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Robert Shesser M.D.,MPH George Washington University EHS 2110
Robert Shesser M.D.,MPHGeorge Washington UniversityEHS 2110
Basic ED Metrics in USA421 visits/1000 persons/year in US (2011)Decreases in DC ED volume during past year129.8 million visits per year (2010)National Hospital Ambulatory Care Survey136.1 million visits per year in US (2009)4400 acute care hospitals15% of patients arrive by ambulance18-25% of ED patients are admitted to hospital36% visits are for an injury60% seen outside of normal business hoursSeasonalitySummer most; Fall leastAbdominal pain, Chest pain, Fever most frequent reasons
ED Utilization Trends
Goals of the Emergency DepartmentRapid diagnosis and treatment of the obviously ill or injuredIdentification of subtle presentations of serious illnessExcluding serious illness in those with appropriate symptomsRapid treatment of minor illness patientsBackstop to the healthcare system
Standard ED clinical paradigmPatients are ill until proved wellIn fact, most patients are not illLots of testing leads to high charges
Reasons for ED utilization increasesHigh Technology interface with general publicLack of comprehensive primary care systemConsumerismPopulation mobilityTime sensitive conditionsViolenceMental health de-institutionalizationLower initial financial barriers to entryBackstop the health care system
Other ED issuesSpecialist backupPhysicians are independent of hospitalsDo not want to cover the EDLifestyle, malpractice, economicsEMTALA (Emergency Medicine Treatment and Labor Act)Everyone gets a medical screening examMust treat until medical emergency can be excludedCannot delay medical screening for financial reasonsCannot refuse transfers for financial reasons if:You have capabilityYou have capacityPatient is emergent
OvercrowdingNot because poor people who cant get access use the ED This is the standard dogma and it is wrongHospital Operational IssuesInpatient interface doesnt work wellOperational UndercapitalizationToo few inpatient beds for demandWell managed hospitals dont have staff sitting around (metrics) Hospital systems do not support the handoff well Lack of creativity, innovationInterspecialty intersticesAdmitted patients occupy ED treatment spaces causing queuing in arriving patients
ED staffing INursesAdminister medicationManage critically ill patientsPatient assessment/triageDischarge/Patient teachingED TechsIVs bloodsSpecimen collectionPoint of care testingAssist physicianWound care/SplintingUnregulated clinical procedures
ED staffing IINursing Shortage in USToo few nursing schoolsHigh attrition/gender issuesUnattractive job description
EDs able to meet future demands if:Find replacement workers for nursesED techs/EMTsBetter trainingCertification/licensure
ED staffing IIIPhysiciansAttending physiciansOn medical staff of HospitalUniversity facultyResidentsHave completed medical schoolIn structured program to become specialistsEmergency Medicine, Internal Medicine, General Surgery, Psych, Ob-GynPhysician AssistantsLicensed by states, must work with supervisionFunction similar to residentsWound care and minor procedural specialists
Traditional model of ED FlowStereotypical, linear, empirically derived, poor measurement metricsVaries for ambulance arrivals (versus ambulatory arrivals)
Greet/Triage/RegistrationPhysician assessmentTesting and treatmentDischarge or Admission
Every patient assigned to teamDetermines which physician will see patient4 teams during busiest part of dayNursing zoning
TriageFrom trier = to sortbattlefield technique adaptedRegistered NursesLess sorting and more data base initiationUse of Emergency Severity Index (1-5)ESI assignment done by greet nurse Additional triage screensAllergies, medicationsPain score, DV screen, TB screen, height, weightBrief history and physical
Ambulatory Front-end No best practice; High degree of variability among different hospitalsWe are constantly in process of re-engineering our processesGreet/registration; Split triage and registration functions; immediate beddingBed available (condition green)- Immediate bedding of all patientsFew beds (1-5) (condition yellow)Immediately Bed ESI 1,2,3Coordinate with charge nurse on ESI 4,5No beds available (condition red)Bed ESI 2Charge nurse will find a spot by moving patients to hallwayESI 3-5 if not immediately beddedSecondary nursing data base developmentParallel processing protocolsUse quick look rooms in lobby
Role of the Greet TeamGreet team is our first point of contact with ambulatory patientsGreet Nurse, Greet Tech, Runner TechAssign an ESI levelVital signsTriage using ESI scaleMandatory to get patient onto tracking boardObtain patients ID card, generate an armbandFirst aidTemporary dressing, ice packImmediate beddingAll ESI 1 and 2 (all the time)All other patients if space available
Greet TeamGreet nurse, Greet Tech, Runner Tech, Protocol TechGreet tech- QPI (quick registration)Enters patient into hospital ADT systemGenerates MRN and Acct NumberArmbandsRunner Tech- immediate bedding; ecg; monitorProtocol Tech- effects parallel processing protocolsQuick look nursesMove to front for conditions yellow and redComplete triage screens; order protocolsTeam Q- providers from ACT complete exam in QL rooms
Parallel processing protocolsNormally nurses do not independently order tests/medsComplaint-driven protocols for:Blood tests, ecgs respiratory treatments, urine tests, xrays, sonograms, pain meds, anti-fever meds, iv fluids, anti-nausea drugs, oxygenOptimally utilize waiting timeShorten throughputPick up emergent conditions quickly (ecgs)
RegistrationInitial processes begun by Greet teamRemainder of registration at bedside by Registration TeamEMTALA (Emergency Medicine Treatment and Labor Act)Often misinterpretedCannot delay care to obtain financial informationObtain good demographic informationCopies of insurance cards and IDsObtains consent/Advance Directives
Assessment and TreatmentStanding orders do not need to be specifically ordered in EMRAll pts with chest pain get ecgsAll chest pain and abnl VS pts get cardiac monitor, pulsoxAll chest pain, SOB, critically ill pts get oxygen (2L/min) IV access- any chest pain patient, all patients with abnormal vital signs or suspicion of critical illnessPhysicians evaluate patients after they are placed in a room and team assignedMajor versus ACT (minor)Orders into placed into EMRCPOE (computerized physician order entry)Techs, nurses assigned to teams effect these orders
Approach to the ED patientAlways wear a uniform with identificationED techs wear navy blue scrubs; tech students wear identifiable scrubsAlways introduce yourself and your roleMost techs use their first nameEye contact, posture, sit if appropriate Deal with both the patient (first) and their visitorsFigure out who is whoExplain procedure and processReiterate multiple timesExude confidence even if notBring issues to physicians and nursesAdmit if you dont know something, but go find out
Oxyhemoglobin Dissociation Curve
Clinical Assessment- visualWheelchair vs. ambulatoryColor and general appearanceObvious wounds/deformitiesBe particularly sensitive to problems of the face, neck, airwayObvious dysfunction (sagging face, slumping toward one side)Obvious pain and discomfortObvious emotional distressApparent ageRespiratory rate (ability to phonate)
Clinical Assessment- HistoryTime of onsetRecent worseningRelative severityMalignant historyRecent hospitalizationShortness of breathDemonstrable weaknessIncludes painful extremity weaknessAnger, depression, impulsivity
Chest and abdominal pain
Lifting the patientNurses #2 occupation for lost time after truck drivers due to sprains/strains12% nurses leave profession due to chronic back painEmphasis on mechanical lifting aidsDo not exist in EDMust use adequate numbers of staff membersDo NOT attempt to do more than reasonable50 lbs/person
Personal ProtectionUniversal PrecautionsFluids from ALL patients considered potentially infectiousBlood (or any fluid contaminated with blood)Semen, vaginal fluid, Do not apply to:Feces, nasal sections, sweat, tears, saliva, urine vomitUNLESS CONTAMINATED OR LIKELY CONTAMINATEDGloves, gowns, aprons, masks
Gloves, MasksGloves should be worn: For touching blood and body fluids requiring universal precautions, mucous membranes, or nonintact skin of all patientsFor handling items or surfaces soiled with blood or body fluidsGloves should be changed after each patient contact Wash hands each time after removing glovesMasks worn for procedures that create dropletsUse in phlebotomy (Will not protect from needle stick)If you have cracks on skinUncooperative patient, childIn training
Sharps Injuries385,000 injuries/year in US (1000 per day)Only 50% are reported57 definite cases HIV in healthcare workers (130 possibles)Few Hep C; Hep B now prevented by vaccinationRisk per stick = 0.09%Hollow-bore needles present greatest riskPreventionDecrease use of needlesIsolate hazard (needle guards)Use instruments to grasp needlesDont pass sharps; verbal announcement if you have toPut directly into sharps container (have enough containers)
Needlestick Epidemiology
Where Needlesticks Occur
Agitated patientsAssaults by patients on staff is occupational hazardProper training can reduce frequency of assaultsTechnique of de-escalationAppear calmSpeak in non-confrontational mannerReinforce feeling that patient is in safe environmentSet limitsRestraints/SeclusionLast resortBring in overwhelming forceSecurity, Charge NurseCode Green
Safety dos and dontsDosSearch and removeOpen doorMeans of egressUncluttered environmentTrust gutAsk about violent thoughtsAsk about weapons
Do notsAllow pts to keep dangerous thingsFeel embarrassed to get helpAllow yourself to get trappedRestrain a patient by yourselfLeave agitated pt unattended
A 45 year old man presents to triage complaining of sudden onset of crushing substernal chest pain while walking on K St. His color is pale and he appears uncomfortable. Pulse 108/min; pulsox 94%
What disease entity is the greet techs major concern??The nurse makes the patient an ESI 2 and places the patient in a room; you are the tech working with the teamWhat should be done next?
An 80 year old woman is brought to the ED by her daughter. The patient is a poor historian. The daughter states that mom has been having abdominal pain and shortness of breath for the past 3 hours.
The patient is sitting quietly and does not appear ill. Pulse 80, pulsox 98.The greet nurse assigns the patient to ESI III. ED is on condition Red.
You are the greet tech. What is the next thing that should happen to the patient?What is (are) the leading candidate(s) for serious illness present?
A 25 year old woman walks into greet doubled over in pain. She notes that she has missed her period and has had sudden onset of lower abdominal pain. Her Pulsox = 100% and pulse is 130/minute. The nurse makes the patient an ESI 2; you are the runner tech and she asks you to take the patient to the treatment area.
What is the most severe condition that would most likely be present?How should the patient be transported?What is the priority upon arrival in the room?
A very anxious young woman comes to triage and indicates that she is considering killing herself. The nurse makes the patient an ESI 2 and asks you to transport the patient to the treatment area.
What should you talk about with the patient on the way back???The patient bolts for the door, what should you do?
A 70 year old man presents with sudden onset severe lower back pain. He looks pale and uncomfortable. He has a pulsox of 93% and a pulse of 120/minute The nurse makes him an ESI 2. You are the runner tech.
While you are taking him back, your colleague asks you why the nurse made him an ESI 2 for back pain. What was the most severe condition he was considering?
A 25 year old woman presents complaining of shortness of breath. She states that she has a history of asthma that has been getting worse over the past 3 hours. Pulse 100/minute; pulsox 88%. The nurse makes the patient an ESI 2 and you are the runner tech who takes the patient to a room.
What should you do first in the room?
A 70 year old man complains of sudden onset severe pain and weakness in the right leg. He happens to mention that he has an artificial heart valve in place and takes blood thinners. His Pulsox= 97% pulse 95/minute. The nurse makes him an ESI 2 and asks you to escort him to the treatment room.
How should the patient be transported?Why do you think he was made an ESI 2?
Stroke-a death or dysfunction of brain tissue usually from vascular causes What are the three major causes of strokes?What are ways of recognizing a stroke at greet???
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