Emergency Department (ER) Overview

1. Emergency Department (ER) Overview Nora Gharib and Nick Khanna

2. Outline • Introduction • Statistics • Emergency Room Medications • Common Cases in ER • Patient Cases • The role of a Pharmacist in the ER • Conclusion

3. The Emergency Room • A medical treatment facility specializing in acute care of patients who present without appointment • Department must be prepared to provide initial treatment for a wide array of illnesses and injuries (some of which may be life-threatening and require immediate attention) • Operates 24 hours a day (staff levels vary)

4. The Emergency Room • Separate section of the first floor of the hospital • Own dedicated entrance • Prioritization of cases based on clinical need – achieved through the application of triage.

5. Triage • First stage the patient encounters • Consists of a brief assessment, set of vital signs, and the assignment of a chief complaint • Usually completed by a nurse • Patients are initially assessed at triage and then passed to another area of the department or hospital, while their waiting time is determined by their clinical need.

6. Triage • Exceptions: minor ailments may be treated at the triage stage • Patients with evidently serious conditions can bypass triage and move straight to the appropriate department

7. Resuscitation area • The area where the most seriously ill or injured patients will be dealt with • Contains the equipment and staff required for dealing with immediately life threatening illnesses and injuries • Typical staffing includes at least one physician and one nurse • May also include hospital pharmacists

8. Acute Care • Patients who are seriously ill but not in immediate danger • Examples include chest pain, difficulty breathing, abdominal pain and neurological complaints • Advanced diagnostic testing completed here (lab tests, scans)

9. Minors Area • Patients with not immediately life threatening conditions will be sent here • Examples include fractures, dislocations and lacerations requiring suturing

10. Emergency Department Use in Canada • Results from the 2003 Canadian Community Health Survey • One in eight Canadians aged 15 or older reported that their most recent contact with a health professional occurred in a hospital emergency room (ER) • Rates of ER use were highest among teenagers and young adults • In Ontario, administrative records for the year 2000 showed that trauma represented the largest proportion of all ER visits • Men were slightly more likely than women to have used ER services: 14% versus 12%. • ER use is inversely associated with household income. • 18% of people in the lowest income group had received their most recent treatment in an ER, in the highest income group was 13%.

11. Emergency Department Use in Canada • Generally, ER use was similar in the provinces and territories.(exceptions were higher use in New Brunswick, Nova Scotia and Yukon) • Residents of rural areas were more likely than urban dwellers to have used an ER: 15% versus 13% • People who reported having a "regular doctor" were just as likely to report ER use as those who said they did not have a "regular" physician. • Those who had consulted a doctor more than five times in the past year were more likely to report use of an ER than were people who went to the doctor less frequently: 21% versus 12%. • Suggests that ER users are heavy users of other medical services, perhaps reflecting their need for ongoing care related to the health problem or injury that brought them to the ER.

12. Emergency Department Use in Canada • Of the 2.4 million people whose most recent hospital visit had been in an ER, just under three-quarters (73%) reported receiving excellent or good care. • Another 16% felt their care was fair; • 11%, poor. • Dissatisfaction with service may be related to over-crowding, waiting times or lack of understanding for the way hospitals prioritize treatment; however, such information is not available from the CCHS. • Statistically significant lower rates of dissatisfaction were reported by residents of Quebec and Yukon. In Ontario, 24% of residents reported dissatisfaction with ER services, much higher than the national rate.

13. Common Emergency Room Medications • Lidocaine • Epinephrine • Furosemide • Diazepam • Haloperidol • Succinylcholine • Atropine • Heparin

14. Common Emergency Room Medications • Lidocaine: • Can be used as a local anesthetic when injected subcutaneously (used for a nerve block). • Used as an antidysrhythmic drug when injected IV (used to treat cardiac dysrhythmias). • Anesthetic preparations come in 2 forms: with and without epinephrine. • Epinephrine • Used in emergencies to stimulate the heart or to dilate the bronchial tree. • Use is limited by cardiac side effects. • Can be mixed with lidocaine to prolong lidocaine’s effect and to control bleeding.

15. Common Emergency Room Medications • Furosemide • Can be given IV or PO, and acts as a diuretic, causing patient to produce more urine • Given to reduce the fluid overload in patients with CHF or hypertension. • Diazepam • Benzodiazepine used as a powerful sedative and as an anti- convulsant for patients with seizures. • Can be used for alcohol withdrawal, cocaine toxicity, and status epilepticus (i.e. uncontrolled seizures). Diazepam may produce respiratory depression.

16. Common Emergency Room Medications • Haloperidol (Haldol) • Antipsychotic with powerful sedative properties. • Used for patients who are acting in a psychotic manner. It • Should not be used to treat alcohol withdrawal or cocaine toxicity. In sufficient quantities it will render the patient unconscious. • Succinylcholine • Paralytic, resulting in total muscular paralysis. It will most often be used for “rapid-sequence-intubation” to make tracheal intubation easier and to allow the patient to be mechanically ventilated. It has no analgesic properities and paralyzed patients see, hear and feel everything - like a zombie! - thus it is never used without sedation.

17. Common Emergency Room Medications • Atropine • Used to induce the heart to beat faster (i.e. chronotropy), as an antidote for certain organophosphate poisonings, or sometimes used as a drug for severe asthma. • Heparin • Anticoagulant used to prevent blood from clotting. • Used in patients suspected of having a myocardial infarction and to prep the syringe for an arterial-blood-gas for the same reason.

18. Top 10 cases of ER visits (US data) • Stomach and abdominal pain, cramps, and spasms • Chest pain and related symptoms • Fever • Cough • Headache, pain in head • Back symptoms • Shortness of breath • Pain, site not referable to a specific body system • Vomiting • Symptoms referable to throat

19. Case Example 1 A 53 old male arrives to the arrives to the emergency department (ER) with a myocardial infarction (heart attack). The following steps to treat this patient are taken: • Triaged to the resuscitation area • There he seen by an ER physician and receive oxygen and monitored and have an early ECG • Nurse will provide him with Aspirin (if not contraindicated or not already administered by the ambulance team); morphine or diamorphine will be given for pain; sublingual (under the tongue) or buccal (between cheek and upper gum) nitroglycerin (unless contraindicated by the presence of other drugs) • Following the ECG which reveals an ST segment elevation or new left bundle branch block suggests complete blockage of one of the main coronary arteries • Patients require immediate reperfusion (re-opening) of the occluded vessel • Two ways to accomplish this: thrombolysis (clot-busting medication) or percutaneous transluminal coronary angioplasty (PTCA). Both of these are effective in reducing significantly the mortality of myocardial infarction PTCA as it is somewhat more effective than thrombolysis if it can be administered early and being more accepted by most hospitals. Patient may need to be transferred to a nearby facility with facilities for angioplasty

20. Case Example 2 • A 25 year old female comes into the ER department with acute exacerbations asthma. The following steps to treat this patient are taken: • She is assessed by triage nurse and treated with oxygen therapy, bronchodilators, steroids or theophylline • An urgent chest X-ray and arterial blood gases are ordered • ER Physician performs an overall assessment of patient from this information and makes a referral home or to the intensive care unit (ICU) if necessary

21. Roles of a Pharmacist in the ER • As part of the interdisciplinary ED care team, pharmacists can provide care to critically ill patients by: • gathering or reviewing medication histories and reconciling patients’ medications • continuously assessing for and managing adverse drug reactions • monitoring patient therapeutic responses (including laboratory values) • monitoring for patient allergies and drug interactions • providing drug information consultation to emergency physicians, emergency nurses, and other clinicians • providing consultation on patient-specific medication dosage and dosage adjustments

22. Roles of a Pharmacist in the ER • providing patient and caregiver education, including discharge counseling and follow-up • Future Pharmacist • offering vaccination screening, referral, and administration

23. Conclusion • Statistics • Emergency Room Medications • Common Cases in ER • Patient Cases • The role of a Pharmacist in the ER

24. To do….. • Please feel free to post any questions on the discussion board (See LEARN) • Complete the Online Quiz • Due March25th, 2013 • Prepare for case presentations for next week’s class

25. References • Carriere, Gisele. Use of hospital emergency rooms. Health Reports 16(1), 2004: 35-9. • Feldman, Henry. Common drugs used in the Emergency Room. 2001. Edited by Lewis Nelson, MD • Nawar, E.W., Niska, R.W., Xy, J. National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary. CDC Advance Data (386), 2007. • ElenbaasRM, Waeckerle JF, McNabney WK. The clinical pharmacist in emergency medicine. Am J Hosp Pharm. 1977; 34:843-6.

26. Thank you !