CONCEPTS, COMPONENTS, AND CONFIGURATIONS
A Conceptual Framework For Emergency Care Planning Jonathan M. Metsch, Dr PH Richard Bassin, MD Michael M. Stewart, MD, MPH Jean Porta, MS Michele G. Greene, MA New York, New York
The e x p e r i e n c e of f u n c t i o n a l p r o g r a m planning, in a d d i t i o n to facilitating the p l a n n i n g p r o c e s s for a n e w e m e r g e n c y unit, h a s h a d additional l~enefits. It h a s g i v e n the staff a c o m m o n c o n c e p t u a l f r a m e w o r k for a n a l y z i n g p a t i e n t c a r e as p r o v i d e d and for i d e n t i f y i n g a r e a s w h e r e imp r o v e m e n t s c a n be m a d e . Also, a n e w a p p r o a c h has b e e n d e v e l o p e d for c o m m u n i c a t i n g w i t h other d e p a r t m e n t s and w i t h h o s p i t a l administration a b o u t d a y - t o - d a y o p e r a t i n g p r o b l e m s w h i c h m a y be useful for add r e s s i n g o t h e r r e s o u r c e a l l o c a t i o n and o p e r a t i n g r o o m t i m e s c h e d u l e s . B y d e v e l o p i n g a p l a n n i n g f r a m e w o r k , it is p o s s i b l e to i n t e g r a t e the exp e r t i s e of v a r i o u s s e r v i c e s , w h i l e r e t a i n i n g an i n t e g r a t e d o v e r a l l orient a t i o n w i t h i n w h i c h the e f f i c a c y o f different p r o p o s a l s c a n be j u d g e d . This a p p r o a c h is critically i m p o r t a n t in h e l p i n g to a v o i d the a d v e r s e effects of f r a g m e n t e d p l a n n i n g .
Metsch JM, Bassin R, Stewart MM, Porta J, Greene MG: A conceptual framework for emergency care planning. JACEP 5:782-786, October 1976.
emergency department, organization and administration.., patients.., staffing; EMS, planning. INTRODUCTION The p l a n n i n g of new or improved emergency care facilities is a m a t t e r of great concern in m a n y hospitals. The objectives of some p l a n n i n g efforts may be quite specific, such as the i n t r o d u c t i o n of new technology for prehospital care, use of new personnel, introduction of special emer-
gency care technology, or developm e n t of new programs for p a r t i c u l a r e m e r g e n c y care p r o b l e m s . O t h e r e m e r g e n c y care p l a n n i n g s t r a t e gies 1-3 m a y focus on h e a l t h care systern i s s u e s , s u c h as p a t i e n t flow models, referral p a t t e r n s , triage methods, a n d priorities in resource allocation.
From the Health Services Research Unit, Department of Ambulatory Care and Community Medicine, Mount Sinai Hospital Services, City Hospital Center at Elmhurst, Elmhurst, New York, and the Department of C o m m u n i t y Medicine, Mount Sinai School of Medicine, New York, New York.
Supported by a grant from the Commonwealth Fund. Address for reprints: Michael M. Stewart, MD, MPH, Director, Department of Ambulatory Care and Community Medicine, Mount Sinai Hospital Services, City Hospital Center at Elmhurst, 79-01 Broadway, Elmhurst, New York 11373.
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There is no single best approach to effective p l a n n i n g and the needs of different hospitals and population g r o u p s v a r y w i d e l y . H o w e v e r , in p l a n n i n g for new or expanded emergency care services, there is a complex and diverse r a n g e of issues and service e l e m e n t s to be considered. Thus, a critical first phase is to develop a p l a n n i n g o r i e n t a t i o n t h a t integrates the information available from a v a r i e t y of sources. Adverse consequences of f r a g m e n t e d p l a n n i n g m a y i n c l u d e purchase of expensive e q u i p m e n t t h a t is u n d e r u s e d , creation of specialized services t h a t place unexpected demands on other bospit a l resources, i n a b i l i t y of existing laboratory, radiology or other services to provide a d e q u a t e technical support, a n d u n e v e n or inappropriate use of emergency care personnel. In recent p l a n n i n g for a new emergency u n i t at City Hospital Center at E l m h u r s t , a 970-bed m u n i c i p a l hospital i n New York City, careful att e n t i o n was given to the development of a conceptual framework t h a t will permit realistic functional planning, t a k i n g into account c u r r e n t patient load, types of problems treated, and a variety of i n s t i t u t i o n a l constraints. The p l a n n i n g approach is based on the following steps: • d e l i n e a t i o n of c a t e g o r i e s of emergency care to be provided, October 1976 J ~ P
• t a s k a n a l y s i s of the activities of e m e r g e n c y u n i t staff for differe n t c a t e g o r i e s of e m e r g e n c y care, • e s t i m a t i o n of r e s o u r c e s needed for d i f f e r e n t e m e r g e n c y c a r e categories_ This p l a n n i n g approach is the subject of the p r e s e n t report.
ELMHURST EMERGENCY UNIT E m e r g e n c y s e r v i c e s at E l m h u r s t are subdivided into psychiatric, pediatric, and a d u l t medical-surgical units. The p s y c h i a t r i c u n i t has app r o x i m a t e l y 600 p a t i e n t v i s i t s p e r month; t h e pediatric unit, 4,000; and the a d u l t m e d i c a l - s u r g i c a l u n i t , which h a n d l e s p e d i a t r i c t r a u m a as well as a d u l t e m e r g e n c i e s , 5,500. T o t a l p a t i e n t v o l u m e is a p p r o x i mately 120,000 visits annually. A m b u l a t o r y p a t i e n t s are i n i t i a l l y evaluated by a t r i a g e nurse at a special n u r s e - t r i a g e booth located in the r e g i s t r a t i o n a r e a ( e x t e r n a l triage)_ Triage for p a t i e n t s a r r i v i n g by ambulance or on stretchers t a k e s place within the emergency care area ( i n t e r n a l t r i a g e ) . P a t i e n t s m a y be referred d i r e c t l y to oral surgery, ophthalmology, otolaryngology, gynecology, or a d u l t w a l k - i n clinics. App r o x i m a t e l y 8,000 p a t i e n t s p e r month are seen by the triage nurses, with some 3,000 (38%) t r i a g e d from the e m e r g e n c y u n i t to other a r e a s in the h o s p i t a l . T h e r e a r e a p p r o x i mately 1,600 admissions to i n p a t i e n t services e a c h m o n t h , w i t h 95% of a d m i s s i o n s b e i n g i n i t i a t e d in t h e emergency unit.
CATEGORIES OF EMERGENCY CARE Before specifying e m e r g e n c y care resources r e q u i r e m e n t s or developing plans for new p r o g r a m components, it is i m p o r t a n t to a n a l y z e e x i s t i n g emergency care d e m a n d s . This has been done at E l m h u r s t by u s i n g a two-dimensional m a t r i x t h a t shows the i n t e r r e l a t i o n o f type of care required a n d urgency of need for medical attention. P a t i e n t care problems are divided into f o u r g e n e r a l t y p e s : s u r g i c a l , medical, p e d i a t r i c , a n d psychiatric_ Patients in each group r e q u i r e similar i n i t i a l e v a l u a t i o n and often reJ~P
October 1976
Figure 1 PATIENT CARE CATEGORIES Continuum of Urgency Type of Care Required Surgical
Emergent Urgent Suspect Nonurgent Observation 1
2
3
4
5
Medical
6
7
8
9
10
Pediatric
11
12
13
14
15
Psychiatric
16
17
18
19
20
Figure 2 COMBINED PATIENT CARE CATEGORIES Continuum of Urgency Type of Care Required
Emergent Urgent Suspect Nonurgent Observation
Surgical
A
Medical
B
Pediatric
C
D
E
H
Psychiatric
quire s i m i l a r types of diagnostic and other a n c i l l a r y services. In addition, we use a f i v e - s t a g e c o n t i n u u m of u r g e n c y of need for medical a t t e n t i o n . Emergent i n c l u d e s p a t i e n t s w i t h l i f e - t h r e a t e n i n g conditions req u i r i n g i m m e d i a t e stabilization. Urgent includes p a t i e n t s w i t h problems r e q u i r i n g e a r l y s t a b i l i z a t i o n and/or rapid diagnostic evaluation and t r e a t m e n t . Suspect includes p a t i e n t s r e q u i r i n g r a p i d diagnostic e v a l u a t i o n due to t h e p o s s i b i l i t y of a s e r i o u s condition. Nonurgent includes walkin p a t i e n t s (at t i m e s w h e n o t h e r clinics a r e closed) and also p a t i e n t s r e t u r n i n g for one-visit follow-up care after previous visits (such as for suture removal). Observation includes p a t i e n t s being observed for diagnostic or c o n s u l t a t i v e purposes u n t i l a d e f i n i t i v e disposition can be made, those b e i n g held for t h e r a p e u t i c purposes before an a l r e a d y d e t e r m i n e d d i s p o s i t i o n can be c a r r i e d o u t and those p a t i e n t s w a i t i n g for transportation. U s i n g t h e s e two c h a r a c t e r i s t i c s , t y p e of c a r e r e q u i r e d a n d r e l a t i v e u r g e n c y of the need for care, emerg e n c y c a r e c a n be c a t e g o r i z e d for p l a n n i n g purposes as e m e r g e n t surgical, urgent medical, nonurgent pediatric, and so on. T w e n t y possible p a t i e n t care categories are indicated
F
G I
J
by the cells of the m a t r i x (Figure 1). H o w e v e r , for f u n c t i o n a l p l a n n i n g purposes it is more useful to combine c e r t a i n p a t i e n t care categories along both axes of the m a t r i x (Figure 2). Thus, while it is i m p o r t a n t to plan s e p a r a t e l y for t h e e m e r g e n t and urg e n t s u r g i c a l c a t e g o r i e s (A and C) and emergent and urgent medical categories (B and D), it is anticipated t h a t both medical and surgical problems in the suspect, n o n u r g e n t or obs e r v a t l o n categories can be m a n a g e d in s i m i l a r physical settings and with s i m i l a r types of personnel and other r e s o u r c e s . T h i s is r e f l e c t e d in categories E, F, and G. F u r t h e r , the pediatric emergent and urgent categories have now been combined (category H). Since pediatric t r a u m a is seen in the a d u l t medical-surgical u n i t ( c a t e g o r y A), o t h e r e m e r g e n t and u r g e n t pediatric care can be considered f u n c t i o n a l l y similar, particularly, since a t E l m h u r s t , true pediatric emergencies (nontraumatic) cons t i t u t e less t h a n 2% of the pediatric case load. F i n a l l y , e m e r g e n c y psychiatric care u s u a l l y requires the use of o n l y c o n s u l t a t i o n rooms or of a secure observation/holding area, m a k i n g two p a t i e n t care categories sufficient (J and K). B e c a u s e of the p a r t i c u l a r charact e r i s t i c s of p a t i e n t s s e e n at E l m Volume 5 Number 10 Page 783
h u r s t , it has also p r o v e n useful to subdivide c e r t a i n categories t h a t require different mixes of emergency u n i t resources• E m e r g e n t m e d i c a l (category B), has been divided into c a r d i o p u l m o n a r y (B1) a n d d r u g oyerdose/coma (B2); u r g e n t surgical (C) i n t o m i n o r s u r g i c a l (C1), orthopedics (C2) and gynecology (C3); and u r g e n t medical (D) into severe a s t h m a (D1), alcohol i n t o x i c a t i o n (D2) and general medical (D3). Patients may move later from one category to a n o t h e r d u r i n g the course of diagnosis a n d therapy. The d e l i n e a t i o n of emergency care c a t e g o r i e s by use of a t w o - d i m e n sional m a t r i x reflecting type of care required as well as degree of urgency is a l o g i c a l e x t e n s i o n of o t h e r methods that have recently been u s e d to c a t e g o r i z e p a t i e n t s v i s i t ing emergency departments. Fenh a v e n d i v i d e d p a t i e n t s i n t o two broad groups, those w i t h e m e r g e n t and urgent problems (emergency medical services) and those with n o n u r g e n t problems (general clinical services). 4 Other workers have used v a r i a t i o n s of a t h r e e - p a r t classification system dividing emergency care problems into emergent, urgent, and n o n e m e r g e n t / n o n u r g e n t groups. ~-~ U r m a n and L a m p k i n have used a n a b b r e v i a t e d t w o - d i m e n s i o n a l classif i c a t i o n s y s t e m w i t h t h e following categories: surgery (traumatic), surgery ( n o n t r a u m a t i c ) , medicine (cardiac), medicine (noncardiac), ob/gyn, a n d other. 8 I n c o n t r a s t with m a n y of these other methods of emergency care classification, the E l m h u r s t categories (Figure 2) have not been developed p r i m a r i l y for triage purposes b u t r a t h e r for i n v e s t i g a t i n g e m e r g e n c y u n i t case m i x a n d the i m p a c t of case m i x on e m e r g e n c y u n i t resource u t i l i z a t i o n , i n c l u d i n g personnel, services, a n d space. The e m e r g e n c y care categories (Figure 2) have proven to be a valuable tool i n p l a n n i n g for a new emergency u n i t at E l m h u r s t . It is likely t h a t t h i s m a t r i x could be r e a d i l y adapted for the categorization of pat i e n t care i n d i f f e r e n t e m e r g e n c y facilities w i t h different populations of users• For example, a high volume of pediatric emergencies m a y make it appropriate to use separate categories for e m e r g e n t a n d u r g e n t pediat-
Page 784 Volume 5 Number 10
tic care. T h e n o n u r g e n t s u r g i c a l medical category (F) could be elimi n a t e d if emergency services are not used for p r i m a r y or follow-up care. For all cells i n c l u d e d i n such a matrix, p a t i e n t care should be identifiable as belonging to one category• Careful d e l i n e a t i o n of the boundaries of p a t i e n t care categories is import a n t in s u b s e q u e n t stages of program planning.
TASK ANALYSIS Based on this c o n c e p t u a l framework, the n e x t step i n p l a n n i n g was to list the sequence of tasks required for each p a t i e n t care category. This step of the p l a n n i n g process required the emergency u n i t staff to review carefully the m a n n e r i n which pat i e n t care was organized. T h i s review m a y r e v e a l ways to expedite both the process of care and the flow of patients. A m a s t e r list of e m e r g e n c y care tasks was developed. Figure 3 shows a c o n d e n s e d v e r s i o n of a t a s k analysis flow chart for p a t i e n t care categories a n d s u b c a t e g o r i e s m a n aged i n t h e a d u l t m e d i c a l - s u r g i c a l u n i t . E a c h v e r t i c a l c o l u m n represents one category, a n d w i t h i n each column, the p a t i e n t care t a s k s req u i r e d for t h a t category are n u m bered from the top in the most likely order of occurrence. For example, the first c o l u m n ( F i g u r e 3) i n d i c a t e s t h a t m o s t patients requiring emergent surgical care (category A) a r r i v e by a m b u lance a n d are i n t e r n a l l y triaged to the t r a u m a room. A n u r s e helps prepare the p a t i e n t while the physician begins the phymcal e x a m i n a t i o n . Int u b a t i o n is performed if necessary, the cardiac monitor is attached, laboratory tests are ordered, and a n int r a v e n o u s (IV) line is e s t a b l i s h e d . M e d i c a t i o n is a d m i n i s t e r e d , x - r a y films are taken, and surgical treatm e n t is i n i t i a t e d . A n a v e r a g e of three or four c o n s u l t a n t s see the pat i e n t a n d c a r r y out special procedures. The p a t i e n t is t h e n admitted to the surgical service for definitive treatment. The s e q u e n c e of t a s k s for m a n a g e m e n t of drug overdose is shown i n the third column (category B2). The p a t i e n t is b r o u g h t by a m b u l a n c e , t r i a g e d to the m e d i c a l life-support
room, prepared by a n u r s e and exami n e d by a p h y s i c i a n • T h e c a r d i a c monitor is attached, laboratory tests are sent, a n d an IV line established. M e d i c a t i o n is g i v e n for p o s s i b l e opiate overdose or hypoglycemia. Int u b a t i o n m a y be r e q u i r e d , x - r a y films are taken, and one or two cons u l t a t i o n s are u s u a l l y required. Pat i e n t s are held i n the o b s e r v a t i o n area for r e - e v a l u a t i o n and most are a d m i t t e d . . I f the p a t i e n t improves rapidly while under observation, psychiatrilc or social service consultation is requested. After discussion of diagnosis a n d disposition w i t h the patient, there' is a visit to the pharmacy a n d t h e n discharge. As shown in the far right column, n o n u r g e n t medical/surgical patients ( c a t e g o r y F) a r e e x a m i n e d by a physician and m a y h a v e simpl e surgical t r e a t m e n t performed. After a staff conference, t h e p a t i e n t s may also be r e f e r r e d to t h e p h a r m a c y prior to discharge. The other eight columns are interpreted i n a s i m i l a r m a n n e r . The inc l u s i o n of specific t a s k s a n d their precise order are not the p r i m a r y issues for discussion here, since the sequence of steps in the process of care m a y vary i n different hospitals, for a n u m b e r of reasons. However, identifying the tasks and their sequence in this m a n n e r enables the p l a n n i n g group to e x a m i n e the resources required.
ESTIMATION OF RESOURCES H a v i n g d e v e l o p e d m e t h o d s for c a t e g o r i z i n g p a t i e n t care and for outl i n i n g t h e s e q u e n t i a l p a t i e n t care tasks required for each category, the t h i r d step is to develop estimates of the resources needed to accomplish those tasks. First, p a t i e n t care data are a n a l y z e d to d e t e r m i n e the app r o x i m a t e n u m b e r s of e m e r g e n c y u n i t visits in each category. Through either retrospective chart review or prospective analysis, a "typical" profile of use is developed• The table shows the estimated d i s t r i b u t i o n by category a n d subcategory of surgical a n d m e d i c a l p a t i e n t s s e e n i n the E l m h u r s t e m e r g e n c y u n i t early in 1974. For p l a n n i n g purposes, it has been assumed t h a t while total utilization of the emergency u n i t is likely to in-
October 1976 ~ P
Figure 3 T A S K A N A L Y S I S BY C A T E G O R Y Category Task
A*
BI*
B2*
Entry-ambulance Walk-in External triage Registration Internal triage Placement-trau ma -Life s u p p o r t - M i n o r OR -Med. exam. rm. -ENT/dental -Gynecology -Cast room Nurse preparation MD e x a m i n a t i o n Intubation Cardiac monitor-ECG ECG only IV established Lab tests sent Medication IPPB Surgical treatment X-ray Consultants - - 1-2 3-4 Special procedu re Observation area Repeat x-ray MD re-evaluation Psych/social service Staff conference Pharmacy Disposition - -Admit -Discharge
1
1
1
2 3
2
2
3
3
C1
C2
(1)t 1 2 3 4
1 2 3 4
C3
D1
D2*
D3
E
F
1
1 2 3 4
1 2 3 4
1 2 3 4
2
(1) 1 2 3 4
5
3
5
5 5 5
6 7
6 7
4 5
6 7
6 7
(8)
(12) 8 (8) 9 10
(8) (8) 6 6
(9) (9) (8) 8 (11) (12)
(11)
(7)
10 (13)
13
9 10 11 12 13
(14) 16 17
13 14
11 12
14
(15) 18
(13) 15
13
1 2 3 4
5 5 6 (7) 4
45 45 5 6 7 7 8
8 8 9
10 9
(10)
4 5 (9) 6 7 7 8
6 7
(9) 8 (10)
10 11
11
9 6 7
11 8 10
(9)
5 5 5 5 5 6 7
(9) 8
10 11
(8) (9) (10)
11 (12) 12 12 13 (14) (15) (16) 13
12
11 12
16 (17)'13
13 14
10 11
14 (1 5) 16 17
(13) 15
12
(15) 18
12
*Registration for categories A, B1, B2 and D2 is usually performed by someone other than the patient in no fixed sequence. tBrackets ( ) indicate tasks sometimes performed, but not usually. f;Tasks performed concurrently are indicated by the same number in any given column.
DISTRIBUTION
Table O F P A T I E N T S BY C A T E G O R Y
A
B1
No. of Patients/Day 18
22
6
% of A d u l t MedicalSurgical Volume
11
3
9
C2
C3
D1
D2
03
E
62
20
6
8
8
20
20
10
31
10
3
4
4
10
10
5
B2 C1
crease, t h e d i s t r i b u t i o n of p a t i e n t s by category will r e m a i n r e l a t i v e l y constant. T h e r e are, of course, m a n y factors w h i c h m a y a l t e r t h e r e l a t i v e frequency of e m e r g e n c y care problems w i t h i n any given time period. Seasonal v a r i a t i o n s n a t u r a l l y occur, for example, in the frequency of h e a t s t r o k e in t h e e l d e r l y , p r i m a r i l y a s u m m e r problem (categories B1, B2, J~P
October 1976
F Total 200 100%
D3, and E), and in the Occurrence of traumatic orthopedic problems (categories A, C1, C2, E) r e l a t e d to motor vehicle and personal accidents caused by p r e v a i l i n g w e a t h e r condit i o n s , p a r t i c u l a r l y s n o w a n d ice. L o n g - t e r m v a r i a t i o n s have also been n o t e d in t h e s o c i o e c o n o m i c a n d ethnic composition of the population i n c l u d e d w i t h i n t h e h o s p i t a l ' s geo-
g r a p h i c s e r v i c e a r e a , as w e l l as changes in the community's utilization p a t t e r n s of e m e r g e n c y and prim a r y care facilities due to i m m i g r a tion, u n e m p l o y m e n t rates, and prev a i l i n g economic conditions. All the f a c t o r s d e t e r m i n i n g case m i x a n d u t i l i z a t i o n are not easily identified, however, and it is i m p o r t a n t in plann i n g for a new emergency facility to incorporate sufficient flexibility, both in a r c h i t e c t u r a l design and resource allocation, to p e r m i t future a d a p t a tion to c h a n g i n g needs for e m e r g e n c y care. At E l m h u r s t , such flexibility is a n i m p o r t a n t c o n s i d e r a t i o n to t h e planning group. Moreover, since c h a n g e s in case mix a n d degree of u r g e n c y u s u a l l y are noted as slow trends, the categorization method deVolume 5 Number 10 Page 785
scribed in this report can be used to monitor p a t i e n t use to identify such trends. Gi v en these d a t a on recent emergency unit use by p a t i e n t care category, it is possible to e s t i m a t e res o u r c e n e e d s in e a c h s p e c i a l i z e d e m e r g e n c y care area, each as well as for the e m e r g e n c y u n i t as a whole. Fo r e x a m p l e , d a t a h a v e b e e n collected on t h e use of radiology services by each p a t i e n t care category, including total n u m b e r of x-ray exa m i n a t i o n s and distribution by t i m e of day. W i t h t h i s i n f o r m a t i o n , tog e t h e r w i t h projected i n c r e a s e s in volume, it is possible to e s t i m a t e the n u m b e r of rooms r e q u i r e d in a new facility as well as the need for technician staffing and radiologist time. A s i m i l ar approach has been followed in e s t i m a t i n g the need for laboratory services, r e s u l t i n g in the determination t h a t c h e m i s t r y and h e m a t o l o g y l a b o r a t o r i e s s h o u l d be l o c a t e d dir e c t l y in t h e n ew e m e r g e n c y unit. The same methodology can be used
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in a n a l y z i n g t h e r e s o u r c e r e q u i r e m e n t s for o t h e r s u p p o r t s e r v i c e s , s u c h as s o c i a l s e r v i c e , p h a r m a c y , food service, and supplies.
2. Jacobs AR, Gavett W, Wersinger R: Emergency department utilization in an urban community: implications for community ambulatory care. JAMA 216:307312, 1971.
Of g r e a t i m p o r t a n c e is t h e f a c t t h a t a r c h i t e c t u r a l plans will be developed from this functional analysis, allowing for a d e q u a t e space for the v ar i o u s tasks, spatial separat i o n of c e r t a i n h e a v i l y u s e d t a s k areas, an d s p a t i a l l i n k i n g of other t a s k areas in a way t h a t m i n i m i zes unnecessary traffic. Since this functional p l a n n i n g m e t h o d will cont i n u e to provide d a t a on v o l u m e of p a t i e n t l o a d by c a t e g o r y , t h e arc h i t e c t u r a l design will include sufficient flexibility to accommodate fut u r e changes in p a t i e n t utilization.
3. Stoddard WD: Emergency services in Iowa: toward more effective utilization of resources and provision of care. Health Care Research Series 15, Iowa City, University of Iowa Graduate Program in Hospitals and Health Administration, 1970.
REFERENCES 1. Noble JH, Weschsler H, LaMontagn ME', et al: Behavioral planning perspectives, in Emergency Health Care Services: Fitting Together the Fragments. New York, Behavioral Publications, 1973, p 561-576.
4. Fenhaven HP, Webb SB, Pearson DA, et al: Emergency medical services and the hospital: a'statewide analysis. Hospital Administration 18:92-109, 1973. 5. Rosen P, Segal M, Coppleson D, et al: A method of triage within an emergency department. Journal of the American College of Emergency Physicians 3"85-86, 1974. 6. Kleinman JC, Tanner MM, Soodalter DL, et al: Planning for emergencymedical services in Boston. Public Health Rep 90:460-466, 1975: • 7..Albin SL, Wassertheil-Smoller S, Jacobsen S, Bell B: Evaluation of emergency room triage performed by nurses. Am J Public Health 65:1063-1068, 1975. 8. Urman JD, Lamkin KR: Emergency room utilization a~ Sha'are Zedek Hospital in Jerusalem. Med Care 11:491-500, 1973.
October 1976 ~ P
A Conceptual Framework For Emergency Care Planning Jonathan M. Metsch, Dr PH Richard Bassin, MD Michael M. Stewart, MD, MPH Jean Porta, MS Michele G. Greene, MA New York, New York
The e x p e r i e n c e of f u n c t i o n a l p r o g r a m planning, in a d d i t i o n to facilitating the p l a n n i n g p r o c e s s for a n e w e m e r g e n c y unit, h a s h a d additional l~enefits. It h a s g i v e n the staff a c o m m o n c o n c e p t u a l f r a m e w o r k for a n a l y z i n g p a t i e n t c a r e as p r o v i d e d and for i d e n t i f y i n g a r e a s w h e r e imp r o v e m e n t s c a n be m a d e . Also, a n e w a p p r o a c h has b e e n d e v e l o p e d for c o m m u n i c a t i n g w i t h other d e p a r t m e n t s and w i t h h o s p i t a l administration a b o u t d a y - t o - d a y o p e r a t i n g p r o b l e m s w h i c h m a y be useful for add r e s s i n g o t h e r r e s o u r c e a l l o c a t i o n and o p e r a t i n g r o o m t i m e s c h e d u l e s . B y d e v e l o p i n g a p l a n n i n g f r a m e w o r k , it is p o s s i b l e to i n t e g r a t e the exp e r t i s e of v a r i o u s s e r v i c e s , w h i l e r e t a i n i n g an i n t e g r a t e d o v e r a l l orient a t i o n w i t h i n w h i c h the e f f i c a c y o f different p r o p o s a l s c a n be j u d g e d . This a p p r o a c h is critically i m p o r t a n t in h e l p i n g to a v o i d the a d v e r s e effects of f r a g m e n t e d p l a n n i n g .
Metsch JM, Bassin R, Stewart MM, Porta J, Greene MG: A conceptual framework for emergency care planning. JACEP 5:782-786, October 1976.
emergency department, organization and administration.., patients.., staffing; EMS, planning. INTRODUCTION The p l a n n i n g of new or improved emergency care facilities is a m a t t e r of great concern in m a n y hospitals. The objectives of some p l a n n i n g efforts may be quite specific, such as the i n t r o d u c t i o n of new technology for prehospital care, use of new personnel, introduction of special emer-
gency care technology, or developm e n t of new programs for p a r t i c u l a r e m e r g e n c y care p r o b l e m s . O t h e r e m e r g e n c y care p l a n n i n g s t r a t e gies 1-3 m a y focus on h e a l t h care systern i s s u e s , s u c h as p a t i e n t flow models, referral p a t t e r n s , triage methods, a n d priorities in resource allocation.
From the Health Services Research Unit, Department of Ambulatory Care and Community Medicine, Mount Sinai Hospital Services, City Hospital Center at Elmhurst, Elmhurst, New York, and the Department of C o m m u n i t y Medicine, Mount Sinai School of Medicine, New York, New York.
Supported by a grant from the Commonwealth Fund. Address for reprints: Michael M. Stewart, MD, MPH, Director, Department of Ambulatory Care and Community Medicine, Mount Sinai Hospital Services, City Hospital Center at Elmhurst, 79-01 Broadway, Elmhurst, New York 11373.
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There is no single best approach to effective p l a n n i n g and the needs of different hospitals and population g r o u p s v a r y w i d e l y . H o w e v e r , in p l a n n i n g for new or expanded emergency care services, there is a complex and diverse r a n g e of issues and service e l e m e n t s to be considered. Thus, a critical first phase is to develop a p l a n n i n g o r i e n t a t i o n t h a t integrates the information available from a v a r i e t y of sources. Adverse consequences of f r a g m e n t e d p l a n n i n g m a y i n c l u d e purchase of expensive e q u i p m e n t t h a t is u n d e r u s e d , creation of specialized services t h a t place unexpected demands on other bospit a l resources, i n a b i l i t y of existing laboratory, radiology or other services to provide a d e q u a t e technical support, a n d u n e v e n or inappropriate use of emergency care personnel. In recent p l a n n i n g for a new emergency u n i t at City Hospital Center at E l m h u r s t , a 970-bed m u n i c i p a l hospital i n New York City, careful att e n t i o n was given to the development of a conceptual framework t h a t will permit realistic functional planning, t a k i n g into account c u r r e n t patient load, types of problems treated, and a variety of i n s t i t u t i o n a l constraints. The p l a n n i n g approach is based on the following steps: • d e l i n e a t i o n of c a t e g o r i e s of emergency care to be provided, October 1976 J ~ P
• t a s k a n a l y s i s of the activities of e m e r g e n c y u n i t staff for differe n t c a t e g o r i e s of e m e r g e n c y care, • e s t i m a t i o n of r e s o u r c e s needed for d i f f e r e n t e m e r g e n c y c a r e categories_ This p l a n n i n g approach is the subject of the p r e s e n t report.
ELMHURST EMERGENCY UNIT E m e r g e n c y s e r v i c e s at E l m h u r s t are subdivided into psychiatric, pediatric, and a d u l t medical-surgical units. The p s y c h i a t r i c u n i t has app r o x i m a t e l y 600 p a t i e n t v i s i t s p e r month; t h e pediatric unit, 4,000; and the a d u l t m e d i c a l - s u r g i c a l u n i t , which h a n d l e s p e d i a t r i c t r a u m a as well as a d u l t e m e r g e n c i e s , 5,500. T o t a l p a t i e n t v o l u m e is a p p r o x i mately 120,000 visits annually. A m b u l a t o r y p a t i e n t s are i n i t i a l l y evaluated by a t r i a g e nurse at a special n u r s e - t r i a g e booth located in the r e g i s t r a t i o n a r e a ( e x t e r n a l triage)_ Triage for p a t i e n t s a r r i v i n g by ambulance or on stretchers t a k e s place within the emergency care area ( i n t e r n a l t r i a g e ) . P a t i e n t s m a y be referred d i r e c t l y to oral surgery, ophthalmology, otolaryngology, gynecology, or a d u l t w a l k - i n clinics. App r o x i m a t e l y 8,000 p a t i e n t s p e r month are seen by the triage nurses, with some 3,000 (38%) t r i a g e d from the e m e r g e n c y u n i t to other a r e a s in the h o s p i t a l . T h e r e a r e a p p r o x i mately 1,600 admissions to i n p a t i e n t services e a c h m o n t h , w i t h 95% of a d m i s s i o n s b e i n g i n i t i a t e d in t h e emergency unit.
CATEGORIES OF EMERGENCY CARE Before specifying e m e r g e n c y care resources r e q u i r e m e n t s or developing plans for new p r o g r a m components, it is i m p o r t a n t to a n a l y z e e x i s t i n g emergency care d e m a n d s . This has been done at E l m h u r s t by u s i n g a two-dimensional m a t r i x t h a t shows the i n t e r r e l a t i o n o f type of care required a n d urgency of need for medical attention. P a t i e n t care problems are divided into f o u r g e n e r a l t y p e s : s u r g i c a l , medical, p e d i a t r i c , a n d psychiatric_ Patients in each group r e q u i r e similar i n i t i a l e v a l u a t i o n and often reJ~P
October 1976
Figure 1 PATIENT CARE CATEGORIES Continuum of Urgency Type of Care Required Surgical
Emergent Urgent Suspect Nonurgent Observation 1
2
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5
Medical
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7
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10
Pediatric
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12
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Psychiatric
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Figure 2 COMBINED PATIENT CARE CATEGORIES Continuum of Urgency Type of Care Required
Emergent Urgent Suspect Nonurgent Observation
Surgical
A
Medical
B
Pediatric
C
D
E
H
Psychiatric
quire s i m i l a r types of diagnostic and other a n c i l l a r y services. In addition, we use a f i v e - s t a g e c o n t i n u u m of u r g e n c y of need for medical a t t e n t i o n . Emergent i n c l u d e s p a t i e n t s w i t h l i f e - t h r e a t e n i n g conditions req u i r i n g i m m e d i a t e stabilization. Urgent includes p a t i e n t s w i t h problems r e q u i r i n g e a r l y s t a b i l i z a t i o n and/or rapid diagnostic evaluation and t r e a t m e n t . Suspect includes p a t i e n t s r e q u i r i n g r a p i d diagnostic e v a l u a t i o n due to t h e p o s s i b i l i t y of a s e r i o u s condition. Nonurgent includes walkin p a t i e n t s (at t i m e s w h e n o t h e r clinics a r e closed) and also p a t i e n t s r e t u r n i n g for one-visit follow-up care after previous visits (such as for suture removal). Observation includes p a t i e n t s being observed for diagnostic or c o n s u l t a t i v e purposes u n t i l a d e f i n i t i v e disposition can be made, those b e i n g held for t h e r a p e u t i c purposes before an a l r e a d y d e t e r m i n e d d i s p o s i t i o n can be c a r r i e d o u t and those p a t i e n t s w a i t i n g for transportation. U s i n g t h e s e two c h a r a c t e r i s t i c s , t y p e of c a r e r e q u i r e d a n d r e l a t i v e u r g e n c y of the need for care, emerg e n c y c a r e c a n be c a t e g o r i z e d for p l a n n i n g purposes as e m e r g e n t surgical, urgent medical, nonurgent pediatric, and so on. T w e n t y possible p a t i e n t care categories are indicated
F
G I
J
by the cells of the m a t r i x (Figure 1). H o w e v e r , for f u n c t i o n a l p l a n n i n g purposes it is more useful to combine c e r t a i n p a t i e n t care categories along both axes of the m a t r i x (Figure 2). Thus, while it is i m p o r t a n t to plan s e p a r a t e l y for t h e e m e r g e n t and urg e n t s u r g i c a l c a t e g o r i e s (A and C) and emergent and urgent medical categories (B and D), it is anticipated t h a t both medical and surgical problems in the suspect, n o n u r g e n t or obs e r v a t l o n categories can be m a n a g e d in s i m i l a r physical settings and with s i m i l a r types of personnel and other r e s o u r c e s . T h i s is r e f l e c t e d in categories E, F, and G. F u r t h e r , the pediatric emergent and urgent categories have now been combined (category H). Since pediatric t r a u m a is seen in the a d u l t medical-surgical u n i t ( c a t e g o r y A), o t h e r e m e r g e n t and u r g e n t pediatric care can be considered f u n c t i o n a l l y similar, particularly, since a t E l m h u r s t , true pediatric emergencies (nontraumatic) cons t i t u t e less t h a n 2% of the pediatric case load. F i n a l l y , e m e r g e n c y psychiatric care u s u a l l y requires the use of o n l y c o n s u l t a t i o n rooms or of a secure observation/holding area, m a k i n g two p a t i e n t care categories sufficient (J and K). B e c a u s e of the p a r t i c u l a r charact e r i s t i c s of p a t i e n t s s e e n at E l m Volume 5 Number 10 Page 783
h u r s t , it has also p r o v e n useful to subdivide c e r t a i n categories t h a t require different mixes of emergency u n i t resources• E m e r g e n t m e d i c a l (category B), has been divided into c a r d i o p u l m o n a r y (B1) a n d d r u g oyerdose/coma (B2); u r g e n t surgical (C) i n t o m i n o r s u r g i c a l (C1), orthopedics (C2) and gynecology (C3); and u r g e n t medical (D) into severe a s t h m a (D1), alcohol i n t o x i c a t i o n (D2) and general medical (D3). Patients may move later from one category to a n o t h e r d u r i n g the course of diagnosis a n d therapy. The d e l i n e a t i o n of emergency care c a t e g o r i e s by use of a t w o - d i m e n sional m a t r i x reflecting type of care required as well as degree of urgency is a l o g i c a l e x t e n s i o n of o t h e r methods that have recently been u s e d to c a t e g o r i z e p a t i e n t s v i s i t ing emergency departments. Fenh a v e n d i v i d e d p a t i e n t s i n t o two broad groups, those w i t h e m e r g e n t and urgent problems (emergency medical services) and those with n o n u r g e n t problems (general clinical services). 4 Other workers have used v a r i a t i o n s of a t h r e e - p a r t classification system dividing emergency care problems into emergent, urgent, and n o n e m e r g e n t / n o n u r g e n t groups. ~-~ U r m a n and L a m p k i n have used a n a b b r e v i a t e d t w o - d i m e n s i o n a l classif i c a t i o n s y s t e m w i t h t h e following categories: surgery (traumatic), surgery ( n o n t r a u m a t i c ) , medicine (cardiac), medicine (noncardiac), ob/gyn, a n d other. 8 I n c o n t r a s t with m a n y of these other methods of emergency care classification, the E l m h u r s t categories (Figure 2) have not been developed p r i m a r i l y for triage purposes b u t r a t h e r for i n v e s t i g a t i n g e m e r g e n c y u n i t case m i x a n d the i m p a c t of case m i x on e m e r g e n c y u n i t resource u t i l i z a t i o n , i n c l u d i n g personnel, services, a n d space. The e m e r g e n c y care categories (Figure 2) have proven to be a valuable tool i n p l a n n i n g for a new emergency u n i t at E l m h u r s t . It is likely t h a t t h i s m a t r i x could be r e a d i l y adapted for the categorization of pat i e n t care i n d i f f e r e n t e m e r g e n c y facilities w i t h different populations of users• For example, a high volume of pediatric emergencies m a y make it appropriate to use separate categories for e m e r g e n t a n d u r g e n t pediat-
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tic care. T h e n o n u r g e n t s u r g i c a l medical category (F) could be elimi n a t e d if emergency services are not used for p r i m a r y or follow-up care. For all cells i n c l u d e d i n such a matrix, p a t i e n t care should be identifiable as belonging to one category• Careful d e l i n e a t i o n of the boundaries of p a t i e n t care categories is import a n t in s u b s e q u e n t stages of program planning.
TASK ANALYSIS Based on this c o n c e p t u a l framework, the n e x t step i n p l a n n i n g was to list the sequence of tasks required for each p a t i e n t care category. This step of the p l a n n i n g process required the emergency u n i t staff to review carefully the m a n n e r i n which pat i e n t care was organized. T h i s review m a y r e v e a l ways to expedite both the process of care and the flow of patients. A m a s t e r list of e m e r g e n c y care tasks was developed. Figure 3 shows a c o n d e n s e d v e r s i o n of a t a s k analysis flow chart for p a t i e n t care categories a n d s u b c a t e g o r i e s m a n aged i n t h e a d u l t m e d i c a l - s u r g i c a l u n i t . E a c h v e r t i c a l c o l u m n represents one category, a n d w i t h i n each column, the p a t i e n t care t a s k s req u i r e d for t h a t category are n u m bered from the top in the most likely order of occurrence. For example, the first c o l u m n ( F i g u r e 3) i n d i c a t e s t h a t m o s t patients requiring emergent surgical care (category A) a r r i v e by a m b u lance a n d are i n t e r n a l l y triaged to the t r a u m a room. A n u r s e helps prepare the p a t i e n t while the physician begins the phymcal e x a m i n a t i o n . Int u b a t i o n is performed if necessary, the cardiac monitor is attached, laboratory tests are ordered, and a n int r a v e n o u s (IV) line is e s t a b l i s h e d . M e d i c a t i o n is a d m i n i s t e r e d , x - r a y films are taken, and surgical treatm e n t is i n i t i a t e d . A n a v e r a g e of three or four c o n s u l t a n t s see the pat i e n t a n d c a r r y out special procedures. The p a t i e n t is t h e n admitted to the surgical service for definitive treatment. The s e q u e n c e of t a s k s for m a n a g e m e n t of drug overdose is shown i n the third column (category B2). The p a t i e n t is b r o u g h t by a m b u l a n c e , t r i a g e d to the m e d i c a l life-support
room, prepared by a n u r s e and exami n e d by a p h y s i c i a n • T h e c a r d i a c monitor is attached, laboratory tests are sent, a n d an IV line established. M e d i c a t i o n is g i v e n for p o s s i b l e opiate overdose or hypoglycemia. Int u b a t i o n m a y be r e q u i r e d , x - r a y films are taken, and one or two cons u l t a t i o n s are u s u a l l y required. Pat i e n t s are held i n the o b s e r v a t i o n area for r e - e v a l u a t i o n and most are a d m i t t e d . . I f the p a t i e n t improves rapidly while under observation, psychiatrilc or social service consultation is requested. After discussion of diagnosis a n d disposition w i t h the patient, there' is a visit to the pharmacy a n d t h e n discharge. As shown in the far right column, n o n u r g e n t medical/surgical patients ( c a t e g o r y F) a r e e x a m i n e d by a physician and m a y h a v e simpl e surgical t r e a t m e n t performed. After a staff conference, t h e p a t i e n t s may also be r e f e r r e d to t h e p h a r m a c y prior to discharge. The other eight columns are interpreted i n a s i m i l a r m a n n e r . The inc l u s i o n of specific t a s k s a n d their precise order are not the p r i m a r y issues for discussion here, since the sequence of steps in the process of care m a y vary i n different hospitals, for a n u m b e r of reasons. However, identifying the tasks and their sequence in this m a n n e r enables the p l a n n i n g group to e x a m i n e the resources required.
ESTIMATION OF RESOURCES H a v i n g d e v e l o p e d m e t h o d s for c a t e g o r i z i n g p a t i e n t care and for outl i n i n g t h e s e q u e n t i a l p a t i e n t care tasks required for each category, the t h i r d step is to develop estimates of the resources needed to accomplish those tasks. First, p a t i e n t care data are a n a l y z e d to d e t e r m i n e the app r o x i m a t e n u m b e r s of e m e r g e n c y u n i t visits in each category. Through either retrospective chart review or prospective analysis, a "typical" profile of use is developed• The table shows the estimated d i s t r i b u t i o n by category a n d subcategory of surgical a n d m e d i c a l p a t i e n t s s e e n i n the E l m h u r s t e m e r g e n c y u n i t early in 1974. For p l a n n i n g purposes, it has been assumed t h a t while total utilization of the emergency u n i t is likely to in-
October 1976 ~ P
Figure 3 T A S K A N A L Y S I S BY C A T E G O R Y Category Task
A*
BI*
B2*
Entry-ambulance Walk-in External triage Registration Internal triage Placement-trau ma -Life s u p p o r t - M i n o r OR -Med. exam. rm. -ENT/dental -Gynecology -Cast room Nurse preparation MD e x a m i n a t i o n Intubation Cardiac monitor-ECG ECG only IV established Lab tests sent Medication IPPB Surgical treatment X-ray Consultants - - 1-2 3-4 Special procedu re Observation area Repeat x-ray MD re-evaluation Psych/social service Staff conference Pharmacy Disposition - -Admit -Discharge
1
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2 3
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(1)t 1 2 3 4
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D2*
D3
E
F
1
1 2 3 4
1 2 3 4
1 2 3 4
2
(1) 1 2 3 4
5
3
5
5 5 5
6 7
6 7
4 5
6 7
6 7
(8)
(12) 8 (8) 9 10
(8) (8) 6 6
(9) (9) (8) 8 (11) (12)
(11)
(7)
10 (13)
13
9 10 11 12 13
(14) 16 17
13 14
11 12
14
(15) 18
(13) 15
13
1 2 3 4
5 5 6 (7) 4
45 45 5 6 7 7 8
8 8 9
10 9
(10)
4 5 (9) 6 7 7 8
6 7
(9) 8 (10)
10 11
11
9 6 7
11 8 10
(9)
5 5 5 5 5 6 7
(9) 8
10 11
(8) (9) (10)
11 (12) 12 12 13 (14) (15) (16) 13
12
11 12
16 (17)'13
13 14
10 11
14 (1 5) 16 17
(13) 15
12
(15) 18
12
*Registration for categories A, B1, B2 and D2 is usually performed by someone other than the patient in no fixed sequence. tBrackets ( ) indicate tasks sometimes performed, but not usually. f;Tasks performed concurrently are indicated by the same number in any given column.
DISTRIBUTION
Table O F P A T I E N T S BY C A T E G O R Y
A
B1
No. of Patients/Day 18
22
6
% of A d u l t MedicalSurgical Volume
11
3
9
C2
C3
D1
D2
03
E
62
20
6
8
8
20
20
10
31
10
3
4
4
10
10
5
B2 C1
crease, t h e d i s t r i b u t i o n of p a t i e n t s by category will r e m a i n r e l a t i v e l y constant. T h e r e are, of course, m a n y factors w h i c h m a y a l t e r t h e r e l a t i v e frequency of e m e r g e n c y care problems w i t h i n any given time period. Seasonal v a r i a t i o n s n a t u r a l l y occur, for example, in the frequency of h e a t s t r o k e in t h e e l d e r l y , p r i m a r i l y a s u m m e r problem (categories B1, B2, J~P
October 1976
F Total 200 100%
D3, and E), and in the Occurrence of traumatic orthopedic problems (categories A, C1, C2, E) r e l a t e d to motor vehicle and personal accidents caused by p r e v a i l i n g w e a t h e r condit i o n s , p a r t i c u l a r l y s n o w a n d ice. L o n g - t e r m v a r i a t i o n s have also been n o t e d in t h e s o c i o e c o n o m i c a n d ethnic composition of the population i n c l u d e d w i t h i n t h e h o s p i t a l ' s geo-
g r a p h i c s e r v i c e a r e a , as w e l l as changes in the community's utilization p a t t e r n s of e m e r g e n c y and prim a r y care facilities due to i m m i g r a tion, u n e m p l o y m e n t rates, and prev a i l i n g economic conditions. All the f a c t o r s d e t e r m i n i n g case m i x a n d u t i l i z a t i o n are not easily identified, however, and it is i m p o r t a n t in plann i n g for a new emergency facility to incorporate sufficient flexibility, both in a r c h i t e c t u r a l design and resource allocation, to p e r m i t future a d a p t a tion to c h a n g i n g needs for e m e r g e n c y care. At E l m h u r s t , such flexibility is a n i m p o r t a n t c o n s i d e r a t i o n to t h e planning group. Moreover, since c h a n g e s in case mix a n d degree of u r g e n c y u s u a l l y are noted as slow trends, the categorization method deVolume 5 Number 10 Page 785
scribed in this report can be used to monitor p a t i e n t use to identify such trends. Gi v en these d a t a on recent emergency unit use by p a t i e n t care category, it is possible to e s t i m a t e res o u r c e n e e d s in e a c h s p e c i a l i z e d e m e r g e n c y care area, each as well as for the e m e r g e n c y u n i t as a whole. Fo r e x a m p l e , d a t a h a v e b e e n collected on t h e use of radiology services by each p a t i e n t care category, including total n u m b e r of x-ray exa m i n a t i o n s and distribution by t i m e of day. W i t h t h i s i n f o r m a t i o n , tog e t h e r w i t h projected i n c r e a s e s in volume, it is possible to e s t i m a t e the n u m b e r of rooms r e q u i r e d in a new facility as well as the need for technician staffing and radiologist time. A s i m i l ar approach has been followed in e s t i m a t i n g the need for laboratory services, r e s u l t i n g in the determination t h a t c h e m i s t r y and h e m a t o l o g y l a b o r a t o r i e s s h o u l d be l o c a t e d dir e c t l y in t h e n ew e m e r g e n c y unit. The same methodology can be used
Page 786 Volume 5 Number 10
in a n a l y z i n g t h e r e s o u r c e r e q u i r e m e n t s for o t h e r s u p p o r t s e r v i c e s , s u c h as s o c i a l s e r v i c e , p h a r m a c y , food service, and supplies.
2. Jacobs AR, Gavett W, Wersinger R: Emergency department utilization in an urban community: implications for community ambulatory care. JAMA 216:307312, 1971.
Of g r e a t i m p o r t a n c e is t h e f a c t t h a t a r c h i t e c t u r a l plans will be developed from this functional analysis, allowing for a d e q u a t e space for the v ar i o u s tasks, spatial separat i o n of c e r t a i n h e a v i l y u s e d t a s k areas, an d s p a t i a l l i n k i n g of other t a s k areas in a way t h a t m i n i m i zes unnecessary traffic. Since this functional p l a n n i n g m e t h o d will cont i n u e to provide d a t a on v o l u m e of p a t i e n t l o a d by c a t e g o r y , t h e arc h i t e c t u r a l design will include sufficient flexibility to accommodate fut u r e changes in p a t i e n t utilization.
3. Stoddard WD: Emergency services in Iowa: toward more effective utilization of resources and provision of care. Health Care Research Series 15, Iowa City, University of Iowa Graduate Program in Hospitals and Health Administration, 1970.
REFERENCES 1. Noble JH, Weschsler H, LaMontagn ME', et al: Behavioral planning perspectives, in Emergency Health Care Services: Fitting Together the Fragments. New York, Behavioral Publications, 1973, p 561-576.
4. Fenhaven HP, Webb SB, Pearson DA, et al: Emergency medical services and the hospital: a'statewide analysis. Hospital Administration 18:92-109, 1973. 5. Rosen P, Segal M, Coppleson D, et al: A method of triage within an emergency department. Journal of the American College of Emergency Physicians 3"85-86, 1974. 6. Kleinman JC, Tanner MM, Soodalter DL, et al: Planning for emergencymedical services in Boston. Public Health Rep 90:460-466, 1975: • 7..Albin SL, Wassertheil-Smoller S, Jacobsen S, Bell B: Evaluation of emergency room triage performed by nurses. Am J Public Health 65:1063-1068, 1975. 8. Urman JD, Lamkin KR: Emergency room utilization a~ Sha'are Zedek Hospital in Jerusalem. Med Care 11:491-500, 1973.
October 1976 ~ P
