Documentation (2024)

November 29, 2024January 1, 2025 ~ iEM Education Project Team ~ Leave a comment

by Muneer Abdulla Al Marzooqi

Introduction

Whether rotating in the Emergency Department or elsewhere, one of the critical skills to learn is writing a complete and legible patient record. Documentation in the emergency department is usually challenging, and it may be difficult to adequately capture and note things promptly, especially when dealing with high acuity or critical case scenarios. Even as a medical student or intern, your medical record is essential. It reflects your general approach, thought process, care provided to patients, and potentially identifying gaps in your knowledge and training. Attending physicians, clerkship directors, and faculty usually emphasize and pay attention to how notes are written and may use them for summative or formative assessments and feedback. These documents are also crucial for communication between the emergency department and respective physicians, specialties, and other stakeholders. Appropriate medical documentation improves the quality of communication within an emergency department and aids the quality assurance process.

“It is said that if something is not written in the chart, it never happened.”

A well-organized and legible chart gives auditors and reviewers a clear picture of the physician’s thought processes and actions. It provides a real-time snapshot of a patient’s general condition at any given encounter. There is always room to learn about and improve medical documentation in the emergency department; therefore, this section will review the critical elements used in ED documentation [1,2].

Emergency Medicine Note

Before writing your note, nursing triage notes and vital signs, if available, need to be reviewed. If apparent discrepancies are seen, they need to be verified with the nurse and patient, as they may be errors. In addition, any abnormal vitals in triage must be acknowledged and written in the notes. Like any other medical record, the ED document comprises history, physical examination findings, differential diagnoses, ordered investigations, laboratory and imaging results, assessment, and plan. Each component will be discussed separately, and suitable examples will be provided accordingly [2-4].

History

When writing a patient’s history, one must be clear and thorough yet concise, avoiding lengthy and complex phrases. Ideally, the history should flow in a logical and chronological sequence. Unnecessary details are better avoided, as they serve as distractors and may confuse other readers. Recording the date and time the patient was seen is crucial, especially in critically ill patients. It will help create a timeline for when time-sensitive interventions or medications were administered [3,4].

The components of history

Chief Complaint

This usually includes the presenting complaint, ideally in the patient’s own words, with the duration (e.g., abdominal pain for two days).

History of Present Illness

Generally, there are two formats for writing the history of present illness (HPI): narrative and bullet points [5,6]. Both are acceptable as long as history is written comprehensively, concisely, and coherently. It is valuable to add pertinent negatives and positives when writing the HPI. It would show the physician’s thought process and lead the person reading the chart toward what differential diagnoses to consider and what to rule out depending on what the patient is presenting with. Specific mnemonics may aid in writing a systematic HPI (e.g., OLD CARS or OPQRST).

Example 1:

A 45-year-old man with a history of Coronary Artery Disease and Hypertension presented to the ED with chest pain that started three hours prior. The pain was gradual onset while sitting on his chair, localized in the center of the chest, and lasted for 20 min. It was described as “a heavy boulder on my chest.” It started when he quarreled with his daughter and was relieved with sublingual nitroglycerin. It was associated with nausea and sweating but not vomiting. It was localized and did not radiate into the shoulders or arms. He claimed the pain was moderately intense at 4/10 on the scale. The patient denied shortness of breath, palpitations, dizziness, or abdominal pain.

Example 2:

A 26-year-old male, previously healthy, presents with a sore throat for one week. It is associated with subjective fever and fatigue. It is aggravated whenever he drinks or eats, but he denies any difficulty swallowing or drooling. Also denies any chills, runny nose, cough, night sweats, or shortness of breath. No recent travel history was reported. Has several sick contacts at home with similar symptoms

Review of Systems

Other organ systems and symptoms not mentioned in the HPI must be reviewed to ensure that the patient has no other complaints or organ system involvement. If a review or system (ROS) cannot be obtained because of the patient’s underlying condition (i.e., unconscious, critically ill, or having dementia), this should be noted in the chart. Generally, patients are asked questions from head to toe (e.g., “Do you have a fever, chills, headache, sore throat, chest pain, abdominal pain, urinary symptoms, etc.”). Document all positive ROS symptoms and state the remaining symptoms as otherwise normal [7].

Past Medical/Surgical History, Medications, and Allergies

List any known illnesses that the patient might have had in the past. Include any surgical procedures he had. State what medications he is actively on and whether he has any drug or food allergies.

Family and Social History

Document a brief family history relevant to the chief complaint (e.g., family history of diabetes and cardiac disease in a patient presenting with chest pain). Social history mainly includes questions about smoking habits, alcohol consumption, sexual history, and illicit drug use. It might also be essential and relevant to ask about the patient’s financial and health insurance status, particularly in specific healthcare settings, to avoid ordering unnecessary tests and paying extra costs.

Physical Exam

Recording physical exam findings starts with the patient’s general appearance and vital signs, highlighting abnormal ones. It is important not to document or fabricate any findings that were not examined, as committing to such findings may have medical and medicolegal implications that are best avoided. Document all findings from the examined systems, including inspection, palpation, auscultation, etc. There is no need to document findings not pertinent to the chief complaint (e.g., neurological examination findings in a patient with a sore throat). Include important positive and negative findings for any given case [3].

Example:

A patient with abdominal pain

Important positive findings: Soft, non-tender abdomen, normal active bowel sounds
Important negative findings: No rebound tenderness, guarding, rigidity, or peritoneal signs

Assessment

It should capture the essence of the case and defend the rationale for further investigation. It usually includes an objective case summary, with differential diagnoses based on history and physical examination findings.

Plan

This section includes the investigations, medications, procedures, and consultations to be ordered or performed. The consultation time is crucial; the doctor’s name and recommendations must be promptly documented.

Disposition

This is usually the last part of the note. It indicates whether the patient will be admitted, discharged, or transferred to another facility. If discharged, follow-up and return instructions should be documented clearly [2-4].

Summary of all components in an ED Note

Chief complaint
History of present illness with pertinent positives and negatives
A brief review of systems
A focused past medical and surgical history
Pertinent medications and allergies
Family and social history, if relevant
Vital signs, highlighting any abnormal readings
A focused and appropriate physical exam
Assessment with differential diagnoses
Plan
Disposition

Few helpful suggestions during documentation

Place the date and time on all notes in the medical record.
Write notes clearly and legibly.
If you make a mistake, draw one line through it and sign your initials.
Document a focused but thorough history and physical.
Avoid using unclear abbreviations that are not commonly used.
Document vital signs and address abnormalities.
Document the results of all diagnostic tests that were ordered when appropriate.
When speaking to a consulting service, document the physician’s name and the time the call was made.
Document the patient’s response to therapy.
Document repeat examinations
Document your thought process (medical decision-making)
Avoid writing derogatory comments in the medical record.
Avoid changing or adding comments to medical records after completion. An addendum may be appropriate, but only if appropriately timed and dated.
Document all procedures performed.
If a patient leaves against medical advice (AMA), document that you have explained the specific risks of leaving and that the patient acknowledges and is aware of the risks.
Document plan for outpatient care and follow-up
If using an electronic medical record (EMR) instead of a handwritten one, all of the above sections, components, and suggestions apply [1,8,9].

Sample ED Note

Date & Time: 23/04/2022 at 07:40 AM

Arrival Mode: Private Vehicle

Source of History: Patient and Father

History Limitations: None

Chief Complaint

Abdominal Pain – since 6 hours

History of Present Illness

A 17-year-old male is brought to the ED complaining of abdominal pain since 6 hours of gradual onset. The pain started in the epigastric area and is now localized around the umbilicus. Pain is localized, persistent, and achy, without radiating to the back. It is associated with nausea and two episodes of vomiting. The vomiting is mostly food content and yellowish fluid, with no blood or bile noted. The patient was ill with nasal congestion and throat pain yesterday. He had a subjective fever at home and a decreased appetite. Denies chills, headache, yellowish eye or skin discoloration, diarrhea, or urinary symptoms. He denies eating food from outside in the past two days. No recent travel or sick contacts were reported. Did not try any medications or remedies at home.

Review of Systems

Other than HPI, the review of systems is otherwise normal.

Past Medical History

Unremarkable

Medications and Allergies

No known allergies and not on any regular medications

Family History

Both parents are known to have Hypertension only.

Social History

Denies alcohol consumption or illicit drug use.

Physical Exam

The patient appears to be in moderate pain, holding his abdomen.
Vitals: BP 130/80 mmHg, PR 120 b/min, RR 20 breaths/min, O2 Saturation: 94% on room air
Head and Neck: Dry oral mucosal, no cervical lymphadenopathy
CVS: Symmetrical pulses bilaterally, S1, S2 heard, no murmurs
Lungs: Clear to auscultation bilateral with no crepitations or wheezes
Abdomen:
- Scaphoid abdomen and not distended on inspection,
- tenderness palpable in the epigastrium, umbilical area, and right lower quadrant
- Positive rebound tenderness in the right lower quadrant
- Positive Rovsing’s and Obturator signs
- No palpable masses or hernias
- Negative Murphy’s sign
- Auscultation revealed sluggish bowel sounds
- Rectal exam revealed a normal tone with no blood in the glove
Genital Exam:
- Normal genitalia with no swelling, hernias, or tenderness
- Normal lying testes with no evidence of torsion
- Normal cremasteric reflex on both sides

Assessment

A 17-year-old previously healthy male presented to the ED with a 6-hour history of abdominal pain of gradual onset associated with anorexia, subjective fever, nausea, and vomiting. The physical examination revealed stable vitals, with abdominal examination showing tenderness in the epigastrium and right lower quadrant with rebound tenderness and positive Rovsing’s and obturator signs.

Provisional Diagnosis

Acute Appendicitis

Differential Diagnoses

Acute Gastroenteritis
Food Poisoning
Diabetic Ketoacidosis
Irritable Bowel Disease

Plan

Medications / Treatment:
- 1 Liter IV Normal Saline
- 1g IV Paracetamol for pain
- 10mg IV Metoclopramide for nausea and vomiting
Lab investigations:
- CBC w/Differential count
- Urea & Electrolytes
- Random Serum Glucose
- C-Reactive Protein
- Coagulation Profile
- Type and Screen
- Urine Analysis
Imaging Studies:
- Ultrasound Abdomen
- Possible CT Abdomen in case Ultrasound is inconclusive.
Consultations:
- General Surgery

Author

Muneer Abdulla Al Marzooqi

Dr. Muneer is a Consultant Emergency Medicine Physician from the UAE. He completed his EM residency at Tawam Hospital in 2017 and has served as an attending physician and educator there since. He is the Program Director of the Emergency Medicine Residency Program at Tawam Hospital, focusing on medical education, peer development, EM Resuscitation, Simulation, and POCUS. Dr. Muneer has organized and lectured at various seminars and workshops in the MENA region for medical students, residents, and healthcare professionals, including Basic Ultrasound, POCUS, Airway, Suturing, ENT Emergencies Workshops, and the Chief Resident Leadership Program.

Listen to the chapter

References

Murphy BJ. Principles of good medical record documentation. Journal of Medical Practice Management. 2001;258-260.
Clerkship Directors in Emergency Medicine (CDEM), Society for Academic Emergency Medicine (SAEM). Medical Student Educators’ Handbook / edited by Robert L. Rogers and Mark Moayedi. 2010.
Carrol S. Documentation | EM Basic [Internet]. Embasic.org. 2016 [cited 25 May 2016]. Available from: http://embasic.org/how-to-give-a-good-ed-patient-presentation/
Carrol S. How to give a good ED patient presentation | EM Basic [Internet]. Embasic.org. 2016 [cited 25 May 2016]. Available from: http://embasic.org/how-to-give-a-good-ed-patient-presentation/
Ronald, Schleifer., Jerry, B., Vannatta. (2011). 4. The Chief Concern of Medicine: Narrative, Phronesis, and the History of Present Illness. doi: 10.1215/00166928-1407531
Adam, Kilian., Laura, A., Upton., John, N, Sheagren. (2020). 2. Reorganizing the History of Present Illness to Improve Verbal Case Presenting and Clinical Diagnostic Reasoning Skills of Medical Students: The All-Inclusive History of Present Illness. doi: 10.1177/2382120520928996
Rui, Zeng. “4. Complete Physical Examination.” (2020). doi: 10.1007/978-981-13-7677-1_50
8. 5 Ways to Improve Medical Documentation in your Emergency Department – Bill Dunbar and Associates [Internet]. Bill Dunbar and Associates. 2014 [cited 25 May 2016]. Available from: http://www.billdunbar.com/2014/02/28/5-ways-to-improve-medical-documentation-in-your-emergency-department/
The Art of Writing Patient Record Notes. Virtual Mentor. American Medical Association Journal of Ethics. 2011;13(7):482-484.

Reviewed and Edited By

Jonathan Liow

Jonathan conducts healthcare research in the Emergency Department at Tan Tock Seng Hospital. A graduate of the University at Buffalo with a BA in Psychology and Communication, he initially worked on breast cancer research studies at GIS A*STAR. His research interests focus on integrating AI into healthcare and adopting a multifaceted approach to patient care. In his free time, Jonathan enjoys photography, astronomy, and exploring nature as he seeks to understand our place in the universe. He is also passionate about sports, particularly badminton and football.

James Kwan

James Kwan is the Vice Chair of the Finance Committee for IFEM and a Senior Consultant in the Department of Emergency Medicine at Tan Tock Seng Hospital in Singapore. He holds academic appointments at the Lee Kong Chian School of Medicine, Nanyang Technological University, and the Yong Loo Lin School of Medicine, National University of Singapore. Before relocating to Singapore in 2016, James served as the Academic Head of Emergency Medicine and Lead in Assessment at Western Sydney University's School of Medicine in Australia. Passionate about medical education, he has spearheaded curriculum development for undergraduate and postgraduate programs at both national and international levels. His educational interests focus on assessment and entrustable professional activities, while his clinical expertise includes disaster medicine and trauma management.

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Disaster Medicine Triage (2024)

April 8, 2024December 3, 2024 ~ iEM Education Project Team ~ Leave a comment

by Parker Maddox, Hassan Khuram & Scott Goldstein

A Brief Introduction to Disaster Medicine

Disaster Medicine is a medical discipline that centers around events significant enough that, without external aid, emergency departments (ED) would not be able to adequately provide care to those affected [1]. For example, a multi-vehicle car accident may result in multiple casualties, but would not be considered a disaster if the responding medical infrastructure was able to handle the influx of patients. Many entities including the United Nations International Strategy for Disaster Reduction (UNISDR) and the World Health Organization (WHO) have amended their definitions of the term “disaster” to specify occurrences that exceed a community’s ability to cope with the effects of said disaster [2,3]. Incidents that have satisfied this requirement include natural disasters and more modern occurrences such as water contamination, human conflict, chemical spills, radiation, power outages resulting in infrastructure collapse, etc. [1]. The field of disaster medicine operates with the goal of aiding with these disaster-level events and all of the associated medical, logistical, and ethical issues that come along with them [4].

This is accomplished through a joint effort by many disciplines within healthcare including emergency medicine (EM), Emergency Medical Services, pediatrics, public health, social work, and many more [5]. However, emergency medicine providers’ experience in high acuity, large patient volume settings set them up to take a leadership role in disaster medicine. The emergency department is also typically the first point of contact between patients and health care providers in a disaster setting providing emergency medicine physicians an advantage in these responses [6]. In addition to their traditional responsibilities of stabilization and disposition of disaster patients, EM physicians are typically delegated the responsibilities of coordinating disaster response as chief medical officer, interfacing with government and community relief efforts, and directing disaster triage efforts [6].

Disaster Triage

When a disaster occurs, hospital systems experience what is known as a critical care surge. This is defined as “any increase in the number of critically ill or injured patients beyond the baseline rate a hospital or critical care unit usually experiences.” [7]. These surges are classified based on the size of the critical patient increase with disasters typically causing large surges or megasurges. Megasurges are caused by grand scale, unexpected disaster events (tsunamis, earthquakes, terrorist attacks, etc.) and can require greater than 200% of the resource capacity a hospital has to care for patients [7]. This dramatic scarcity of resources in the face of overwhelming casualties results in an inevitable need to ration resources.

According to the World Health Organization, “triage” is the rapid examination and sorting of patients into groups according to their medical needs and the availability of resources [8]. In this setting of mass casualties and resource scarcity, disaster triage protocols are governed by the utilitarian concept of doing the greatest good for the greatest number[9]. As opposed to routine triage seen in the ED, this requires a shift of focus from the outcomes of single patients to outcomes on a population level [7].

However, despite the common misconception, disaster triage is not simply making the decision of whether to treat a patient or not. Disaster triage is more complex with most decisions centering around what level of treatment a patient should receive [7]. Rarely is it decided or even proposed that a patient should receive no treatment at all [7]. The consensus within disaster medicine is that disaster triage should optimize patient care and resource allocation by considering the incremental improvement in survival that a treatment would provide a patient in their current condition[10]. In order to make these decisions, the foundation of disaster triage lies in the use of triage tools and protocols to systematically assess patient conditions and prognoses following these devastating events. With proper triage and resultant treatment, it has been shown that trauma patients can experience at least a 25% reduction in mortality [11]. In disaster settings where hundreds to thousands of lives hang in the balance, 25% is not an insignificant number.

Measures of Success: Undertriage and Overtriage

Prior to discussing the wide array of triage methods used in disasters, it is pertinent to describe the terms used describe and assess them. Triage efficacy is typically judged by its validity, or how accurate the acuity assigned during triage, by tool or clinical assessment, is to the actual acuity of the patient. In order to measure this validity, we rely on rates of undertriage and overtriage observed during real world scenarios (Table 1) [12].

Concept	Definition	Impact	Sensitivity & Specificity	Acceptable Rate
Undertriage	Patient condition is classified as a lower acuity than it actually is.	Patients are under prioritized, under treated, and providers may miss savable lives.	Low sensitivity	Low (<5-10% of patients)
Overtriage	Patient condition is classified as a higher acuity than it actually is.	Patients are overtreated leading to disorganization, misallocation of scarce resources, and wasting time that could be used to save other patients.	Low specificity	Variable depending on context (25-35% and others 50-60%)

Table 1: Definitions, major impacts, relationships to sensitivity and specificity, and acceptable rates of overtriage and undertriage [11, 12, 13, 15, 17].

Undertriage

Undertriage is when a patient’s condition or injury is under classified in terms of acuity, and the patient is under prioritized or under treated as a result. This results in situations where critically ill patients could have benefited from a justifiable use of resources to further evaluate and treat their injuries [13, 14]. An example of this could be a severely injured patient that was transferred to a non-trauma center, or a patient that could have survived with prioritized evacuation and admission to the ICU or OR. However, it is worth noting that moderately injured patients are the most often undertriaged since severe acuity patients are more easily recognized [11]. Nonetheless, these are essentially missed opportunities to save patients and, statistically, this would represent a low sensitivity of the triage process. Therefore, there is a low tolerance for undertriage with most entities recommending an acceptable undertriage level of less than 5-10% of patients [15].

Overtriage

Overtriage is defined as the inaccurate classification of a patient as high priority or acuity when their injuries are actually non-urgent [11]. A classic example of overtriage would be when a stable, non-critical patient is unnecessarily expedited ahead of sicker patients for a surgery they do not acutely require. According to Foley and Reisner, another form of overtriage is when patients with little to no chance of surviving receive aggressive medical treatment, inappropriately allocating scarce resources [13]. Compared to undertriage, overtriage represents a poor specificity and complicates triage by creating disorganization that misallocates time and resources [14,16]. In the setting of a disaster, overtriage can be just as dangerous as undertriage as this misallocation can take away scarce resources and time that could be used to save other patients. The acceptable level of overtriage is more debated, with some sources recommending 25-35% [15] and others 50-60% of patients [13].

The reason for less stringency surrounding acceptable overtriage rates is due to the influence the two rates have on each other. Overtriage and undertriage do not exist independently of one another and demonstrate an inverse relationship [13]. As overtriage rates increase and patients are treated more liberally, undertriage rates decrease as less savable patients are missed. Therefore, when faced with the decision of overallocating resources or missing a potential savable life, most entities recommend maintaining a higher allowance for overtriage in order to reduce undertriage. Previously, it was reported that 50% of overtriage was required to reduce the rate of undertriage to 0% [17], but more recently that recommendation has been decreased to 25-35% [15] due to the detrimental effects higher overtriage can have on triage efforts with minimal decrease in undertriage rates [11, 18].

However, when applying these rules to real life disaster triage, it is important to also factor in the environment and working conditions of the disaster. The amount of acceptable overtriage and undertriage in a mass casualty event should change depending on resources and casualties present [13]. For example, in a scenario where casualties are few and resources are plenty, the risks of raising the overtriage rate are outweighed by the benefit of possibly reducing undertriage as there would be little chance of running out of resources or time. On the other hand, in a grand scale disaster where resources are extremely limited, a lower overtriage rate would be acceptable, despite the possible increase in undertriage, due to the higher likelihood of running out of resources and time. Therefore, it is imperative in disaster triage to always perform an initial survey of the amount of casualties and resources available in order to form an educated plan to maximize the greatest benefit for the greatest number of people [19].

Primary, Secondary, and Tertiary Triage

In comparison to traditional triage in an ED, disaster victims are triaged multiple times throughout their medical course beginning at the site of the incident and continuing through possible admission to the ICU or OR. These multiple points of reevaluation account for the evolving nature of disasters over time in terms of resource availability, treatment delays, and injury progression or resolution [20]. Triage in the setting of mass casualties can be broken down into three different types: primary, secondary, and tertiary triage (Table 2). These different classifications differ based on the triage timing, location, and what level of care is being addressed [19, 21, 22].

Primary Triage

Primary triage occurs at first contact with patients after a disaster [22]. This can occur at the scene of the disaster, or any other setting outside of the hospital including an area away from the incident [19]. The goal of primary triage is to establish the priority of injured patients for on-site treatment and evacuation to the nearest available hospital [21]. This can also include decisions such as routing patients to trauma versus non-trauma centers or performing life saving measures in the field [7, 19]. Primary triage is regarded as the most critical stage in the disaster triage process with the greatest potential to save lives and influence population outcomes [21, 23]. As a result, many different tools and methods for primary triage have been developed and primary triage will be the major focus of this chapter [14]. The tools and specifics of primary triage will be discussed in more detail in the Triage Tools section.

Secondary Triage

Secondary triage is the second evaluation of patients’ condition and overall acuity. This occurs upon patient arrival to the hospital and commonly takes place in the emergency department [21]. However, the level of care being addressed in secondary triage changes depending on the context of the disaster and the resulting bottlenecks in ED patient care. If it is a mass casualty event involving patients with highly acute complaints such as trauma, then secondary triage will focus on prioritizing patients for initial stabilizing measures in the ED [7]. Alternatively, if the disaster takes a less acute and more extended course, such as the Coronavirus Disease 2019 pandemic, then secondary triage will focus on determining disposition of patients from the ED after the initial stabilization has been performed. The disposition prioritization can include what patients are admitted to the hospital, transferred to more specialized areas within the ED, or discharged home [19, 21]. Secondary triage is especially vital when evacuation from the site of a disaster is prolonged resulting in a large influx of deteriorating patients arriving to the hospital [22].

Tertiary Triage

Tertiary triage is the third evaluation of patients involved in a disaster taking place after initial stabilization or hospital admission. This also occurs within the hospital, but does not need to be in the ED [19]. Tertiary triage is when questions of definitive care are addressed and prioritized such as ICU admission, surgery, and other procedures including those performed by interventional radiology [21]. This final form of triage is typically performed by a physician with critical care training or a surgeon [22]. This is also a chance to reassess continued medical management of severe patients in the setting of dwindling resources such as continuing life support measures or additional treatment after poor prognostic laparoscopic findings [19]. In disasters with fewer critical patients with life threatening injuries, tertiary triage is less utilized [7].

Triage	Timing	Location	Level of Care (LOC)
Primary Triage	First patient contact	At the scene of the disaster	Determines the priority order for treatment in the field and emergency transport. Can also prioritize patients to be transported to trauma vs. non-trauma centers.
Secondary Triage	Second evaluation upon entry into the hospital	In the emergency department	Determines priority order for resuscitation in the ED and disposition after stabilization
Tertiary Triage	After initial treatment and stabilization in the ED	Anywhere in the hospital, not restricted to the ED	Determines the priority order for definitive care including ICU admission, surgery, or transfer to a higher-level facility,

Table 2: Definitions, timing, location, and level of care being decided on for the three levels of triage: primary, secondary, and tertiary [19, 21, 22].

How to Triage: Primary Triage Classification & Tools

Classification

How to properly perform primary triage in the field of a disaster has been a highly contentious area of research since before the establishment of disaster medicine [14]. In non-disaster level traumas, most medical providers in North America minimize their pre-hospital evaluation and treatment in favor of more expedient transportation to the hospital[24]. This is known as “scoop and run” and restricts pre-hospital treatment to Basic Life Support (BLS) with minimal classification of patient acuity. “Scoop and run” has been proven to have significant benefits in terms of trauma outcomes[24, 25], but more rigid triage systems are typically utilized in disasters to expedite patient prioritization, minimize uncertainty, and maximize effective use of resources to do the “greatest good for the greatest number” [26].

Globally, differing disaster triage tools and systems are implemented without any clear consensus in the literature on their efficacy [21]. However, one commonality among the majority of these systems is the four-level classification schema they use to group and prioritize disaster victims [26, 27]. First proposed by the World Medical Association (WMA), this system categorizes disaster victims into four different groups based on their acuity and how urgently they require medical intervention (Table 3) [26]. The literature labels these groups in various manners including by triage tag color (red, yellow, green, black), urgency of required treatment (emergency/immediate, delayed, minimal, expectant), or their priority level (P1, P2, P3, P4) [13, 21, 26, 28].

The immediate/emergency group consists of patients who are in critical condition, but can still be saved with immediate treatment within, at most, the next few hours. A red triage tag is commonly used to label this group [28].

The delayed patients are those who are not experiencing an imminent threat to their life, but urgent, definitive medical care will be required at some point. These patients are often labeled with a yellow triage tag [26].

The minimal group are sometimes referred to as the “walking well” or “walking wounded” and have the least severe injuries [27, 29]. These nicknames stem from the fact that most patients in the minimal group can walk following the incident. Various triage tools will even use the ability to ambulate in their algorithms since multiple studies have shown that walking following a disaster is a strong indicator of a relatively low risk patient with a good prognosis [22, 30]. These patients are labeled with a green triage tag and often require only minimal treatment that can be delayed until the rest of the patient categories have been treated.

The final category, deemed expectant, is marked with a black triage tag, and is made up of patients that are either dead or critically ill to the point that efforts to save them are deemed futile. This classification is typically made in situations where the patient’s condition is beyond treatment or when the complex treatment required to save the patient would be putting other patients at risk by misallocating already limited time and resources [21, 26]. It is important to acknowledge that this can be an especially difficult classification for providers to make. The WMA has addressed this by releasing a statement expressing that “It is unethical for a physician to persist, at all costs, at maintaining the life of a patient beyond hope, thereby wasting to no avail scarce resources needed elsewhere.[31]” However, as disasters are fluid and ever-evolving, it is the responsibility of a triage to repeatedly reassess the situation including reviewing the priority designations previously assigned to patients [28].

Table 3: Priority number, color, name, and description for the four commonly used triage tags [21, 26, 28, 30].

Tools

Despite a consensus on what priority groupings are used to sort patients during a disaster, how to place patients in each grouping is still highly divisive. The literature has been unable to provide any significant evidence for or against specific triage strategies resulting in a wide array of disaster triage systems used internationally [14, 21, 22]. In the 1980’s, formal triage scoring systems were developed for primary triage that categorized patients based on objective measures. The most used scoring systems are the Revised Trauma Score (RTS) and Champion’s Trauma Score (CTS), both of which utilize a patient’s Glasgow Coma Scale (GCS), systolic blood pressure, and respiratory rate to calculate a total score that sorts patients into the appropriate priority groupings [32]. However, triage scoring systems have been shown to not be as efficacious in the pre-hospital setting since objective measures of vital signs do not always correlate with clinical condition. As a result, triage scores have demonstrated poor sensitivity in the field and there have been instances where normal vital signs masked critical illness in disaster patients resulting in undertriage [13, 32]. Additionally, vital signs taken at the scene of a disaster are not always reliable due to various confounding variables and can create provider uncertainty in the field [32]. Therefore, triage scoring systems have fallen out of favor in disaster triage and this chapter will focus on the use of multi-tier triage algorithms.

Formalized triage algorithms are a set of rigid, pre-determined decision trees that quickly guide providers through the initial assessment of disaster victims in the field [14]. Triage algorithms base their decision making more in components of clinical presentation such as ability to ambulate and breathe rather than objective measures. These algorithms tend to be more suitable for mass casualty disasters as they minimize the time spent making active decisions and are easy to learn in a restricted amount of time [13]. The disadvantage of these algorithms is their lack of flexibility. As discussed previously in the Measures of Success: Undertriage and Overtriage section, it is important to be able to tailor your protocol, and subsequently your over and undertriage rates, depending on the number of casualties and the availability of resources. However, the rigid procedure of these algorithms does not allow for modifications of treatment criteria when time and resources are more plentiful [13]. Many algorithms have been developed with slightly different applications based on patient demographics, mechanism of the disaster, geography, etc. [14]. Due to the sheer number of triage algorithms currently available, this chapter will focus on the most used primary triage tools in disaster medicine: the Simple Triage and Rapid Treatment (START) and Sort, Assess, Lifesaving interventions, Treatment/Transport (SALT) algorithms.

The Simple Triage and Rapid Treatment (START) triage algorithm was originally developed as a result of joint efforts between a California Fire department, Marine department, and medical providers in 1983 [33]. This was one of the first triage systems developed outside of the military and, following its conception, the Domestic Preparedness Program of the Department of Defense made it standard practice in disaster events [28]. It is now the most prolific mass casualty triage system used in the United States [27].

The START triage algorithm was designed as an expedient triage system that would be easily teachable to emergency providers with minimal training [26]. The objective of the system is the be able to evaluate patients older than eight years old within 30-60 seconds and triage them into one of the four priority groupings discussed previously: immediate/emergency (red), delayed (yellow), minimal (green), expectant (black) [14, 27]. This is accomplished through strict criteria looking at patient ambulation, respiratory rate, radial pulse, mental status, and capillary refill, though many versions of START no longer assess capillary refill due to variabilities from the environment [13, 22, 33].

As depicted in Figure 5, the initial step of START is to prompt patients to walk [27]. If a patient can walk following a disaster, this has been shown to be an indicator of low risk and good prognosis [22, 30]. Therefore, patients who can walk are immediately classified as minimal, green, or priority 1. Following this initial step, the remaining non-minimal patients are evaluated based on their respiration, perfusion, and finally mental status. Examples of methods used to assess mental status during START triage include asking patients to perform simple command such as opening and closing their eyes or squeezing a hand [34]. A Yellow tag or delayed status is assigned to all patients that were not originally deemed minimal, but meet the respiratory, perfusion, and mental status criteria set by START. An easy mnemonic to remember the parameters looked at by START is “RPM:30-2-can do”, with RPM standing for Respiration,Perfusion, Mental status. The second portion “30-2-can do” are the associated cut off values for each category: > 30 respirations per minute, presence of radial pulse or capillary refill <2 seconds, and can follow simple commands [26, 27].

Figure 1: START Algorithm to triage patients based on severity [22, 28].

Though there is little research analyzing the overall efficacy of START, the triage system has demonstrated higher overtriage rates in more critically ill patients during a disaster [28]. In a study by Kahn et. al, START was shown to have an overall accuracy of 44.6% in assigning the correct acuity level for patients. Upon further analysis, START was shown to perform well when identifying patients in the minimal category, with the walk test demonstrating accurate prognostic predictions [35]. However, the triage system experienced higher levels of overtriage (53.38%) in the two more critical patient categories with a significant number of patients inappropriately being placed in the immediate/emergency classification when they belonged in the delayed category [35].

The Sort, Assess, Lifesaving interventions, Treatment/Transport (SALT) algorithm was designed to unify the many existing triage algorithms. Due to a significant lack of research surrounding the efficacy of these triage tools, the Center for Disease Control and Prevention (CDC) assembled a committee in 2008 to combine the most effective features of the current mass triage algorithms into a national standard [22, 28]. This resulted in a new triage algorithm that is very similar to START, but with some key differences. SALT performs a more comprehensive triage of patients of all ages by performing multiple stages of sorting and prioritization with opportunities for reassessment [27]. Additionally, SALT prioritizes life-saving interventions by incorporating them into the triage algorithm leaving less room for hesitancy and uncertainty [13]. The protocol and unique features of SALT can be further elucidated by breaking down what SALT stands for.

Sort refers to the first step, unique to the SALT protocol, which entails an initial sorting of patients into three groups, prior to formal evaluation, to determine what order patients should be clinically assessed. This pre-sorting is based on their ability to ambulate and perform simple commands (Figure 2) [36]. If patients are able to ambulate, then they are placed in the “Walk” or “Able to walk” group. These patients will be assessed last due to the low risk associated with the ability to ambulate [22, 30]. Patients who are unable to walk, but are able perform purposeful movements such as waving will be placed in the “Wave” or “Able to make purposeful movements category” and assessed second. Finally, patients who have obvious life-threatening injuries or remain still despite prompts to walk or wave are placed in the “Still” or “Severely injured” category. These patients will be clinically evaluated first [27].

Figure 2: Step 1 of SALT algorithm to prioritize who to clinically assess first [22, 27, 28].

The Assess and Lifesaving interventions steps come next and are performed almost simultaneously. Assessrepresents the clinical evaluations that are performed after the three priority groupings have been established during the Sort step. This step is looking for any life-threatening injuries that require immediate stabilization [14]. As threats to life are found during this evaluation, the Lifesaving interventions step calls for immediate medical intervention during triage to stabilize these patients. These interventions typically include opening the airway, hemorrhage control, needle thoracostomy for pneumothoraxes, and antidote auto-injection for poisoning [14, 22].

The last phase of SALT, Treatment/Transport, requires an additional evaluation of patients following lifesaving interventions in order to place patients in the same four priority classifications for evacuation and definitive treatment utilized in START (Figure 3). This step affords the triage an opportunity to reassess patients following life-saving interventions and factor in their response [14]. This reassessment involves many of the same parameters looked at in START including breathing, mental status, and peripheral pulse. However, it also includes a step to consider the patient’s condition in the setting of the resources available [22]. Similar to START, once the patients have been sorted and tagged, they are transported and treated according to their priority group.

Figure 3: Step 2 of SALT algorithm [31, 36, 37].

SALT has taken over as one of the major triage algorithms used in disasters and is endorsed by numerous entities including the American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, American College of Emergency Physicians, and more [36]. Studies have already begun to show that SALT provides more accurate triaging when compared to START and other triage systems [37, 38]. On the other hand, some studies have observed high levels of overtriage in SALT, similar to those seen in START, and even instances of high undertriage [28, 37, 38]. However, it is important to keep in mind that no clear conclusions can be drawn regarding SALT’s efficacy until more research is performed.

Summary

Disaster Medicine Triage focuses on managing medical care during events that overwhelm local emergency departments, necessitating additional aid. Definitions of “disaster” have evolved to describe situations beyond a community’s coping capability, encompassing natural and man-made incidents like water contamination and power outages. Emergency Medicine, among other healthcare disciplines, plays a crucial role, particularly in disaster response coordination and triage, aiming to do the best possible care for the greatest number. Triage, a core component, involves sorting patients based on their medical needs versus resource availability. With mass casualties, effective use of resources becomes inevitable, underpinning the need for efficient triage to optimize care and resource allocation, emphasizing the utilitarian principle of maximizing survival on a population level.

Authors

Parker MADDOX BA, MS

Parker Maddox is a fourth-year medical student at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia. He graduated from the University of Virginia with a double major in Biology and Chemistry and went on to obtain a master’s degree in Biophysics and Physiology at Georgetown University. Since arriving to medical school, Parker has developed a passion for Emergency Medicine and has performed research on a wide range of topics including early sepsis recognition, pandemic viruses including Coronavirus 2019 and Monkeypox, ischemic stroke, Bell’s palsy, and international ECMO critical care protocol. This work has yielded multiple publications and a presentation at the Society for Academic Emergency Medicine (SAEM) 2022 Conference.

Hassan KHURAM BS, MS

Hassan Khuram is a 4th year medical student at Drexel University College of Medicine, with a background in psychology, biotechnology, and business of healthcare. He graduated Magna Cum Laude with a Bachelor of Science in Psychology from Virginia Commonwealth University and a Master of Science in Biotechnology from Georgetown University. He is passionate about neurocritical care, medical education, and bioethics. He has an extensive background in research, having conducted studies on various subjects, including substance misuse, Parkinson's disease, mindfulness meditation and more. He has published articles on neurological emergencies and ethical issues in neurological care.

Scott GOLDSTEIN, DO, FACEP, FAEMS, FAAEM, EMT-PHP

Dr. Scott Goldstein started his medical career at New York College of Osteopathic Medicine in New York where he received his Doctorate of Osteopathy and continued his training at Einstein Healthcare Network in the field of Emergency Medicine, Philadelphia. Dr. Goldstein is dual-boarded through the American Board of Emergency Medicine in Emergency Medicine and Emergency Medicine Services (EMS). He currently works at a Level 1 academic trauma center, Temple University Hospital, in Philadelphia where he is the Chief of EMS and Disaster Medicine. He has continued to be an active member of the education community and EMS community where he holds the title of Fellow of American College of Emergency Medicine through ACEP, Fellow of the Academy of Emergency Medical Services through NAEMSP and Fellow of the American Academy of Emergency Medicine through AAEM. His current academic title is one of Clinical Associate Professor of Emergency Medicine at Lewis Katz School of Medicine at Temple University.

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Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Being a team member/leader and team dynamics in ED (2024)

March 30, 2024April 22, 2024 ~ iEM Education Project Team ~ Leave a comment

by Munawar Farooq & Bret Nicks

Introduction

Emergency care worldwide has organizational and regional nuance, mainly due to differences in healthcare systems, infrastructure, resources, and history. However, the team’s value proposition remains critical for success in all emergency departments. Over the past several decades, it has become evident that teams and teamwork can positively impact many aspects of the care environment and the engagement of those serving there. When we consider the myriad challenges impeding quality decision-making in the emergency department (ED), such as a lack of time, evolving information, chaotic environment, limited resources, and constant interruptions, amongst others, having a dedicated team can make a significant difference.

While the concept of a team is not new, our understanding of the value proposition of a team and the attributes of effective teams continues to evolve. For many of us in medicine, working in a group is expected. However, there are distinct differences between working in a group and being part of a team. What differentiates a team from a group is the commitment to a common purpose, shared desired outcomes, collaborative and complementary approach, value team over self, and shared accountability. A team’s foundation develops from those that collaborate around a shared goal. However, successful Emergency Medicine (EM) teams require a broader understanding of the essential attributes, processes, and expectations needed for a highly variable, chaotic, intellectually challenging environment dedicated to exceptional patient care. For these reasons and many others, EM epitomizes the ideal of team sports in healthcare.

Psychology of Team

Team dynamics are the learned, unconscious psychological forces influencing a team’s behavior and performance. Organizational culture and departmental culture significantly affect team dynamics. Further influencing factors include the nature of the work, the work environment, work relationships within and across teams within the department, the level of perceived support, and the work effort itself.[1] Recognizing the challenging environment of acute and emergency medicine, awareness of and creating an integrated and positive team dynamic is essential. High-functioning teams demonstrate better clinical outcomes, increased team retention, increased wellness, higher resiliency, and better comparative financials.

High Performing Team Characteristics

Characteristics of successful teams and team members have been studied extensively in various professions ranging historically from the aviation industry to more modern companies like Google. [2] The aviation industry mandates that the flight and cabin crew work together as a team using standard operating procedures (SOPs) and formal training to facilitate teamwork and communication. They recognize that cognitive and psychological stressors can lead to human errors that can occur in high-stakes environments.

Looking at a very different workplace, researchers at Google asked what makes a (Google) team effective. While they anticipated finding the mix of those on the team to be the most influential on the team’s success, they found that the way team members interacted with each other mattered more than the composite of the team [1]. While competency requirements exist in EM and other clinically-based teams, much of Google’s findings apply. They identified five characteristics that promoted effective teams: psychological safety, dependability, structure, clarity, meaning, and impact (Figure 1).

Figure 1: Characteristics of Highly Functioning Teams.

Adopted from Rozovsky J. The five keys to a successful Google team. 2015. URL:
https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team/

Although EM is not Google, recognize that the foundation of all highly effective teams remains the same: trust. In the 5 Dysfunctions of a Team, Lencioni states that you cannot have a successful team without trust. Further, with a lack of trust, team members fear engagement in healthy conflict, essential to reaching better decisions and team member commitment. Only committed team members can hold each other accountable so that the team remains focused on collective goals (Figure 2).

Figure 2: Lencioni, Patrick. The five dysfunctions of a team. London: Wiley, 2002

In emergency medicine (and perhaps medicine in general), metrics and outcomes are commonly the focus of many teams. While quality, safety, and administrative outcomes are essential, one should recognize that top performance of these outcomes flows from teams built on trust, embracing conflict, commitment to a common goal, and shared accountability. When these are in place, quality metrics follow. Addressing team dysfunctions takes work. It requires a desire for positive change, courage, and creating team alignment.

Further, emergency medicine teams are dynamic interdisciplinary teams working in a constantly changing environment with highly fluid teams of junior and senior emergency physicians, nurses, other specialists, students, residents, and other medical assistants. With so many variable team inputs, solidifying the departmental culture and creating the expectation for and practice of highly functional teams helps ensure that any patient receives safe and efficient healthcare, meeting high-quality standards without fail regardless of date, time, and acuity of presentation.

Literature on high-performing teams across multiple professions supports these and additional common characteristics. Dr Tim Baker, in his book ‘Winning Teams’ presents eight characteristics of Winning Teams, as shown in Figure 3.

Figure 3: Adopted with permission Winning Teams, Dr. Tim Baker. Used with copyright permission from DBOS. 8 Key Characteristics of a High-Performing Team | by DBOS AU | Medium

Fulfilling this model, our emergency room teams are diverse but flexible. We adopt safe and effective working procedures like cognitive aids and structured communication tools. We aspire to achieve a shared goal of efficient and safe patient care. We create teams that build trust and mutual respect through transparent communication and clear leadership. We accomplish this by continuously learning and practicing together the necessary clinical skills and critical human factors.

Team development and its success are predicated on a supportive culture that recognizes a just cause. For high-performing organizations, that culture is well-established across all departments and levels. Regardless, organizational culture is simply what you see when you watch and experience the service provided. It comprises a complex pattern of values, expectations, ideas, attitudes, and behaviors around a shared goal.

Effective Emergency Team Leadership

One key challenging but rewarding role of the emergency physician is to orchestrate and lead diverse teams in a relatively stressful and unpredictable environment. While this may represent one of the major attractions of the emergency physician, it can be daunting for some. For a junior physician, it is essential to identify good leadership attributes early and apply them continuously, as it benefits the team and a leader’s clinical navigation during resuscitation. Something can be learned from every member of an interprofessional resuscitation team. Observing how they serve as role models and clinical leaders in any situation and how they interact with colleagues, patients, and families provides a basis for personal growth and reflection.

Advanced life support simulation studies identified better outcome metrics (higher quality cardiopulmonary resuscitation with better technical performance, shorter pre-shock pauses, with lower total hands-off ratio, and shorter time to first shock) with teams having leaders with more experience and refined leadership attributes. [3] Although variability exists with healthcare leader experience, having a high-performing team enhances team dynamics and outcomes. Regardless, effective team leaders must embrace and demonstrate the following leadership elements:

Understand the team value proposition and roles of its members
Manage well in challenging and changing situations
Effectively communicate
Embrace mutual accountability and responsibility
Set specific goals while persevering to achieve them
Balance individual tasks and promote teamwork
Build solid connections and relationships
Demonstrate adaptive learning from their experiences.

It is important to note that most of these attributes are not related to knowledge and skills commonly taught in medical schools but rather experientially or intentionally developed emotional intelligence skills. Developing and deploying these elements can positively influence everyday tasks performed by emergency physicians, such as:

Organize the team and resources to maximize performance
Articulate clear goals with delegation of tasks
Make decisions through the collective input of members
Empower team members to speak up and challenge the leader when appropriate, using group norms to guide behavior
Actively promote and facilitate good team processes
Skillfully prevent and resolve any conflict

Although historically called soft skills or abstract skills, data would suggest that these critical leadership skills are as necessary as clinical competencies. Effective leaders not only work on their clinical and content competence but also on emotional intelligence, communication skills, and performance under pressure.

The Team Player

What makes a team player exceptional? When you think about your current team(s), are they made up of ideal team players? If not, what are you doing about it?

While exceptional team leaders can navigate the professional nuances of their team members, the team’s success is often limited by the leader’s capacity and by the attributes of those team members. High-performing teams are far more multiplicative rather than the simple sum of individual member performances. How we identify future team members or invest time and effort into developing current team members impacts not only outcomes but also influences the quality and capacity of the team.

Often, we hire team members based on their clinical competencies, educational accomplishments, and career success. However, moving beyond competence to team and organizational cultural alignment is essential as we look more closely at developing high-performing teams. Leaders must identify and employ people with three traits that all good team players share: humility, hunger, and smart people (interpersonal intelligence). In his book, “The Ideal Team Player,” Lencioni recommends considering aligning the essential virtues of a team player into three characteristics:

Humble (not arrogant or ego-centric; team-focused)
Hungry (great work ethic; never settling for the minimum)
Smart (skilled in emotional intelligence and people skills)

The ideal team player must have all three characteristics to be a trusted and proficient team member. Assessing teams requires self-reflection regarding these three traits, a conscious desire, and a focused effort to improve. Awareness and growth in this area catalyze individual and team success. When only one or two of these attributes are present, team leaders must consider the value proposition of developing these team members or identifying other opportunities that might be better for that team member.

Key Principles of Teamwork

In addition to discussing the psychology of teams, attributes of high-performing teams, effective team leadership, and ideal team players, further studies have looked at systematic approaches to creating a culture of teamwork within healthcare. TeamSTEPPS, an educational program about teamwork, highlights the fundamental principles of an effective team structure, clear communication process, transforming leadership, situational awareness, and mutual support. [2]

Leaders use Delegation, Pre-Brief and Debrief, and Group Huddles in effective teams to clarify team goals, roles, and expectations. Both team leaders and members maintain situational awareness, cross-monitor each other, and provide constructive feedback. Everyone uses structured communication tools like SBAR (Situation, Background, Assessment, Recommendation), Checking Back, Advocacy, and Gradual Assertiveness to communicate clearly and deliver the safest and best possible care.

Practical Tips to Improve Teamwork

Understanding the attributes of high-performing teams, team leaders, and team members considering the challenges of emergency medicine is foundational to change. However, identifying practical applications that begin to create change and further support culture is essential. [5] Below are some typical applications that have been suggested in the literature and through clinical experience:

Department awareness: Before you start working in a new department, visit, observe, identify the culture, and ask yourself how you can be a catalyst.
Bring your clinical competence and communicate medical decision-making with your team.
Developing empathy in daily challenges requires intentionally understanding another’s perspective, avoiding early judgment, recognizing inherent emotions, and responding genuinely to that emotion. (Brene Brown)
Understand and set role expectations while understanding how your personal attributes influence how you perceive your role.
Huddle first, then get started. Know your team – names and roles. Set expectations for team goals and find opportunities to engage and communicate in person with colleagues throughout the shift.
Consider the patient and their family an essential and valuable team member. The ‘nothing about me without me’ principle applies to everyone, including the patients and staff.
Lend a helping hand. Look for such opportunities and do not wait for the request.
Self-reflection increases continuous learning and improvement. Make it a regular practice regardless of the outcome or situation.
In any resuscitation or other emergency team management situation, follow the principles of clear roles, closed-loop communication, task focus, situational awareness, and the courage to speak up if required for patient or staff safety.
Listen actively by paying attention to non-verbal clues and perspectives while being aware of your own. Listen to understand – do not listen to respond.
Avoid negatively inferred language that feigns responsibility and creates blame or division. This rapidly erodes teamwork and a supportive culture.
Handoffs matter. Align your approach and expectations, as this directly impacts patient and team outcomes.
Offer compliments and appreciation genuinely and frequently. Recognize a job well done with gratitude. It reinforces positive effort and builds team rapport.
Build relationships outside the work environment when feasible. Know your colleagues through their interests, values, goals, achievements, and challenges.
Advocate for patient safety. Learn how to challenge a team member or leader if there is any concern for patient safety. Use a structured tool like “CUS” (Figure 4) or simply state, “I have a concern.”
Never think you are alone. Help is always available. Working in the emergency department is not easy – recognize it. If you need assistance, clinically or personally, ask.

Figure 4: CUS, graded assertiveness tool. Source: TeamSTEPPS. https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html

Case Scenario Application of Team Dynamics

Let us apply all the above learning to a resuscitation scenario and understand how a resuscitation team works. You are part of a resuscitation team when EMS encodes that they are bringing a 10-year-old boy whose scooter was hit by a car. The suspected injuries include a head injury and a possible right thigh injury. The trauma resuscitation team manages the patient very well through the following teamwork processes:

Pre-arrival

Assigned roles. The assigned team leader knows the team members’ strengths, limitations, and expectations. Every member acknowledges their assigned role and any concerns or needs they may have. Doing so before the patient’s arrival helps mitigate positional limitations during the resuscitation. Any members outside this team are also informed as required according to local resources, e.g. Radiographer, Pediatric Surgeons, Orthopedics, etc.
Environment and equipment are prepared with enough space to work around. Airway and resuscitation equipment, confirmed at the beginning of the shift, is assessed based on any specified checklists and procedures.

Post Arrival

On arrival of EMS, handover is taken using pre-defined handover tools or processes with prehospital teams. The noise and distractions are kept to a minimum to optimize patient care information handoff and prompt transfer.
The team leader directs care with the team – and, when possible, stands at the foot of the bed to maintain situational awareness and monitor the team’s performance.
Team members perform assigned roles while maintaining situational awareness, monitoring the patient and teammates, and reporting back.
Clear and respectful closed-loop communication. Team leaders direct requests to every member using their names, and team members acknowledge the understanding of the task by repeating back and then announcing the completion of the task.
The team leader frequently shares ongoing medical decision-making with the team throughout the resuscitation by describing the situation and plan. For example, after completion of the primary survey, the team leader announces, “It appears that the child has an isolated head injury. Let us aim to intubate this patient and transport him to a CT scan within the next 15 minutes”. This provides directional clarity and offers an opportunity for feedback.
Teams use cognitive aids like checklists to prevent any medical errors. In contrast, the team leader maintains an open, respectful, and empowering environment where every member can challenge and raise patient safety concerns. Team members use graded assertiveness tools like ‘CUS’ to raise their concerns.
A culture of vulnerability and trustworthiness is maintained when team leaders or team members express when they are unsure of something and freely ask for help or a second opinion. Before any significant high-risk decision, the team leader shares the medical decision-making rationale and plan with the team.
Updating or briefing new members from other teams by the team leader or a designated member allows for clarity of ongoing care and consultative expectations. Recognize the emergency department is your home, but that may not be true for others.
After resuscitation, a hot debrief is performed with the team to express objective gratitude, provide compliments, discuss what went well, and identify areas for improvement. Critical issues should be addressed in a more formal debrief, especially if future application is intended.

As mentioned throughout this chapter, the benefits of developing a high-performing team in the emergency department are myriad. It will improve departmental morale and greatly influence the quality of care provided, create mission alignment, foster resiliency, and attract exceptional team members. Table 1 presents additional benefits of effective teamwork [6].

Organizational benefits	Team benefits	Patient benefits	Benefits to team members
Reduced time and costs of hospitalization	Improved coordination of care	Enhanced satisfaction with care	Enhanced job satisfaction
Reduction in unexpected admissions	Efficient use of healthcare services	Acceptance of treatment	Greater role clarity
Services are better accessible to patients.	Enhanced communication and professional diversity	Improved health outcomes and quality of care, reduced medical errors	Enhanced well-being

Table 1: The benefits of effective teamwork

Summary

Successful teamwork is challenging but worthwhile. Trust represents the foundation of all successful teams. They also embrace a shared common purpose and a dedication to quality in an environment where team members work together, communicate effectively, anticipate and meet each other’s demands, and inspire confidence, resulting in coordinated collective action. For many, the phrase, ‘teamwork can make the dream work,’ resonates with them. It is an uphill climb. It starts with trust. It requires courage. And it requires effort. If the dream is high-quality patient care in a safe and respectful department, start with your team.

Authors

Munawar FAROOQ

Dr. Munawar Farooq, with qualifications including MBBS, FCPS (Pak), MRCS (UK), FACEM (Australia), and a Pg. Dip. in Medical Toxicology from Cardiff University, UK, is currently an Assistant Professor of Emergency Medicine at CMHS, UAEU. His prior roles include Consultant in Emergency Medicine in Canberra, Australia, and Doha, Qatar, Clinical Lecturer at Australian National University (ANU) in Canberra, ACT Australia, and Honorary Senior Lecturer in MSc Resuscitation at Queen Mary University London, UK. His special interests are in resuscitation medicine, toxicology, trauma, and medical education. His research focuses on detecting deteriorating patients, early warning scores, oxygen delivery device requirements in COVID outbreak, on-floor low fidelity simulations, and Leadership Training. In medical education, he is particularly interested in teaching leadership skills, Emotional Intelligence, and Human factors.

Bret NICKS

Bret Nicks, MD, MHA is an emergency physician that embraces the breadth of our specialty. He is a Professor and Executive Vice Chair of Emergency Medicine at Wake Forest University School of Medicine. He is the past president of the North Carolina College of Emergency Medicine. He served as the Chief Medical Officer of the award-winning Wake Forest Baptist Davie Medical Center. Dr. Nicks served as the founding Associate Dean for the Wake Forest Office of Global Health. He has lived, practiced, and led in many resource austere locations globally, although calls the academic tertiary care emergency department his home. He is passionate about, consults and lectures on the interface of clinical quality, leadership and team culture – and is dedicated to developing EM leaders for the future of our specialty and the transformation of healthcare. He loves anything outdoors, enjoys blogging on various life and leadership topics; http://www.bretnicksmd.com/blog, and recently published his first book.

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References

Rice MM. Strategies for clinical team building: the importance of teams in medicine. Emergency Department Leadership and Management: Best Principles and Practice. 2014 Nov 27:47
Rozovsky, Julia. “The five keys to a successful Google team. 2015.” URL: https://rework. withgoogle. com/blog/five-keys-to-a-successful-google-team (2015).
Yeung JH, Ong GJ, Davies RP, Gao F, Perkins GD. Factors affecting team leadership skills and their relationship with quality of cardiopulmonary resuscitation. Crit Care Med. 2012;40(9):2617-2621. doi: 10.1097/CCM.0b013e3182591fda
Clapper TC, Kong M. TeamSTEPPS®: The patient safety tool that needs to be implemented. Clinical Simulation Nursing. 2012;8(8):367-373
Vazquez CE. Successful work cultures: recommendations for leaders in healthcare. Leadersh Health Serv (Bradf Engl). 2019;32(2):296-308. doi:10.1108/LHS-08-2018-0038
Babiker A, El Husseini M, Al Nemri A, et al. Health care professional development: Working as a team to improve patient care. Sudan J Paediatr. 2014;14(2):9-16.

Free online resources for further self-learning

CanadiEM Frontline Primer, Emergency Department Culture 101. https://canadiem.org/canadiem-frontline-primer-emergency-department-culture-101/
Rozovsky J. The five keys to a successful Google team. 2015. URL: https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team/
Lencioni P. The 5 Dysfunctions of a Team. Teamwork 5 Dysfunctions | The Table Group
Pocket Guide: TeamSTEPPS https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html
Podcast; Dr. Randy Sorge with Dr. Ryan Stanton, Teamwork makes the dream work – Team Dynamics in the ED. https://music.amazon.com/podcasts/816785e7-0c23-47c0-96f4-38017c4b11ba/episodes/6a12c8fd-71f1-4b64-8274-ea72e4189fe3/acep-frontline—emergency-medicine-teamwork-makes-the-dream-work—team-dynamics-in-the-ed

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Discharge Communications (2023)

May 15, 2023May 18, 2023 ~ iEM Education Project Team ~ Leave a comment

by Dominique Gelmann, Bret Nicks

Introduction

The process of emergency department (ED) discharge provides critical information for patients regarding the next steps of their care. Discharge instructions are often required by hospital accreditation and governmental organizations for quality or monitoring metrics. However, studies show that many patients do not fully understand or recall the instructions they receive [1,2]. In addition to patient-specific factors contributing to lack of comprehension and care compliance, the myriad situational challenges inherent to every emergency department as well as individual clinician skills and knowledge of best discharge practices further impact patient experience, understanding, and subsequent outcomes.

In many instances, the discharge process is often limited to a brief exchange of documents, prescriptions, and verbal description of the diagnosis, frequently leaving patients with uncertainty about their care plan. Understanding discharge instructions can be very challenging for a variety of reasons. Physical or emotional discomfort can impact receptiveness to and comprehension of imparted information, for example. Patients or family members eager to leave may be less interested in the instructions; conversely those presented with a devastating diagnosis may be less able to process specific details.

Moreover, a significant number of patients have low literacy and/or health literacy levels. In addition, the busy ED setting may distract the patient’s attention from such instructions. Understanding the challenges surrounding discharge communications in the ED from the patient’s perspective and having a clear approach and purpose is essential. Much more critical than an afterthought, discharge is the first step of a patient’s care transition and greatly impacts quality outcomes, litigation, experience, and team morale [3,4].

Understanding the Challenges

Emergency physicians face unique challenges while ensuring high-quality care due to distractions and time limitations that are common throughout ED settings. In most cases, emergency physicians have little or no previous knowledge of their patients and are unlikely to partake in the follow-up process, making effective communication paramount when patients are discharged from the ED. Providing clear and consistent communication throughout the entire patient care encounter, including the discharge process, is an important aspect of quality and patient-centered emergency medical care.

Unfortunately, many patients are discharged from the ED with an incomplete understanding of the information needed to safely care for themselves at home or when to promptly return to the ED [1, 5-6]. Patients have particular difficulty comprehending post-ED care instructions regarding medications, home care, and follow-up expectations. And while all patients discharged from the emergency department should be provided instructions for ongoing management of their medical condition, studies demonstrate that patient recall and understanding of diagnosis, treatment, and follow-up plan are generally quite poor [1,2,5-9]. This raises significant concerns for care plan adherence and medical outcomes, which studies show are poorer in cases of low health literacy. Given current trends toward value-based care and the fact that nearly half of the lawsuits in emergency medicine revolve around discharge instructions and plans, ongoing improvements in the discharge communication process is essential [3,4].

While some of this relates heavily to the ability of the provider to establish a trusting and positive patient-provider relationship within the ED constraints, several additional strategies can be used to enhance the recall of instructions, improve compliance, and minimize litigation.

Discharge Essentials

Effective discharge communication provides an opportunity for the emergency department team to summarize a patient’s visit, teach them how to safely care for themselves at home, and provide specifics regarding the next steps in their care process. It also gives ED physicians a chance to address any remaining questions or concerns, often augmenting patient and family understanding while improving care plan retention. Although patient education at discharge typically begins with initial assessments and conversations with patients and family, other factors can also influence the success or failure of how information is transmitted at discharge.

Common interventions promoting an effective ED discharge process include using a standardized approach to relaying content, providing various modes of information delivery and tailoring them to the individual patient, confirmation of comprehension, post-discharge care follow-up planning, review of vital signs, and a patient-centered closure (Table 1) [8,9].

Table 1: Interventions in the ED Discharge Process

Domain	Intervention
Content	Standardize approach
Delivery	Verbal instructions (language and culture appropriate)
	Written instructions (mindful of lower literacy levels)
	Basic Instructions (including return precautions)
	Media, visual cues, or adjuncts
Comprehension	Confirm comprehension (teach-back method)
Implementation	Resource connections (Rx, appointment, durable medical supplies, follow-up)
	Medication review

Content refers to the education provided to our patients related to their ED testing, procedures, and treatment, as well as further education on diagnosis, expected course of illness, post-ED treatment and follow-up plan, and medication reconciliation. Instructions should specifically highlight time-sensitive next steps in care plans, including when and how to schedule follow-up appointments with whom and why. Further, emergency physicians should assist in arranging critical follow up prior to discharge as able. Precautions regarding when to return to the ED versus waiting for any follow-up appointments should additionally be provided, as well as instructions for how to care for oneself until follow-up. These basic tenants of discharge, often described as the ‘rules of the road’ (Table 2), may serve as a basic framework for the discharge process.

Table 2: Rules of the Road for Successful Discharge

Have the right diagnosis
Time & Action Specific Instructions
- What to do
- When to do it
Provider Specific
- Who to contact
- Why and When
- Printed Information
- Verbally explained
- Verbally confirmed

In addition to the content itself, the importance of the quality and approach of its delivery cannot be overstated. The ED provider and care team members must consider the wide range in literacy, health literacy, cultural backgrounds, and access to outpatient resources when delivering the ongoing care instructions [6,7]. In many instances, EDs attempt to improve patient and family understanding of discharge instructions through standardization and simplification of written and verbal instructions. Due to literacy variability, current literature recommends instructions are written at a late elementary educational level [10]. Verbal discussions in conjunction with written instructions have been shown to be superior to written instructions alone [11]. For patients with a primary language differing from that of the clinician, use of interpreter services, when available, has been shown to improve quality of discharge communication and clinical understanding [12]. Other approaches that may benefit patient outcomes include providing supplemental written information and using visual and multimedia adjuncts to support understanding [8,9].

Essential to any successful approach is the comprehension of the patient regarding all of the information provided. After all, if the content and delivery are exceptional but the comprehension is poor, this should be seen as a discharge failure as it decreases care compliance and outcome quality. To address this specific aspect of the discharge process, instituting a read-back or teach-back method is recommended. This method involves asking the patient to repeat back their understanding of the information imparted, which allows the physician to identify any remaining gaps in understanding and provide additional instruction as needed.

The implementation of discharge care processes frequently falls short due to unidentified social and medical factors that prevent the plan from being carried out. Social factors could include homelessness, low income, uninsured/underinsured status, lack of transportation, or lack of primary care. Medical factors could include concurrent psychiatric illness, substance abuse, cognitive impairment, inability to care for self, or young/advancing age. Understanding these circumstances will help identify patients at high risk for discharge complications and trigger additional resource considerations for these patients.

The discharge process provides an opportunity to ensure the patient’s condition is well understood, that no additional medical red flags need to be addressed, and that the care plan and follow-up are well understood. In an online video, Dr. Oller provides another process to engage the ‘moment of safety‘ related to discharge and outlines 5 essential steps (Table 3) for any ED discharge [13].

Table 3: ED Discharge: Moment of Safety

Has the medical provider discussed the findings, diagnosis and plan of care (including medications and follow-up plan)?
Confirm the discharge instructions and prescriptions match the patient identifiers
Review all prescriptions and clarify any changes
Review current vital signs
Provide closure

Barriers to Successful Discharge

The barriers to successful discharge are myriad. Some are intrinsic to the ED work environment and nature of emergency department patient arrival and flow. Others relate to the challenging or often unidentified social and medical factors that prevent the plan from being completely carried out. In a recent American College of Emergency Physician Quality Improvement and Patient Safety section meeting, Dr. Pham shared a conceptual framework for understanding the barriers to success and improving the discharge process (Figure 1) [14].

Figure 1: Barriers to Successful ED Discharge

While this framework may not be uniformly representative of all EDs, it addresses many of the operational failures that occur outside of the ED and outlines opportunities for hospitals and health systems to align for improved patient care outcomes. And while screenings for high-risk discharges in EDs occur, the additional resources needed to ensure appropriate social work or case management care coordination are often limited.

Post-discharge follow-up processes for patients at risk for failing discharge instructions exist in some systems. This may include flagging a patient’s chart for a social work follow-up to assess and assist with the patient’s ability to obtain necessary medications, make and attend follow-up appointments, or address other concerns identified by the provider. Some physician groups routinely call patients the next day to see how the patient is doing and ensure understanding of their discharge instructions and care plan [7,8].

Types of Discharge Information Packets

Discharge instructions vary widely by practice location and resources available. However, there remain 3 primary means of providing discharge information and instruction: a basic care instruction note, a preformatted illness specific instruction sheet, and a templated software-based discharge product [8].

Commonly used, an instruction note is simply a set of instructions handwritten or typed on plain paper, without the assistance of computer programs. In settings with limited resources, this may be the only means of providing essential care information for the patient, their family, and the provider with whom they may follow-up. While uniquely tailored, they may lack substantial content for care, take time to prepare, and be limited by literacy and handwriting.

Information sheets are pre-printed education and instruction documents that describe care information related to one specific illness. They can be developed for the most common medical illnesses for each institution and have essential information regarding plans of care. Information sheets are immediately available, inexpensive, reproducible, and can be designed to include simple language and or pictorial education. They are not patient specific, may not provide adequate instruction in difficult or complicated cases, and require computer, printer, and copying capacity.

For settings with an integrated EHR, software products that create discharge packets (including discharge diagnoses, medications, medical care instructions and information regarding the illness, outlined care course after leaving the ED, and essential contact information for those next steps) are available. These are highly resource dependent and therefore may not be routinely available.

Each form of written discharge materials offers its own unique benefits and drawbacks. Regardless of type utilized, physicians should exercise the basic principles outlined above in ensuring appropriate readability and quality of information provided. While specific details are helpful and important, distilling instructions into a short, high-yield sheet has been shown to be more effective than providing a large stack of superfluous [information] that patients may not entirely review [15].

Leave Against Medical Advice and Elopement

In certain circumstances, patients may request to leave prior to completion of their medical evaluation and treatment. In this situation, it is essential for the last health care professional caring for the patient to clearly document why the patient left and attest that the patient had the mental capacity to make such a decision at that time. While some electronic documentation systems have templates in place to assist with this documentation, Table 4 provides basic information for against medical advice (AMA) discharge documentation that can be used to create a uniform template [3,4,16,17].

Table 4: Documentation for Patients Leaving Against Medical Advice

Component	Description
Capacity	Establish a patient’s decision-making capacity, and clarify aspects of care which may affect capacity (i.e. patient is now clinically sober, etc.)
Risks	Specific condition-associated risks that were discussed (missed diagnosis, potential harms from untreated disease process, etc.)
Verify comprehension	Patient’s understanding of the risks
Patient’s decision	Include the patient’s decision, and any alternative plans (i.e. patient refused admission, but agreed to follow up with the primary physician tomorrow)
Signatures	Patient’s and provider’s signatures

An attempt should be made to provide the patient with appropriate discharge instructions, even in the event that a complete diagnosis may not yet be determined. Include advice for the patient to follow up with their own physician, strict return precautions, and concerning symptoms that should prompt the patient to seek further care. In addition, it should be made clear that leaving against medical advice does not prevent the patient from returning to the emergency department for further evaluation if their symptoms worsen or if they change their mind about receiving care. Despite a common notion to the contrary, AMA discharge does not automatically provide the emergency physician with immunity from potential medical liability [16,17]. In the event that a patient lacks decision-making capacity to adequately understand the rationale and consequences of leaving AMA and their condition places them at risk for imminent harm, involuntary hospitalization is warranted and often legally required depending on the location of practice. In unclear circumstances and if available, a psychiatrist can assist in determining capacity, especially in the case of patients with mental health conditions.

Elopement is a similar process in which patients disappear during the care process. While it is difficult to provide discharge paperwork for these patients, documenting the actions taken to find the patient is essential (e.g. searching the ED, having security check the surrounding areas). In addition, clinicians should attempt to reach the patient by phone to discuss their elopement and any additional care issues or concerns. Documentation of these attempts or any additional conversation is critical in mitigating legal risks [3,4].

Conclusion

Discharge instructions are a very important part of the emergency department care process and record. It is essential to ensure each patient has a complete understanding of their instructions in order to promote care compliance and improve transitions in care. Verbal instructions remain more effective than written instructions, but both are needed and a multimodal approach to relaying information is preferable to a single modality. Be explicit, keep it simple, and have the patients repeat back instructions to ensure understanding. These simple steps will improve patient outcomes and compliance, and help clinicians avoid medical and legal pitfalls.

Authors

Dominique GELMANN

Dominique Gelmann is an Emergency Medicine resident at Wake Forest University. Her interests include patient-physician communication and health literacy. During medical school she completed a one-year research and leadership fellowship investigating health literacy as a social determinant of health, and helped author an institutional white paper with actionable strategies for improving health literacy education. She has given several lectures on the topic to various audiences, and developed a curriculum on health literacy and best-practice patient-provider communication principles for a free student-run health clinic. She looks forward to continuing strengthening her passion for this work throughout her career.

Bret NICKS

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2018 version of this topic – https://iem-student.org/discharge-communications/

References

Clarke C, Friedman SM, Shi K, et al. Emergency department discharge instructions comprehension and compliance study. CJEM 2005 Jan;7(1):5-11.
Clark PA, Drain M, Gesell SB, et al. Patient perceptions of quality in discharge instruction. Patient Educ Couns. 2005 Oct;59(1):56-68.
Henry GL, Gupta G. (2013). Medical-Legal Issues in Emergency Medicine. In Adams (Ed.), Emergency Medicine Clinical Essentials, 2^nd Ed; 1759-65. Philadelphia, PA: Elsevier.
Siff JE. (2011). Legal Issues in Emergency Medicine. In Tintinalli’s (Ed.), Emergency Medicine, 7^th Ed; 2021-31. McGraw-Hill.
Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med 1997;15:1–7
Engel KG, Buckley BA, Forth VE, et al. Patient Understanding of Emergency Department Discharge Instructions: Where Are Knowledge Deficits Greatest? Acad Emerg Med 2012; 19(9):1035-1044.
Sameuls-Kalow ME, et al. Unmet Needs at the Time of Emergency Department Discharge. Acad Emerg Med. 2015 Dec 18.
Taylor DM, Cameron PA. Discharge instructions for emergency department patients: what should we provide? J Acad Emerg Med. 2000; 17:86-90.
Zeng-Treitler Q, Kim H, Hunder M. Improving Patient Comprehension and Recall of Discharge Instructions by Supplementing Free Texts with Pictographs. AMIA Annu Sympo Proc 2008:849-853.
Choudhry AJ, Baghdadi YM, et al. Readability of discharge summaries: with what level of information are we dismissing our patients? Am J Surg. 2016 Mar; 211(3): 631–636. PMID: 26794665.
Al-Harthy N, Sudersanadas KM, Wagie AE, et al. Efficacy of patient discharge instructions: A pointer toward caregiver friendly communication methods from pediatric emergency personnel. J Family Community Med. 2016 Sep-Dec; 23(3): 155–160. PMID: 27625582.
Gutman CK, Cousins L, Gritton J, et al. Professional interpreter use and discharge communication in the pediatric emergency department. Acad Pediatr. 2018;18(8):935–943. PMID: 30048713.
Oller C. Discharge Moment of Safety. Available at: https://www.youtube.com/watch?v=xuLjBWkfomE Accessed January 30, 2016.
Pham JC, Ijagbemi M. Improving the ED Discharge Process. ACEP. Available at: http://www.acep.org/content.aspx?id=90940 Accessed January 15, 2016.
DeSai C, Janowiak K, Secheli B, et al. Empowering patients: simplifying discharge instructions. BMJ Open Qual. 2021 Sep; 10(3).
Levy F, Mareiniss DP, Lacovelli C. The Importance of a Proper Against-Medical-Advice (AMA) Discharge. How Signing Out AMA May Create Significant Liability Protection for Providers. J Emerg Med. 2012;43(3):516-520.
Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51:899-902.

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Special Considerations for Homeless Patients in the Emergency Department

July 5, 2021June 12, 2021 ~ Helena Halasz, Hungary ~ Leave a comment

The emergency department is often the first place that a homeless patient steps into to seek medical aid, and as such, the special considerations in the care of this particularly vulnerable patient population is an important discussion for aspiring emergency medicine physicians.

In 2017, a YaleGlobal article estimated that there were approximately 1.5 million homeless people worldwide, which made up 2% of the global population at the time. In the same report, they noted that an estimated 1.6 billion people lacked “adequate housing,” which unfortunately has no specific definition and thus varies from country to country, as well as from study to study.¹

Nevertheless, it is apparent that the numbers are staggering. For an in-depth overview of the statistics relating to homeless on a global scale, Wikipedia offers a list of countries by homeless population, linked here.² Many of these individuals do not have easy access to maintenance healthcare and end up resorting to emergency services for both acute and non-acute issues.

Numerous studies have shown that homeless patients are generally high utilizers of emergency services; according to the Center for Disease Control in the United States, there was an annual average of 42 ED visits per 100 non-homeless people between 2015-2018, compared to an average of 203 ED visits per 100 homeless persons in the same timeframe.³

So the question becomes: what are some of the special considerations that we, as emergency medical staff, should be weighing when treating homeless patients? Here are some tips:

Start thinking about disposition early, and, if your facility has access to them, get social workers involved as soon as possible. Take into consideration the closing time(s) of nearby shelters, and plan accordingly.
Discuss and document your patient’s social history thoroughly; this can not only help whatever further research that may be conducted but also help build better rapport with your patient. Ask whether they live in a shelter or on the street, for how long, transportation needs, etc., and be sure to document key findings.
Evaluate ability to perform activities of daily living, assess the level of functional independence and ambulatory capabilities.
Provide clothing, food, warm blankets, and mobility devices, when appropriate.
Assess access to follow-up healthcare. Familiarize yourself with the resources available: what are the organizations in your area that might be of help? Are there non-profits that work explicitly with the homeless population?
Discuss any potential substance abuse and attempt counseling.*

* In the United States, consider obtaining an x-waiver, which would allow you to prescribe buprenorphine. For more information about the significance of the x-waiver and information on how to obtain one online for free, click here.

Prepare discharge papers with clear, easy-to-understand instructions for follow-up and care. Avoid medical jargon and use comprehensible language; one recommendation suggests keeping language to a fifth-grader level.

Areas of improvement:

Each institution that deals with homeless patients will likely have its own protocols in place for its management. It is helpful to get acquainted with these protocols and to look around your emergency department to see if there is any room for improvement.

Below are some of the interventions which were undertaken, many of which ultimately showed a reduction in re-presentation and ED utilization, and could lead to an increase in patient satisfaction.

transition of care: a review examining the effect of various interventions in discharging homeless patients found that all three studied categories (those being case management, individualized care plans, and information sharing) had a modest impact, with varying degrees of success based on different studies.⁴
dedicated homeless clinics: a single-center study in 2020 found that a dedicated homeless clinic initiative reduced ED disposition failures and inappropriate ED visits, defined as seeking care for non-emergent conditions.⁵
transportation considerations: while some hospitals are able to subsidize travel costs (taxi vouchers, shuttle service, etc.), that might not be possible at all institutions, so alternatives should be considered.

[A 2012 community-based participatory research approach was undertaken to understand how homeless patients (n = 98) reflected on their care. Of the patients surveyed, 42% mentioned that there had been no discussion of transportation, while 11% noted that they had slept on the street the night after discharge.⁶ This goes to show how important it is to discuss disposition early and thoroughly.]

adding social determinants into electronic medical record-keeping systems: a paper reflected on the changes, such as adding fields for social determinants to the electronic health record (EHR) system, that were undertaken in Hawaii, USA.⁷ Some institutions tag their homeless patients in a certain way, but making changes at the EHR level could help integrate social needs into clinical care across multiple providers.

References and Further Reading

Chamie J. As Cities Grow Worldwide, So Do the Numbers of Homeless. YaleGlobal Online. https://truthout.org/articles/as-cities-grow-worldwide-so-do-the-numbers-of-homeless/. Published 2017. Accessed June 8, 2021.
Wikipedia. List of countries by homeless population. Wikipedia. https://en.wikipedia.org/wiki/List_of_countries_by_homeless_population#cite_note-1. Accessed June 8, 2021.
QuickStats: Rate of Emergency Department (ED) Visits, by Homeless Status and Geographic Region — National Hospital Ambulatory Medical Care Survey. MMWR Morb Mortal Wkly Rep. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a8.htm. Published 2020. Accessed June 8, 2021.
Soril LJJ, Leggett LE, Lorenzetti DL, Noseworthy TW, Clement FM. Reducing frequent visits to the emergency department:A systematic review of interventions. PLoS One. 2015;10(4):1-18. doi:10.1371/journal.pone.0123660
Holmes CT, Holmes KA, MacDonald A, et al. Dedicated homeless clinics reduce inappropriate emergency department utilization. J Am Coll Emerg Physicians Open. 2020;1(5):829-836. doi:10.1002/emp2.12054
Greysen SR, Allen R, Lucas GI, Wang EA, Rosenthal MS. Understanding transitions in care from hospital to homeless shelter: A mixed-methods, community-based participatory approach. J Gen Intern Med. 2012;27(11):1484-1491. doi:10.1007/s11606-012-2117-2
Trinacty CM, LaWall E, Ashton M, Taira D, Seto TB, Sentell T. Adding Social Determinants in the Electronic Health Record in Clinical Care in Hawai’i: Supporting Community-Clinical Linkages in Patient Care. Hawaii J Med Public Health. 2019;78(6 Suppl 1):46-51. http://www.ncbi.nlm.nih.gov/pubmed/31285969http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC6603884.

[cite]

Healthcare: A back up industry

June 16, 2021April 30, 2021 ~ Sajan Acharya, Nepal ~ Leave a comment

Examples of system failure are littered around the medical field and often disguised as professionalism or better yet heroism. “One resource seems infinite and free: the professionalism of caregivers”, says an opinion piece published in The New York Times. The article goes on to say that an overwhelming majority of health care professionals do the right thing for their patients, even at a high personal cost. Noteworthy is the availability heuristic that comes into play. “Of course they should work in favor of their patients, no matter what, isn’t that why they chose the medical profession!?”, you ask. They sure did. A lot of why you believe that medical professionals must go out of their way to help patients can be explained by what news you are being exposed to these days. The availability heuristic! That kept aside the gist of the article can roughly be summed up in the following excerpt

“Counting on nurses and doctors to suck it up because you know they won’t walk away from their patients is not just a bad strategy. It’s bad medicine. This status quo is not sustainable — not for medical professionals and not for our patients.”

I invite you to, for some minutes, drop all the preoccupation and think about it logically. I have, time and again, submitted myself to the idea that empathy and not logic is the best way to get my point across. But today, let us first think about some pertinent analogies.

As we anticipate the dreaded tsunami of COVID-19, many governmental healthcare institutes are sending out a notice for recruiting doctors and nurses for a certain time. My sister who is a nurse said, “Why do they have to make it sound like we are disposable?”. To which, I wittingly replied, “ Well they are probably looking for paid volunteers.” But the same recurring theme covers the core of our conversation. We simply were treating healthcare as a per-need industry. When the reality is, again, a contrasting opposite. Indeed, healthcare is a backup industry. You do not wish to use it when things are going smoothly. The healthcare system of any country should stand on its mighty ability to deal with crises.

Most other industries can either do with the number of people already in the industry or have to let go of people they already had, during a disaster. That is a contrasting opposite to the healthcare industry. Every time the health of the public is threatened we start to search for volunteers and temporary hires. I argue this is because the healthcare industry is ruled by businesses in the most powerful countries. To the point that the notion of just enough or even fewer doctors working in a setting is looked upon as a heroic measure. I don’t suppose you would say. “Oh! That busy bank has only one teller, and she also works as a receptionist. How heroic of her!”, do you?

There are reserves in almost every industry. Take transportation as another example: I visited Kathmandu on a night bus during my vacation as a child. My dad introduced me to two men. Both of them were drivers. I was taken by surprise when I found out the bus only had one steering wheel. “What would the other driver do!?”, the inquisitive child in me asked. My dad was semi-asleep when he answered, “They will drive for the whole night. Don’t you think they need to rest?”. I sure do Dad, I sure do!

In aviation, the first officer (FO) is the second pilot (also referred to as the co-pilot) of an aircraft. The first officer is second-in-command of the aircraft to the captain, who is the legal commander. In the event of incapacitation of the captain, the first officer will assume command of the aircraft. A second officer is usually the third in the line of command for a flight crew on a civil aircraft. Usually, a second officer is used on international or long haul flights where more than two crews are required to allow for adequate crew rest periods.

There have been some examples of what would be analogous to a natural disaster in other industries. Let us take some economic ups and downs as examples. Remember, India demonetized Rs. 500 and Rs. 1000 notes? Bankers had to work extra hours to make sure the undertaking completed in due time. They, of course, were paid an extra allowance for that. Interestingly they did not have to open up more positions for the work to be carried out. Remember the great economic recession? It “forced” business owners to let go of their employees. Not recruit more!

I vividly remember feeling proud of one of my seniors who was portrayed as an ideal healthcare worker. “He was arranging the medicine cabinet when we visited him”, one of my professors boasted. I felt not only proud but a desire to be at his place and do as he did one day. Today I understand that 1) he could be doing something way more productive and 2) what my senior was doing when my professor reached there was a clear example of a system failure.

Let me give you an example of my intern year to demonstrate the lack of consideration of the human element in designing healthcare systems. I had to take leave for some days. It was the flu. I understand that the coronavirus situation has alchemized the glory that flu deserved all along, but those were different times. I had a severe sore throat and my body ached like some virus was gnawing on my bones. I remember feeling very guilty about being ill because while I was sniffing Vicks and popping paracetamols in the hostel. My friends (fellow interns) were working their asses off. But when the system was designed, did no one think that someone might get sick? I mean, we work around infections every day. C’mon system designers, that is blindness, not just shortsightedness. The irony is: we are in an industry where we boast about our ability to empathize with human pain, suffering, and ill-health.

Human development has been punctuated by disasters of some sort, time and again. It is almost comical that we haven’t learned our lessons and that harrowing circumstances have to keep reminding us of the need for preparedness. It almost feels like I am writing a reminder the second time. After I failed to follow through my previous reminder. For me, the first time was the Nepal earthquake 2015. I am sure you have your own first time. I can only speak of the healthcare industry because that is what I have been fortunate enough to see closely. I am sure preparedness means different things in different settings. For healthcare, it means 1) taking into account the human element and 2) realizing that healthcare is a backup industry.

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The Unspoken Damage of COVID-19 on Spanish-Speaking Patients

January 11, 2021January 1, 2021 ~ Sarah Bridge, USA ~ Leave a comment

The COVID-19 pandemic has uncovered some ugly truths about the American healthcare system. One of the ugliest is discrimination against non-English-speaking patients. This form of discrimination particularly affects native Spanish-speaking only patients (defined in this article as “Spanish-speaking patients), who comprise not only a large proportion of America’s hospital patronage but also a majority of those suffering from COVID-19.

In May 2020, as part of my Emergency Medicine residency training, I worked at a small community hospital in northern Virginia, located in an agricultural area with a large number of Central American and Mexican migrant workers. The first few days of the rotation were relatively unremarkable until the COVID-19 cases began to pour in. Most of those suffering from severe COVID-19 were Spanish-speaking patients employed at a local plant nursery where an outbreak was occurring.

I intubated a COVID-19 patient almost every day I worked there. I speak Spanish fluently, and since I was able to communicate with Spanish-speaking patients and their families, I was able to obtain consent for the procedure. I will never forget one patient who had tears rolling down his face shortly after intubation as we titrated his post-intubation sedation medications. I spoke with his son over the phone, in Spanish, who thanked me profusely and cried, worried he would never see his father alive again. He asked if he could visit his father in the hospital. He cried more when I explained the no visitor policy for hospitalized COVID-19 patients. He still thanked me.

The ER staff also thanked me, because until I arrived, few in-person Spanish interpreters or fluent Spanish-speaking providers worked there. Therefore Spanish-speaking patients consented to intubations using a phone-based interpretation service. Though The Joint Commission states that telephone or video interpretation is sufficient to obtain informed consent (especially during the COVID-19 pandemic), in-person interpretation has proved superior. Unfortunately, at this small hospital, out of necessity and due to inundation by COVID-19 victims, Spanish-speaking patients had occasionally been intubated without true informed consent. For example, I remember a case when the overwhelmed nursing staff struggled to connect to and understand the phone-based interpreter while donning PPE and equipping a Spanish-speaking patient’s room for emergent intubation, only to be followed shortly thereafter by another critical COVID-19 patient.

Despite the large number of Spanish-speaking patients receiving care in the United States, a 2016 survey of 4,586 American hospitals showed that only 56 percent offered some sort of linguistic and translation services. As a former volunteer Spanish interpreter for a university hospital, the cost is cited as the primary reason, among many. Discrimination against undocumented people and xenophobia are unstated reasons. I remember distinctly a Grand Rounds presentation about native Spanish-speaking patients in hospitals and how a Latinx pediatrician emotionally expressed how often she witnessed Spanish-speaking families receive worse care than their English-speaking counterparts. Indeed, inadequate or inaccurate interpretation has resulted in serious legal, financial, and patient safety repercussions for hospitals.

In June, I worked in the COVID-19 ICU at my residency program’s hospital. Most of the COVID-19 ICU patients had been transferred from the same small hospital where I worked the previous May. After rounds, most of my afternoon was spent contacting Spanish-speaking family members and updating them on their loved one’s condition. It was heartbreaking to tell these families that they could not visit their loved ones in the hospital. Undoubtedly, the family is incredibly important to all cultures, and particularly to central and Mexican-Americans. Sadly, these strong family ties underscore an important reason Latinx people have been disproportionately affected by COVID-19: many live in large, multigenerational family homes, accelerating virus exposure and transmission. Furthermore, many are undocumented and work under substandard conditions, with few or no COVID-19 precautions. They may also be underinsured or have no insurance or benefits like sick leave, further fueling the virus’ devastation.

When you pull the bandage off a gangrenous wound to expose the decaying flesh below, you have two options: put the bandage back on and let someone else deal with it, or clean the wound and treat it so it can heal. The COVID-19 pandemic has pulled the bandage off and exposed certain disgusting realities of our health care system – how can we as Emergency Physicians heal this wound?

We must recognize that hospital under-investment in adequate Spanish interpreters is a form of racism. Medical Spanish should be required curriculum for medical students and residents. The knowledge of basic conversational Spanish goes a long way when communicating with patients and their families. Medical Spanish is not difficult, and there are enough cognates and Latin derivatives that most people, with minimal practice, can get through history and physical in Spanish. Most importantly, hospitals should invest in full-time in-person Spanish interpreters, at the very least for the Emergency Department.

The COVID-19 pandemic has ravaged our healthcare system in myriad ways. With destruction comes the opportunity to rebuild and improve. This is one area that needs it.

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Expert Opinion: Luis Vargas – ED Overcrowding

March 29, 2019September 4, 2019 ~ iEM Education Project Team ~ Leave a comment

EMERGENCY DEPARTMENT OVERCROWDING

Dear students, emergency departments are suffering overcrowding since long time. There are various causes of this situation as well as solutions. It is better to know about ED overcrowding before your first shift. Dr. Luis Vargas from Colombia summarizes his lecture presented in 30th Emergency Medicine Congress of Mexican Society in Cancun.

ED Overcrowding - English

Manejo y consecuencias del sobrecupo en urgencias

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Against Medical Advice and Elopement

March 1, 2019February 27, 2019 ~ iEM Education Project Team ~ Leave a comment

In certain circumstances, patients may request to leave prior to completion of their medical evaluation and treatment. In this situation, it is essential for the last health care professional caring for the patient to document clearly why the patient left and attested that the patient had the mental capacity to make such a decision at that time (Henry, 2013). While some electronic documentation systems have templates in place to assist with this documentation, Table 2 provides basic information for against medical advice (AMA) discharge documentation that can be used to create a uniform template (Henry, 2013; Siff, 2011; Levy, 2012; Devitt, 2000).

What to do?

Interventions in the ED Discharge Process

Domain	Intervention
Content	Standardize approach
Delivery	Verbal instructions (language and culture appropriate) Written instructions (literary levels) Basic Instructions (including return precautions) Media, visual cues or adjuncts
Comprehension	Confirm comprehension (teach-back method)
Implementation	Resource connections (Rx, appointment, durable medical supplies, follow-up) Medication review

An attempt should be made to provide the patient with appropriate discharge instructions, even if a complete diagnosis may not yet be determined. Include advice for the patient to follow up with his physician, strict return precautions, and concerning symptoms that should prompt the patient to seek further care. It should also be made clear that leaving against medical advice does not prevent the patient from returning to the emergency department for further evaluation if his symptoms worsen, or if he changes his mind. Despite a common notion to the contrary, simply leaving against medical advice does not automatically imply that physicians are immune to potential medical liability (Levy, 2012; Devitt, 2000). If a patient lacks decision-making capacity to be able to adequately understand the rationale and consequences of leaving AMA and his condition places him at risk for imminent harm, involuntary hospitalization is warranted. In unclear circumstances and if available, psychiatry can assist in determining capacity, especially in the case of patients with mental health conditions.

Elopement is a similar process where patients disappear during the care process. While it is difficult to provide discharge paperwork for these patients, documenting the actions taken to find the patient is essential (e.g., searching the ED, having security check the surrounding areas). In addition, attempt to reach the patient by phone to discuss his elopement and any additional care issues or concerns. Documentation of these attempts or any additional conversation is very important (Henry, 2013; Siff, 2011).

To Know More About It?

References

Brooten J, Nicks B. Discharge Communications. In: Cevik AA, Quek LS, Noureldin A, Cakal ED (eds) iEmergency Medicine for Medical Students and Interns – 2018. Retrieved February 27, 2019, from https://iem-student.org/discharge-communications/
Henry GL, Gupta G. (2013). Medical-Legal Issues in Emergency Medicine. In Adams (Ed.), Emergency Medicine Clinical Essentials, 2nd Ed; 1759-65. Philadelphia, PA: Elsevier.
Siff JE. (2011). Legal Issues in Emergency Medicine. In Tintinalli’s (Ed.), Emergency Medicine, 7th Ed; 2021-31. McGraw-Hill.
Levy F, Mareiniss DP, Lacovelli C. The Importance of a Proper Against-Medical-Advice (AMA) Discharge. How Signing Out AMA May Create Significant Liability Protection for Providers. J Emerg Med. 2012;43(3):516-520.
Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51:899-902.

Introduction

Emergency Medicine Note

History

The components of history

Physical Exam

Summary of all components in an ED Note

Few helpful suggestions during documentation

Sample ED Note

Author

Muneer Abdulla Al Marzooqi

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Arif Alper Cevik, MD, FEMAT, FIFEM

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Scott GOLDSTEIN, DO, FACEP, FAEMS, FAAEM, EMT-PHP

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Conclusion

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