EMERGENCY DEPARTMENT

EMERGENCY DEPARTMENTMINAKSHI GAUTAMASSISTANT PROFESSORIncreasing load in the hospitals due to disasters

People affected in terms of health dislocation are very large

Demand for proper set up and planning of emergency services

Apart from trauma and burn cases, patients with heart attack, kidney failure, breathlessness, pains and reactions, etc. are also receivedINTRODUCTIONDerived from Latin word URGENS pressing

Term emergency is frequently used especially in modern hospitals

Medical Dictionary Emergency refers to an unlooked for contingency or happening or a sudden demand for action or situation requiring prompt action.INTRODUCTIONCasualty As defined by MoH, London means a patient who comes to the hospital unannounced with accidental injury and is seen and treated otherwise than at a consultative session.INTRODUCTIONINTRODUCTIONMedical emergency is defined as a situation where the patient requires urgent and high quality medical care to prevent loss of life, limb or organ and initiate action for the restoration of normal healthy life.INTRODUCTIONAlso defined as a condition determined clinically or perceived by the patient or his/her relatives as requiring immediate medical, dental or allied services failing which may result in loss of life or limb

WHOINTRODUCTIONThe Emergency department is a very critical and sensitive unit of any hospital and is involved in the management of emergency cases.The emergency service brings about an interface between the hospital and the community, which is emotionally subcharged.

INTRODUCTIONQuick and competent care can save lives and also reduce the severity and duration of illness.The emergency service provides immediate, emergency diagnostic and therapeutic care to the patients with:Injuries by accidents, orSudden attacks of illness or exacerbation of disease.

INTRODUCTIONThese patients require immediate attention and treatment.

Emergency patients receive resuscitation and life saving treatment.

If the patient is serious it can make all the difference between life and death.

High quality of outcome is expected by patientsINTRODUCTIONThe ED is also referred as casualty wing for emergency cases

It should have a distinct entry independent of OPD main entryINTRODUCTIONTo the patient high quality of outcome means;

Right timeRight careRight expertiseRight attitudeRight costINTRODUCTION The first and foremost requirement of a Casualty is that it should do the patient no harm

Florence NightingaleINTRODUCTIONIt should be an independent department working round the clock.

It should be located in the complex of the OPD for reasons of easy accessibility and sharing medical facilities with the OPD.

It shall be on the ground floor of the hospital.

Guidance to the route from main entrance to the doorways of reception hall shall be provided.

INTRODUCTIONThere should be an easy ambulance approach with sufficient space for free passage of vehicles and covered areas for alighting patients.

The arrangements for reception of trolleys and walking patients should be close by.

Waiting space also for persons accompanying the patients.INTRODUCTIONAs accident cases are closely related with police department, a separate room for their use shall be provided in this area.

toilet facilities for men and women vicinity.

Therefore, ED provides round-the-clock, immediate diagnosis and treatment for illness of an urgent nature and injuries from accidents.INTRODUCTIONEmergency service is acquiring increasing importance due to modern problems arising out of urbanization and mechanization.

Excellent services must be provided as the patients and their relatives are under emotional strain and subcharged with suspense and anxiety about the consequences.Normal LifePhysicalSudden DisruptionSocialSpiritualMentalSudden feeling of restlessnessSome form of disaster (Natural or Man-Made)Admitted to EmergencySympathetic and Confident DoctorsDiagnosisTreatmentMaking the Patient ConfidentOperation if NeededRelieved with advice to Visit OPDTreatment

Process RequirementsSimple cases after administering preliminary treatment are discharged with instructions to attend OPD as follow up measure.

Cases of serious nature are admitted in emergency wards to provide immediate medical care.

Such patients are either discharged after 2-3 days or are transferred to permanent inpatient units.

Percentage of Inpatient admissions from ED accounts for 20-25%Centralized Emergency Services should be developed to deal with the increasing number of cases of accidents and injuries.

The need to have such service should be considered as National Health Service priority keeping in view that:

50% of all categories of accident cases admitted are due to traffic accident.There is no organization efficient enough to deal with these large number of injuries and accident cases.Other Facts60% of deaths resulting from myocardial infarction occur within 1 hour of onset.With proper emergency care, percentage of coronory deaths which occur outside hospitals and can be prevented is 40%

Other FactsThe union health ministry is implementing a project for the upgradation and strengthening of emergency trauma care facility in state government hospitals located on national highways under National Highway Development Project.

The project is under the scheme Assistance for Capacity Building to provide immediate treatment to the victims of road traffic injury

The scheme was started in the 11th plan with a total outlay of Rs 732.75 crore for establishing 140 trauma care centres along the Golden Quadrilateral highways.

Other FactsThe hospital beds are inadequate to deal with this vast problem.

An efficient transport system to lift the patients from the scene of accident does not exist.

It has been realized that the most efficient treatment of accident cases should start from the scene of accident itself.Other FactsIt is necessary to have :An effective communication system.

Speedy transportation of the accident victims for immediate first aid and resuscitation, starting from the place of accident.

Coordination and harmonious working with the other hospitals, especially identified for this purpose.

A multi-disciplinary approach for the treatment of poly trauma cases involving all the surgical and medical disciplines.

Other FactsAccident and emergency (A&E) departments are specialized to handle patients with acute emergencies that require urgent medical assessment and treatment.

But it is found that these departments are becoming more of a popular venue for primary care.

The significant increase of inappropriate attendance is considered as a serious threat to the healthcare system because of inefficient utilization of resources and depriving the true emergency cases of quality care.

Other FactsCore Design

TYPES OF EMERGENCYSurgeons have classified emergencies into following categories:

First Emergency : what must be done within a few minutes or hour?

Second Emergency: What must be done within 6 hours?

Third Emergency: What must be done within 24 hrs?

This classification means delayed surgery for surgeon and not for resuscitator.

Outdated classification

Emergency to be classified taking into account rapidity of the outcome for different pathologiesTYPES OF EMERGENCYTYPES OF EMERGENCYMajor Emergency Services: In general such facilities are provided in teaching and training hospitals.

Basic Emergency Services: In all hospitals

Stand by emergency services: Usually in primary healthcare set up.

Divided in two parts

Outside the hospitalInside the hospital

Outside services can again be divided into two groups:

Alarm and communication systemAmbulance services

Types of Emergency Medical ServicesOBJECTIVES AND SCOPE OF SERVICESEmergencies of following type are received:

Emergencies like coronary diseases, respiratory diseases, obstructions of gut, perforations and colics.Accidents road or industry having lacerations, haemorrhage, sprains, dislocations, fractures, shock, falls, etc.Foreign bodiesBurn of all typesDog bites and snake bitesMass causalities from food poisoning, drinks, riots, etcMedico-legal cases Cases of acute severe pain or distressSeptic conditionsObstetric emergencies real or pseudo in naturePseudo emergency cases

- Pseudo emergency cases mostly includes fear of unknown, lack of competence of G.P., Easy accessibility, Stress and strainOBJECTIVES AND SCOPE OF SERVICESManaging accidents victims, Providing first aid, Treatment of minor injuries Referred to appropriate specialty or hospital, in case specialized care is necessary and cannot be provided in the hospital.Attending all medico-legal formalities, including documentation of clinical conditions and other particulars and liaison with the police.Attending the patients coming outside the routine outpatient working hours, and screening them for admission.Observing them for short period to determine whether they need admission, or Providing outpatient care.Briefing the relativesMaintaining recordsTraining

Location, Accessibility and LayoutBroadly the department should have the following:

Consultation and examination roomEquipped with:

Doctors seating arrangement with office furniture.Examination CouchBP Instrument (Sphygmomanometer)StethoscopeClinical ThermometerTorch

Procedure Room

Equipped with facilities for minor procedures like suturing, Endotracheal Intubation, Dressing, Plaster, Catheterization, Ryles Tube.Operation Theatre LightSuction MachineBoilerDrip StandGlucometer

Treatment Room

Equipped with

DC Shock MachineBeds for treatmentCardiac TableInstruments for vaccination

Toilet, and Waiting Area

Location, Accessibility and LayoutReception and Information area

Physical Facilities for 200-300 bedded emergency departmentS. No.Name of facilityNumberSizeArea in Sq ft 1Ambulance entrance1--2Main entrance to casualty 18ft x 10ft803Waiting area120ft x 20 ft4004Reception 1-1405Examination cubicle480 sq ft3206Observation ward10 beds84 sq ft each4807Emergency X-Ray Room112 ft x 15 ft1808Emergency Laboratory112 ft x 15 ft1809Treatment Room112 ft x 15 ft180Physical Facilities for 200-300 bedded emergency departmentS. No.Name of facilityNumberSizeArea in Sq ft 10Fracture/ Plaster Room112 ft x 10 ft12011Doctors Duty Room124024012Nurses Duty Room112 ft x 10 ft12013ECG Technicians Room112 ft x 10 ft12014Room for Gr C and D112 ft x 10 ft12015Store Room112 ft x 10 ft12016Staff toilets28 ft x 10 ft16017Water cooler1--18Police Post112 ft x 15 ft18019Patients toilets112ft x 15 ft180Acute patient care room

EQUIPMENTS Some of the equipments of ED:VentilatorsDefibrillatorsPulse OximeterDrop Infusion Pump (Dosimeter)Suction MachineLaryngoscopeAirwayCardiac MonitorsAmbu BagECG MachinePortable X-Ray MachineEmergency TrolleysSplinting EquipmentsStethoscope, Clinical Thermometer, Torch

Separate Counters

Registration Charges

Bed Charges

REGISTRATION PROCEDURE FOR EMERGENCY CASESOn an average a patient is kept for 2 hrs in ED and then either he is discharged or admitted and shifted to respective ward.

Average Time for ED StayOPERATION THEATREMinor operations are performed in the procedure room, which can be called minor operation theatre.

In case of any major operation such as Head Injury the operations are performed in main operation theatre of the hospital by the consultants.

Medical CasesSurgical CasesDiagnostic Services VaccinationBlood TransfusionInjections

FACILITIES PROVIDED IN THE EDEmergency Incharge (Senior Doctor)CMO in each shiftNurses (Diploma in Nursing and midwifery)Ward boysSanitary Attendant

STAFFDUTY ROASTERSMorning Duty 8am 2 pmEvening Duty2pm 9 pmNight Duty9 pm 8 am

A new concept in emergency care has been introduced with the employment of Scribes who is member of nursing staff and whose function is;

Taught to record physicians findings as well as pertinent segments of the history while the patient is being interviewed and examined

Scribe conveys the physician orders to other members of the team while the physician continues with other patients

Scribes also prepares the prescription ordered by the physician to be ready for his signatureSTAFFPATIENT FLOWCritical PatientEmergency DepartmentConsultant ExaminesPayments and Registration at OPD CounterVitals CheckedInvestigations (ECG, Blood SugarEmergency Care given to patient (IV fluids, suction, etc)Treatment initiatedDischarged Admitted to IPDThe equipment like ECG and Defibrillator etc. are present in the department and are in adequate numbers.

The drugs like Injection Avil, Injection Lasix, Injection Adrenaline, Injection Rentac, Injection Reglan, Injection Regafortan, IV Dextrose and other fluids should be present.

Whenever any item has to be procured from stores, sister Incharge should fill the indent form.

Availability and Adequacy of Equipments, Drugs and other suppliesDoctors duty report with total history and treatment done on the patient and it is reported by the doctor on duty.Nurses Record Register Stock register maintained by nurseInjection register maintained by nurseThalessemia register maintained by Sister InchargeVaccination Register

Emergency OPD cases should be registered separatelyTrend of cases according to seasons should be monitoredDying declaration by Medical officer

RECORDS MAINTAINED IN EMERGENCY DEPTKEY PLANNING AND DESIGNING PARAMETERSPatient load is very important factor.

Emergency patients account for 10% of all OPD cases (jain Committee report)

25% should be added to current patient load to avoid overcrowding in the first 4-5 years of operation.

1 out of 8 beds are occupied by an injured patient.

1 of every 42 vehicles in the country meets with accidents.

Percentage of beds to be allocated are 10% of total hospital inpatient beds.

Need to rationalize and organize emergency services as close to community as possible.

GOI planning, organizing and developing trauma services for control of RTAs

KEY PLANNING AND DESIGNING PARAMETERSThe design and planning should be done so as not to impede the movement of patients and staff and equipment.

The equipment should be located in designated spaces to be readily accessible when needed.

It should provide privacy during management of patients.

There should be minimum criss-crossing of patient traffic.

A separate entrance and exit may be planned to facilitate unidirectional patient flow.

It should provide easy access for ambulances, patients and general public.KEY PLANNING AND DESIGNING PARAMETERSThe entrance should be easily identifiable, protected from inclement weather and accessible to disabled patients.

Depending on type and location of hospital a helipad may be planned.

Ground level location is best since it avoids need for patient access by stairs or elevators, and provides easy access for patients and ambulances.

It should ideally be situated near ICU and Operating Room.

As a rule of thumb daily patient load of 100 in ED will require approx 1000 sq mtr of space.KEY PLANNING AND DESIGNING PARAMETERSPatient waiting area should be welcoming, visually appealing and comfortable.

There should be a readily identifiable triage area with expansion facilities for utilization during management of disasters.

It should have acute care rooms arranged around the main nursing work area.

It should have trauma rooms in proximity to the entrance.

There should be effective day and night sign posting.KEY PLANNING AND DESIGNING PARAMETERSDoor should be wide enough to accommodate stretcher, trolleys and portable X-Ray machine.

A door of width 1.8 m allows attendants to walk on either side of a stretcher or trolley.

Clinical care areas should have exposure to maximum feasible day light.

Safety and security of staff, patients and visitors.

Each treatment area requires space of 15 m sq.

The resuscitation room/bay should have space to accommodate specialized resuscitation bed, allow 360 degree access to all parts of the patient for facilitating procedures.

Ceiling mounted power columns simplifies access of monitoring lines and devices.

Policy 1

Any patient seeking for emergency care irrespective of types of emergency will first report to this department. Here the patient will be assessed about the nature of illness and the treatment required for the management of the condition. After careful examination, needed care been provided, the patient will be either disposed off or be taken to the specific care treatment area and patient care will be given for further management of the disease.

HOSPITAL POLICIES FOR ED Policy 2e.g.The department can accept any type of emergency except Medico-Legal Cases. Medico-Legal Cases are not accepted except for giving first aid. (hospital to hospital policy may vary)

These cases include:Accident casesPoisoning cases (Suicidal, Homicidal)Burn cases

The other cases that are not attended are:Infective casesOpen tuberculosis cases

Note: Medico legal cases load in an emergency department accounts for 20% of total workload and out of these 50% are RTAs

HOSPITAL POLICIES FOR ED Policy 3

The department has to attend to provide immediate relief and management of patients arriving at the hospital with acute medical and surgical emergency for e.g. Acute MI, Shock, Status Asthmatius, Acute Abdomen, etc.

HOSPITAL POLICIES FOR ED Policy 4

The department has to attend to the patients coming outside the routine outpatients working hours, and

Screen them for admissionObserve them for short period to determine whether they need admissionProvide Outpatient Care

HOSPITAL POLICIES FOR ED Policy 5

The department has to see patients on Sundays as the OPD is closed on Sundays.

Policy 6

The ED in order to deliver the above mentioned services has been and will be equipped with diagnostic and therapeutic equipments which are needed to manage critical patients. The purchase of new equipment will be through Central Purchase Committee (CPC)

HOSPITAL POLICIES FOR ED Policy 7

The ED will have trained medical and nursing professional to manage patients coming to it.

Policy 8

The emergency department will avail the services of specialists and super-specialists associated with the hospital whenever the services are required for the management of the casualty cases.

HOSPITAL POLICIES FOR ED Policy 9

The ED will provide ambulance services for bringing the patients to the hospital.

Policy 10

the patient will be received and brought in to the emergency department by the ward boys on the stretcher if the patient is non ambulatory.

HOSPITAL POLICIES FOR ED Availability of Quality manualProcedure for receiving patientWell rehearsed protocolsAdmission of the patient and transfer to the wardRecording the case detailsValuables of the patientsPatient refusing the admissionMedico legal casesDisaster planTriagingProtocol for death casesProcedure for calling Consultants on callDaily check of all medical itemsControl of narcotic, cytotoxic drugsEquipment checks on daily basisSchedule of chargesPeriodic audit

Quality of the process of careResponse time for dispatch of ambulance when asked forResponse time of the consultantTime taken for treatment and starting the definitive treatmentDeath rate in A & E departmentLength of stay on observation beds and emergency ward beds bothSatisfaction level of patients and attendantsType of cases received in emergencyDaily attendance and percentage of cases admittedResponse time of code blue teamEmployee satisfaction

Measuring Quality for A & E services