Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

An American Perspective on Italian Emergency Care

10/2/2015 4:07:11 PM | 7 comments

On a recent trip to Italy, I fell down a hill and landed hard on my left wrist. The swelling and instability told me I would soon be getting up close and personal with the Italian healthcare system.
Despite being freaked out, I was curious. After all, proponents of healthcare reform tend to romanticize public healthcare systems like Italy's, saying they're more humane and cost-effective.
On the other hand, many Americans associate "socialized" healthcare with endless wait times, defunct equipment, crumbling facilities, lack of privacy, outdated treatments, rationing and even death panels.
In my (admittedly limited) experience, the truth is somewhere in the middle. Here's my story and my impressions of the care I received.

A (Mostly) Public System

By objective measures, Italian healthcare is excellent. The World Health Organization ranks Italy's health system second best in the world. Italy also ties for second in life expectancy. (If there are death panels here, they appear to be incredibly lenient.) Healthcare expenditures accounted for just 9.2 percent of the Italian GDP in 2012, compared with over 17 percent in the United States.
Seventy-eight percent of the care delivered in Italy is publically funded through taxes, though private doctors and insurance are available. While some services require copays, emergency care is free of charge. Patients in the public system do endure long wait times for diagnostic tests and elective surgeries, though they can shorten the wait by paying out of pocket.
Of course, I didn't know any of this when I walked into the campground office with my rapidly swelling wrist. I just wanted help fast.

Emergency Medical Services

My accident happened in Corvara, a small ski town with no hospital. It also happened on a Sunday when local doctors' offices were closed.
The campground receptionist suggested we call an ambulance. To me, that seemed like overkill for a broken arm. But the Italian EMTs were lifesavers. After checking out my arm, they made some phone calls to see if they could locate a private doctor for me. It turned out the closest one available was about an hour away, so they encouraged me to go to the nearest public hospital instead.
During the 45-minute ambulance ride to Brunico, the EMTs were very attentive and kind. I was surprised to learn later that the Italian EMS system is mostly staffed by volunteers. It's apparently a very respected role in society, and the EMTs and paramedics take their work and training seriously.

The Emergency Department (ED)

We arrived at Brunico's ED to find it (and the rest of the hospital) pretty much deserted. Apparently Italian hospitals shut down a lot of services and run on a skeleton crew on Sundays. This makes sense on many levels, but it was pretty mind-blowing to me as an American.
I first saw the triage nurse, who told me to go out in the hall and stand outside Door A. This rolled up revealing a passably modern x-ray room. Within minutes, I was looking at my digital x-rays with the emergency physician.
No one in the ED spoke enough English to give me more than very general information. However, the doctor did manage to get across that my wrist was fractured, and that he couldn't determine from the x-ray whether it needed surgery. Then he told me that because it was Sunday, I would need to come back to the hospital the next day and get a CT scan.
This was the only point in the whole experience when I really wished I were home in America. Returning to this hospital seemed like an impossible task without my own car. I also wondered what would happen if someone came in with a stroke or other life-threatening emergency. (I imagine they have a technician on call for those cases, but I really don't know for sure.)
While the delay was an inconvenience, the ED staff did what they could to help. Because I was headed to Venice in three days, the doctor wrote me a special order so I could get a scan right away in the morning, which I appreciated.

The ED … Again

When I returned (by public bus) the next morning, I found the hospital and ED transformed. The place was totally packed, and the halls were lined with very sick-looking patients on gurneys. I figured that I was now going to learn about the "long wait" part of socialized healthcare.
I was wrong. After I located the radiology department, my CT scan was done in about 45 minutes. Back in the ED, I waited only about 30 minutes before being ordered to stand in front of Room E with four other patients.
The area in front of the door served as an internal waiting room. From here, a nurse called us into the "ambulatory room" one by one. After being seen, some patients were sent to stand in front of other doors (I presume for x-rays and procedures). At first, I found the stand-in-front-of-a-door system a little strange and impersonal, but it turned out to be pretty efficient.
When I was finally called into Room E, everything went well. After a brief battle with the EMR, the emergency physician pulled up my CT scan and told me no surgery would be necessary. I was totally relieved, — and grateful to the ED staff who had worked together to handle my case quickly.

Could Public Healthcare Work for America?

Overall, I was left with a pretty positive view of the Italian health system. The highlights, in my opinion:
  • My longest ED visit was just over two hours, which seems on par with American wait times.
  • The physicians and staff defied all negative stereotypes of public employees. They were friendly, sensitive to my situation and provided good customer service.
  • The care quality seemed comparable to the States (though slightly less thorough).
  • The facilities and equipment weren't gleaming or new, but they were sufficient to get the job done.
  • There was definite attention to efficiency and moving patients quickly through the ED.
I think if the United States ever adopted a system like Italy's, the hardest part would be convincing people to wait for non-emergent care. I'll admit that waiting overnight for a CT scan didn't sit well with me! On the other hand, there was no real harm in waiting a day, and reducing staffing on Sundays probably saves the system (and the public) money.
The best part of the Italian health system was the bill. To my utter shock, an ambulance ride, two ED visits, an x-ray and a CT scan cost me 271 Euros, or just under $300.
"Do I pay now?" I asked the cashier.
"No," she said, handing me the bill. "Just give this to your insurance."
It was like the hospital didn't really care about getting paid. Talk about a cultural difference.

Dave Birdsall
Great article Sara. Thank you for writing it (sorry about your arm). It is very interesting to hear what other countries are doing.
11/23/2015 8:42:03 AM

Sarah Maurer
Thanks all who commented. It's been fun to hear everyone's thoughts. That's really interesting about Australia and Italy having a reciprocal agreement for healthcare.
10/6/2015 11:44:07 AM

Thanks for sharing your experience Sarah. Waiting for non-emergent care can certainly make sense - and let's not forget Sarah's accident happened on a Sunday leaving 6 days of the week in which she probably would not have waited for the care received; I'm willing to bet most Americans would happily wait a night for non-emergent care (after having been assessed to ensure waiting was appropriate as in this case) if it meant avoiding a $2000 or more deductible. Your care was very reasonably priced Sarah, but I'm guessing the bill for an Italian citizen would have been $0. I live in Australia and Italy has an agreement with Australia and many other countries in which my public hospital care would be completely covered at $0 out-of-pocket expense were I travelling and needed care. Americans need to open their eyes to how healthcare is structure elsewhere in the world. I've heard of too many Americans suffering bankruptcy or stuck in a job they hate because of health insurance - why is the USA the only first world country in the world without a public healthcare system?
10/5/2015 11:40:30 PM

Cyndy Flores
Thanks for sharing Sarah. I always wonder about how other health systems would function. I have always felt bad for people who are visiting out of the area, much less out of the country and have to visit an ED - it has to be so unsettling. I'm glad you were well cared for and hope your wrist is all better!
10/5/2015 12:26:06 PM

John Fredericks
Thanks for sharing Sarah - hope you're feeling better. Your story reminds me of my family's very similar experience in 2007 when we visited an ED in Ribera, Sicily after my son had a moped accident. It's great to see good care being provided by caring staff in other parts of the world.
10/5/2015 11:40:06 AM

Jed Grant
Very interesting! Thank you for sharing your experience.
10/5/2015 9:46:51 AM

"Convincing people to wait for non emergent care" would be a huge hurdle in this country, but something most EP's would welcome. I would say the demands of the non emergent patients are the biggest contributor to EM burnout. The scenario Ms. Maurer illustrates here regarding Sunday staffing makes sense for a community ED. In my opinion, it is high time we stand up and publicize that most of what we see can easily wait to be seen a day later in an urgent care, a physician's office or, as in this case, a return visit the next day for a non urgent scan. It would go a long way to promoting longevity in the field both for physicians as well as nurses.
10/5/2015 8:24:28 AM