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Introduction to emergency care

Emma Tippins and Cliff Evans

Emergency care
Emergency Care is politically and socially one of the highest priorities in
society today. Increasing patient expectations and the advancement in
scientific and medical knowledge have had a dramatic effect on the provision
of emergency care. The Department of Healths (DoH) White Paper on Reforming Emergency Care (2001) stipulates that emergency care provision should
address the demands and needs of patients, regardless of setting. A solid
foundational knowledge in the skills of triage and assessment are, therefore,
essential precursors to all emergency practitioners in order to enable patients
to be treated quickly, appropriately and effectively, i.e., right skill, right time,
right place. The different, diverse and unique needs of patients provide a
constant challenge to emergency practitioners.
The Emergency Department (ED) is the portal for over 16.5 million annual
visits in England (Alberti 2004). In the United States of America (USA) there
are over 100 million annual visits, accounting for 40 per cent of hospital
admissions (McCaig and Burt 1999). These millions of patients will attend
with any number of clinical presentations and complaints requiring the
assistance of every medical speciality. The role of the emergency practitioner is
unique in this respect, as in no other clinical setting will clinicians be called
upon to assess and identify the needs of such a wide range of potential patient
conditions.
The ED is commonly the interface between patients and emergency
care, within this setting a patients first contact with a healthcare professional
will usually be at the point of initial assessment; the process of triage. Triage
is a dynamic decision-making process that will prioritize an individuals
need for treatment on their presenting history, the nature of the incident, and
the presenting clinical complaint. An efficient triage system aims to identify
and expedite time-critical treatment for patients with life-threatening conditions, and ensure every patient requiring emergency treatment is prioritized

THE FOUNDATIONS OF EMERGENCY CARE

according to their clinical need. The ethos of triage systems relates to the
ability of a professional to detect critical illness, which has to be balanced
with resource implications of over-triage (a triage category of higher acuity is
allocated). A decision that underestimates a persons level of clinical urgency
may delay time-critical interventions; furthermore, prolonged triage processes
may contribute to adverse patient outcomes (Geraci and Geraci 1994; Travers
1999), and impede the assessment of others.
In this context, the practitioners ability to take an accurate patient
history, conduct a brief physical assessment, and rapidly determine clinical
urgency are crucial to the provision of safe and efficient emergency care
(Travers 1999). These responsibilities require practitioners undertaking triage
to justify their clinical decisions with evidence from clinical research, and to
be accountable for decisions they make within the clinical environment.
This book is directed at facilitating front-line practitioners and students
aiming to specialize within emergency care, to gain the essential assessment
skills necessary for acute care environments, and to forge a solid foundation of
theoretical knowledge and understanding upon which to base their clinical
practice.

Applying theory to practice

In order to deliver expert individualized care, emergency care providers
need to make multiple decisions rapidly, in highly complex environments
and under increasing pressure. Emergency care is a dynamic specialism very
different from many other areas of care provision, yet the skills associated
with emergency care can be applied to all acute areas. Patients often present
critically ill and frequently highly unstable, as a result, their rapidly changing
conditions demand intelligent and decisive decision-making from practitioners in short time frames. Despite this, there remains minimal research on
the clinical decision-making skills of emergency care providers. Consequently
much of the content and structure of the decision-making process remains
unclear (Fonteyn and Ritter 2000).
Clinical decision-making can be defined as the process practitioners use
to gather patient information, evaluate that information and make a judgement that results in the provision of patient care (Andersson et al. 2006). This
process involves collecting information through the use of both scientific and
intuitive assessment skills. This information is then interpreted through the
use of knowledge and past experiences (Cioffi 2000; Tippins 2005).
Recent research indicates that many practitioners have a solid foundation
of theoretical knowledge but often fail to apply this knowledge directly to
patient care (Tippins 2005). The Resuscitation Council, European and UK,
have acknowledged this phenomenon based on several research studies identi-

INTRODUCTION TO EMERGENCY CARE

fying that up to two-thirds of in-hospital cardiac arrests are potentially avoidable (Franklin and Matthew 1994; Hodgetts et al. 2002). Seeking to address
these issues, the DoH set national guidelines, stating that all healthcare
providers should receive competency-based high dependency training (DoH
2000). Universities introduced higher educational modules attempting to
facilitate experienced and novice post-registration practitioners into gaining
these fundamental skills associated with the process of initial and ongoing
patient assessment. This essential ability to recognize both patients at risk
of critical illness and sudden physical deterioration, and those actually
experiencing critical illness is now an indispensable component of modules
which all pre-registration nurses have to pass in order to register in the UK
(NMC 2004).
The recently revised Resuscitation Guidelines (RCUK) 2006) directly
address the DoHs objectives by focusing on the recognition and treatment
of the critically ill patient in order to prevent cardiac arrest. This focus on
preventative education has seen the development of locally delivered courses
such as the Acute Life Threatening Events: Recognition and Treatment
(ALERT) course, and the development of early warning scores (EWS). Within
the UK EWS are now commonly used to identify patients at risk of clinical
deterioration. The use of an EWS ensures a structured approach to patient
assessment and the regular recording of physiological observations, a crucial
first step in recognizing patients at risk. Physical parameters are used to identify patients who are deteriorating, or are at risk of doing so. The scoring
system alerts the carer to the potential for serious illness and initiates a call for
senior assistance.
Regardless of the individual setting, practitioners encountering acutely ill
patients need to be able to identify those at risk of serious illness, act on these
findings and evaluate their chosen treatment route. Although these key skills
may be used in other clinical settings, they are essential to emergency care
provision and are seen as an integral part of an acute practitioners scope of
clinical practice.
Emergency care management is a complex and dynamic specialism.
The role of the emergency practitioner comprises numerous fundamental
clinical skills. Practitioners, regardless of their discipline, need the ability to
relate these skills, including a foundational knowledge of the physical changes
synonymous with serious illness, to the patient assessment process. This
can be achieved by applying the key skills of critical thinking and analysis to
everyday clinical decision-making.
The argument surrounding the clinical application of theoretical knowledge has continued throughout nursing and healthcare education. The NHS
Plan (DoH 2000) identified the NHS as deficient in national evidence-based
standards and, therefore, much of the practice subjective to individual interpretation. This initiated the current protocol-driven approach to care which

THE FOUNDATIONS OF EMERGENCY CARE

aims to provide practitioners, and subsequently patients, with evidencebased objective treatment regimens, in contrast to individual subjective
preferences. A prime example is demonstrated by the advanced life support
algorithms, which have revolutionized multi-disciplinary care delivery.
Changing practice within the vast institution of healthcare is a monumental task and to this end clinical governance was established. The clinical
governance initiative is conveyed into clinical practice by the National
Institute of Health and Clinical Excellence (NICE). NICE, in conjunction with
several specialist professional institutions, have released numerous national
guidelines on specific patient presentations or illnesses. These are also supplemented by the DoHs National Service Frameworks (NSF), which set clinical
standards in relation to specific disorders and specialist organizations such as
the British Thoracic Society, which promote best-practice. These initiatives
have combined to produce a constantly progressive clinical arena in which
novice practitioners and students can easily become lost.
There is, therefore, a clear need to apply a tool or structure to the
diagnostic process directly aimed at facilitating practitioners with the ability
to base their clinical findings on objective rather than subjective data. This
facilitation centres on two components: first, a solid understanding of the
signs and symptoms associated with physical illness, and second, the application of critical thinking to their practice. The first component is demonstrated
throughout this book by experienced practitioners who discuss their own
experiences in the form of patient scenarios which highlight both common
clinical encounters and the frameworks and protocols they use to prioritize,
and manage, patients quickly, appropriately and effectively. In addition, the
clinicians discuss the associated anatomy and physiology providing the reader
with several key words or triggers. This enquiry-based learning approach promotes lifelong learning by encouraging the reader to seek key texts listed
at the end of each chapter, thereby gaining further knowledge and understanding of the topics.
The framework used throughout this book is based on a modification of
Alfaro-LeFevres (2004) approach to critical thinking, the DEAD framework.
Novice practitioners frequently require an unambiguous approach to patient
assessment, which can be achieved by applying the DEAD acronym. This
framework not only aids practitioners in critically analysing their care
delivery, it also directly provides a safety net by leading the practitioner to
question other possibilities regarding the patient presentation, and this component is paramount to those working in acute care settings as a missed diagnosis can be fatal. This structured approach is applied to everyday clinical
presentations via the use of clinical scenarios. The scenarios demonstrate
classic emergency care presentations and focus on the practitioner applying
their theoretical understanding of both anatomy and physiology to determine
an individuals clinical status. The practitioners assessment plan broadens to

INTRODUCTION TO EMERGENCY CARE

encompass a holistic approach by adopting the critical thinking approach

that guides the practitioner through four categories, which results in a safe
and effective method of identifying critical illness through an elimination
of serious pathology. The practitioner will increase their understanding of
relevant emergency skills and knowledge by directly seeing the application
of theoretical knowledge within clinical practice. The enhancing critical
thinking approach encourages the reader to seek further understanding of
relevant theory, this follows the Nursing and Midwifery Council guidelines
on lifelong learning and the ability of the practitioner to be fit for practice
(NMC 2004).
This approach is outlined in Box 1.1.
Box 1.1
D
E
A

The DEAD mnemonic outlined

Data (scientific facts) these should be based on the facts the practitioner
holds and any other data that can be collected to validate or negate them.
Emotions (intuition or gut feelings/reactions) what are your instincts telling
you?; how can you consolidate or negate these?
Advantages advantages to others that would result from actions the
clinician takes, i.e., would an action instigated at the initial assessment
improve the patients prognosis, an example being the dispensing of an
anti-platelet drug to a patient experiencing an acute coronary syndrome?
The practitioner should also consider that a test requested when the patient
presents might hasten their visit and result in an increasingly efficient
service.
Disadvantages (differential diagnoses) what could go wrong, in the worst
case scenario what could this be?; how I can rule this out?

By utilizing this structured framework, those less experienced in critical

thinking will have a clear systematic outline to assist them in the organization
of their thought processes and subsequent clinical practice. This, in turn,
could facilitate the individual development of critical thinking and decisionmaking-skills.
The focal point of this book is to facilitate practitioners to acquire the
essential skills of patient assessment and priority assignment, as these comprehensive skills have been highlighted as being paramount to emergency care
providers (DoH 2005).