Emergency Hospital Services,

an Introduction

Agus Barmawi
Emergency Installation
Faculty of Medicine GMU/Sardjito General
Hospital Yogyakarta

Learning Objectives
After completion of this topic the
student will be able to :
A. Understand the system of emergency in
Indonesia
B. Understand the goal of emergency
services
C. Understand of initial assessment
D. Understand the triage setting
E. Understand of patient safety in
emergency room

Introduction
In instances of emergency,
immediate, rapid medical response is
vital to minimize the extent of injury.
When numerous patients arrive at an
emergency room or a large scale
disaster occurs, a hospital's
emergency staff employs triage
procedures.

Introduction
This systematic set of procedures
ensures that all patients are seen and
evaluated immediately and then
prioritized to allow the most critical
patients to receive the most
immediate assistance

Definition
An Emergency Department (ED), also
known as Accident & Emergency
(A&E), Emergency Room (ER),
Emergency Ward (EW), or Casualty
Department is a medical treatment
facility, specializing in acute care of
patients who present without prior
appointment, either by their own
means or by ambulance.

Indonesia Concept of
Emergency Services

Triage--START

The Goal of emergency services

To reduce mortality
To reduce morbidity
The principle of treatment is
Live saving
Limb saving

Patient Safety
Patient safety is the reduction of risk of
unnecessary harm associated with
healthcare to an acceptable minimum. An
acceptable minimum refers to the
collective notions of given current
knowledge, resources available and the
context in which care was delivered
weighed against the risk of nontreatment or other
treatment(Morrison.L.J., et al.2009)

Patient safety Goal

Improve the accuracy of patient identification.
Improve the effectiveness of communication among
caregivers.
Improve the safety of using medications.
Improve the safety of using infusion pumps.
Reduce the risk of health care-associated infections.
Accurately and completely reconcile medications
across the continuum of care.
Reduce the risk of patient harm resulting from
falls. (JCAHO,2005)

Each patient will be evaluated

about initial assessment :
The
Air way
Breathing
Circulation
Disability

Emergency Services in Sardjito

General Hospital Cases
Trauma
Any kinds of trauma

Brain injury
Trauma of the face
Thoraxic injury
Abdominal trauma
Musculoskeletal trauma

Cervical
Back bone
Pelvis
extremity

Emergency Services in Sardjito

General Hospital Cases
Trauma

Burn injury
Pediatric trauma
Eyes trauma
Trauma of pregnancy

Emergency Service Cases at

Sardjito General Hospital
Non Trauma
Infections
Bacterial

Meningitis
Oropharyngeal phlegmon
Pneumonia/bronchitis
TBC
Pyogenic infections

 Non Trauma
Infections
Viral

Dengue fever/DHF/DSS
Hepatitis
HIV
Swine flu
Avian/Bird/H5N1 flu
Sars

Parasites

 Non Trauma

Infections
Parasites

Malaria
Amoebiasis
Leptospirosis

Non Trauma Non Infection

Cardiac arrest
Heart attack
Congestive Heart failure
Asthma bronchiale

Non Trauma Non Infection

COPD
DM
Hyperosmolar Hyperglycaemic NonKetotic Coma (HONK)
CKD
Upper/lower GI tract bleed
Bowel obstruction due to any causes
Stroke
Pre eclampsia

Non Trauma Non Infection

Extopic pregnancy
Abortion
Others obgy emergencies
Emergency of oncology
Emergency of Congenital disesase
Atresia esophagus
Atresia ani
Others

Urine retention

Steps to Triage
Hospital Setting
Day to day emergency services of triage
More detail
Anamnesis
Physical examination
Supportive data
Consultation
Diagnose
Definitive treatment
Disaster Setting

 Disaster Setting Triage

Field triage
Field treatment area
Limited supportive data
Stabilization and transportation
No definitive treatment/Limited
definitive treatment

How to Complete Triage Procedure

The initial intake medical exam should take no
more than 60 seconds.
During this time, the medical professional
must perform a basic assessment of the
patient's injuries.
The majority of this examination is visual,
with the practitioner glancing over the victims
body and using his hands to feel for any
palpable wounds or indications of serious
problems.

Complete a basic examination

If necessary, emergency personnel can take
the patient's vitals at this stage.
All complex testing must wait until the
patient has been categorized and
processed. If the patient has injuries that
are an immediate threat to his survival, the
team can perform immediate emergency
care.

Provide immediate emergency care

If the patient has an actively gushing
wound or is not breathing, the
medical team immediately performs
any necessary life-saving procedures,
including stopping the flow of blood
through the use of a tourniquet or
performing cardiopulmonary
resuscitation (CPR) to restart the
heart.

Provide immediate emergency care

Immediate emergency care should
only be provided if the patient's life is
in imminent danger.
If it is not, the patient should be
prioritized and placed with others in a
central waiting room.

Complete a prioritization
To determine the order of treatment,
all patients must be prioritized.
During prioritization, the emergency
medical personnel must group the
patients based on the threat
presented by their wounds.

Complete a prioritization
This prioritization is completed
quickly and with only the information
obtained from the 60-second intake
examination.
Patients are then categorized and
given easily identifiable color-coded
bands.

Tag patients for easy reference

Patients with only minor wounds receive a green tag,
indicating that they can be seen last.
Patients with slightly more serious wounds receive a
yellow tag, showing that they need to be seen before
the minor wound patients.
Patients with serious wounds that require immediate
attention receive a red tag, allowing personnel to easily
determine that they should be the first treated.
Patients who are already deceased are labeled with a
black tag.

The management Problem at ED

Bottlenecked patient flow
Communication problems
Long waiting times

The Challenges in Emergency

Department Services
How to track real time patient status in the ED
How to improve efficiencies in triage, patient
flow, lab, x-ray, and dispositions
How to improve communication among the ED
staff and between ED staff and other
departments
How to track important milestones for review
and analysis
How to do all of the above without increasing
the work load of an ED staff already at or near
its limits

Bringing Visibility to Complex ED Workflows

Patients Flow in The Emergency Department

Input
Emergency care
Seriously ill from
community and
referral

Unscheduled urgent
care
Lack of available
Ambulatory care
Desire for immediate
care

Safety net care

Vulnerable
Populaton
Access barriers

Throughput
Ambulance
diversion

Patient arrives
At ED

Output

Ambulatory
Care system
Triage and room
placement

Demand
For ED
Care

Lack of access to
Follow up care

Leave without
Treatment
complete

Transfer to
other facility

Diagnostic
Evaluation and
ED treatment
Patient
disposition
ED boarding of
patients

Lack of available
staffed Inpatient
beds

Admit to
hospital

Tracking and Communication System in ED

Automatic tracking

Strategies to Improve Flow

In October 2007, Yen and Gorelik
reviewed in Pediatric Emergency Care
various strategies to improve flow in the
Pediatric ED at the different stages of
the flow process.

Picture Archiving and Communication

System (PAC System)
PAC systems with integrated reporting
capabilities, provide radiology departments
with the means to manage medical images
in a digital format on a variety of computer
networks.
By changing the way that images are
collected, displayed, reported and stored
within a department, major efficiencies can
be obtained. (Mc Callum.1995)

Intake
Improve the triage process
Increase triage staffing
Limit the scope of triage to the minimal information
gathering necessary to allow prioritization
2-tiered triage system: limited initial screen allowing
some to bypass a second more comprehensive screen
(those who require immediate attention or are clearly
"fast track" patients)
Physician or allied health provider triage- possible
disposition from triage or allows treatment to begin
earlier
Collaborative practice protocols: standing orders for
certain lab test, imaging studies, etc
Clinical pathways

Intake
Improve the registration process
Use minimum demographic information to
generate a chart and then complete
registration at the bedside.
Placement of patients in exam rooms and
assignment to physician and nursing staff
Active assignment by a charge nurse of
physician in a time-prioritized manner

Outflow
Strategies to decrease holding admitted patients in ED
Dedication of an inpatient ward to admissions from
the ED
Establish a short-stay unit
Simplify the admission process
Early prediction of need for admission may permit
earlier bed requests

Facilitate discharge of patients going home

Dedicated discharge nurse
Preprinted discharge and educational materials
Facilitation of primary or specialty care follow-up

 ED overcrowding impacts all the stakeholders

in healthcare system.
The strategies described may help improve
flow and provide immediate relief of
overcrowding; however, long-term solutions
are needed.
Further research is needed exploring the link
between crowding and quality of care and
studying interventions to alleviate ED
overcrowding.
Pediatric Emergency Medicine Section - March
2008, Vol 19, #2

Diagnostic Testing and ED Treatment

Collaborative proactive protocols leading to earlier lab test ordering

Use of point-of-care testing (rapid strep, influenza, electrolytes,

hematocrit, urine pregnancy, fecal and gastric blood and urinalysis)

Improve laboratory turn around time

Point-of-care imaging: bedside ultrasound

Improve predictors of staffing needs based on historical flow data

Ensure adequate ancillary staff

Create a separate stream for low-acuity patients in the ED ("fast track")

Technological improvements: electronic tracking board, bar-coding

patients, PACS, EMR, telemedicine for consultants, electronic
prescriptions

 Traumatology (from Greek "Trauma" meaning injury

or wound) is the study of wounds and injuries caused
by accidents or violence to a person, and the surgical
therapy and repair of the damage.
Traumatology is a branch of medicine. It is often
considered a subset of surgery and in countries
without the specialty of trauma surgery it is most
often a sub-specialty to orthopedic surgery.
Traumatology may also be known as accident surgery.

Factors in the assessment of wounds are:

the nature of the wound, whether it is a
laceration, abrasion, bruise or burn
the size of the wound in length, width and
depth
the extent of the overall area of tissue
damage caused by the impact of a
mechanical force, or the reaction to
chemical agents in, for example, fires or
exposure to caustic substances.

The ASA physical status classification system is a system for

assessing the fitness of patients before surgery. In 1963 the
American Society of Anesthesiologists (ASA) adopted the fivecategory physical status classification system; a sixth category was
later added. These are:

1.
2.
3.
4.

A normal healthy patient.

A patient with mild systemic disease.
A patient with severe systemic disease.
A patient with severe systemic disease that is a
constant threat to life.
5. A moribund patient who is not expected to survive
without the operation.
6. A declared brain-dead patient whose organs are being
removed for donor purposes.
If the surgery is an emergency, the physical status
classification is followed by E (for emergency) for
example 3E