SPECIAL CONTRIBUTION

A Guideline for the Organization Of an Emergency Department In the University Setting James R. Mackenzie, MD Carl Jelenko, III, MD Paul James, MD Charles Erey, MD

INTRODUCTION

An e m e r g e n c y d e p a r t m e n t associated with a medical school is p a r t of a t e a c h i n g i n s t i t u t i o n and m u s t provide the atmosphere, facilities and staff for t h e education of students, p h y s i c i a n s a n d allied h e a l t h professionals. It also has the r e s p o n s i b i l i t y for developing new knowledge in e m e r g e n c y medical care t h r o u g h r e s e a r c h because of its academic set. ting. The c o m m i t m e n t to education and r e s e a r c h is often in conflict w i t h the c o m m i t m e n t to p a t i e n t care. These m u s t be b r o u g h t into h a r m o n y if the e m e r g e n c y d e p a r t m e n t is to r u n smoothly. The e m e r g e n c y d e p a r t m e n t where education t a k e s place p r o b a b l y will be located in a major medical facility. It must, therefore, be capable of c a r i n g for the broad s p e c t r u m of emergencies t h a t originate in c o m m u n i t i e s i m m e d i a t e l y surr o u n d i n g the h o s p i t a l as well as for those referred from hospitals of the region. Thus, the e m e r g e n c y d e p a r t m e n t in a u n i v e r s i t y s e t t i n g will be e i t h e r a Comprehensive E m e r g e n c y Service or a Major E m e r g e n c y Service, as defined by the A m e r i c a n Medical Association Conference on t h e Categorization of H o s p i t a l E m e r g e n c y Capabilities. 1 Therefore, i t has the specialized facilities necessary for regionalized e m e r g e n c y medical care - - one of the major components of a total h e a l t h care s y s t e m (Figure 1). This guideline for the organization of an e m e r g e n c y d e p a r t m e n t in the u n i v e r s i t y setting will •

identify the o p e r a t i o n a l goals of the medical school p e r t a i n i n g to t h e e m e r g e n c y d e p a r t m e n t s e t t i n g



define the operational objectives of the e m e r g e n c y d e p a r t m e n t p e r t a i n i n g to p a t i e n t care, education a n d research



develop a n o r g a n i z a t i o n of personnel, space, e q u i p m e n t and facilities t h a t will allow t h e operationM objectives to be met.

I_ Types of e m e r g e n c y d e p a r t m e n t s in the u n i v e r s i t y s e t t i n g A. There are e s s e n t i a l l y t h r e e a r r a n g e m e n t s by which a hospital and its e m e r g e n c y d e p a r t m e n t are p a r t of the u n i v e r s i t y setting: 1_ the u n i v e r s i t y hospital 2.

the u n i v e r s i t y affiliated hospital, ie, a c o m m u n i t y hospital which h a s a formal educational a g r e e m e n t with the medical school

3.

a c o m m u n i t y hospital in which the emergency d e p a r t m e n t , b u t not all d e p a r t m e n t s , is included in an affiliation a g r e e m e n t with the m e d i c a l school.

Developed by the Committee on Emergency Department Design and Organization of the University Association for Emergency Medical Services. Address for reprints: James R. Mackenzie, MD, UA/EMS Headquarters, Post Office Box 1241, East Lansing, Michigan 48823.

Page 364 Volume 5 Number 5

May 1976 J ~ P

FACILITY 4ealth Care Program Primary

(Secondary) Specialized

(Tertiary) Very Specialized

Surgery, Med. Peds.; Psycho.

Trauma; Burns; Open Heart, etc.

~reventative

Emergency

Ambulance; Clinic; Emergency Department

Elective - - episodic continuous

ED Out Clinic

Patient

:~ehabilitative Fig. 1. The Organization of Health Care Services. 6 The four basic programs in a total health care system are listed in the left hand column. The program may be located in one o f three facilities; primary, secondary (specialized) or tertiary (very specialized). Generally, p r i m a r y care will be provided in the home, at the scene of an incident, in an ambulance, physician's office, clinic or emergency department. Secondary care is usually given in a hospital, while highly specialized care will be given only in a large hospital, usually university-based, serving a region o f more than 500,000 population. A director should be appointed to, and be responsible for, each major health care program.

II. Goals a n d Objectives A. U n i v e r s i t y objectives m e t by the emergency d e p a r t m e n t 1.

To provide core and specialty p r o g r a m s for students, g r a d u a t e s , p o s t g r a d u a t e s a n d continuing education for p h y s i c i a n s , n u r s e s and allied h e a l t h professionals.

2.

To offer a p p r o p r i a t e curricula and sufficient i n s t r u c t i o n to assure t h a t all physicians, nurses a n d allied h e a l t h professionals are a d e q u a t e l y p r e p a r e d to m a n a g e e m e r g e n c y problems.

3.

To s u p p l y c o m m u n i t i e s w i t h i n the region with a d e q u a t e n u m b e r s of e m e r g e n c y p h y s i c i a n s and other specialties to t r e a t emergencies.

4.

To d e m o n s t r a t e the v a l u e of emergency medical care in t h e total h e a l t h care system.

5.

T h r o u g h e m e r g e n c y medical care a u d i t i n g s y s t e m s as t e a c h i n g models to d e m o n s t r a t e a m e c h a n i s m for assuring h i g h q u a l i t y medical care.

6.

To g a t h e r d a t a on emergency medical care for r e s e a r c h and development.

7.

To use r e s e a r c h and development as an i n n o v a t i v e educational tool.

B. E m e r g e n c y d e p a r t m e n t objectives w i t h i n the u n i v e r s i t y s e t t i n g 1.

P a t i e n t Care - - The e m e r g e n c y d e p a r t m e n t must: a)

serve all who seek help, t h a t is (1)

provide care for all emergency h e a l t h p r o b l e m s

(2)

provide e m e r g e n c y medical care for all p a t i e n t s in the s u r r o u n d i n g c o m m u n i t y a n d for all p a t i e n t s referred from hospitals in the region

b) provide an e n t r y into the h e a l t h care system d u r i n g p a t i e n t s ' i n i t i a l visit either on-site or by direct referral to a n o t h e r t r e a t m e n t facility c)

encourage c o m m u n i t y practitioners, hospitals and other c o m m u n i t y emergency care agencies to use the Comp r e h e n s i v e or Major E m e r g e n c y C a r e F a c i l i t y for serious emergencies

d) be p r e p a r e d to t r e a t

2.

J~P

(1)

minor disasters independently

(2)

m a j o r m a n - m a d e , medical or n a t u r a l d i s a s t e r s in conjunction with other c o m m u n i t y or r e g i o n a l e m e r g e n c y agencies.

E d u c a t i o n 2,s __ The emergency d e p a r t m e n t in a u n i v e r s i t y s e t t i n g is a m u l t i d i s c i p l i n a r y educational facility and must:

May 1976

Volume 5 Number 5 Page 365

a) participate i n a n emergency medical care system t h a t demonstrates (1)

the foregoing p a t i e n t care objectives

(2)

the economy and advantage of a n i n t e g r a t e d system

(3)

the educational value of all parts of the system

b) provide educational programs for

c)

(1)

u n d e r g r a d u a t e s - - medical, m l r s i n g and allied health professionals

(2)

graduates - - core programs i n emergency medical care for those not p u r s u i n g a career i n emergency medicine

(3)

graduates - - residency programs for those p u r s u i n g a career i n emergency medicine

(4)

c o n t i n u i n g education i n emergency medical care

assure t h a t the educational programs (1)

provide the s t u d e n t and graduate with the skill to (a) recognize emergency conditions (b) recognize the priority of the emergency (c)

diagnose a n d begin therapy in emergency conditions u n d e r pressure of an emergency

(d) t r e a t emergency conditions i n the e m e r g e n c y d e p a r t m e n t t h a t do not r e q u i r e recourse to other specialists (e) resuscitate patients with l i f e - t h r e a t e n i n g conditions u n t i l a n o t h e r specialist arrives (13 recognize the point at which a p a t i e n t needs specialized help or transfer to/~ more appropriate facility, ie, recognize their l i m i t a t i o n and those of the facility (2)

instill attitudes t h a t compel the s t u d e n t a n d graduate (a) to review their emergency care with i m p a r t i a l i t y (b) to view themselves as members of a n emergency care team (c) to act and t h i n k i n d e p e n d e n t l y in a n emergency

3.

III.

(3)

i n t e g r a t e the educational resources of the emergency d e p a r t m e n t with those of other multidisciplinary p a t i e n t care units, such as b u r n units, t r a u m a u n i t s and critical care u n i t s

(4)

a u d i t emergency medical care for educational purposes.

Research - - The emergency d e p a r t m e n t i n a u n i v e r s i t y setting is obligated to use the academic atmosphere of the hospital and the u n i v e r s i t y to develop research programs. These programs should a)

assure o p t i m u m p a t i e n t care and h a r m o n i o u s c o m m u n i t y relations

b)

use the emergency medical care audit system to identify and solve clinical and organizational problems

c)

develop testing programs that validate the solutions

d)

educate students, graduates, and qualified teachers in emergency medicine

e)

demonstrate to the u n i v e r s i t y and other i n s t i t u t i o n s the academic value of emergency medical c~:r~

f)

provide academic satisfaction for those engaged in emergency medicine.

Policies and organization related to program objectives

A. G e n e r a l - - the success of programs for p a t i e n t care, education and research u l t i m a t e l y depends upon the ability of the emergency d e p a r t m e n t staff 1.

to develop effective policies related to the objectives outlined. These policies m u s t be flexible a n d constantly reviewed

2.

to gain approval and u n d e r s t a n d i n g of the hospital, the university, the local and r e g i o n a l c o m m u n i t y for its proposed course of action

3.

to organize as a t e a m to effectively carry out the policies formulated

4.

to develop sound fiscal policies.

B. Policies 1.

Status (Figure 2) a) Hospital - - The emergency d e p a r t m e n t should have the same a d m i n i s t r a t i v e status a n d fiscal m e c h a n i s m s as other clinical departments.

Page 366 Volume 5 Number 5

May 1976 J ~ P

COMMUNITY

HOSPITAL

UNIVERSITY

Board of Governors

Y

l

Executive Dire~

~ %

I ~

Coordinating Committee

. - ~

Medical Advisory Committee

I Nursing

Medical Admin.

Committee Structure OR, ICU,ED, etc.

Department Chairmen

Personnel

Space

Equipment

Facilities

I Patient Care

Education

Research

Fig. 2. Organizational Structure of a University Hospital. The Board of Governors of the university hospital acts on behalf of the community (local and regional), the university and the hospital staff in order to carry out the functions of patient care, education and research. It delegates its aztthority as suggested by the flow chart_ b)

Academic - - Emergency medicine must have academic status w i t h i n the university. The director must be a n appointee of the dean and a m e m b e r of the major educational, research and scientific policy setting committees. Other m e m b e r s of the emergency d e p a r t m e n t staff should have appropriate academic r a n k .

c) C o m m u n i t y - - The emergency d e p a r t m e n t i n a u n i v e r s i t y setting is u s u a l l y the regional emergency facility most able to care for all types of emergencies. It is also the region's educational and research reservoir. A r e p r e s e n t a t i v e from this emergency d e p a r t m e n t should, therefore, have a leading role on the emergency care advisory committee in the region_

2.

M a n a g e m e n t - - The emergency d e p a r t m e n t in a u n i v e r s i t y setting provides those functions of a hospital, university and c o m m u n i t y t h a t are related to emergency medicine. The m a n a g i n g body of the emergency departm e n t m u s t have the authority to initiate policies and to develop standards for emergency medicine. This authority should b e delegated to the director who will act on behalf of the governing bodies of the hospital, the

J ~ P May 1976

Volume 5 Number5 Page367

The Emergency Department Director I.

Qualifications

I1.

A.

Physician - - licensed to practice medicine in state or province of appointment,

B.

Specialized knowledge in the broad field of emergency medicine and/or certificate of competence in some aspect of emergency medicine from a recognized residency program.

Appointment A. Hospital - - by the board of governors on the recommendation of the medical advisory committee to the active staff and to the department of emergency medicine as chairman. B.

C.

University - - by the dean of medicine on behalf of the senate to the appropriate academic department and to the major scientific educational and research committees of the university. Rank - - asso(~iate professor or higher. C o m m u n i t y - - by the regional health c o u n c i l or other recognized c o m m u n i t y health body to the emergency care advisory committee of the region as the coordinator of education and research programs in emergency medicine; or as a representative where more than one university is involved.

II1. Remuneration

IV.

A.

By the university for research and educational endeavors.

B.

By the hospital for patient care and administration.

Terms of Reference A.

Define emergency department policies, standards and functions with the aid of the emergency department committee.

B.

Plan, organize and manage space, facilities, e q u i p m e n t and personnel for the f u n c t i o n s defined for the emergency department. This includes the right to hire and fire all emergency department personnel and to define and manage the emergency department budget (in Consultation with the appropriate hospital or university department).

C.

Direct educational, scientific and research endeavors in emergency medicine.

D.

Coordinate emergency medicine functions within other areas in the hospital, university or community.

E.

Represent the hospital and university in emergency medicine affairs to outside bodies.

F.

Continue to review and update knowledge of emergency medicine and to audit patient care.

F i g . 3. Qualifications and responsibilities of an emergency department director.

u n i v e r s i t y and the community. The director should be advised by a committee t h a t coordinates the policies of the e m e r g e n c y d e p a r t m e n t with these governing bodies. a) E m e r g e n c y d e p a r t m e n t director - - The director, w i t h the advice of the e m e r g e n c y d e p a r t m e n t committee, will d e f i n e e m e r g e n c y d e p a r t m e n t policies and s t a n d a r d s . The director will p l a n for a n d organize the space, facilities, e q u i p m e n t and personnel necessary to c a r r y out these policies and standards. This includes the right to hire and dismiss all e m e r g e n c y d e p a r t m e n t staff and to define and m a n a g e the b u d g e t for p a t ! e n t care, education, and research. The director is responsible for the m a i n t e n a n c e of s t a n d a r d s and e n d o r s e m e n t of. policies r e l a t e d to p a t i e n t care, education and r e s e a r c h and for t h e i n t e g r a t i o n and i n v o l v e m e n t of the emergency d e p a r t m e n t w i t h the hospital, u n i v e r s i t y and c o m m u n i t y (Figure 3). The director m a y 0r" m a y not be the p h y s i c i a n director of an e m e r g e n c y d e p a r t m e n t shift_ (see C 2. Personnel and F i g u r e 5). b) E m e r g e n c y d e p a r t m e n t committee - - The e m e r g e n c y d e p a r t m e n t committee, t h r o u g h advice t o t h e director, provides the m e c h a n i s m for i n t e g r a t i n g the policies and s t a n d a r d s of the e m e r g e n c y d e p a r t m e n t with the hospital a n d the university. Approval of these policies and s t a n d a r d s will proceed t h r o u g h the director to the governing boards of the hospital or u n i v e r s i t y (Figure 4). 3.

Fiscal - - The director m u s t be able to compete for resources on an equal basis with the o t h e r m a n a g e r i a l groups w i t h i n the hospital, u n i v e r s i t y or community. It follows t h a t the director m u s t have the a u t h o r i t y to develop and m a n a g e t h e e m e r g e n c y d e p a r t m e n t b u d g e t and to cost account expenses a g a i n s t r e v e n u e produced in the same m a n n e r as other m a n a g e r i a l groups.

C. O r g a n i z a t i o n 1.

R a t i o n a l e 4-6 - - 1000 people g e n e r a t e a p p r o x i m a t e l y 500 emergency d e p a r t m e n t visits (400 in u r b a n a r e a s and 600 in r u r a l areas) a n d 40 to 50 a m b u l a n c e calls a n n u a l l y . In addition, an emergency d e p a r t m e n t in a referral hospital will receive one or two e m e r g e n c y t r a n s f e r s per 1,000 people in the community. A n average of 5% of the visits will be l i f e - t h r e a t e n i n g emergencies, 60% will be u r g e n t (diagnosis and t r e a t m e n t sometime d u r i n g the day of the visit) and 35% will be n o n u r g e n t or elective. Fifty percent of the total e m e r g e n c y d e p a r t m e n t cases

Page 368 Volume 5 Number 5

May 1976 ~ )

The Emergency Department Committee I.

Composition - - multidisciplinary

I1.

A.

Physicians - - appointed by and responsible to the Medical Advisory Committee.

B.

N u r s e s - - t h e nursing supervisor of the emergency depadment and one registered nurse appointed by the director of nursing of the hospital.

C.

Administration - - appointed by the executive director, usually the administrator responsible for ambulatory care.

D.

University - - appointed by the dean and representing education and research interests at the medical school. (May be the director).

E.

Students and graduates - - appointed by their own representative bodies - - optional.

F.

Appropriate representatives of the community at the discretion of the board of governors.

Terms of reference A.

Advise the director concerning emergency department policies, standards, functions, planning and organization.

B.

Represent the governing bodies of the university and hospital to the director and vice versa, ie, as the primary coordinating body between the emergency department and the rest of the university and hospital.

C.

Make certain that the inhospital and university facilities necessary for patient care, education and research are available to the emergency department.

Fig. 4. Composition and responsibilities of the emergency department committee.

Physician Director of Emergency Department I.

Qualifications

I1.

A.

Licensed to practice medicine in the state or province of appointment.

B.

Qualified to provide emergency medical care. Preferably a graduate of a recognized emergency residency program.

Appointment A. Hospital appointment to active staff by board of governors on the advice of the director. B.

II1.

Terms of Reference A.

IV.

Appointed to appropriate university department by dean of medicine on behalf of senate on advice of the director. Be the operational director of the shift staff in the emergency depa~'tment. If there is more than one physician per shift, one is operational director to whom the others are responsible.

B.

Monitor the quality of patient care given by the emergency department staff on shift.

C.

Contribute to the education of emergency department staff during shift.

D.

Concerned with the other academic pursuits of the department.

Source of Income - - same as director.

Fig. 5. Qualifications and responsibilities of the physician director of an emergency department shift. could be seen in another facility (eg, physician's office) even though they are urgent. ~-6 Of those who visit a n emergency d e p a r t m e n t , 12% (range 10%-15%) will be admitted to inhospital facilities. Forty percent of these admissions will be surgical, 40% medical and 20% psychosocial, Ob/Gyn and other. Forty percent (range 30%50%) of most hospital admissions were generated from the emergency department. A physician can h a n d l e 6,000 undifferentiated cases i n a n emergency d e p a r t m e n t each year. 4 If the cases are differentiated, a physician can m a n a g e 9,600 n o n u r g e n t , 5,760 urgent, or 1,920 l i f e - t h r e a t e n i n g cases. Obviously, the actual n u m b e r of patients a physician can care for will depend upon the ratio of life-threatening/ u r g e n t / n o n u r g e n t . A physician in a u n i v e r s i t y setting is obligated to teach and, therefore, would spend a t h i r d of the t i m e i n this pursuit. Therefore, this p h y s i c i a n would only be able to see 4,000 u n d i f f e r e n t i a t e d cases per year. On the other hand, a resident i n the same emergency d e p a r t m e n t would be expected to see another 2,000 to 3,000 p a t i e n t s a n n u a l l y . If each physician works 40 hours per week for 48 weeks each year, a m i n i m u m of five physicians is necessary to cover all shifts in the emergency department. Therefore, the m i n i m u m n u m b e r of u n d i f f e r e n t i a t e d visits to an J~F

) May 1976

Volume 5 Number 5 Page 369

The Nursing Director (Supervisor)

I.

II.

Qualifications A. B.

Baccalaureate degree or practical equivalent in nursing administration, Graduate of an emergency department nursing program or equivalent.

C.

Registered by state or provincial body of registered nurses,

Appointment A.

Hospital 1.

By director of nursing only after the approval and consent of the emergency department director.

2.

B.

By the emergency department director with the advice of the director of nursing in those hospitals with decentralized nursing. Academic 1.

III.

IV.

By dean of nursing on the advice and consent of the director.

Terms of Reference A.

Be responsible to the emergency department director for nursing and other nonphysician personnel in the emergency department.

B.

Organize nursing and paramedic teams for the care of patients with life-threatening emergencies, major and minor emergencies, observation, reception, and triage.

C.

Be responsible to the emergency department director for curriculum content and mechanisms for paramedic education.

D.

Carry out and direct research projects where appropriate.

Remuneration and Recognition A.

By university for research and educational endeavors.

B.

By hospital for administrative duties and patient care.

F i g . 6. Qualifications and responsibilities of the emergency department nursing director or supervisor.

Other Personnel - - registered nurses, LPNs (RNA), EMT students, etc.

I.

Qualifications A.

Licensed to practice in state or province (where applicable) by appropriate licensing body.

B.

Attend an appropriate course in emergency medicine before being hired or before becoming a full member of the emergency department staff.

II.

Appointment - - by the emergency director on behalf of the appropriate body.

III.

Remuneration - - same as the nursing supervisor where applicable.

IV.

Terms of Reference - - see description under personnel (p371).

F i g . 7. Qualifications and responsibilities of other emergency department personnel. efficient e m e r g e n c y d e p a r t m e n t in a university setting with a c t i v e t e a c h i n g responsibilities will be 20,000. Each residency position will require 2,000 a d d i t i o n a l visits (eg, a total of 30,000 patients, if 5 residents are educated in the e m e r g e n c y d e p a r t m e n t each year). It is possible to develop a model for the o r g a n i z a t i o n of an e m e r g e n c y d e p a r t m e n t in a u n i v e r s i t y s e t t i n g using the preceding data. It will have a m i n i m u m u n d i f f e r e n t i a t e d a n n u a l p a t i e n t load of 30;000 and will employ five p h y s i c i a n s and have five residency t r a i n i n g positions. It will employ 50 other personnel (average 10 p e r shift) r e g i s t e r e d nurses, r e g i s t e r e d n u r s i n g a s s i s t a n t s (licensed practical nurses), n u r s i n g assistants, orderlies, and secretaries to c a r r y out p a t i e n t care functions - - and a v a r y i n g n u m b e r of t e a c h i n g and r e s e a r c h personnel. The ratio of r e g i s t e r e d n u r s e s to the other n o n p h y s i c i a n personnel will depend upon the ratio of l i f e - t h r e a t e n i n g and u r g e n t p r o b l e m s to n o n u r g e n t problems. T h i r t y percent of the e m e r g e n c y d e p a r t m e n t visits need the services of a n o t h e r specialist. F o r t y percent of these cases (12% of the t o t a l emergency d e p a r t m e n t visits) are medical or surgical. Since one i n t e r n i s t or surgeon could see b e t w e e n 2,000 and 2,500 specialized cases per y e a r and it t a k e s five p h y s i c i a n s to provide 24-hour coverage, a special medical or surgical division could be e s t a b l i s h e d in t h e e m e r g e n c y d e p a r t m e n t whenever Page 370 Volume 5 Number 5

May 1976 J ~ P

t h e r e were 10,000 to 12,500 people n e e d i n g specialized a t t e n t i o n each year. Since this group is 12% of emergency d e p a r t m e n t visits, the total u n d i f f e r e n t i a t e d visits needed to support major specialized units would be between 83,000 a n d 105,000 per year. It is assumed t h a t the specialists and residents who w o r k in the e m e r g e n c y dep a r t m e n t would r o t a t e with t h e i r colleagues on the i n p a t i e n t service. The u n d i f f e r e n t i a t e d portion of the emergency d e p a r t m e n t would t h e n act as a k i n d of t r i a g e facility for specialized units. 2.

Personnel a) E m e r g e n c y p h y s i c i a n - - one faculty-appointed e m e r g e n c y p h y s i c i a n m u s t be p r e s e n t and responsible for pat i e n t care, education and emergency d e p a r t m e n t m a n a g e m e n t on each shift. If t h e r e is more t h a n one physician p r e s e n t per shift t h e n one m u s t be d e l e g a t e d m a n a g e m e n t responsibilities (Figure 5). If the e m e r g e n c y d e p a r t m e n t is large enough, an associate director w i t h qualifications, a p p o i n t m e n t and rem u n e r a t i o n s i m i l a r to the director's m a y be needed. If the emergency d e p a r t m e n t employs several physicians per shift, t h e n the director m a y need an associate director to m a n a g e each shift. b) N u r s i n g supervisor - - the n u r s i n g supervisor is responsible to the emergency d e p a r t m e n t director for the n o n p h y s i c i a n staff. Other responsibilities include education and r e s e a r c h (Figure 6). c)

N u r s e practitioners, physician's a s s i s t a n t s a n d s i m i l a r professionals needed to c o m p l e m e n t t h e emergency p h y s i c i a n m a y be appointed by the e m e r g e n c y d e p a r t m e n t director.

d) H e a d n u r s e - - appointed by n u r s i n g supervisor and responsible to d u t y physician for n o n p h y s i c i a n staff duri n g the shift (Figure 7). e)

Nurses, n u r s i n g assistants, receptionists - - These employees are appointed by the emergency d e p a r t m e n t n u r s i n g supervisor and are responsible to t h e head nurse for p a t i e n t care. In general, t h e r e will be 10 to 12 n o n p h y s i c i a n staff per physician (Figure 7).

f)

Interns, residents, medical students and other p h y s i c i a n s - i n - t r a i n i n g rotate t h r o u g h the e m e r g e n c y departm e n t for t r a i n i n g . U n d e r a p p r o p r i a t e guidance, t h e y will m a n a g e those e m e r g e n c y p a t i e n t s assigned. The r e s p o n s i b i l i t y given to t h e m will depend upon t h e i r level of competence d e t e r m i n e d by the d u t y physician. The d u t y p h y s i c i a n will supervise them, m a k i n g certain t h a t t r a i n e e s l e a r n skills and i n d e p e n d e n t t h o u g h t and t h a t t h e q u a l i t y of p a t i e n t care and p a t i e n t satisfaction r e m a i n s high. Trainees' competence will be judged by the e m e r g e n c y d e p a r t m e n t director and will be r e p o r t e d to the a p p r o p r i a t e p r o g r a m director.

g) Medical care teams, as appropriate, m a y be developed. They will include the aforem~entioned personnel and use for the t e a m approach to p a t i e n t care, education, or research. P r e f e r a b l y t h e y will rotate. T h e r e will be a t e a m captain, p e r h a p s a t r a i n e e with an a p p r o p r i a t e level of competence, responsible for the project. 3.

FacilitiesT, s a)

G e n e r a l - - A facility is composed of personnel, e q u i p m e n t and space organized to c a r r y out its assigned functions. A group of facilities constitutes a d e p a r t m e n t . The e m e r g e n c y d e p a r t m e n t in a u n i v e r s i t y setting is composed of a n u m b e r of organized facilities grouped to perform the functions assigned to it by the community, the hospital and the university. The m a j o r i t y of the facilities will be located in one geographical a r e a and be staffed and/or controlled by the emergency d e p a r t m e n t . Other facilities m a y be s h a r e d w i t h other hospital, u n i v e r s i t y or c o m m u n i t y services and be l i n k e d to the e m e r g e n c y d e p a r t m e n t t h r o u g h a p r e - a r r a n g e d organiz a t i o n a l structure. In general, the facilities necessary for the functioning of an e m e r g e n c y d e p a r t m e n t in a u n i v e r s i t y s e t t i n g will conform to those of a C o m p r e h e n s i v e or Major E m e r g e n c y Medical Service as defined by t h e A m e r i c a n Medical Association p a m p h l e t on the Categorization of HoSpital E m e r g e n c y C a p a b i l i t i e s 2 A specific facility m a y .be composed of one or more units_ E a c h u n i t m u s t be able to c a r r y 9ut t h e functions of t h e facility as a whole. The n u m b e r of units c o n s t i t u t i n g the facility will depend upon the d e m a n d s placed upon it. The r e l a t i o n s h i p between the unit, facility and e m e r g e n c y d e p a r t m e n t is discussed f u r t h e r under

Space. b) P a t i e n t care (1)

I n t e g r a t i n g facilities

(a) C o m m u n i c a t i o n s - - A system should be developed in which a d e s i g n a t e d control center directs p a t i e n t flow; coordinates the functions of the staff with the d e m a n d s placed upon the facilities; l i n k s the emergency d e p a r t m e n t with inhospital facilities i m p o r t a n t to its function, (eg, intensive care unit, operating room) and links the e m e r g e n c y d e p a r t m e n t with facilities in the community, (eg, other emergency dep a r t m e n t s , c e n t r a l a m b u l a n c e dispatch services and police departments). (b) Control desk - - This facility is designed: i) ii) iii)

~ ] ~ P May 1976

to identify a p a t i e n t ' s p r i o r i t y and to direct him to the a p p r o p r i a t e e m e r g e n c y d e p a r t m e n t or inhospital facility (triage) to p r e p a r e all p a t i e n t s (except those w i t h l i f e - t h r e a t e n i n g conditions) for e x a m i n a t i o n and t r e a t m e n t to observe p a t i e n t s u n t i l t h e y are a d m i t t e d to a t r e a t m e n t a r e a

Volume 5 Number 5 Page 371

iv) (2)

to r e a s s u r e and comfort the p a t i e n t u n t i l definitive t r e a t m e n t is started:

Comfort and welcome facilities

(a) W a i t i n g room - - Separate, spacious, t a s t e f u l l y decorated facilities should be provided for children a~d adults. Both can be staffed by v o l u n t e e r s 24 hours a day. The w a i t i n g rooms should be in view of the control desk. (b) Toilet facilities - - located close to the w a i t i n g area, w i t h sufficient space for a wheelchair. (3)

Diagnostic facilities - - The e m e r g e n c y d e p a r t m e n t should have i m m e d i a t e access to diagnostic facilities, p r e f e r a b l y on-site, but at least close by.

(a) Radiology staffed and equipped to perform and consult, expeditiously, on routine musculoskeletal, chest, abdomen, skull films and contrast procedures. In any s i t u a t i o n where excessive p a t i e n t movement or u n s k i l l e d p a t i e n t m a n a g e m e n t would increase the r i s k to the patient, studies should be performed in the e m e r g e n c y d e p a r t m e n t . (b) L a b o r a t o r y - - m u s t be a v a i l a b l e 24 hours a day and be capable of a n a l y z i n g s a m p l e s of blood, urine, stool or g a s t r o i n t e s t i n a l contents. (c) E n d o s c o p y (bronchoscopy, colonoscopy, e s o p h a g o s c o p y , g a s t r o s c o p y , s i g m o i d o s c o p y , cystoscopy, peritoneoscopy, and culdoscopy)_ These should be e a s i l y accessible to the e m e r g e n c y d e p a r t m e n t 24 hours a day. (4)

T r e a t m e n t facilities - - The f u n d a m e n t a l concept of e m e r g e n c y care includes the r a p i d a s s e s s m e n t of pa. t i e n t p r i o r i t y and d e t e r m i n a t i o n of the need for, and sequence of, resuscitation, diagnosis a n d definitive t r e a t m e n t . Therefore, facilities are needed for the m a n a g e m e n t of the following.

(a) L i f e - t h r e a t e n i n g problems - - All p a t i e n t s with l i f e - t h r e a t e n i n g emergencies, w h e t h e r medical, surgical or psychosocial, should be r e s u s c i t a t e d in the s a m e a r e a using the same e q u i p m e n t (except w h e n patient d e n s i t y d e m a n d s the division of the e m e r g e n c y d e p a r t m e n t into specialized units). This a r e a should be accessible to emergency d e p a r t m e n t diagnostic and t r e a t m e n t facilities and the back-up hospital treatmerit facilities, although located where traffic is least dense_ (b) Major emergencies - - P a t i e n t s with p r o b l e m s d e m a n d i n g u r g e n t diagnosis and m a n a g e m e n t require ex. peditious care, and usually, hospital admission. U r g e n t emergencies should be h a n d l e d in one location and t r e a t e d by the same t e a m each t i m e t h a t h a n d l e s l i f e - t h r e a t e n i n g emergencies since t h e density of the l a t t e r is low in most i n s t i t u t i o n s (except when p a t i e n t density d e m a n d s the division of the emergency d e p a r t m e n t into specialized units). (c) Minor emergencies - - P a t i e n t s who require expeditious diagnosis and definite t r e a t m e n t , but u s u a l l y not hospital admission, should be seen in an a r e a a w a y from the major and l i f e - t h r e a t e n i n g emergency t r e a t m e n t a r e a s but n e a r the control desk. The m a j o r i t y of p a t i e n t s fall into this category and most will leave via the control desk_ They will f r e q u e n t l y need x-ray and special diagnostic facilities and should have r e a d y access to them. General r a t h e r t h a n specialized skills are needed to m a n a g e m i n o r emergencies. Therefore, the physician-nurse t e a m c a r i n g for these p a t i e n t s m i g h t be different from t h a t caring for p a t i e n t s with major and l i f e - t h r e a t e n i n g emergencies. This t e a m m i g h t also be responsible for the triage functions of the control desk and work closely with the community clinics located within, or associated with, the h o s p i t a l . . (d) N o n - u r g e n t problems - - The e m e r g e n c y d e p a r t m e n t has an obligation to provide a p p r o p r i a t e care for ali p a t i e n t s y e t should not be overloaded to the point where care is too slow or less competent for non-urgent problems. W h e n the emergency d e p a r t m e n t load exceeds the capacity of the staff to m a n a g e it, then n o n - u r g e n t problems m a y be referred to a family practice facility for initial diagnostic care a n d management. The e m e r g e n c y d e p a r t m e n t could m a i n t a i n a clinic facility for this purpose. The t e a m assigned to the m i n o r e m e r g e n c y problems could a t t e n d the n o n u r g e n t group of p a t i e n t s when the clinic is closed. W h i l e specialty clinics provide back-up support for t h e e m e r g e n c y d e p a r t m e n t , a family practice group w i t h i n the hospital could provide follow-up and c o n t i n u i n g care for p a t i e n t s w i t h o u t p r i v a t e physicians. (e) O p e r a t i n g room Operative surgery u n d e r general a n e s t h e t i c should not be done except in 'the regular o p e r a t i n g room suite unless the e m e r g e n c y d e p a r t m e n t can achieve s i m i l a r s t a n d a r d s of safety, quality and sterility. (f)

O b s e r v a t i o n - h o l d i n g - - M a n y e m e r g e n c y d e p a r t m e n t p a t i e n t s have problems t h a t are probably not urg e n t b u t need observation until the diagnosis is clear and safe disposition can be h~ade. These patients constitute about one-third of the inhospita! admissions from the emergency department_ Therefore, a~ o b s e r v a t i o n - h o l d i n g area, including a quiet room soothingly decorated tbr p a t i e n t s w i t h psychosocial problems, could reduce inhospital admissions. It could be located in the e m e r g e n c y d e p a r t m e n t or near" by. T h e r e should be a 24-hour l i m i t on s t a y and its staff should have no other p a t i e n t care resp0nsi" bilities w i t h i n the emergency d e p a r t m e n t .

Page 372 .Volume 5 Number 5

,May 1976 J ~ P

(g) Inhospital - - The emergency d e p a r t m e n t cannot provide total medical care. The specialized care for the recognition, diagnosis and i n i t i a l m a n a g e m e n t of the emergency d e p a r t m e n t p a t i e n t m u s t be given in a short period of time. Inhospital services m u s t complement and complete the total care obligations of the i n s t i t u t i o n . I n general, the obligations of emergency facilities follow those laid out in the A m e r i c a n Medical Association guide on Categorization of Hospital Emergency Capabilities 1 concerning operating room, acute care facility, blood bank, clinical laboratory, x-ray and c o n s u l t i n g services. i)

O p e r a t i n g room - - 24-hour service, with personnel in the hospital who can initiate a n y type of emergency operative procedure.

ii)

Acute care facility - - formed by the i n t e g r a t i o n of recovery room, intensive care unit, coronary care unit, t r a u m a u n i t and any other specialized acute care unit. This should operate 24 hours a day, staffed by personnel capable of u n d e r s t a n d i n g a n d c a r r y i n g out the required procedures and consultations.

iii)

Blood b a n k - - this should be a 24-h0ur service staffed by personnel capable of delivering uncrossed group-specific blood to the emergency d e p a r t m e n t i n five m i n u t e s , quick cross-matched blood w i t h i n 15 m i n u t e s and fully cross-matched blood w i t h i n 45 m i n u t e s . They must also be able to deliver blood fractions w i t h i n 20 m i n u t e s and fresh blood w i t h i n two hours. A direct "hotline" should be established with a central b a n k i n g system (district, regional or federal) that can supply r a r e blood types or fractions.

iv)

Clinical laboratory services - - see Diagnostic facilities

v)

Radiology - - facilities for more sophisticated diagnostic and t r e a t m e n t procedures t h a n those done in the emergency d e p a r t m e n t should be available. The emergency d e p a r t m e n t radiologist should be able to i n i t i a t e a n inhospital procedure with the back-up support of the on-call staff.

vi)

C o n s u l t i n g services - - All medical a n d surgical specialties a n d social services m u s t be able to provide on-call inhospital consulting services on a 24-hour basis. The inhospital c o n s u l t a n t m u s t be able to i n i t i a t e a n d continue care u n t i l other specialists who are on call b u t not in the hospital arrive to take command_

c)

E d u c a t i o n 2,~ - - Facilities and e q u i p m e n t for education should be provided w i t h i n the e m e r g e n c y department, i n c l u d i n g a library/conference area. This area should be supplied with c u r r e n t publications related to all aspects of emergency medicine. E q u i p p i n g this area with a wide range of reference materials, i n c l u d i n g a n a t o m i c a l models, computer-based physiological simulators (eg, m a t h e m a t i c a l models of the cardiovascularrespiratory system), and physiological models (eg,.Resusci-Ann), is highly recommended. A v a i l a b i l i t y of selfi n s t r u c t i o n a l materials, TV auto-assessment recordings and video tapes is also recommended. Where appropriate, one-way windows should be used for supervision and e v a l u a t i o n of students' clinical performance.

d)

Research - - Facilities in which clinical research can be conducted m u s t be in, near, or f u n c t i o n a l l y attached to the emergency department. In addition, there m u s t be u n i n h i b i t e d access to i n s t i t u t i o n a l laboratory space where •supportive a n i m a l research can be performed. Research programs should be coordinated and approved by the central research committee of the i n s t i t u t i o n . Research associated with emergency medicine must have the same fiscal status as other research projects in the hospital or university.

e)

A d m i n i s t r a t i v e - - A d m i n i s t r a t i v e services of the emergency d e p a r t m e n t must be functionally linked to the central a d m i n i s t r a t i v e services of the hospital and u n i v e r s i t y b u t the responsibility of the emergency departm e n t director.

f)

Design 7 (Figure 8) - - The general a r r a n g e m e n t s of the foregoing facilities will vary according to the architecture of the hospital. However, if a new hospital is being planned, and where possible, the emergency dep a r t m e n t functions best with the following a r r a n g e m e n t s ; (1)

G e n e r a l practice, family practice and specialist clinics are next to the emergency d e p a r t m e n t with a connection to the control desk_

(2)

The emergency d e p a r t m e n t should be located on the same floor close to the diagnostic a n d t r e a t m e n t facilities needed to care for the l i f e - t h r e a t e n i n g and major emergencies: blood b a n k , radiology, endoscopy, operating room and acute care_

(3)

The h a l l w a y should be adequate for good control facilities so t h a t the entrance, the major resuscitating areas, the w a i t i n g room and observation holding areas are u n d e r the direct s c r u t i n y of personnel at the control desk.

(4)

For stretcher mobility, doors should be 31/2 feet wide, side hallways 7'/2 feet wide and the m a i n e n t r a n c e h a l l w a y 15 feet wide_

(5)

The center h a l l w a y plan for mobile storage carts allows easy access to common supplies for all t r e a t m e n t a n d diagnostic rooms.

v • F) May 1976

Volume 5 Number 5 Page 373

a

Washing etc. Staff facilities

Holding and Observation

Resuscitation Major

Special I OR

Operating Acute room care X-Ray etc.

L

Supply

t carts

\ I

7 c .o

Research and Education

Waiting rooms

o~

._~o BR

t

Outpatient department

Diagnostic services

tran~

b

Cast room

.......... J.........

I

........ [ ........

I

Observation room

BR

I

Cardiology

ork ursn saon area

Triage !

Conference J--L room

LL

~

Doctors' room

IR

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Security

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raq--rkSeeT-rrSs 1 . Nuc

F i g . 8a, b. 8 Two possible arrangements for facilities of a hospital emergency department.

Page 374 Volume 5 Number 5

May 1976 U ~ 11

Table 1 SPACE FOR FACILITIES

Table 2 SPACE FOR UNITS Sq. Ft.

Registration - - records, c o n t r o l , nursing

400

Holding Area - - f o u r s t r e t c h e r s

250

D e c o n t a m i n a t i o n - - t u b and shower

75

Waiting Area - - c h i l d and a d u l t

600

Storage and C l e a n i n g

400

Toilet - - one unit f o r a w h e e l - c h a i r ( d o o r t h r e e feet w i d e , unit 31/2 by 41/2 feet) and t w o s t a n d a r d t o i l e t units.

4.

140

Space a)

General (1)

The total space required by an emergency d e p a r t m e n t depends upon

(a) the major i n t e r e s t of the i n s t i t u t i o n - - pat i e n t c a r e ( g e n e r a l h o s p i t a l or v e r y s p e c i a l i z e d h o s p i t a l ) , e d u c a t i o n or research (b) the functions to be carried out in the dep a r t m e n t , n e a r b y or somewhere in the institution (c) the space allocated for each facility carrying out the emergency d e p a r t m e n t functions. (2)

The space allocated for each facility will depend upon

L i f e - t h r e a t e n i n g (resuscitate t w o at one time)

700

2

M a j o r ( m a n a g e one or t w o )

250

2

Minor or non-urgent ( o n e per r o o m )

150

4

Family c o u n s e l l i n g or m i n o r (one per r o o m )

150

2

Quiet r o o m - - (drug ingestion)

150

1/2

S p e c i a l t y r o o m (eg, ENT)

250

3

Booked procedureoperating room

250

2

Cast r o o m ( m a n a g e one or two)

250

4

Observation-Disaster -6 beds 12 beds

600 1200

*

350

5

R a d i o l o g y - - per x-ray unit -- developing and v i e w i n g

300

Education resource room

700

Research Laboratory analysis ~

500

Patient care - monitoring

300

Administration Director

150 150

Secretary - - i n c l u d i n g filing

100

Staff c h a n g e r o o m and lounge, toilets (male & female)

500

On-call - - s t u d y r o o m

100

(a) store the u n i t ' s e q m p m e n t

Police, press, c h a p l a i n

100

(b) perform the u n i t ' s functions

Ambulance attendants

100

(c) give t h e p e r s o n n e l t h e " e l b o w - r o o m " needed to perform their duties.

Psychosocial s u p p o r t services

**

(b) the space necessary for each unit. (3)

The space allocated for each u n i t of a facility will depend upon the space needed to

b) P a t i e n t care facilities - - The space needed, i n square feet, for each facility is based upon 100 p a t i e n t s per day (Table 1). In the average undifferentiated emergency department this should m e a n five life-threatening cases, 50 urgent cases (major or m i n o r emergencies), 35 n o n u r g e n t c a s e s ( e i t h e r b o o k e d or u n a n nounced) a n d 12 to 15 hospital admissions. Fifty percent of the patients will be seen during one peak eight hour shift each day (ie, the average peak use).~, 5

J~P

No. of Patients

Nursing d i r e c t o r

(a) t h e n u m b e r of u n i t s (see F a c i l i t i e s - General) necessary to meet the average peak use of the facility

c)

Sq. Ft.

Patient Care Units

P a t i e n t care u n i t s (Table 2) - - No a t t e m p t is

May 1976

* The number that this unit can hold will depend upon policy (see Observation-Holding). Generally, no more than two patients per shift would be held over eight hours. Therefore, two beds would be occupied and four beds per shift would be free on that shift. (At least 14 per day could be observed per 6 bed unit). ** depends upon the number of staff needed; 75 sq ft per shift is the minimal requirement.

made to determine the n u m b e r of units necess a r y i n e a c h f a c i l i t y to care for t h e t o t a l emergency d e p a r t m e n t load since t h a t will deV o l u m e 5 N u m b e r 5 Page 375

pend u p o n t h e r a t i o of n o n - u r g e n t / u r g e n t / l i f e threatening; child/adult: booked cases/nonbooked cases and procedural policies. Each room h a s a supply c a r t and desk for i n t e r v i e w ing or r e c o r d i n g data. d)

E d u c a t i o n - r e s o u r c e r o o m (Table 21

e)

R e s e a r c h ITable 2/

f~

A d m i n i s t r a t i o n t T a b l e 2)

REFERENCES 1. Recommendatmns of the Conference on the Guidelines for the Categorization of Hospital Emergency Capabilities. Chicago, American Medical Association, 1971. 2. Johnson G: Emergency medicine fbr every physician, a basic curriculum, in Report on the Conference on Education of the

Page 376 Volume 5 Number 5

Physician in Emergency Medical Care. Chicago, American Medi. cal Association, July, 1973. 3. McGoey J, Orovan W, Strictler AC, et al: Emergenqy Medical Care Electives. McMaster University, Hamilton, 1973. 4. Report of the Project Team on Emergency Medical Services and Primary Care Province of Ontario, Administration 0f Health, Personnel Health Division. Toronto, Ontario, tOctl 1975. 5. Report of the Emergency Care Advisory Committee to the Hamilton Division Health Council, Hamilton, Ontario 197I and 1972. 6. Mackenzie JR: Winds of change. Presidential address to the University Association for Emergency Medical Services Annual Meeting, Dallas, Texas, May 1974. 7. Emergency Department: A Handbook for the Medical Staff Chicago, American Medical Association, 1966. 8. Jenkins AL: Emergency Department Organization and .~aa. agement. American College o[' Emergency Physicians St. Louis, CV Mosby Co, 1975.

May 1976 J ~ P

A guideline for the organization of an emergency department in the university setting.

SPECIAL CONTRIBUTION A Guideline for the Organization Of an Emergency Department In the University Setting James R. Mackenzie, MD Carl Jelenko, III,...
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