EMERGENCY DEPARTMENT PLAN

EMERGENCY DEPARTMENT
PLAN
Action Plan

Prepared by:

Dr. Shahid Bashir Chaudhary

ER Specialist

AUGUST 27, 2016

KING SAUD HOSPITAL
Unaizah, Al-Qassim, Kingdom of Saudi Arabia

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 EMERGENCY DEPARTMENT PLAN

Table of Content

Contents Page

1 Preface 2
2 Critical Condition handled in ER 3
3 Triage 4
4 Referral policy 5
5 If bed is not available 8
6 Before transferring to other hospital 8
7 Before discharge from Emergency Room 8
8 Procedures not allowed to do in ER (MOH Policy) 8
9 Code blue 8
10 Medico legal Aspects 9
11 Medical, surgical and Pedia & Female ward in ER 10
12 Infection Control Measures 10
13 Saudi Council 11
14 Duty Roster 11
15 Counseling/Peer review 11
16 Relationship with trainees, students and learners 12
17 Sepsis 12
18 Intravenous antibiotics be made available in ER Pharmacy 12
19 Professional regulations 13
20 Endorsement of ER Patients on change of shif 13
21 Training program 13

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 EMERGENCY DEPARTMENT PLAN

PREFACE

This Action Report is written on the order of honorable Hospital Director Dr. Abdullah Ibrahim Al-
Moosa to identify the areas where there is space to improve the status as well as quality of work of
Physician to provide safe and quality health services to community.

This precise Improvement Plan (IP) is produced with the help, advice and assistance from Dr. Ridwan
Ismail Chief of ER and other ED Physicians and non-clinical staff.

MOH has laid down comprehensive policies and procedures to streamline the emergency
Department but maximum number of healthcare providers are not aware of these policies. I have
mentioned that policy by number in the original document. This action report will serve as a
compendium of lessons learned, outlines the necessary corrective action recommendations, and
provides the basis for on-going emergency planning, training and future exercise needs.

I hope that this report, document our readiness and map plans for improvement.

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 EMERGENCY DEPARTMENT PLAN

An emergency department (ED), also known as an accident & emergency department (A&E),
emergency room (ER) or casualty department, is a medical treatment facility specializing in
emergency medicine, the acute care of patients who present without prior appointment; either by
their own means or by that of an ambulance.

Critical Conditions Handled

Following are the critical conditions that are handled in King Saud Hospital Emergency Department

Cardiac Arrest
Cardiac arrest may occur in the ED/A&E or a patient may be transported by ambulance to the
emergency department already in this state. Treatment is advanced life support as taught in
advanced life support and advanced cardiac life support courses. This is an immediately life-
threatening condition which requires immediate action in salvageable cases.

Myocardial Infarction
Patients arriving to the emergency department with a myocardial infarction (heart attack) are likely
to be triaged to the resuscitation area OR directly in resuscitation room if transported by ambulance.
They will receive oxygen and monitoring and have an early ECG; aspirin will be given if not
contraindicated or not already administered by the ambulance team.

Trauma
Major trauma, the term for patients with multiple injuries, ofen from a road traffic accident or a
major fall, is initially handled in the Emergency Department. The services that are provided in an
emergency department range from x-rays to immediate CT scan of brain and spine along with basic
investigations and interventions if deemed necessary.

Mental Illness
Some patients arrive at an emergency department for a complaint of mental illness. who appear to
be mentally ill and to present a danger to themselves or others may be brought against their will to
an emergency department by law enforcement officers for psychiatric examination. The emergency
department conducts medical clearance rather than treats acute behavioral disorders. From the
emergency department, patients with significant mental illness may be transferred to a psychiatric
unit with consultation to o/c Psychiatrist.

Asthma and COPD

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Acute exacerbations of chronic respiratory diseases, mainly asthma and chronic obstructive
pulmonary disease (COPD), are assessed as emergencies and treated with oxygen therapy,
bronchodilators, steroids. an urgent chest X-ray and arterial blood gases and are referred for
intensive care if necessary. Noninvasive ventilation in the ED has reduced the requirement for
tracheal intubation in many cases of severe exacerbations of COPD. Moderate asthmatic patients are
nebulized in respiratory room

TRIAGE
Triage of the king hospital is one the best adopted system in Qaseem region, (Canadian Emergency
Department Triage and Acuity Scale (CTAS)). Recently FAST Track is also started. As we know that
Triage systems aim to distribute medical resources according to patients’ needs. Trained triage
Physician as well as nurses are usually responsible for giving a triage level for patients’ conditions
based on an established triage system within a short timeframe. King Saud Hospital triage system is
providing safe and efficient services to the community attending emergency department. The Staff
who is triaging the patients take into consideration the foundations of triage systems the values of
human life, health care resources, and fairness in distribution. The triage is dynamic process
therefore the space of improvement is always there according to day to day experience

Following are the proposals to improve the triage.

1. In triaging calling system there is no level 2. Since FAST track is started level 4 patients are sent
back to PHC OR immediate service is provided. Then only level 2 and level 3 patients are needed
to be entertained in ER, therefore Level 4 can be removed from triaging calling system and level 2
needs to be included.
2. Category I and II patients should be directed and seen in the resuscitation area, while other
categories can be seen in the examination room/ areas (3.5)
3. On the counter medication be allowed to dispense from the triage to solve the administrative
problem as many of the patients are aggressive or reluctant to go to PHC and most of these
patients fall in category level 4 and 5. For these patients, registration is not mandatory, only afer
monitoring vital signs these medications can be written on triage sheet column.
4. There should be Peak flow meter in triage as the area is more prone to bronchial asthma.
5. There must be a social worker in the triage area or duty administrator must repeatedly visit the
triage and be responsive if there is any clash between triage staff and patient on sending back to
PHC.
6. A security guard vigilantly be available in the triage or waiting area.
7. Trained doctors and nurse be assigned in triage room who had taken triage course and having
minimum 3 years’ experience of working in ED as supervisor
8. MOH policy regarding triaging should be comply strictly that include:
8.1. No triage out done by nurse, only by physician
8.2. Known diabetic patients should have gluco-check in triage
8.3. Resuscitation room Physician will be notified upon completion of initial nursing and
physician assessment. Notifications will be documented if the patient is triaged level 2.
8.4. Chest pain patients must have ECG in triage.

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8.5. 2nd visit for same complaint or within short duration to ER must be awarded triage level
according to acuity.

9. ER Physician must examine and re- assess the patient according to triage level and if it deems
that patient needs upgrade or downgrade the triage level, the concerned Physician by himself
will notify and document all the data.
10. If there is any confusion in assigning the triage level, ED Consultant or Specialist can be called to
assess the patient in triaging room and it is better to give high triage level in that cases.
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11. Sepsis patient identification needs to be expertise and be given level 2.
12. The ER physician is the only authorized person responsible for admission to ER (no patient should
be admitted without his permission). (4-1)
13. Harmony between staff must be maintained in triaging the patient
14. Patient’s respect is always a priority, talk very politely with slow tone and if there is any conflict,
call administrator or social worker or senior.
15. Triage Physician must examine patient by himself even he/she is busy in FAST TRACK.
16. If there are more number of triage patient , token number are issued and requested the patient
to wait till there turn however keep an eye not to miss serious patient.
17. Minimize the gathering of doctors and nurses in triage premises that may lead to poor physician-
patient communication, failing to provide the necessary care altogether, or even having to decide
whose life to save when not everyone can be saved. These consequences challenge the ethical
quality of emergency care.

Referral Policy

In emergency department maximum issues are related to over stay or delay in admission/transfer of
patients to in or out of hospital causing mental torture to attendants, patient as well as ER Physicians
and the basic reason lies in the unawareness to referral policy laid down by MOH.
Before I state salient features that are needed to be implemented with immediate effect, it is
suggested that a medical director should make a monitoring committee who assess referral of
patient in ER on daily basis.

Definitions:
Referral is a procedure being conducted in the ED where in a patient is assessed and evaluated by the
ED physician, and then referred to another doctor for further investigation and evaluation (i.e. for
definite diagnosis and treatment).

1. The ED Physician may refer patient directly or by phone to any specialty on call team. Where-
possible, before referring the patient to a specialty, the Consultant (team leader Specialist) on
duty in ED should be asked to review the patient. This allows for diagnosis that is more definite
and may prevent unnecessary delay in the management of the patient (reduced unnecessary
referrals).

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2. When decision is taken to refer patient to other specialty within the hospital, calling sequences
for a designated specialty are maintained as follows:
Sequence until the response is achieved:
2.1 Call 1st on call three (3) times every five (5) minutes.
2.2 Call 2nd on call three (3) times every five (5) minutes.
2.3 Call 3rd on call three (3) times every five (5) minutes.
2.4 Call Head of Department/Section
2.5 Call Hospital/Center/Administration Director
2.6 Call Medical Director/Executive on Duty afer working hours.
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3. The nurse responsible of area will document:
3.1 Time and number of initiating the call/calls.
3.2 Time of response by the medical staff.
3.3 Time of arrival of the medical staff on-call to the ED.

4. In life threatening situations, the on-call specialty staff must be present in the ED within 5 to 10
minutes, afer answering the call. For all other consultations, response by telephone within 15
minutes and presence in the ED is within 30 minutes is mandatory for the counseled specialty.
5. If the Consultant on-call does not respond within 15 minutes or the specialty on-call physician
answered and does not come within 30 minutes, the ED Consultant on-duty shall be informed to
call the consultant on-call, head of department of the counseled specialty and/or the hospital
Medical Director and an incident report should be made to the Head of ED, as appropriate (if the
on-call physician is busy with other patient , the priority will be for the most sick patient, and
he /she should inform his senior as backup plan to respond in a proper time to the referrals).
6. The first on-call physician will evaluate the patient and communicate with his/ her Registrar or
Consultant on call. The registrar/Consultant shall come to see the patient, if needed. The
decision to admit or discharge will be the privilege of on-call specialist, and this shall be
documented in patient’s file.
7. The ED physician may, in special situations, immediately call the Registrar or consultant if in his
medical judgment an immediate action needs to be taken and that will be in the best interest
and welfare of this patient.
8. The on-call specialist afer assessing the patient, should provide a feedback to the ED consultant
about the treatment plan inform of the patient disposition and any changes should be approved
by ED consult.
9. If the ED physician (or ED consultant) assess the patient in ED, the condition of patient need a
referral to subspecialty on-call, he /she should contact on-call physician afer referral form was
filled in a proper way. (The ER Physician writes on ER sheet time and sub specialty that is
computerized).
10. In the event where the referral was done for more than one specialty and the consultants (or the
on call teams) do not agree to whom the patient admission belongs, the ED consultant has the
authority to admit the patient under the specialty that he thinks the most responsible for the
care of the patient.
11. In case the patient was referred to one specialty, and this specialty referred the patient to other
specialty, the consultant on call specialty to whom the case was first referred should admit the
case as primary treating consultant, and the other consultant should follow the case till a definite

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diagnosis, or the second team was consulted by the first on call specialty agree to admit the
patient. All the process should not exceed 6 hours from patient arrival to the ED.
12. If patient was referred from ED physician to the on call specialty, no back to ED is allowed. On call
specialty either admit, or discharge, or refer the patient to other on call specialty or other health
institute under their responsibility (on call specialty the patient was referred to them).
13. No patient can stay in ED more than 6 hours from time of ED arrival without disposition either
admission or discharge or transfer.
14. Junior ED Physician shall discuss cases requiring referral with the ED Consultant on-duty.

15. Documentation needs to take place in the patient’s chart detailing the care given by the ED,
reason of referral.
16. The ED staff must document the patient›s name, number, location, time requested and brief
statement of the patient’s problem and reason the consultation.
17. If the ED physician (or ED consultant) want the patient to be seen in OPD of the hospital, the ED
Physician must communicate verbally with the on-call Consultant/Specialist of choice to take his
approval to send this patient to the on-call consultant clinic afer filling the referral form for OPD
depend on urgency of the condition and patient stable to be discharge from ED.
18. If the patient treated at hospital ED as the condition not need a specialized clinic only a family
medicine, patient can have a follow-up with PHC in his area afer a document will be given to the
patient include in diagnosis, procedures done for him at ED, and the recommendations for
continue his treatment as dressing daily or remove of stitches afer 5 days ...etc.
19. Patient attending OPD who develops emergency conditions should be sent immediately to the
ED, to be attended by the appropriate specialist. Prior to transfer, resuscitative measures should
be instituted in OPD by OPD specialty clinic team where the patient is being followed up.
20. The patient should be accompanied by a medical health provider from OPD to ED according to
the severity of the case which will be the responsibility of the referred physician who will decide
who should go with the patient for example physician, EMS staff, nurse. If the referring physician
thinks that patient can go to ED without a health provider company it is acceptable under his
responsibility.
21. If the Consultant at OPD wants the patient referred to the ED, the Consultant must communicate
verbally with the ED Consultant (team leader) at the, and document the reason for referral in the
patient›s chart.
22. Consultant to Consultant (TEAM LEADER SPECIALIST) is a must and pre- requisite for any patient
acceptance for any location in ED.
23. ED Consultant approval is a must and pre-requisite for any patient acceptance for any location in
ED.
24. If there is disagreement in accepting the referral, the first non-consultant on- call doctor should
call his/her consultant to resolve the issue.
25. At ED if the ED physician (afer approval by his Consultant) or the ED consultant do the ED
management, and patient need a referral to on call specialty a referral form should be written
with a verbal communication to on call doctor in the suggested of time sequence (2hrs in KSH
max.) with full documentations.
26. The referral to the on call specialty depends on the need of patient clinical condition. It can be
one or more specialty need for patient referral, although one referral specialty is preferable.

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27. ED consultant afer acceptance the patient to be referred from OPD to ED the acceptance form
should be filled by ED consultant, and given to the charge nurse during the shif which should
inform and handle the acceptance form to the ED Triage nurse this will assure better
communications and good patient care (all these procedures should be documented at the
acceptance ED form)
28. ED Physicians will advise the patient to have a follow up visit to his / her PHC in case patient was
assessed and managed in ED provided patient had a simple clinical condition not an urgent base
(for example dressing, and removal of stitches), patient can have a referral from PHC to the
hospital OPD if patient condition later need a follow up.
29. If ED physician need to refer the patient to hospital OPD, contact the on-call specialty physician
and filling the referral form is must. Referral form should include the name of the clinic
consultant, and the name of the on-call physician who accept the referral.

If the Bed is Not Available______________________________________________________

and the patient is admitted through ER and waiting for a vacant bed, it is the responsibility of the
admitting team to follow up (patient condition, bed arrangement and patient transfer). (4-2)

Before Transferring to Another Hospital__________________________________________

1. Emergency Room physicians should make a comprehensive assessment of the patient’s condition
to determine the necessity of transfer from the hospital
2. If the patient for transfer is an ER patient it is the responsibility of ER department to arrange the
transfer process with a ER doctor accompanying the patient.
3. If the patient for transfer is belongs to other medical specialty it is the specialty to arrange the
transfer process and a physician of the concerned specialty not the ER doctor will accompany the
patient.to another facility. (3-1)

Before Patient Discharge from ER:_________________________________________________

1. All abnormal vital signs will be brought to the attention of the physician by duty nurse and will be
repeated and addresses prior to discharge from the Emergency Room.
2. Patient’s condition should be stabilized before discharging patient from the ER either for the
purpose of transfer to another facility or direct home discharge (3-6)
3. ER Physician working in any area will abide by this rule they must re- evaluate the patient and
document vital signs that may include blood pressure, saturation and pulse that may include
blood pressure, saturation and pulse in ER Sheet in the computer before they decide by
themselves to discharge.

Procedure Not Allowed to do in ER, as per the MOH Policy_______________________________

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1. Suture removal
2. Non-emergency cast removal
3. Second dressing for burn or
wound.
4. Admission of elective cases.
5. Checkup investigation.
6. Preadmission investigations.
7. Giving medications brought
from outside.
8. Refilling of medications.
Code Blue

Code Blue will be announced exclusively by ER doctor on when there is

confirmation that patient is: ·
1. Unresponsive
2. No breathing.
3. No pulse in carotid or femoral artery.

The ED should be encouraged to have a code team inside ED for rapid and
optimal response for better patient care. (6-10)
According to MOH guidelines in the manual there is no mention that code
blue is announced other than cardiac arrest or the criteria mentioned above.
In view of guidelines there is no role to announce code blue if patient
desaturates, having hypotension or altered state of consciousness, in these
cases if it deems necessary, then the ER team or ICU team will intubate the
patient and all procedure and vital signs are documented.

Medicolegal Aspects:

There is some religious issue that are related with Islamic sharia needs to be
observed strictly and if not followed before must be comply in future
according to MOH policy.

1. If there is death of any Muslim patient irrespective of nationality, Muslim

Nurse/Doctor of the same gender shall render the post-mortem care. (5-
4).
2. While handling the dead body following steps are followed:
2.1 Wash hands,
2.2 Wear gloves,
2.3 Apron, mask and follow infection control measures.
2.4 Disconnect IV tubing, suction, and oxygen.
2.5 Remove cannula, catheters, drains and tubes if present.
2.6 Position the deceased in proper body alignment.
2.7 Close eyelids.
2.8 Put back dentures, if any.
2.9 Wash and clean the body with wash cloth removing all dirt, blood
stains, and secretions.
2.10 Dry with towel. Apply proper dressing to open wounds.
2.11 Fill up 3 identification tags.

3. Medicolegal aspects of emergency department are always neglected and

ER Physicians are not scientifically trained to manage the cases that fall in
this category like:
 EMERGENCY DEPARTMENT PLAN

3.1 Any dead body brought by Buladiyia will be observed by senior ER

Physician.
3.2 The following cases should be reported to the police through the
duty administrator/social worker:
3.2.1 Any injury deliberately inflicted by another person, by Battery
3.2.2 All stab wounds.
3.2.3 Assault with vehicle (road traffic Accident)
3.2.4 Known or suspected child abuse or neglect
3.2.5 Poisoning.
3.2.6 Gun-shot wounds.
3.2.7 Attempted suicides.
3.2.8 Known or alleged criminal abortions.
3.2.9 Known or suspicion rape.
3.2.10 Founding children or babies

3.3 The emergency Department Consultant, or Medical Director, should

be contacted if there are any unusual circumstances or problems in
the Emergency Department, e.g. major accidents, criminal cases.

4. It is recommended at least 3 Physician are sent for forensic training

course.
5. Any dead body needs to take in mortuary directly and ER Physician will
examine there and write report.

Making Medical, Surgical and Pedia/Gyne Wards

Due to increased population of Unaizah and vicinity it is very important that

emergency department shall be up graded according to major emergencies
brought here that includes:
1. Medical Emergencies
2. Surgical Emergencies
3. Pediatrics and Female Emergencies.

Now there is a need to establish three wards in the department where these
emergencies are managed separately with appropriate manner.

The suggested plan that can be considered is as:

Resuscitation Room.
1. Two beds in the resuscitation room are fixed for code blue and code
yellow and are called resuscitation room.
Medical Emergency Ward.
2. The male observation room and present resuscitation room is declared as
medical emergency ward and dividing wall between both is partially
removed and there is no need for observation room.
Surgical Emergency Ward.

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3. Present respiratory rooms can be shifed to Psychiatry OPD (that can be

shifed to other area in hospital) and these two rooms are declared
surgical emergency ward. The advantage of these rooms is:
4. Surgical on call resident and Ortho resident must be present in the surgical
ward, initial assessment will be by triage Physician and examination room
physician
5. Any trauma patient who is level 2 and 3 will be sent directly to surgical
emergency ward while level 1 patient will be resuscitated in the
resuscitation room and afer stabilizing or intubation, will be shifed to
surgical emergency ward. These patient will be admitted by on call surgical
team and will be under supervision of surgical on call team until dispose of
either to in or out of hospital.
6. Minor surgical procedure will be done by on call surgical team in
treatment room, and if needed patient can be kept in surgical ward.
Pediatric & female Emergency ward
7. Present female observation room can be declared as Pedia & Female
emergency room and one pedia resident from in patient will be there and
ER resident will support. Policy and procedure can be laid down afer
consultation.
8. The above said plan is blueprint according to medical point of view and
the requirement is based on bed occupancy and volume of the patient
visiting in ER
9. Engineering department can do survey to make the feasibility report.
10. The matter can be discussed in the medical executive committee meeting
for appropriates of project.

Infection Control Measures

1. Physician working in ER must wear skinny sleeve shirts or half sleeve white
uniform or scrub suits because.
2. Infection Control. Researchers collected samples from the sleeves, waists
and pockets of 75 registered nurses and 60 doctors at a busy university-
based hospital to confirm the germs. Half of the samples tested positive
for one or more pathogens; potentially dangerous bacteria were isolated
from at least one site on 63 percent of the uniforms. Of those, 11 percent
of the bugs were resistant to multiple front-line antibiotics. These data
suggest that personnel attire may be one route by which pathogenic
bacteria are transmitted to patients,” concluded the researchers, led by Dr.
Yonit Wiener-Well of the Shaare Zedek Medical Center in Jerusalem.)
3. If it is mandatory to wear white coat for professional appearance, then
Hospital should institute one or more of the following measures:
3.1 The health professional should have two or more white coats
available and have access to a convenient and economical means to
launder white coats.

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3.2 Institutions should provide coat hooks that would allow removal of
the white coat before contact with patients or a patient's immediate
environment.
3.2.1 Footwear: all footwear should have closed toes, low heels,
and non-skid soles.
3.2.2 Shared equipment including stethoscopes should be cleaned
between patients.it is better that all physician must have their
own stethoscope and instrumental disinfectant made
available in the areas where the doctors are in contact with
patient i.e. examination room, triage room, resuscitation
rooms and wards.
3.2.3 Vaccination and N95 fitness is mandatory for physician
working in ER.

Saudi Council

It is mandatory for doctors working in ER to have SCFHS license and

malpractice insurance certificate, The Physician who fail to get it within one
year of joining, dealt as per hospital policy.

Duty Roster:
1. ER physician are in the dilemma of shif duty, in roster many doctors have
to come on evening duty afer night that hurts the health fitness as well as
concentration towards the patient, this practice needs to be stopped.
2. Minimum 9 to 10 off per month.
3. Compensation if extra duty is performed by ER Physician during holidays
like, Eid, Hajj and Ramadan.
4. ER consultant and specialist be on call accordingly and be compensated.

Counseling/ Peer review

Due to stress and shif duties many doctors are coming late or feel
uncomfortable during duty and cannot concentrate towards patients, there
must be counseling of those Physician by head of department and if needed
he can take help of Psychiatrist, all counseling data needs to be documented.
A peer review process be started in emergency department to save the patient
from any mishap, When any physician is found deficient in competence or
character through appropriate peer review process, it is morally imperative to
protect patients and to assist that physician in addressing and, if possible,
overcoming such deficiencies. Corrective action may include internal discipline
or remedial training.

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Relationships with students, trainees, and other

learners_______________________________
In emergency department, trainees, and medical students are assigned, ER
Specialist and consultant working in critical area and triage are responsible to
provide maximum information and share the cases, Teaching physicians must
fulfill their obligation to teach and provide appropriate levels of supervision
for students under their tutelage. Performance evaluations and letters of
recommendation require a careful assessment of the learners’ strengths and
weaknesses. Such evaluations must be accurate and clearly identify those
individuals who may jeopardize patient care. Patient interests should not be
compromised in the education process, and patients should never be required
to participate in teaching activities.
Those Physician who participate in teaching process need to be awarded
financially or by leaves in annual vacations .

SEPSIS__________________________________________________________
___________
Protocol of sepsis patient in ED is followed up and ER Physician should start
medication and be allowed laboratory to accept the blood and urine samples
for sepsis work up from Emergency Department by ER Consultant and
specialist .

Intravenous Antibiotics be made available in ER

Pharmacy____________________________

Intravenous antibiotics are not available in the ER Pharmacy , these must be

made available to treat infection especially for sepsis and trauma patients who
are delayed for non-availability of bed .

Professional
regulations______________________________________________________
________

No ER Physician is allowed to bypass Chief of ER for any documentation or

complaint against any patient or colleague. If the grievance is not solved at ER
level then he/she must proceed to Medical Director.

Endorsement of
Patients___________________________________________________
___

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The process of endorsement among ER Physician is very poor except in

resuscitation room. It needs to be observed closely and monitored; there is
suggestion that in ER Sheet a column is introduced for endorsement.

Training
program___________________________________________________
__________
All ER Physician must complete BLS/ACLS/PALS/ATLS/FCCS and other training
courses time to time offered including triage course FAST or airway
management etc.

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