General principles of EM Flashcards
Emergency Room Mindset
- Jack of all trades, and master of none
- The first 2 hours of every specialty
- I don’t care where they go, but they can’t stay here
- Admit, Discharge, Transfer
- Comfortable with uncertainty
- Never say Always, and Never say Never
- Multiple patients at once, important to prioritize
- Think worst first
Coordination of Prehospital Resources
- An extension of emergency care
- Non-physician personnel
– Under physician supervisor - 911 Call Center- enhanced public access
– Access without ability to pay - BLS vs ALS Ambulance levels
- Helicopter Life Flights
- Triage and Mass Casualties
Electronic Medical Record (EMR) allows for
everything to be timed:
- Door to Nurse
- Door to Doc time
- Length of Stay
- Door to Antibiotics
- Turn around time
- Left without treatment- “The patient eloped”
When a patient cannot be safely discharged
- Social circumstances ie. home environment unsafe or inadequate care givers present, elderly, expected poor follow-up
What does Admit for Observation mean?
- In the hospital, but not
really in the hospital - < 24 hrs
- Often used for chest
pain evaluation
Post- ED Care Coordination
Obligated to ensure patient has a direction to go, with clear instructions
Follow-up Care Pitfalls
* Absence of an established primary care
* Uninsured, or specialist don’t take their insurance
* Time sensitive
* Poor understanding of discharge instructions
* Risk of returning to the ED if condition worsens
Emergency Medical Treatment and Active Labor Act
- Federal statute passed in 1985 dictating hospital rules
- All patients arriving in an ED must have an evaluation
– Regardless of the patient’s ability to pay ie. Insurance
– Cannot delay treatment to determine insurance - Penalties can be significant
– Heavy government fines attached, loss of medicare
– Medical malpractice lawsuit could occur - Significant if arising from EMTALA violations
- Unfunded mandate
All patients arriving in an ED seeking care must have:
– Evaluation from qualified medical personnel
– Looking for an emergency medical condition
– Stabilizing the emergency condition if found, ie. not to resolution
– And/or transfered if indicated to further stabilize the condition
– EMTALA duty completed if no emergency condition is found
Triage
– Nursing triage alone does not count, only prioritizes patients (1-5 scale)
* Medical evaluation may include labs, imaging, treatments
provided, duty to stabilize within facility capabilities
* Emergency Medical Condition defined:
– Health in serious jeopardy
– Risk of serious impairment or body dysfunction
– Risk or threat to the pregnant women having contractions or risk to the unborn child
Consent in the ED
Patients sign a general consent upon
arrival, but this does not cover risky or
invasive procedures and treatment
* Informed medical choice
– Patient autonomy and well being
* Patient or their surrogate
* Will obtaining consent cause harmful delay
* Decision making
– Capacity vs Competence
Capacity for consent in the ED
- Could be altered based on illness, intoxication, injury
- Capacity can vary over time, as condition improves or declines
- Do they understand the risk and/or gravity of the choice they make
- Documentation is essential; including their capacity
- Qualified surrogate and family hierarchy
Implied Consent in the ED
- When consent cannot be obtained or is delayed
- Emergent treatment may outweigh the timeliness or capability to
obtain informed consent - The rationality follows that a “reasonable person” would have
given consent to emergency treatment - If the situation improves or changes, then informed consent is
then sought
Intoxicated Patient challenges in ED
- A unique challenge
- Patients at special risk
- May mask serious illness or injury
– Eg. NEXUS criteria for C-spine injury - Patients in police custody still have rights
- Intoxicated patients vs Capacity intact?
Psychiatric Patients in the ED
- Patient can be put on psychiatric involuntary hold
- Example if psychiatric patients
– Pose a risk to themselves or others
– Can restrain chemically/ mechanically - Blue sheets (Medical) and pink sheets (Law Enforcement)
- Psychiatric emergencies and needed stabilization also fall
under EMTALA, including transfers and admissions - More to come
Consent in the ED- Minors
- Typically consent is sought from legal guardian Eg. parent
- Minors are not legally able to give consent (< 18 yrs old)
- Emergent Treatment
– Initial evaluation and if emergent stabilization is required - Can be initiated while still trying to obtain consent
- Should wait if treatment carries significant risk and is non-emergent
- Parent or guardian needs to have capacity intact (Eg intoxicated)
- In cases of abuse or neglect when parents are implicated
– Render care and seek CPS input and/or legal aid
