Emergency Hospital Services, an Introduction

Agus BarmawiEmergency InstallationFaculty of Medicine GMU/Sardjito General Hospital Yogyakarta

Learning Objectives

After completion of this topic the student will be able to :

A. Understand the system of emergency in Indonesia

B. Understand the goal of emergency services

C. Understand of initial assessmentD. Understand the triage settingE. Understand of patient safety in

emergency room

Introduction In instances of emergency,

immediate, rapid medical response is vital to minimize the extent of injury.

When numerous patients arrive at an emergency room or a large scale disaster occurs, a hospital's emergency staff employs triage procedures.

Introduction

This systematic set of procedures ensures that all patients are seen and evaluated immediately and then prioritized to allow the most critical patients to receive the most immediate assistance

Definition

An Emergency Department (ED), also known as Accident & Emergency (A&E), Emergency Room (ER), Emergency Ward (EW), or Casualty Department is a medical treatment facility, specializing in acute care of patients who present without prior appointment, either by their own means or by ambulance.

Indonesia Concept of Emergency Services

Triage--START

The Goal of emergency services

To reduce mortality To reduce morbidity

The principle of treatment isLive savingLimb saving

Patient Safety

Patient safety is the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum. An acceptable minimum refers to the collective notions of given current knowledge, resources available and the context in which care was delivered weighed against the risk of non-treatment or other treatment(Morrison.L.J., et al.2009)

Patient safety Goal Improve the accuracy of patient identification.         Improve the effectiveness of communication among

caregivers. Improve the safety of using medications. Improve the safety of using infusion pumps. Reduce the risk of health care-associated infections. Accurately and completely reconcile medications

across the continuum of care.  Reduce the risk of patient harm resulting from

falls. (JCAHO,2005)

Each patient will be evaluated about initial assessment :

TheAir wayBreathingCirculationDisability

Emergency Services in Sardjito General Hospital Cases

Trauma Any kinds of trauma

Brain injury Trauma of the face Thoraxic injury Abdominal trauma Musculoskeletal trauma

Cervical Back bone Pelvis extremity

Emergency Services in Sardjito General Hospital Cases

Trauma Burn injury Pediatric trauma Eyes trauma Trauma of pregnancy

Emergency Service Cases at Sardjito General Hospital

Non Trauma Infections

Bacterial Meningitis Oropharyngeal phlegmon Pneumonia/bronchitis TBC Pyogenic infections

Non Trauma Infections

Viral Dengue fever/DHF/DSS Hepatitis HIV Swine flu Avian/Bird/H5N1 flu Sars

Parasites

Non Trauma Infections

Parasites Malaria Amoebiasis Leptospirosis

Non Trauma Non Infection

Cardiac arrest Heart attack Congestive Heart failure Asthma bronchiale

Non Trauma Non Infection COPD DM Hyperosmolar Hyperglycaemic Non-

Ketotic Coma (HONK) CKD Upper/lower GI tract bleed Bowel obstruction due to any causes Stroke Pre eclampsia

Non Trauma Non Infection Extopic pregnancy Abortion Others obgy emergencies Emergency of oncology Emergency of Congenital disesase

Atresia esophagus Atresia ani Others

Urine retention

Steps to Triage Hospital Setting

Day to day emergency services of triageMore detail

AnamnesisPhysical examinationSupportive dataConsultationDiagnoseDefinitive treatment

Disaster Setting

Disaster Setting TriageField triageField treatment areaLimited supportive dataStabilization and transportation“No definitive treatment”/Limited definitive treatment

How to Complete Triage Procedure The initial intake medical exam should take

no more than 60 seconds.

During this time, the medical professional must perform a basic assessment of the patient's injuries.

The majority of this examination is visual, with the practitioner glancing over the victims body and using his hands to feel for any palpable wounds or indications of serious problems.

Complete a basic examination If necessary, emergency personnel can

take the patient's vitals at this stage. All complex testing must wait until the

patient has been categorized and processed. If the patient has injuries that are an immediate threat to his survival, the team can perform immediate emergency care.

Provide immediate emergency care

If the patient has an actively gushing wound or is not breathing, the medical team immediately performs any necessary life-saving procedures, including stopping the flow of blood through the use of a tourniquet or performing cardiopulmonary resuscitation (CPR) to restart the heart.

Provide immediate emergency care

Immediate emergency care should only be provided if the patient's life is in imminent danger.

If it is not, the patient should be prioritized and placed with others in a central waiting room.

Complete a prioritization

To determine the order of treatment, all patients must be prioritized.

During prioritization, the emergency medical personnel must group the patients based on the threat presented by their wounds.

Complete a prioritization

This prioritization is completed quickly and with only the information obtained from the 60-second intake examination.

Patients are then categorized and given easily identifiable color-coded bands.

Tag patients for easy reference Patients with only minor wounds receive a green tag,

indicating that they can be seen last.

Patients with slightly more serious wounds receive a yellow tag, showing that they need to be seen before the minor wound patients.

Patients with serious wounds that require immediate attention receive a red tag, allowing personnel to easily determine that they should be the first treated.

Patients who are already deceased are labeled with a black tag.

The management Problem at ED

Bottlenecked patient flow Communication problems Long waiting times

The Challenges in Emergency Department Services

How to track “real time” patient status in the ED How to improve efficiencies in triage, patient

flow, lab, x-ray, and dispositions How to improve communication among the ED

staff and between ED staff and other departments

How to track important milestones for review and analysis

How to do all of the above without increasing the work load of an ED staff already at or near its limits

Bringing Visibility to Complex ED Workflows

Emergency careSeriously ill from community and

referral

Unscheduled urgent careLack of available Ambulatory careDesire for immediatecare

Input Throughput Output

Ambulancediversion

Leave withoutTreatmentcomplete

Patient disposition

Safety net careVulnerable PopulatonAccess barriers

Demand For EDCare

Patient arrivesAt ED

Triage and roomplacement

Diagnostic Evaluation and ED treatment

ED boarding ofpatients

AmbulatoryCare system

Transfer to other facility

Admit tohospital

Lack of access toFollow up care

Lack of available staffed Inpatient beds

Patients Flow in The Emergency Department

Tracking and Communication System in ED

Automatic tracking

Strategies to Improve Flow

In October 2007, Yen and Gorelikreviewed in Pediatric Emergency Carevarious strategies to improve flow in thePediatric ED at the different stages ofthe flow process.

Picture Archiving and Communication System (PAC System)

PAC systems with integrated reporting capabilities, provide radiology departments with the means to manage medical images in a digital format on a variety of computer networks.

By changing the way that images are collected, displayed, reported and stored within a department, major efficiencies can be obtained. (Mc Callum.1995)

IntakeImprove the triage process Increase triage staffing Limit the scope of triage to the minimal information

gathering necessary to allow prioritization 2-tiered triage system: limited initial screen allowing

some to bypass a second more comprehensive screen (those who require immediate attention or are clearly "fast track" patients)

Physician or allied health provider triage- possible disposition from triage or allows treatment to begin earlier

Collaborative practice protocols: standing orders for certain lab test, imaging studies, etc

Clinical pathways

Intake Improve the registration process Use minimum demographic information to

generate a chart and then complete registration at the bedside.

Placement of patients in exam rooms and assignment to physician and nursing staff

Active assignment by a charge nurse of physician in a time-prioritized manner

Outflow

Strategies to decrease holding admitted patients in ED

Dedication of an inpatient ward to admissions from the ED

Establish a short-stay unit Simplify the admission process Early prediction of need for admission may permit

earlier bed requests

Facilitate discharge of patients going home Dedicated discharge nurse Preprinted discharge and educational materials Facilitation of primary or specialty care follow-up

ED overcrowding impacts all the stakeholders in healthcare system.

The strategies described may help improve flow and provide immediate relief of overcrowding; however, long-term solutions are needed.

Further research is needed exploring the link between crowding and quality of care and studying interventions to alleviate ED overcrowding.

Pediatric Emergency Medicine Section - March 2008, Vol 19, #2

Diagnostic Testing and ED Treatment

Collaborative proactive protocols leading to earlier lab test ordering

Use of point-of-care testing (rapid strep, influenza, electrolytes, hematocrit, urine pregnancy, fecal and gastric blood and urinalysis)

Improve laboratory turn around time

Point-of-care imaging: bedside ultrasound

Improve predictors of staffing needs based on historical flow data

Ensure adequate ancillary staff

Create a separate stream for low-acuity patients in the ED ("fast track")

Technological improvements: electronic tracking board, bar-coding patients, PACS, EMR, telemedicine for consultants, electronic prescriptions

Traumatology (from Greek "Trauma" meaning injury or wound) is the study of wounds and injuries caused by accidents or violence to a person, and the surgical therapy and repair of the damage.

Traumatology is a branch of medicine. It is often considered a subset of surgery and in countries without the specialty of trauma surgery it is most often a sub-specialty to orthopedic surgery.

Traumatology may also be known as accident surgery.

Factors in the assessment of wounds are: the nature of the wound, whether it is a

laceration, abrasion, bruise or burn the size of the wound in length, width and

depth the extent of the overall area of tissue

damage caused by the impact of a mechanical force, or the reaction to chemical agents in, for example, fires or exposure to caustic substances.

The ASA physical status classification system is a system for assessing the fitness of patients before surgery. In 1963 the American Society of Anesthesiologists (ASA) adopted the five-category physical status classification system; a sixth category was later added. These are:

1. A normal healthy patient.2. A patient with mild systemic disease.3. A patient with severe systemic disease.4. A patient with severe systemic disease that is a

constant threat to life.5. A moribund patient who is not expected to survive

without the operation.6. A declared brain-dead patient whose organs are being

removed for donor purposes.

If the surgery is an emergency, the physical status classification is followed by “E” (for emergency) for example “3E”