. Sweeney: So that sounds like a bad burn, right? That sounds like probably a second- or third-degree burn. So that would be an emergency department visit. And the reason for that is because we have the direct access to the burn specialists. Right? 

Keith: Which, again, would be, I mean, if you go to Immediate Care, then you would probably send them there to get that. Yeah, and again, that's the good thing about having that full-service emergency department, you know, like you were talking about the specialists right there in that immediate need for people to be treated. And then once they're treated and stabilized or whatever, and they need further care, again, we're in our system. And so you can just pass them right along to a specialist that they may need. 

Dr. Sweeney: Absolutely. 

Keith: All right. Well, that was fun, I hope a little bit for you guys. But since you do this every day, probably a little bit more for me, but that's okay. Well, that's it. That wraps us up. I just want to mention again that for Immediate Care, you can go to Southern New Hampshire Health's website, SNHHealth.org, then go to the services section and Immediate Care. You can schedule your arrival time, right, Sue, if you'd like. Or, as you mentioned, book a virtual care appointment, which is wonderful. Dr. Brett Sweeney, medical director at Southern New Hampshire Medical Center's emergency department, and Sue Hills, director of operations for Southern New Hampshire Health's Immediate Care. Thanks so much for joining us. 

Dr. Sweeney: Thanks for having us. 

Sue: Thanks for having us. 

Keith: You've been listening to On Call from Southern New Hampshire Health. For more information about the health system, or to learn more about some of the topics featured in this podcast, visit us on social media and on our website, SNHHealth.org.