EMERGENCY DEPARTMENT MINAKSHI GAUTAM ASSISTANT PROFESSOR
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- EMERGENCY DEPARTMENT MINAKSHI GAUTAM ASSISTANT PROFESSOR
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- Increasing 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 received
INTRODUCTION
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- Derived 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.
INTRODUCTION
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- Casualty 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. INTRODUCTION
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- INTRODUCTION Medical 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.
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- INTRODUCTION Also 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 WHO
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- INTRODUCTION The 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.
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- INTRODUCTION Quick 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, or Sudden attacks of
illness or exacerbation of disease.
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- INTRODUCTION These 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
patients
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- INTRODUCTION The ED is also referred as casualty wing for
emergency cases It should have a distinct entry independent of OPD
main entry
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- INTRODUCTION To the patient high quality of outcome means;
Right time Right care Right expertise Right attitude Right
cost
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- INTRODUCTION The first and foremost requirement of a Casualty
is that it should do the patient no harm Florence Nightingale
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- INTRODUCTION It 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.
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- INTRODUCTION There 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.
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- INTRODUCTION As 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.
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- INTRODUCTION Emergency 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.
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- Normal Life Physical Sudden Disruption Social Spiritual Mental
Sudden feeling of restlessness Some form of disaster (Natural or
Man-Made) Admitted to Emergency Sympathetic and Confident Doctors
Diagnosis Treatment Making the Patient Confident Operation if
Needed Relieved with advice to Visit OPD Treatment
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- Process Requirements Simple 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%
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- 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 Facts
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- 60% 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 Facts
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- The 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 Facts
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- The 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 Facts
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- It 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 Facts
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- Accident 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 Facts
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- Core Design
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- TYPES OF EMERGENCY Surgeons 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?
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- 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 pathologies TYPES OF EMERGENCY
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- Major 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.
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- Divided in two parts Outside the hospital Inside the hospital
Outside services can again be divided into two groups: Alarm and
communication system Ambulance services Types of Emergency Medical
Services
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- OBJECTIVES AND SCOPE OF SERVICES Emergencies 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 bodies Burn of
all types Dog bites and snake bites Mass causalities from food
poisoning, drinks, riots, etc Medico-legal cases Cases of acute
severe pain or distress Septic conditions Obstetric emergencies
real or pseudo in nature Pseudo emergency cases - Pseudo emergency
cases mostly includes fear of unknown, lack of competence of G.P.,
Easy accessibility, Stress and strain
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- OBJECTIVES AND SCOPE OF SERVICES Managing 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 relatives Maintaining records
Training
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- Location, Accessibility and Layout Broadly the department
should have the following: Consultation and examination room
Equipped with: i.Doctors seating arrangement with office furniture.
ii.Examination Couch iii.BP Instrument (Sphygmomanometer)
iv.Stethoscope v.Clinical Thermometer vi.Torch
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- Procedure Room i.Equipped with facilities for minor procedures
like suturing, Endotracheal Intubation, Dressing, Plaster,
Catheterization, Ryles Tube. ii.Operation Theatre Light iii.Suction
Machine iv.Boiler v.Drip Stand vi.Glucometer Treatment Room
Equipped with i.DC Shock Machine ii.Beds for treatment iii.Cardiac
Table iv.Instruments for vaccination Toilet, and Waiting Area
Location, Accessibility and Layout
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- Reception and Information area
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- Physical Facilities for 200-300 bedded emergency department S.
No.Name of facilityNumberSizeArea in Sq ft 1Ambulance entrance 1--
2Main entrance to casualty 18ft x 10ft80 3Waiting area120ft x 20
ft400 4Reception1-140 5Examination cubicle 480 sq ft320
6Observation ward10 beds84 sq ft each 480 7Emergency X-Ray Room 112
ft x 15 ft 180 8Emergency Laboratory 112 ft x 15 ft 180 9Treatment
Room112 ft x 15 ft 180
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- Physical Facilities for 200-300 bedded emergency department S.
No.Name of facilityNumberSizeArea in Sq ft 10Fracture/ Plaster Room
1 12 ft x 10 ft 120 11Doctors Duty Room1240 12Nurses Duty Room112
ft x 10 ft120 13ECG Technicians Room 112 ft x 10 ft120 14Room for
Gr C and D 112 ft x 10 ft120 15Store Room112 ft x 10 ft120 16Staff
toilets28 ft x 10 ft160 17Water cooler1-- 18Police Post112 ft x 15
ft180 19Patients toilets112ft x 15 ft180
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- Acute patient care room
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- EQUIPMENTS Some of the equipments of ED: Ventilators
Defibrillators Pulse Oximeter Drop Infusion Pump (Dosimeter)
Suction Machine Laryngoscope Airway Cardiac Monitors Ambu Bag ECG
Machine Portable X-Ray Machine Emergency Trolleys Splinting
Equipments Stethoscope, Clinical Thermometer, Torch
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- Separate Counters Registration Charges Bed Charges REGISTRATION
PROCEDURE FOR EMERGENCY CASES
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- On 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 Stay OPERATION THEATRE Minor 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.
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- Medical Cases Surgical Cases Diagnostic Services Vaccination
Blood Transfusion Injections FACILITIES PROVIDED IN THE ED
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- Emergency Incharge (Senior Doctor) CMO in each shift Nurses
(Diploma in Nursing and midwifery) Ward boys Sanitary Attendant
STAFF DUTY ROASTERS Morning Duty 8am 2 pm Evening Duty2pm 9 pm
Night Duty9 pm 8 am
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- 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 signature STAFF
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- PATIENT FLOW Critical Patient Emergency Department Consultant
Examines Payments and Registration at OPD Counter Vitals Checked
Investigations (ECG, Blood Sugar Emergency Care given to patient
(IV fluids, suction, etc) Treatment initiated Discharged Admitted
to IPD
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- The 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
supplies
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- Doctors 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 nurse Injection register
maintained by nurse Thalessemia register maintained by Sister
Incharge Vaccination Register -Emergency OPD cases should be
registered separately -Trend of cases according to seasons should
be monitored -Dying declaration by Medical officer RECORDS
MAINTAINED IN EMERGENCY DEPT
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- KEY PLANNING AND DESIGNING PARAMETERS Patient 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
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- KEY PLANNING AND DESIGNING PARAMETERS The 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.
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- KEY PLANNING AND DESIGNING PARAMETERS The 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.
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- KEY PLANNING AND DESIGNING PARAMETERS Patient 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.
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- KEY PLANNING AND DESIGNING PARAMETERS Door 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.
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- 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
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- Policy 2 e.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 cases Poisoning cases (Suicidal,
Homicidal) Burn cases The other cases that are not attended are:
Infective cases Open 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
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- 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
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- Policy 4 The department has to attend to the patients coming
outside the routine outpatients working hours, and Screen them for
admission Observe them for short period to determine whether they
need admission Provide Outpatient Care HOSPITAL POLICIES FOR
ED
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- 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
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- 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
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- 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
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- Availability of Quality manual Procedure for receiving patient
Well rehearsed protocols Admission of the patient and transfer to
the ward Recording the case details Valuables of the patients
Patient refusing the admission Medico legal cases Disaster plan
Triaging Protocol for death cases Procedure for calling Consultants
on call Daily check of all medical items Control of narcotic,
cytotoxic drugs Equipment checks on daily basis Schedule of charges
Periodic audit Quality of the process of care
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- Response time for dispatch of ambulance when asked for Response
time of the consultant Time taken for treatment and starting the
definitive treatment Death rate in A & E department Length of
stay on observation beds and emergency ward beds both Satisfaction
level of patients and attendants Type of cases received in
emergency Daily attendance and percentage of cases admitted
Response time of code blue team Employee satisfaction Measuring
Quality for A & E services