Emergency Center: “The time until the doctor sees the patient is used efficiently”

After an accident or in case of an acute illness fast help is needed. Ambulance vehicles, the flying ambulance and the walking patients – they all seek help at the accident and emergency department of a hospital. But how can you achieve to care for a number of critical patients simultaneously in an optimal way? 10/01/2011

What kind of help does the patient
need? The initial assessment provides
an overview; © beta-web

MEDICA.de spoke with Doctor Ingo Gräff, Medical Coordinator of the Emergency Centre of the University Hospital of Bonn.

MEDICA.de: What is so unique about a multidisciplinary emergency center?

Ingo Gräff: To answer this question, you first need to take a look back to the past and the development of the hospital landscape in terms of emergency care within a hospital. At first, it’s not about what emergency physicians and emergency rescue services achieve, but rather the care that’s provided at the hospital. In the past, the individual specialty departments at the University Hospital Bonn each had their own emergency unit. They were spread out all over the University Hospital.

For example, if a patient with non-specific symptoms – for instance abdominal pain – arrived at the hospital, she was perhaps at first presented to the surgical emergency unit. From there it was on to the internist and then perhaps on to the gynecologist. That’s why we deliberated that it would make more sense to centralize emergency care under one roof. This meant optimizing processes and thus emergency care and subsuming multiple special disciplines, so they all can take care of the patient directly and in a multidisciplinary way. And we managed to accomplish this. On 1500 square meters, physicians from now 14 disciplines attend to patients at the Bonn Emergency Center.

MEDICA.de: What kinds of processes are set in motion when a patient enters the emergency care unit or is admitted, respectively?

Gräff: Let’s take a patient that walked in. He arrives at the emergency care center and tells us he has a problem. He promptly meets a trained nurse, who immediately attends to the patient. Now a process sequence as defined by the Primary Nursing Concept takes place, by this we mean three steps concentrated in one place. First of all, of course there is the administration, meaning recording the patient’s name, date of birth etc. This needs to be done, so you can safely work with the patient, because when the nurse later draws blood for instance, the laboratory values must also be allocated to this particular patient. Next a triage rating is given. We use an initial assessment protocol that’s supported by data processing and that’s integrated in our hospital system. One component in the protocol is the triage rating according to the so-called Manchester Triage System.

After the initial assessment, this system assigns a triage rating. All in all there are five steps, from “The doctor needs to come here immediately” to “It’s not urgent“. And finally the third step is the department allocation. Here the nurse follows so-called standard operating procedures, in short SOP. That is to say, after the first three steps she will continue by taking laboratory values. For instance a urinalysis or an ECG is performed. The time until the doctor finally arrives and sees the patient is used efficiently. This was different in the past. The patient stood in line at the admission, was seated in the waiting room and asked to come into the surgery at one point, where the doctor took a look at him and then ordered the different laboratory values. The patient needed to wait some more until those were completed and the nurses would only call the doctor again when the laboratory results were in. Then the patient was brought into surgery again to consult with the physician. That’s how it was in the past. Thanks to today’s structures, the flow is much more efficient. By introducing the triage rating and reorganizing the process sequence, we managed to significantly reduce the process times themselves – from the moment the patient arrives until his first contact with the physician.

MEDICA.de: How do you ensure short times between the individual treatment steps?

Gräff: Of course this can not be accomplished just by having improved hardware. Obviously during the second step you need to navigate and optimize processes in a way to where the hardware can work properly. This means you first have to consider how you can actually filter out the “urgent patient”. I have mentioned it already – just creating new premises and then have the patients stand in line and still treat them one by one makes no sense. You need to be able to quickly identify the critically ill patient. We have solved this issue by collaborating with our process management. Over the course of three months, in collaboration we then developed the computer-supported initial assessment.

MEDICA.de: So this system is only used by you?

Gräff: In terms of how the data processing system is integrated into our hospital information system, it is only used by us in this way. Although by now there are also other hospitals that conduct triage ratings for patients – thanks to the integration into our in-house hospital information system we continue to have a pioneering role.

MEDICA.de: Is the system suitable for adults as well as children? Or do you differentiate between the two?

Gräff: The initial assessment protocol is also suited for children. However, we are not a pediatric multidisciplinary emergency center, but primarily in charge of adults. Exceptions are certainly severely injured, traumatized children after traffic accidents. They are also being treated in our emergency center. But other illnesses like diarrhea for instance or febrile convulsions are passed on to our pediatric clinic.

MEDICA.de: How important are associates for an optimal implementation of these new structures?

Gräff: Very important! The emergency center is very care-oriented. That’s why for instance in each shift we have a coordinating nurse as well as a team that also implements the new processes, like for example the initial assessment. Of course as a medical coordinator I depend on this. Nothing gets done without the support and commitment of the nursing team and especially the nursing supervisor. You can only establish new structures, if synergies between the coordinator and the nursing supervisor are being created, and are used by both sides.
MEDICA.de: How many people are working in your team?
Gräff: We have a total of 21.5 full-time positions for about 25,000 patients per year. Plus 8,000 elective patients.

MEDICA.de: How many physicians work in the emergency center?

Gräff: During the day we have a fixed physician staff in the core fields like for instance internal medicine, trauma surgery and general surgery. Physicians from these areas are always present. From other areas like for example ENT medicine or oral and maxillofacial surgery, physicians are on call to come to us. That is to say, those physicians support us as needed.

MEDICA.de: You also take in emergency patients via rescue helicopter. What special challenges does a physician team on a rescue helicopter face? Are there big differences compared to “regular” ambulance vehicles?

Gräff: The team needs to be experienced in terms of helicopter specifics and flying ambulances, respectively. After all, you have to deal with different altitude ratios and other physiological exposure to the body while you are in a helicopter. This doesn’t necessarily have a negative impact on the patient, but might also have a positive effect. For example, patients who injured their spine should be transported as gently as possible. That’s possible in a helicopter. On the other hand, you have less space in a helicopter. That’s why you need to work very proactively, if you transport a patient in the air. Unlike in road traffic, you cannot just stop on the side of the road and stabilize your patient when you are up in the air.

For this reason, air rescue is really in its own category. This also pertains to working in a team, because air rescue does not just deal with mere patient care. There are air rescue specific circumstances that need to be considered, like for instance cooperation with the pilot or current weather conditions. There are some clear differences between emergency care on the ground and in the air.

MEDICA.de: Every day you are confronted with people who are in very difficult, sometimes life-threatening health situations. How do you cope with such a daily routine?

Gräff: Quite quickly we came to realize that through acceptance, especially by the emergency rescue service and also the population, we were confronted with increasing patient numbers. And indeed as a University hospital that provides maximum care, we experience many severely injured patients and their fate. This has led us to form a task force and crisis intervention team at the University Hospital Bonn. This team will swing into action at the beginning of January/February 2011, so we will have some type of call center in the future, where we can get fast professional help to the emergency center during a crisis intervention. This is how we handle it as a team.

The interview was conducted by Simone Ernst and translated by Elena O’Meara
MEDICA.de