Emergency department

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.

Upon arrival in the ED, people typically undergo a brief triage, or sorting, interview to help determine the nature and severity of their illness. Individuals with serious illnesses are then seen by a physician more rapidly than those with less severe symptoms or injuries. After initial assessment and treatment, patients are either admitted to the hospital, stabilized and transferred to another hospital for various reasons, or discharged. The staff in emergency departments not only includes doctors, nurse practitioners but physician assistants (PAs) and nurses with specialized training in emergency medicine and in house Paramedics and/or emergency medical technicians, respiratory therapists, radiology technicians, Healthcare Assistants (HCAs), medical scribes, volunteers, and other support staff who all work as a team to treat emergency patients and provide support to anxious family members. The emergency departments of most hospitals operate around the clock, although staffing levels are usually much lower at night. Since a diagnosis must be made by an attending physician, the patient is initially assigned a chief complaint rather than a diagnosis. This is usually a symptom: headache, nausea, loss of consciousness. The chief complaint remains a primary fact until the attending physician makes a diagnosis.

1 Department layout
2 Signage
3 Nomenclature
4 United States
5 United Kingdom
6 Patient experience
7 Critical conditions handled
8 Special facilities, training, and equipment
9 Non-emergency use
10 Doctors in training
11 Emergency departments in the military
12 See also
13 References
14 External links

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.

In the triage area, patients are seen by a triage nurse who completes a preliminary evaluation, before transferring care to another area of the ED or a different department in the hospital. Patients with life or limb-threatening conditions may bypass triage and be seen directly by a physician.

The resuscitation area is a key area of an emergency department. It usually contains several individual resuscitation bays, usually with one specially equipped for paediatric 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.

The majors, or general medical, area is for stable patients who still need to be confined to bed (note that a "bed" in the ED context is almost always a gurney or trolley rather than a full hospital bed). This 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 suturing.

A paediatric area for the treatment of children has recently become standard, to dedicate separate waiting areas and facilities for children. Some departments employ a play therapist whose job is to put children at ease to reduce the anxiety caused by visiting the emergency department, as well as provide distraction therapy for simple procedures.

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 first.

Many hospitals have a separate area for evaluation of psychiatric problems. These are often staffed by psychiatrists and mental health nurses and social workers. There is typically at least one room for people who are actively a risk to themselves or others (e.g. suicidal).

Emergency departments may also have a separately streamed service for minor and rapidly treatable conditions, such as minor injuries. The fast track may be staffed by emergency nurse practitioners, Physician Assistants and/or physicians, and special consultation rooms are specifically designated for this purpose. This system allows for quicker treatment of patients who may otherwise be forced to wait for more pressing cases to resolve. This part of the department may be called by several names e.g. Urgent Care Centre, Fast Track Unit or Primary Care Suite depending on the local emphasis. Where this type of service is provided on a separate site from the local ED it is called a Minor Injuries Unit or an Urgent Care Clinic.

Signage

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",^[1] 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.

The popular term casualty is no longer considered appropriate by emergency physicians in Australia, the United Kingdom and Ireland.

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. The ED interacts with every other department in the hospital and often represents a significant percentage of the hospital's work load and finances. It is common for emergency department doctors to work for a company hired by the hospital to provide emergency services.

During the 1990s, an effort was made to change to the more accurate term emergency department (ED), which is a term increasingly used by members of the specialty internationally. The effort failed and ED never caught on among the U.S. public, perhaps because of the popularity of the TV show ER, and the heavy marketing of the euphemism "ED" for erectile dysfunction by pharmaceutical companies. However, the term does have some circulation among emergency medicine staff. Individual hospitals may also refer to the department by different names, such as emergency ward, emergency center, emergency unit, etc.

Leading journals, including the Annals of Emergency Medicine, published by the American College of Emergency Physicians, and the Emergency Medicine Journal (emj) of the British Association for Emergency Medicine (BAEM), consistently use the term Emergency Department.

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.

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.

Under this law, any person presenting to an Emergency Department is entitled by law to a Medical Screening Exam. The purpose of that exam is to determine if any illness or injury is present that, could have serious consequences if treatment is delayed more than 24 hours. In practice, doing so often requires a full evaluation of all patients presenting to an Emergency Department. Only after that exam is fully complete may patients be referred to an outpatient clinic or their primary care physician if their condition and/or diagnosis allows it. According to a May 2003 American Medical Association (AMA) study, emergency physicians annually provide, on average, $138,300 of uncompensated care under the aegis of EMTALA.

A&E sign common in the UK.

United Kingdom

Traditionally, 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.^[2]

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.^[3] Depending on the patient's condition, the Emergency Medical Technician or Paramedic^[4] may consult with the emergency department physician (considered online medical control in many areas) who may direct the ambulance crew to begin specific interventions while still en route that are not considered standing protocols in their scope of practice. Upon an ambulance arrival at the hospital the patient can be delivered to the emergency departments resuscitation area or consultation room (which is hospital dependent and different based on geographical location), where they are met by a team with the expertise to deal with the patients' conditions.^[5] For example, patients with major trauma are seen by a trauma team consisting of emergency physicians, nurses, paramedics, a surgeon, and an anestheologist. If the patients is suffering from minor complaints, 1 registered nurse (RN) may be sufficient in triaging and registering the patient for the emergency room physicians to evaluate the patient.

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.

Critical conditions handled

Cardiac arrest

Cardiac arrest may occur in the ED/A&E or a patient may be transported by ambulance to the emergency department already in this state. Treatment is basic and advanced life support as taught in the Advanced Life Support and Advanced Cardiac Life Support courses. This is an immediately life-threatening condition which requires immediate action in salvageable cases.

Heart attack

See main article: Myocardial infarction

Patients arriving to the emergency department with a myocardial infarction (heart attack) are likely to be triaged to the resuscitation area. They will receive oxygen and monitoring and have an early ECG; aspirin will be given if not contraindicated or not already administered by the ambulance team; morphine or diamorphine will be given for pain; sublingual (under the tongue) or buccal (between cheek and upper gum) glyceryl trinitrate (nitroglycerin) (GTN or NTG) will be given, unless contraindicated by the presence of other drugs, such as drugs that treat erectile disfunction.

An ECG that reveals ST segment elevation or new left bundle branch block suggests complete blockage of one of the main coronary arteries. These patients require immediate reperfusion (re-opening) of the occluded vessel. This can be achieved in two ways: thrombolysis (clot-busting medication) or percutaneous transluminal coronary angioplasty (PTCA). Both of these are effective in reducing significantly the mortality of myocardial infarction. Many centers are now moving to the use of PTCA as it is somewhat more effective than thrombolysis if it can be administered early. This may involve transfer to a nearby facility with facilities for angioplasty.

Trauma

Main article: Physical trauma

Major trauma, the term for patients with multiple injuries, often from a road traffic accident or a fall, is treated by a trauma team who have been trained using the principles taught in the internationally recognized Advanced Trauma Life Support (ATLS) course of the American College of Surgeons. Some other international training bodies have started to run similar courses based on the same principles.

The services that are provided in an emergency department can range from simple x-rays and the setting of broken bones to those of a full-scale trauma center. A patient's chance of survival is greatly improved if the patient receives definitive treatment (i.e. surgery or reperfusion)within one hour of an accident (such as a car accident) or onset of acute illness (such as a heart attack). This critical time frame is commonly known as the "golden hour."

Some emergency departments in smaller hospitals are located near a helipad which is used by helicopters to transport a patient to a trauma center. This inter-hospital transfer is often done when a patient requires advanced medical care unavailable at the local facility. In such cases the emergency department can only stabilize the patient for transport.

Mental Illness

Some patients arrive at an emergency department for a complaint of mental illness. In many jurisdictions (including many U.S. states), patients who appear to be mentally ill and to present a danger to themselves or others may be brought against their will to an emergency department by law enforcement officers for psychiatric examination. From the emergency department, patients thought to be mentally ill may be transferred to a psychiatric unit (in many cases involuntarily).

Asthma and COPD

Acute exacerbations of chronic respiratory diseases, mainly asthma and chronic obstructive pulmonary disease (COPD) are assessed as emergencies and treated with oxygen therapy, bronchodilators, steroids or theophylline, have an urgent chest X-ray and arterial blood gases and are referred for intensive care if necessary. Non invasive ventilation in the ED has reduced the requirement for intubation in many cases of severe exacerbations of COPD.

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.

ED staff must also interact efficiently with pre-hospital care providers such as EMTs, paramedics, and others who are occasionally based in an ED. The pre-hospital providers may use equipment unfamiliar to the average physician, but ED physicians must be expert in using (and safely removing) specialized equipment, since devices such as Military Anti-Shock Trousers ("MAST") and traction splints require special procedures. Among other reasons, given that they must be able to handle specialized equipment, physicians can now specialize in emergency medicine, and EDs employ many such specialists.

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. The best-known example is defibrillators, which spread first to ambulances, then in an automatic version to police cars, and most recently to public spaces such as airports, office buildings, hotels, and even shopping malls.

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.

Non-emergency use

Emergency departments around the world are increasingly being used for non-emergency care because of overburdened healthcare systems. Many people, afflicted by minor injuries or illnesses late at night or at times when their doctor's office is closed, are forced to resort to attending the ED. This is especially true for conditions with distressing symptoms, such as a child's ear infection. People in lower socioeconomic classes are more likely to use the ED for primary care services, as they typically find it inconvenient or impossible to miss work for a visit to the General Practitioner (GP).

In the United Kingdom, it has become more popular to visit the A&E since it became mandatory for patients to be fully treated and discharged from the department within four hours of arrival. Also, the introduction of the new contract for primary care doctors in that country decreased the accessibility of GP services. Under this contract GPs can opt out of on-call cover, and patients sometimes present instead to the A&E.

In many Primary Care Trusts there may be out of hours doctor services sometimes known as Keydoc or something similar (varying by area) provided by volunteer General Practitioners.

Patients attending the ED for minor complaints do not contribute significantly to the overall workload of the department. (Despite the level of complaints in the general public and by health staff.) Studies, in Australia at least, have shown that improved after-hours GP access has no effect on ED workload or waiting times.

In the United States, and many other countries, hospitals are beginning to create areas in their emergency rooms for people with minor injuries. These are commonly referred as Fast Track or Minor Care units. These units are for people with non life-threatening injuries. The use of these units within a department have been shown to significantly improve the flow of patients through a department and to reduce waiting times.

Doctors in training

Doctors in training provide a large portion of the medical care in emergency departments.

In the United States, they are called residents and are supervised by ABEM board certified attending physicians. The chief resident (chosen by the university faculty) is often the best all-around resident, universally thought of as the most talented resident physician.

In the United Kingdom, many doctors rotate through the emergency department during their second foundation year (F2), or as part of a rotational specialty training programme in General Practice or Emergency Medicine.