Robert Shesser M.D.

,MPH
George Washington
University
EHS 2110

Basic ED Metrics in USA

421 visits/1000 persons/year in US (2011)
Decreases in DC ED volume during past year
129.8 million visits per year (2010)
National Hospital Ambulatory Care Survey

136.1 million visits per year in US (2009)

4400 acute care hospitals
15% of patients arrive by ambulance
18-25% of ED patients are admitted to hospital
36% visits are for an injury
60% seen outside of normal business hours
Seasonality
Summer most; Fall least

Abdominal pain, Chest pain, Fever most frequent reasons

ED Utilization Trends

Goals of the Emergency Department

Rapid diagnosis and treatment of the obviously ill or injured
Identification of subtle presentations of serious illness
Excluding serious illness in those with appropriate

symptoms
Rapid treatment of minor illness patients
Backstop to the healthcare system

Standard ED clinical paradigm

Patients are ill until proved well
In fact, most patients are not ill
Lots of testing leads to high charges

Reasons for ED utilization increases

High Technology interface with general public
Lack of comprehensive primary care system
Consumerism
Population mobility
Time sensitive conditions
Violence
Mental health de-institutionalization
Lower initial financial barriers to entry
Backstop the health care system

Other ED issues
Specialist backup
Physicians are independent of hospitals
Do not want to cover the ED

Lifestyle, malpractice, economics

EMTALA (Emergency Medicine Treatment and Labor Act)

Everyone gets a medical screening exam

Must treat until medical emergency can be excluded

Cannot delay medical screening for financial reasons

Cannot refuse transfers for financial reasons if:

You have capability

You have capacity
Patient is emergent

Overcrowding
Not because poor people who cant get access use the

ED
This is the standard dogma and it is wrong

Hospital Operational Issues

Inpatient interface doesnt work well

Operational Undercapitalization

Too few inpatient beds for demand

Well managed hospitals dont have staff sitting around (metrics)

Hospital systems do not support the handoff well

Lack of creativity, innovation
Interspecialty interstices

Admitted patients occupy ED treatment spaces

causing queuing in arriving patients

ED staffing I
Nurses
Administer medication
Manage critically ill patients
Patient assessment/triage
Discharge/Patient teaching

ED Techs
IVs bloods
Specimen collection
Point of care testing
Assist physician
Wound care/Splinting
Unregulated clinical procedures

ED staffing II
Nursing Shortage in US
Too few nursing schools
High attrition/gender issues
Unattractive job description

EDs able to meet future demands if:

Find replacement workers for nurses
ED techs/EMTs

Better training

Certification/licensure

ED staffing III
Physicians
Attending physicians

On medical staff of Hospital

University faculty
Residents
Have completed medical school
In structured program to become specialists
Emergency Medicine, Internal Medicine, General Surgery,
Psych, Ob-Gyn
Physician Assistants
Licensed by states, must work with supervision
Function similar to residents
Wound care and minor procedural specialists

Traditional model of ED Flow

Stereotypical, linear, empirically derived, poor measurement

metrics
Varies for ambulance arrivals (versus ambulatory arrivals)
Greet/Triage/Registration
Physician assessment
Testing and treatment
Discharge or Admission
Every patient assigned to team
Determines which physician will see patient
4 teams during busiest part of day
Nursing zoning

Triage
From trier = to sort
battlefield technique adapted

Registered Nurses
Less sorting and more data base

initiation
Use of Emergency Severity Index (15)
ESI assignment done by greet nurse
Additional triage screens
Allergies, medications
Pain score, DV screen, TB screen,

height, weight
Brief history and physical

Ambulatory Front-end
No best practice; High degree of variability among different hospitals
We are constantly in process of re-engineering our processes
Greet/registration; Split triage and registration functions; immediate

bedding

Bed available (condition green)- Immediate bedding of all patients

Few beds (1-5) (condition yellow)

Immediately Bed ESI 1,2,3

Coordinate with charge nurse on ESI 4,5

No beds available (condition red)

Bed ESI 2
Charge nurse will find a spot by moving patients to hallway
ESI 3-5 if not immediately bedded
Secondary nursing data base development
Parallel processing protocols
Use quick look rooms in lobby

Role of the Greet Team

Greet team is our first point of contact with ambulatory

patients
Greet Nurse, Greet Tech, Runner Tech

Assign an ESI level

Vital signs
Triage using ESI scale
Mandatory to get patient onto tracking board
Obtain patients ID card, generate an armband
First aid
Temporary dressing, ice pack
Immediate bedding
All ESI 1 and 2 (all the time)
All other patients if space available

Greet Team
Greet nurse, Greet Tech, Runner Tech, Protocol Tech
Greet tech- QPI (quick registration)

Enters patient into hospital ADT system

Generates MRN and Acct Number

Armbands

Runner Tech- immediate bedding; ecg; monitor

Protocol Tech- effects parallel processing protocols

Quick look nurses

Move to front for conditions yellow and red
Complete triage screens; order protocols
Team Q- providers from ACT complete exam in QL

rooms

Parallel processing protocols

Normally nurses do not independently order

tests/meds
Complaint-driven protocols for:
Blood tests, ecgs respiratory treatments, urine

tests, xrays, sonograms, pain meds, anti-fever

meds, iv fluids, anti-nausea drugs, oxygen

Optimally utilize waiting time

Shorten throughput
Pick up emergent conditions quickly (ecgs)

Registration
Initial processes begun by Greet team
Remainder of registration at bedside by Registration Team
EMTALA (Emergency Medicine Treatment and Labor Act)
Often misinterpreted
Cannot delay care to obtain financial information

Obtain good demographic information

Copies of insurance cards and IDs

Obtains consent/Advance Directives

Assessment and
Treatment
Standing orders

do not need to be specifically ordered in EMR

All pts with chest pain get ecgs

All chest pain and abnl VS pts get cardiac monitor, pulsox
All 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 illness
Physicians evaluate patients after they are placed in a room
and team assigned

Major versus ACT (minor)

Orders into placed into EMR

CPOE (computerized physician order entry)
Techs, nurses assigned to teams effect these orders

Approach to the ED
patient

Always wear a uniform with identification

ED techs wear navy blue scrubs; tech students wear identifiable
scrubs
Always introduce yourself and your role
Most techs use their first name

Eye contact, posture, sit if appropriate

Deal with both the patient (first) and their visitors
Figure out who is who
Explain procedure and process
Reiterate multiple times

Exude confidence even if not

Bring issues to physicians and nurses
Admit if you dont know something, but go find out

Vital signs
Pulse
60<normal<100 beats/minute

Measure for 15 seconds

Normally take the radial pulse
Palpating a radial pulse=systolic BP > 70 mmHg
Blood pressure (measured indirectly)

Mercury, aneroid, automated (oscillimetric), hybrid

All need to be calibrated regularly

Leading cause of inaccuracy is wrong cuff size

At least arm circumference should be covered by bladder

Be very skeptical of automated readings in critically ill patients

Vital signs
Temperature
Most expressed in Celsius (38C=100.4F)
Electronic devices (oral, rectal, axillary)
Infrared devices (tympanic)- posterior/superior tug improves accuracy

Respiratory rate
Diameter of chest wall varies by 20% in normal respirations
Observe for at least 15 seconds

Pulsoximetry
Measures hemoglobin saturation with light waves
Hemoglobin makes blood red; delivers oxygen to tissues

>95% normal
90-95% significant; consider supplemental oxygen
85-90% very significant; give large dose of oxygen
<85% life threatening

Oxyhemoglobin Dissociation Curve

Clinical Assessmentvisual
Wheelchair vs. ambulatory
Color and general appearance
Obvious wounds/deformities
Be particularly sensitive to problems of the face, neck, airway

Obvious dysfunction (sagging face, slumping toward one

side)
Obvious pain and discomfort
Obvious emotional distress
Apparent age
Respiratory rate (ability to phonate)

Clinical AssessmentHistory
Time of onset

Recent worsening

Relative severity
Malignant history
Recent hospitalization

Shortness of breath
Demonstrable weakness
Includes painful extremity weakness

Anger, depression, impulsivity

Chest and abdominal pain

Clinical Assessment-Vital
signs
Pulse
Kids faster than adults
May be elevated due to anxiety
>120 in anyone older than 50 is usually

significant

Pulsoximeter
< 95% consider supplemental oxygen
<90% needs immediate treatment/oxygen

Lifting the patient

Nurses #2 occupation for lost time after truck drivers due to

sprains/strains
12% nurses leave profession due to chronic back pain

Emphasis on mechanical lifting aids

Do not exist in ED
Must use adequate numbers of staff members
Do NOT attempt to do more than reasonable
50 lbs/person

Personal Protection
Universal Precautions
Fluids from ALL patients considered potentially infectious

Blood (or any fluid contaminated with blood)

Semen, vaginal fluid,
Do not apply to:

Feces, nasal sections, sweat, tears, saliva, urine vomit

UNLESS CONTAMINATED OR LIKELY CONTAMINATED

Gloves, gowns, aprons, masks

Gloves, Masks
Gloves should be worn:
For touching blood and body fluids requiring universal

precautions, mucous membranes, or nonintact skin of all

patients
For handling items or surfaces soiled with blood or body fluids
Gloves should be changed after each patient contact
Wash hands each time after removing gloves
Masks worn for procedures that create droplets
Use in phlebotomy (Will not protect from needle stick)
If you have cracks on skin
Uncooperative patient, child
In training

Sharps Injuries
385,000 injuries/year in US (1000 per day)
Only 50% are reported

57 definite cases HIV in healthcare workers (130 possibles)

Few Hep C; Hep B now prevented by vaccination
Risk per stick = 0.09%

Hollow-bore needles present greatest risk

Prevention
Decrease use of needles
Isolate hazard (needle guards)
Use instruments to grasp needles
Dont pass sharps; verbal announcement if you have to
Put directly into sharps container (have enough containers)

Needlestick Epidemiology

Where Needlesticks
Occur

Agitated patients
Assaults by patients on staff is occupational hazard
Proper training can reduce frequency of assaults

Technique of de-escalation
Appear calm
Speak in non-confrontational manner
Reinforce feeling that patient is in safe environment
Set limits

Restraints/Seclusion
Last resort
Bring in overwhelming force
Security, Charge Nurse

Code Green

Safety dos and donts

Dos
Search and remove
Open door

Do nots

Means of egress
Uncluttered environment

things
Feel embarrassed to get help
Allow yourself to get trapped
Restrain a patient by yourself
Leave agitated pt unattended

Trust gut
Ask about violent thoughts
Ask about weapons

Allow pts to keep dangerous

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 team
What 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???