Additional
Requirements : Emergencies
Version 0.3, 21 Aug 2011, Etienne Saliez /
- Objectives:
- Expected additional requirements in the context of an emergencies.
- Scenarios:
- Scenarios before the hospital:
- First aid on site::
- In general anybody should have a minimum of knowledge about
what to do as first aid and at least how and where to call for
urgent help.
- Emergency call:
- First person at the site of the accident:
- Should know how and where to call for support.
- In general anybody could be the witness of a cardiac
emergency and should have a minimum of basic knowledge.
Hopefully there is a nurse nearby or even a doctor.
- Basic "case" information:
- A minimum of information should be communicated to the
call center:
- The exact location of the patient and the context of
did happen.
- The main symptoms. A predefined checlist of questions
could help here.
- Observations as pulse rate, blood pressure,
consciensiouness level, if a cardiac condition is
suspected an ECG record, a picture of a wonded patient,
etc....
- Assuming that an electronic network is available, the
new case should be immediately recorded once in the
computer network and made available to several involved
actors as alocal doctor nearby, ambulance staff,
cardiologic center.
- Identification:
- A case has immediately a provisional "case
iidentification" and can be retrieved by time,
location, calling person, and maybe exact patient
identity if available.
- However the exact patient identification is perhaps
not yet available:
- If possible one will seek for an existing patient
record. If any an overview of known health
problems could be important for the current
care.
- Otherwise a new patient record will be created
and will keep archive of the current emergency
event.
- Usually the initial recording will be initiated in the
network by the call center , but anybody else could
occasionally initiate an emergency case record. The other
actors will continue to extend the information about the
case.
- Role of the regional call center:
- Provisional rough evaluation of the situation. Which
type of problem? Which kinds of resources should be alerted
first? Of course an overview of possible care services
should be always available.
- First aid recommendations.
- Coordination of the care, as sending an ambulance,
notification to the most nearby cardiologic center. who
will try to make a more precise assesment of the situation
and recommendation for the initial treatment e.g.
defribrillation, etc...
- A very temporary role before taken over by a medical
center.
- Medical center:
- When receiving notification of the call:
- The medical center could already try to get more
information in order to make a more precise assessment,
for example is an ECG record can be transmitted.
- Could try to provide advices about what to do, for
example to use a defibrillator.
- Scenario of the emergency unit at the intrance of the hospital:
- Introduction:
- If not yet anticipated in the above scenarion, the case
registration is done here in a similar way as above. The common software requirement
of level "A" are assumed to be already available in the
hospital and the scenario focus now on specific requirements
related to an emergency department at the entrance of a
hospital.
- Missions:
- First aid in case of life threatening situations:
- A challenging medical situation: any kind of medical
problem can appear at any time, as well road accidents as
well any disease.
- Moreover during night and week-ends the emergency
department is also one of the few units inside the
hospital, remaining fully operational 24 hours a day.
- Very variable workload, hours with nothing to do but
sometimes at once several emergencies. A first look at
the arrival define priorities. Patients with obviouly
relatively minor problems may have to wait several
hours.
- Evaluation:
- Patient examination The emergency unit has a priority
access to technical services
- The doctor move between several patients, and come back
when the results of the first test become available, as
lab, images, etc .
- Triage:
- Decision about where the patient should go:
- Admission:
- Either admitted in the hospital after urgent
measures if necessary. For example trasferred to
the surgery department.
- Discharge:
- Or reassurance of the patient advised to go back
at home and to be followed in the next days, by the
GP and maybe at the consultation of a
specialist.
- At the same time simple care is provided here,
e.g. a prescription to be get in an external
pharmacy, immobilisation of a simple fracture,
etc....
- The trend is that this kind of basic care is
increasing to more than 80 %. Indeed GP become
less available out of working hours and patients
hope better care in hospital. The latest point is
not necessarily true. Anyhow patient going to
hospital get as a mean much more expensive
technical examinations, lab, XRays, etc... while a
GP with common sense and well knowing the patient
can solve many problems.
- Patient should leave the emergency unit as soon as
possible, in principle within less the 2 hours.
- Report:
- In all cases a report need to be available when tha
patient leave the emergency unit, as well in case of
transfert to a hospital department as well if the patient
is discharged as non urgent and referred to external
consultations. This mean that the information should be
recorded directly on site, step by step, in such a way that
the record should always be closed when the patient leave,
as far as possible.
- Specific additional requirement for emergencies:
- Reuse of the common platform:
- The common software
requirement of level "A" are assumed to be already available.
- From the "Problem List" point of view an emergency call is a new
"Health Issue". The problem will have an evolution from a rough
"reason for calling" to a more precise medical definition. For
example the initial version could something like "patient in bad
condition found by the police", while the medical department will
later identify a precise diagnose, moreover which can be classified
with an ICD code from the WHO.
- Patient group:
- The patients and the cases the emergency unit is currently in
charge of. The patients actually present in the emergency unit,
as well new cases just known via a call and expected to arrive
soon.
- The common
Patient Group module should be extended as a kind of dashboard.
Indeed an emergency unit need to follow several cases in
parallel. Therefore they need a kind of dashboard showing the
current patient list with a short presentation of the most
important information.
The list should usually be sorted on emrgency level and secondarily
on time of arrival.
- The emergency unit must remain operational 24 hours a day:
- For many hours there are nearly no real emergency patient.
However there is always some work, but mostly as primary
care.
- In case of a catrastrophic event there could be far too
many. The question is then to identify qhickly the most
urgent ones and to sort the list according to urgency level.
- Dashboard:
- Motivation:
- The dashboard is used as a way to follow the evolution of the
group of emergency patients. The elements of this list
contain a short summary of every patient.
- It make easy to move from one case to the next one. A click
on this short summary provide a zoom into the full patient
record.
- Content of a dashboard entry:
- A few essential informations intended to the coordination of
the emergency unit. Typically:
- Identification: patient ID number or at least a case
number, patient name,
- Primary responsible staff member taking charge of this
particular patient.
- Location of the patient: box number, and my be
currently moved to radiology,
- Urgency level, optional alarm icon and sound, in case a
monitoring device would raise an alarm, for example if a
cardiac arrect.
- Summary ogf the main current problems.
- Summary of the currensituation of the action plan: for
example lab requested and waiting for results.
- ....
- Collaboration issues:
- Nearly all patients are of course new and not known in advance in
the emergency unit:
- Access to a previouly well maintained up to date patient
record should be very desirable. An overview of the already
known problems can help to make safer and more quickly
decisions.
- Required reports:
- Normally all patients are transferred within less than about
2 hours. When the patient arrive by a new colleague it is
critical to have a report of all what was observed and done
during the stay in the emergency department. It is
particularly critical if the patient is admitted in a depetment
of the hospital. If the patient is discharged th GP should
have access to the report the same day.
- Other documents are less urgents, but it is efficient to
close a case completly when the patient is leaving. There is
not always time to do it immediately, but doing that work a few
days later would be more difficult and more time consuming.
- Approaches:
- The idea is to register the information once immediatly at
the source by the person getting the information. Having the
information in the computer it can be reused several time in
order to produce the various reports, as electronic messages
and/or printer documents.
- Most usual reports:
- Medical summary intended for the colleagues where the
patient is transferred.
- optional prescriptions if the patient may be
discharged.
- Optional certificates for an employer or a school,
- Administrative declaration,
- Insurance documents,
- Classification code intended for the statistics.
- Access rigths:
- Normally the rule is that in order to get get access to any
personal patient record, one must be an agreed member of the care
team of the patient, with his/her explicit agreement.
- In practice emergency units need an exception, allowing the
doctor to declare himself to be a member of the care team of the
patient. However as a preventive measure, the list of such forced
accesses can be reviewed later for justification. Moreover the
patient should be informed afterwards of any forced access.