Emergency care
Emergency Care is politically and socially one of the highest priorities in society today. Increasing patient expectations and the advancement in scientific and medical knowledge have had a dramatic effect on the provision of emergency care. The Department of Health’s (DoH) White Paper on Reforming Emergency Care (2001) stipulates that emergency care provision should address the demands and needs of patients, regardless of setting. A solid foundational knowledge in the skills of triage and assessment are, therefore, essential precursors to all emergency practitioners in order to enable patients to be treated quickly, appropriately and effectively, i.e., right skill, right time, right place. The different, diverse and unique needs of patients provide a constant challenge to emergency practitioners.
The Emergency Department (ED) is the portal for over 16.5 million annual visits in England (Alberti 2004). In the United States of America (USA) there are over 100 million annual visits, accounting for 40 per cent of hospital admissions (McCaig and Burt 1999). These millions of patients will attend with any number of clinical presentations and complaints requiring the assistance of every medical speciality. The role of the emergency practitioner is unique in this respect, as in no other clinical setting will clinicians be called upon to assess and identify the needs of such a wide range of potential patient conditions. The ED is commonly the interface between patients and emergency care, within this setting a patient’s first contact with a healthcare professional will usually be at the point of initial assessment; the process of triage. Triage is a dynamic decision-making process that will prioritize an individual’s need for treatment on their presenting history, the nature of the incident, and the presenting clinical complaint. An efficient triage system aims to identify
and expedite time-critical treatment for patients with life-threatening conditions, and ensure every patient requiring emergency treatment is prioritizedaccording to their clinical need. The ethos of triage systems relates to the ability of a professional to detect critical illness, which has to be balanced with resource implications of ‘over-triage’ (a triage category of higher acuity is allocated). A decision that underestimates a person’s level of clinical urgency may delay time-critical interventions; furthermore, prolonged triage processes may contribute to adverse patient outcomes (Geraci and Geraci 1994; Travers 1999), and impede the assessment of others. In this context, the practitioner’s ability to take an accurate patient history, conduct a brief physical assessment, and rapidly determine clinical urgency are crucial to the provision of safe and efficient emergency care (Travers 1999). These responsibilities require practitioners undertaking triage to justify their clinical decisions with evidence from clinical research, and to be accountable for decisions they make within the clinical environment. This book is directed at facilitating front-line practitioners and students aiming to specialize within emergency care, to gain the essential assessment skills necessary for acute care environments, and to forge a solid foundation of theoretical knowledge and understanding upon which to base their clinical practice.
Applying theory to practice
In order to deliver expert individualized care, emergency care providers need to make multiple decisions rapidly, in highly complex environments and under increasing pressure. Emergency care is a dynamic specialism very different from many other areas of care provision, yet the skills associated with emergency care can be applied to all acute areas. Patients often present critically ill and frequently highly unstable, as a result, their rapidly changing conditions demand intelligent and decisive decision-making from practitioners in short time frames. Despite this, there remains minimal research on the clinical decision-making skills of emergency care providers. Consequently much of the content and structure of the decision-making process remains unclear (Fonteyn and Ritter 2000). Clinical decision-making can be defined as the process practitioners use to gather patient information, evaluate that information and make a judgement that results in the provision of patient care (Andersson et al. 2006). This process involves collecting information through the use of both scientific and intuitive assessment skills. This information is then interpreted through the use of knowledge and past experiences (Cioffi 2000; Tippins 2005). Recent research indicates that many practitioners have a solid foundation of theoretical knowledge but often fail to apply this knowledge directly to patient care (Tippins 2005). The Resuscitation Council, European and UK, have acknowledged this phenomenon based on several research studies identi-fying that up to two-thirds of in-hospital cardiac arrests are potentially avoidable (Franklin and Matthew 1994; Hodgetts et al. 2002). Seeking to address these issues, the DoH set national guidelines, stating that all healthcare providers should receive competency-based high dependency training (DoH 2000). Universities introduced higher educational modules attempting to facilitate experienced and novice post-registration practitioners into gaining these fundamental skills associated with the process of initial and ongoing
patient assessment. This essential ability to recognize both patients at risk of critical illness and sudden physical deterioration, and those actually experiencing critical illness is now an indispensable component of modules which all pre-registration nurses have to pass in order to register in the U (NMC 2004). The recently revised Resuscitation Guidelines (RCUK) 2006) directly address the DoH’s objectives by focusing on the recognition and treatment of the critically ill patient in order to prevent cardiac arrest. This focus on preventative education has seen the development of locally delivered courses such as the Acute Life Threatening Events: Recognition and Treatment (ALERT) course, and the development of early warning scores (EWS). Within the UK EWS are now commonly used to identify patients at risk of clinical deterioration. The use of an EWS ensures a structured approach to patient
assessment and the regular recording of physiological observations, a crucial first step in recognizing patients at risk. Physical parameters are used to identify patients who are deteriorating, or are at risk of doing so. The scoring system alerts the carer to the potential for serious illness and initiates a call for senior assistance. Regardless of the individual setting, practitioners encountering acutely ill patients need to be able to identify those at risk of serious illness, act on these findings and evaluate their chosen treatment route. Although these key skills may be used in other clinical settings, they are essential to emergency care provision and are seen as an integral part of an acute practitioner’s scope of clinical practice.
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Emergency care management is a complex and dynamic specialism.
The role of the emergency practitioner comprises numerous fundamental clinical skills. Practitioners, regardless of their discipline, need the ability to relate these skills, including a foundational knowledge of the physical changes synonymous with serious illness, to the patient assessment process. This can be achieved by applying the key skills of critical thinking and analysis to everyday clinical decision-making.
The argument surrounding the clinical application of theoretical knowledge has continued throughout nursing and healthcare education. The NHS Plan (DoH 2000) identified the NHS as deficient in national evidence-based standards and, therefore, much of the practice subjective to individual interpretation. This initiated the current protocol-driven approach to care whichaims to provide practitioners, and subsequently patients, with evidencebased objective treatment regimens, in contrast to individual subjectiveencompass a holistic approach by adopting the critical thinking approach that guides the practitioner through four categories, which results in a safe and effective method of identifying critical illness through an elimination
of serious pathology. The practitioner will increase their understanding of relevant emergency skills and knowledge by directly seeing the application of theoretical knowledge within clinical practice. The enhancing critical thinking approach encourages the reader to seek further understanding of relevant theory, this follows the Nursing and Midwifery Council guidelines on lifelong learning and the ability of the practitioner to be fit for practice (NMC 2004). preferences. A prime example is demonstrated by the advanced life support algorithms, which have revolutionized multi-disciplinary care delivery. Changing practice within the vast institution of healthcare is a monumental task and to this end clinical governance was established. The clinical governance initiative is conveyed into clinical practice by the National
Institute of Health and Clinical Excellence (NICE). NICE, in conjunction with several specialist professional institutions, have released numerous national guidelines on specific patient presentations or illnesses. These are also supplemented by the DoH’s National Service Frameworks (NSF), which set clinical standards in relation to specific disorders and specialist organizations such as the British Thoracic Society, which promote ‘best-practice’. These initiatives have combined to produce a constantly progressive clinical arena in which novice practitioners and students can easily become lost. There is, therefore, a clear need to apply a tool or structure to the
diagnostic process directly aimed at facilitating practitioners with the ability to base their clinical findings on objective rather than subjective data. This facilitation centres on two components: first, a solid understanding of the signs and symptoms associated with physical illness, and second, the application of critical thinking to their practice. The first component is demonstrated throughout this book by experienced practitioners who discuss their own experiences in the form of patient scenarios which highlight both common clinical encounters and the frameworks and protocols they use to prioritize, and manage, patients quickly, appropriately and effectively. In addition, the clinicians discuss the associated anatomy and physiology providing the reader with several key words or triggers. This enquiry-based learning approach promotes lifelong learning by encouraging the reader to seek key texts listed at the end of each chapter, thereby gaining further knowledge and understanding of the topics. The framework used throughout this book is based on a modification of Alfaro-LeFevre’s (2004) approach to critical thinking, the DEAD framework. Novice practitioners frequently require an unambiguous approach to patient assessment, which can be achieved by applying the DEAD acronym. This framework not only aids practitioners in critically analysing their care delivery, it also directly provides a safety net by leading the practitioner to question other possibilities regarding the patient presentation, and this component is paramount to those working in acute care settings as a missed diagnosis can be fatal. This structured approach is applied to everyday clinical presentations via the use of clinical scenarios. The scenarios demonstrate classic emergency care presentations and focus on the practitioner applying their theoretical understanding of both anatomy and physiology to determine an individual’s clinical status. The practitioner’s assessment plan broadens toBy utilizing this structured framework, those less experienced in critical thinking will have a clear systematic outline to assist them in the organization of their thought processes and subsequent clinical practice. This, in turn, could facilitate the individual development of critical thinking and decisionmaking- skills. The focal point of this book is to facilitate practitioners to acquire the essential skills of patient assessment and priority assignment, as these comprehensive skills have been highlighted as being paramount to emergency care providers (DoH 2005).
