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The Emergency Department (ED), sometimes termed Accident & Emergency (A&E), Emergency Room (ER), Emergency Ward (EW), or Casualty Department is a hospital or primary care department that provides initial treatment to patients with a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. In some countries, Emergency Departments have become important entry points for those without other means of access to medical care. Staff teams treat emergency patients and provide support to family members. The emergency departments of most hospitals operate around the clock, although staffing levels attempt to mirror patient volume, which in most ED's finds its nadir between 2:00 am and 6:00 am. Most patients seek the Emergency Department in the afternoon and evening hours, and staffing mirrors this phenomenon.

Contents

History

The first specialized trauma care center in the world was opened in 1911 in the United States at the University of Louisville Hospital in Louisville, Kentucky, and was developed by surgeon Arnold Griswold during the 1930s. Griswold also equipped police and fire vehicles with medical supplies and trained officers to give emergency care while en route to the hospital. [1]

Department layout

The emergency department entrance at Mayo Clinic's Saint Marys Hospital. The red-and-white emergency sign is clearly visible.

A typical emergency department has several different areas, each specialized for patients with particular severities or types of illness.

In the triage area, patients are seen by an RN or LPN, who completes a preliminary evaluation, before they are transferred to another area of the ED or a different department in the hospital. One body of expertise that seems particularly applicable to emergency medicine services is Operations Management. Operations management utilizes a systems approach to the provision of a service, including the definition of the particular characteristics of a service (such as the service package, the service process, and the virtual value chain embedded in that service), structured planning for service quality, appropriate service metrics, selected management tools, and consideration of strategies for interdisciplinary collaboration, as well as cultural change. The resuscitation area is a key ultimately, the value of an operations management approach to management of the ED is explicit consideration of all salient elements of the service process in a systematic manner. In doing so, it is important to link clearly the service function to the institutions mission/strategic plan, as well as the expectations and needs of ED patients who are served there. They are sent to the minors area. Such patients may still have been found to have significant problems, including fractures, dislocations, and lacerations requiring suturing.

Asplin (A Conceptual Model of Emergency Department Crowding. Ann Emerg Med. 2003; 42:173-180), describes a three-phase “input – throughput – output” model of emergency services. This model is applicable to the challenge and solutions to the problem of ED overcrowding that has occurred in many communities in the US.

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Some departments employ a play therapist whose job is to put children at ease to reduce the anxiety caused by visiting the emergency department, as well as provide distraction therapy for simple procedures.

Many hospitals have a separate area for evaluation of psychiatric problems. These are often staffed by psychiatrists and mental health nurses and social workers. There is typically at least one room for people who are actively a risk to themselves or others (e.g. suicidal).

Intangibility: Services are not manufactured according to precise standards, nor can they be stored. How consumers perceive services is very subjective, since they are a performance rather than a tangible good. Variability: Consistent service delivery is very difficult, particularly in fields such as medicine, due to the high labor contribution of the service along with the variation between clinicians. Inseparability: Service quality is extremely difficult to control since it is produced and consumed at the same time. There is no opportunity to measure or inspect the service prior to actually delivering it. Additionally, the consumer (patient) significantly impacts the quality of the service provided. For example, the description of a patient's symptoms can significantly affect the outcome of the visit. The better the description, the more likely a better outcome.

Signage

An example of California hospital signage

A hospital with an emergency department usually has prominent signage reading Emergency or Accident and Emergency (often in white text on a red background) and an arrow to indicate where patients should proceed. Some American states closely regulate the design and content of such signs and require wording such as "Comprehensive Emergency Medical Service" and "Physician On Duty",[2] to prevent persons in need of critical care from presenting to facilities that are not fully equipped and staffed.

Nomenclature

In Australia and Canada, the department is usually referred to as the Emergency Department or Emerg.

In the United Kingdom, New Zealand, Hong Kong, Singapore, and Ireland specifically, the department is known as A&E (Accident & Emergency). In response to the number of 'minor' injuries that are often presented within the department, some hospitals now choose to only use the term ED (Emergency Department) in order to emphasise urgent cases only. Despite this, all road signs to the department throughout the UK read A&E, and this remains unchanged. Most teaching hospitals and district general hospitals (DGHs) have an A&E department. The largest such department in the UK is in the city of Leicester (Leicester Royal Infirmary). The term Casualty, which preceded A&E in the UK (and is still at times informally used to denote the emergency department of a hospital) is no longer considered appropriate by emergency medical staff in the United Kingdom and Ireland, for similar aforementioned reasons.

In the United States an emergency department is often referred to by both laypeople and medical professionals as an emergency room or an "ER." [Medical professionals occasionally call it whatever its name is within their specific hospitals, or simply "emergency."] The term "emergency room" is based on historic usage and is a misnomer today, for a modern hospital's emergency facilities do not consist of only a single room. The ER interacts with every other department in the hospital and often represents a significant percentage of the hospital's work load and finances.

During the 1990s, an effort began to change to the more accurate term emergency department (ED), which is a term increasingly used by members of the specialty internationally. The updated name has not yet caught on to the mainstream American public, perhaps due in part to the popularity of the TV show ER, and the heavy marketing of the abbreviation "ED" for erectile dysfunction by pharmaceutical companies.[citation needed] However, the term does have wide circulation among emergency medicine staff. Individual hospitals may also refer to the department by different names, such as emergency ward, emergency center, emergency unit, etc.

Leading journals, including the Annals of Emergency Medicine, published by the American College of Emergency Physicians, and the Emergency Medicine Journal (emj) of the British Association for Emergency Medicine (BAEM), consistently use the term emergency department.[citation needed]

In some countries, including the United States, Europe and Canada, a smaller facility that may provide assistance in medical emergencies is known as a clinic. Larger communities often have walk-in clinics where people with medical problems that would not be considered serious enough to warrant an emergency department visit can be seen. These clinics often do not operate on a 24 hour basis.

The term "urgency" instead of "emergency" is used in some Latin American countries. Emergency departments are known as "servicios de urgencia" and they function in a similar fashion to European emergency departments.

United States

Many U.S. emergency rooms are exceedingly busy. A survey of New York area doctors in February 2007 found that injuries and even deaths have been caused by excessive waits for hospital beds by ER patients.[3] A 2005 patient survey found an average ER wait time from 2.3 hours in Iowa to 5.0 hours in Arizona.[4]

One inspection of Los Angeles area hospitals by Congressional staff found the ERs operating at an average of 116% of capacity (meaning there were more patients than available treatment spaces) with insufficient beds to accommodate victims of a terrorist attack the size of the 2004 Madrid train bombings. Three of the five Level I trauma centers were on "diversion", meaning ambulances with all but the most severely injured patients were being directed elsewhere because the ER could not safely accommodate any more patients.[5] This controversial practice was banned in Massachusetts (except for major incidents, such as a fire in the ER), effective January 1, 2009; in response, hospitals have devoted more staff to the ER at peak times and moved some elective procedures to non-peak times.[6] [7]

In 2009, there were 1,800 ERs in the country.[8]

United Kingdom

A&E sign common in the UK.

All A&E departments throughout the United Kingdom are financed and managed by the NHS of each constituent country (England, Scotland, Wales and Northern Ireland). As with most other NHS services, emergency care is provided to all, both resident citizens and those not ordinarily resident in the UK, free at the point of need and regardless of any ability to pay.

Historically, waits for assessment in A&E were very long in some areas of the UK. In October 2002, the Department of Health introduced a four-hour target in emergency departments that required departments to assess and treat patients within four hours of arrival, with referral and assessment by other departments if deemed necessary. Present policy is that 98% of all patient cases do not "breach" this four-hour wait.

The 4-hour target triggered the introduction of the acute assessment unit (also known as the medical assessment unit), which works alongside the emergency department but is outside it for statistical purposes in the bed management cycle. It is claimed that though A&E targets have resulted in significant improvements in completion times, the current target would not have been possible without some form of patient re-designation or re-labelling taking place, so true improvements are somewhat less than headline figures might suggest and it is doubtful that a single target (fitting all A&E and related services) is sustainable.[9]

Patient experience

If the patient's service expectation is not met, there are ways to remedy this shortcoming. Service recovery is an effective tool to prevent patient defection, but it is necessary to have a well crafted plan in place before the actual event occurs. Patient retention can have a significant financial impact.

Patients are becoming more sophisticated and the healthcare industry must take notice of this. Other sectors of the economy are providing an ever higher quality of service and are raising consumers' expectations along with it. If budget motels, low cost airlines and quick auto lube outlets can produce consistently high quality service encounters, patients will only come to expect that much and more from high-tech and high-cost medical encounters.

Critical conditions handled

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Cardiac arrest

Cardiac arrest may occur in the ED/A&E or a patient may be transported by ambulance to the emergency department already in this state. Treatment is basic life support and advanced life support as taught in advanced life support and advanced cardiac life support courses. This is an immediately life-threatening condition which requires immediate action in salvageable cases.

Heart attack

See main article: Myocardial infarction

Patients arriving to the emergency department with a myocardial infarction (heart attack) are likely to be triaged to the resuscitation area. They will receive oxygen and monitoring and have an early ECG; aspirin will be given if not contraindicated or not already administered by the ambulance team; morphine or diamorphine will be given for pain; sub lingual (under the tongue) or buccal (between cheek and upper gum) glyceryl trinitrate [nitroglycerin] (GTN or NTG) will be given, unless contraindicated by the presence of other drugs, such as drugs that treat erectile dysfunction.

An ECG that reveals ST segment elevation or new left bundle branch block suggests complete blockage of one of the main coronary arteries. These patients require immediate reperfusion (re-opening) of the occluded vessel. This can be achieved in two ways: [thrombolysis] (clot-busting medication) or percutaneous transluminal coronary angioplasty (PTCA). Both of these are effective in reducing significantly the mortality of myocardial infarction. Many centers are now moving to the use of PTCA as it is somewhat more effective than thrombolysis if it can be administered early. This may involve transfer to a nearby facility with facilities for angioplasty.

Trauma

Major trauma, the term for patients with multiple injuries, often from a road traffic accident or a major fall, is sometimes handled in the Emergency Department. However, trauma is a separate (surgical) specialty from emergency medicine (which is a medical specialty, and has certifications in the United states from the American Board of Emergency Medicine).

Trauma is treated by a trauma team who have been trained using the principles taught in the internationally recognized Advanced Trauma Life Support (ATLS) course of the American College of Surgeons. Some other international training bodies have started to run similar courses based on the same principles.

The services that are provided in an emergency department can range from simple x-rays and the setting of broken bones to those of a full-scale trauma center. A patient's chance of survival is greatly improved if the patient receives definitive treatment (i.e. surgery or reperfusion) within one hour of an accident (such as a car accident) or onset of acute illness (such as a heart attack). This critical time frame is commonly known as the "golden hour."

Some emergency departments in smaller hospitals are located near a helipad which is used by helicopters to transport a patient to a trauma center. This inter-hospital transfer is often done when a patient requires advanced medical care unavailable at the local facility. In such cases the emergency department can only stabilize the patient for transport.dr jawed

Mental Illness

Some patients arrive at an emergency department for a complaint of mental illness. In many jurisdictions (including many U.S. states), patients who appear to be mentally ill and to present a danger to themselves or others may be brought against their will to an emergency department by law enforcement officers for psychiatric examination. The emergency department conducts medical clearance rather and treats acute behavioral disorders. From the emergency department, patients with significant mentally illness may be transferred to a psychiatric unit (in many cases involuntarily).

Asthma and COPD

Acute exacerbations of chronic respiratory diseases, mainly asthma and chronic obstructive pulmonary disease (COPD), are assessed as emergencies and treated with oxygen therapy, bronchodilators, steroids or theophylline, have an urgent chest X-ray and arterial blood gases and are referred for intensive care if necessary. Non invasive ventilation in the ED has reduced the requirement for intubation in many cases of severe exacerbations of COPD.

Special facilities, training, and equipment

An ED requires different equipment and different approaches than most other hospital divisions. Patients frequently arrive with unstable conditions, and so must be treated quickly. They may be unconscious, and information such as their medical history, allergies, and blood type may be unavailable. ED staff are trained to work quickly and effectively even with minimal information.

ED staff must also interact efficiently with pre-hospital care providers such as EMTs, paramedics, and others who are occasionally based in an ED. The pre-hospital providers may use equipment unfamiliar to the average physician, but ED physicians must be expert in using (and safely removing) specialized equipment, since devices such as Military Anti-Shock Trousers ("MAST") and traction splints require special procedures. Among other reasons, given that they must be able to handle specialized equipment, physicians can now specialize in emergency medicine, and EDs employ many such specialists.

ED staff have much in common with ambulance and fire crews, combat medics, search and rescue teams, and disaster response teams. Often, joint training and practice drills are organized to improve the coordination of this complex response system. Busy EDs exchange a great deal of equipment with ambulance crews, and both must provide for replacing, returning, or reimbursing for costly items.

Cardiac arrest and major trauma are relatively common in EDs, so defibrillators, automatic ventilation and CPR machines, and bleeding control dressings are used heavily. Survival in such cases is greatly enhanced by shortening the wait for key interventions, and in recent years some of this specialized equipment has spread to pre-hospital settings. The best-known example is defibrillators, which spread first to ambulances, then in an automatic version to police cars, and most recently to public spaces such as airports, office buildings, hotels, and even shopping malls.

Because time is such an essential factor in emergency treatment, EDs typically have their own diagnostic equipment to avoid waiting for equipment installed elsewhere in the hospital. Nearly all have an X-ray room, and many now have full radiology facilities including CT scanners and ultrasonography equipment. Laboratory services may be handled on a priority basis by the hospital lab, or the ED may have its own "STAT Lab" for basic labs (blood counts, blood typing, toxicology screens, etc) that must be returned very rapidly.

Non-emergency use

Metrics applicable to the ED can be grouped into three main categories, volume, cycle time, and patient satisfaction. Volume metrics including arrivals per hour, percentage of ED beds occupied and age of patients are understood at a basic level at all hospitals as an indication for staffing requirements. Cycle time metrics are the mainstays of the evaluation and tracking of process efficiency and are less widespread since an active effort is needed to collect and analyze this data. Patient satisfaction metrics, already commonly collected by physician groups and hospitals, are useful in demonstrating the impact of changes in patient perception of care over time. Since patient satisfaction metrics are derivative and subjective, they are less useful in primary process improvement.

In many Primary Care Trusts there may be out of hours doctor services sometimes known as Keydoc or something similar (varying by area) provided by volunteer General Practitioners.

Patients attending the ED for minor complaints do not contribute significantly to the overall workload of the department.[citation needed] (Despite the level of complaints in the general public and by health staff.) Studies, in Australia at least, have shown that improved after-hours GP access has no effect on ED workload or waiting times.

In the United States, and many other countries, hospitals are beginning to create areas in their emergency rooms for people with minor injuries. These are commonly referred as fast track or Minor Care units. These units are for people with non life-threatening injuries. The use of these units within a department have been shown to significantly improve the flow of patients through a department and to reduce waiting times. Urgent care clinics are another alternative, where patients can go to receive immediate care for non-life-threatening conditions.

Doctors in training

Doctors in training provide a large portion of the medical care in emergency departments.

In the United States, they are called residents and are supervised by ABEM board certified attending physicians.

In the United Kingdom, many doctors rotate through the emergency department, such as during their second foundation year (F2), or as part of a rotational specialty training programme in General Practice or Emergency Medicine.

Emergency departments in the military

Emergency departments in the military benefit from the added support of enlisted personnel who are capable of performing any task they have been trained for, regardless of actual education obtained from civilian schooling. For example, in Naval hospitals, Hospital Corpsmen perform tasks that fall under the scope of practice of both doctors (i.e. sutures and incision and drainages) and nurses (i.e. medication administration and foley catheter insertion). Often, some civilian education and/or certification will be required such as an EMT certification, in case of the need to provide care outside of the base where the member is actually stationed.

See also

Notes

References

  • John B Bache, Carolyn Armitt, Cathy Gadd, Handbook of Emergency Department Procedures, ISBN 0-7234-3322-4
  • Swaminatha V Mahadevan, An Introduction To Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department, ISBN 0-521-54259-6
  • Academic Emergency Medicine, ISSN: 1069-6563, Elsvier

External links


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