|Year : 2016 | Volume
| Issue : 2 | Page : 108-114
Setting up and functioning of an Emergency Medicine Department: Lessons learned from a preliminary study
K Asish, Varun Suresh
Department of Anaesthesia and Critical Care, Medical College, Thrissur, Kerala, India
|Date of Web Publication||12-Feb-2016|
Department of Anaesthesia and Critical Care, Medical College, Thrissur - 680596, Kerala
Source of Support: None, Conflict of Interest: None
Background and Aims: Tertiary care teaching hospitals remain referral centres for victims of trauma and mass casualty. Often specialists from various disciplines manage these crowded casualty areas. These age old casualty areas are being replaced, throughout the country by Emergency Medicine Departments (EMDs), presumed to be better planned to confront a crisis. We aimed to gather basic data contributive in setting up of an EMD at a tertiary care teaching hospital from the lessons learned from functioning existent systems. Methods: This is primarily a questionnaire-based descriptive study at tertiary care referral centres across the country, which was purposively selected.The study models included one from a hospital without designated EMD and the other four from hospitals with established EMDs. Direct observation and focus group meetings with experienced informants at these hospitals contributed to the data. In the absence of a validated hospital preparedness assessment scale, comparison was done with regard to quantitative, qualitative and corroborative parameters using descriptive analysis. Results: The EMDs at best practice models were headed by specialist in Emergency Medicine assisted by organised staff, had protocols for managing mass casualty incident (MCI), separate trauma teams, ergonomic use of infrastructure and public education programmes. In this regard, these hospitals seemed well organised to manage MCIs and disasters. Conclusion: The observation may provide a preliminary data useful in setting up an EMD. In the absence of published Indian literature, this may facilitate further research in this direction. Anaesthesiologists, presently an approved Faculty in Emergency Medicine training can provide creative input with regard to its initial organisation and functioning, thus widening our horizons in a country where there is a severe dearth of trained emergency physicians.
Keywords: Anaesthesia, emergency medicine, mass casualty incidents
|How to cite this article:|
Asish K, Suresh V. Setting up and functioning of an Emergency Medicine Department: Lessons learned from a preliminary study. Indian J Anaesth 2016;60:108-14
|How to cite this URL:|
Asish K, Suresh V. Setting up and functioning of an Emergency Medicine Department: Lessons learned from a preliminary study. Indian J Anaesth [serial online] 2016 [cited 2019 Oct 19];60:108-14. Available from: http://www.ijaweb.org/text.asp?2016/60/2/108/176273
| Introduction|| |
Disaster in a hospital set up is declared when the requirements overwhelm the resources of the involved hospital. Hospital disaster may be of any size and is not limited to mass casualty incidents (MCIs). India with its mammoth population, diverse culture, mass gatherings and densely populated regions make the problem more dangerous in a case of mass casualty. As per the international disaster database data, India has suffered from 773 natural disasters during 1990–2009. Man made disasters are also on the rise demanding stringent intervention.
Every critical event is unique and every involved hospital has unique way of tackling it. Although referral hospitals are expected to have a pre-designed plan of managing a crisis, Hospital Emergency Incident Command System and Joint Commission of Accrediting Health Organization have suggested mass casualty management protocols; however, they are seldom universally followed.,,
Anaesthesiologists not only serve as the backbone of physician-staffed pre-hospital emergency medical services in many countries ,, but also were instrumental in the creation of modern emergency medicine services. In our country, where Emergency Medicine Departments (EMDs) are still in infancy, their role is being played by the age old multi-departmental casualty areas managed by non-specialised medical officers; hence, our role is even more relevant. The dearth of trained emergency physicians, similarity in duties performed, brisk responses and easy availability has attracted and absorbed anaesthesiologists to take up the challenge of organising and maintaining an EMD. There has been a significant reduction in mortality and morbidity due to a systematic approach to trauma care and emergency medicine services.,
Organised systems integrating pre-hospital and in hospital trauma care for definitive treatment are generally non-existent in most developing countries. Through our study, we tried to compare a traditional interdisciplinary casualty area, at a tertiary care teaching hospital (study hospital) lacking a dedicated EMD to similar hospitals across the country having a fully functioning EMD. The data gathered during the study will help to lay down some basic blueprint in setting up an EMD in Indian scenario; however, a standard guideline in this regard fulfilling our supply-demand ratio is currently unavailable.
| Methods|| |
We observed the facilities, human as well as non-human resource management and level of disaster preparedness in a government-run tertiary care teaching hospital lacking an EMD (study model) to tertiary care referral hospitals having fully functioning EMD (best practice models). The study hospital had 24 h functioning interdepartmental casualty area. Senior residents from various specialties managed this classic model casualty (representing many teaching hospitals across the country) while the best practice model EMDs had physicians qualified in Emergency Medicine.
After approval from the Institutional Review Board, permissions were obtained for data collection from the study hospital and best practice models. Since validated standard scales to assess the quality of emergency care and disaster preparedness uniformly applicable to all models in the study and applicable to Indian scenario were unavailable, we devised a questionnaire for data collection with the provision of descriptive entry and observational results. The components comprising the questionnaire were compiled from Government of India - United Nations Development programme for disaster reduction, and also the expert consensus of anaesthesiologists having a minimum experience of 5 years in the field were considered. With the questionnaire [Table 1],[Table 2],[Table 3]; four practice model hospitals (hospitals A-D) in the region were identified to be compared to the study hospital. The questionnaire was answered by the head of the EMDs and observational data were compiled by the primary investigator after direct observation and focussed discussions. The data was collected from the study hospital during the same period, organised in a tabular format and analysed.
|Table 2: Information regarding Emergency Medicine Department infrastructure for managing mass casualty incidents|
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Collected data pertaining to hospital preparedness for disasters were subdivided into qualitative, quantitative, and corroborative parameters [Table 1],[Table 2],[Table 3]. A descriptive analysis was used for each of these.
| Results|| |
All hospitals except the study hospital had a separate EMD headed by a lead consultant and supported by specialists with a post-graduate qualification in emergency medicine. The study hospital maintained an interdepartmental casualty manned by trainee resident doctors under the supervision of multiple departmental heads [Table 1].
All hospitals followed the triage system of classification to be adopted in emergencies. The EMD in hospital A followed an indigenous triage system where patients were categorized on admission into R1, R2 and R3 based on decreasing order of severity of illness and emergency care needed. It was also observed that the patients after being stabilised or on improvement get shifted to R2 and on further improvement to R3. The hospitals B, C and D had EMDs with separate patient care bays each dedicated to decontamination, trauma, resuscitation, paediatric, obstetric and general medical care, where patients get admitted receive treatment and stay there until being shifted to the inpatient department.
The EMDs in hospital A, C and D conducted six monthly mock drills as a preparation to meet exigencies of MCIs. Regular upgradation of knowledge; both theoretical and practical skills of doctors and support staff were ensured by regular lectures and serial objective structured clinical examinations in hospitals A, C and D.
Trauma team headed by EMD physician and supported by general surgeons, orthopaedic surgeons and anaesthesiologists, takes over an MCI in hospitals B, C and D, while hospital A had a Hospital Incident Command System (HICS), headed by the EMD chief. In the multidisciplinary casualty, hospital superintendent trained only in a particular specialty may have to assume charge and coordinate while independent departments work at their area and pace. The working hours in hospitals A-D was three 8 h shifts in a 24 h cycle. The study hospital followed a 24 h work shift system. All hospitals A-D had own protocols for declaring MCIs whereas disaster was declared only on such proclamation by the government authorities/local administration.
Certain features were unique to each of the hospitals A-D. Hospital A maintained a characteristic resuscitation alarm which when initiated signals the requirement of more manpower at the EMD. Hospital B had social media of instant messaging (WhatsApp) for ease and speed of clinical communication among lead consultant, medics and paramedics. Hospital C conducted major exercise mock drill once in 2 years, apart from the 6 monthly regular drills, in collaboration with local airport authorities. Hospital D allotted a unique barcode embossed tag for patients in EMD. Paramedics used hand held barcode scanners for easy aggregation of clinical and demographic data.
The total inpatient bed strength was highest in hospital A and lowest in hospital C [Table 2]. All beds in hospitals A-D were equipped with oxygen delivery devices, suction apparatus and electronic monitoring systems. Hospitals A-D performed well with regard to availability of personal protective devices, availability of ambulances and telephone connectivity to the EMD. Although the study hospital had a higher percentage of casualty beds, the bed-wise availability of ancillary facilities such as oxygen delivery devices, suction apparatus, electronic monitoring systems and availability of personal protective devices were less. Hospitals A and B conducted monthly school and college education programmes on creating awareness among public regarding disaster preparedness [Table 3]. Hospital C conducted periodic resuscitation skill enhancement programmes at the community level. Hospital D conducted periodic organisation oriented awareness programmes to factory labourers, non-clinical hospital support staff, bank employees, employees of non-governmental organisation and others. Hospitals A-D reported acceptance from public to such awareness and training sessions to be salutary. Such public awareness systems were absent in the study hospital.
| Discussion|| |
India with its unique geo-climatic conditions is prone to face many disasters. It was estimated that 27 Indian states/union territories are disaster prone. However, it was only in 2005, we formulated a Disaster Management Act and in 2013 the Comptroller and Auditor General report on disaster preparedness showed dismal results. This necessitates every Indian healthcare system to improvise both in quantity and quality.
Tertiary care hospitals in India are managed by private sector or public sector undertakings. The facilities pertaining to patient care and medical education vary across these institutions irrespective of the management. The majority of tertiary care public sector hospitals have a 24 h functioning casualty, and only a very few maintain a dedicated EMD. Casualty is an interdepartmental model of emergency medicine practice where the first attending doctor, a resident trainee/internship trainee first attend the patient and allocates them to speciality based on history/injury as the case may be. In dedicated EMD's, physicians provide initial assessment and first-line treatment that has the added advantage of saving precious time and providing expert care.
The WHO toolkit for assessing health-system capacity for crisis management has only select components pertaining to disaster preparedness for hospitals. Hence, we designed a novel scale to assess disaster preparedness for hospitals in our study. Apart from the WHO method, the Joint Commission for Accreditation of Healthcare Organizations survey also assesses the MCI preparedness of the healthcare system; but has been criticised as it primarily focuses on structural and process measures and lacks performance measures. The idea of our questionnaire was not only to assess the effectiveness/preparedness for managing mass casualty, but also to offer a descriptive data and observational inputs and experiences derived from focused discussion, which can be of help in formulating a basic plan to set up an EMD.
A dedicated EMD headed by a lead consultant with ample experience and expertise in managing a mass casualty or disaster appeared well prepared. These dedicated EMDs were located at the most accessible sites of hospital with separate entry and exit gates, avoiding 'flow in' restrictions. There is separate ambulance ramp; most well-functioning models have outsourced ambulance services with a single ambulance call number (e.g., 108, 1098 etc.). This not only reduced recurring expenses but also takes away managerial issues and provides better connectivity resulting in quick access to trauma site.
A lead consultant/head, assisted by 3–4 trained emergency physicians on 8-h shift, heads the EMDs. Resident/trainees are helping these physicians on shift. Nursing staff, technical assistants and supporting staff work on a similar shift. Triage area, located at the entrance itself maintain the register and allocate patients to different bays (i.e., resuscitation, medicine, surgical, paediatric, gynaecology etc., facilitating specialised care and easy identification of the patient). A priority based R1, R2, R3 system can also be followed as in hospital A if the patient load is high. Triaging is performed in best practice models by trained nursing staff or technical assistants under the guidance of physicians, to reduce doctor's load. As per the merit, patients are guided to resuscitation, stabilisation or different specialty bays. Whole EMDs perform a protocol-driven management, which saves valuable time in golden hour and treatment bias. Although some EMDs did not exhibit protocols, a regular knowledge and skill assessment with mock drills reinforced the management strategy. A multidisciplinary casualty may find it difficult to coordinate and assign role between various specialties, affecting time and efficiency in patient care.
Hospital planning groups are responsible for deciding the infrastructure and staff pattern in hospitals. In our study, the presence of such groups was not universal. However; a trauma team constituted by an emergency physician, anaesthesiologist, orthopaedic surgeon, general surgeon, neurosurgeon, radiologist and other support staff was present in all the best practice models we studied. A HICS may substitute or compliment the trauma team and deal with activation of MCI and plan the logistics, communication, transportation and liaison work including escalation of bed strength and workforce in need. The EMDs also had rooms for storage, decontamination, emergency procedure and academic activities. It also provided refreshment facilities for doctors, nurses and staff.
A central station harbours reception, public information system, record keeping with connectivity to pharmacy, laboratory, blood bank, internet, library and other departments of the hospital. A liquid-crystal display/light-emitting diode screen exhibiting details of patients in EMD, whether they are attended and orders executed, based on colour indicators add to the efficiency of EMD.
EMDs empower the public too, as public information and education invariably were a concern of priority across all best practice models. This was achieved through differing ways like school and college education programmes, community resuscitation skill enhancement programmes and professional/worker organisation oriented programmes. It was observed that media can increase awareness and society involvement in disaster. They have also made deliberate attempts to have better connectivity with improved telecommunication and transporting facilities. EMDs delivered faster definitive care, while inevitable delays in obtaining cross consultation may occur in a multidisciplinary casualty set up, delaying definitive treatment. An efficient public information system proves useful in case of recruiting external support in terms of workforce or supplies or public in disasters.
Despite the absence of an EMD the existence of higher percentage of casualty beds in the study hospital deserve special mention (6.25% vs. 1.60%, 2.43%, 4.57% and 4.00%) [Table 2]. This larger number of casualty bed strength in multidepartment system may have resulted from percentage sharing by various departments. However, protocols pertaining to such allotment of casualty beds as a fixed percentage of total beds of the concerned department are unavailable. Multidepartment system in the study hospital, even though enhanced the bed strength in the emergency room, may not be cost effective. Residents from contributing departments may not maintain work, proportionate to the need, in the case of an MCI. A 24 h duty schedule followed in such casualty can be tiresome to the doctors employed, affecting their efficiency.
Studies assessing disaster preparedness for hospitals in the Indian scenario are lacking. Bremer studied the pre-event societal disaster preparedness and disaster relief provided to the victims of the January 2001 earthquake in Gujarat, India. Evaluation of the pre-event status of the affected society revealed a complex situation in a vulnerable society with substantial deficiencies in the existing health system that added to the severity of the disaster. The author stated, the relief provided to the disaster victims had reduced quality on account of reasons such as absent public health indicators, lack of efficient coordination, delay in the provision of relief measures and non-availability of policies on the delivery of disaster relief measures. The study emphasised an efficient disaster/mass casualty response system. Another study on disaster management after the Asian Tsunami in India was limited to a single hospital.
Around the globe, similar studies are plagued by the absence of a validated scale for evaluating hospital disaster preparedness. Shoaf et al. studied the hospital preparedness in select hospitals across Brazil using a semi-structured key informant interview. However, this study was limited by the selection of only a small number of hospitals per city.
Evaluation of the health system preparedness for disasters in the 27 European Union member countries using a modified version of the WHO toolkit for assessing health-system capacity for crisis management is published. Similar study by Ingrassia et al. reported comparable findings. The limitations of the study were a small number of hospitals included in the member countries and the questionnaire used in the study even though modified from the WHO checklist, was not previously validated. A systematic review on hospital emergency preparedness evaluation instruments across various centres in China has also been published. Researchers suggested that a holistic assessment tool be developed to evaluate hospital preparedness extensively. In the United States, since the 2001 World Trade Centre attacks and the anthrax bioterrorism, with subsequent shift of focus in view of hurricane Katrina and major influenza outbreaks, the National Center for Health Statistics survey analysed hospital preparedness. These clearly show the global awareness about prompt and efficient emergency medical services and need for preparedness, while Indian studies are limited.
Outside select practice models the current status of emergency medicine in India is not promising. The Medical Council of India is the apex body for medical degree registration, teaching institution accreditation and medical practice licensing at graduate, post-graduate and post-doctoral levels. Until date, there are 398 medical teaching institutions in India with more than 20,000 total post-graduate diploma/degree courses training seats per year. Among this only a meagre of 48 training seats per year (0.24% of total) in 24 institutions (6.03% of total), exist for emergency medicine post-graduate training.
Our study is a unique effort to stimulate anaesthesiologists to take up the challenge, provide them basic information on setting up an EMD and plan for disaster preparedness in hospitals. The study attains further relevance in the context that mass gatherings are an unpredictable and unsteady situation, with any restive incident resulting in MCIs amounting to disaster. Our study hospital is situated in an area, which witnesses the gathering of hundred thousands of spectators annually for religious reasons. The limitations of our study are descriptive methodology and non-uniformity of inpatient bed strength of hospitals studied. The data in our study were collected from the study hospital and practice models over a period of 6 months. Confounding effects of changes in the infrastructure of these hospitals during the study period cannot be excluded.
| Conclusion|| |
Establishment of an EMD apt for our population, for their needs and work culture, is a challenging task, especially, with scanty literature, regarding its staff pattern and functioning. The task becomes more demanding; when one intend to propose a model applicable to a varied geography, population, economy and attitude. We have attempted to provide basic data and rough plan towards this direction so that anyone, mostly anaesthesiologist entrusted on setting up a unit of an EMD will not just have to imbibe data from the Western world, or end-up by modifying the casualty. Further studies in this field shall incorporate more number of hospitals, employ validated questionnaire thereby providing a more lucid picture of EMD and disaster preparedness of the hospitals involved.
IRB Government Medical College, Thrissur. Dr. VP Chandrasekhar, Dr. Suresh David, Dr. Mahesh Joshi, Dr. AB Saji and Dr. KK Mubarak for providing data from the hospitals studied.
Financial support and sponsorship
State Board of Medical Research, Kerala, India and Institutional Review Board, Medical College, Thrissur, Kerala, India.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]