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Emergency department

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"Emergency room" redirects here. For other uses, see Emergency room (disambiguation).

The emergency department (ED), sometimes termed the emergency room (ER), emergency ward (EW), accident & emergency (A&E) department or casualty department is a hospital or primary care department that provides initial treatment to patients with a broad spectrum of illnesses and injuries, some of which may be life-threatening and requiring immediate attention.

Emergency departments developed during the 20th century in response to an increased need for rapid assessment and management of critical illnesses. In some countries, emergency departments have become important entry points for those without other means of access to medical care. The abbreviation ER is generally used throughout the United States, while A&E is used in many Commonwealth nations. ED is preferred in Canada and Australia.

History

The first specialized trauma care center in the world was opened at the University of Louisville Hospital in Louisville, Kentucky, United States in 1911 and developed by surgeon Arnold Grishwold during the 1930s. Grishwold also equipped police and fire vehicles with medical supplies and trained officers to give emergency care while en route to the hospital. [1]

Department layout

The emergency department entrance at Mayo Clinic's Saint Marys Hospital. The red-and-white emergency sign is clearly visible.

A typical emergency department has several different areas, each specialized for patients with particular severities or types of illness.


The resuscitation area is a key area of an emergency department. It usually contains several individual resuscitation bays, usually with one specially equipped for pediatric resuscitation. Each bay is equipped with a defibrillator, airway equipment, oxygen, intravenous lines and fluids, and emergency drugs. Resuscitation areas also have ECG machines, and often limited X-ray facilities to perform chest and pelvis films. Other equipment may include non-invasive ventilation (NIV) and portable ultrasound devices. Very few EDs have a dedicated area for obstetrics nowadays. In most cases, a pregnant woman who presents to the ED is sent immediately to the obstetrics/maternity ward or the Labour and Delivery suite, unless she has another medical condition that requires treatment.

The majors, or general medical, area is often very busy, filled with many patients with a wide range of medical and surgical problems. Many will require further investigation and possible admission. Patients who are not in need of immediate treatment are sent to the minors area. Such patients may still have been found to have significant problems, including fractures, dislocations, and lacerations requiring surgical suture.

Signage

File:Emergencyroomsign.jpg
An example of California hospital signage

A hospital with an emergency department usually has prominent signage reading Emergency or Accident and Emergency (often in white text on a red background) and an arrow to indicate where patients should proceed. Some American states closely regulate the design and content of such signs, and require wording such as "Comprehensive Emergency Medical Service" and "Physician On Duty",[2] to prevent persons in need of critical care from presenting to facilities that are not fully equipped and staffed.

Nomenclature

In Australia, the department is usually referred to as the Emergency Department or the ED.

In New Zealand, it is always referred to as A & E in speech (ie. for 'Accident and Emergency').

In Hong Kong, Singapore and Ireland it is usually called the Accident and Emergency department.

In Canada, it is referred to as the Emergency Department. Emerge is a slang word used in some regions of Canada.

Throughout the United Kingdom, the department is known as A&E (Accident & Emergency). Some hospitals choose to use the term ED (Emergency Department), and drop the "Accident" from the title. This is considered appropriate by some hospitals due to people turning up with minor injuries after an accident, rather than with a real emergency. Although some hospitals use the term ED, all road signs to the department still read A&E. Most teaching hospitals and district general hospitals (DGHs) have an A&E department. The largest such department in the UK is in St Thomas' Hospital.

In the United States an emergency department is often referred to by laypeople as an emergency room (ER). Medical professionals typically call it whatever its name is within their specific hospitals, or simply "Emergency." The term "emergency room" is a misnomer, as a modern hospital's emergency facilities consist of dozens of rooms.[citation needed]

In some countries, including the United States, Canada and increasingly in countries in Europe, a smaller facility that may provide assistance in medical emergencies is known as a clinic. Larger communities often have walk-in clinics where people with medical problems that would not be considered serious enough to warrant an emergency department visit can be seen. These clinics often do not operate on a 24 hour basis.

The term "urgency" instead of "emergency" is used in some latin american countries. Emergency departments are known as "Servicios de Urgencia" and they function in a similar fashion to the european emergency departments.

United States

In 1986, Congress passed a law commonly referred to as EMTALA (Federal Emergency Medical Treatment and Active Labor Act, also known as the Patient Anti-Dumping Law) to address a growing concern that EDs were refusing to treat patients based on their inability to pay. This law requires every ED to provide a minimal level of care to all comers regardless of their ability to pay.

One inspection of Los Angeles area hospitals by Congressional staff found the ERs operating at an average of 116% of capacity (meaning there were more patients than available treatment spaces) with insufficient beds to accommodate victims of a terrorist attack the size of the 2004 Madrid train bombings. Three of the five Level I trauma centers were on "diversion", meaning ambulances with all but the most severely injured patients were being directed elsewhere because the ER could not safely accommodate any more patients.[3] This controversial practice was banned in Massachusetts (except for major incidents, such as a fire in the ER), effective January 1, 2009; in response, hospitals have devoted more staff to the ER at peak times and moved some elective procedures to non-peak times.[4] [5]

United Kingdom

File:A&E.PNG
A&E sign common in the UK.

Historically, waits for assessment in A&E were very long in some areas of the UK. In October 2002, the Department of Health introduced the Four Hour Emergency Target that required departments to assess and treat patients within four hours of arrival, with referral and assessment by other departments if deemed necessary. Present policy is that 98% of all patients do not "breach" this four-hour wait.

This triggered the introduction of the Acute Assessment Unit (also known as the Medical Assessment Unit), which works alongside the Emergency Department but is outside it for statistical purposes in the bed management cycle. It is claimed that though A&E targets have resulted in significant improvements in completion times, the current target would not have been possible without some form of patient re-designation or re-labelling taking place, so true improvements are somewhat less than headline figures might suggest and it is doubtful that a single target (fitting all A&E and related services) is sustainable.[6]

Patient experience

Patients arrive at emergency departments in two main ways: by ambulance or independently. The ambulance crew notifies the hospital beforehand of the patient's condition and begins Basic Life Support or Advanced Life Support measures as dictated by regional and state protocols.[7]

Patients arriving independently or by ambulance are typically triaged by a nurse with training in emergency medicine. Patients are seen in order of medical urgency, not in order of arrival. Patients are triaged to the resuscitation area, majors area, or minors area. Emergency/Accident and Emergency departments usually have one entrance with a lobby and a waiting room for patients with less-urgent conditions, and another entrance reserved for ambulances.

Special facilities, training, and equipment

An ED requires different equipment and different approaches than most other hospital divisions. Patients frequently arrive with unstable conditions, and so must be treated quickly. They may be unconscious, and information such as their medical history, allergies, and blood type may be unavailable. ED staff are trained to work quickly and effectively even with minimal information.

Because time is such an essential factor in emergency treatment, EDs typically have their own diagnostic equipment to avoid waiting for equipment installed elsewhere in the hospital. Nearly all have an X-ray room, and many now have full radiology facilities including CT scanners and ultrasonography equipment. Laboratory services may be handled on a priority basis by the hospital lab, or the ED may have its own "STAT Lab" for basic labs (blood counts, blood typing, toxicology screens, etc) that must be returned very rapidly.

ED staff have much in common with ambulance and fire crews, combat medics, search and rescue teams, and disaster response teams. Often, joint training and practice drills are organized to improve the coordination of this complex response system. Busy EDs exchange a great deal of equipment with ambulance crews, and both must provide for replacing, returning, or reimbursing for costly items.

Cardiac arrest and major trauma are relatively common in EDs, so defibrillators, automatic ventilation and CPR machines, and bleeding control dressings are used heavily. Survival in such cases is greatly enhanced by shortening the wait for key interventions, and in recent years some of this specialized equipment has spread to pre-hospital settings.

See also

References

  1. ^ url=http://www.louisville.edu/ur/ucomm/mags/summer2000/cover_story.htm
  2. ^ Title 22, California Code of Regulations, Section 70453(j).
  3. ^ http://oversight.house.gov/documents/20080505102428.pdf
  4. ^ http://www.boston.com/news/local/articles/2008/09/13/state_orders_hospital_ers_to_halt_diversions/?page=full
  5. ^ http://www.boston.com/news/health/articles/2008/12/24/fewer_patients_diverted_from_ers/?page=full
  6. ^ Mayhew, Les (2006). "Using queuing theory to analyse completion times in accident and emergency departments in the light of the Government 4-hour target". Cass Business School. pp. 2, 34. ISBN ISBN 978-1-905752-06-5. Retrieved 2008-05-20. {{cite web}}: Check |isbn= value: invalid character (help); Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  7. ^ "What is EMS?". NHTSA. Retrieved 3008-08-09. {{cite web}}: Check date values in: |accessdate= (help)
  • John B Bache, Carolyn Armitt, Cathy Gadd, Handbook of Emergency Department Procedures, ISBN 0-7234-3322-4
  • Swaminatha V Mahadevan, An Introduction To Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department, ISBN 0-521-54259-6
  • Academic Emergency Medicine, ISSN: 1069-6563, Elsvier
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