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Introduction

Research Question
How can emergency department protocols and guidelines be improved or altered so all
processes in the department run smoothly and effectively?
Research Purpose
The purpose of this study is to determine if the protocols and layout of emergency
departments are set appropriately to benefit patients in the best way. All protocols in emergency
departments are set reasonably for each patients medical experience and their well-being. The
intent of this study is to try and find different ways to alter them for a better patient experience.
Studies have shown specific changes in emergency departments are effective. This study will
offer a few aspects of the emergency department, rather than just being focused on one. Patient
experience versus physician responsibility is taken into account along with the difference
between pediatric and adult protocols and emergency department layout. The emergency
department is very functional and always developing; this research is introducing possible
improvements to its protocols and layout.
Background Information
There is a common theme throughout all of the sources and studies in this research of
how emergency rooms function. Whether emergency departments are functioning poorly or
remarkably, there is always room for improvement. A study was done at a University Medical
Center in Germany to implement new protocols in their emergency rooms. After analyzing the
existing protocols in their emergency rooms, the department of anesthesiology of the Medical
University of Gottingen (UMG) developed new emergency room protocols that were
department-specific. As as result, they created 13 different sections to represent the protocol and

its contents; general characteristics, emergency event, initial findings and interventions, vital
parameters, injury pattern, vascular access, hemodynamics, hemogram/blood gas analysis
(BGA), coagulopathy, diagnostics, emergency interventions, termination of ER treatment and
final evaluation. (Ross, Hinz, Mansur, Mielck, Roessler and Quintel, 2015) This study is useful
because it gives a completely different perspective of hospital emergency rooms and the list of
things they choose to improve. These improvements succeeded in the UMG emergency room,
but in the United States, there is still a lot of question about what could work to best benefit
American health systems.
Jim Crispino, the president of Philadelphia-based firm Francis Cauffman believes that the
emergency department is a pivotal component to the rest of the hospital's success. The
emergency department is the beginning of many patients hospital experience, so the consultation
they have there is critical. Crispino also says that the ER is becoming hospitals new front doors.
Usually for a regional medical center or a community hospital, 25 to 30 percent of people go to
the emergency department first, he says. Of the people admitted to the hospital, over 50
percent are generally coming in from the emergency department. Crispino has designed health
care facilities for many years; his clients are starting to question the relationship between the
emergency department and hospital. Francis Cauffman has done evidence-based design studies
to explore how the physical environment of an emergency department impacts patient outcomes
and staff efficiency as cited in (Dickinson, E. E., 2007). These techniques have helped improved
emergency rooms, but there is of course always room for more improvement.
A prevailing problem that continues to arise in emergency departments is the ability to
pay. It is required by law for emergency departments to treat everyone who walks through the
door. A lot of patients who enter the emergency department dont need the extensive care an ED

can provide, but they go anyways because they have no insurance plan to get in anywhere else.
This population of people would be much better off going somewhere like a walk in clinic, but
since they have no insurance that is not an option for them. In the article The Crisis in America's
Emergency Rooms and What Can Be Done, OShea says, Misusing the ED to provide primary
medical care is more costly than providing the same care in a physician's office, and primary
medical care received through the ED is of poorer quality. A question that policymakers and
physicians might ask is whether or not its worth it to continue letting uninsured people walk into
the emergency department. It is worth considering making a separate facility for uninsured
patients. (OShea, 2007)
The priority of care is most often based on triage categories. Triage of patients is
determined based on the urgency of their situation when they walk into an emergency
department. Triage decision making must be persistent to have a successful health care delivery
to all of the patients that come through an emergency department. Knowledge and experience are
crucial to give a definite patient assessment. Both nurses and physicians are responsible for
knowing triage categories so they can in turn give a correct patient diagnosis and pinpoint an
illness. The treatment of pediatric patients versus adult patients is very different, so knowing
these triage categories is important in diagnosing each type of patient. Pediatric patients pattern
of illness should be treated differently than that of an adult. Since pediatric patient treatment is so
particular compared to other ages, a normal emergency department doctor must be able to care
for both pediatrics and adults. Presenting symptoms of patients that walk into an E.D. vary for all
ages, so when making and assessing protocols, physicians and/or policymakers must consider
different ages. (Maldonado & Avner, 2004) The methods conducted in the study written in
Triage of the pediatric patient in the emergency department: are we all in agreement? by Theresa

Maldonado and Jeffrey R. Avner consider 12 pediatric scenarios that physicians in pediatrics and
general emergency departments were asked to try. They were also asked to use a 3-tier triage
system (emergent, urgent, nonurgent) to assess the patients in these scenarios. The male and
female patients were a variety of ages below 12 years of age. Within these 12 scenarios, triage of
children, time to termination of resuscitation efforts, sedation use, treatment of a febrile child, &
management of febrile seizures are all taken into account. The 12 scenarios were created
according to each patients chief complaint which included, fever(3 cases), head trauma, barking
cough, wheezing, seizure abdominal pain, not drinking, fever and decreased oral intake, chest
pain, and not walking. Triage categorization from both pediatric emergency medicine (PEM) and
general emergency medicine (GEM) doctors was evaluated in this study. In most circumstances,
the two parties agreed on the level of triage for a patient, their response rate was very successful
at 99%. GEM participants were more likely to triage children with certain febrile illnesses at
higher acuity levels as compared with their PEM counterparts. (Maldonado & Avner, 2004)
Emergency department doctors must be prepared for any case that comes through the door. Since
pediatrics is handled so differently, they must know and practice the correct protocols for not
only adult patients, but also pediatric patients.
For a well functioning emergency department, physicians must be prepared for any case
that may come through the door. All ages enter the emergency room every day, therefore there
must be correct equipment to care for any type of patient at any age. Certain supplies and
equipment are required to care for pediatrics, just like in Triage of the pediatric patient in the
emergency department: are we all in agreement? by Theresa Maldonado and Jeffrey R. Avner,
how there must be specific protocols when assessing and diagnosing a pediatric patient. The
emergency department is the starting place for many patients, so the equipment must be able to

adapt to each patients needs. An effective ED must have the necessary resources to serve
pediatrics since their care is so different compared to an adult. Some guidelines were created by
the American College of Early Physicians (ACEP) for pediatric patients that may enter an
emergency department. Although resources within emergency and trauma care systems vary
locally, regionally, and nationally, it is essential that hospital ED staff and administrators and
EMS systems administrators and medical directors seek to meet or exceed these guidelines in
efforts to optimize the emergency care of children they serve (ACEP, 2009) Hospital EDs must
constantly be prepared to treat pediatric patients. In Guidelines for Care of Children in the
Emergency Department, ACEP lists major protocols and guidelines that should be followed by
administration, physicians, nurses, and other health care providers. There are also guidelines
regarding patient safety, quality improvement (QI), performance improvement (PI), policies,
procedures, support services, equipment, supplies, and medications all pertaining to pediatrics. It
is very important to be well prepared to follow all of these guidelines when working in an
emergency department. Since the majority of people that come into the ED are not children, the
use of these guidelines could come at any time of the day. This relatively infrequent exposure of
hospital-based emergency care professionals to seriously ill or injured children represents a
substantial barrier to the maintenance of essential skills and clinical competency (ACEP, 2009)
Emergency physicians should be prepared to treat whoever walks through the door. These
guidelines will train physicians to strive for improvement and provide the care that is necessary
for any patient. Care of children in the emergency department: guidelines for preparedness.
(American Academy Of Pediatrics) also states how different pediatric care needs to be in an
emergency department. A lot of components to emergency care are made for children, but arent
limited to children. The statement in this article provides guidelines for pediatric patients so they

can get the best care. It is imperative that all hospital EDs and EMS agencies have the
appropriate equipment, staff, and policies to provide high quality care for children. Is a big idea
to consider when improving EDs. (American Academy of Pediatrics, 2001)
The layout of an emergency department is crucial to how successful it can function. If
there is a poor layout, patient flow of information wont move as efficiently throughout the
emergency department as it could with a more convenient layout. Emergency departments are
continually faced with rising and unpredictable patient visits while at the same time striving to
improve their efficiency and quality in their day to day work. There is always room for
improvement in an emergency department, especially when considering layout. In Best Of 2014:
Rethinking The Emergency Department by John F. Wheary, the goal of this ED renovation was
to develop an innovative design solution, adopting a model designed for the rapid assessment
and evaluation of emergency patients: a rapid assessment unit (RAU). (Wheary, 2014)
Healthcare is constantly changing, so emergency departments must also be changing and further
improving their layout to continue to treat patients in the best ways. Patient information and care
can only be improved with innovative thinking and designs. Lehigh Valley HospitalMuhlenberg
(LVH-M), a community hospital in Bethlehem, PA, was the first hospital to undergo a new type
of emergency department layout. In this approach, patient volume and ED capacity was the main
focus. Through this approach, they found that better patient outcomes can be achieved when
there is not constantly a space issue.
To successfully improve an emergency department, there must be a cost effective plan in
place. Without thinking about the expenses that come with improving and creating a new
emergency department layout, any plans that are made wont be successful. Everything comes
with a pricetag, so to improve an ED, price and time must be considered. In COST

EFFECTIVENESS OF A PHYSICIAN DESIGNED PROTOCOL IN THE EMERGENCY


DEPARTMENT, William J. Beach, J. L. Skolnick, H. L. Phelps and P. Cerrito, wrote about a
study pertaining to shortness of breath and respiratory care. It sought out to see if respiratory care
practitioners (RCP) using a physician designed protocols (PDP) would produce the same patient
outcomes more cost-effectively than individual physicians orders (IPO) (William J. Beach, J. L.
Skolnick, H. L. Phelps and P. Cerrito, 1999) They concluded,A PDP, administered by an RCP
staff, promotes cost effective treatment of patients in the ED with c/o SOB (shortness of breath),
compared to an IPO model, with equal or better outcomes. (William J. Beach, J. L. Skolnick, H.
L. Phelps and P. Cerrito, 1999) Hourly costs of treating a patient in the emergency department is
costly, but RCP variable costs add an additional amount on top of the price you receive from an
emergency department. Using PDPs from RCPs would result in savings of a few hundred hours
per year, then leading to a lower possible cost. (William J. Beach, J. L. Skolnick, H. L. Phelps
and P. Cerrito, 1999)

Hypothesis
Based on the research above, there is always room for improvement in emergency
departments. If protocols, guidelines, and layout of the general emergency department are altered
and improved, then a more efficient ED can be developed to care for patients of all ages.
Methodology
Emergency departments function to most benefit patients. To further improve day to day
events in emergency departments, two points of view must be considered. The best way to do
that for this research is to make surveys that ask questions about patient experience and

physician experience in the emergency department. Two surveys were given asking questions
about emergency department protocols. The first survey was created to identify physicians
opinions and ideas about emergency department protocols during their everyday job. The second
survey was directed towards the public about emergency department experiences as a patient or
as an assistant to a patient.
The first survey in Appendix A asked emergency department physicians about their
everyday routine and what protocols they must follow or abide by while attending to patients in
the emergency departments.
The second survey was exclusively asking about patient experience and opinions. Many
questions throughout the survey were directed towards each patients experience. Some questions
were asking more directly about any protocols that each patient noticed while they were in an
emergency department. Most participants listed at least one idea that could have made their
experience faster and/or more effective. These survey questions are listed in Appendix B.
The design and layout of an emergency department will likely determine how effective it
can function. An ideal emergency department layout will be considered and drawn. If an ideal
layout for the emergency department is made, many of the protocols in the ER can be improved.
A third, shorter survey will be created to get opinions on whether or not the said drawn layout of
an ideal ER would be effective.

References
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