Emergency department
The
emergency department (ED), sometimes termed the emergency room (ER), emergency ward (EW), accident & emergency department (A&E) or casualty department is a
hospital or
primary care department that provides initial treatment to
patients with a broad spectrum of
illnesses and
injuries, some of which may be
life-threatening and requiring immediate attention. Emergency departments developed during the
20th century in response to an increased need for rapid assessment and management of critical illnesses. In some countries, emergency departments have become important entry points for those without other means of access to medical care.
Upon arrival in the ED, people typically undergo a brief
triage, or sorting, interview to help determine the nature and severity of their illness. Individuals with serious illnesses are then seen by a physician more rapidly than those with less severe symptoms or injuries. Depending on resources, if the anticipated waiting time is particularly long, patients with minor symptoms may be directed to visit a
primary care physician or outpatient clinic instead. After initial assessment and treatment, patients are either admitted to the hospital, transferred to a specialty hospital, or discharged. The staff in emergency departments often includes doctors and
nurses with specialized training in
emergency medicine. The emergency departments of large hospitals operate continuously and accept after-hours cases not seen by smaller hospitals.
A typical emergency department has several different areas, each specialized for patients with particular severities or types of illness.
In the
triage area, patients are seen by a triage nurse who completes a preliminary evaluation, before transferring care to another area of the ED or a different department in the hospital. Patients with life or limb-threatening conditions may bypass triage and to be seen directly by a physician.
The
resuscitation area is a key area of an emergency department. It usually contains several individual resuscitation bays, usually with one specially equipped for
paediatric resuscitation. Each bay is equipped with a
defibrillator, airway equipment,
oxygen,
intravenous lines and fluids, and emergency drugs. Resuscitation areas also have
ECG machines, and often limited
X-ray facilities to perform chest and pelvis films. Other equipment may include
non-invasive ventilation (NIV) and
portable ultrasound devices.
The
majors, or general medical, area is for stable patients who still need treatment that requires a
gurney (trolley). This area is often very busy, filled with many patients with a wide range of medical and surgical problems. Many will require further investigation and possible admission. Patients who are not in need of immediate treatment are sent to the
minors area. Such patients may still have been found to have significant problems, including
fractures,
dislocations, and
lacerations requiring
suturing.
A
pediatric area for the treatment of children has recently become standard, to dedicate separate waiting areas and facilities for children. Some departments employ a
play therapist whose job is to put children at ease to reduce the
anxiety caused by visiting the emergency department, as well as provide distraction therapy for simple procedures.
The
obstetrics area, for women before, during and after
pregnancy, is usually a separate part of an emergency department and/or a separate part of a hospital. Women are often primarily seen by obstetricians in an environment where equipment is available for specialized care.
Many hospitals have a separate area evaluation of
psychiatric problems. These are often staffed by
psychiatrists and psychiatry-trained nurses and psychiatric
social workers. There is typically at least one room for people who are actively a risk to themself or others (e.g.
suicidal).
Emergency departments may also have a separately streamed service for minor and rapidly treatable conditions, such as minor injuries. The fast track may be staffed by emergency nurse practitioners and/or physicians, and special consultation rooms are specifically designated for this purpose. This system allows for quicker treatment of patients who may otherwise be forced to wait for more pressing cases to resolve. This part of the department may be called by several names e.g. Urgent Care Centre or Primary Care Suite depending on the local emphasis. Where this type of service is provided on a separate site from the local ED it is called a
Minor Injuries Unit.
|
An example of California hospital signage |
A hospital with an emergency department usually has prominent signage reading
EMERGENCY Or Accident and Emergency (often in white text on a red background) and an arrow to indicate where patients should proceed. Some
American states closely regulate the design and content of such signs, and require wording such as "Comprehensive Emergency Medical Service" and "Physician On Duty"
[Title 22, California Code of Regulations, Section 70453(j).], to prevent persons in need of critical care from presenting to facilities that are not fully equipped and staffed.
Commonwealth nations
In
Australia and
New Zealand, the department is usually referred to as the
emergency department, and this internationally recognized title is becoming more common as well in the UK and Ireland. In the
United Kingdom,
Hong Kong,
Singapore and
Ireland it is usually called the
accident and emergency department (A&E). The popular term
casualty is no longer considered appropriate by emergency physicians in Australia, the United Kingdom and Ireland. Leading journals including the
Annals of Emergency Medicine, published by the
American College of Emergency Physicians and the
Emergency Medicine Journal (emj), journal of the
British Association for Emergency Medicine (BAEM), consistently use the term
Emergency department.
In
Canada, a slang word for the emergency department is "emerge".
In
Malaysia the patients are triaged -one, two, three and four according to the patients status and then seen according to the triage.(HUKM).Emergency Medicine is quite well developed in
Kuala Lumpur, post graduate studies are available in various medical schools.
United States
In the
United States an emergency department is often referred to as an
emergency room (ER). Emergency rooms are actually departments of a hospital with many rooms. The ER interacts with every other department in the hospital and often represents a significant percentage of the hospital's work load and finances. It is common for emergency department doctors to work for a company hired by the hospital to provide emergency services.
During the
1990s, an effort was made to change to the more accurate term
emergency department (ED), which is a term increasingly used by members of the specialty internationally. The effort failed and ED never caught on among the U.S. public, perhaps because of the popularity of the TV show
ER, and the heavy marketing of the euphemism "ED" for
erectile dysfunction by
pharmaceutical companies. However, the term does have some circulation among emergency medicine physicians.
A smaller facility that may provide assistance in medical emergencies is known as a
clinic. Larger communities often provide a drop-in clinic where people with medical problems that would not be considered serious enough to warrant an emergency department visit can be seen. These clinics often do not operate on a 24 hour basis, and visiting them is sometimes less expensive than going to the ED.
United Kingdom
Most teaching hospitals and district general hospitals (DGHs) have emergency departments. The largest such department in the UK is in
St Thomas' Hospital. Traditionally, waits for assessment in the ED were very long in some areas of the UK. In October
2002, the Department of Health introduced a policy that forced departments to assess and treat patients within four hours of arrival, with referral and assessment by other departments if deemed necessary.[
1]. Present policy is that 98% of all patients do not "breech" this four-hour wait.
In other countries without this policy (such as Ireland and Australia), patients may be faced with prolonged waits of hours or even days on trolleys for hospital beds.
Patients arrive at emergency departments in two main ways: by emergency ambulance or independently. Ambulance
paramedics or technicians notify the hospital beforehand if they are transporting a severely-ill patient. These patients are rushed to the emergency department's resuscitation area, where they are met by a team with the expertise to deal with the patients' conditions. For example, patients with
major trauma are seen by a
trauma team consisting of emergency physicians and nurses, a
surgeon, and an
anesthesiologist (anaesthetist).
Patients arriving independently or by ambulance are typically triaged by a nurse with training in emergency medicine. Patients are seen in order of medical urgency, not in order of arrival. Patients are triaged to the resuscitation area, majors area, or minors area. Emergency/Accident and Emergency departments usually have one entrance with a
lobby and a
waiting room for patients with less-urgent conditions, and another entrance reserved for ambulances.
Cardiac arrest
Cardiac arrest may occur in the ED/A&E or a patient may be transported by ambulance to the emergency department already in this state. Treatment is
basic and advanced life support as taught in the
Advanced Life Support and
Advanced Cardiac Life Support courses. This is an immediately life-threatening condition which requires immediate action in salvageable cases.
Heart attack
Patients arriving to the emergency department with a
myocardial infarction (heart attack) are likely to be triaged to the resuscitation area. They will receive oxygen and monitoring and have an early ECG;
aspirin will be given if not
contraindicated or not already administered by the ambulance team;
morphine or
diamorphine will be given for
pain; sublingual (under the tongue) or buccal (between cheek and upper gum)
glyceryl trinitrate (
nitroglycerin) (GTN or NTG) will be given.
If the ECG confirms an ST elevation myocardial infarction or there is onset of
left bundle branch block this indicates complete blockage of one of the main cardiac blood vessels. These patients require reperfusion (re-opening) of the occluded vessel. This can be achieved in two ways:
thrombolysis (clot-busting medication) or
percutaneous transluminal coronary angioplasty (PTCA). Both of these are effective in reducing significantly the mortality of myocardial infarction. Many centers are now moving to the use of PTCA as it is somewhat more effective than thrombolysis if it can be administered early. This may involve transfer to a nearby facility with facilities for angioplasty.
Trauma
Major trauma, the term for patients with multiple injuries, often from a
road traffic accident or a fall, is treated by a
trauma team who have been trained using the principles taught in the internationally recognized
Advanced Trauma Life Support (ATLS) course of the
American College of Surgeons. Some other international training bodies have started to run similar courses based on the same principles.
The services that are provided in an emergency department can range from simple x-rays and the setting of broken bones to those of a full-scale
trauma center.
Emergency medical technicians often work as support staff in emergency departments under the supervision of nurses and doctors. A patient's chances of survival are greatly improved if emergency care begins within one hour of an accident (such as a car accident) or onset of acute illness (such as a heart attack). This critical time frame is commonly known as the "
golden hour."
Some emergency departments in smaller hospitals are located near a
helipad which is used by helicopters to transport a patient to a trauma center. This inter-hospital transfer is often done when a patient requires advanced medical care unavailable at the local facility. In such cases the emergency department can only
stabilize the patient for transport.
Some patients arrive at an emergency department for a complaint of mental illness. In many jurisdictions (including many U.S. states), patients who appear to be mentally ill and to present a danger to themselves or others may be brought against their will to an emergency department by law enforcement officers for psychiatric examination. From the emergency department, patients thought to be mentally ill may be transferred to a psychiatric unit (in many cases involuntarily).
Asthma and COPD
Acute exacerbations of chronic respiratory diseases, mainly
asthma and
chronic obstructive pulmonary disease (COPD) are assessed as emergencies and treated with
oxygen therapy,
bronchodilators,
steroids or
theophylline, have an urgent
chest X-ray and
arterial blood gases and are referred for
intensive care if necessary.
Non invasive ventiation in the ED has reduced the requirement for
intubation in many cases of severe exacerbations of COPD.
An ED requires different equipment and different approaches than most other hospital divisions. Patients frequently arrive with unstable conditions, and so must be treated quickly. They may be unconscious, and information such as their medical history, allergies, and blood type may be unavailable. ED staff are trained to work quickly and effectively even with minimal information.
ED staff must also interact efficiently with pre-hospital care providers such as
EMTs,
paramedics, and others who are occasionally based in an ED. The pre-hospital providers may use equipment unfamiliar to the average physician, but ED physicians must be expert in using (and safely removing) specialized equipment, since devices such as
Military Anti-Shock Trousers ("MAST") and
traction splints require special procedures. Among other reasons, given that they must be able to handle specialized equipment, physicians can now specialize in emergency medicine, and EDs employ many such specialists.
ED staff have much in common with ambulance and
fire crews,
combat medics,
search and rescue teams, and
disaster response teams. Often, joint training and practice drills are organized to improve the coordination of this complex response system. Busy EDs exchange a great deal of equipment with ambulance crews, and both must provide for replacing, returning, or reimbursing for costly items.
Cardiac arrest and major trauma are relatively common in EDs, so
defibrillators, automatic ventilation and
CPR machines, and bleeding control dressings are used heavily. Survival in such cases is greatly enhanced by shortening the wait for key interventions, and in recent years some of this specialized equipment has spread to pre-hospital settings. The best-known example is defibrillators, which spread first to ambulances, then in an automatic version to police cars, and most recently to public spaces such as
airports and
office buildings.
EDs usually have their own surgical facilities. They also require very fast laboratory work for
blood-typing, measurements of
drug levels in
overdose, and so on, so they may have separate lab facilities, or first priority when using shared labs.
Emergency departments around the world are increasingly being used for non-emergency care because of overburdened healthcare systems. Many people, afflicted by minor injuries or illnesses late at night or at times when their doctor's surgery is closed, are forced to resort to attending the ED. This is especially true for conditions with severe symptoms, such as a child's
ear infection. People in lower socioeconomic classes are more likely to require treatment for primary care ailments from ED.
In the United Kingdom, it has become more popular to visit the ED since it became mandatory for patients to be fully treated and discharged from the department within four hours of arrival. Also, the introduction of the new contract for primary care physicians in that country decreased the accessibility of
general practitioner (GP) services. Under this contract GPs can opt out of on-call cover, and patients sometimes present instead to the ED.
* John B Bache, Carolyn Armitt, Cathy Gadd,
Handbook of Emergency Department Procedures, ISBN 0723433224
* Swaminatha V Mahadevan,
An Introduction To Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department, ISBN 0521542596
*
on call*
Ambulance *
Emergency department in France*
Trauma center*
ED visits (US)*
ED wait times (Canada)*
Group dedicated to improving A&E departments in East Kent (UK)
