Emergency department

A clearly marked Emergency Department at the Edinburgh Royal Infirmary

An Emergency Department (ED), also known as Accident & Emergency (A&E), Emergency Room (ER), Emergency Ward (EW), or Casualty Department is a medical treatment facility, specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance. The emergency department is usually found in a hospital or other primary care center.

Due to the unplanned nature of patient attendance, the department must provide initial treatment for a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. In some countries, emergency departments have become important entry points for those without other means of access to medical care.

The emergency departments of most hospitals operate 24 hours a day, although staffing levels may be varied in an attempt to mirror patient volume.

History

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

Department operation

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

As patients can present at any time and with any complaint, a key part of the operation of an emergency department is the prioritization of cases based on clinical need. This is usually achieved though the application of triage.

Triage is normally the first stage the patient passes through, and most emergency departments have a dedicated area for this to take place, and may have staff dedicated to performing nothing but a triage role. In most departments, this role is fulfilled by a nurse, although dependant on training levels in the country and area, other health care professionals may perform the triage sorting, including paramedics or doctors.

Most patients will be assessed and then passed to another area of the department, or another area of the hospital, with their waiting time determined by their clinical need. However, some patients may complete their treatment at the triage stage, for instance if the condition is very minor and can be treated quickly, if only advice is required, or if the emergency department is not a suitable point of care for the patient. Conversely, patients with evidently serious conditions, such as cardiac arrest, will bypass triage altogether and move straight to the appropriate part of the department.

The resuscitation area is key in most departments and the most serious patients will be dealt with in this area, and it contains the equipment and staff required for dealing with immediately life threatening illnesses and injuries.

Patients whose condition is not immediately life threatening will be sent to an area suitable to deal with them, and these areas might typically be termed as a majors or minors area. Such patients may still have been found to have significant problems, including fractures, dislocations, and lacerations requiring suturing.

Children can present particular challenges in treatment and some departments have dedicated pediatrics areas and 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.

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).

Fast decisions on life-and-death cases are critical in hospital emergency rooms. As a result, doctors face great pressures to overtest and overtreat. The fear of missing something often leads to extra blood tests and imaging scans for what may be harmless chest pains, run-of-the-mill head bumps, and non-threatening stomachaches, with a high cost on the Health Care system. ^[2]

Nomenclature

During the 1990s, an effort began to change previous naming conventions to the more accurate term Emergency Department (ED), which is a term increasingly used by members of the speciality internationally.

Historic terminology still exists across the world, especially in vernacular usage. For instance, terms such as the previously accepted formal term 'Accident and Emergency' or 'A&E' are still widely known in countries such as the United Kingdom and its former territories, as are common informal terms such as 'Casualty', or 'Casualty Department'. The same applies to 'Emergency Room' or 'ER' in North America, originating when emergency facilities were provided in a single room of the hospital.

In the cases of both 'ER' in North America and 'Casualty' in the United Kingdom, the continued prevalence can be to some extent linked to the existence of long running television dramas bearing those respective names. See ER (TV series) and Casualty (TV series).

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 European Emergency Departments.

Signage

An example of California hospital signage

Regardless of naming convention, there is a widespread usage of directional signage in white text on a red background across the world, which indicates the location of the emergency department, or a hospital with such facilities.

Signs on emergency departments may contain additional information, and in some American states there is close regulation of the design and content of such signs and require wording such as Comprehensive Emergency Medical Service" and "Physician On Duty",^[3] to prevent persons in need of critical care from presenting to facilities that are not fully equipped and staffed.

In some countries, including the United States, Europe and Canada, 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

Many U.S. emergency rooms are exceedingly busy. A survey of New York area doctors in February 2007 found that injuries and even deaths have been caused by excessive waits for hospital beds by ER patients.^[4] A 2005 patient survey found an average ER wait time from 2.3 hours in Iowa to 5.0 hours in Arizona.^[5]

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.^[6] 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.^[7] ^[8]

In 2009, there were 1,800 ERs in the country.^[9]

United Kingdom

A&E sign common in the UK.

All A&E departments throughout the United Kingdom are financed and managed publicly by the NHS of each constituent country (England, Scotland, Wales and Northern Ireland). As with most other NHS services, emergency care is provided to all, both resident citizens and those not ordinarily resident in the UK, free at the point of need and regardless of any ability to pay.

Historically, waits for assessment in A&E were very long in some areas of the UK. In October 2002, the Department of Health introduced a four-hour target in emergency departments that required departments in England 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 patient cases do not "breach" this four-hour wait.

The 4-hour target 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-labeling 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.^[10]

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 life support and advanced life support as taught in 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; sub lingual (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 dysfunction.

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 major fall, is sometimes handled in the Emergency Department. However, trauma is a separate (surgical) specialty from emergency medicine (which is a medical specialty, and has certifications in the United states from the American Board of Emergency Medicine).

Trauma 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. The emergency department conducts medical clearance rather and treats acute behavioral disorders. From the emergency department, patients with significant mentally illness 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 tracheal 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 defibrillator's, 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

Metrics applicable to the ED can be grouped into three main categories, volume, cycle time, and patient satisfaction. Volume metrics including arrivals per hour, percentage of ED beds occupied and age of patients are understood at a basic level at all hospitals as an indication for staffing requirements. Cycle time metrics are the mainstays of the evaluation and tracking of process efficiency and are less widespread since an active effort is needed to collect and analyze this data. Patient satisfaction metrics, already commonly collected by physician groups and hospitals, are useful in demonstrating the impact of changes in patient perception of care over time. Since patient satisfaction metrics are derivative and subjective, they are less useful in primary process improvement.

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. Urgent care clinics are another alternative, where patients can go to receive immediate care for non-life-threatening conditions.

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.

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