(ed. note: Emergency Room (ER) and Emergency Department (ED) are used interchangeably. While many facilities call themselves ED to reflect a larger scope of service, ER is still the more recognizable term.)

Introductory Commentary

Describing the ideal “Efficient Emergency Department” helps us understand the Emergency Department culture and the expectations of all involved in an ED experience. This norm - or goal - to which almost all departments strive, is the baseline level of function and process that a pandemic or other crisis can affect. Observing the norm helps us see potential failure points and plan for actions to avoid breakdown. It also helps us understand the mindset of the constituencies involved in the process. Those preconceived attitudes may be dynamically affected by the challenges a pandemic will create.

An “Efficient Emergency Department” is one that rapidly greets and assesses new arrivals, quickly meets immediate patient medical and emotional needs, completes testing and interventions/treatments in a timely fashion to avoid delay, accomodates visitors, and arranges “disposition” (discharge of the patient from the ED, to an inpatient bed, transfer to another more appropriate care facility, or discharge back to the community)as rapidly as possible.

During that process, the patient’s condition is appropriately diagnosed to the extent possible utilizing the resources available to the department, s/he receives appropriate care for identified and anticipated medical/social/emotional needs (immediate and sometimes, longer term), the patients medical condition is improved or at least stabilized, his pain is treated effectively, his comfort and myriad concerns continually addressed, follow-up “continuity of care” is arranged. If all goes well, the patient and his significant others are satisfied with the experience and outcome. In most ED’s it is expected that this goal will be met dozens or hundreds of times a day.

Studies confirm the criteria that patients use to “rank “ their experience differs quite a bit from the criteria that ED staff members unconsciously use to rank their own performance. Awareness of this dichotomy is important, it creates confusion between the staff and public due to differing expectations of the process and outcomes.

Patient satisfaction is directly tied to length of stay- how long his ED experience lasts (the shorter the better!), if he percieves the staff cared about him as a person, and how rapidly his pain and other comfort needs are addressed. Staff tend to value professional expertise- i.e., making the “difficult” diagnosis, getting an IV in a patient with no visible veins, catching the subtle signs of a more serious condition then first appeared obvious, before the patients condition deteriorates.

Staff generally prioritize resource need based on severity of condition- to the detriment and frustration of those with relatively minor complaints. Patients usually tolerate some reasonable delay if they are kept aware of the cause and it appears valid. Frequent, sensitive communication about the treatment, tests, interventions and the time anticipated to accomplish it all is proven to improve satisfaction. It rarely occurs as often as it should, even in the best departments. Such communication is an “untaught” skill, one that is often difficult to deliver to already upset and possibly hostile patients and visitors. Because of that discomfort; staff may shy away from it, and make the situation worse by doing so.

Another conflict is due to staff realization of just how challenging it can be tomake the right diagnosis and choose the right course of treatment. On the other hand the ED patient assumes that he will receive correct, rapid and appropriate diagnosis and treatment. His satisfaction is directly tied to the softer side of the “conjoined twins” of the sciences of medicine and nursing. Staff focuses on “High Tech” and the public values “High Touch”. An efficient ED must consistently deliver both.

Public expectations are unlikely to change. To ensure a high level of patient satisfaction the ED staff must balance the need to meet the patients perceived priorities with their own. This may be the most challenging skill any ED staff member needs to master- and its not taught in school! Smart ED Managers make sure the staff understands the patient expectations and works to meet them. Most hospitals religiously conduct patient surveys, and the feedback and scores matter a great deal to administration and management.

Some ED specific definitions:

  • Acuity - how sick a patient is, and/or how many resources he uses. A patient having a heart attack has a much higher acuity then a patient with a sprained ankle. High acuity patients need more nursing and physician time, more lab and X Ray tests, respiratory therapy treatments, etc. Their length of stay is relatively long compared to the average patient stay. High acuity patients are usually admitted or transferred to other appropriate facilites. Acuity ranking helps with staffing level decisions-the higher acuity of the patient population, the more staff is needed for care.

We can anticipate that Pandemic Flu patients that present to the ED will represent the entire spectrum of acuity - from the “worried well” with no real disease, to the critically ill pneumonia patient in ARDS. Hopefully succesful public education campaigns will manage to shift the less acute patients to more appropriate treatment options. The high acuity of the patients that do present may still overwhelm current resources.

The Emergency Department (ED) and the Pandemic

The Average ED

Here’s some backgound info, to help readers understand just how an “average ED” is set up and functions. No ED will be exactly like the example given-its an amalgam of my experience in the last 30 years in 5 different states. Very small (less then 10 beds) and larger (more then 25 beds) will have significant differences. Here’s the basic “cast of characters” and what they do:

The ED Physician(s) (ED MD)

One or more on duty - in the ED at all times. The ED Doc is usually “Captain of the Ship” and in most facilites, has responsibility and/or significant input into almost every aspect of ED function. S/he examines every patient- with the fairly rare exception of patients who come to the ED to meet or be treated by telephone orders of their own private physician (PMD). In many facilites, they retain accountability even for those patients, and may informally see those also. They direct all care by the method of giving the rest of the staff - usually nursing, sometimes Nurse Practitioners or Physician Assistants - written or verbal “orders”. Medications, even over the counter (OTC) drugs, treatments and tests must be ordered by the physician before they are given or done.

In some facilites, “Standing Orders” (SO) exist - physican approved guidelines of what can be done for patients even before the doctors see them. SO’s are usually based on Chief Complaint (CC) - what the patient says is wrong with them when they present to the ED. An example would be a chest pain CC - in most ED’s you can put the patient on the monitor, start an IV, get an EKG, etc. before the Doc examines them-but the ED Doc is still ultimately responsible for those orders and actions.

The experience, efficiency, personality, and skills of the ED physican(s) on duty have a very significant impact on patient flow, staff function, morale and attitude-and quality of care delivered.That impact may even extend into the next shift, especially if a slow doc preceded you, and patient flow is slow. Just like “gridlock” can make highway commuting a crawl, "DocLock" can greatly increase Length of patient Stay (LOS) in the department. Efficient physicans usually have low LOS and good patient satisfaction scores. Even with an efficient MD, ED waits in larger facilities can still take hours from start to finish.

Most ED MD’s are either employed by the facility, or belong to physican group that contracts to the facility to provide 24 ED coverage. They do not usually care for the patient after the ED visit is over - the patient’s primary care or other staff physican is the “admitting physican” who assumes responsibility for the care of the patient while hospitalized.

Non-Physican Providers

Many ED’s hire Nurse Practitioners (NP) or Physician Assistants (PA). These providers are cost effective “Physican Extenders” (a.k.a Mid-level Practitioners or Non-Physician Providers) who usually function in the capacity of an ED MD, but are directly responsible to the supervising ED MD for all their orders and decisions. Their practice usually must take place under the direct supervision of a physician physically present in the department or facility. Laws governing advance practice providers vary from state to state, or by facility policy. Statements about the ED MD above apply.

ED Nurses (ED RN)

Most facilities currently hire only Registered Nurses (RN) to staff the ED, although some still have LPN’s in ED (or any specialty unit) practice. Nurses carry out the orders of physicians and extenders, and also provide patient assesment and interventions that do not require a physician order. Putting an ice pack on your swollen ankle is a nursing intervention - but giving you the pain pill requires a physician order. Most ED’s staff, during peak hours at least, to have one nurse per every three to four patient beds. Very sick patients may need much more attention then a nurse carrying a patient load of three of four others - or even the attention of more then one nurse at at time. This can result in a delay for the less acutely ill patients in the department. Trauma or a motor vehicle accident (MVA) is an example of when that might happen unexpectedly.

A large number of ED’s are chronically understaffed when it comes to Nursing Personnel. The current nursing shortage is partly responsible, but in some facilites there’s also a financial issue. Nursing salary costs are usually the largest single budget line of most hospital departments where direct nursing care is delivered.

The first person to assess and begin treatment of a patient is usally an ED RN. Triage - the intial evaluation of the patient to determine how sick they may be, and in what order they are seen and in what area of the department - is usually done by RN’s in most facilites.

Just like the physician, the experience, efficiency and attitude of the nursing staff on-duty has a direct influence on patient flow, LOS and quality of care.

Nursing Assistants (NA)

One or more on duty at a time, they may provide direct patient care for intervention not required to be provided by licensed personnel. They do many non-nursing tasks to keep the department functioning, which often includes transporting patients, cleaning and readying rooms for the next patient, stocking supplies, and “other duties as required”. Most facilites require state certification, some hire EMT’s or Paramedics in this role when state practice laws allow. State practice law as well as facility policy affects the role of the NA, and may vary greatly.

Unit Secretary or Unit Communications Coordinator (UCC)

The unit secretary runs the phones, is usually at the nursing station desk or computer. Usually not medically trained, they may have advanced education in medical office management. The secretary role is extremely demanding-they field all calls, incoming and outgoing, enter EDMD orders, order tests-they are usually constantly busy. Its a very stressful role, and their experience and flexibility is crucial to department flow and efficiency.

Ancillary Staff

These frequent ED players are often physically seen in the ED even though they may actually be employees of other hospital departments, and answer to other surpervisors. Thay all have direct or indirect impact impact on ED function and efficiency. Facility policy and process may differ widely, different roles may have different responsibilites in your ED.

Laboratory Technicians and Phlebotomists: some EDs draw their own blood, collect their own speicimens for lab testing. Others rely on lab department personnel for all or some of their phlebotomy (blood drawing) needs. Laboratory technicians test the specimens, according to the doctors orders, in the laboratory itself. Each ED has a process for sending specimens to the lab. A pneumatic tube system, or the use of runners or tranporters to deliver the specimens are common. Human transport decreases the avialable time of other ED personnel, so it’s the least efficient system. lab techs are careful and well informed about the dangers of contracting illnes from human specimens. But with each direct contact with an infected patient a technicians chance of contracting illness increases. In a pandemic situation, our best practice would be to limit the numbers of staff in contact with the flu patient. This may be difficult and add to the challenges that some departments face as new skills are needed, for others its business as usual.

Imaging Services Personnel: Imaging Services is the new fancy name for Radiology - what most of us call "XRay". The new moniker is a bow to the expanded capabilites of our modern technology- not all imaging is via actual XRay's any more. As the technology has advanced, so has the specialization within the field. Not all “Radiology Technicians” (RadTechs) can perform all procedures. There is currently a very severe shortage of radiology personnel in most of the US. Pandemic flu will likely increase the needs for Chest Xrays, and that is a basic skill most should be able to remaster. The already limited availability of more specialized tests such as MRI or CT Scans will become more restricted if the radiology specialists who perform them become ill. As with lab techs, they would be in direct contact with many flu-infected patients and at high risk of infection.

Respiratory Therapists: RT’s are the specialists that deal with interventions needed by those suffering from respiratory illness. They have the training, skill, and experience to deliver respiratory treatments, manage ventilators, and assess patient response to these therapies. Because of their skills they will be critically needed in a flu pandemic.

The education and skills of these specialties is very field specific. Their tasks cannot easily be done by other healthcare workers (less critical for RT’s). Most states limit practice in these areas to those certified in these skills. We must consider reducing their exposure to infection by limiting direct patient contact duties as much as possible. While this will predictably lead to increased demand on other direct care staff - especially nursing - and increased LOS it may be essential to keep departments functioning. Their physical presence may conceivably be limited to ICUs to manage ventilators if the demand exceeds supply (see acuity explanation).

Admitting Personnel : usually under the auspices of the business office, these “acess management” hospital employees collect and process the demographic and insurance information needed to create and maintain patient records. They are not medicaly trained, and may or may not have any specific higher education for the task. They must demonstrate the abiity to deal with people under stres, accurately record and clarify sometimes confusing data, and some familiarity with the information system (computer hardware and software) and medical records system in use in their facility. Untrained individuals with the right potential could be rapidly trained to function in that capacity.

“Patient Representatives”: some larger facilites have “ombudsmen” that help patients with issues that arise. They assist in resolving problems and issues and act as advocates. They often help explain the flow and what patients may expect. They help demystify the often confusing hosptial enviorment and culture. In some hospitals, they may be an essential part of the patient complaint resolution process.

Patient Flow

Patient flow is a term often used in health care- and like many others has dual meaning. It can refer to the steps through the patients individual visit, from entry into the ED to discharge from the department. It may also refer to large numbers of patients, as they passage through the system. We’ll use the term here to describe the individual patient who presents for emergency care.

Let’s explore the average ED visit by using a fictitous patient- Mr. Joe Smith. Mr. Smith is a 45 year old office worker. It’s late Sunday afternoon, and after doing some heavy yard work, he’s just not feeling right. Must have been the heat-or that extra 20 pounds he’s been carrying around lately! He’s lightheaded, and had the cold sweats until he sat down and rested for a few minutes.

Joes wife Sally notices he’s a little pale when they sit down to dinner, and he’s just picking at his favorite burger and fries, not really hungry- and her concern goes up a notch more when she sees him rubbing his chest. When she asks whats wrong, he sheepishly admits that maybe that beer he had when mowing the lawn didnt sit well, he’s a bit queasy and has some indigestion…

Joe is a lucky guy. His wife remembers that those symptoms are just like the ones his dad had the week before his heart attack some years back. She grabs the keys, and gets her protesting husband into the car, and off they go to the local community hospital Emergency Department. He’s not happy about this, but just doesn’t quite feel well enough to argue much more! Besides, they’ll probably just give him something for his indigestion and he’ll get home in time to see the end of the big game on TV, right?

When they get to the Emergency Department entry, Sally pulls the car up and lets Joe out. He’s feeling a bit better, the cool air in the car seemed to help. He walks up the the front ED desk, and the greeter asks him what he’s there for. As he explains his symptoms as “indigestion” the greeter notices his sweaty brow and sends him directly to the Triage Desk ahead of the patients already waiting to be checked in.

There he talks with an experienced Registered Nurse, who will check his vital signs, ask more questions about his current complaint (health issues/symptoms are called “complaints” in the medical world) his medical history, what medicines he’s taking, and any allergies he might have and others. By the time the triage interview is finished (it usually takes about 4 minutes) Joe’s nurse is concerned enough to assign him a high treatment priority- he may be having a heart attack.

He’s taken immediately to an open appropriate treatment room (one with a cardiac monitor) by wheelchair. Even before he sees a doctor, the nursing staff will start to do the usual “chest pain workup”-attaching a cardiac monitor, starting an IV, obtaining an EKG, administering oxygen and possibly ordering a Chest XRay and bloodwork.

They can do this in most facilites because of the “standing orders” that the facility has developed and approved to deal with certain high priority chief complaints. Otherwise those actions and interventions would require a doctor to see the patient before any interventions are done. Standing orders may need to be developed to deal with flu patients in pandemic situation. The importance of standing orders is that they speed and standardize the care of the patient in a situation where the phsyican may not be immediately available.

Back to Joe- his wife is now at the bedside with him. In some ED’s she might have had to wait to see him until she had gone to Registration and given the demographic and insurance info they needed to create his record. In Joes hospital, they do “bedside registration”. The registrar comes to the patients’ bedside to collect the information after he’s seen the doctor (a growing trend, especially in light of the recent EMTALA legislation). The first flurry of activity of getting Joe set up in bed and the first intervetions completed has just ended when the ED Doctor on duty enters the room and introduces himself.

Joe and Sally answer more questions- about what is happening today, and his personal past and family history. Many of the questions will be repeats of what he talked to the nurses about- and sometimes thats frustrating, but the repitition serves an important purpose-many times, the answers are different because we remember more once were relaxed and feeling better then we did at triage. During the 5 to 10 minutes it takes to do the evaluation, Joe’s doctor will also phsyically examine him- listening to his heart and lungs, checking his ankles for swelling (edema) and perhaps looking in his throat and eyes and ears, and feeling his pulses. Since the EKG was done before the doctor saw Joe, he takes it into the room with him to review it with the patient. With that EKG, and his evaluation complete; the doctor already has a good idea of the type of care Joe is going to need.

Doctor Jones explains that the EKG is a bit suspicious, it indicates that Joes heart muscles are not getting quite enough oxygen. Joe is shocked- and quiet. Doctor Jones congratulates Sally on bringing him in- explaining that it doesnt look quite like a heart attack YET from the EKG, but if he has ignored this warning signal, the results might have been very serious. The good thing is that his vital signs are stable, his pain is better, and we can now evaluate whats going on and the bloodwork results will soon be back. Joes nurse comes in to apply some nitroglycerin paste to his skin- it absorbs slowly and dilates the blood vessels in his heart, increasing the oxygen reaching the stressed heart tissue. Joe has been in the ED about 30 to 40 minutes.

By the time an hour has passed,the blood tests results will start trickling off the printer. Doctor Jones will also check the XRay that was done at bedside when that film is available. But before he gets the results, he’s pretty sure Joe will have to stay in the hospital for further tests and evaluation.

He knows from experience that Joe likely has Coronary Artery Disease. He’s going to need a Stress Test, and perhaps a Cardiac Catheterization. If seriously blocked arteries are found duringthe “cath”, Joe will have a stent placed in the closed artery to open it up and get the blood flowing freely to the heart muscle again. During his hopital stay Joe will also need some education on lifestyle changes, and possibly start ongoing prescription medication to help stabilize his heart condition.

The blood test results are complete just about an hour and half from the time Joe entered the ED door. Luckily, theres no elevation in his bloodwork of the enzymes that are found in cardiac muscle- if Joe had damaged heart muscle cells due to a heart attack, those levels will rise. Dr Jones calls Joes family doctor to arrange for his admission to the hospital. ED doctors don’t treat patients that are admitted, and the order for admission must come from a staff doctor with admitting privledges at that facility.

If Joe didnt have a private doctor, or his doctor doesnt practice at that hospital; he would be assigned a staff doctor to care for him during his stay. Dr Jones will also tell the Unit Secretary to contact the hospital supervior or admissions department “bed control” office to arrange for a bed assignment- for Joe, a Telemetry bed, where he can recieve continuous cardiac monitoring and be cared for by nursing staff that are trained in cardiac care.

Before three hours have passed since his ED arrival, Joe is ready for admission. His ED nurse has called the floor nurse and given report-explaining Joes complaint, what interfentions have been done or orders that are still needed, reviewing lab and test results with the next nurse to care for him. He’s sent to the floor in stable condition.

Joe has had a succesful and fairly uneventful Emergency Department experience. He recieved the correct triage assessment, was transported to an open treatment room right away, and the right tests and treatments were started promptly. This type of intervention happens thousands of times a day in Emergency Departments everywhere that have those capabilities-even busy ones. But in a pandemic situation, Joe’s story might have been very different.

The Beginning

Sally glanced once more at her watch. Ten to eleven. Time to start the night shift. She slammed shut her locker door and headed for the nurses’ station. She’d be relief charge nurse tonight. She’d done it so many times before, it really wasnt stressful. Until the last week.

Flu season usually meant a rise in patient census and acuity. But this last week had been way out of the ordinary. They’d had at least twice the cases she’s normally expect- several dozen a day. In her 16 bed ED, that was quite a stress on the usual flow. Waits had accelerated for all patients. Patients and visitors had been grumpier than usual as visit times grew lengthier. Even the staff was snapping at each other more than normal. She wasnt looking forward to tonights shift.

That feeling got stronger as she reached the station and took report. Every bed was already full, with a dozen waiting to be seen in the waiting room. Even if no other patients arrived, it would take almost the whole shift to clear the backlog.

Fully half the patients had fever and cough. A few frank pneumonia patients filled the big rooms, on monitors; she could hear the steady hiss of a breathing treatment in use in the room just beyond the station. Two were waiting for beds upstairs, the nursing supervisor had been called for bed assignment and she should be getting a call back any minute on what rooms to move them to.

The sound of the ambulance radio interrupted the “good-nights” of the evening shift. Two units- bringing in four family members with flu symptoms, two in respiratory distress. Plus an infant that seemed asymptomatic- but they couldnt locate a family member to leave the baby with yet, so were bringing him to the ED for the staff to care for until family could respond.

The staff mobilized in a rush to ready for the units. Two patients in beds soon to be discharged were put in wheelchairs near the nurses station, and the rooms made ready for the incoming ambulances. Both protested how long they’d been waiting for discharge instructions. Nurses apologized, explaining the ED doctor has been tied up in a critical patients room. They didnt mention that beyond the wall the wheelchairs were parked next to, the body of a 65 year old nursing home patient- dead from respiratory failure and pneumonia- was being prepared for a trip to the morgue.

Sally pushed open the door to the treatment room the dead patient was in, and hissed at the nursing assistants- “Hurry Up, I need the room!” She didnt wait to see their startled faces. Reaching the nurses station, she called out to the Unit secretary- “Get me the Supervisor, now!” She grabbed a wheelchair and headed for the ambulance bay, just as the automatic garage door opened to admit the unit.

The supervisor called as the unit started unloading. It took Sally just a minute to explain the situation- they needed beds clear for the admission they had waitign to go upstairs. People to tranport those admissions to the floor for them, unlike doing it themselves as they usually did. Security to take the dead patient to the morgue. and any exptra staff she could spare to help for a short time until the backlog and new arrivals could be brought under control.

To be continued - adding the effect a pandemic may cause.

Open thread in the Forum on this entry here.

Page last modified on October 22, 2006, at 12:25 AM by pogge