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Risk Management in the Emergency Department

As we define the process of risk management in the emergency department, it is important to define the concept of risk in its broadest meaning: “Risk is an uncertain event or condition in the future that, if it occurs, has a positive impact (and thus called an opportunity) or a negative impact (and called a threat)”. Meanwhile, the science of risk management covers “all the processes concerned with conducting risk management planning, identification, analysis, responses and monitoring and control on a project.”

Assessing and managing risks is the best weapon that can be used to avert catastrophes. By evaluating the action plan for potential problems and developing strategies to address them, one can improve one’s chances of a successful, if not perfect, execution and implementation of services. Even the most carefully planned activities can run into trouble. No matter how well a plan is orchestrated, there is always a chance to encounter unexpected problems. Team members get sick or quit, resources that you were depending on turn out to be unavailable, even the weather can throw you for a loop (e.g., a hurricane).

To understand risk in the Emergency Department (ED), it is important to examine the workflow of the patient journey in an ED. The Emergency Department is a dynamic and often unpredictable place, which makes it a high-risk inducing environment. The staff of an ED may see anything in the course of a shift, ranging from a common cold or upset stomach that are treated with a simple medication to a trauma or cardiac arrest that requires full resuscitation efforts. Speed, efficiency, and accuracy of assessing, diagnosing, and treating patients are essential, due to the unpredictable and often heavy flow of patients through an ED. A visit to an ED involves a complex series of decisions, interactions, and activities, which will make it vital for risk planning and assessing to be accurate. A systematic approach that facilitates fast, efficient and accurate patient documentation and treatment within defined processes is required to minimise unexpected failures or human errors.

ED’s can have multiple areas within the department, such as Minors, Majors, Resus, Observation and Treatment. Emergency Departments can be split into two types: Minor Injury Unit (MIU), Acute ED, etc.
Minor Injury Units, as the name suggests, tend to deal with patients with minor injuries. These units often only consist of 2-3 treatment areas and a waiting room. Most are also nurse-led units staffed by Emergency Nurse Practitioners who will see, treat, and discharge patients. Following clinical protocols and care pathways will enable a more controlled and safe environment for patient treatment. The workflows in these units can differ greatly depending on its size, hours of opening, and number of patients seen.

Typically, patients self-present and are fully registered. In smaller units, the nurse will complete this registration. Patients will then wait to be seen in a queue based on length of stay. Young children and those clearly requiring more attention that is urgent will be fast-tracked.

Acute Emergency departments are larger units that require a more robust workflow. Patients can enter the ED either by ambulance or on their own. Whilst the initial workflow between these patients may differ slightly, the same systematic approach is taken with both.

The vast majority of patients will self-present to the ED receptionist. Once they are fully registered they will be seen by a nurse to triage or stream them. A front sheet will be printed on completion of registration. This will include demographic information and the reason for visit. This sheet can then be combined with an investigation sheet.

Triage involves a brief assessment where the patient will be assigned a priority which will dictate the order in which they are seen. Clearly patients who require immediate investigation and intervention will be moved straight into a room. Those with lower priority will be asked to wait in the waiting room until called by the doctor or primary nurse. The Triage Nurse will decide which area the patient is more suitably seen (Majors or Minors). They will assign the patient to that particular queue. The nurse in charge of the assigned area will look through the patients in their queue, ordering the patients on a combination of their triage category and length of stay.
Patients arriving by ambulance will be brought to a specific area where they can be streamed. This is often to the nurse in charge of majors. The nurse will complete a brief assessment to ascertain where they are best treated. The patient may immediately be assigned a bed in Majors, moved to Minors or Resus, or moved into the waiting room to be formally triaged from there.

Patients assigned to a bed will be seen by their primary nurse. The nurse will complete the formal triage and complete their initial assessment. This will include vital signs. Hence, it is important to ensure the comprehensiveness of data entry at the triage stage.

Although doctors will move around the different areas of the department depending on the demand, they tend to concentrate on the area they have been assigned for their shift. After assessment, the doctor will document their findings and plan of action. If the patient has been in the hospital before, the doctor may ask reception to request any previous notes from medical records. They may also request investigations such as blood and X-rays, and treatments such as initiation of intravenous fluids and drugs. The primary nurse will be informed of these requests verbally and/or sometimes using a whiteboard. Care for the patient is a continual process carried out at any point as needed prior to, during, and after diagnostic tests are complete, in collaboration with the ED doctor. Interventions and course of care are based on the patient’s needs.

Patients that are to be discharged home from the ED will be given prescriptions (these will have to be collected from the hospital pharmacy), and/or any patient education documentation they require. A discharge summary also will be completed by the ED doctor and sent to their family physician or general practitioner (GP).

Should the ED doctor decide that the patient might need admission, they will contact the appropriate on call team (e.g. Surgery, Medicine, etc). If the team accepts the patient, the process of arranging a ward bed is initiated. Hospitals with admissions units, such as Medical Admissions Unit (MAU) may now transfer the patient to the MAU to await assessment by the on-call team. After this assessment is complete, the patient may be moved to the ward, or discharged home.

With hospitals that do not have an MAU, or when the MAU is full, the admission to ward process is initiated. Large hospitals have teams of Bed/Site managers responsible for assessing the current bed state and assigning new admissions to suitable beds. Once the decision to admit (DTA) has been made, the bed manager will be contacted either by the nurse in charge or the patient’s primary nurse. Once an available bed has been found, the bed manager will ring back to the ED to let them know where the patient will be going. In the meantime, the primary nurse will be completing the documentation necessary for the admission. The receptionist will make up the hospital notes. The primary nurse generally contacts the ward to verbally handover the patient. When the patient is unstable they will accompany the patient to the ward and handover in person.
Not all patients can be fully registered on admission to the ED. The patient may arrive unconscious. In this situation, the patient will be given an emergency code so that they can be entered onto the system and investigations and treatments can be initiated immediately. If the patient is identified during the admission, the receptionist may combine the patient notes, or this process will be managed by medical records.

Within the ED environment, managing operational risk is vital in the following dimensions:

  • People and skills
  • Processes and procedures
  • Systems and technology

Emergency clinicians (physicians and nurses) face the challenge of treating patients in short encounters with the possibility of not seeing the same patient again. These short spells of interaction and the rapid pace of the workflow in the ED represents fertile ground for unexpected circumstances to take place any time. Challenges occur under circumstances that could range from minor injuries to life-threatening cases. The rapid decision-making process characterises the nature of a high-risk environment which requires managing risk through well-established controls and procedures.
There are many factors that contribute to increased risk in an emergency department:

  • Lack of knowledge or experience
  • Incomplete demographic information collected at the ED registration
  • Inadequate clinical history documented by the triage or assessment nurse
  • Failure to perform adequate examination or investigation
  • Mis-diagnosing the patient due to lack of evidence-based assessment
  • Inability to interpret lab or radiology investigations
  • Mis-treating the patient based on incorrect documentation or human-induced errors
  • Lack of communication is a significant threat that might result in severe consequences
  • Incorrect decision not to admit a patient and instead opt to discharge the patient

These are examples that show how a sense of constant analysis and use of data will enable better risk planning and more effective mitigation of threats. The automation of the ED is a solution to build robust risk management process by utilising and analysing the all the data collected. Digital innovation will enable the ED staff to produce effective tools and policies to mitigate risk and predict threats.
In conclusion, the working environment of the ED is a unique, complex, and dynamic environment. This is reflected in the varying, often overwhelming volume of patients seen in busy EDs, as well as in the range of acuity of clinical encounters. With decisions being made under time constraints, often with incomplete information, emergency physicians are highly vulnerable to error and claims of malpractice. Thorough clinical documentation is critical not only for protecting emergency clinicians but also for ensuring the continuity and quality of care for patients.

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