Objectives of patients flow map For easy identification of life and limb-threatening condition For smooth flow of patients To prevent unnecessary overcrowding Control non emergency case Proper quality auditing Research purposes

What we need for proper patient flow Good ED design Well equipped different sections Well trained staff Systems guidelines and policies Good administrative support Follow up and quality measure plans

ED design Easy axis Clear entrance Open cubicles Central stations

Station and sections Pre-hospital service Decontamination room Triage Resuscitation room Main ED room Minor procedure room Fast tract Waiting area

Knowledgeable personnel Triage Room Place Knowledgeable personnel Triage system First station Identify life-threatening cases Prioritize patient Smooth patient flow Observe waiting area (Re-triage)

Parameters used in triage Quick look Brief history Vital signs Diagnostic tools

Triage Category Acuity level Physiological Status 1 2 3 4 5 Canadian Triage and Acuity Scale Triage Category Acuity level Physiological Status 1 Resuscitation Resuscitation/actual life-or limb threatening presentation 2 Emergent Unstable/ potential life – or limb threatening presentation 3 Urgent Potentially unstable 4 Less urgent Stable 5 Non urgent Routine

Resuscitation Room

Resuscitation Room Close Monitor Many interventions Well equipped Well staffed - one to one

What interventions in Resuscitation CPR Management of Airway Breathing Circulation Disability It need team work

What interventions in Resuscitation Airway Assess the need for intubation Perform intubation Crush RSI

What interventions in Resuscitation Breathing : Assess breathing Manage tension pneumothorax Assist ventilation Bronchodilator Manage Pulmonary edema

What interventions in Resuscitation Circulation : Fluid resuscitation Consider blood Consider inotropes Stop bleeding

What interventions in Resuscitation Disability : Assess LOC ( GCS ) Stop seizures Manage acute stroke

Monitoring Blood pressure Pulse Respiratory rate Oxygen Saturation Cardiac rhythm LOC

Acute area Few simple intervention Less monitoring Less staff needed Usually Category 111

Acute area Most of the patient are those stable , but may need admission Patient who need IV fluid or IV medication Patient who need further investigation

Fast Track Simple cases No intervention No/simple investigation Prescription and go Consider Triage-out

Waiting area Confortable place Easy observed by triage team

Well trained staff CME Courses Workshops Simulation sessions Bed-side teaching

Systems guidelines and policies Triage system Clinical guidelines for common presentation Hospital and ED policies Code system Referral and transfer system

Good administrative support Strict application of interdepartmental policies Easy disposition of patient Good diagnostic facilities ( Lab & Image ) Support ED decisions Participating and follow quality measure

Follow up and quality measure plans For proper follow up Documentation Quality committee Identify key-point indicators Data collection Analysis and recommendation

Key-point indicators Time to physician of different categories Number of patients and admission percentage Length of patient stay in ED

Summary of patient's flow Station Place Patient Category Parameter Responsibility First Reception Life threatening General Look Nurse Second Triage room Potential life threatening Brief history & Vital signs Third Triage Room2 Emergency cases Details history & Examination Physician

Triage Nurse Resuscitation Main area Triage physician ECG Glucocheck

Key-Point Any patient with non traumatic chest pain ECG shall be done and interpreted within 10 minute Any patient with decreased level of consciousness glucocheck shall be done

Prescription and discharge Send in for possible admission or Procedure Triage physician Prescription and discharge Investigation And reassess Send in for possible admission or Procedure Triage out