Accident & Emergency

Department
Discussion
 Hospital

Hospital as medical
centre of community
stands for service in
any time of need

/68 2
2009 vimal
 Accident & Emergency (A&E) Department
Society considers hospital
A&E department to be
community centre for
outpatient care
More than 2/3rd of all visits
to this department not
classified as emergency
visits
Broad spectrum of types
of cases seen
All branches of medicine
must be available
Competent and
experienced medical
personnel required for
triage of patients
Day & night service must
be available

/68 3
2009 vimal
 A&E Department

A&E department is
one of the most
important and nt & Emerg
ency
Accide

sensitive
departments of
hospital
Deals with patients
during the most
crucial phase after
disease or injury

/68 4
2009 vimal
 A&E Department

One place in the

community where
attention to the patient
needs is available
round the clock, every
day of the year

Also provides services

as in the regular
outpatient department
outside the regular
working hours

/68 5
2009 vimal
 A&E Department
Accident & Emergency (A&E)
Department required to be
prepared to treat any case
ranging from:

a frightened child &

concerned parent

to a major disaster

/68 6
2009 vimal
 A&E Department
Many of the patients
require emergency
admission to the
hospital
Hosp Admissions A&E, 30

A&E department
responsible for 16-30%
of hospital admissions
Others, 70

/68 7
2009 vimal
 Attendance

A quarter of patients treated -

Children under 16

Main group
Between 17 and 74

Small percent
Over 74

/68 8
2009 vimal
 A&E Department
Significant increase in visits to A&E in recent years

Major contributing factor - increase in the number of accidents

Annually about 3.5 million accident deaths all over world

Trauma remains the commonest cause of death under the age of

35 years

India - highest road accident rate in the world vis-à-vis the

number of vehicles on the road

1 accident every 4 min

Convenience
delay in getting a consultant’s appointment

/68 9
2009 vimal
 Accidents

After most accidents the

condition of casualty
deteriorates with time

Rate of deterioration
related to the type and
severity of injury

Three-fold increase in
mortality for every 30 min
delay in start of treatment

/68 10
2009 vimal
 ‘Emergency’

A condition determined clinically

threat to life or limb

or considered by the patient or his relatives

as requiring urgent management by medical,
dental, or allied services
a condition, which they perceive as requiring
immediate attention by doctor

/68 11
2009 vimal
 Acute MI

In Acute MI the highest mortality is in

the 1st hour

‘Golden Hour’ –
1st hour immediately after injury

60% of the deaths from myocardial

infarction occur within one hour of onset

Training personnel and providing for

facilities to handle this emergency
disorder will do much to save lives

/68 12
2009 vimal
 Additional deaths from other causes:

Poisoning

Drowning

Obstetrical complications

Preventable if attended to in
time

/68 13
2009 vimal
 Emergency Medical System encompass:

Resuscitation and
maintenance of life at
the site

Care in transportation
of the patient with life
support

Rapid diagnosis and

treatment of the basic
medical problems at
the hospital

/68 14
2009 vimal
 A&E Department

Following are at stake:

Life or limb of patient
Reputation and image of hospital
and treating physician

/68 15
2009 vimal
 A&E Department

A&E Department can

‘make or mar’ the image
of the hospital
one of the most sensitive
areas for public relations of
the hospital

‘Hospital's Hospital’
everything that happens in
hospital also happens here on
a smaller scale

/68 16
2009 vimal
 Requisites of Efficient Service :

Adequate physical facilities, equipment, and stores

Alert, well trained, motivated, and sympathetic staff

who can render immediate and correct life saving
treatment and also be able to meet the emotional
requirement of the patient and his attendants

A prompt service with an efficient and foolproof

communication system

/68 17
2009 vimal
 Functions of A&E Department:
Collection of casualties

Rapid institution of BLS to critically ill at site, enroute & in hospital

Initial diagnosis & speedy assessment

Arrange for definitive care

OPD for minor ailments

Liaison with police, fire, other hospitals, community, & other departments

Information centre to render advice on telephone or in person, on simple

medical queries

Information centre during disaster

Training & research

/68 18
2009 vimal
 Types of A&E Department (based on the level of
facilities and staff available)
Type I: Large hospital with all specialists available round the
clock

Type II: Emergency room physician available round the

clock and specialists on call

Type III: Standby emergency facilities with physicians &

nurses on call

Type IV: Referral emergency service where only nurse

available - first aid & refer

/68 19
2009 vimal
 Three levels of A&E Department (Committee on
Trauma of the American College of Surgeons)

Optimal:
1000 admissions per year of seriously injured. Hospitals
of =/> 500 beds

Intermediate:
Similar but for staff availability

Minimal:
Limitation of facilities, equipment, & staff

/68 20
2009 vimal
 Planning of A&E Department

Primary role of the A&E Department

Care of critically ill
Planning be made keeping this in mind

While planning although esoteric and aesthetic considerations

play a role in department design
it must be functional

To have a functional and pleasant department, ‘user

requirements’ for the architectural team be prepared by a
committee composed of:
Hospital Planner and A&E Department Staff

/68 21
2009 vimal
 Planning of A&E Department
Factors to be kept in mind while planning:
location – urban, semi-urban & rural, especially in relation to main road
industries in draining area
population characteristics
communication facilities
patient load, hours of maximum patient load, morbidity pattern
Regional emergency facilities for same population
architectural design of hospital
Other planning aspects to be considered:
A&E visits increase by
5-6% per year
Admissions through A&E
16-30% and include 10% of OPD load
Peak loads in A&E
1700h to 2100h, 2100h to 0100h

/68 22
2009 vimal
 Location

Ground floor

Direct access from main road

Separate approach, other

than the OPD with a spacious
parking area for cars and 2-
wheelers

Located adjacent to OPD to

share the resources such as
diagnostics and also pool
resources in case of a
disaster

/68 23
2009 vimal
 Location

Well lighted and boldly signposted both for day and night
Direction signs should be put on the main traffic routes passing through
the station (If happens to be the only emergency service in the station)

Drive through and covered ambulance post capable of

accommodating at least two ambulances

Helipad for major trauma centres and in rural, hilly, or unapproachable

areas

Good and well maintained lawn with fixed benches and seasonal
flowers
Serves as an additional waiting area for relatives

/68 24
2009 vimal
 Interrelationship

Close interrelationship with operation theatre,

radiology, blood bank, laboratory, ICU, obstetrics,
records, OPD, and mortuary

Some authorities recommend close relationship

with CCU as well

Many sub-departments required in A&E

Department itself
OT, Diagnostics etc

/68 25
2009 vimal
 Work & Traffic Flow

Efficiency of any busy and high intensity department can be

greatly increased by smooth and orderly flow of traffic
Patients
Staff
Supplies

Internal traffic flow should aim at maximising efficiency at all

times

All modalities of communication be employed to save time

such as telephone, intercom etc

/68 26
2009 vimal
 Circulation in a A&E Department
Seriously injured patients Ambulant patients

Reception and Waiting Rooms

First Attenders Follow-up Patients

Resuscitation Examination, Diagnosis, Treatment

(Including diagnostic, x-ray facilities)

Further Treatment
(theatres, plaster rooms
Recovery beds)

Discharge Mortuary
Transfer

Out-patients In-patients General Practitioner Another Hospital

/68 27
2009 vimal
 Area

Thumb rule Putsep

Total spatial needs
A daily patient load of 100 patients
requires about 1000 SqM

/68 28
2009 vimal
 Layout Types

Core type
Treatment spaces situated around a central point in which
department personnel work

Corridor outside treatment area from where the patients enter

Visitors and ancillary personnel all use corridor outside the core

Support rooms such as cast room and supply rooms are along the
periphery of this corridor

Main advantage of this design

Freedom of department personnel

Circular is one of its modification

/68 29
2009 vimal
 Layout: Core type

/68 30
2009 vimal
 Layout Types

Arena type
Like core plan but without peripheral corridor

Nurses and physicians have good view of all cubicles

Less fatigue, as distances are less

Good for small department

Corridor type
Larger departments prefer this design, especially if there
is separation of services

/68 31
2009 vimal
 Entrance

Entrance is important for need and convenience

Entrance be separate from main hospital’s entrance and separate for

ambulant and stretcher bound patients - ramp

1.6M wide, 2-way doors Putsep

with glass panel at eye height
spring to keep them in open position
should open into the reception area

Automatic sliding doors to prevent accidents as in case of swinging

doors Jenkins
Limitation - jamming due to dust, maintenance etc

Entrance to registration be at a close distance

/68 32
2009 vimal
 Reception Area

Entrance should open into a large open space with reception

desk in front

Trolley, stretcher, and wheel chair parking area as well as a

facility for cleaning stained trolleys

Other areas that open into this area:

Waiting room for patients and relatives, police desk room, room for
drivers, space for medico-social worker, cafeteria, toilets,
registration and records, security, cash counter, and telephone
booth

Other areas recommended:

Puja room, grief room, flower, chemist, and bookshop

Size of reception area depend on patient load:

0.75 SqM per patient for 1/3rd of attending population in waiting area
BIS recommends 1.75 SqM per hospital bed for reception area

/68 33
2009 vimal
 Registration area

Also located in reception area but has to be approachable from

the nursing station also, maybe by means of a pass through
window

Functions include:
Record keeping
Admissions
Billing
Checking for and keeping valuables
Liaison with staff physicians and with other departments

Provide interview cubicles or booths for admission

/68 34
2009 vimal
 Waiting area

Functions
Waiting area for ambulant patients and accompanying family members
To prevent people from entering clinical areas
To be converted as triage area in case of disaster

Separate waiting area for serious and psychiatric patients

Visible from reception desk

Provisioning for reading material and wall posters regarding health as

well as for public relation activity

Facilities such as drinking water, ladies and gents toilets, television

and channel music

/68 35
2009 vimal
 Examination and Treatment Area

Main area of A&E department.

Going as per patient flow, the various rooms/ areas in this are:-
Triage area - separate area or lobby may be used

Nurses and physicians station

Near entrance and registration area, with multiple communication modes,
maybe glass enclosed above counter level, and a private toilet

Have work area with lockers, refrigerator, counter sink, a small flash
steriliser, IV fluids and medicine storage

Dispensing/ storage cabinets, ample counter and drawer space, CC

monitoring TV for surveillance of holding and treatment areas, bulletin
boards, racks for references and manuals, and storage area for supplies

Have easy approach to clean and dirty utility area

/68 36
2009 vimal
 Examination and Treatment Area

Examination and main treatment area

The importance of this area is ‘urgency in diagnosis and treatment’ and not any
social consideration

Large, unobstructed, well-illuminated space

For moving heavy equipment, stretchers, and team of health care providers

7 X 13.5 M for an open emergency treatment room Putsep

Access to patient from all sides

Treatment spaces/ cubicles calculated by-

1 per 2000 annual visits or as 5 to 7 spaces per physician in A&E department

Partitions by curtains or semi-permanent booths

Where cubicles exist

3.3 X 4.5M in size
Doors at least 1.3 M wide

/68 37
2009 vimal
 Resuscitation room

30 SqM room

Required for stabilisation of injured or acutely ill patients who need

taking care of:
Airway, Breathing & Bleeding, and Circulation (ABC)

Equipment intensive area, requiring both diagnostic and therapeutic

equipment such as patient’s trolley, piped oxygen and suction,
adjustable lamps, cupboards, wash basin, work tops, as well as
equipment for minor surgeries

All shelves and drawers be clearly labelled

Connected to emergency electrical supply and from here patient

moved either to intensive care area, operation theatre, recovery room,
treatment room, or transported to a nursing unit

/68 38
2009 vimal
 Operation room

The decision to have operation rooms in A&E

Whether to have or not? If yes, how many
What level cases would be taken up here
A fully furnished OT Lauffman
Only emergency surgery here and rest in main OT complex Putsep
OT only in large A&E departments Jenkins

Advantages
Ease in urgent surgery, no requirement of transferring contaminated cases to
main OT complex, flexibility in location of A&E department, and schedule of
normal OT not disturbed by emergency cases

Disadvantages
Decentralisation of resources (men and material), duplication of facilities,
quality of service and environment may be compromised, some operation
rooms may lie unutilised

For a turn over of 20,000 or more patients per year, preferable to have
one room for clean operations and one for septic/ contaminated cases.
The latter can also double for plaster room

Both of these must provide enough space for staff, instrument trolley,
mobile X-ray apparatus, and storage

/68 39
2009 vimal
 Other areas required

Intensive care or high dependency unit

Observation ward

/68 40
2009 vimal
 Support Areas

Radiology
25% of A&E patients require radiographic investigations
Often a bottleneck in smooth flow
Size and facility depend on relation and distance from main radiology department
Unless latter is just adjacent, a satellite X-ray unit definitely required
When established, should have all functional elements
A larger X-ray room may be divided by partition into two or three bays, each large
enough to carry out an examination of patient on stretcher
Besides a mandatory mobile unit, recommended to have
a static 300/ 500 mA unit dedicated to a large A&E department
a CT scan unit for a large trauma centre
access to ultrasonography facility

Laboratory
Type and size of laboratory depends on relation to main hospital laboratory
An emergency facility capable of performing routine blood and urine analysis,
bacterial smears and stains definitely required
Advanced tests such as BGA, and biochemistry maybe done in main laboratory

/68 41
2009 vimal
 Support Areas

ECG

Blood bank
Closely related to or easy access to a blood bank recommended

Duty room
A 9 SqM room with bed, chair, desk, bookshelf, TV, telephone, lockers,
toilet, and a shower required

Storage area
Area/ alcove for mobile equipment such as Mobile X-ray, crash cart,
ventilators etc. required
Area for storing mobile furniture, clean instruments and linen, drugs, IV
fluids, and dirty utility

Janitor’s closet

/68 42
2009 vimal
 Administrative Areas
Office for
Director
Matron
Secretary

Conference hall
Required in a teaching institute, preferably be with a reference library

Pantry
7 sqm pantry for providing hot and cold fluid/ beverages

Disaster area
90 SqM well-lighted open space, close to the entrance, with little fixed furniture and adequate
storage spaces Putsep
Separate entrance and exit and also have easy access to admission ward and main treatment
area

Communication room

/68 43
2009 vimal
 Communication

Two way radio communication with ambulances

Intercommunication between hospitals

Intramural communication in the form of:

Check-in board
PA system
Telephone (including hotline)
Intercom
Computer network
Dumbwaiters

/68 44
2009 vimal
 Fire Safety

Fire safety standards

as required for health
care institutions

/68 45
2009 vimal
 Engineering Services

Air-conditioning
Main treatment area and resuscitation areas; OT, ICU
Lighting
300 lux - general area
1100 lux - examination area
Spotlights - examination and treatment area
Emergency lights - critical areas
Stand by supply
For essential areas
Preferably for whole department including air handling
units
UPS for life-saving equipment

/68 46
2009 vimal
 Furniture

Fixed furniture
Patient beds or stretchers with side rails- preferably
with X-ray tops and mobile tops
Provision for oxygen cylinder, IV poles, arm boards,
instrument cabinets, utility shelves
An area of pegboard on the wall to hold airways,
suction tips, bag-mask units (for immediate selection)

Mobile
Stretchers, patient moving trolleys, wheelchairs,
instrument trolleys, folding screen, foot steps

/68 47
2009 vimal
 Equipment

Examination and treatment area

Wall mounted oxygen and suction equipment
Otoscope-ophthalmoscope unit
Sphygmomanometer
Movable spotlight- preferably ceiling mounted
Monitor-defibrillator unit
Resuscitation equipment, crash cart with usual
equipment and medications, speciality eye, ENT,
gynaecology, orthopaedics, dental equipment,
monitors, and pulse oximetres
Operation theatre
Operation light and table
Anaesthesia machine/ cabinet
Instruments and trolleys, and X-ray view boxes

/68 48
2009 vimal
 Equipment

Diagnostic equipment
X-ray machine 60 mA mobile unit
300/ 500 mA unit, CT scan, (preferable in large A&E and
trauma centres)
Ultrasound machine
Auto/ semi-auto analyser
BGA
Equipment for haematocrit/ urinalysis, microscope, and
centrifuge
Others
Special procedure trays
Patient transport frame, warmer blankets,
Ice machine, blood warmer and autotransfuser, refrigerator,
and deep freeze

/68 49
2009 vimal
 Organisation & Staffing

Medical director - both professional as well as administrative

head
3 chains of command - administrative, medical, and nursing
Each has a special but different interest in the department

Number of physicians depend on type of department, patient

load, time-weekend etc, capability of the ancillary staff
American College of Emergency Physicians recommends
staffing by emergency physicians

Planning and overall direction of the emergency room entrusted

to a committee consisting of:
Surgeon, anaesthetist, medical specialist, and hospital
administrator

/68 50
2009 vimal
 Organisation & Staffing

Depending upon scope of service following persons

considered essential to man service (some are available
round the clock & others on call): -
Surgeon
Anaesthetist
Medical specialist
Medical Officer
Nursing Staff including OT Staff
Laboratory Technician
X-Ray Technician
BT Assistant
Stretcher Squad
Sweepers
Driver

/68 51
2009 vimal
 Organisation & Staffing

Nursing staff
Emergency nurse (backbone of department)
At least eight nurse shifts (3+3+2) of 8 hours each per 100 patients
Additional staff required If A&E has observation ward
Some male nurses If available

Other ancillary personnel

Two attendants for each 8-hour shift

Clerical staff
Minimum requirement for a department handling excess of 30,000
patients per year
Two registration clerks for each day and afternoon shift, one for night shift
Unit secretary for each shift

/68 52
2009 vimal
 Organisation & Staffing

Transcriptionists
Nursing/ clerical staff trained to record physical findings and parts of
history while physician examines patients
Also prepares prescriptions and puts them up for physicians signature

Unit Manager
Responsible for taking on charge of equipment and demanding to keep
stocks updated

Security staff

Others
Social service, volunteers for public relations, PRO and interpreters in
a multilingual society

/68 53
2009 vimal
 Training of staff

Training of staff of utmost importance to run an efficient accident &

emergency service
Training to be a continuous process as staff keeps on changing in
a large hospital

Regular training programme of personnel must for employment in

emergency service

Not only highly proficient in own trade but should also be trained in
good human relationship as well
The acute distress, anxiety and urgency on part of patient and relatives
to be matched by calm, alert and reassuring attitude of staff

Human relations and human attitudes are consistently put to a very

severe test

Success depends largely on reputation of hospital and confidence of

community in its service

/68 54
2009 vimal
 Essential requirements for a well-organised A&E
department
A&E department readily accessible to afford quick transference
of patient from ambulance to bed or operating table

Efficient, promptly responding, well equipped ambulance

service with competent personnel in charge

Well equipped, emergency operating room with supplies always

ready for use

Recovery room where patient can be sent after emergency

treatment

/68 55
2009 vimal
 Essential requirements for a well-organised A&E
department
Efficient hospital personnel always on duty or on call which
should include at least a competent physician, nurse, and an
attendant or orderly

Supervision of treatment of fractures by a well qualified

surgeon, and supervision of the care of other injuries by those
who are competent in their respective fields

Adequate diagnostic and therapeutic facilities under competent

medical super- vision

Complete medical record of all patients treated which includes

particularly immediate record of injury and a detailed
description of physical findings, treatment and results

/68 56
2009 vimal
 Accident and Emergency Ward

Essential part of every A & E Department

Provides expertise in management of its typical patients

They stay in hospital for shorter periods than in other wards
Often better and more economically managed because of the
use of social and other liaison Services for crisis intervention

Provides a safety net for some patients who might otherwise be

discharged injudiciously

Flexibility of use is also an important feature

/68 57
2009 vimal
 Accident and Emergency Ward

SITE
In, or next to A & E department

BEDS
A department should have one bed for every 5,000 new
attenders in A & E department

/68 58
2009 vimal
 Accident and Emergency Ward

Staffing
Medical
Direct control
Consultant in charge of department

Immediate responsibility for medical supervision of patients in the

ward
Middle-grade doctor or Senior House Officer on duty

Nursing
Separately and adequately staffed by trained nurses
At least two at any time, being increased according to load

Separate allocation of nurses for the ward, so that rest of

department maintains its normal staffing quotient

/68 59
2009 vimal
 Accident And Emergency Ward

Patients

Patients requiring observation for a limited period of time –for minor

head injury, drunkenness, self-poisoning, 'social‘ reasons, temporary
incapacitation, etc

Patients awaiting further consultation or the results of investigation

Patients awaiting or recovering from procedures in the department

There may also be a teaching consideration to be borne in mind

Patients should not stay more than 36 hours, save at weekends

Children are best admitted to Paediatric wards

/68 60
2009 vimal
 Ambulance Services

The ambulance has been defined by the Committee on ambulance

design criteria, USA as
a vehicle for emergency care which provides a driver compartment and a
patient compartment

which can accommodate two emergency medical technicians and two lying
patients

so positioned that at least one patient can be given intensive life support
during transit

two way radio communication for safeguarding personnel and patient's

under hazardous condition and light rescue procedures

which is designed and constructed to afford maximum safety and comfort

and to avoid aggravation of the patient's condition, exposure to

complication and threat to survival

/68 61
2009 vimal
 Ambulance Services

A vehicle should not be termed as an ambulance

unless it is designed, built, equipped and staffed to
cope with medical emergencies outside the
hospital

Ambulances are of two types depending on the

equipment and staff provided;
Ambulance with BLS (Basic Life Support System)

Ambulance with ALS (Advanced Life Support System)

/68 62
2009 vimal
 Ambulance Services

Ambulance Equipment
Portable suction apparatus
Hand operated bag mask ventilation
with oxygen supply
Airway - adult, child, and infant sizes
Mouth gags
Resuscitation tubes
Portable oxygen equipment
Sterile intravenous fluids and sets
Sterile universal dressings
Splints
ECG machine
Defibrillator
Poison kit
Sterile obstetrical kit
Blood pressure manometer and
stethoscope

/68 63
2009 vimal
 Ambulance Services

Only about 10% of all patients seen in the emergency

department arrive by ambulance

Rest arrive by various other means of private and public

transportation

Provision must be made for approach by others as well

/68 64
2009 vimal
 Ambulance Services: Criteria Based Despatch

Emergency calls prioritised into 3 categories according to the severity

of patients’ conditions:
Category A
Life threatening conditions where rapid intervention may positively influence the
eventual outcome of the patient

75% of these calls to be responded to within 8 minutes

Category B
Patients whose condition is serious but not life threatening

95% of these calls to be responded to within 19 minutes

Category C
Patients whose condition is neither serious nor life threatening

Initial thinking suggested that alternative means of transport or care could be found
for these, however, they are dealt with as per Category B (response within 19
minutes)

95% of all Urgent calls to be responded to within 15 minutes of the time

specified

/68 65
2009 vimal
A&E: Present situation in Armed Forces

At present military hospitals do not have a separate A&E

department

MI Room, which is also the general OPD, caters to and attends

to all emergencies

/68 66
2009 vimal
 A&E: Present situation in Armed Forces

Revised scales of accommodation for armed forces hospitals 1997

OPD provided with emergency unit including operation suite, plaster room, and recovery room

SN Facilities Floor area in square meters for hospitals of bed strength Constructional requirements

25-49 50-99 100-199 200-399 400-599 600 & above Army & Comd

11. Emergency Unit 21.00 21.00 21.00 28.00 28.00 28.00 28.00 (i) Sink with elbow/knee
(a) Minor Surgery operated tap.
Room (ii) Wider door 1.50m clear
width
(iii) Shadowless lamp.

(b) Instrument 7.00 7.00 7.00 7.00 7.00 7.00 7.00 Sink & DB.
Sterelisation

(c) Wash up & sluice 7.00 7.00 7.00 7.00 7.00 7.00 7.00 Slop sink, sink & DB.

12. Fracture treatment with --- --- --- 14.00 14.00 14.00 14.00 (i) w.h.b.
plaster preparation (ii) sink & plaster trap
room (iii) Wider door not less than
1.2m.

13. Recovery Room 14.00 14.00 14.00 14.00 14.00 21.00 28.00 (i) w.h.b.
(ii) Wider door not less than
1.2m.

/68 67
2009 vimal
 /68 68
2009 vimal