Life in the Emergency Department
This
chapter describes the way the Emergency Department operates, and some of the
unwritten rules. The prevalence of Emergency Department-based drama generates
plenty of misconceptions about what occurs in the Emergency Department. For
instance, it is generally inadvisable to say ‘stat’ at the end of one’s
sentences, and neither of the authors has been mistaken for George Clooney!
What happens when a patient arrives at the Emergency
Department?
Alert phone
Also known as the ‘red phone’ or sometimes ‘the
Bat-phone’, this is the dedicated phone line that the ambulance service uses to
prewarn the Emergency Department of incoming patients likely to need
resuscitation.
Triage
The concept of triage comes from military medicine –
doing the most good for the most people. This ensures the most effective use of
limited resources, and that the most unwell patients are seen first.
Nurses rather than doctors are usually used to perform
the triage because doctors tend to start treating patients. Systems of rapid
assessment and early treatment by senior medical staff can be effective, but
risk diverting attention from the most ill patients.
Reception/registration
The reception staff are essential to the function of the
Emergency Department: they register patients on the hospital computer system,
source old notes and keep an eye on the waiting room. They have to deal with
difficult and demanding patients, and are good at spotting the sick or
deteriorating patient in the waiting room.
Waiting room
Adult and paediatric patients should have separate
waiting rooms, and some sort of entertainment is a good idea. Aggression and
dissatisfaction in waiting patients has been largely eliminated in the UK by
the 4-hour standard of care: all patients must be seen and discharged from the
Emergency Department within 4 hours.
Treatment areas in the Emergency Department
Resuscitation bays
Resuscitation bays are used for critically ill and
unstable patients with potentially life-threatening illness. They have advanced
monitoring facilities, and plenty of space around the patient for clinical
staff to perform procedures. X-rays can be performed within this area.
High acuity area
This is the area where patients who are unwell or
injured, but who do not need a resuscitation bay, are managed. Medical
conditions and elderly patients with falls are common presentations in this
area.
Low acuity area
The ‘walking wounded’ – patients with
non-life-threatening wounds and limb injuries – are seen here. Patients with
minor illness are discouraged from coming to the Emergency Department, but
continue to do so for a variety of reasons.
There is a common misconception that patients in this
area are similar to general practice or family medicine patients. Numerous
studies have found that there is an admission rate of about 5% and an appreciable
mortality in low acuity
patients, whereas only about 1% of GP consultations result in immediate
hospital admission.
Other areas
Imaging
Imaging, such as X-rays and ultrasound, are integral to
Emergency Department function. Larger Emergency Departments have their own CT
scanner.
Relatives’ room
When dealing with the relatives of a critically ill
patient and breaking bad news, doctors and relatives need a quiet area where
information is communicated and digested. This room needs to be close to the
resuscitation area.
Observation/short stay ward
This is a ward area close to the Emergency Department,
run by Emergency Department staff. This unit treats patients who would otherwise need
hospital admission for a short time, to enable them to be fully stabilised and
assessed. The function of these units is described in Chapter 28.
Hospital in the home
Some hospitals run a ‘hospital in the home’ programme
for patients who do not need to be in hospital but who need certain therapy,
e.g. intravenous antibiotics, anticoagulation. The Emergency Department is the
natural interface between home and hospital.
Culture of the Emergency Department
There is a much flatter (less hierarchical)
organisational structure in the Emergency Department than most other areas in
the hospital. This occurs because all levels of medical, nursing and other
staff work together all the time, and the department cannot function without
their cooperation. Ensuring good teamwork requires good leadership, an
atmosphere of mutual respect and a bit of patience and understanding.
The resulting atmosphere can be one of the most
enjoyable and satisfying places to work in a hospital. A feature of this less
hierarchical culture that surprises junior doctors is that nurses will question
their decisions; this is a sign of a healthy culture in which errors are less
likely to occur, and is actively encouraged.
Emergency Department rules
Being a doctor in the Emergency Department is different
from elsewhere in the hospital. There is nowhere to hide and, for the first
time in most medical careers, you are responsible for making the decisions. On
the positive side, there are plenty of people around to help you, who have all
been through the same process.
Some basic advice:
•
Write legible, timed, dated
notes.
•
Show respect for other
professional groups and be prepared to learn from them.
•
Do not be late for your shifts;
do not call in sick less than 6 hours before a shift.
•
Patients who re-present are
high risk and need senior review.
•
Take your breaks. You need
them.
•
Keep calm.
•
If in doubt, ask.
•
Do not pick up so many patients
that you cannot keep track of them.
•
Do not avoid work or avoid seeing
difficult patients. We do notice.
•
The nurse in charge is usually
right.
With so many people working closely together in a
stressful atmosphere, it is inevitable that conflicts will occur. Do not let
them fester; some ground rules for resolving such conflicts are:
•
Resolve it now.
•
Do it in private.
•
Do it face to face.
•
Focus on facts.
•
Criticise action, not person.
•
Agree why it is important.
•
Agree on a remedy.
•
Finish on a positive.
