Posted by: Tony Shannon | April 27, 2012

Emergency Medicine: typical challenges at the frontline..

Emergency Medicine: typical challenges at the frontline..

(This post is adapted from an earlier article here
and is being posted in parallel on the Emergency Physicians International social network)

In the lead up to ICEM 2012 in June in Dublin, we began this series by looking at Emergency Departments as Complex Systems at the Edge of Chaos.

As most of us are well aware that that healthcare (and thereby Emergency Medicine) is under pressure across the world to change,  let us now look at a typical scenario  at the frontline, to identify some common challenges in the complexity of  Emergency Medicine and the “change challenge” ahead of us.. ..

Let us begin with a look at a single patient journey, a common case of a patient who has an acute episode of abdominal pain for instance…..

If the patients problem begins at home, they can (at least in some healthcare systems such as the NHS in England)  telephone a healthcare advice line and undergo a form of telephone assessment and get related advice…. e.g. please self-care/ go to your doctor/ go to the Emergency Dept/ an ambulance may be called.

If an ambulance is asked to attend, the paramedic will likely also perform another assessment, begin some preliminary investigations, commence some treatment before usually escorting the patient to the Emergency Department (ED).

At the Emergency Department the paramedic may hand over care of this patient to reception or nursing staff who will take over the care of the patient. Here they are usually seen by an ED nurse to reassess the patients condition, take a brief story from the patient and some vital signs (e.g. heart rate, blood pressure) , perhaps some more questions about the nature of their abdominal pain and then make a judgement their “acuity” (to triage), and assign them to a care “stream”.

Now  the doctor will review the patient and usually begin with what we call “history taking” ….this is a process that involves getting details on the patients most recent story (often a narrative of the patients problem) and more structured detail on past medical history, their medications, allergies, smoking, alcohol status etc.  Now while it is quite common for much of that information to be recorded somewhere else, the information required is often scattered around the rest of the healthcare system.
Without access to a shared patient-centred electronic health record, the Emergency Physician is often unable to get access and so reverts to safety first principles and reassesses the patient from scratch. (While there is absolutely merit in reassessing the patients condition at regular intervals along the patient journey, some of this is being done to cover for inefficiencies in the current system and highlights real room for improvement.)

After history taking, medical school teaches doctors to examine the patient and document related findings. There is a common structure to the approach required for this and this should be reflected in the patients notes..

Investigations are often performed and the results of previous investigations may also be needed at this point. Ordering tests and getting the reports of results is another extremely common healthcare process, one that is also information intensive and again an area ripe with room for improvement.

A “differential” diagnosis or problem list may now be in mind at this time after reviewing the “history” and examination. (e.g. is this appendicitis? a urinary tract infection? constipation? inflammatory bowel disease?)
This may be drawn from the doctors memory and innate knowledge base, or they may need to go to the books/online to check up on their knowledge.
There is an acknowledged gap in the “bench to bedside” cycle of medical discovery and its implementation in clinical practice, which can mean a gap of years changing “what we know to what we practice”
This is another point where information and knowledge management is critical in helping with the decision making process and thereby patient care. Their is no doubt much room for improvement in the current approach to this, with many doctors currently relying on their tacit knowledge base at the frontline which, while mostly effective, is subject to human error.

Once the differential diagnosis or problem list is drawn up, then a related treatment plan should be formulated, and treatments in the form of procedures and/or prescriptions for medications may be required.

The medical notes that are made to document the patients journey are collated during the patient clinician encounter. These are critical in several aspects- aiding the decision making process, helping to share information with the next person involved in the care of this patient (e.g. inpatient team), as a medico legal record (increasingly important) and as a record of care that can form part of a wider audit of clinical practice (as per the clinical audit/and or research process).

The patient may then be admitted to an inpatient team or discharged to a clinic or to the care of that patients General Practitioner and so the cycle of care continues….

Of note, in looking at this single patient encounter, it should be evident that the majority of the patient provider care processes in Emergency Medicine are very information intensive
Naturally any inefficiencies in the physician patient encounter of history-taking , examination, investigations, results, treatments are often replicated during successive encounters the patient will have with the healthcare system.
You can see that the current approach builds in much repetition as a safety measure though there remains considerable room for reducing both wastage and risk.

If we in Emergency Medicine are to be involved in a more patient-centred, cross- organisational approach to healthcare delivery/care pathways etc, you can see that changes needed in Emergency Medicine Information Systems will be vital to the future.

In the next article we will look at some common challenges at a Emergency Departmental level.


Further reading

This article is based on a series of related articles on healthcare improvement at;

PS. For those of you who already have /think you may have an early interest in EM Informatics, please consider joining the EM Informatics Chapter here at Emergency Physicians International).


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