Emergency Unit Management:

a guide to better practiceBasil Bonner

Head:Emergency Unit

Milnerton Medi-Clinic

Careful balance

• Benefits and opportunities of providing effective emergency care

• Enhance hospital’s image

• Emergency department viewed as a source of problems in hospital operation

Scope of EU management

• Complex interplay of factors pertaining to the productive functioning of the Emergency Unit– Operational– Financial -assets , stocks, expenses– Staffing and interpersonal issues – Clinical and client focus

Clinical and client focus

Staffing and relatedMatters

Financial factors

Operational issues

Emergency Unit

Operational issues

• Chain of command – relationship between hospital administration and medical staff

• System of Unit Management:– nursing Unit manager and Clinical Head /

director

• Clinical environment – consultative, diagnostic/therapeutic and procedural

Operational issues cont..

• Administrative functions related to patient registration and interaction

• Access to other related clinical and non clinical services

• Disaster plan ready• Relationship with EMS and disaster planning • General management function - POLC

Financial management

• Volumes vs. staffing

• Billing and re imbursement

• Debt management and financial reports

• Monthly assessments of all aspects of business

• Budgets - heads / capital / smalls

Asset management

• Stock

• Capital items and equipment

• Smalls < R300

• Furniture

Staffing issues

• Choosing right mix and balance

• Getting the numbers right

• Nursing /medical /admin /support services

• Back up and on call / standby

• Communication network

Human resources

• Staffing expectations– Professional / Career– personal

• Participative management

• Contracts

• Hours / leave / other

Personal development & Training

• Personal development plans

• Liaison with training dept.

• Performance appraisal

• Training budget – Maintain professional standards , encourage

growth

• Library and IT access / look up

Clinical management

• Clinical governance

• Medico-legal considerations

• Risk management

• Ethical

• Quality improvement

Clinical Governance :defined

• “framework through which organisations are accountably improving the quality of their services, and creating an environment in which excellence in clinical care can occur”

Scally, G. BMJ 4 july 1998

Clinical governance: Key Issues

• Clinical audits and critical outcome reviews

• Risk assessment review and strategy

• Communication strategy

• Client service and experience

• Personnel development

• Data acquisition

• Research and education

Medico-legal issues

• EU lends itself to possibilities for liability risk

• Risk management strategy required to minimise risk

• Knowledge of patients and staff rights very important

Risk management

• Documentation standards • Regular review of patterns in EU• Drug register audits • Identification and Review of all potential risks

– Financial– Ethical / moral– Attitudes– Clinical standards

Risks

• IH transfers – stability of patients….• Substance abuse • Long/excessive duty shifts• Telephonic advice• Written admission orders• Shift change over times• Multi-trauma / complex medical problems• Refuse Hospital Treatment / Against Medical Advice• Poor record keeping• Patient who presents twice in 24 hours

Strategies for risk management

• Document all incidents• Maintain good communication• Use specialists appropriately and judiciously• Provide adequate staff cover – docs and nurses• Prescribe carefully• Allow time for patient’s questions• Code accurately • Mortality reviews• Discrepancy reviews of X rays / ECG’ s……..

Quality cycle

2. Determine solution

5. Monitor and analyse

7. Document and educate 3. Implement solution

6. review accordingly 4. Communicate the process

I Identify a problem

Research and Development

• Essential component of clinical governance

• Reviews and audits

• Original research (ethics approval)

• Participative studies and trials

Clinical standards

• Must set norms and standards for

• Practice– Policy and procedures– Clinical guidelines

• Communication

• Appropriate and professional Referrals

• Updates/training

Policy and Procedures

• Operational plan to meet local needs

• Staffing and organising emergency system responses

• Integration with other depts. In hospital

• Ongoing education for all personnel

• Admissions register

• Quality assurance control.

Client service

• Create forum for client service feedback

• Everyone’s responsibility!

• Review of patient opinion surveys

• Answering calls and complaints

• Complaints register

• Link to medico–legal assistance / advice

Ethics and emergency medicine

• Each decision must be made for the individual, with compassion, based on ethical principles and available scientific information

• Principles must prevail of – autonomy – beneficence – non malevolence – justice

• Patients bill of rights

summary

• EU management must – Provide a place where patients can feel

wanted and cared for– Provide high quality emergency patient care– Attract and maintain personnel with necessary

skills and attitudes– Support a vision that sets sights at ever

increasing standards of service delivery .