EM Notes – Emergency Department Organisation

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Information Systems (Computerised Vs Manual)

Manual systems

Pros

  1. Cheap
  2. Easy
  3. Convenient

Cons

  1. Failed documentation – notes, timing, summaries, legibility
  2. Difficult to research
  3. Poorer access to records

Computerised systems

Pros

  1. Ensuring critical data entry
  2. Less labour required to do calculations
  3. Times incorporated
  4. Access to same data from multiple sites
  5. May automate other tasks e.g. letters

Cons

  1. Training
  2. Cost – set up, maintaining
  3. Data security
  4. Acceptability

Quality Assurance

  1. Science of process management
  2. Quality is doing those things necessary to meet the needs and reasonable expectations of those we service (consumers) and doing those things right every time
  3. Quality cycle – plan, do, study, act
  4. Total quality management – whole hospital approach, interested players
  5. Difference between QA and research – aim to improve practice not gain new knowledge
  6. Bench-marking – use of best practices in the field to act as a marker for improvement, aim is better than average

Examples of QA areas

  1. Access – waiting times
  2. Safety – needle stick injury
  3. Acceptability – complaints
  4. Effectiveness – time to PTCA
  5. Continuity – discharge letters, head injury advice cards

Financial Issues

Case mix funding systems

  1. DRG – diagnosis related groupings – used for inpatients, difficult in ED as diagnosis not made at initial triage e.g. AMI vs reflux
  2. URG – urgency related groups – urgency and disposition groups eg triage 1 and admitted, triage 1 and discharged
  3. UDAG – urgency, disposition and age groups

Equipment purchasing eg defibrillator

  1. Assess – dept needs, likely costs, stakeholders, others with similar needs (ICU, OT)
  2. Compare Products – cost, ease of use, safety, portability, maintenance, supplier factors, staff training, colour and styles
  3. Trial – biomedical certification of equipment, ensure all users may comment,
  4. Fund – <$2000 approved by dept head, >$2000 approved by hospital admin, major items tendering process, consider lease vs purchase

The Media

  1. Who – person in charge, media experience, well dressed, well spoken
  2. Setting – preferable in front of hospital, not in ED as difficult to maintain, security, confidentiality, check media identification, no interruptions
  3. Information – give description of the event (prepared statement), how many people, how serious, how situation being handled –
    1. if not known: “monitoring the situation” “too early to tell”
    2. no speculation, no lies, no confidential patient info inc VIP info

VIP Patient

Need extra measures to maintain normal patient care eg security, privacy, confidentiality

MX

  1. Senior staff involvement
  2. Notify – security, admin, media liaison
  3. Setting – avoid waiting room, single room, space for security/entourage, media area
  4. ED staff – small numbers, inform of VIP nature of patient
  5. Avoid short cuts – assess and manage appropriately in ED

Emergency Department Design

  1. Effective provision of acute care, major source of admissions, roles in trauma and disaster

General

  1. Communication system, lighting, climate control, sign posting, power, medical gases, hand basins, plaster sumps, toilets/ shower, corridors, security, safety, call facilities
  2. Access – ground floor, close to public transport and car parking, wheelchair access
  3. Storage areas for linen, blanket warmer, equipment, beverage prep area, cleaners room

Areas

  1. Ambulance access
  2. Decontamination area
  3. Waiting room
  4. Triage
  5. Clerical
  6. Resus / blood fridge
  7. Acute treatment
  8. Consult rooms
  9. Specialty areas – eye, ENT, plaster, psych, SA, isolation, procedure, pharmacy, S8 safe
  10. Paed
  11. EMU
  12. Patient relatives’ quiet room
  13. Clean and dirty utility
  14. Staff base / write up area
  15. Staff room / change and toilet
  16. Tutorial room
  17. Admin rooms
  18. Security
  19. Access to other areas in the hospital
  20. Disaster store

ACEM ED Designs Guidelines

  1. 50 sq m per 1000 attendances (2500 sq m)
  2. Treatment beds 1 per 1300 attendance/ year (40)
  3. Resus beds 1 per 15 000 yearly attendances (4)
  4. Acute – half bed areas should have physiological monitoring
  5. Waiting room 1 seat per 1000 yearly attendances (55)
  6. Isolation rooms 1 per 10 000 yearly attendances (5)
  7. 2.5m between beds
  8. Resus 40 sq m

Correcting Poor Performance

Diagnose the cause

  1. D and A, psych, social (new baby, divorce, studying for exams), medical condition
  2. Poor understanding of job requirements, lack of skill or training or knowledge of systems, poor time management skills, perceived fear of punishment/ mistake
  3. Poor communication (style, language)
  4. Poor performance at that time (hungry, angry, late and tired)
  5. Lack of motivation

Modifying behaviour

  1. Correct cause
  2. Praise publicly, criticise privately
  3. Positive reinforcement
  4. Ignore attention seeking and disruptive behaviour
  5. Clearly define what is acceptable/uunacceptable
  6. Punishment – withdrawal of benefits due to poor performance

Performance Appraisal Interview

  1. Describe good behaviours as well as those requiring modification
  2. Ask interviewee for good and poor behaviours
  3. Describe specific behaviours that require modification
  4. Ask for suggestions for improvement from the interviewee and then inform them

Work Stress

  1. Work stressors
    1. Work interruptions,
    2. Conflicting demand on time by others,
    3. Workload,
    4. Time management,
    5. Organizational politics,
    6. Finding time for outside activities (esp shift workers),
    7. Responsibility for subordinates
  2. Personal stressors – family, relationships, exams, finances
  3. Reducing stress – social support, exercise, eat well, relaxation
  4. Roster – clockwise rotation, publish ahead