Emergency medicine (perhaps more so than any other medical or surgical specialty) is not a silo unto itself. The practice of Emergency medicine is inherently multidisciplinary and interdependent upon multiple pre-hospital, in-hospital, and health system-wide structures and processes. Emergency physicians work closely with their nursing and paramedic colleagues in the service of patient care in the emergency department. Emergency physicians are involved in primary, secondary and tertiary prevention strategies, compliment the role of primary care physicians, and collaborate with other specialists and sub-specialists in the continuum of care and return to health. Emergency physicians also contribute to patient care at the population/public policy level through their leadership and design of trauma systems, regional poison control centres, disaster/mass casualty planning and other integrated networks of emergency (cardiac, stroke, sepsis, neonatal, air medical transport, etc, etc) care.
Practically, the type of patient presentations that are considered to be ideally treated in an emergency department run the spectrum from Canadian Triage and Acuity Scale (CTAS) level 1 – the most acute, to CTAS 5; from major trauma (e.g. motor vehicle crash or gunshot wound), to a small child with fever and lethargy (rule out meningitis or other serious infection), to a laceration of the hand (rule out neurovascular or tendon injury). When considered in this way there are important implications that follow with regards to educating physicians, improving inter-disciplinary teamwork, and optimizing system design to improve patient and population outcomes.
Emergency Medicine
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Unforeseen
Unscheduled
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Predictable Scheduable
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CTAS 1, 2
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Critical Care of the acutely ill and injured
- Does include exacerbations of chronic problems
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CTAS 3
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Critical Decision making in undifferentiated/unscheduled health events
- Vast majority of fixed costs of ED are to meet population burden of acute illness and injury (ie unscheduled CTAS 1,2,3 patients) <4>
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Potentially "avoidable" ED visits: (ED as safety net)
- frail elderly with no acute event or health problem
- partial diagnosis requiring further work up
- chronic condition requiring monitoring and/or has predictable clinical course
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CTAS 4, 5
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Appropriate ED visits
- DO NOT cause ED overcrowding<2,3>
- Very low marginal cost to treat in ED<4,5>
- Majority of successful lawsuits in EM
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Potentially "inappropriate" ED visits: (ED as gate keeper)
- Relatively low proportion of pts in urban centres and often from vulnerable or transient pt populations
- Higher proportion of visits in rural centres (occ due to difficult access to primary care).
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To improve patient outcomes for the acutely ill and injured, timely access to high quality and well trained Emergency Physicians and their colleagues in nursing and paramedicine is essential. While system design and staffing models of care should focus on the unscheduled CTAS 1,2,3 patient population, managing unscheduled CTAS 4,5s in the ED improves quality, is cost effective, and does not contribute to ED access block. Preventing ED visits from the complex (frail elderly, chronic dx, no acute medical event), but potentially schedulable patient cohort, would significantly improve ED flow and overall patient care in the ED.
- ACEP definition of Emergency Medicine: http://www.acep.org/content.aspx?id=29164
- MYTH: Emergency room overcrowding is caused by non-urgent cases - October 2009 Canadian Health Research Foundation Myth Buster of the year series
- The Effect of Low-Complexity Patients on Emergency Department Waiting Times Schull MJ, Kiss A, Szalai JP. Ann Emerg Med. 2007 Mar;49(3):257-64, 264.e1. Acad Emerg
- The Costs of Visits to Emergency Departments, Robert M Williams , M.D., .PhD (N Engl J Med 1996;334:642-6.)
- Emergency Medical Care: 3 Myths Debunked, Huffington Post. Leigh Vinocur, M.D. Director of Strategic Initiatives at the University of Maryland School Medicine.