The Ideal Emergency Department Design lecture presented by Dr Ahmed Kamal at the Egyptian Critical Care Summit , Cairo, egypt 2015

1. The Ideal ED
Design, Man power and
Governance issues
Ahmed Kamal
Consultant in ED
South Wales - UK
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

2. 24/10/2014

3. Egyptain Critical Care Summit 12-15 January
2015 Cairo

4. Egyptain Critical Care Summit 12-15 January
2015 Cairo

5. Egyptain Critical Care Summit 12-15 January
2015 Cairo

6. Elements of Success:
 1. “A System”.
 2. The Flow.
 3. The Process ( which insures the flow).
 The management of pts starts before
arriving to the ED and finishes after they
it.
 The ED is a snap shot or a scene of the
film.
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

7. The NHS
 Primary care : GP
 Secondary care : Hospital
 Tertiary care : Burns, Neurosurgery, World leading centres.
– St Mark’s
– Great Ormond St
 NHS V Private (Consultant level only).
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

8. Emergency Medicine
 The UK ( population 64.1 Million):
 23.7 Million new pt attendance per year =
37%
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

9. Emergency Medicine
 Wide ranged &
Comprehensive.
 Fast.
 Dynamic.
 Fluid.
 Unpredictable in
Nature.
Distinctive
environment for
Potential Errors
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

10. Emergency Medicine
Sensitive Indicator of the
“Health”
of whole Health system.
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

11. Key aspects of Modern EM practice
 Early Involvement of Senior EM Clinicians
 Prompt commencement of time critical
treatment.
 Unrestricted access to imaging (CT,US and plain
radiology)
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

12. Key aspects of Modern EM practice
 Early informed decision regarding patient
disposition – admit / discharge
 Expertise in relevant critical care skills in
collaboration with Colleagues from
Anaesthesia and ITU.
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

13. Therefore
 One model for all :
 What work is:
The Flow
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

14. Effective Pt Flow
requires
Sound Process
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

15. Delivery of service – dependent on:
 1.Pts’ Numbers
 2.Type of case Mix – Inner city V Rural
 3. Flow of Pts
 1 . In – Predictable.
 2. Out – although can be predictable – However
– Complex
– Out side the control of ED
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

16. My Aim
 A Model that works :The UK standard
 Obstacles / Difficulties and how to address
 Applicability to Egypt
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

17. Fundamentals for a functioning ED
 1. The Building
 2. Man Power
 3. Supporting Network
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

18. Entrance
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

19. Security Room
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

20. Reception
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

21. Reception
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

22. Reception
 Booking Pts in & out
 Coding
 Scanning documents
 Updating all personal information
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

23. Reception
 X ray reports
 Review clinic planning
 Telephone enquires : hands-free sets
 Alert Triage nurse to serious presentations
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

24. Waiting area
 In view of the triage
Nurse.
 Tannoy speakers
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

25. Waiting area
 Waiting time Screen
 TV / Beverages
 Relevant leaflets
(sponsored)
 Separate Paediatric
waiting room
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

26. Triage
 Experienced Nurse
 Approved system (Manchester triage)
 Pain relief
 X-ray requests
 PGD (patient group directive)
 Triage V See & Rx
 Bottle neck ?
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

27. Patient Group Directions
 PGDs provide a legal framework that allows
some registered Health professionals to supply
and/or administer a specified medicine(s) to a
pre defined group of patients, without them
having to see a doctor.
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

28. Triage Board
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

29. Streaming Area
 Experienced clinician
 Chair centric
 Rapid assessment
 Initial investigation
 Patient distribution
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

30. Streaming Room at RGH
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

31. Streaming at UHW
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

32. Nursing station
 U shaped
 Strategically placed.
 Senior Nurse / Ward
Clerk / Assistant
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

33. Nursing station
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

34. Egyptian Critical Care Summit 12-15 January
2015 - Cairo
ASHICE
Date
Time
Age
Sex
History
Onset of symptoms
Injury
Condition
Resp Rate Heart Rate Blood pressure
AVPU or GCS FAST
-ve +ve
Time..............
Intubated
Y N
Cannulated
Y N
Drugs Given
1.....................
2.....................
3.....................
Defibrillated?
ETA
Nurse in
Charge
Informed
Name The Nurse in Charge should be informed of all ASHICE calls
Senior EU
Doctor
Informed
Name The Senior Doctor for the Emergency Unit should be informed of
all ASHICE calls.
Resuscitation
Team Call
Initiated?
Y N A senior nurse or doctor in the Emergency Unit should decide if an
external team is call
Cardiac Trauma Paeds
Time Initiated:
Patient
Arriving by
Helicopter
Called?
Y N If alerted of the arrival of an Air Ambulance by ASHICE (i.e. from
ambulance control) switchboard must be alerted by dialling 100
giving ETSA and requesting that the Helipad is prepared for
landing.
Time Initiated:
Stroke Team
Called?
Y N
A Senior Doctor in the EU should decide to call Stroke Team for
FAST positive patients.
9-5 Mon-Friday Dr Dewar 07827084059
Outside 9-5 Bleep 6000 Medical Registrar
Time Initiated:
Call received by :

35. Walking wounded : Minors
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

36. Walking wounded : Minors
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

37. Walking wounded: so called
“Minors”
 60-80% of work load
 Staffing:
– Minor Trauma Team ( D & N)
– NP/ ANPs
 Close to radiology
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

38. Walking wounded: so called
“Minors”
 Risks :
– Rapid turn over ( staff for 2 hours
Max)
– Abuse
– Underestimation
 Fencing in small size EDs
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

39. Walking wounded UHW
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

40. Trolley area
 In view of Nursing station
 The most vulnerable area for:
– Mismanagement.
– Serious Errors.
– Delays in assessment.
 The one hour role.
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

41. Handover
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

42. Egyptian Critical Care Summit 12-15 January
2015 - Cairo

43. Egyptian Critical Care Summit 12-15 January
2015 - Cairo
NEWS:
National
Emergency
Warning
Score

44. Trolley area
 In view of Nursing station
 24 hours manned
 The most vulnerable area for:
– Mismanagement.
– Serious Errors.
– Delays in assessment.
 The one hour role.Egyptian Critical Care Summit 12-15 January
2015 - Cairo

45. Resuscitation room
 Large room
 Appropriately equipped
for:
– ED
– Other relevant
specialities
 Guidelines and protocols.
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

46. Paediatric Facility
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

47. Short stay Unit
 24 - 48 hour stay.
 Tight protocols
 Types of admission:
– Head injuries
– Post manipulations Obs
– Overdose management
– ? Social admission over night
Caution
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

48. Clinical Decision unit
 Protocol driven.
 Chair - centric
 Type of patients:
– Chest pain.
– Neurological presentations (TIA).
– DVT
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

49. Pathways, Protocols and
Guidelines
 Head Injury NICE Guidelines
 Canadian Rules for C Spine X Ray
 Trauma call
 Consultant on Call alert
 Sepsis 6
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

50. Egyptian Critical Care Summit 12-15 January
2015 - Cairo

51. Egyptian Critical Care Summit 12-15 January
2015 - Cairo

52. Egyptian Critical Care Summit 12-15 January
2015 - Cairo

53. Egyptian Critical Care Summit 12-15 January
2015 - Cairo

54. Egyptian Critical Care Summit 12-15 January
2015 - Cairo

55. Man Power
 24 hour Consultant lead department
 On call 24/7 + 20 minutes away from ED.
 24 hour Middle Grade presence on the shop
floor.
 24 hour Nursing staff lead by a senior Sister.
 Nurse Practitioners /Advanced Nurse
Practitioners
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

56. Secretarial support
 Rota organisation
 Departmental Letters
 Communication:
– Inter Departmental
– Primary Care
– Patients
 Leave allocation
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

57. SUPPORTING SERVICES
 Radiology
 TAT - Therapy Assessment Team
 Physiotherapy
 Mental Health
 Paramedics and Ambulance staff
 Management staff
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

58. Egyptian Critical Care Summit 12-15 January
2015 - Cairo

60. Man Power : Egypt
 Current status.
 Career structure.
 Governing Body:
– Independent from but works with DOH
– Representative of Members
– Elected from members of EM speciality for a
fixed period
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

61. Essentials
 Clarity of Purpose.
 Fit for purpose building.
 Funding.
 Personnel.
 Leadership
 Institution support.
 Strong and adaptable IT
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

62. Egyptian Critical Care Summit 12-15 January
2015 - Cairo

63. The Flow : starts before and ends after the ED
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

64. Thank you to my friend
Mr Nicholas Jenkins
Consultant ED - UHW
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

65. Thank you
Egyptian Critical Care Summit 12-15 January
2015 - Cairo
Dr Sue Robinson
Consultant EM
Addenbrooke Hospital
Cambridge

66. I have failed over and over and over again in my life.
And that’s precisely why I succeed.
Michael Jordan
Egyptian Critical Care Summit 12-15 January
2015 - Cairo

67. Thank you for listening
Egyptian Critical Care Summit 12-15 January
2015 - Cairo