EMERGENCY DEPARTMENT

1. EMERGENCY DEPARTMENT MINAKSHI GAUTAM ASSISTANT PROFESSOR

2. INTRODUCTION • 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

3. INTRODUCTION • 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.

4. INTRODUCTION • 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.

5. 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.

6. 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

7. 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.

8. 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.

9. 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

10. INTRODUCTION • The ED is also referred as casualty wing for emergency cases • It should have a distinct entry independent of OPD main entry

11. INTRODUCTION • To the patient high quality of outcome means; • Right time • Right care • Right expertise • Right attitude • Right cost

12. INTRODUCTION • “ The first and foremost requirement of a Casualty is that it should do the patient no harm” Florence Nightingale

13. 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.

15. 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.

16. 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.

17. 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.

18. Mental Physical Normal Life Social Spiritual Some form of disaster (Natural or Man-Made) Sudden Disruption Sudden feeling of restlessness Sympathetic and Confident Doctors Making the Patient Confident Admitted to Emergency Diagnosis Treatment Relieved with advice to Visit OPD Operation if Needed Treatment

20. 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%

21. Other Facts • 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.

22. Other Facts • 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%

23. Other Facts • 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 crorefor establishing 140 trauma care centres along the Golden Quadrilateral highways.

24. Other Facts • 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.

25. Other Facts • 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.

26. Other Facts • 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.

27. Core Design

29. 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?

30. TYPES OF EMERGENCY • 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

31. TYPES OF EMERGENCY • 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.

32. Types of Emergency Medical Services • 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

33. 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

34. 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

35. Location, Accessibility and Layout Broadly the department should have the following: • Consultation and examination room Equipped with: • Doctors seating arrangement with office furniture. • Examination Couch • BP Instrument (Sphygmomanometer) • Stethoscope • Clinical Thermometer • Torch

36. Location, Accessibility and Layout • Procedure Room • Equipped with facilities for minor procedures like suturing, Endotracheal Intubation, Dressing, Plaster, Catheterization, Ryles Tube. • Operation Theatre Light • Suction Machine • Boiler • Drip Stand • Glucometer • Treatment Room • Equipped with • DC Shock Machine • Beds for treatment • Cardiac Table • Instruments for vaccination • Toilet, and Waiting Area

37. Reception and Information area

38. Physical Facilities for 200-300 bedded emergency department

39. Physical Facilities for 200-300 bedded emergency department

40. Acute patient care room

42. 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

43. REGISTRATION PROCEDURE FOR EMERGENCY CASES • Separate Counters • Registration Charges • Bed Charges

44. Average Time for ED Stay 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. 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.

45. FACILITIES PROVIDED IN THE ED • Medical Cases • Surgical Cases • Diagnostic Services • Vaccination • Blood Transfusion • Injections

46. STAFF • Emergency Incharge (Senior Doctor) • CMO in each shift • Nurses (Diploma in Nursing and midwifery) • Ward boys • Sanitary Attendant DUTY ROASTERS • Morning Duty 8am – 2 pm • Evening Duty 2pm – 9 pm • Night Duty 9 pm – 8 am

47. STAFF • 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 physician’s 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

48. PATIENT FLOW Emergency Department Consultant Examines Critical Patient Payments and Registration at OPD Counter Vitals Checked Investigations (ECG, Blood Sugar Emergency Care given to patient (IV fluids, suction, etc) Treatment initiated Admitted to IPD Discharged

49. Availability and Adequacy of Equipments, Drugs and other supplies • 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.

50. RECORDS MAINTAINED IN EMERGENCY DEPT • Doctor’s duty report with total history and treatment done on the patient and it is reported by the doctor on duty. • Nurse’s 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