Emergency and Disaster Nursing:A Systematic Approach to Providing Care

The Challenges of ED Care

• 1/3 of hospital care begins in the emergency department

• The majority of ED patients require immediate care

• In 2003, 114 million visits to Emergency Rooms occurred

 • Since 1993, there has been a 14-percent decrease in

the number of Emergency Departments nationwide.

• In the 1990’s, hospitals lost 103,000 staffed inpatient medical/surgical beds and 7,800 ICU beds.

• In 2004, nearly 70 percent of urban hospitals went on diversion to ambulances citing lack of critical care beds.

American Hospital Association (2006). Prepared to care: The 24/7 standby role of America’s full service hospitals. Retrieved September 28, 2009 from http://www.aha.org/aha/research-and-trends/AHA-policy-research/PreparedToCareIndex.html

American College of Emergency Physicians (2004). Report from a roundtable discussion: Meeting the challenge of emergency department overcrowding/boarding. Retrieved September 28, 2009, from

http://www.acep.org/workarea/downloadasset.aspx?id=34350

5 ESI Level Triage• Level One: Resuscitation – patients require immediate

evaluation and management

• Level Two: Emergent – patients require evaluation within 15 minutes for potential threats to life or limb

• Level Three: Urgent – patients have conditions that cause significant discomfort and should be evaluated within 30-60 minutes

• Level Four: Less Urgent – patients do not require rapid intervention, but should be evaluated within 60 minutes

• Level Five: Non-urgent – patients may be seen in a delayed fashion and could be referred to other areas of the health care systemPrah Ruger, J., Lewis, L.M., & Richter, C.J. (2007). Identifying high-risk patients for triage and resource

allocation in the ED. AmericanJournal of Emergency Medicine. 25, 794-798.

Primary Survey

Airway

• Assessed while maintaining Cervical Spine

• Signs and symptoms of compromised airway

• Jaw Thrust Maneuver

Breathing• Causes

• Assessment

• Treatment

Circulation

• Central Pulse is Checked

• Color, Temperature, Moisture

• AMS and delayed capillary refill are the most significant signs of shock

• 2 large bore IV’s with NS or LR

Disabilities

• Level of Consciousness

• Glasgow Coma Scale

• Pupil Size

Secondary Survey

Secondary

Expose – remove all clothing (special consideration for forensics)

Full Set of Vital SignsFamily PresenceFive Interventions

Give Comfort

History and Head to Toe Assessment

Forensics Trauma victims

are often victims or perpetrators of crime

Work collaboratively with law enforcement

Maintain the chain of evidence

Diagnostic Tests• Blood type and cross• Blood alcohol level• Urine drug screen• Pregnancy test

• What others can you think of?

Diagnostic Tests cont.• X-Ray, CT, MRI

• Diagnostic Peritoneal Lavage (DPL)

• Abdominal Ultrasound -

Focused Assessment with Sonography for Trauma (FAST)

MedicationsBlood, crystalloids –NS or LR, volume expanders

- HespanInotropic drugs after IV fluids

Dopamine, dobutamine, isoproterenol

Vasopressorsdopamine, epinephrine

Opioids - pain controlTetanus prophylaxisAntibioticsMannitol

Death in the ER

Gerontologic Populations

• Atypical presentations

• Cognitive Impairment

• Co-morbidities

• Polypharmacy – Coumadin,Beta-blockers, Anti-hypertensives

Hwang, U., Richardson, L.D., Sonuyi, T.O., & Morrison, R.S. (2006). The Effect of emergency department crowding on the management of pain in older adult with hip fracture. Journal of the American Geriatric Society. 54, 270-275.

Poisonings

1-800-POISON1 Activated charcoal, gastric lavage, eye/skin irrigation,

hemodialysis, hemoperfusion, urine alkalinization, chelating agents and antidotes - acetylcysteine

Contraindicated in AMS, ileus, diminished bowel sounds, ingestion of substance poorly absorbed by charcoal

Violence

Crosses all socioeconomic and sociocultural barriers

1.5 million women and 834,000 men treated at ED’s have been battered by persons known to them

Make referrals, provide emotional support, inform victims about their options, ensure patient safety

Suspected abuse of elders, persons with disabilities and children MUST be reported by law. It is not an option to assume the social worker or doctor will report.

Bioterrorism

Chemical Emergencies• Release of a

hazardous chemical that has the potential for harm• Biotoxins• Blood agents• Pulmonary agents• Nerve agents

• Treatment depends on the chemical - some have no treatment

Radiation Emergencies• Can be incurred from

handling of or exposure to radioactive materials

• Radiological technicians/First Responders, ED personnel

• Weapons of Mass Destruction –everyone is exposed

Mass Casualty Incident

Assessments conducted in less than 15 seconds…

System of colored tags to determine seriousness of injury and likelihood of survival

Total number of casualties a hospital can expect is estimated by doubling the number of casualties that arrive in the first hour.

NDMS, DMAT & CERT

Reverse Triage• Injury identification-rapid assessment at

scene• Penetrating injuries to abdomen, pelvis, chest,

neck or head• Spinal cord with deficit• Crushing injury to head, chest or abdomen• Major burns

• Critical interventions• providing life support, immobilizing the cervical

spine, managing the airway, and treating hemorrhage and shock

• Rapid transport-ASAP to regional trauma center

Triage Tag• Patient Information• Triage Status• Chief Complaint• Transportation• Peel - off Bar Codes• Transport Record• Vital Signs • History• Treatment

MIEMSS

HOSP NOTIFIED Maryland Emergency Medical Services

TRIAGE TAG

A V P U

A V P U

A V P U

Inflated at _______________PASG

Gauge

Tourniquet @ _______

Extremity Splint

Gross Decon. Final Decon.

Maryland Department of Transportation

Chief Complaint Section• Major obvious injuries or illness can be circled• Indicate injuries on the human figure• Additional information is added on the comments

line

Pre-Hospital Care• Paramedics

communicate with ED• Brief report about client

with ETA

• Severity of condition determines ED response

• Champion Revised Trauma Scoring System

Nursing Diagnosis• Ineffective airway clearance• Altered tissue perfusion• Impaired gas exchange• Risk for infection• Impaired physical mobility• Spiritual distress• Risk for post-trauma syndrome

PTSD / Compassion Fatigue• Risk for patients and

caregivers• Emotions range from fear,

anger denial and shock.• May experience flashbacks

and nightmares

Implications for Nursing

• Recognition of our own values and perceptions

• Need for evidenced based practice

• Continuing education through inservices and online training

• Department specific policies – no more than 8 hours in triage

• Use of a different triage ranking system such as ESI where specific complaints are automatic level assignments

Worker’s Comp

Where did I put my keys?

It’s like there’s something stuck in my throat…