Emergency Room (ER)

Department of Emergency Medicine (DEMS)

Emergency Medicine Department (EMD)

 

Nov 18, 2008

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

Head, Corporate Planning Office

Manila Doctors Hospital

 

(One of three topics: Department of Surgery; OR; ER)

(Recommendation: Read first “Framework on Managing and Leading a Hospital Department”)

 

Short Course on Hospital Organization and Management of Selected Clinical, Ancillary, and Support Departments

Nov. 17 – 21, 2008

College of Public Health

University of the Philippines Manila

 

Let’s now tackle the Emergency Room (ER) or Department of Emergency Medicine (DEMS) or Emergency Medicine Department (EMD).  The commonly used terms for emergency room nowadays are the department of emergency medical services or DEMS and Emergency Medicine Department or EMD.

 

ER is an area in the hospital where patients with emergent health conditions can go to for consultation and management.  It operates 24/7.  Those with non-emergent conditions can go to the outpatient department or doctors’ clinics which operate

during weekdays and specified office hours.

 

The ER is primarily intended for patients with acute life-threatening health problems needing immediate resuscitation and stabilization.  However, in real practice, only about 30% consulting in the ER have real emergencies by medical standards.  Thus, one of the basic issues that the hospital administration has to resolve and set down as a policy is whether to limit the clients of the ER to patients with life-threatening conditions by medical standards or to accept all clients who are brought into it, regardless of whether they have real life-threatening conditions or not based on medical standards, accepting whatever be and respecting the perception of the patients and their relatives that they have life-threatening conditions.  Since it is really difficult to sort patients into those with real and non-real life-threatenining conditions until they have been fully evaluated by the staff of the ER, the tendency of the hospital and ER administration is accept all initially and then refer them out accordingly and as soon as possible so to decongest the ER.  This policy, if adopted, is for the benefit of the hospital administration and ER in the long run, both medicolegal wise and revenue wise, particularly for the private hospitals.  If a hospital, particularly, a government one, would like to limit the ER clients with life-threatening conditions, it must establish a very structured, reliable, and safe triage system at the instance patients are brought into the ER.

 

There is usually one ER per hospital. 

 

Before the advent of an emergency room officership which is now being assumed by physicians, graduates of the specialty known as emergency medicine or emergency room medicine, the administrative head of an ER has always been a nurse, similarly to the set-up of an OR, ICU, etc.  With the presence of medical specialists in emergency room medicine, slowly, the head of the ER can be an ER physician with a nurse supervisor or head nurse taking care of the day-to-day activities of the unit.

 

Majority of the clients of the ER are the public who have no pre-identified physicians affiliated with the hospital to take care of them at the time they decide to go to the ER.  These are the so-called “walk-in” patients.  The other group of clients are those who have pre-identified physicians affiliated with the hospital but who decide to go to the ER and not to the doctors’ clinics for one reason or another, such as non-availability of their physicians, their condition is life-threatening, etc.  This group of patients can be labeled as “consultants’ patients” and they expect the ER staff to inform their pre-identified doctors, during and immediately after their treatment in the ER.  Note: This is one of the challenges of the ER staff in terms of coordination and collaboration with the hospital-affiliated consultant staff.  A coordinating body consisting of representatives of the different clinical departments will be helpful in effecting efficient management of the ER.

 

A note from DOH licensure requirements for Level 4 Hospitals:

 

Level 4 Hospitals shall be given until 2010 to comply with the requirement of having a Department of Emergency Medicine.  The implication here is that Emergency Medicine or Emergency Room Medicine is now being recognized as a specialty.

 

There are now at least two established training programs in ER medicine in the Philippines, one in Makati Medical Center and the other in the Philippine General Hospital.

 

There are now several hospitals in the Philippines, particularly in Metro Manila, whose emergency rooms are being manned by graduates of a formal training program in ER medicine.

 

After that introduction on the terminologies, nature, clients, governance, and present situation of the ER in the Phiippines, let’s  now create a scenario to properly position ourselves for a more focused discussion.

 

Before that, remember our specific learning objectives on ER are the following:

1. Identify the organizational and operational requirements of a hospital department  (specifically, ER) in terms of philosophy, objectives, structure, staffing, operating policies and procedures, programs, and resources.

2. Identify common problems in the management of a department (specifically, ER) and the commonly used approaches in controlling them.

Imagine you, an EMERGENCY ROOM PHYSICIAN, are going to be appointed Head of an existing ER in a hospital (whether government or private).

 

Existing or new one?

Let’s use the scenario of an existing one as this is a more common situation.

 

What are initial and eventual things you have to do as the newly appointed head of an existing ER?

 

First two requirements before you assume officially the headship of the ER

 

  1. Make sure you have an official appointment paper to be the head of the ER before you start doing anything.  (Chief of Hospital take note!)
  2. Make sure you have an official job description as head of the ER before you start doing anything.  (Chief of Hospital take note!)

 

The appointment paper gives you the authority.   The job description spells out your duties and responsibilities with corresponding authority.  The job description also serves as a basis of your performance evaluation.

 

The job description is very important to know the true and specific extent of your responsibility, jurisdiction and  power.  This will enable you to act accordingly especially in the light of overlapping and conflicting concerns with tthe consultant staff over the use of the ER.  

 

Initial activities of a newly appointed head

 

Initial quick assessment of the ER

After getting your appointment paper together with a job description,

scan the department in terms of its authorized functions, structure, staff and staffing, policies and procedures, programs, and resources – through observation and inspection to get a quick assessment of the status of the abovementioned essential elements needed in the management of the department (present or not; if present, needs improvement or not; if improvement needed, prioritize and strategize; resources – source and level of difficulty)

           

Initial resuscitative and corrective measures if needed / indicated

Based on your initial quick assessment, if there is something very important and urgent that needs to be resuscitated and corrected, do so as soon as possible.

            Examples of important and urgent needs:

no staff to man the department

no resuscitative equipment in the department

lack of clear description of limit of authority

 

Eventual activities

 

Detailed assessment of the ER

When you have settled down as chair, usually in a month or two, do a more detailed assessment of the department again at least in terms of its authorized functions, structure, staff and staffing, policies and procedures, programs, and resources. Other parameters may be used like culture, values, practices, work habits, etc.  Identify the gaps and what needs to be changed or improved and then make a tentative plan on how to improve the present system, on how to manage the department, and on how to lead your staff.

 

Formulation and implementation of strategic and specific action plans

Formulate strategic and specific action plans with consultation and collaboration from your staff.  Then gradually but surely and effectively and efficiently implement them through technical and coordinating teams.  Don’t forget to include a system of evaluation of results of implementation of your strategic and specific action plans.

 

Essential things to consider for gap analysis, corrective actions, and for continual improvement

 

Authorized functions of an ER

 

There must be a document stating the authorized functions of your ER. 

It must be complete and clear with general and specific functions and it must be authorized by a higher office (ideally by the Chief of Hospital).

           

This document on authorized functions will serve as a steering wheel or guide for everything you will do in the department.  It describes the roles and responsibilities of your department in the context of the whole hospital.

It gives your department the authority to do what you should be doing. It will serve as a guide in determining what you need in your department to function properly and adequately such as in terms of structure, staffing, policies and procedures, programs, and resources.  It will serve as a guide in determining what programs, projects, tasks, and activities you can do to accomplish your functions, both on a long term and short term basis.  It will serve as a basis for evaluating your department’s performance, at the very least, whether you have been accomplishing your expected functions on a daily basis and annually.

 

The authorized functions contain at the very least the service functions of the department.  They can include training and research functions.

 

The formulation of service functions of a department is guided by the current expectations on the specialty of the department by the health care industry and medical profession; vision-mission of the hospital; expectations of the community where the hospital is situated; and benchmarking and trends in the hospital industry both locally and internationally.

 

There is a need to specify scope of functions because of rapid changes in the medical specialties and health industry; because of overlapping of specializations nowadays (General Surgery – Otorhinolaryngology; Neurosurgery – Orthopedic Surgery; Internal Medicine – minimally invasive surgery; etc.); to avoid confusion among staff and patients and public also; and to facilitate integration, coordination, and collaboration within and among units (a challenge to chief hospital, medical director, and nursing director).

 

Whatever be the formulated authorized functions of a particular ER, they must be officially authorized by a higher office (ideally by the Chief of Hospital).

 

Examples of authorized functions of an ER  

 

General Function:

 

To provide prompt and proper medical service to all patients who seek help in the emergency room.

 

Specific Functions:

 

Service:

 

  • To provide immediate resuscitative measures to patients with life-threatening conditions who are brought to the ER.
  • To examine all patients who seek help in the ER and to make a rational and accurate diagnosis of their medical problems.
  • To provide all immediate treatment that can possibly be rendered within the limits of the ER set-up and facilities.
  • To refer patients to appropriate physicians for follow-up or definitive management after being served at the ER.

 

Training:

 

  • To provide continuing professional education to all staff of the Emergency Room and all concerned paramedical staff so as to maintain and improve quality of service.

 

  • To provide training in ER medicine to medical students, residents, fellows, and nurses.

 

Research:

 

  • To engage in research in the field of emergency room services that will improve quality of service.

 

  • To promote research in the ER.

 

Structural or physical requirements of an ER

 

Based on the authorized functions and other ancillary functions of the ER, such as governance, training and research,  determine the structure or physical requirements.

 

Structural or physical requirements based on the usual authorized and expected service functions of an ER

 

There are several issues to consider when establishing or making available the structures and physical facilities required by an ER.  These are, namely:         

 

·         Location within the hospital (lay-out and functional flow within the hospital)

·         Quantity

·         Size

·         Design

·         Equipment requirement

 

How to resolve the issues?  How to decide?

 

Resolution of the above issues will be dependent on the following general determining factors:

 

·         government regulations (particularly the licensing requirements of DOH Bureau of Health Facilities and Services) [http://www.doh.gov.ph]

·         quality and professional standards requirements (particularly the PhilHealth Benchbook and international standards such as International Organization for Standardization or ISO and Joint Commission International or JCI) [http://www.philhealth.gov.ph]

·         usual and anticipated increase in patient load (cost-benefit considerations)

·         needs and expectations of the community

·         integration, coordination and collaboration with other units in the hospital for efficient use of physical resources – the physician-users and the various clinical medical departments

·         allowance for expansion (space availability)

·         value-added, vision-mission, and benchmarking considerations (sustainability purpose)

 

·         Location within the hospital (lay-out and functional flow within the hospital)

 

Refer to DOH GUIDELINES IN THE PLANNING AND DESIGN OF A HOSPITAL AND OTHER HEALTH FACILITIES, November 2004 [http://www.doh.gov.ph]

 

The ER shall be located in the outer zone of the hospital, in the area that is immediately accessible to the public.  It is located near the entrance of the hospital.

 

It shall be located in the ground floor to ensure immediate access.  A separate entrance to the ER shall be provided.

 

There must be adequate road signs and signboards indicating the location of the ER.

 

It must be in an area where hospital routines will NOT be disrupted when there is a sudden and great flow of patients to the ER.

 

Supportive departments such as laboratory, radiology, and operating room must NOT be far from the ER.

 

DOH requirements:

19. Zoning: The different areas of a hospital shall be grouped according to zones as follows:

 

19.1 Outer Zone – areas that are immediately accessible to the public: emergency service, outpatient service, and administrative service. They shall be located near the entrance of the hospital.

19.2 Second Zone – areas that receive workload from the outer zone: laboratory, pharmacy, and radiology. They shall be located near the outer zone.

19.3 Inner Zone – areas that provide nursing care and management of patients: nursing service. They shall be located in private areas but accessible to guests.

19.4 Deep Zone – areas that require asepsis to perform the prescribed services: surgical service, delivery service, nursery, and intensive care. They shall be segregated from the public areas but accessible to the outer, second and inner zones.

19.5 Service Zone – areas that provide support to hospital activities: dietary service, housekeeping service, maintenance and motorpool service, and mortuary. They shall be located in areas away from normal traffic.

 

20 Function: The different areas of a hospital shall be functionally related with each other.

 

20.1 The emergency service shall be located in the ground floor to ensure immediate access. A separate entrance to the emergency room shall be provided.

20.2 The administrative service, particularly admitting office and business office, shall be located near the main entrance of the hospital. Offices for hospital management can be located in private areas.

20.3 The surgical service shall be located and arranged to prevent non-related traffic. The operating room shall be as remote as practicable from the entrance to provide asepsis. The dressing room shall be located to avoid exposure to dirty areas after changing to surgical garments. The nurse station shall be located to permit visual observation of patient movement.

20.4 The delivery service shall be located and arranged to prevent non-related traffic. The delivery room shall be as remote as practicable from the entrance to provide asepsis. The dressing room shall be located to avoid exposure to dirty areas after changing to surgical garments. The nurse station shall be located to permit visual observation of patient movement. The nursery shall be separate but

immediately accessible from the delivery room.

20.5 The nursing service shall be segregated from public areas. The nurse station shall be located to permit visual observation of patients. Nurse stations shall be provided in all inpatient units of the hospital with a ratio of at least one (1) nurse station for every thirty-five (35) beds. Rooms and wards shall be of sufficient size to allow for work flow and patient movement. Toilets shall be immediately accessible from rooms and wards.

 

Accessibility to patients and to interfacing patient care units is the main and initial guidepost for determining the location of the ER.  The physical location of the unit structure per se within the hospital complex is the initial determinant of accessibility.  The other determinants for location of the unit structures  include sterility zoning, privacy zoning, traffic zoning, and inter-relationship with other units in the hospital. 

 

Aside from actual physical location, roads and directional signages can be used to promote accessibility.

 

·         Quantity  

 

There is usually one ER per hospital.

 

It could be an ER complex located in one area of the hospital with several rooms or cubicles identified for use by the different clinical departments that cater to emergency cases. 

 

NOTE: As a rule, an ER complex or centralized ER is more cost-beneficial than several ERs located in different locations within the hospital compound.  There is sharing of equipment and functional areas and there is multiple tasking of personnel resulting in maximal utilization of spaces, equipment, and personnel.

 

·         Size

 

Refer to DOH GUIDELINES IN THE PLANNING AND DESIGN OF A HOSPITAL AND OTHER HEALTH FACILITIES, November 2004 [http://www.doh.gov.ph]

 

Space: Adequate area shall be provided for the people, activity, furniture, equipment and utility.

 

ER

Area in sq m

Waiting Area

0.65/person

Toilet

1.67

Nurse Station

5.02/staff

Examination and Treatment Area with Lavatory/Sink

7.43/bed

Observation Area

7.43/bed

Equipment and Supply Storage Area

4.65

Wheeled Stretcher Area

1.08/stretcher

 

There must be ADEQUATE SPACE to enable the staff to function effectively and efficiently and to allow patients, personnel, beds, stretchers, and wheelchairs to move freely and safely.  The number of patients coming in at any given time for consultation and treatment as well as equipment requirements also determine size.

 

·         Design

 

Refer to DOH GUIDELINES IN THE PLANNING AND DESIGN OF A HOSPITAL AND OTHER HEALTH FACILITIES, November 2004 [http://www.doh.gov.ph]

 

A hospital and other health facilities shall be planned and designed to observe appropriate architectural practices, to meet prescribed functional programs, and to conform to applicable codes as part of normal professional practice.

 

Minimum service areas in an ER to be included in design:

                       

ER

Waiting Area

Toilet

Nurse Station

Examination and Treatment Area with Lavatory/Sink

Observation Area

Equipment and Supply Storage Area

Wheeled Stretcher Area

 

 

A sample of design that has been useful:

 

 

Other recommendations:

 

Entrance must be of a size that can accommodate a standard stretcher bed.

 

Curtains or varifolds are recommended for cubicle dividers to give a larger space when needed.

 

Stretcher-beds are preferred over stationary examining tables and standard hospital beds for mobility and flexibility.

 

Piped-in gases and suction contribute to convenience and efficiency.

 

The cubicles are flexibly assigned specific purposes (such as consultation, observation and operations); types of patients in terms of urgency in management (primary, secondary, and tertiary care); and for use by different clinical medical departments (obstetrics, pediatrics, psychiatry, surgery, etc.)

 

Whatever be the design, foremost it must promote FUNCTIONAL FLOW of patients and staff and one that will promote effectiveness and efficiency and safety in achieving the service functions of the ER. It must create a healthy and esthetic atmosphere and environment for patients, public, and staff. 

 

Structural or physical requirements based on other ancillary functions of an ER such as governance, training, and research

 

•         Office for the head of unit / nurse supervisor or head nurse

•         Conference room

•         Library

•         Computer system, IT, with Internet access

 

Equipment and material requirements based on the usual authorized and expected service functions of an ER

 

Based on objectives, minimum general essential equipment and material include the following:

            - for cardiopulmonary resuscitation

            - those needed to resuscitate and stabilize patients with life-threatening      conditions before a more definitive treatment can be done within the   hospital proper.

 

Specific essential equipment and materials:

 

•         Airway adjuncts

•         Breathing adjuncts

•         Electrocardiographic equipment

•         Emergency drugs and IV fluids

•         Surgical equipment and supplies

•         Obstetrical equipment and supplies

•         Diagnostic equipment and facilities

•         Record system

•         Transport system

•         Telecommunication system

•         At least one ambulance

                                    - considered extension of the ER

- fully equipped with at least basic and advanced life support system

 

Equipment and materials must be:

•         Effective and of high quality

•         Efficient in carrying out objectives of ER

                        -Stored in cabinets with proper labeling

                        -Always available when needed

                        -Convenient to use by personnel

 

DOH minimum requirements

 

See minimum licensing requirements for equipment and instrument of a hospital (Level 1 to 4) in the ER [http://www.doh.gov.ph]

 

ER

Minimum Requirement

Ambu Bag - adult

1

Ambu Bag - pedia

1

Clinical Weighing Scale

1

Defibrillator

1

ECG Machine

1

EENT Diagnostic Set

1

Emergency Cart

1

Examining Table

1

Gooseneck Lamp / Examining Light

1

Instrument Table

1

Laryngoscope with Blades

1

Medicine Cabinet

1

Minor Surgery Instrument Set

1

Nebulizer

1

Neurological Hammer

1

Oxygen Unit

1

Sphygmomanometer - Adult Cuff

1

Sphygmomanometer - Pediatric Cuff

1

Stethoscope

1

Suction Apparatus

1

Suturing Set

1

Tracheostomy Set

1

Vaginal Speculum Set

1

Wheelchair

1

Wheeled Stretcher

1

 

There are several issues to consider in the management of equipment and material requirements of an ER.  These are, namely:

 

·         Who determines the equipment and material requirements of an ER? (what and how much to store)?

·         Who gives the supply?

·         Who does the inventory?

·         Who regulates the supply (quality, safety, and durability considerations)?

 

·         Who determines the equipment and material requirements of an ER (what and how much to store)?

 

The DOH

The physician-users (primarily the ER physicians)

Other clinical medical departments who are allowed to use the ER

The nurse supervisor or head nurse of the ER

The central supply and stockroom

 

DOH

See minimum licensing requirements for equipment and instrument of a hospital (Level 1 to 4) in the ER [http://www.doh.gov.ph]

 

The physician-users

The ER physicians are the primary users or, more specifically, the prescribers of what and when to use the equipment and materials for their patients.  Thus, nursing supervisor and heads of pharmacy, central supply, and stockrooms should consult the ER physicians.  The other medical specialists who are allowed to use the ER should also be consulted.  If not, there will be wastage due to unused equipment and supplies.

 

The nurse supervisor or head nurse of the ER

The pharmacy

The central supply and stockroom

 

The nurse supervisor of the ER and heads of the pharmacy, central supply and stockrooms can also determine what and how much to store for use by the physician-users but this should be done in coordination with, if not authorization from them. 

 

Based on the inventory and usage data, they can determine what and how much to store.

 

·         Who gives the supply?

 

The hospital management and at times, higher office, especially in government hospitals.

 

·         Who does the inventory?

 

The ER, pharmacy, central supply and stockrooms and even a higher office, such as an auditing office or finance department.

 

·         Who regulates the supply (quality, safety and durability considerations)?

 

Approval of requests by physician-users and nursing supervisor of ER has to pass through a body or office which will study the requests for acquisition.

 

Physician-users may request sophisticated and expensive equipment, instruments, and materials for their use.  Decision for approval, aside from the logistical considerations, should be guided by government regulations, quality standards requirements, cost-benefit considerations, value-added, vision-mission, and benchmarking considerations; and financial viability.   (Physicians should promote returns on investment on equipment requested.)

 

Equipment should have preventive maintenance and calibration at planned intervals to ensure accuracy and safety in their use and longer life span.  

 

EQUIPMENT/INSTRUMENT

DOH requirements

Licensing requirements of DOH Bureau of Health Facilities and Services on equipment / instruments [http://www.doh.gov.ph]

 

4.1. All equipment and instruments necessary for the safe and effective provision of services are available and are properly maintained.

4.1.1. Records of equipment are maintained and updated regularly.

4.1.2. A preventive maintenance program ensures that all

equipment are maintained and/or calibrated to an appropriate

standard or specification.

4.1.3. There is a plan in place for essential equipment replacement.

4.1.4. Personnel are competent when using equipment in line with

manufacturer’s instruction/operational manual.

4.1.5. Operational manuals of all equipment and instruments are

available for reference and guidance.

 

In the mangement of equipment, be guided by the following:

 

Licensing requirements of DOH Bureau of Health Facilities and Services on equipment / instruments [http://www.doh.gov.ph]

 

Quality and professional standards requirements (particularly the PhilHealth Benchbook and international standards such as ISO and Joint Commission International or JCI) [http://www.philhealth.gov.ph]

 

Staff requirements of an ER

 

For an effective functioning of an ER, at least the following kinds of staff are needed:

 

•         Physicians

•         Nurses / nursing aides / utility workers

•         Security guard

•         Driver of ambulance

 

These must be adequate in number and in competency.

 

General determining factors on staff requirements of an ER (particularly on qualification and quantity)   

 

Resolution of the above issues will be dependent on the following general determining factors:

·         government regulations (particularly the licensing process of DOH Bureau of Health Facilities and Services)

·         quality and professional standards requirements (particularly the PhilHealth Benchbook and international standards such as ISO and Joint Commisssion International or JCI)

·         usual and anticipated increase in patient load (cost-benefit considerations)

·         needs and expectations of the community

·         integration, coordination and collaboration with other units in the hospital for efficient use of human resources

·         value-added, vision-mission, and benchmarking considerations

 

In fulfilling the staff requirements, be guided by the:

 

Licensing requirements of DOH Bureau of Health Facilities and Services on equipment / instruments [http://www.doh.gov.ph]

 

Quality and professional standards requirements (particularly the PhilHealth Benchbook and international standards such as ISO and Joint Commisssion International or JCI) [http://www.philhealth.gov.ph]

 

            Department of Labor and Employment (DOLE) requirements

 

On qualification for physicians and non-physician staff, DOH has the following basic staff requirements:

 

3. Personnel

The health facility appoints and allocates personnel who are suitably qualified, skilled and/or experienced to provide the service and meet patient needs.

3.1.1. Each personnel is qualified, skilled and/or experienced to

assume the responsibilities, authority, accountability and

functions of the position.

3.1.2. Professional qualifications are validated, including evidence

of professional registration/license, where applicable, prior to

employment.

3.1.3. An organized medical and nursing staff shall be responsible

for the quality of patient care and for the ethical conduct and

professional practices of its members.

 

On quantity of staff,

 

For physicians, DOH has NO specific prescriptions on quantity except for the following:

The physician must not go on continuous duty for more than forty-eight (48) hours.

           

For Nurses and Nursing Attendants, DOH has NO specifc prescriptions.  The general rules, though, can be followed with ER considered as a critical care unit:

 

Supervising Nurse

            50 beds and below = 1;

51 –100 beds = 2;

101 – 150 beds = 3

151 beds and above = 4

Supervising Nurse (Critical Care Units)= 2

Head Nurse = 1:15 Staff Nurses

Staff Nurse = 1:12 beds at any time

Staff Nurse (Critical Care Units = 1:3 Critical Care Unit beds at any time

Nursing Attendant/ Midwife = 1:24 beds at any time

Nursing Attendant/ Midwife (Critical Care Units = 1:3 Critical Care Unit beds at any time

 

For every three (3) Nurses or Nursing Attendants/Midwives, there must be one (1) reliever.

 

Competency of physician staff

           

DOH has the following prescriptions for a level 4 and level 3 hospital accreditation:

 

For Physicians in Clinical Service:

 

The Department Head must be Diplomate/Fellow of a Specialty/ Subspecialty Society.

 

Consultant Physicians are must be Diplomates/Fellows of a Specialty/Subspecialty Society.

 

Medical Staffing

·         By residents and interns

·         By consultants

·         By physicians hired by the hospital

·         Combination of the above

 

Pattern of medical staffing is dependent on:

1. Presence of trainees (residents and interns)

2. Willingness of consultants to go on duty

3. Economic feasibility and viability of employing MDs to man the ER

 

Whatever be the pattern of medical staffing,

there should be adequate coverage by competent physicians who are physically present in the ER and who are supported by medical staff with full clarification of all professional, legal, and financial implications.

 

Who should man the ER?

Any full-pledged MD will do as long as he knows what he is supposed to do.  However, the best person will be an emergency room specialist.  No interns should man the ER without the presence of a resident or a consultant.  Minimum will be a resident-physician.

 

Coordination of ER staff with the hospital’s consultant staff

 

A policy in the ER is that only immediate medical treatment that can be rendered within the limits of the ER setup are administered.  Most patients will be needing follow-up or further treatment.  Thus, an effective medical referral system is needed in decongesting the ER in the soonest time possible.

 

For an effective functioning of an ER, particularly on establishing an effective and efficient referral system so as to make quick disposition decision and to decongest the ER, there must be integration, cooperation, and collaboration between the ER staff and the hospital’s consultant staff.   The best way to effect this is through a policy-making and coordinating body in the form of a committee, such as the ER committe. 

 

Policies and procedures in an ER

 

Operations Manual

 

To provide order, to promote standardization, to facilitate communication, to promote effectiveness and efficiency, and to provide a guide to present and future staff, among other things, policies and procedures must be in place. 

 

These must be collaborated by the ER physicians, nurses and other physician-users through the ER committee and authorized by it and a higher office.

 

These must be aligned with those of the hospital.

 

These should be reviewed and revised periodically.

 

Presence of policies and procedures is a requirement for licensing by DOH, accreditation by PhilHealth and other accrediting bodies like ISO and JCI.

 

There must be policies and procedures on

Governance

Service (Patient Management)

            Clinical practice guidelines in the ER

            Clinical pathways in the ER

            ER nursing care

General nursing care

           

Training

Research

 

In patient management, clinical practice guidelines and clinical pathways are useful in standardization of procedures as well as in the promotion of efficiency.

 

Clinical practice guidelines – systematically developed statements, built on synthesis of evidence, which provide formal recommendations about appropriate and necessary care, intended to assist practitioner and patient to make decisions about appropriate health care for specific clinical circumstances.

 

Clinical pathway – an interdisciplinary plan of care that outlines the optimal sequencing and timing of interventions and expected outcomes for patients with a particular diagnosis, procedure or symptom.

 

The following are useful references in making policies and procedures:

 

PhilHealth Benchbook, Joint Commission International, and Investors in People Standards

 

Established clinical practice guidelines of the recognized society of emergency medicine in the Philippines

 

PhilHealth Benchbook [http://www.philhealth.gov.ph]

 

            A reference manual originating from PhilHealth containing accreditation standards that will evaluate processes that hospitals and professionals use to provide health care and evaluate outcomes that occur as a result of health care provision.  It is essentially a benchbook of quality health care that will be used as a yardstick against which the quality of care rendered by PhilHealth and its accredited health providers and professionals will be measured.

 

            Seven groups of standards:

            Patient Rights and Organizational Ethics

            Patient Care

            Leadership and Management

            Human Resource Management

            Information Management

            Safe Practice and Environment

            Performance Improvement

 

Joint Commission International Accreditation Standards for Hospital (JCI)

[http://www.jointcommissioninternational.org]

It is a reference manual produced by the Joint Commission International, an international arm of The Joint Commission (USA) containing accreditation standards on quality and patient safety.

            Patient-centered Standards

                        Access to Care and Continuity of Care

                        Patient and Family Rights

                        Assessment of Patients

                        Care of Patients

                        Anesthesia and Surgical Care

                        Medication Management and Use

                        Patient and Family Education

            Health Care Organization Management Standards

                        Quality Improvement and Patient Safety

                        Prevention and Control of Infections

                        Governance, Leadership, and Direction

                        Facility Management and Safety

                        Staff Qualifications and Education

                        Management of Communication and Information

Investors in People Standards [http://www.investorsinpeople.co.uk]

Accreditation standards on improving organizational performance through better planning, implementation and evaluation of learning and development programmes across the organization.  It is essentially a framework for delivering organizational improvement through people.

Standards

  • Business strategy
  • Learning and development strategy
  • People management strategy
  • Leadership and management strategy
  • Management effectiveness
  • Recognition and rewards
  • Improvement and empowerment
  • Learning and development
  • Performance measurement
  • Continuous improvement

 

 

Programs of an ER

 

Based on the authorized functions, programs and projects can be designed to achieve the functions and then continually improve the department.

 

General programs and projects consist of the following:

            Programs on Governance

            Programs on Improving Service

            Programs on Teaching

            Programs on Research

 

Examples of programs based on functions:

 

Functions

Parameters / indicators

Programs / Projects

To provide quality services in the ER.

With structured program in the management of patients

 

With implementation of Project Cost-Effective Management (Health-Process-Evidence-based Clinical Practice Guidelines)

 

With structured quality-monitored service program

 

Recovery Rate – 90%

Mortality Rate – 5%

Morbidity Rate – 5%

 

Customer Satisfaction Rating  ≥ 85%

 

Not more than 3 written and valid complaints per year

Project Excellent Service

 

Project Cost-effective Management (Health-Process-Evidence-based Clinical Practice Guidelines)

 

Project Customer Satisfaction

To provide quality training for its staff with the view of ensuring provision of quality service.

With structured quality-monitored training program for staff

 

Project Excellent Education and Training

 

Project Customer Satisfaction

To provide quality research among its staff with the goal of ensuring provision of quality service.

With structured quality-monitored research program

 

Action researches with impact on quality service – at least one a year

Project Excellent Research  (Project Action Research Program / Continuous Quality Improvement )

 

 

Program on sudden influx of patients

 

In the ER, there is always the possibility of a surge of patients.  Thus, there must be a program on how to deal with this event once it occurs.  This must be done in coordination and collaboration with the other staff of the hospital. 

 

Resources in an ER

 

Resources include infrastructure, equipment, people and other logistics needed for the operations of the organization.

 

The assumption is always there is a limit to resources.

 

In a private hospital setting, resources come from revenues of operations of the department.

 

In a government hospital setting, resources come from allocated tax payment and are usually limited. 

 

The head of the department should determine how much he needs based on his planned programs, where he can get them, and how to get them.  This is the challenge to his leadership and managership.

 

 

Common problems and solutions in an ER

 

Categories

Common Problems

Suggested Strategies

MAN

Consultants

Residents

Colleagues in other units

Chief of Hospital

Competencies

 

Number

 

Integration, coordination, collaboration

Leadership and managership

 

Investor in People Standards

 

Managing your boss

 

Use of an ER committee with multi-professional memberships

SYSTEM AND METHOD

Lack of systematization

Lack of standard procedures

Use DOH requirements

Use quality standards (PhilHealth Benchbook and JCI)

Policies and procedures

Clinical practice guidelines

Clinical pathways

MACHINE/EQUIPMENT

Lack of management system

Lack of calibration

Lack of preventive maintenance

Policies and procedures

 

MONEY

Other resources

Limited

Leadership

Innovativeness

TRENDS

Rapid changes - difficulty in coping

Knowledge management system (constant tracking and continual education)

Benchmarking

Innovativeness

 

Managership of the head of an ER

 

 

Leadership of a head of an ER

 

As a leader, you must lead and coach your staff in formulating the vision-mission statements, core values, quality policy, and quality objectives of your department. 

 

The vision-mission statements, core values, quality policy, and quality objectives must be aligned with those of the hospital or cascaded from those of the hospital.

 

The formulation of the governance statements and objectives should be an outcome of collaborative activities of all the staff as much as possible in order to facilitate accomplishment driven by sense of ownership and spirit of commitment.

 

Example of a vision statement of an ER:

           

We envision our ER to be

 

a model (or an excellent or an outstanding) ER in the community (or in the Philippines) providing quality and safe services.

 

After formulating the governance statements of the department, as a leader and manager, you must lead and coach your staff in formulating a 3 to 5 years strategic plan and an annual management action plan.  There must be monitoring and evaluation of the implementation of the plans at planned intervals, end of the year and at the end of your terms.  It is only after getting the results of the evaluation can you and your chief of hospital and nursing director really say whether you have been a good leader and a manager.