28 January 2009 Dr. Clinton King

1. 28 January 2009 Dr. Clinton King

2. Defining a minor case •  Defining a ‘minor case’ may not be as easy as it seems. • Different criteria could be used. • Those classified as ‘Green’ by triage score. • Those not needing specialist attention. • Those for a quick fix and discharge .

3. Planning the treatment of minor cases Are there other facilities in the health care system that are accessible to clients with minor complaints? Primary Health Care facilities the hours that they are open Out Patient Clinic capacity/ booking/ waiting times Staff resources, quantity and quality Infra-structure Quantifying number of patients seen in total, number of minor cases.

4. SCENARIO: • Level Two/ Regional Hospital Emergency Department in Public Sector. • Few 24hr Primary Health Care Facilities accessible to population served. • Approximately 110 patient visits a day. 20% classified as ‘Green’, 44% Yellow by SATS. • Total 50% admission rate. • Training site for Emergency Medicine Registrars.

5. FIRST COME, FIRST SERVE: This option is contrary to principles of Emergency Medicine and Health Care Planning. Public may not always understand this. Why must the patients with severe backache wait 6hrs when the stabbed gangster gets seen immediately? NOT AN OPTION. They need to be sorted and triaged. Public need to be educated, but not by politicians who promise instant attention in election years.

6. SORTING and TRIAGE: • Broadly defined, ‘sorted’ patients are not formally seen in the ED. • They are being screened pre-triage to assess if they are at the correct facility. • Patients may self present with minor complaints. • ED staff may be alerted to these patients by reception staff or triage staff. • Patients are NOT to be turned away, they need to be RE-ROUTED.

7. SORTING: • This needs to be done with great care and usually by a clinician who has the experience to ‘ eye-ball’ and listen to the patient and be confident that they will not collapse on route or be referred back from primary facility. • They also need to be familiar with systems and resources available to the patient.

8. SORTING: • Best done by giving the patient a covering letter to a specific facility. • These resources for minor cases may vary after-hours. Public needs to be made aware what appropriate facilities are available to them by public information campaigns. • If any doubt by the ‘sorter’, patient is to be formally admitted to system and triaged.

9. TRIAGE: • Triage of patients is trying to determine how quickly the patient needs to be seen and not how sick the patient is.

10. TRIAGE: Using a system like SATS patients are initially screened with the goal of defining those patients who require the most urgent attention for the best outcome, bearing in mind resource limitations. Uses physiological parameters, eg. RR, SBP, AVPU and secondary screening. Additional criteria, eg. psychotic, seizures, hypoglycaemia. Discretion of experienced clinician. Individualized assessment crucial.

11. Example: an Elderly man who has a small cut on his thumb, needing some stitches, lives across the road from the hospital and who constantly has to have in his company his demented wife, will be classified as minor/ green but may need to be prioritized. Clearly if resources are limited this may not be possible; staff can’t be pulled from a resuscitation to attend to a cut thumb. An option is to organize the resources and after triage consider streaming patients.

12. Streaming: This is a system of allocating some of the available resources specifically to different categories of triaged patients. This is the same as the supermarket ‘Ten- items- or- less’/ ‘Baskets only’ queue. The reasoning is the same. To decongest the shop/ ED, to improve efficiency of shop/ED, to use the skills of staff appropriately, to offer a better service/ outcome to clients. The same aims apply to Major Incident/ Mass Casualty (Disaster) triage procedures.

13. Advantages of streaming: • Minor cases are not exposed to the often invasive procedures and unpleasantries involved in managing a more critical patient and if required specific resources are available for specific conditions in specified areas with patient care being optimized. • For example patients streamed to resuscitation area, plaster-room, cardiac monitors, child friendly or an isolation area for infectious conditions. • In the above scenario infrastructure limitations may limit these options.

14. Streaming away from ED: This is only feasible if infrastructure and staffing allows. An example would be re-routing to a general out-patients possibly staffed by Family Physicians. The advantages are that the ED is decongested and those with skills in caring for the critically ill are properly utilized. The disadvantages are that this service would probably not be a 24/7 service and a dual service structure would have to be catered for in ED. Is there enough demand to warrant a separate service area/ staff? In the above scenario +/- 20 pts a day, probably not

15. Disadvantages of re- triaging: Another disadvantage is that the re-triaging may not be done as efficiently, patients may deteriorate if not triaged with forsight. The conflicting domains of Family Medicine and Emergency Medicine are not as simple as those caring for the non-urgent and urgent cases. Ought the Emergency practitioner not be skilled in removing thorns and diagnosing ‘rashes’ and the art of interacting with patients in distress, (even minor cases are distressed with their condition) and not only with focusing on a life-threatening pathology? This training and exposure would be denied them if minor cases were removed from the ED. 

16. Streaming within the ED: After triaging specific staff are allocated to cater for minor cases, this can be done on a rotational basis. Designated areas for major and minor cases would be ideal but not always feasible. The advantages are that the department is to some degree decongested by the fast-tracking of patients who would otherwise have had to wait until the last more ‘serious’ case had been seen

17. Streaming goals: • Decongestion • Efficiency • Better service and • Better outcome.

18. Outcomes of streaming goals: Using this system it means that Emergency Medicine trainees get exposure to minor complaints and it is accepted that these cases make up part of their patient profile. The disadvantages are that the ‘middle-classes’, may receive delayed treatment. The ‘yellow’ patients suffer long delays. ( 50% admission rate means there are many unwell cases in the unit and also space is occupied in ED by those awaiting admission) This especially in resource limited environments. To obviate this dynamic streaming and constant review is essential.

19. Dynamic streaming within ED • An Emergency Department is a dynamic environment and a potentially chaotic one. • This system is reliant on experienced and present, (shop-floor) clinical staff within a system

20. System of dealing with minor and major cases alike: In the scenarios mentioned before this would be the most appropriate system: • It would entail acknowledging that there is a place for minor cases in an ED of this nature. • Sorting and triage systems in place initially. • Staff assigned to minor/ green patients. Fast-tracking when feasible. • Presence of experienced clinical staff (Nursing and Doctors/ Team) to monitor patient flow and load in the ED.

21. Unit rounds frequently. Awareness of priorities. • Review/ re-triaging of waiting patients (out of sight) folders frequently by senior. • Dynamic assessment of patients and re-allocation of resources. • Communicating with waiting patients and relatives. • Adaptability and co-ordination of skills present in unit.

22. Conclusion: In the ideal world there would be no need for management as needs and demands would equal supply and satisfaction. But sadly paradise is lost and managers are required.

23. The managers of EDs where diverse pathologies present and have to be prioritized need both knowledge and wisdom. Wisdom being a difficult thing to teach.