Emergency Department
Introduction
• Emergency a dangerous or serious situation that happens unexpectedly and needs fast
action in order to avoid harmful results.
• Emergency care starts in pre hospital setting, usually provided by paramedic and ambulance
services.
• Continued at the hospital at the Emergency Department
What do we do?
• Casualty → Emergency Department
• Stabilise critically ill patients from all ages groups, across all specialities
• Ensure that patients receive appropriate further care from concerned departments
• Training and Research
Scope of patient footfall
Expected patients
• Trauma and Accident victims
• Acute medical or surgical illness - MI, CVA, Acute Abdomen etc
• Poisoning and Deliberate Self Harm
Non emergent visits
• Patients with admission slips but lack of beds
• Patients who require admission from OPD but delay in arranging beds
• Patients with CLD, CKD, etc on routine follow up
• Patients referred to other departments for further management
CMC Emergency Department
• Started in the ground floor of OPD building and was managed by interns (Casualty)
• Moved to the current location in 1990’s and became an independent Emergency department
(A & E)
• 1 year fellowship course was started in 1997 which was extended to 2 year course in 2008.
• Currently it has evolved into Department of Emergency medicine with a recognised MD
program, and is further staffed by fellowship registrars and senior house officers
ED Personnel
• Consultants - MD/MS/FAEM/MRCEM
• Registrars - PG, Fellowship and Non PG trainees
• Staff nurses
• Emergency medicine technicians/Paramedics
• Attenders
• Housekeeping staff
• Radiology technicians
• Security
Emergency Department Layout
• Triage
• Resuscitation Room
- Immediate threat to life and/or limb
- ABC Compromise
• Bays 1, 2, 3, Trauma bay
- Incumbent threat to ABC
- Pain relief, Pregnant women
- Trauma patients without immediate ABC compromise
• Consultation room
- Stable patients, no danger to life, limb or ABC
Flow of Patient Care
Triage
• Trier” ––‘To Sort’
• “The right patient gets the right treatment at the right time”
• Different systems exist 1 - 3, 1 - 5, Colour systems, etc
• In CMCH, follow a 1 - 4 system
• Done by a trained Triage Nurse, can also be done by a Doctor
Triage Priority Condition Time to be seen
I -ABC compromise Immediately
-Immediate threat to life or limb
II -Haemodynamically stable, needing ½ hour to 1 hour, earlier if feasible
intervention/further care
-Potential ABC compromise
-Severe pain
-Pregnancy
III -Vitals stable, ambulant >1-2hours depending on patient
-Chronic complaints flow
-No emergency care needed
IV -OPD referral required Usually sorted out at presentation
Priority I Resuscitation Room
• Triage level 1, should be seen immediately
• Manned by 1- 2 doctors, trained in advanced airway management, ACLS, Trauma
management
• Separate nursing and EMT team
• Blood gas analysis, NIV, mechanical ventilation if required
• Bedside Ultrasound E FAST, RUSH protocol
• Rapid handover and disposition
Priority II - Bays I, II, III, Trauma
• No immediate danger to life/limb ; No ABC compromise
• Bulk of ED patients, should be seen within ½ hour to 1 hour
• PI patients can be shifted here after stabilisation
• 2 - 4 doctors
• Focussed history, examination, differential diagnoses. Relevant investigations and
interventions (analgesia, splintage , IV fluids, etc)
• Handover to concerned unit
Priority III and IV Consultation room
• Stable, ambulant patients. Waiting time often longer than an hour
• 1 - 4 doctors, depending on need/availability
• Usually referred to other speciality departments
• May be evaluated if needed, if no obvious acute intervention needed, sent to OPD
• Vigilance needed here as well
Core competencies required
• Good clinical skills, better decision making skills
• Must have a basic knowledge of emergencies from all fields
• ACLS, Trauma care, Advanced airway management, IV access, Intra osseus access
• Basic Bedside Ultrasonography
• Anaesthesiology, Orthopaedics, Paediatrics
• Diplomacy, good people skills
Equipment required
• Trolley mobile, tiltable
• Monitors with SpO2 , ECG, NIBP and ETCO 2
• Wall Oxygen supply as well as O 2 cylinders
• Defibrillators with pacing paddles
• Airway Direct and Video Laryngoscope
• CPAP, BiPAP and Ventilators
• AMBU bag and Bain’s circuit
• Portable Ultrasound machine
• Blood gas analyser
• Blood glucose and serum ketone analyser
• Portable X ray machine
• In house Radiology suite
• Handheld doppler
• Opthalmoscope and Otoscope
• Computers and Telephones
• Refrigerators for drugs
• Opthalmoscope and Otoscope
• Splints
• Tiltable, mobile trolleys
• Uninterrupted Central Oxygen supply
• Oxygen cylinders, periodically checked and maintained
• Biphasic Defibrillator(s)
• Monitors with continuous NIBP, pulse oximetry, ECG monitoring
• Blood glucose/serum ketone strips
• Urine dipstick tests
• Refrigerators at strategic areas
• Drugs, including cardio active and anaesthetic agents
• Computer terminals and telephones at all areas
• Blood Gas Analysers
• Splints
• In house radiology suite
• Portable X Ray
• Bedside USG
Special Liaisons
1. Trauma services
• Special Trauma pager, through the telephone exchange
• Trauma surgery, Orthopaedics, Neurosurgery, Radiology
2. Stroke Team
• Within 4.5 hours of a clinically diagnosed stroke
• Stroke team manages the patient and decides on further care
3. Obstetrics
• Rapid transfer to Labour room/Scan room after initial stabilisation
4. Cardiology
• Shift for PCA/Thrombolysis once ECG diagnosis of STE ACS is made, and initial management
done
Services offered
• Procedural Sedation and Analgesia
• Code blue rapid response team for certain areas of the hospital
• Stabilisation of OPD patients
• Command centre in the event of a Mass
Medico legal duties
• Road Traffic Accidents - Incident Report, detailed documentation of injuries, blood alcohol levels
• Brought dead - Incident report if unnatural death suspected/confirmed
• Deliberate Self Harm - Incident report
• Child Abuse/Sexual assault - Incident report, inform senior paediatrician/obstetrician
Training
• Structured training courses
• MD Emergency Medicine (3 years), Fellowship in Accident and Emergency Medicine (2 years)
• Non PG residency also offered
• EMTC, MSEED
Quality
• External:
• NABH
• Internal:
• Audits
• Chart audit
• CPR audit
• Mortality audit
• DAMA/DAR audit
• 72 hr revisit audit
• Trauma
No Trolleys!!!
• Code grey declared, no more patients to be admitted in the ED
• Duty ED consultant directly speaks to the admitting unit consultant, involves in admitting patients
• De prioritise patients to priority III, or directly discharge patients to OPD
• Code red can be lifted when trolleys are free
Conclusion
• Face of the hospital for the sickest patients, 24 x 7 x 365
• Ensure competency and compassion in patient care
• Proper acute management of sick patients can make the difference between life and death
• Needs support of other departments to prevent overcrowding and optimal functioning
