The Emergency Department is responsible for the provision of all surgical and medical care to patients that arrive at the hospital in need of such. Usually, such patients are in critical condition. These services are offered as an emergency therefore Emergency Department. There are certain situations which can be responded to by the hospital staff in the emergency department like cardiac arrests. This department is also referred to as the emergency room. This paper will look into the process that is followed from when a patient is admitted in the emergency room until when they are discharged or admitted under the inpatient settings. In particular, the focus of this research will be patients with chest pains.
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Usually, chest pains are a symptom of Acute Coronary Syndrome. Currently, the evaluation of patients with chest pains in the emergency department includes the electrocardiography (ECG). Such patients are also likely to be taken through the cardiac biomarker of choice. This test is used for diagnosis and also risk stratification (Newby et al., 2001). The patients with chest pains are divided into two categories after the results of the ECG are acquired. They are divided into those diagnosed with ST-elevation myocardial infarction (STEMI) and those with non-ST-elevation acute coronary syndrome (NSTEACS) (Antman, 2008).
The clinicians in the emergency department have difficulties when it comes to the identification of patients to admit and which to send home. Apparently, majority of the patients that are presented to the ED do not have cardiac cause. However, of the patients that are commonly admitted, it is recorded that most of them (up to 60%) do not register as having acute coronary syndromes. It is recorded that there is a huge number of patients that are admitted with chest pains unnecessarily.
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It is important that we note the statistics on chest pain reports at the ED. According to Goldman et al. (1982), there are about 5.8 million ED visits in a year. Of these, it is noted that a very high number of approximately 4.4 million patients report having chest pains. Nevertheless, it is also recorded that around 79% of these cases that are reported to the ED are not critical. On the downside, 85% of the patients are recorded as not having undergone a cardiac diagnosis whereas 2-8% missed the diagnosis.
Patient Admission Process at the Emergency Department
The first step in this process is the arrival of the patient at the hospital’s emergency department/room. The following is the process that patients will undergo upon arrival at the emergency department:
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Admission (door to bed) process.
Firstly, the patient has to be admitted to the hospital and their details recorded. There are different systems that are employed at different health institution which enable quick and better door to bed time. In this research, the hospital recorded the patient’s registration information as well as their clinical triage information. To be specific, the hospital will record information that is specific to the patient’s condition. Since it is an emergency situation, usually there will be no much time to discuss in details some information like the payment modes, etc. However, the recording nurse is expected to record all the necessary information within the shortest time possible.
At this initial stage, the patient’s personal identification is recorded, their list of allergies, list of all current medication being taken, list of the patient’s medical conditions, all surgeries they have ever undergone, the patient’s primary care physician, copy of the patent’s advance directive, and finally the patient is expected to bring with them all the necessary insurance coverage cards(Fleisher et al., 2004).
The first step after the elective admission is completed is the risk assessment. This assessment includes the assessment of the patient’s history as well as their physical examination. Here the patients are classified as being a category 1-5. These categorize will help determine the next course of action for the emergency treatment of the patient. The stage 1 patients are those that are diagnosed as having ST-segment elevation on initial ECG while those classified as stage 2 are without ST-Segment elevation but have been found to be at high risk depending on the ECG findings. The 3rd classification is for the patients with no objective evidence or symptoms that warrant evaluation, and finally the 4th group is for those patients that do not have cardiac causes of the present symptoms.
The patients categorized under category 1 are evaluated for immediate therapy. Then category 2 patients are admitted at the hospital. However, if there are no contraindications they should just receive antithrombotic and antiplatelet treatment. If the patient has ongoing symptoms and persistent ECG changes, they should be checked for coronary angiography. Most patients will find themselves in category 3. This category is for the patients that are low-risk. Such patients undergo further evaluation to better determine their ailment. However, the treatment of the category 4 patients is determined by the alternative diagnosis.
After the risk assessment, the patient will then be referred to a physician and other hospital staff ready to cater for their specific emergency case. This paper specifically focuses on chest pains. In such a case, the patient will be referred to a cardiac specialist who will carry out the diagnosis tests. In case the physician sees the need to ask for assistance from other personnel, they will do so. However, there are certain tests that can be carried out by other personnel under the supervision of the cardiac specialist.
In the case of the chest pains, the following are the tests that will most likely be conducted on the patient. First, the Electrocardiogram (ECG) tests – this test is carried out to record the electric activity of the heart (Neilson, 2013). This is done through the electrodes that are attached to the patient’s skin. Since abnormal electromagnetic charges are conducted by injured heart muscles, results indicating a heart attack might be presented by this test. Secondly, the patient’s history will be checked as an initial assessment of the patient. Objective evidence is used here to stratify the patients as either being high or low-risk. Here the patient is asked to describe their ‘discomfort’. Usually, they will not consider this a pain that why discomfort is applicable here. For best risk stratification, the discomfort as well as any other associated symptoms are very necessary.
A physical examination is necessary for people classified as being low-risk. There are symptoms that are used to help determine the high risk patients. These include chronic heart failure (CHF), low blood pressure, as well as elevated heart rate.
There are different employees involved in the process of admission of a patient in the ED who reports as having chest pains. These employees can be classified as follows;
- Nurses – the nurses are involved in the caring of the patients. Different nurses will be present during the day and night shifts in the ED. The different nurses will also be assigned different tasks in the process of admitting and testing a patient in the department. The interaction between the nurse and the patient starts after the patient is through with the registration staff. Once all the necessary details are recorded, the patient will be referred to the nurse on duty who upon having a look at the recorded information, will refer the patient to the necessary physician or even undertake a different course of action. According to the information given by the patient, the nurse might be prompted to carry out some immediate tests or medical procedure as he/she awaits the physician’s presence in the ED. Where there is no medical officer on call 24/7, the nurse might be required to sign the Chest Pain Pathway form in their place. They are also expected to comply with the minimum standards of the chest pain evaluation.
- Registration staff – the duty of the registration staff is to obtain the details of the patient as when they come to the hospital to obtain treatment, This is done regardless whether they go to the ED or other hospital departments.
- ED administrative staff – The administrative staff are endowed with certain administration duties which include; hospital administration, patient service administration, making of critical decisions on patient course of treatment, make decisions on admission of patients and their release from the ED to the outpatient or inpatient departments. The administrative department works with what the registration staff recorded as well as the results recorded by the different nurses that might be assigned to carry out tests on the patient. The administrative staff of the facility are expected to ensure that the minimum standards for chest pain tests are implemented.
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- Laboratory technicians – these professionals are endowed with the tasks of carrying out tests whose results will help the physician prescribe the mode of treatment suitable for the patient. The tests that are carried out on the patient are essential for diagnosis purposes. The staff at the laboratory noted that they do not come into much contact with the patient apart from when they are carrying out the tests. These tests include sample patient stool tests. The staff noted that some patients would at times be adamant that the results found were not correct especially if they are not positive. At times, the patients will request both kindly and rudely for the tests to be redone. However, the standards of the hospital do not allow for this because of logistics involved. Retests can only be done with the express request of the physician diagnosing the patient.
- Transporters – The staff that transport the patients to the ED (ambulance drivers) indicate that they get to meet with different kinds of patients. There are some that will be seriously sick and seem not to be while others will be the opposite of this. According to these drivers, transporting emergency cases is crucial and there are times when a patient has lost their life before arriving at the hospital. However, the drivers note that there are very few such cases of patients who had just reported chest pains. Apparently, the drivers note that when they follow up on a case, they realize that the patient was not a high risk patient. Apparently, it seems that chest pains are really feared by the majority of patients and are usually taken to be symptoms for very serious cardiac issues.