1 Introduction to emergency care

Emma Tippins and Cliff Evans

Emergency care

Emergency Care is politically and socially one of the highest priorities insociety today. Increasing patient expectations and the advancement inscientific and medical knowledge have had a dramatic effect on the provisionof emergency care. The Department of Health’s (DoH) White Paper on Reform-ing Emergency Care (2001) stipulates that emergency care provision shouldaddress the demands and needs of patients, regardless of setting. A solidfoundational knowledge in the skills of triage and assessment are, therefore,essential precursors to all emergency practitioners in order to enable patientsto be treated quickly, appropriately and effectively, i.e., right skill, right time,right place. The different, diverse and unique needs of patients provide aconstant challenge to emergency practitioners.

The Emergency Department (ED) is the portal for over 16.5 million annualvisits in England (Alberti 2004). In the United States of America (USA) thereare over 100 million annual visits, accounting for 40 per cent of hospitaladmissions (McCaig and Burt 1999). These millions of patients will attendwith any number of clinical presentations and complaints requiring theassistance of every medical speciality. The role of the emergency practitioner isunique in this respect, as in no other clinical setting will clinicians be calledupon to assess and identify the needs of such a wide range of potential patientconditions.

The ED is commonly the interface between patients and emergencycare, within this setting a patient’s first contact with a healthcare professionalwill usually be at the point of initial assessment; the process of triage. Triageis a dynamic decision-making process that will prioritize an individual’sneed for treatment on their presenting history, the nature of the incident, andthe presenting clinical complaint. An efficient triage system aims to identifyand expedite time-critical treatment for patients with life-threatening con-ditions, and ensure every patient requiring emergency treatment is prioritized

according to their clinical need. The ethos of triage systems relates to theability of a professional to detect critical illness, which has to be balancedwith resource implications of ‘over-triage’ (a triage category of higher acuity isallocated). A decision that underestimates a person’s level of clinical urgencymay delay time-critical interventions; furthermore, prolonged triage processesmay contribute to adverse patient outcomes (Geraci and Geraci 1994; Travers1999), and impede the assessment of others.

In this context, the practitioner’s ability to take an accurate patienthistory, conduct a brief physical assessment, and rapidly determine clinicalurgency are crucial to the provision of safe and efficient emergency care(Travers 1999). These responsibilities require practitioners undertaking triageto justify their clinical decisions with evidence from clinical research, and tobe accountable for decisions they make within the clinical environment.

This book is directed at facilitating front-line practitioners and studentsaiming to specialize within emergency care, to gain the essential assessmentskills necessary for acute care environments, and to forge a solid foundation oftheoretical knowledge and understanding upon which to base their clinicalpractice.

Applying theory to practice

In order to deliver expert individualized care, emergency care providersneed to make multiple decisions rapidly, in highly complex environmentsand under increasing pressure. Emergency care is a dynamic specialism verydifferent from many other areas of care provision, yet the skills associatedwith emergency care can be applied to all acute areas. Patients often presentcritically ill and frequently highly unstable, as a result, their rapidly changingconditions demand intelligent and decisive decision-making from practi-tioners in short time frames. Despite this, there remains minimal research onthe clinical decision-making skills of emergency care providers. Consequentlymuch of the content and structure of the decision-making process remainsunclear (Fonteyn and Ritter 2000).

Clinical decision-making can be defined as the process practitioners useto gather patient information, evaluate that information and make a judge-ment that results in the provision of patient care (Andersson et al. 2006). Thisprocess involves collecting information through the use of both scientific andintuitive assessment skills. This information is then interpreted through theuse of knowledge and past experiences (Cioffi 2000; Tippins 2005).

Recent research indicates that many practitioners have a solid foundationof theoretical knowledge but often fail to apply this knowledge directly topatient care (Tippins 2005). The Resuscitation Council, European and UK,have acknowledged this phenomenon based on several research studies identi-

2 THE FOUNDATIONS OF EMERGENCY CARE

fying that up to two-thirds of in-hospital cardiac arrests are potentially avoid-able (Franklin and Matthew 1994; Hodgetts et al. 2002). Seeking to addressthese issues, the DoH set national guidelines, stating that all healthcareproviders should receive competency-based high dependency training (DoH2000). Universities introduced higher educational modules attempting tofacilitate experienced and novice post-registration practitioners into gainingthese fundamental skills associated with the process of initial and ongoingpatient assessment. This essential ability to recognize both patients at riskof critical illness and sudden physical deterioration, and those actuallyexperiencing critical illness is now an indispensable component of moduleswhich all pre-registration nurses have to pass in order to register in the UK(NMC 2004).

The recently revised Resuscitation Guidelines (RCUK) 2006) directlyaddress the DoH’s objectives by focusing on the recognition and treatmentof the critically ill patient in order to prevent cardiac arrest. This focus onpreventative education has seen the development of locally delivered coursessuch as the Acute Life Threatening Events: Recognition and Treatment(ALERT) course, and the development of early warning scores (EWS). Withinthe UK EWS are now commonly used to identify patients at risk of clinicaldeterioration. The use of an EWS ensures a structured approach to patientassessment and the regular recording of physiological observations, a crucialfirst step in recognizing patients at risk. Physical parameters are used to iden-tify patients who are deteriorating, or are at risk of doing so. The scoringsystem alerts the carer to the potential for serious illness and initiates a call forsenior assistance.

Regardless of the individual setting, practitioners encountering acutely illpatients need to be able to identify those at risk of serious illness, act on thesefindings and evaluate their chosen treatment route. Although these key skillsmay be used in other clinical settings, they are essential to emergency careprovision and are seen as an integral part of an acute practitioner’s scope ofclinical practice.

Emergency care management is a complex and dynamic specialism.The role of the emergency practitioner comprises numerous fundamentalclinical skills. Practitioners, regardless of their discipline, need the ability torelate these skills, including a foundational knowledge of the physical changessynonymous with serious illness, to the patient assessment process. Thiscan be achieved by applying the key skills of critical thinking and analysis toeveryday clinical decision-making.

The argument surrounding the clinical application of theoretical know-ledge has continued throughout nursing and healthcare education. The NHSPlan (DoH 2000) identified the NHS as deficient in national evidence-basedstandards and, therefore, much of the practice subjective to individual inter-pretation. This initiated the current protocol-driven approach to care which

INTRODUCTION TO EMERGENCY CARE 3

aims to provide practitioners, and subsequently patients, with evidence-based objective treatment regimens, in contrast to individual subjectivepreferences. A prime example is demonstrated by the advanced life supportalgorithms, which have revolutionized multi-disciplinary care delivery.

Changing practice within the vast institution of healthcare is a monu-mental task and to this end clinical governance was established. The clinicalgovernance initiative is conveyed into clinical practice by the NationalInstitute of Health and Clinical Excellence (NICE). NICE, in conjunction withseveral specialist professional institutions, have released numerous nationalguidelines on specific patient presentations or illnesses. These are also sup-plemented by the DoH’s National Service Frameworks (NSF), which set clinicalstandards in relation to specific disorders and specialist organizations such asthe British Thoracic Society, which promote ‘best-practice’. These initiativeshave combined to produce a constantly progressive clinical arena in whichnovice practitioners and students can easily become lost.

There is, therefore, a clear need to apply a tool or structure to thediagnostic process directly aimed at facilitating practitioners with the abilityto base their clinical findings on objective rather than subjective data. Thisfacilitation centres on two components: first, a solid understanding of thesigns and symptoms associated with physical illness, and second, the applica-tion of critical thinking to their practice. The first component is demonstratedthroughout this book by experienced practitioners who discuss their ownexperiences in the form of patient scenarios which highlight both commonclinical encounters and the frameworks and protocols they use to prioritize,and manage, patients quickly, appropriately and effectively. In addition, theclinicians discuss the associated anatomy and physiology providing the readerwith several key words or triggers. This enquiry-based learning approach pro-motes lifelong learning by encouraging the reader to seek key texts listedat the end of each chapter, thereby gaining further knowledge and under-standing of the topics.

The framework used throughout this book is based on a modification ofAlfaro-LeFevre’s (2004) approach to critical thinking, the DEAD framework.Novice practitioners frequently require an unambiguous approach to patientassessment, which can be achieved by applying the DEAD acronym. Thisframework not only aids practitioners in critically analysing their caredelivery, it also directly provides a safety net by leading the practitioner toquestion other possibilities regarding the patient presentation, and this com-ponent is paramount to those working in acute care settings as a missed diag-nosis can be fatal. This structured approach is applied to everyday clinicalpresentations via the use of clinical scenarios. The scenarios demonstrateclassic emergency care presentations and focus on the practitioner applyingtheir theoretical understanding of both anatomy and physiology to determinean individual’s clinical status. The practitioner’s assessment plan broadens to

4 THE FOUNDATIONS OF EMERGENCY CARE

encompass a holistic approach by adopting the critical thinking approachthat guides the practitioner through four categories, which results in a safeand effective method of identifying critical illness through an eliminationof serious pathology. The practitioner will increase their understanding ofrelevant emergency skills and knowledge by directly seeing the applicationof theoretical knowledge within clinical practice. The enhancing criticalthinking approach encourages the reader to seek further understanding ofrelevant theory, this follows the Nursing and Midwifery Council guidelineson lifelong learning and the ability of the practitioner to be fit for practice(NMC 2004).

This approach is outlined in Box 1.1.

By utilizing this structured framework, those less experienced in criticalthinking will have a clear systematic outline to assist them in the organizationof their thought processes and subsequent clinical practice. This, in turn,could facilitate the individual development of critical thinking and decision-making-skills.

The focal point of this book is to facilitate practitioners to acquire theessential skills of patient assessment and priority assignment, as these com-prehensive skills have been highlighted as being paramount to emergency careproviders (DoH 2005).

Box 1.1 The DEAD mnemonic outlined

D Data (scientific facts) – these should be based on the facts the practitionerholds and any other data that can be collected to validate or negate them.

E Emotions (intuition or gut feelings/reactions) – what are your instincts tellingyou?; how can you consolidate or negate these?

A Advantages – advantages to others that would result from actions theclinician takes, i.e., would an action instigated at the initial assessmentimprove the patient’s prognosis, an example being the dispensing of ananti-platelet drug to a patient experiencing an acute coronary syndrome?The practitioner should also consider that a test requested when the patientpresents might hasten their visit and result in an increasingly efficientservice.

D Disadvantages (differential diagnoses) – what could go wrong, in the worstcase scenario what could this be?; how I can rule this out?

INTRODUCTION TO EMERGENCY CARE 5