Got to visit the ER at Rouen with Nicholas - a few random observations.
340 patients per day average (recently had 489 in 24 hours! Yow!). Plus another 40,000 per year at pediatrics next door, and 15,000 per year at the OB/GYN hospital a block away (If seen at OB/GYN and turns out not to be gyn - after the pelvic done - they're transferred by ambulance over to the main ER.) And a separate ophthalmology ER - not sure how many they see. (I recall from Nepal, that Nico was surprised that we had some ophthalmology skills - like using a direct ophthalmoscope - that weren't part of general medicine in France). 3000 inpatient beds. In summary: BIG!
Oh, I forgot - there's also a 22 bed observation unit staffed by 2 ER MD's. Keep in OBS up to 48 hours.
The main ER has 5 attendings and 9 residents during the day, and 3 attendings and 5 residents at night - 10 hour shifts. If you do the math, the throughput is pretty high. The attendings tend to see the sickest patients with a resident, and to turn the crank on the least complex to keep things moving. The residents see those in between with no online attending oversight. YOYO.
The main ER is 69 beds plus a number of triage beds, and sometimes hallway beds (which are counted as inpatient beds for billing purposes - you move to a hallway bed to be "admitted". Proves that the US doesn't have a monopoly on stupid accounting procedures in medicine.)
Like University Hospital, on the electronic tracking board a red "stop" sign appears when a patient has been in the ER long enough that a disposition should be considered. But in Rouen it's at 6 hours, rather than at 2 hours. That must mean something, but I'm not sure what.
A quick scan down the board shows a preponderance of 2-3-4 hour length of stay.
A casual glance around shows differences in the physical space: most beds don't have monitors, no beds have TV's to keep the patients amazed and amused, the whole space looks old and not very bright and cheery by US standards. There's not much privacy for patients - get to say "Bonjour" to everyone as you walk by. Far less in the way of creature comforts (though they do have pillows). Less technology - paper charts instead of electronic, x-rays on film rather than digital, and only one old ultrasound machine.
Those working at University will appreciate: small rooms, cramped spaces generate a lot of sound damping. It's quiet! You can hear people talk in a normal voice without listening in on other conversations, and being assaulted by bells, and sirens from all over the giant hangar! Nice.
All the staff wear white - nurses, Docs, everyone that I saw. None of the hierarchy of colored scrubs. (Sadly, no nursing caps.)
The CT scanner does about 55 studies per day - 2/3 for the ER - the rest for ICU. That seems to be about 10% of patients get scanned, a bit less than half of the percentage that we scan.
The ED does a patient satisfaction survey every 3 years (!) and reports 91% favorable rating (take that Press-Ganey).
The most interesting difference: the communication centers. The European version of 911 is 112. Calls come in to a center where they get triaged to police, fire, medical. Medical is then picked up by a technician and in some cases turned over to a Doctor who staffs the call center - 2 in the day, one at night. The doctor can give advice, send a transport only basic rig, or send a rapid response car including a doctor and nurse along with the transport ambulance (the doctor and nurse also staff inter-hospital critical care transfers). The doc/nurse combo then stabilizes and hops in the transport rig for the trip to hospital. There is also a PCP communication center !!!!! whose doctor can give advice, ask for EMS help, or arrange a same day clinic appointment at the nearest available clinic. That seems just too reasonable to work in the US. Well, maybe Kaiser.
There's a backup disaster comm center - staffed full time during the million visitors for the "tall ships" gathering a couple weeks ago.
I've noticed that in Paris, for a large city, there are relatively few ambulance sirens - I'm guessing that if an MD triages the call, then most ambulance transports are not lights and sirens to the scene which should cut down sirens by 90% or more compared to the US system of all EMS calls get a lights/sirens response and then most get a routine trip to the hospital since most EMS calls aren't time critical emergencies. Way cool, and nice for the auditory environment.
I only spent an hour or so at the ER, and saw so much of interest, I need to go back sometime and spend a few days just following cases through to see how the system functions.
It seemed in a very brief run through to be much more oriented to functionality, and less to high tech, less to hardware, and less to creature comforts. Wonder how much is choice, social expectations, and how much is flat out budgetary constraint.
Gotta come back some day. Nicholas: thanks for the tour! I'm kinda hoping to have a nice bike crash while I'm here - to test the system personally. (Not!)
340 patients per day average (recently had 489 in 24 hours! Yow!). Plus another 40,000 per year at pediatrics next door, and 15,000 per year at the OB/GYN hospital a block away (If seen at OB/GYN and turns out not to be gyn - after the pelvic done - they're transferred by ambulance over to the main ER.) And a separate ophthalmology ER - not sure how many they see. (I recall from Nepal, that Nico was surprised that we had some ophthalmology skills - like using a direct ophthalmoscope - that weren't part of general medicine in France). 3000 inpatient beds. In summary: BIG!
Oh, I forgot - there's also a 22 bed observation unit staffed by 2 ER MD's. Keep in OBS up to 48 hours.
The main ER has 5 attendings and 9 residents during the day, and 3 attendings and 5 residents at night - 10 hour shifts. If you do the math, the throughput is pretty high. The attendings tend to see the sickest patients with a resident, and to turn the crank on the least complex to keep things moving. The residents see those in between with no online attending oversight. YOYO.
The main ER is 69 beds plus a number of triage beds, and sometimes hallway beds (which are counted as inpatient beds for billing purposes - you move to a hallway bed to be "admitted". Proves that the US doesn't have a monopoly on stupid accounting procedures in medicine.)
Like University Hospital, on the electronic tracking board a red "stop" sign appears when a patient has been in the ER long enough that a disposition should be considered. But in Rouen it's at 6 hours, rather than at 2 hours. That must mean something, but I'm not sure what.
A quick scan down the board shows a preponderance of 2-3-4 hour length of stay.
A casual glance around shows differences in the physical space: most beds don't have monitors, no beds have TV's to keep the patients amazed and amused, the whole space looks old and not very bright and cheery by US standards. There's not much privacy for patients - get to say "Bonjour" to everyone as you walk by. Far less in the way of creature comforts (though they do have pillows). Less technology - paper charts instead of electronic, x-rays on film rather than digital, and only one old ultrasound machine.
Those working at University will appreciate: small rooms, cramped spaces generate a lot of sound damping. It's quiet! You can hear people talk in a normal voice without listening in on other conversations, and being assaulted by bells, and sirens from all over the giant hangar! Nice.
All the staff wear white - nurses, Docs, everyone that I saw. None of the hierarchy of colored scrubs. (Sadly, no nursing caps.)
The CT scanner does about 55 studies per day - 2/3 for the ER - the rest for ICU. That seems to be about 10% of patients get scanned, a bit less than half of the percentage that we scan.
The ED does a patient satisfaction survey every 3 years (!) and reports 91% favorable rating (take that Press-Ganey).
The most interesting difference: the communication centers. The European version of 911 is 112. Calls come in to a center where they get triaged to police, fire, medical. Medical is then picked up by a technician and in some cases turned over to a Doctor who staffs the call center - 2 in the day, one at night. The doctor can give advice, send a transport only basic rig, or send a rapid response car including a doctor and nurse along with the transport ambulance (the doctor and nurse also staff inter-hospital critical care transfers). The doc/nurse combo then stabilizes and hops in the transport rig for the trip to hospital. There is also a PCP communication center !!!!! whose doctor can give advice, ask for EMS help, or arrange a same day clinic appointment at the nearest available clinic. That seems just too reasonable to work in the US. Well, maybe Kaiser.
There's a backup disaster comm center - staffed full time during the million visitors for the "tall ships" gathering a couple weeks ago.
I've noticed that in Paris, for a large city, there are relatively few ambulance sirens - I'm guessing that if an MD triages the call, then most ambulance transports are not lights and sirens to the scene which should cut down sirens by 90% or more compared to the US system of all EMS calls get a lights/sirens response and then most get a routine trip to the hospital since most EMS calls aren't time critical emergencies. Way cool, and nice for the auditory environment.
I only spent an hour or so at the ER, and saw so much of interest, I need to go back sometime and spend a few days just following cases through to see how the system functions.
It seemed in a very brief run through to be much more oriented to functionality, and less to high tech, less to hardware, and less to creature comforts. Wonder how much is choice, social expectations, and how much is flat out budgetary constraint.
Gotta come back some day. Nicholas: thanks for the tour! I'm kinda hoping to have a nice bike crash while I'm here - to test the system personally. (Not!)
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