EMERGENCY DEPARTMENT OF HOSPITAL

1. EMERGENCY DEPARTMENT
By
Tanaya Ghosh Choudhury

2.  Increasing load in the hospitals due to disasters
 People affected in terms of health dislocation are very large
 Demand for proper set up and planning of emergency
services
 Apart from trauma and burn cases, patients with heart attack,
kidney failure, breathlessness, pains and reactions, etc. are
also received
INTRODUCTION

3.  Derived from Latin word ‘URGENS’ – pressing
 Term ‘emergency’ is frequently used especially in
modern hospitals
 Medical Dictionary – Emergency refers to an
unlooked for contingency or happening or a
sudden demand for action or situation requiring
prompt action.
INTRODUCTION

4.  Casualty – As defined by MoH, London means a
patient who comes to the hospital unannounced
with accidental injury and is seen and treated
otherwise than at a consultative session.
INTRODUCTION

5. INTRODUCTION
 Medical emergency is defined as a
situation where the patient requires
urgent and high quality medical care
to prevent loss of life, limb or organ
and initiate action for the restoration of
normal healthy life.

6. INTRODUCTION
 Also defined as a condition
determined clinically or perceived by
the patient or his/her relatives as
requiring immediate medical, dental or
allied services failing which may result
in loss of life or limb”
WHO

7. INTRODUCTION
 The Emergency department is a very
critical and sensitive unit of any
hospital and is involved in the
management of emergency cases.
 The emergency service brings about
an interface between the hospital and
the community, which is emotionally
subcharged.

8. INTRODUCTION
 Quick and competent care can save
lives and also reduce the severity and
duration of illness.
 The emergency service provides
immediate, emergency diagnostic and
therapeutic care to the patients with:
◦ Injuries by accidents, or
◦ Sudden attacks of illness or exacerbation
of disease.

9. INTRODUCTION
 These patients require immediate
attention and treatment.
 Emergency patients receive resuscitation
and life saving treatment.
 If the patient is serious it can make all
the difference between life and death.
 High quality of outcome is expected by
patients

10. INTRODUCTION
 The ED is also referred as casualty wing for emergency
cases
 It should have a distinct entry independent of OPD main
entry

11. INTRODUCTION
 To the patient high quality of outcome
means;
◦ Right time
◦ Right care
◦ Right expertise
◦ Right attitude
◦ Right cost

12. INTRODUCTION
 “ The first and foremost requirement of
a Casualty is that it should do the
patient no harm”
Florence
Nightingale

13. INTRODUCTION
 It should be an independent department working
round the clock.
 It should be located in the complex of the OPD for
reasons of easy accessibility and sharing medical
facilities with the OPD.
 It shall be on the ground floor of the hospital.
 Guidance to the route from main entrance to the
doorways of reception hall shall be provided.

14. INTRODUCTION
 There should be an easy ambulance approach with
sufficient space for free passage of vehicles and
covered areas for alighting patients.
 The arrangements for reception of trolleys and
walking patients should be close by.
 Waiting space also for persons accompanying the
patients.

15. INTRODUCTION
 As accident cases are closely related with police
department, a separate room for their use shall be
provided in this area.
 toilet facilities for men and women vicinity.
 Therefore, ED provides round-the-clock, immediate
diagnosis and treatment for illness of an urgent
nature and injuries from accidents.

16. INTRODUCTION
 Emergency service is acquiring increasing
importance due to modern problems arising out of
urbanization and mechanization.
 Excellent services must be provided as the patients
and their relatives are under emotional strain and
subcharged with suspense and anxiety about the
consequences.

17. Normal Life
Physic
al
Sudden
Disruption
Social
Spiritual
Menta
l
Sudden feeling of
restlessness
Some form of
disaster (Natural or
Man-Made)
Admitted to Emergency
Sympathetic and
Confident Doctors
Diagnosis
Treatment
Making the Patient
Confident
Operation if Needed
Relieved with advice
to Visit OPD Treatment

19. Process Requirements
 Simple cases after administering preliminary
treatment are discharged with instructions to attend
OPD as follow up measure.
 Cases of serious nature are admitted in emergency
wards to provide immediate medical care.
 Such patients are either discharged after 2-3 days
or are transferred to permanent inpatient units.
 Percentage of Inpatient admissions from ED
accounts for 20-25%

20.  Centralized Emergency Services should be
developed to deal with the increasing number of
cases of accidents and injuries.
 The need to have such service should be
considered as National Health Service priority
keeping in view that:
◦ 50% of all categories of accident cases admitted are due to
traffic accident.
◦ There is no organization efficient enough to deal with these
large number of injuries and accident cases.
Other Facts

21. ◦ 60% of deaths resulting from myocardial infarction occur
within 1 hour of onset.
◦ With proper emergency care, percentage of coronory
deaths which occur outside hospitals and can be prevented
is 40%
Other Facts

22. ◦ The hospital beds are inadequate to deal with
this vast problem.
◦ An efficient transport system to lift the patients
from the scene of accident does not exist.
◦ It has been realized that the most efficient
treatment of accident cases should start from the
scene of accident itself.
Other Facts

23.  It is necessary to have :
◦ An effective communication system.
◦ Speedy transportation of the accident victims for
immediate first aid and resuscitation, starting from the
place of accident.
◦ Coordination and harmonious working with the other
hospitals, especially identified for this purpose.
◦ A multi-disciplinary approach for the treatment of poly
trauma cases involving all the surgical and medical
disciplines.
Other Facts

24.  Accident and emergency (A&E) departments are
specialized to handle patients with acute emergencies
that require urgent medical assessment and treatment.
 But it is found that these departments are becoming
more of a popular venue for primary care.
 The significant increase of inappropriate attendance is
considered as a serious threat to the healthcare system
because of inefficient utilization of resources and
depriving the true emergency cases of quality care.
Other Facts

25. Core Design

27. TYPES OF EMERGENCY
 Surgeons have classified emergencies into
following categories:
◦ First Emergency : what must be done within a few minutes
or hour?
◦ Second Emergency: What must be done within 6 hours?
◦ Third Emergency: What must be done within 24 hrs?

28.  This classification means delayed surgery for
surgeon and not for resuscitator.
 Outdated classification
 Emergency to be classified taking into account
rapidity of the outcome for different pathologies
TYPES OF EMERGENCY

29. TYPES OF EMERGENCY
 Major Emergency Services: In general such facilities
are provided in teaching and training hospitals.
 Basic Emergency Services: In all hospitals
 Stand by emergency services: Usually in primary
healthcare set up.

30.  Divided in two parts
◦ Outside the hospital
◦ Inside the hospital
Outside services can again be divided into two groups:
◦ Alarm and communication system
◦ Ambulance services
Types of Emergency Medical Services

31. OBJECTIVES AND SCOPE OF
SERVICES
◦ Emergencies of following type are received:
 Emergencies like coronary diseases, respiratory diseases, obstructions
of gut, perforations and colics.
 Accidents – road or industry having lacerations, haemorrhage, sprains,
dislocations, fractures, shock, falls, etc.
 Foreign bodies
 Burn of all types
 Dog bites and snake bites
 Mass causalities from food poisoning, drinks, riots, etc
 Medico-legal cases
 Cases of acute severe pain or distress
 Septic conditions
 Obstetric emergencies real or pseudo in nature
 Pseudo emergency cases
- Pseudo emergency cases mostly includes fear of unknown, lack of
competence of G.P., Easy accessibility, Stress and strain

32. OBJECTIVES AND SCOPE OF
SERVICES
◦ Managing accidents victims,
◦ Providing first aid,
◦ Treatment of minor injuries
◦ Referred to appropriate specialty or hospital, in case specialized
care is necessary and cannot be provided in the hospital.
◦ Attending all medico-legal formalities, including documentation of
clinical conditions and other particulars and liaison with the police.
◦ Attending the patients coming outside the routine outpatient
working hours, and screening them for admission.
◦ Observing them for short period to determine whether they need
admission, or Providing outpatient care.
◦ Briefing the relatives
◦ Maintaining records
◦ Training

33. Location, Accessibility and Layout
Broadly the department should have the following:
◦ Consultation and examination room
Equipped with:
i. Doctors seating arrangement with office furniture.
ii. Examination Couch
iii. BP Instrument (Sphygmomanometer)
iv. Stethoscope
v. Clinical Thermometer
vi. Torch

34. ◦ Procedure Room
i. Equipped with facilities for minor procedures like suturing, Endotracheal
Intubation, Dressing, Plaster, Catheterization, Ryles Tube.
ii. Operation Theatre Light
iii. Suction Machine
iv. Boiler
v. Drip Stand
vi. Glucometer
◦ Treatment Room
Equipped with
i. DC Shock Machine
ii. Beds for treatment
iii. Cardiac Table
iv. Instruments for vaccination
◦ Toilet, and Waiting Area
Location, Accessibility and Layout

35. Physical Facilities for 200-300 bedded emergency
department
S. No. Name of facility Number Size Area in Sq
ft
1 Ambulance
entrance
1 - -
2 Main entrance to
casualty
1 8ft x 10ft 80
3 Waiting area 1 20ft x 20 ft 400
4 Reception 1 - 140
5 Examination
cubicle
4 80 sq ft 320
6 Observation ward 10 beds 84 sq ft
each
480
7 Emergency X-
Ray Room
1 12 ft x 15
ft
180
8 Emergency
Laboratory
1 12 ft x 15
ft
180
9 Treatment Room 1 12 ft x 15
ft
180

36. Physical Facilities for 200-300 bedded emergency
department
S. No. Name of facility Number Size Area in Sq
ft
10 Fracture/ Plaster
Room
1 12 ft x 10
ft
120
11 Doctor’s Duty Room 1 240 240
12 Nurse’s Duty Room 1 12 ft x 10 ft 120
13 ECG Technician’s
Room
1 12 ft x 10 ft 120
14 Room for Gr C and
D
1 12 ft x 10 ft 120
15 Store Room 1 12 ft x 10 ft 120
16 Staff toilets 2 8 ft x 10 ft 160
17 Water cooler 1 - -
18 Police Post 1 12 ft x 15 ft 180
19 Patient’s toilets 1 12ft x 15 ft 180

37. EQUIPMENTS
Some of the equipments of ED:
 Ventilators
 Defibrillators
 Pulse Oximeter
 Drop Infusion Pump (Dosimeter)
 Suction Machine
 Laryngoscope
 Airway
 Cardiac Monitors
 Ambu Bag
 ECG Machine
 Portable X-Ray Machine
 Emergency Trolleys
 Splinting Equipments
 Stethoscope, Clinical Thermometer, Torch

38. ◦ Separate Counters
◦ Registration Charges
◦ Bed Charges
REGISTRATION PROCEDURE FOR EMERGENCY CASE

39. On an average a patient is kept for 2 hrs in ED and then
either he is discharged or admitted and shifted to respective
ward.
Average Time for ED Stay
OPERATION THEATRE
• Minor operations are performed in the procedure room,
which can be called minor operation theatre.
• In case of any major operation such as Head Injury the
operations are performed in main operation theatre of the
hospital by the consultants.

40. ◦ Medical Cases
◦ Surgical Cases
◦ Diagnostic Services
◦ Vaccination
◦ Blood Transfusion
◦ Injections
FACILITIES PROVIDED IN THE ED

41. ◦ Emergency Incharge (Senior Doctor)
◦ CMO in each shift
◦ Nurses (Diploma in Nursing and midwifery)
◦ Ward boys
◦ Sanitary Attendant
STAFF
DUTY ROASTERS
◦ Morning Duty 8am – 2 pm
◦ Evening Duty 2pm – 9 pm
◦ Night Duty9 pm – 8 am

42. ◦ A new concept in emergency care has been
introduced with the employment of “Scribes” who
is member of nursing staff and whose function is;
 Taught to record physician’s findings as well as pertinent
segments of the history while the patient is being
interviewed and examined
 Scribe conveys the physician orders to other members of
the team while the physician continues with other
patients
 Scribes also prepares the prescription ordered by the
physician to be ready for his signature
STAFF

43. PATIENT FLOW
Critical Patient
Emergency
Department
Consultant Examines
Payments and
Registration at
OPD Counter
Vitals Checked
Investigations
(ECG, Blood
Sugar
Emergency Care
given to patient (IV
fluids, suction, etc)
Treatment initiated
Discharged Admitted to IPD

44. ◦ The equipment like ECG and Defibrillator etc. are present in
the department and are in adequate numbers.
◦ The drugs like Injection Avil, Injection Lasix, Injection
Adrenaline, Injection Rentac, Injection Reglan, Injection
Regafortan, IV Dextrose and other fluids should be present.
◦ Whenever any item has to be procured from stores, sister
Incharge should fill the indent form.
Availability and Adequacy of Equipments,
Drugs and other supplies

45. ◦ Doctor’s duty report with total history and treatment done on
the patient and it is reported by the doctor on duty.
◦ Nurse’s Record Register –
◦ Stock register maintained by nurse
◦ Injection register maintained by nurse
◦ Thalassemia register maintained by Sister Incharge
◦ Vaccination Register
- Emergency OPD cases should be registered separately
- Trend of cases according to seasons should be monitored
- Dying declaration by Medical officer
RECORDS MAINTAINED IN EMERGENCY
DEPT

46. KEY PLANNING AND DESIGNING PARAMETERS
 Patient load is very important factor.
 Emergency patients account for 10% of all OPD cases (jain Committee
report)
 25% should be added to current patient load to avoid overcrowding in
the first 4-5 years of operation.
 1 out of 8 beds are occupied by an injured patient.
 1 of every 42 vehicles in the country meets with accidents.
 Percentage of beds to be allocated are 10% of total hospital inpatient
beds.
 Need to rationalize and organize emergency services as close to
community as possible.
 GOI planning, organizing and developing trauma services for control of
RTAs

47. KEY PLANNING AND DESIGNING PARAMETERS
 The design and planning should be done so as not to impede
the movement of patients and staff and equipment.
 The equipment should be located in designated spaces to be
readily accessible when needed.
 It should provide privacy during management of patients.
 There should be minimum criss-crossing of patient traffic.
 A separate entrance and exit may be planned to facilitate
unidirectional patient flow.
 It should provide easy access for ambulances, patients and
general public.

48. KEY PLANNING AND DESIGNING PARAMETERS
 The entrance should be easily identifiable, protected from
inclement weather and accessible to disabled patients.
 Depending on type and location of hospital a helipad may be
planned.
 Ground level location is best since it avoids need for patient
access by stairs or elevators, and provides easy access for
patients and ambulances.
 It should ideally be situated near ICU and Operating Room.
 As a rule of thumb daily patient load of 100 in ED will require
approx 1000 sq mtr of space.

49. KEY PLANNING AND DESIGNING PARAMETERS
 Patient waiting area should be welcoming, visually appealing
and comfortable.
 There should be a readily identifiable triage area with
expansion facilities for utilization during management of
disasters.
 It should have acute care rooms arranged around the main
nursing work area.
 It should have trauma rooms in proximity to the entrance.
 There should be effective day and night sign posting.

50. KEY PLANNING AND DESIGNING PARAMETERS
 Door should be wide enough to accommodate stretcher, trolleys and
portable X-Ray machine.
 A door of width 1.8 m allows attendants to walk on either side of a
stretcher or trolley.
 Clinical care areas should have exposure to maximum feasible day light.
 Safety and security of staff, patients and visitors.
 Each treatment area requires space of 15 m sq.
 The resuscitation room/bay should have space to accommodate
specialized resuscitation bed, allow 360 degree access to all parts of the
patient for facilitating procedures.
 Ceiling mounted power columns simplifies access of monitoring lines
and devices.

51. Policy 1
◦ Any patient seeking for emergency care irrespective of types of
emergency will first report to this department.
◦ Here the patient will be assessed about the nature of illness and
the treatment required for the management of the condition.
◦ After careful examination, needed care been provided, the patient
will be either disposed off or be taken to the specific care
treatment area and patient care will be given for further
management of the disease.
HOSPITAL POLICIES FOR ED

52. Policy 2
e.g.
◦ The department can accept any type of emergency except
Medico-Legal Cases. Medico-Legal Cases are not accepted
except for giving first aid. (hospital to hospital policy may vary)
◦ These cases include:
 Accident cases
 Poisoning cases (Suicidal, Homicidal)
 Burn cases
◦ The other cases that are not attended are:
 Infective cases
 Open tuberculosis cases
Note: Medico legal cases load in an emergency department
accounts for 20% of total workload and out of these 50% are
RTAs
HOSPITAL POLICIES FOR ED

53. Policy 3
◦ The department has to attend to provide immediate relief and
management of patients arriving at the hospital with acute
medical and surgical emergency for e.g. Acute MI, Shock, Status
Asthmatius, Acute Abdomen, etc.
HOSPITAL POLICIES FOR ED

54. Policy 4
◦ The department has to attend to the patients coming outside the
routine outpatients working hours, and
 Screen them for admission
 Observe them for short period to determine whether they need
admission
 Provide Outpatient Care
HOSPITAL POLICIES FOR ED

55. Policy 5
◦ The department has to see patients on Sundays as the OPD is
closed on Sundays.
Policy 6
The ED in order to deliver the above mentioned services has
been and will be equipped with diagnostic and therapeutic
equipment’s which are needed to manage critical patients. The
purchase of new equipment will be through Central Purchase
Committee (CPC)
HOSPITAL POLICIES FOR ED

56. Policy 7
◦ The ED will have trained medical and nursing professional to
manage patients coming to it.
Policy 8
The emergency department will avail the services of specialists
and super-specialists associated with the hospital whenever the
services are required for the management of the casualty cases.
HOSPITAL POLICIES FOR ED

57. Policy 9
◦ The ED will provide ambulance services for bringing the patients
to the hospital.
Policy 10
the patient will be received and brought in to the emergency
department by the ward boys on the stretcher if the patient is non
ambulatory.
HOSPITAL POLICIES FOR ED

58. ◦ Availability of Quality manual
◦ Procedure for receiving patient
◦ Well rehearsed protocols
◦ Admission of the patient and transfer to the ward
◦ Recording the case details
◦ Valuables of the patients
◦ Patient refusing the admission
◦ Medico legal cases
◦ Disaster plan
◦ Triaging
◦ Protocol for death cases
◦ Procedure for calling Consultants on call
◦ Daily check of all medical items
◦ Control of narcotic, cytotoxic drugs
◦ Equipment checks on daily basis
◦ Schedule of charges
◦ Periodic audit
Quality of the process of care

59. ◦ Response time for dispatch of ambulance when asked for
◦ Response time of the consultant
◦ Time taken for treatment and starting the definitive treatment
◦ Death rate in A & E department
◦ Length of stay on observation beds and emergency ward beds
both
◦ Satisfaction level of patients and attendants
◦ Type of cases received in emergency
◦ Daily attendance and percentage of cases admitted
◦ Response time of code blue team
◦ Employee satisfaction
Measuring Quality for A & E services

60. THANK YOU