Millions of Americans visit an emergency room each year, and millions more have seen the popular television show ER, which has sparked an avid interest in the fascinating, 24-hour-a-day, nonstop world of emergency medicine.
Although an integral part of hospital service, emergency medicine is a relatively new specialty. In 1968 the American College of Emergency Physicians (ACEP) was established. The first emergency training program was introduced at the Cincinnati General Hospital in the 1970s, and in 1979, by a vote of the American Board of Medical Specialties, emergency medicine became a full-fledged specialty.
Today, the term emergency room has been largely replaced by a term encompassing an entire hospital department focused on fast, quality medical care. In our area, six hospitals are staffed with emergency departments (EDs) that work tirelessly to provide the fastest, most efficient and complete level of care possible.
EDs Cut Time While Providing Quality Care
By Judith P. Nembhard
An Organized System
Dr. James Creel, chief of emergency medicine for both Erlanger Medical Systems and Hamilton County, states that 12.2 million people are seen in emergency departments in America annually. “It is the busiest department in hospitals,” he says.
Many systems and a host of qualified individuals come together to make the emergency department function smoothly and effectively. “The ED physician,” says Cathy Ferguson, director of the emergency department at Hamilton Medical Center, “oversees the treatment and care of the patients.” The ED physician must have the skills of many specialties – the ability to resuscitate a patient, to manage a difficult airway, suture a complex laceration, set a fractured bone or dislocated joint, treat a heart attack, workup a pregnant patient with vaginal bleeding, insert a chest tube, stop a nosebleed, and perform countless other tasks for patients who present at the ED.
Completing a team of skilled personnel (among others) are nurses, nurse specialists, technicians, physician’s assistants and phlebotomists who draw blood for medical testing. Case managers assist with patient discharge needs such as medical resources for home use.
Through the ED
If you were to go to an emergency department for help, when you arrive, whether by EMS, by car or walk-in, what happens first depends on your condition and complaint or your triage level – that is, how critical your case is. At triage, you are assessed, and your situation is evaluated and prioritized. Your condition will be noted in one of three categories: immediately lifethreatening, urgent but not immediately life-threatening, and less urgent. Priority is determined by your perceived level of sickness.
This first step is followed by registration, where a nurse obtains your vital statistics. Here you provide insurance information, Medicare, Medicaid or HMO card. If you arrived by ambulance, or if your condition is life-threatening, this registration may be completed later at your bedside.
The next stop is the examination room, where an emergency department nurse obtains more detailed information about you and provides a patient gown for proper examination. Once the nurse completes these tasks, the emergency medicine physician enters, examines you and may, based on your needs, give orders for testing, medication, IV fluids, etc. The physician gets a more detailed medical history of your present illness, past medical problems, family history, social history, and does a complete review of your body systems. The physician then formulates a list of possible symptoms – called a differential diagnosis. Based on the symptoms observed and the physical examination, a diagnosis is determined. However, if information is still inadequate to provide a diagnosis, then diagnostic tests are run.
The nurse carries out the orders and monitors your progress. Technicians assist with the orders and communication to you or your family. Once the diagnosis is made, the physician and nurse educate you and your family and either discharge, admit, or transfer you.
Saving Time, Saving Lives
To a person in pain, it may seem that the process is long and involved, but emergency medicine practitioners are always looking for ways to provide quality care quickly. In the emergency department, time is of the essence. Saving time means saving lives so area hospitals are always working to provide faster and more efficient services to patients.
At SkyRidge Medical Center, according to Diedre Suits, MSN, RN emergency department director, the hospital has addressed saving time and lives with a new state-of-the-art emergency department which includes triage, a Fast Track area, general medical area, acute care area, 64 Slice CT and radiology services. “This new center is unique in it’s design, which assists us in our abilities to expedite care by having all of these services located on one floor in one department,” states Dr. Madison Torrence, medical director of the emergency department. Built in 2009 as part of a $45 million expansion, the 41 bed, 7,000-square-foot department has three triage rooms designed to provide direct visualization of patients in the reception area, ten rooms dedicated to Fast Track patients, three rooms to OB/GYN, ENT and casting. There are four rooms dedicated to trauma and cardiac with a nursing station equipped with a pneumatic tube system which allows specimens to be delivered expeditiously to the lab.
As the region’s Level One Trauma Center, Erlanger sees the most serious and the most traumatic cases in the region – along with everyday, non life-threatening emergencies. According to Dr. Creel at Erlanger, “We have established protocols in the ED to evaluate and move patients as quickly as possible to get needed care. For example, Erlanger’s procedure for getting someone with chest pains or a heart attack to the cath lab for evaluation after they arrive in the ED is 28 minutes faster than national standards, and we’re constantly working to improve those numbers.” Dr. Creel adds, “At Erlanger, we have moved mid-level personnel into triage to better assess people. This hospital is an active, busy place,” he says, “which gets the sickest and most seriously injured patients in the region.”
At Hamilton Health Care System, the emergency department has implemented a “lean” initiative for health care. According to Ferguson along with Dr. William Pullen, emergency medical director, and Dr. Jonathan Thompson, regional emergency medical director, “lean” practices minimize “waste” (i.e. time) and add value to processes. “As a result of the initiative,” Ferguson explains, “we have implemented rapid triage/triage nurse super track, where the patient is evaluated, treated and discharged from triage, and we have improved throughput by analyzing all our processes to eliminate bottlenecks.” The ED team maximizes the efficiency of its workflow by bringing patients to rooms as quickly as possible and completing administrative tasks while patients are waiting for medical test results. Because of this, the ED at Hamilton Medical Center has experienced a decrease in patients’ overall length of stay, door-to-door provider times, test turnaround times, and door-to-discharge times.
At Memorial Hospital, according to Jan Woods, emergency director, several initiatives have been implemented to improve the speed of quality care. The Fast Track system, designed to match care to a patient’s immediate need has reduced the length of stay for Fast Track patients – those with minor injuries or illnesses such as a sore throat or rash – by over 60 percent. An expanded version of electronic documentation, implemented in November 2010, has allowed for quicker and more accurate access to patient records. Additionally, she notes that nurses and physicians regularly collaborate to provide patient orders, given presenting complaints, so X-rays and blood tests can be completed quickly and diagnostics can begin even before a room is available for a patient. This process, Woods says, “usually results in a shorter ED length of stay and greater satisfaction for the patient.”
Memorial is currently undergoing a $60 million expansion that includes a 30-bed clinical decision unit built directly above the emergency department. The project is planned to be completed in April 2012, and is expected to further drive faster care at the emergency department.
Parkridge Medical Center has also implemented several measures to be faster and more efficient in providing services. According to Robin Marsh, emergency department director, these include triage and registration at the bedside as often as possible. Additionally, there is an hourly evaluation of staffing and physician/provider scheduling to ensure that staffing is in place for peak visit times. Marsh notes that one of the goals is to have an average arrival to physician greet time of 20 minutes. When patient rooms are full, the ED utilizes a RAZ (rapid assessment zone) to see non-urgent patients.
Cindy Hoggard, interim associate chief nursing officer at Hutcheson Medical Center, speaks of their continual drive for improvement. She notes, “Over the last three years, we have decreased our turnaround time (TAT) tremendously, and we are now proud to be at an average of less than 180 minutes, which is below the national benchmark. Each segment [in the ED] has an initiative to try to decrease time,” Hoggard says. “For example, we have a ‘pull to full’ approach.” This means that if a bed is available, the patient goes directly to it and receives bedside registration later. A five-level triage system facilitates determining the appropriate area for the patient to receive care based on his or her complaint.
In emergency medicine “the golden hour” refers to a period of time, lasting from a few minutes to several hours following a traumatic injury, during which there is the highest likelihood that prompt medical treatment will prevent death. It has been well established that an individual’s chances of survival are greatest if medical care is received within a short time after a severe injury. Through teamwork, exceptional skills and an ongoing dedication to improving work processes, emergency departments provide lifesaving and critical care each and every day, delivering the fastest, most efficient services possible.