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Guidelines for hospital emergency medical service in a university hospital in France
Guidelines for Hospital Emergency Medical Service In a University Hospital in France A Progress Report
Jean E. Murat, MD, FACS, Tours, France Jean L. Vaur, MD, Orleans,
France
Jean L. Bernard, MD, Orleans,
France
Joel Pasdeloup, MD, Tours, France
The emergency department is a major portal of entry into the health care system, even in nonemergency situations, and involves 1,500,OOO patients a year in France, equivalent to 2.5 percent of the population. This approach is often used not only because of the lack of knowledge of nonurgent and traditional features of hospitals, especially in widespread university hospitals, but also because of the ideal of “instant care” for all. Thus, the mixture of a psychosociologic incidence and life-threatening situation produces a difficult relation not only between patients and the emergency staff but also between emergency and specialty department personnel concerning proper care [I]. Efforts to maintain the patient-physician relation must be based on a clear categorization of health problems (major and minor emergencies and nonurgent cases) and hospital capabilities (heavy resuscitation units, specialty or general departments) [2]. Categorization of hospital emergency services has been implemented voluntarily in all French regions on the basis of historic and geographic reasons and centered about a university hospital, 30 in the entire state (Paris area not included). Progress has been made during the past 10 years [3] but has elicited much criticism; transportation with specially trained anesthetists (Urgent Medical Aid Service [SAMU]) has markedly improved the initial emergency care of group IV or V patients (according to the Abbreviated Injury Scale) with From the Emergency Surgical Department, University of Tours Medical School and the Surgical Department of Orleans Hospital, OrlBans, France. Reprint rec@ests should be addressed to Jean E. Murat, MD, Service de Chirurgie d’urgence, HBpital Universitaire, F 37044, Tours Cedex, France.
240
life-threatening conditions. However, throughout the country, less than 20 percent of the patients are covered by the SAMU system and more than four of five patients enter the hospital directly through the so-called emergency department. Under such conditions, the hospital administrators as well as emergency medical personnel are involved with a most impressive heterogeneous group of patients, a factor that is really responsible for the hospital’s recognition in the city. “Adequate capacity to accommodate the direct and referred patient loads of the region served and professional personnel of other hospitals and health facilities in the same region” [4] is the specific goal of university hospitals in France as in all parts of the world. However, problems with hospital emergency entrance can be studied by our “field testing” progress over a 10 year period, which demonstrates specificity and difficulties in attempting to implement a new constructive activity based not only on a strictly medical appreciation but also on patient demand, representing population [5].
TABLE I
roughly
Age of Emergency
Age W Under 15 15-25 25-35 35-45 45-55 55-65 Over 65
one tenth
Admissions
Percentage Of Surgical Admissions 4.6 32.4 21.7 13.0 11.9 6.4 10.0
of the city’s
Of Medical Admissions 9.0 13.0 13.8 11.8 14.5 2.5 35.4
The American Journal of Surgery
Hospital
TABLE II
30-60 31
Analysis of Emergency
Admissions
(min)
Percentaae
Service
Delay Between Admission and Discharge From Emergency Department O-30 20
Yme
Emergency
60-90 22
From 1967 to 1977 the flow of patients through the emergency department of the university hospital in Tours, France, increased fourfold, from 7,000 to 28,263 per year. Medical admissions fluctuate from 26.2 percent in summer months to 33.3 percent in winter months, whereas surgery ranges from 66.7 to 73.8 percent. SP.Y ratio. In 1977, 68.5 percent of surgical patients and 60 percent of medical patients were male. This predominance is partly explained by the direct admission of’ patients from the Department of Gynec~)logy and Obstet,rics. The distribution
of patients
in relation
to age
sh:)ws a predominance
of young patients (15 to 35 years old) among surgical admissions (children are directed to another hospital) but a predominance of patients over age 65 among medical admissions (Table I). The nlrans of arrival are various: 78 percent arrived by personal car, 4.5 percent by private ambulance and 17.5 percent by Urgent Medical Aid System with an anesthetist-resuscitation physician on board. In Tours, t.his SAMU is operated under the su;)ervision of the Surgical Emergency Department and has a special, easy-to-memorize telephone number for urgent calls. Evaluation of reasons for passing PIT;et-genqj department is difficult.
through
the
For medical ad mission vital prognosis is supposed to be involved in 9 percent, organic lesions involving a potential functional disorder in 81 percent and social or strictly pe*sonal reasons in 10 percent. In surgical patients similar ratios are 5.7 percent for supposed vital prognosis, 90 percent for functional disorders and 4.3 pe;_cent for personal reasons. The delay between adnission and discharge from the emergency depa-tment. is less than 1 hour in half of the cases and les; than 2 hours in 88 percent of the cases (Table 11) Ana1~xi.s vf Surgical Admissions by the Abbrer,iatecL Injury Scale (AIS). According to AIS, pa-
tients in group I represent 62.85 percent of the total, group II, 28.80 percent; group III, 5.19 percent; group IV. 1.29 percent; and group V, 0.77 percent. For road accidents exclusively (42 percent), the percentages are as follows: group 0 (undue call), 2 percent; group I. tX0.S5 percent; group II, 27.25 percent; group III,
Volume 139, February 1980
120-180 8
go-120 15
180-240 3
240-300 1
5.25 percent; group IV, 2.75 percent; and group V, 2 percent. Traumatic lesions represent 75 percent and nontraumatic lesions 25 percent of surgical admissions. The number of lesions of traumatic origin is only one in 54.5 percent of patients, two in 14.5 percent of patients and more than two in 6 percent of patients, for a single accident. A majority of surgical patients require only external care and are not kept in the hospital (“rejection rate” 61 percent). Ambulatory treatment is given by the emergency department personnel under the supervision of the patient’s private physician. Of the remaining 39 percent of patients, 12.5 percent are sent as emergency cases to the operating room and 2 percent are sent to a more specialized department than general surgery. Ana1ysL.s of medical admissions. Seventy percent of patients require specific care from specialized personnel (Table III), and 30 percent require care for general problems; 83 percent of medical admissions are kept in the hospital, 2 percent are directed to more specialized departments and I5 percent are treated as outpatients (including 6 percent with acute alcoholism). Efficiency is more difficult to prove among medical than among surgical admissions. Thus, we compared the diagnosis made in the emergency department
TABLE Ill
Analysis of Medical Admissions
Reasons
Percentage of Cases
For specific care (70 percent) Digestive Neurologic Pneumologic Cardiovascular’ Psychiatric Bone and joints Dermatologic Urogenital Ophthalmologic and ear, nose and throat Hematologic Total For general conditions (30 percent) Functional reasons Social reasons Suicidal attempts Obstetrics *
18 14.8 9.7 8.5 6.8 3.5 3.1 3.0 1.6 1.4 70.4 12.1 11.4 45 .._
1.6
’ Usually direct entrance in specialized departments.
241
Murat et al
TABLE IV Comparison of the Precision of Diagnosis and Treatment in the Emergency Department and After Hospitalization
Diagnosis Level 1 Level 2 Level 3 Treatment Symptomatic treatment Etiologic treatment Resuscitation Pursuing former treatment
In Emergency Department (%)
Alter Hospitalization (%)
42.44 37.52 20.04
74.26 20.31 5.43
80.79 11.19 5.82 2.20
74.71 11.25 8.00 6.04
with that obtained in the hospital department, according to three levels of precision: level 1: a diagnosis giving etiologic precision; level 2: a diagnosis limited to the description of a precise symptom; level 3: a symptomologic diagnosis without conclusion. The increased accuracy of diagnosis after hospitalization is shown in Table IV. Similar progress is reported in treatment, especially when the etiology of the problem is known. A comparison of the accuracy of diagnosis in all patients with emergency conditions and after hospitalization shows an increase in precision of one level in 25.81 percent and two levels in 10.17 percent, no change in 62.03 percent and regression of one level in 1.29 percent. The mortality is 0.36 percent, and 2.21 percent of patients leave the hospital against medical advice. The validity of orientation is demonstrated by the finding that only 12 percent of all patients changed departments. In this group (12 percent of the total) the reasons for the change in hospital department were as follows: for a specific etiologic treatment in 50.95 percent of cases, nonmedical reasons in 13.53 percent, intercurrent disease in 10.45 percent and more adequate secondary orientation in 13.43 percent. Thus, the overall accuracy rate of initial orientation is approximately 96 percent among all admissions. Comments
A major trend in recent years in emergency departments is an increase in the number of medical nonemergency cases [6]. In addition, the rate of hospitalization, especially in the surgical emergency department, could be usefully reduced: 61 percent of patients with surgical emergencies are not hospitalized and 62.85 percent have group I lesions according to the Abbreviated Injury Scale, which is a
242
good justification for nonhospitalization. These findings emphasize the need for giving the emergency department a status equal to that of other departments, as it has expanded its diagnostic and referral role similar to that of private practitioners in recent years [I]. In addition, the emergency department should maintain a continuous link with patients treated for acute conditions. Medical and nonemergency problems need a multidisciplinary approach and a high level of emergency life-saving measures as well as psychologic training of all personnel to examine and discharge patients in a reasonable time (12 percent of admissions or rejections wait over 2 hours) and provide medical care and orientation if necessary. Based on a yuality approach, a nonstop working unit with an essential staff at least 3rd year postdoctoral physicians directed by a head equal to those of the other departments could improve results and reduce time lost in fruitless investigations [7]. However, diagnosis and care have been, up to now, relatively correct and demonstrate the use of such a multidisciplinary approach (81. We have previously [5] stressed compulsory hospital specifications such as blood bank laboratory services and radiologic and intensive care units directly and continuously linked with emergency departments in the case of university hospitals. All of these services must be available within minutes. A specific link with the SAMU is necessary for good coordination in true emergency care [9]. Specific coordination must be maintained to avoid unnecessary hospitalization by consultants (the high 83 percent hospitalization rate for medical patients could be considered as a too-low “rejection rate” and may be partly related to the surgical orientation of the head of the department). Coordination between the emergency department or unit (depending on the number of emergencies) and other hospital medical or surgical departments is compulsory on an equal basis. No proper work schedule can be organized in medical or surgical departments when the flow of emergency patients reaches 20,000 per year. However, the individualization of emergency hospitals competitive with nonemergency ones is not realistic either economically and psychologically. The need for operating and recovery rooms will depend on the total number of hospital admissions: with fewer than 20,000 admissions per year, other specialty departments of a university hospital of 1,500 beds can handle the surgical admissions in addition to their own practice. However, with over 20,000 admissions, which is about one tenth the usual areas’ population, a comprehensive emergency de-
The American Journal of Surgery
Hospital
partment including operating and recovery rooms is necessary in all university hospital emergency departments. Essential staff must at least be in their :rrd postdoctoral year, and all personnel must have I)r,)ati training in emergency life-saving measures as well as pscyhologic abilities, which are at least as important as adequate heavy equipment. A later goal is to adapt medical emergency care to the patient’s demand. More specific and comprehensive teaching of emvrgcncy care in medical school may increase the concern of medical personnel and decrease the undue demands of the population (about 20 percent of so-called medical emergencies need only a practitioner’s advice). This concept confirms the basic idea of the unique value of the emergency department as a technical multidisciplinary service where a permanent surgical and a medical staff with equal training makes diagnoses by simple means, carries on simple or symptomatic therapy (resuscitation and hemostasis) and brings the correct specialist on call to the patient with the least possible delay. The importance of this task is increasing and is leading to outpatient care and an extensive consultal ion structure with private practitioners, enabling palients with true emergency conditions to receive specialized attention more rapidly, in addition to he: ter treatment.
Emergency
Service
cations based on the number of emergency cases is important. Better coordination with other departments on an equal basis must be achieved to reduce the time lost in waiting for the best orientation, treatment, or eventual discharge of the patient. Complementary consultation procedures are necessary to improve follow-up study with the private practitioners under well t,rained supervision. Teaching of practical emergency care should he increased and offered to all medical students to restore the responsibility of private practitioners and the confidence of the population necessary to stop the increase in unnecessary emergency cases. Summary
The emergency department has hecome a major portal of entry in university hospitals for patients with life-threatening conditions as well as for nonurgent cases. A fourfold increase in IO years (28,263 patients in 1977) allows an analysis of admissions according to the Abbreviated Injury Scale and of the value of diagnosis. Results emphasize the need for complementary surgical consultant and operatory structures, a rapid and good quality approach and a specific coordination on an equal hasis between the emergency depart.ment and other specialized departments. Teaching of practical emergency care should be adapted and increased.
Conclusions
An increase in the flow of patients through the emergency department of a university hospital (from 7,000 to 28,000 in 10 years) shows the specificity of the so-called emergency problem. Emergency departments are necessary for both emergency and nonemergency cases to satisfy the psychologic need for safety of the population. Thus, there is a complete sccpe of medical situations that require a multidisciplinary full-time approach for the best quality care because of difficulties in diagnosis and treatment (especially in non-life-threatening conditions) and the economic impact, of numerous “minor” surgical procedures. University hospitals must develop their role as consultants because of their teaching position and because, on average, two thirds of nonhospitalized patients are in the surgical group. The medical and psychologic training of personnel together with a high standard for hospital specifi-
Volume 139, February 1980
References 1.
Sadler AM Jr., Sadler BL, Webb SB Jr. Emergency medical care, the neglected public service, Vol 1 Cambridge: Ballinger, 1977; 125.
2. Mills JD. Overview of field of emergency medicine. In: Jenkins AL, ed. Emergency department organization and management, Vol 1. St Louis: CV Mosby, 1975; 1. 3. Payne JT, Kranz JM, Eade GG. A survey of hospital emergency rooms in the State of Washington. A project. Bull Am Coi Surb 1973; 58:7-10. 4. Hampton OP. Categorization of hospital emergency capabilities. Bull Am Coil Surg 1975; 60:6-l 1. 5. Murat JE. Needs and-practice of emergency hospital departments in France. Curr Top Crit Care Med 1977; 3:171-75. 6. Fineberg DA, Stewart MM. Analysis of patient flow in the emergency room. Mt Sinai J Med 1977; 44551-g. 7. Reilly TA, Stewart MM, Metsch JM, Fine KC. Medical admissions from an emergency room: factors associated with long delays. Mt Sinai J Med 1977; 44:544-50. 8. Dwyer WA. Criteria evaluation of emergency room medical care. Bull Am Colt Surg 1975: 60:10-15. 9. Committee on Trauma. ACS guidelines for the patient physician relationship in the emergency 1977; 2:15.
department.
Bull Am Coil Surg
243
Jean E. Murat, MD, FACS, Tours, France Jean L. Vaur, MD, Orleans,
France
Jean L. Bernard, MD, Orleans,
France
Joel Pasdeloup, MD, Tours, France
The emergency department is a major portal of entry into the health care system, even in nonemergency situations, and involves 1,500,OOO patients a year in France, equivalent to 2.5 percent of the population. This approach is often used not only because of the lack of knowledge of nonurgent and traditional features of hospitals, especially in widespread university hospitals, but also because of the ideal of “instant care” for all. Thus, the mixture of a psychosociologic incidence and life-threatening situation produces a difficult relation not only between patients and the emergency staff but also between emergency and specialty department personnel concerning proper care [I]. Efforts to maintain the patient-physician relation must be based on a clear categorization of health problems (major and minor emergencies and nonurgent cases) and hospital capabilities (heavy resuscitation units, specialty or general departments) [2]. Categorization of hospital emergency services has been implemented voluntarily in all French regions on the basis of historic and geographic reasons and centered about a university hospital, 30 in the entire state (Paris area not included). Progress has been made during the past 10 years [3] but has elicited much criticism; transportation with specially trained anesthetists (Urgent Medical Aid Service [SAMU]) has markedly improved the initial emergency care of group IV or V patients (according to the Abbreviated Injury Scale) with From the Emergency Surgical Department, University of Tours Medical School and the Surgical Department of Orleans Hospital, OrlBans, France. Reprint rec@ests should be addressed to Jean E. Murat, MD, Service de Chirurgie d’urgence, HBpital Universitaire, F 37044, Tours Cedex, France.
240
life-threatening conditions. However, throughout the country, less than 20 percent of the patients are covered by the SAMU system and more than four of five patients enter the hospital directly through the so-called emergency department. Under such conditions, the hospital administrators as well as emergency medical personnel are involved with a most impressive heterogeneous group of patients, a factor that is really responsible for the hospital’s recognition in the city. “Adequate capacity to accommodate the direct and referred patient loads of the region served and professional personnel of other hospitals and health facilities in the same region” [4] is the specific goal of university hospitals in France as in all parts of the world. However, problems with hospital emergency entrance can be studied by our “field testing” progress over a 10 year period, which demonstrates specificity and difficulties in attempting to implement a new constructive activity based not only on a strictly medical appreciation but also on patient demand, representing population [5].
TABLE I
roughly
Age of Emergency
Age W Under 15 15-25 25-35 35-45 45-55 55-65 Over 65
one tenth
Admissions
Percentage Of Surgical Admissions 4.6 32.4 21.7 13.0 11.9 6.4 10.0
of the city’s
Of Medical Admissions 9.0 13.0 13.8 11.8 14.5 2.5 35.4
The American Journal of Surgery
Hospital
TABLE II
30-60 31
Analysis of Emergency
Admissions
(min)
Percentaae
Service
Delay Between Admission and Discharge From Emergency Department O-30 20
Yme
Emergency
60-90 22
From 1967 to 1977 the flow of patients through the emergency department of the university hospital in Tours, France, increased fourfold, from 7,000 to 28,263 per year. Medical admissions fluctuate from 26.2 percent in summer months to 33.3 percent in winter months, whereas surgery ranges from 66.7 to 73.8 percent. SP.Y ratio. In 1977, 68.5 percent of surgical patients and 60 percent of medical patients were male. This predominance is partly explained by the direct admission of’ patients from the Department of Gynec~)logy and Obstet,rics. The distribution
of patients
in relation
to age
sh:)ws a predominance
of young patients (15 to 35 years old) among surgical admissions (children are directed to another hospital) but a predominance of patients over age 65 among medical admissions (Table I). The nlrans of arrival are various: 78 percent arrived by personal car, 4.5 percent by private ambulance and 17.5 percent by Urgent Medical Aid System with an anesthetist-resuscitation physician on board. In Tours, t.his SAMU is operated under the su;)ervision of the Surgical Emergency Department and has a special, easy-to-memorize telephone number for urgent calls. Evaluation of reasons for passing PIT;et-genqj department is difficult.
through
the
For medical ad mission vital prognosis is supposed to be involved in 9 percent, organic lesions involving a potential functional disorder in 81 percent and social or strictly pe*sonal reasons in 10 percent. In surgical patients similar ratios are 5.7 percent for supposed vital prognosis, 90 percent for functional disorders and 4.3 pe;_cent for personal reasons. The delay between adnission and discharge from the emergency depa-tment. is less than 1 hour in half of the cases and les; than 2 hours in 88 percent of the cases (Table 11) Ana1~xi.s vf Surgical Admissions by the Abbrer,iatecL Injury Scale (AIS). According to AIS, pa-
tients in group I represent 62.85 percent of the total, group II, 28.80 percent; group III, 5.19 percent; group IV. 1.29 percent; and group V, 0.77 percent. For road accidents exclusively (42 percent), the percentages are as follows: group 0 (undue call), 2 percent; group I. tX0.S5 percent; group II, 27.25 percent; group III,
Volume 139, February 1980
120-180 8
go-120 15
180-240 3
240-300 1
5.25 percent; group IV, 2.75 percent; and group V, 2 percent. Traumatic lesions represent 75 percent and nontraumatic lesions 25 percent of surgical admissions. The number of lesions of traumatic origin is only one in 54.5 percent of patients, two in 14.5 percent of patients and more than two in 6 percent of patients, for a single accident. A majority of surgical patients require only external care and are not kept in the hospital (“rejection rate” 61 percent). Ambulatory treatment is given by the emergency department personnel under the supervision of the patient’s private physician. Of the remaining 39 percent of patients, 12.5 percent are sent as emergency cases to the operating room and 2 percent are sent to a more specialized department than general surgery. Ana1ysL.s of medical admissions. Seventy percent of patients require specific care from specialized personnel (Table III), and 30 percent require care for general problems; 83 percent of medical admissions are kept in the hospital, 2 percent are directed to more specialized departments and I5 percent are treated as outpatients (including 6 percent with acute alcoholism). Efficiency is more difficult to prove among medical than among surgical admissions. Thus, we compared the diagnosis made in the emergency department
TABLE Ill
Analysis of Medical Admissions
Reasons
Percentage of Cases
For specific care (70 percent) Digestive Neurologic Pneumologic Cardiovascular’ Psychiatric Bone and joints Dermatologic Urogenital Ophthalmologic and ear, nose and throat Hematologic Total For general conditions (30 percent) Functional reasons Social reasons Suicidal attempts Obstetrics *
18 14.8 9.7 8.5 6.8 3.5 3.1 3.0 1.6 1.4 70.4 12.1 11.4 45 .._
1.6
’ Usually direct entrance in specialized departments.
241
Murat et al
TABLE IV Comparison of the Precision of Diagnosis and Treatment in the Emergency Department and After Hospitalization
Diagnosis Level 1 Level 2 Level 3 Treatment Symptomatic treatment Etiologic treatment Resuscitation Pursuing former treatment
In Emergency Department (%)
Alter Hospitalization (%)
42.44 37.52 20.04
74.26 20.31 5.43
80.79 11.19 5.82 2.20
74.71 11.25 8.00 6.04
with that obtained in the hospital department, according to three levels of precision: level 1: a diagnosis giving etiologic precision; level 2: a diagnosis limited to the description of a precise symptom; level 3: a symptomologic diagnosis without conclusion. The increased accuracy of diagnosis after hospitalization is shown in Table IV. Similar progress is reported in treatment, especially when the etiology of the problem is known. A comparison of the accuracy of diagnosis in all patients with emergency conditions and after hospitalization shows an increase in precision of one level in 25.81 percent and two levels in 10.17 percent, no change in 62.03 percent and regression of one level in 1.29 percent. The mortality is 0.36 percent, and 2.21 percent of patients leave the hospital against medical advice. The validity of orientation is demonstrated by the finding that only 12 percent of all patients changed departments. In this group (12 percent of the total) the reasons for the change in hospital department were as follows: for a specific etiologic treatment in 50.95 percent of cases, nonmedical reasons in 13.53 percent, intercurrent disease in 10.45 percent and more adequate secondary orientation in 13.43 percent. Thus, the overall accuracy rate of initial orientation is approximately 96 percent among all admissions. Comments
A major trend in recent years in emergency departments is an increase in the number of medical nonemergency cases [6]. In addition, the rate of hospitalization, especially in the surgical emergency department, could be usefully reduced: 61 percent of patients with surgical emergencies are not hospitalized and 62.85 percent have group I lesions according to the Abbreviated Injury Scale, which is a
242
good justification for nonhospitalization. These findings emphasize the need for giving the emergency department a status equal to that of other departments, as it has expanded its diagnostic and referral role similar to that of private practitioners in recent years [I]. In addition, the emergency department should maintain a continuous link with patients treated for acute conditions. Medical and nonemergency problems need a multidisciplinary approach and a high level of emergency life-saving measures as well as psychologic training of all personnel to examine and discharge patients in a reasonable time (12 percent of admissions or rejections wait over 2 hours) and provide medical care and orientation if necessary. Based on a yuality approach, a nonstop working unit with an essential staff at least 3rd year postdoctoral physicians directed by a head equal to those of the other departments could improve results and reduce time lost in fruitless investigations [7]. However, diagnosis and care have been, up to now, relatively correct and demonstrate the use of such a multidisciplinary approach (81. We have previously [5] stressed compulsory hospital specifications such as blood bank laboratory services and radiologic and intensive care units directly and continuously linked with emergency departments in the case of university hospitals. All of these services must be available within minutes. A specific link with the SAMU is necessary for good coordination in true emergency care [9]. Specific coordination must be maintained to avoid unnecessary hospitalization by consultants (the high 83 percent hospitalization rate for medical patients could be considered as a too-low “rejection rate” and may be partly related to the surgical orientation of the head of the department). Coordination between the emergency department or unit (depending on the number of emergencies) and other hospital medical or surgical departments is compulsory on an equal basis. No proper work schedule can be organized in medical or surgical departments when the flow of emergency patients reaches 20,000 per year. However, the individualization of emergency hospitals competitive with nonemergency ones is not realistic either economically and psychologically. The need for operating and recovery rooms will depend on the total number of hospital admissions: with fewer than 20,000 admissions per year, other specialty departments of a university hospital of 1,500 beds can handle the surgical admissions in addition to their own practice. However, with over 20,000 admissions, which is about one tenth the usual areas’ population, a comprehensive emergency de-
The American Journal of Surgery
Hospital
partment including operating and recovery rooms is necessary in all university hospital emergency departments. Essential staff must at least be in their :rrd postdoctoral year, and all personnel must have I)r,)ati training in emergency life-saving measures as well as pscyhologic abilities, which are at least as important as adequate heavy equipment. A later goal is to adapt medical emergency care to the patient’s demand. More specific and comprehensive teaching of emvrgcncy care in medical school may increase the concern of medical personnel and decrease the undue demands of the population (about 20 percent of so-called medical emergencies need only a practitioner’s advice). This concept confirms the basic idea of the unique value of the emergency department as a technical multidisciplinary service where a permanent surgical and a medical staff with equal training makes diagnoses by simple means, carries on simple or symptomatic therapy (resuscitation and hemostasis) and brings the correct specialist on call to the patient with the least possible delay. The importance of this task is increasing and is leading to outpatient care and an extensive consultal ion structure with private practitioners, enabling palients with true emergency conditions to receive specialized attention more rapidly, in addition to he: ter treatment.
Emergency
Service
cations based on the number of emergency cases is important. Better coordination with other departments on an equal basis must be achieved to reduce the time lost in waiting for the best orientation, treatment, or eventual discharge of the patient. Complementary consultation procedures are necessary to improve follow-up study with the private practitioners under well t,rained supervision. Teaching of practical emergency care should he increased and offered to all medical students to restore the responsibility of private practitioners and the confidence of the population necessary to stop the increase in unnecessary emergency cases. Summary
The emergency department has hecome a major portal of entry in university hospitals for patients with life-threatening conditions as well as for nonurgent cases. A fourfold increase in IO years (28,263 patients in 1977) allows an analysis of admissions according to the Abbreviated Injury Scale and of the value of diagnosis. Results emphasize the need for complementary surgical consultant and operatory structures, a rapid and good quality approach and a specific coordination on an equal hasis between the emergency depart.ment and other specialized departments. Teaching of practical emergency care should be adapted and increased.
Conclusions
An increase in the flow of patients through the emergency department of a university hospital (from 7,000 to 28,000 in 10 years) shows the specificity of the so-called emergency problem. Emergency departments are necessary for both emergency and nonemergency cases to satisfy the psychologic need for safety of the population. Thus, there is a complete sccpe of medical situations that require a multidisciplinary full-time approach for the best quality care because of difficulties in diagnosis and treatment (especially in non-life-threatening conditions) and the economic impact, of numerous “minor” surgical procedures. University hospitals must develop their role as consultants because of their teaching position and because, on average, two thirds of nonhospitalized patients are in the surgical group. The medical and psychologic training of personnel together with a high standard for hospital specifi-
Volume 139, February 1980
References 1.
Sadler AM Jr., Sadler BL, Webb SB Jr. Emergency medical care, the neglected public service, Vol 1 Cambridge: Ballinger, 1977; 125.
2. Mills JD. Overview of field of emergency medicine. In: Jenkins AL, ed. Emergency department organization and management, Vol 1. St Louis: CV Mosby, 1975; 1. 3. Payne JT, Kranz JM, Eade GG. A survey of hospital emergency rooms in the State of Washington. A project. Bull Am Coi Surb 1973; 58:7-10. 4. Hampton OP. Categorization of hospital emergency capabilities. Bull Am Coil Surg 1975; 60:6-l 1. 5. Murat JE. Needs and-practice of emergency hospital departments in France. Curr Top Crit Care Med 1977; 3:171-75. 6. Fineberg DA, Stewart MM. Analysis of patient flow in the emergency room. Mt Sinai J Med 1977; 44551-g. 7. Reilly TA, Stewart MM, Metsch JM, Fine KC. Medical admissions from an emergency room: factors associated with long delays. Mt Sinai J Med 1977; 44:544-50. 8. Dwyer WA. Criteria evaluation of emergency room medical care. Bull Am Colt Surg 1975: 60:10-15. 9. Committee on Trauma. ACS guidelines for the patient physician relationship in the emergency 1977; 2:15.
department.
Bull Am Coil Surg
243