Building blocks of a working Emergency Department

[VitaMedicus]

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Greetings!

I have been reading this forum occasionally, with great interest, for some years now. As my studies are nearing their end I find myself in the position where it would be good to start making some choices about the future. To this end, I have a request for the emergency medicine specialists frequenting this forum. This post is a rather long one and I apologize for that, but I have found no similar threads even after reading through the whole history of this forum. It may not be an easy one to answer, but I would greatly appreciate any insight you could give me on this. But first let me tell you a little bit about myself and the situation I find myself in to put it into context. If you are not interested in this information skip over the next two paragraphs.

I'm a medical student a couple of months away from graduation. I got interested in emergency medicine in the army, where I served as an ambulance driver (partly because of an old sports injury in my knee). It motivated me to get a job in the ambulance during my medical studies, where I worked part time for almost two years. When my studies had advanced far enough that I was allowed to start working in a hospital as a trainee, I immediately secured a spot in the (internal) medicine emergency, where I worked for most of that summer and part of the next one. All in all I have found the daytime work in the emergency department the most satisfying experince during my still short career in medicine (the nights not being that much worse, except for the fact that you are alone there and the stress it brings).

There has been discussion about setting up a recognized specialty program for emergency medicine in my country for many years now. It would seem that they are finally coming through with it this next year. Naturally I will attempt to enroll in the specialization program. Many details are still under discussion, but from what I've heard, it seems that the idea would be for these specialists to work as attendings and consults in emergency rooms, advanced monitoring and/or ICUs, which would make it analogue to most similar systems in Europe.

However, my interest in emergency medicine is not limited to just the clinical side. Truth is, this specialty is really needed because the current emergency room arrangement just does not work in many places. From my limited experience, some of the main reasons for this are:

• The emergency room is run by doctors who spend most of their time on the patient wards and just do occasional shifts there, so they often lack the routine required to make it run smoothly.
• The emergency room is most of the time under-manned, leaving the doctors who do their shift there exhausted and waiting for their next shift in dread (rotating people in the emergency allows for running it this way without anyone burning out, at least in theory...).
• Patients in the emergency room are usually divided into medical and surgical patients (with the addition of neurological in bigger hospitals) due to the lack of a specialty that could handle all of them, leading to rigid and inefficient consultation-schemes within the emergency department.

...to name a few.
So in addition to working in the emergency I would also be most interested in developing it further. This brings us to the question in question (no pun intended):

What are the elements that make your emergency department work and run smoothly? Also, what do you find problematic and feel that contributes to making your job harder? (Or, in other words, what would you change and how if you had the chance?)

I am primarily looking for general observations, but if you have practical details that you find especially frustrating feel free to share those too (such as the overuse of EKG that I read about some time ago). I value any input or discussion by people who are experienced in this field. Although I may not be in the position to influence any of the decisions that actually matter in the near future, I do hope to pick up some ideas that I could work with down the road. Ideally, I will try and look into the possibility of getting some actual training experience in an American or British EM center at some point during my specialization if that is possible (perhaps through academic exchange).
This far I've tried searching PubMed and MedLine/Ovid with little success; the few hits being old or having limited accessibility. So if you happen to know good articles on the subject I would greatly appreciate some references.

Also, as running the emergency department is a team effort if anything, I would be very interested in knowing what nurses working there find positive and negative in the arrangements of their current workplaces. I can imagine there may not be many nurses reading these forums, but perhaps someone could direct me to a more appropriate forum?

If you have read this far all I can do is thank you for your patience. Also, thank you in advance for any input on the matter.

PS: Apologies for any grammatical/typing errors. English is not my native tongue and writing this post took a lot longer than I anticipated...

PPS: Of course you don't have to formulate your post as a direct answer to my question, free discussion on the topic is just as welcome 🙂

 

[RustedFox]

Wow. Well thought-out and phrased question, OP. English is not your native tongue ? You had me fooled.

I just want to get the ball rolling, things that make our ED run smoothly include:

1) Excellent triage or what is "first priority" and what can wait.
2) Excellent nursing staff, who are well-versed in the 'bread-and-butter' cases of EM.
3) In-department (or really-close-to-the-department) radiography.
4) Adequate staffing, and staffing appropriate to the task at hand (midlevels have a fast-track that they can run of and by themselves, high-acuity stuff goes straight to the MD/DO on hand, etc.)

- there's a lot that I'm missing... Just wanted to post before I caught a nap.

Good luck, OP.

 

[VitaMedicus]

Thanks for you response, RustedFox.

If there is something good about the system we have in place, it is that the nursing staff in emergency is usually very competent and motivated. Then again, they don't have the same system of forced rotation of shifts around the hospital and can work mostly in the emergency if that is what they prefer. It also means that the expertise they accumulate often "stays" in the emergency department. This is another problem I forgot to mention in my original post. Since most departments run on minimal staff, residents who are far in their specialization studies are often used to run the policlinic instead, limiting the time they get to spend in the emergency. When they become attendings this time in the emergency basically drops to zero, as the department cannot spare them even for night shifts in fear of having a catastrophe in their hands if they have to cancel appointments even for one day. So in the end all the experience they have gathered in the emergency during their residency is lost, while a new group of freshly graduated residents are put in charge of running the ED. I believe this is one of the main problems that the planned emergency medicine specialty is expected to help alleviate.

Of course if anyone has ideas how they would want to further develop the system at their emergency department I would love to hear about that too. I will edit it into my original post.

 

[deleted65604]

You've got to have a dedicated CT scan available emergently 24 hours a day and a lab that can handle a surge of patients and maintain throughput. A fast-track as well as dedicated "critical care rooms" are helpful in handling surge.

http://journals.lww.com/em-news/Ful..._Matters__The_Emergency_Department,_By.8.aspx

http://construction.seattlechildrens.org/2011/10/designing-a-best-of-the-best-emergency-department/

http://www.acem.org.au/media/policies_and_guidelines/G15_ED_Design.pdf

http://webapps.acep.org/sa/Syllabi/SA-22.pdf

The above articles will get you started.

I like the idea of having a post-evaluation-ambulatory-waiting for test results waiting room that is dedicated to patients while they are awaiting results or being observed after medication administration. It is frustrating to get your department completely full and then to get a wave of new patients, some of which need beds immediately and having numerous gurneys filled with ******s who are ambulatory and probably don't even need to be in the ER, let alone taking up a bed that is needed for an actual sick patient.

 

[ccfccp]

The main thing that I've noticed that effects department throughput (or how smoothly the department runs) actually has little to do with the emergency department itself. It has more to do with staffing upstairs. When the hospital is full (from a staff perspective, not a bed perspective) we end up boarding people in the ED for several hours at a time. This leads to patients backing up and the waiting room filling up all while attendings and residents are sitting there looking at each other waiting for something to do.

 

[VitaMedicus]

Thanks for your replies guys, especially your list of articles Jarabacoa. I think going through that Australian one is going to take me a while, but they all seem like a good read! Don't hesitate to speak out if you have something to add.

 

[Hamhock]

The main thing that I've noticed that effects department throughput (or how smoothly the department runs) actually has little to do with the emergency department itself. It has more to do with staffing upstairs. When the hospital is full (from a staff perspective, not a bed perspective) we end up boarding people in the ED for several hours at a time. This leads to patients backing up and the waiting room filling up all while attendings and residents are sitting there looking at each other waiting for something to do.

Yes - I am a believer in the idea that "over-use" or "over-crowding" is not our (EM) issues, solely...Jara said it better than I can and many editorials have pointed out how crazy it is that inpatients can "board" in the ED, but under not circumstances can "board" upstairs.

I still view this as an obstacle towards EM becoming an "equivalent" specialty...in this case, it has a lot to do with EM nursing, who lack as much political power as "EM" docs....sad

HH