Tuesday, 6 January 2015

Accomplishing Core Measures in Crowded Emergency Departments: A Race Against Time !


From the Desk of
Sagar Galwankar, MD

As I walked into my shift I saw the busy waiting area of my emergency department and remembered my days as a medical student when patients waited for the one single doctor who did triage based on observing the patient and calling the speciality he felt was appropriate to examine the patient. 

Today things have changed and EM has come a long way. 

Around the world there are evidence based algorithms for traige and standardized protocols for acute care. 

The Monitoring of the overall care of patients is done by  looking at indicators called as "Core Measures". These are actions which are mandatory and are benchmarks of efficient patient care in emergency departments.

Individual Emergency Departments do emphasize on many actions and indicators and monitor many benchmarks as they strictly evaluate the quality of care. 

Pain is an Important part of the symptom presentations in the emergency department. Pain anywhere is Still PAIN. It can be Headache/Chest Pain/Abdominal Pain/Back Pain or pain in extremities or GU area. Fever / Bleeding / Rash / Loss of Function (LOF) are some common presentations in the Emergency Departments.

Pain/ Fever / Rash / Bleeding and LOF are what I call the Major5 of EM Care. Treating the Major5 is the Fundamental of these core measures.

Getting Complete Set of Vitals : T/P/R/BP/Pox is the first step in this regard.  Additional data on GCS / Pain Score and Bedside Sugar will be the next few steps to be accomplished.

In the past few years Traige EKG has gained immense importance. Two sets of 12 Lead EKG in traige with one done at traige and one of recent past pulled from the records is printed and it
is expected that the Emergency Physician reads the same in 5 minutes and comments on it. If its ACS/MI or unstable Arrythmia the patient is brought to the emergency bed immidiately.

Diziness/ Uneasiness/ Weakness/ Syncope/ Chest Pain/ Abdominal Pain/ Back pain/ Shortness of Breath/ Palpitations can all be signs of a Cardiac Event and in Busy Emergency Departments missing ACS/MI can be avoided by this measure.

Administering Pain Medications and Anti-Pyretic Medications is paramount core measure in ED's Around the world.

Giving Aspirin in Chest Pain with Nitro is another crucial core measure.

If Patient has a Fever with Signs of Sepsis namely Tachycardia / Hypotension/ SOB/ Fever etc then Giving Antipyretics IV Lines Fluids and First dose antibiotics are important components of the sepsis core measures.

Bleeding patients (Orifices or from skin) need immediate control of bleeding, vitals check, Airway-Breathing-Circulation Check and IV Lines and Fluids administered.

Patients with Stroke need CT done Stat and then TPA administered if the findings and presentation meets the Stroke Algorithm.

Door to Triage, Door to Physician, Bed to Physician, Door to Ballon and Door to TPA times are extremly important as Emergency Care evolves further pushing towards levels of maximal efficiency.

As I sit and pen my thoughts I realize how Dynamic and Complex has Emergency Care Become. 

Developed Nations are at the forefront of monitoring newer and increasing number of indicators and inserting a longer list of core measures. Nations where EM is developing are yet struggling to establish Emergency Medicine. 

Getting the nations in transition and thier Emergency Departments to the level of monitoring these complex indicators is a task for the future, which I hope is not far.

Core Measure are Monitors for Quality and Efficiency and they are important as they give the physicians and the whole Emergency Health System a direction focussed on  progress towards better efficiency and patient safety.

What ever we do OR Whatever we should do , Must always be focussed on the best cinical care for our patients.
It is these Patients in ours ED who define our mere existence &  without them there is no Emergency Medicine !

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