Emergency Department - Department Operation

Department Operation

Today, a typical hospital has its emergency department in its own section of the first floor of the campus, with its own dedicated entrance. 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 through the application of triage.

Triage is normally the first stage the patient passes through, and consists of a brief assessment, a set of vital signs, and the assignment of a "chief complaint" (i.e. chest pain, abdominal pain, difficulty breathing, etc.). Most emergency departments have a dedicated area for this process 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 dependent on training levels in the country and area, other health care professionals may perform the triage sorting, including paramedics or physicians (DOs or MDs). Triage is typically conducted face-to-face when the patient presents, or a form of triage may be conducted via radio with an ambulance crew; in this method, the paramedics will call the hospital's triage centre with a short update about an incoming patient, who will then be triaged to the appropriate level of care.

Most patients will be initially assessed at triage 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, commonly referred to as "Trauma" or "Resus", is a key area in most departments. The most seriously ill or injured patients will be dealt with in this area, as it contains the equipment and staff required for dealing with immediately life threatening illnesses and injuries. Typical resuscitation staffing involves at least one attending physician (DO or MD), and at least one and usually two nurses with trauma and Advanced Cardiac Life Support training. These personnel may be assigned to the resuscitation area for the entirety of the shift, or may be "on call" for resuscitation coverage (i.e. if a critical case presents via walk-in triage or ambulance, the team will be paged to the resuscitation area to deal with the case immediately). Resuscitation cases may also be attended by residents, medical students, nursing students, emergency medical technicians, and/or hospital pharmacists, depending upon the skill mix needed for any given case and whether or not the hospital provides teaching services.

Patients who are seriously ill but not in immediate danger of life or limb will be triaged to "acute care" or "majors," where they will be seen by a physician and receive a more thorough assessment and treatment. Examples of "majors" include chest pain, difficulty breathing, abdominal pain and neurological complaints. Advanced diagnostic testing may be conducted at this stage, including laboratory testing of blood and/or urine, ultrasonography, CT or MRI scanning. Medications appropriate to manage the patient's condition will also be given. Depending on the resolution of the patient's chief complaint, he or she may be discharged home from this area or admitted to the hospital for further treatment.

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 prompt care 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. 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 stomach aches, with a high cost on the Health Care system.