aziz mba in hospital management project 0205009
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Health administration or healthcare administration is the field relating toleadership, management, and administration ofhospitals, hospitalnetworks, health care systems, and public health systems. Health care
administrators are considered health care professionals.The discipline is known by many names, including healthmanagement, healthcare management, health systems management, health caresystems management, andmedical and health services management
EDUCATION TRANING
Amaster's degree is considered the "standard credential for most healthadministrators in the United States. There are multiple recognized degree typesthat are considered equivalent from the perspective of professional preparation.
The Commission on the Accreditation of Healthcare ManagementEducation (CAHME) is the accrediting bodyoverseeing master's-level programsin the United States and Canadaon behalf of the United States Department ofEducation. It accredits several degree program types, including Master of Health
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Services Administration (MHSA), Master of Business Administration in HospitalManagement (MBA-HM), Master of Health Administration (MHA), Master ofPublic Health (MPH, MSPH, MSHPM), Master of Science (MS-HSM, MS-HA),and Master of Public Administration (MPA).
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Professional Organizations
There are numerous professional associations related to health systemsmanagement, which can be subcategorized as either personal orinstitutional membership groups. Personal membership groups are joinedby individuals, and typically have individual skill and career development as
their focus. Larger personal membership groups include the AmericanCollege of Healthcare Executives, the Healthcare Financial ManagementAssociation, and the Healthcare Information and Management SystemsSociety. Institutional membership groups are joined by organizations; theytypically focus on organizational effectiveness, and may also include data-sharing agreements and other best-practice sharing vehicles for memberorganizations. Prominent examples include the American HospitalAssociation and the University Healthsystems Consortium
theMaster of Health AdministrationorMaster of HealthcareAdministration(MHA) is a master's-levelprofessional degreegrantedto students who complete a course of study in the knowledge andcompetencies needed for careers inhealth administration, involving themanagement of hospitals and other health services organizations, as well aspublic health infrastructure. Programs can differ according to setting;althoughpractitioner-teacher modelprograms are typically found incolleges of medicine or allied health, classroom-based programs can befound in colleges of business or public health.
Accredited programs of study typically require students to complete appliedexperiences as well as course work in areas such as population health,healthcare economics, health policy, organizational behavior,management of healthcare organizations, healthcare marketing and
communications, human resource management, information systemsmanagement and assessment, operations assessment and improvement,governance, leadership, statistical analysis and application, financialanalysis and management, and strategy formulation and implementation.The degree program is designed to give graduates ofhealthdisciplines (inparticular) greater understanding ofmanagementissues and preparethem for senior management roles, and is awarded by many American,European and Australian universities. The degree traditionally focuses onhealth administration at the local, state, and federal level as well as in thenonprofit sector. This contrasts with the generalMaster of Business
Administrationor theMaster of Public Administrationdegrees.
Pharmacists
Pharmacists are highly-trained and skilled healthcare professionals whoperform various roles to ensure optimal health outcomes for their patients.Many pharmacists are also owners, owning the pharmacy in which theypractice.
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Pharmacists are represented internationally by the International PharmaceuticalFederation International_Pharmaceutical_Federation> (FIP). They arerepresented at the national level by professional organisationsProfessional_body> such as the Dutch Pharmacists AssociationDutch_Pharmacists_Association&action=edit&redlink=1> (VNA) Royal
Pharmaceutical Society of Great.wikipedia.org/wiki/Royal_Pharmaceutical_Society_of_Great_Britain>(RPSGB), the Pharmacy Guild of Australia (PPS) and theAmerican Pharmacists Association American_Pharmacists_Association
In some cases, the representative body is also the registering body, which isresponsible for the ethics
Ibn al-Haytham
Translation
Ibn al-Haytham
Infobox_Muslim scholars | notability = Muslim scientist| era = Islamic GoldenAge| color = #cef2e0 |
| image_caption = Ibn al-Haytham drawing taken from a 1982 Iraqi 10-dinarnote.
name = Unicode|Ab Al al-asan ibn al-asan ibn al-Haytham
DEPARTMENT OF HOSPITAL
An acute assessment unit, acute medical unit (AMU) or acute admissions unit
(AAU) is a short-stay department in some hospitals that is sometimes part of
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the emergency department, although a separate department. The AAU acts as a
gateway between a patient's general practitioner, the emergency department, and
the wards of the hospital. The AAU helps the emergency department produce a
healthy turnaround for patients, helping with the four-hour waiting rule. An AAU
is usually made up of several bays and has a small number of side-rooms and
treatment rooms. They are fully equipped with emergency medical treatment
facilities including defibrilators and resuscitation equipment.
Patients
From the emergency department, patients can be moved to AAU where they willundergo further tests and stabilisation before they are transferred to therelevant ward or sent home. Also, patients can be admitted straight to AAUfrom their general practitioner if he or she believes the patient needshospital treatment. A patient's stay in the unit is limited, usually no more
than 48 hours.
The AAU deals with admissions only, patients will never be transferred from award to the AAU. Surgical Procedures are not carried out in the unit either;these are referred on to the relevant theatre such as cardiothoracics andgeneral surgery.
Staff
Senior staff in an AAU include aconsultantin generalmedicine,emergency medicine, orcritical care. Often aregistraringeneral medicine, and award sisteror acharge nursehave roles in the
unit. A number ofstaff nurseswork alongside the senior staff to providecare to patients in the unit.
Although AAU has its own staff trained to deal with patients and provide care,members of staff from other departments in the hospital are needed in AAU toassess patients and provide further diagnosis. Typical examples of staff who maybe needed in AAU are general surgeons, cardiothoracic surgeons, cardiologists,and a psychiatric liaison nurse.
Alternative names for the department
Different hospitals use different names for the department - common names for
this department are:
Acute Assessment Unit (AAU)
Acute Admissions Unit (AAU)
Acute Medical Unit (AMU)
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Clinical Decision Unit (CDU)
Emergency Assessment Unit (EAU)
Emergency Medical Assessment/Admissions Unit (EMAU)
Medical Assessment and planning unit (MAPU) or, informally, MAP unit -in Australia and New Zealand
Medical Assessment Unit (MAU) Multi speciality Assessment Area (MSAA)
Medical Receiving Unit (MRU)
Emergency Receiving Unit (ERU)
The department can also include pharmacists, who carry out duties such asmedical history taking.
ACUTE ASSESSMENT UNIT
AN(AMU)ORACUTE ADMISSIONS UNIT (AAU)IS A SHORT-STAYDEPARTMENT IN SOME HOSPITALS THAT IS SOMETIMES PART OFTHEEMERGENCY DEPARTMENT, ALTHOUGH A SEPARATEDEPARTMENT. THE AAU ACTS AS A GATEWAY BETWEEN APATIENT'SGENERAL PRACTITIONER, THE EMERGENCYDEPARTMENT, AND THE WARDS OF THE HOSPITAL. THE AAU HELPSTHE EMERGENCY DEPARTMENT PRODUCE A HEALTHYTURNAROUND FOR PATIENTS, HELPING WITH THEFOUR-HOUR
WAITING RULE. AN AAU IS USUALLY MADE UP OF SEVERAL BAYSAND HAS A SMALL NUMBER OF SIDE-ROOMS AND TREATMENTROOMS. THEY ARE FULLY EQUIPPED WITH EMERGENCY MEDICALTREATMENT FACILITIESINCLUDINGDEFIBRILATORSANDRESUSCITATIONEQUIPMENT.
Patients
From the emergency department, patients can be moved to AAU where they will
undergo further tests and stabilisation before they are transferred to the relevant
ward or sent home. Also, patients can be admitted straight to AAU from their
general practitioner if he or she believes the patient needs hospital treatment. A
patient's stay in the unit is limited, usually no more than 48 hours.
The AAU deals with admissions only, patients will never be transferred from a
ward to the AAU. Surgical Procedures are not carried out in the unit either; these
are referred on to the relevant theatre such as cardiothoracics and general
surgery.
Staff(6)
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Senior staff in an AAU include a consultant in general medicine, emergency
medicine, or critical care. Often a registrar in general medicine, and award
sister or a charge nurse have roles in the unit. A number ofstaff nurses work
alongside the senior staff to provide care to patients in the unit.
Although AAU has its own staff trained to deal with patients and provide care,members of staff from other departments in the hospital are needed in AAU toassess patients and provide further diagnosis. Typical examples of staff who maybe needed in AAU are general surgeons, cardiothoracic surgeons, cardiologists,and a psychiatric liaison nurseAlternative names for the department
Different hospitals use different names for the department - common names for
this department are:
Acute Assessment Unit (AAU)
Acute Admissions Unit (AAU)
Acute Medical Unit (AMU)
Clinical Decision Unit (CDU)
Emergency Assessment Unit (EAU)
Emergency Medical Assessment/Admissions Unit (EMAU)
Medical Assessment and planning unit (MAPU) or, informally, MAP unit -
in Australia and New Zealand
Medical Assessment Unit (MAU)
Multi speciality Assessment Area (MSAA)
Medical Receiving Unit (MRU)
Emergency Receiving Unit (ERU)
The department can also include pharmacists, who carry out duties such as
medical history taking.
(7)
http://en.wikipedia.org/wiki/Consultanthttp://en.wikipedia.org/wiki/Internal_medicinehttp://en.wikipedia.org/wiki/Emergency_medicinehttp://en.wikipedia.org/wiki/Emergency_medicinehttp://en.wikipedia.org/wiki/Critical_care_medicinehttp://en.wikipedia.org/wiki/Specialist_registrarhttp://en.wikipedia.org/wiki/Nurse#Nursing_titleshttp://en.wikipedia.org/wiki/Nurse#Nursing_titleshttp://en.wikipedia.org/wiki/Nurse#Nursing_titleshttp://en.wikipedia.org/wiki/Nursehttp://en.wikipedia.org/wiki/General_surgeonhttp://en.wikipedia.org/wiki/Cardiothoracic_surgeryhttp://en.wikipedia.org/wiki/Cardiologistshttp://en.wikipedia.org/wiki/Psychiatryhttp://en.wikipedia.org/wiki/Consultanthttp://en.wikipedia.org/wiki/Internal_medicinehttp://en.wikipedia.org/wiki/Emergency_medicinehttp://en.wikipedia.org/wiki/Emergency_medicinehttp://en.wikipedia.org/wiki/Critical_care_medicinehttp://en.wikipedia.org/wiki/Specialist_registrarhttp://en.wikipedia.org/wiki/Nurse#Nursing_titleshttp://en.wikipedia.org/wiki/Nurse#Nursing_titleshttp://en.wikipedia.org/wiki/Nurse#Nursing_titleshttp://en.wikipedia.org/wiki/Nursehttp://en.wikipedia.org/wiki/General_surgeonhttp://en.wikipedia.org/wiki/Cardiothoracic_surgeryhttp://en.wikipedia.org/wiki/Cardiologistshttp://en.wikipedia.org/wiki/Psychiatry -
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CORONARY CARE UNIT
ACORONARY CARE UNIT(CCU) ORCARDIAC INTENSIVE CAREUNIT(CICU) IS A HOSPITAL WARD SPECIALIZED IN THE CAREOFPATIENTSWITHHEART ATTACKS,UNSTABLE
ANGINA,CARDIAC DYSRHYTHMIAAND (IN PRACTICE) VARIOUS
OTHER CARDIAC CONDITIONS THAT REQUIRE CONTINUOUSMONITORING AND TREATMENT.
CHARACTERISTICS
The main feature of coronary care is the availability oftelemetryor the
continuous monitoring of the cardiac rhythm byelectrocardiography.
This allows early intervention
withmedication,cardioversionor defibrillation, improving the
prognosis. Asarrhythmias are relatively common in this group, patients
with myocardial infarction or unstable angina are routinely admitted to the
coronary care unit. For other indications, such asatrial fibrillation, a
specific indication is generally necessary, while for others, such as heart
block, coronary care unit admission is standard
Local differences
In the United States, coronary care units are usually subsets ofintensive care
units (ICU) dedicated to the care of critically ill cardiac patients. These units are
usually present in hospitals that routinely engage in cardiothoracic surgery.
Invasive monitoring such as with pulmonary artery catheters is common, as are
supportive modalities such as mechanical ventilation and intra-aortic balloon
pumps (IABP).
Certain hospitals, such as Johns Hopkins , maintain mixed units consisting of
both Acute care units for the critically ill, and intermediate care units for patients
who are not critical.
Acute coronary care
Acute coronary care units (ACCU), also called "critical coronary care units"(CCCU) is equivalent to intensive care in the level of service provided. Patients
with acute myocardial infarction,cardiogenic shock, or post-operative "open-
heart" patients commonly abide here.
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Subacute coronary care
Subacute coronary care units (SCCU), also called Progressive care units (PCU),
Intermediate coronary care units (ICCU), or stepdown units, and provide a level
of care intermediate to that of the intensive care unit and that of the general
medical floor. These units typically serve patients who require cardiac telemetry
such as those with unstable angina
History
Coronary care units developed in the 1960s when it became clear that close
monitoring by specially trained staff, cardiopulmonary resuscitation and medical
measures could reduce the mortality from complications of cardiovascular
disease. The first description of a CCU was given in 1961 to the British Thoracic
Society, and early CCUs were located in Sydney, Kansas CityandPhiladelphia.
Studies published in 1967 revealed that those observed in a coronary care setting
had consistently better outcomes.[1] The first coronary care unit was opened at
Bethany Medical Center in Kansas City, Kansas by Dr Hugh Day, and he coined
the term. Bethany Medical Center is also where the first "crash carts" were
developed.
EMERGENCY DEPARTMENT
"Accident and Emergency" and "Emergency room" redirect here. For other
uses, see Accident and Emergency (disambiguation) andEmergency room
(disambiguation).
"Resus" redirects here. For Resuscitation, see Cardiopulmonary resuscitation.
A clearly marked emergency department at the The Royal Infirmary of Edinburgh
An emergency department (ED), also known as accident &
emergency (A&E), emergency room (ER), or casualty department is a medical
treatment facility specialising in acute care of patients who present without prior
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appointment, either by their own means or byambulance. The emergency
department is usually found in a hospital or other primary care center.
Due to the unplanned nature of patient attendance, the department must provide
initial treatment for a broad spectrum of illnesses and injuries, some of which
may be life-threatening and require immediate attention. In some countries,
emergency departments have become important entry points for those without
other means of access to medical care.
The emergency departments of most hospitals operate 24 hours a day, although
staffing levels may be varied in an attempt to mirror patient volume.
History
Accident services were already provided by workmen's compensation plans,
railway companies, and municipalities in Europe and the United States by thelate mid-nineteenth century, but the first specialized trauma care center in the
world was opened in 1911 in the United States at the University of
Louisville Hospital in Louisville, Kentucky, and was developed by surgeon Arnold
Griswold during the 1930s. Griswold also equipped police and fire vehicles with
medical supplies and trained officers to give emergency care while en route to the
hospital.
Department operation
The emergency department entrance at Mayo Clinic's Saint Marys Hospital. The
red-and-white emergency sign is clearly visible.
Today, a typical hospital has its emergency department in its own section of thefirst floor of the campus, with its own dedicated entrance. As patients can present
at any time and with any complaint, a key part of the operation of an emergency
department is the prioritization of cases based on clinical need. This is usually
achieved though the application oftriage.
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Triage is normally the first stage the patient passes through, and consists of a
brief assessment, a set ofvital signs, and the assignment of a "chief complaint"
(i.e. chest pain, abdominal pain, difficulty breathing, etc). Most emergency
departments have a dedicated area for this process to take place, and may have
staff dedicated to performing nothing but a triage role. In most departments, this
role is fulfilled by a nurse, although dependent on training levels in the country
and area, other health care professionals may perform the triage sorting,
including paramedics or physicians. Triage is typically conducted face-to-face
when the patient presents, or a form of triage may be conducted via radio with an
ambulance crew; in this method, the paramedics will call the hospital's triage
center with a short update about an incoming patient, who will then be triaged to
the appropriate level of care.
Most patients will be initially assessed at triage and then passed to another areaof the department, or another area of the hospital, with their waiting time
determined by their clinical need. However, some patients may complete their
treatment at the triage stage, for instance if the condition is very minor and can
be treated quickly, if only advice is required, or if the emergency department is
not a suitable point of care for the patient. Conversely, patients with evidently
serious conditions, such as cardiac arrest, will bypass triage altogether and move
straight to the appropriate part of the department.
The resuscitation area, commonly referred to as "Trauma" or "Resus", is a keyarea in most departments. The most seriously ill or injured patients will be dealt
with in this area, as it contains the equipment and staff required for dealing with
immediately life threatening illnesses and injuries. Typical resuscitation staffing
involves at least one attending physician, and at least one and usually two nurses
with trauma andAdvanced Cardiac Life Support training. These personnel may
be assigned to the resuscitation area for the entirety of the shift, or may be "on
call" for resuscitation coverage (i.e. if a critical case presents via walk-in triage or
ambulance, the team will be paged to the resuscitation area to deal with the case
immediately). Resuscitation cases may also be attended byresidents, medical
students, nursing students, emergency medical technicians, and/or
hospital pharmacists, depending upon the skill mix needed for any given case and
whether or not the hospital provides teaching services.
(11)
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Patients who are seriously ill but not in immediate danger of life or limb will be
triaged to "acute care" or "majors," where they will be seen by a physician and
receive a more thorough assessment and treatment. Examples of "majors"
include chest pain, difficulty breathing, abdominal pain and neurological
complaints. Advanced diagnostic testing may be conducted at this stage,
including laboratory testing of blood and/or
urine, ultrasonography, CT or MRI scanning. Medications appropriate to manage
the patient's condition will also be given. Depending on the resolution of the
patient's chief complaint, he or she may be discharged home from this area or
admitted to the hospital for further treatment.
Patients whose condition is not immediately life threatening will be sent to an
area suitable to deal with them, and these areas might typically be termed as
aprompt care or minors area. Such patients may still have been found to havesignificant problems, including fractures, dislocations,
and lacerations requiring suturing.
Children can present particular challenges in treatment. Some departments have
dedicated pediatrics areas, and some departments employ a play therapist whose
job is to put children at ease to reduce the anxiety caused by visiting the
emergency department, as well as provide distraction therapy for simple
procedures.
Many hospitals have a separate area for evaluation ofpsychiatric problems. These
are often staffed bypsychiatrists and mental health nurses and social workers.
There is typically at least one room for people who are actively a risk to
themselves or others (e.g. suicidal).
Fast decisions on life-and-death cases are critical in hospital emergency rooms.
As a result, doctors face great pressures to overtest and overtreat. The fear of
missing something often leads to extra blood tests and imaging scans for what
may be harmless chest pains, run-of-the-mill head bumps, and non-threatening
stomach aches, with a high cost on the Health Care system.
Nomenclature in English
Emergency Departmentbecame the preferred term when Emergency Medicine
was recognised as a medical speciality and hospitals and medical centers
developed Departments of Emergency Medicine to provide services. Other(12)
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common variations include 'Emergency Ward,' 'Emergency Center' or
'Emergency Unit.'
Historic terminology still exists across the English-speaking world, especially in
vernacular usage. The previously accepted formal term 'Accident and Emergency'
or 'A&E' is still widely known in countries such as the United Kingdom and its
former territories, as are earlier terms such as 'Casualty', or 'Casualty Ward'
which continue to be used informally. The same applies to 'Emergency Room' or
'ER' in North America, originating when emergency facilities were provided in a
single room of the hospital by the Department of Surgery.
Signage
Regardless of naming convention, there is a widespread usage of directional
signage in white text on a red background across the world, which indicates the
location of the emergency department, or a hospital with such facilities.
Signs on emergency departments may contain additional information. In some
American states there is close regulation of the design and content of such signs.
For example, California requires wording such as "Comprehensive Emergency
Medical Service" and "Physician On Duty", to prevent persons in need of critical
care from presenting to facilities that are not fully equipped and staffed.
In some countries, including the United States and Canada, a smaller facility that
may provide assistance in medical emergencies is known as a clinic. Larger
communities often have walk-in clinics where people with medical problems that
would not be considered serious enough to warrant an emergency department
visit can be seen. These clinics often do not operate on a 24 hour basis. Very large
clinics may operate as "free-standing emergency centers," which are open 24
hours and can manage a very large number of conditions. However, if a patient
presents to a free-standing clinic with a condition requiring hospital admission,
he or she must be transferred to an actual hospital, as these facilities do not have
the capability to provide inpatient care.
United States
Many U.S. emergency departments are exceedingly busy. A survey of New York
area doctors in February 2007 found that injuries and even deaths have been
caused by excessive waits for hospital beds by ED patients. A 2005 patient survey
found an average ED wait time from 2.3 hours in Iowa to 5.0 hours in Arizona.(13)
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One inspection of Los Angeles area hospitals by Congressional staff found the
EDs operating at an average of 116% of capacity (meaning there were more
patients than available treatment spaces) with insufficient beds to accommodate
victims of a terrorist attack the size of the 2004 Madrid train bombings. Three of
the five Level I trauma centers were on "diversion", meaning ambulances with all
but the most severely injured patients were being directed elsewhere because the
ED could not safely accommodate any more patients. This controversial practice
was banned in Massachusetts (except for major incidents, such as a fire in the
ED), effective January 1, 2009; in response, hospitals have devoted more staff to
the ED at peak times and moved some elective procedures to non-peak times.
In 2009, there were 1,800 EDs in the country.
United Kingdom
All A&E departments throughout the United Kingdom are financed and managed
publicly by the NHS of each constituent country
(England,Scotland,Wales and Northern Ireland). As with most
other NHS services, emergency care is provided to all, both resident citizens and
those not ordinarily resident in the UK, free at the point of need and regardless of
any ability to pay.
Historically, waits for assessment in A&E were very long in some areas of the UK.
In October 2002, the Department of Health introduced a four-hour target in
emergency departments that required departments in England to assess and treat
patients within four hours of arrival, with referral and assessment by other
departments if deemed necessary. Present policy is that 95% of all patient cases
do not "breach" this four-hour wait.
The 4-hour target triggered the introduction of the acute assessment unit (also
known as the medical assessment unit), which works alongside the emergency
department but is outside it for statistical purposes in thebed management cycle.
It is claimed that though A&E targets have resulted in significant improvements
in completion times, the current target would not have been possible without
some form of patient re-designation or re-labeling taking place, so true
(14)
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improvements are somewhat less than headline figures might suggest and it is
doubtful that a single target (fitting all A&E and related services) is sustainable.
Critical conditions handled
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 isbasic
life support and 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. Not
to be confused with Cardiakthe music producer.
Heart attack
Patients arriving to the emergency department with a myocardial infarction
(heart attack) are likely to be triaged to the resuscitation area. They will receive
oxygen and monitoring and have an earlyECG; aspirin will be given if
not contraindicated or not already administered by the ambulance team;
morphine or diamorphine will be given for pain; sub lingual (under the tongue)
or buccal (between cheek and upper gum) glyceryl trinitrate [nitroglycerin] (GTN
or NTG) will be given, unless contraindicated by the presence of other drugs,
such as drugs that treat erectile dysfunction.
An ECG that reveals ST segment elevation or newleft bundle branch
blocksuggests complete blockage of one of the main coronary arteries. These
patients require immediate reperfusion (re-opening) of the occluded vessel. This
can be achieved in two ways: thrombolysis (clot-busting medication)
or percutaneous transluminal coronary angioplasty(PTCA). Both of these are
effective in reducing significantly the mortality of myocardial infarction. Many
centers are now moving to the use of PTCA as it is somewhat more effective than
thrombolysis if it can be administered early. This may involve transfer to a nearby
facility with facilities for angioplasty.Trauma
Major trauma, the term for patients with multiple injuries, often from a road
traffic accident or a major fall, is initially handled in the Emergency Department.
However, trauma is a separate (surgical) specialty from emergency medicine
(15)
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(which is a medical specialty, and has certifications in the United states from the
American Board of Emergency Medicine).
Trauma is treated by a trauma team who have been trained using the principles
taught in the internationally recognized Advanced Trauma Life Support (ATLS)
course of theAmerican College of Surgeons. Some other international training
bodies have started to run similar courses based on the same principles.
The services that are provided in an emergency department can range from
simple x-rays and the setting of broken bones to those of a full-scale trauma
center. A patient's chance of survival is greatly improved if the patient receives
definitive treatment (i.e. surgery or reperfusion) within one hour of an accident
(such as a car accident) or onset of acute illness (such as a heart attack). This
critical time frame is commonly known as the "golden hour".
Some emergency departments in smaller hospitals are located near a helipad
which is used by helicopters to transport a patient to a trauma center. This inter-
hospital transfer is often done when a patient requires advanced medical care
unavailable at the local facility. In such cases the emergency department can
onlystabilize the patient for transport.
Mental illness
Some patients arrive at an emergency department for a complaint of mental
illness. In many jurisdictions (including many U.S. states), patients who appearto 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
(in many cases involuntarily).
Asthma and COPD
Acute exacerbations of chronic respiratory diseases, mainlyasthma and chronicobstructive pulmonary disease (COPD), are assessed as emergencies and treated
with oxygen therapy,bronchodilators, steroids or theophylline, have an
urgent chest X-rayand arterial blood gases and are referred for intensive care if
necessary. Non invasive ventilation in the ED has reduced the requirement
for tracheal intubation in many cases of severe exacerbations of COPD.(16)
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Special facilities, training, and equipment
An ED requires different equipment and different approaches than most other
hospital divisions. Patients frequently arrive with unstable conditions, and so
must be treated quickly. They may be unconscious, and information such as their
medical history, allergies, and blood type may be unavailable. ED staff are trained
to work quickly and effectively even with minimal information.
ED staff must also interact efficiently with pre-hospital care providers such
as EMTs, paramedics, and others who are occasionally based in an ED. The pre-
hospital providers may use equipment unfamiliar to the average physician, but
ED physicians must be expert in using (and safely removing) specialized
equipment, since devices such as Military Anti-Shock Trousers ("MAST")
andtraction splints require special procedures. Among other reasons, given that
they must be able to handle specialized equipment, physicians can now specialize
in emergency medicine, and EDs employ many such specialists.
ED staff have much in common with ambulance and fire crews, combat
medics, search and rescue teams, and disaster response teams. Often, joint
training and practice drills are organized to improve the coordination of this
complex response system. Busy EDs exchange a great deal of equipment with
ambulance crews, and both must provide for replacing, returning, or reimbursing
for costly items.
Cardiac arrest and major trauma are relatively common in EDs, so defibrillators,
automatic ventilation and CPRmachines, and bleeding control dressings are used
heavily. Survival in such cases is greatly enhanced by shortening the wait for key
interventions, and in recent years some of this specialized equipment has spread
to pre-hospital settings. The best-known example is defibrillators, which spread
first to ambulances, then in an automatic version to police cars, and most
recently to public spaces such as airports, office buildings, hotels, and even
shopping malls.
Because time is such an essential factor in emergency treatment, EDs typically
have their own diagnostic equipment to avoid waiting for equipment installed
elsewhere in the hospital. Nearly all have an X-ray room, and many now have full
radiology facilities including CT scanners and ultrasonography equipment.
Laboratory services may be handled on a priority basis by the hospital lab, or the
(17)
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ED may have its own "STAT Lab" for basic labs (blood counts, blood typing,
toxicology screens, etc.) that must be returned very rapidly.
The use ofElectronic Medical Records in U.S. EDs has increased rapidly as a
result of the 2009 HITECH Act. Companies such asWellsoft Corporation provide
Emergency Department Information Systems (EDIS) that help hospitals meet
HITECH requirements.Functionality typically offered by these systems include
patient tracking, discharge planning, clinical documentation and coding.
Non-emergency use
Metrics applicable to the ED can be grouped into three main categories, volume,
cycle time, and patient satisfaction. Volume metrics including arrivals per hour,
percentage of ED beds occupied and age of patients are understood at a basic
level at all hospitals as an indication for staffing requirements. Cycle time metricsare the mainstays of the evaluation and tracking of process efficiency and are less
widespread since an active effort is needed to collect and analyze this data.
Patient satisfaction metrics, already commonly collected by physician groups and
hospitals, are useful in demonstrating the impact of changes in patient perception
of care over time. Since patient satisfaction metrics are derivative and subjective,
they are less useful in primary process improvement.
In manyPrimary Care Trusts there may be out of hours doctor services
sometimes known as Keydoc or something similar (varying by area) provided by
volunteer General Practitioners.
In the United States, and many other countries, hospitals are beginning to create
areas in their emergency rooms for people with minor injuries. These are
commonly referred asFast Track orMinor Care units. These units are for people
with non life-threatening injuries. The use of these units within a department
have been shown to significantly improve the flow of patients through a
department and to reduce waiting times. Urgent care clinics are another
alternative, where patients can go to receive immediate care for non-life-
threatening conditions.
Doctors in training
Doctors in training provide a large portion of the medical care in emergency
departments.
(18)
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In the United States, they are called residents and most are supervised by ABEM
or AOBEM board certified attending physicians.
In the United Kingdom, many doctors rotate through the emergency department,
such as during their second foundation year (F2), or as part of a rotational
specialty training programme in General Practice orAcute Care Common
Stem training (Emergency Medicine,Acute medicine,Anaesthetics, and Intensive
Care).
Overcrowding
Emergency department overcrowding is when function of a department is
hindered by an inability to treat all patients in an adequate manner. This is a
common occurrence in emergency departments world wide.[ Overcrowding
causes inadequate patient care which leads to poorer patient outcomes.Frequent presenters
Frequent presenters are persons who will present themselves at a hospital
multiple times, usually those with complex medical requirements or with
psychological issues complicating medical management. These persons
contribute to overcrowding and typically use require more hospital resources
despite the fact that they do not account for a significant amount of visits.
Emergency departments in the military
Emergency departments in the military benefit from the added support of
enlisted personnel who are capable of performing any task they have been trained
for, regardless of actual education obtained from civilian schooling. For example,
in Naval hospitals, Hospital Corpsmen perform tasks that fall under the scope of
practice of both doctors (i.e. sutures and incision and drainages) and nurses (i.e.
medication administration and foley catheter insertion). Often, some civilian
education and/or certification will be required such as an EMT certification, in
case of the need to provide care outside of the base where the member is actually
stationed.
Geriatric intensive-care unit
Geriatric intensive care unit is a special type ofintensive care unit dedicated to
management of critically ill elderly.(19)
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Geriatric intensive care unit's goal is to restore physiologic stability, prevent
complications, maintain comfort and safety, and preserve pre-illness functional
ability and quality of life (QOL) in older adults admitted to critical-care units.
Origin
Geriatric intensive care units appeared in response to the world's
population aging. Managing Geriatrics diseases is unlike adults or pediatrics
diseases, particularly for the critically ill. Not allcritical care physicians are fully
oriented to the peculiarties of geriatric patients.
One definition of a critically ill older adult is:
a person, age 65 or older, who is currently experiencing or at risk for some form
of physiologic instability or alteration warranting urgent or emergent, advanced
nursing/medical interventions and monitoring.
More than half (55.8%) of all ICU days are incurred by patients older than
65.
Older adults are living longer, are more racially and ethnically diverse,
often have multiple chronic conditions, and more than one-quarter report
difficulty performing one or more activities of daily living (ADLs). These
factors may affect both the course and outcome of critical illness.
Once hospitalized for a life-threatening illness, older adults often:
1. Experience high ICU, hospital, and long-term crude mortality rates.
2. Are at risk for deterioration in functional ability and post-discharge
institutional care.
Older age is a factor that could conceptually lead to:
1. Potential bias in refusing ICU admission.
2. The decision to withhold mechanical ventilation, surgery, or
dialysis.
3. An increased likelihood of an established resuscitation directive.
Most critically ill older adults:
(20)
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1. Demonstrate resiliency.
2. Report being satisfied with their QOL post-discharge.
3. Would reaccept ICU care and mechanical ventilation if needed.
Chronologic age alone is not an acceptable or accurate predictor of pooroutcomes after critical illness.
Factors that may influence an older adults ability to survive a catastrophic
illness include:
1. Severity of illness
2. Nature and extent of co-morbidities
3. Diagnosis, reason for/duration of mechanical ventilation
4. Complications length of ICU/hospital stay.
5. Distribution
Geriatric intensive care units have been established many countries.
Practice issues
The most important effort in critical care practice is
maintaining physiological function and restoring homeostasis. However, when
the urgent episode subsides, general practice guidelines and clinical approaches
may be inappropriate in older adults who often have less physiological reserve.
Further, specific geriatric syndromes, medication issues and problems that can be
prevented if they are anticipated. Sleep disorders are prevalent in the elderly.
During a critical care episode, sleeping and waking cycles are disturbed. Because
of the noise in an ICU, less sleep and more noise may trigger delirium.
Altered eating and feeding patterns are common in geriatric intensive care
units. Enteral tube feeding and total parenteral nutrition have many advantages
and disadvantages.
Foley catheters are regularly inserted in patients in the intensive care unit tomonitor fluid balance, this should be changed. urinary catheters are known to
cause urinary tract infections, which are potentially lethal to the elderly. Thus,
when possible, catheters should be avoided in the ICU. In addition, the use
ofincontinence undergarments should be avoided, given the propensity for skin
irritation and breakdown.
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The ICU environment has been linked to delirium in the
elderly. Disorientation to time or place because of overstimulation, pain and
metabolic imbalances frequently results in cognitive changes. Optimally, critical
care nurses must obtain a baseline mental status on the older patient upon
admission and follow the changes through the use of a standardized assessment
instrument such as a Mini-Mental State Examination. Early detection and
intervention can reduce the use of either physical or chemical restraints
Ethical issues
Geriatric critical care can give rise to ethical issues. Despite the pervasive
conceptual emphasis on evidence-based health care, there is insufficient research
to guide the Geriatrics critical care clinician, which leaves substantial subjectivity
in crucial decisions. Outcome prediction models have been proposed, with age as
one of numerousvariables, but such models have been inadequately validated.
Age alone may not necessarily be a predictor of short-term or long-term outcome
in the older patient who is critically ill. Rationing decisions for intake to a critical
care bed during periods of reduced availability may be based on triage factors of
uncertain importance
Intensive-care unit
ICU room
An Intensive Care Unit (ICU), Critical Care Unit (CCU), Intensive Therapy
Unit or Intensive Treatment Unit (ITU) is a highly specialized department of
a hospital that provides intensive-care medicine.
Intensive Care Units cater to patients with the most serious injuries and illnesses,
most of which are life-threatening and need constant, close monitoring and
support from equipment and medication in order to maintain normal bodily
functions. They have higher levels of staffing and specialist monitoring and
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treatment equipment, alongside doctors and critical care nurseswho are specially
trained in caring for the most severely ill patients
History
In 1854, Florence Nightingale left for the Crimean War, where triage was used toseparate seriously wounded soldiers from the less-seriously wounded was
observed. Until recently, it was reported that Nightingale reduced mortality from
40% to 2% on the battlefield. Although this was not the case, her experiences
during the war formed the foundation for her later discovery of the importance of
sanitary conditions in hospitals, a critical component of intensive care.
In 1950, anesthesiologist Peter Safar established the concept of "Advanced
Support of Life," keeping patients sedated and ventilated in an intensive-care
environment. Safar is considered to be the first practitioner of intensive-caremedicine as a speciality.
In response to a polioepidemic (where many patients required constant
ventilation and surveillance), Bjrn Aage Ibsen established the first intensive-
care unit in Copenhagen in 1953. The first application of this idea in the United
States was in 1955 by Dr. William Mosenthal, a surgeon at the Dartmouth-
Hitchcock Medical Center.[ In the 1960s, the importance ofcardiac
arrhythmias as a source ofmorbidityand mortalityin myocardial
infarctions (heart attacks) was recognized. This led to the routine use of cardiac
monitoring in ICUs, especially after heart attacks.
Specialities
Hospitals may have ICU's that cater to a specific medical speciality or patient,
such as those listed below:
Neonatal Intensive Care Unit (NICU)
Pediatric Intensive Care Unit (PICU)
Psychiatric Intensive Care Unit (PICU)
Coronary Care Unit (CCU) - Also known as Cardiac Intensive Care Unit
(CICU)
Post Anesthesia Care Unit (PACU) - Also known as the Post-Operative
Recovery Unit, or Recovery Room, the PACU provides immediate post-op
observation and stabilisation of patients following surgical operations and
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anesthesia. Patient's are usually held in such facilities for a limited amount of
time, and must meet a set physiological criteria before transfer back to a ward
with a qualified nurse escort takes place. Due to high patient flow in Recovery
Units, and owing to the bed management cycle, if a patient breaches a time
frame and is too unstable to be transferred back to a ward, they are normally
transferred to a High Dependency Unit (HDU) or Post-Operative Critical Care
Unit (POCCU) for closer observation.
High Dependency Unit (HDU) - Many hospitals have a transitional High
Dependency (HDU) facility for patients who require close observation,
treatment and nursing care that cannot be provided on a general ward, but
whose care is not at a critical enough level to warrant an ICU bed. These units
are also called step-down, progressive and intermediate care units and are
utilised until a patient's conditions stabilises enough to qualify them fordischarge to a general ward
Equipment and Systems
Common equipment in an ICU includes mechanical ventilators to assist
breathing through an endotracheal tube or a tracheotomy; cardiac monitors
including those with telemetry;
externalpacemakers; defibrillators; dialysis equipment for renal problems;
equipment for the constant monitoring of bodily functions; a web ofintravenous
lines, feeding tubes, nasogastric tubes, suction pumps, drains, and catheters; and
a wide array ofdrugs to treat the primary condition(s) of
hospitalization. Medically induced comas, analgesics, and induced sedation are
common ICU tools designed to reduce pain and prevent secondary infections.
Quality of Care
The available data suggests a relation between ICU volume and quality of care for
mechanically ventilated patients. After adjustment for severity of
illnesses, demographicvariables, and characteristics of different ICUs (including
staffing by intensivists), higher ICU staffing was significantly associated with
lower ICU and hospital mortalityrates. A ratio of 2 patients to 1 nurse is
recommended for a medical ICU, which contrasts to the ratio of 4:1 or 5:1
typically seen on medical floors. This varies from country to country, though; e.g.,
in Australia and the United Kingdom most ICUs are staffed on a 2:1 basis (for
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High-Dependency patients who require closer monitoring or more intensive
treatment than a hospital ward can offer) or on a 1:1 basis for patients requiring
very intensive support and monitoring; for example, a patient on a mechanical
ventilator with associated anaesthetics or sedation such
as propofol, Midazolam and use of strong analgesics such
as morphine, fentanyl and/or remifentanil
Neonatal intensive care unit
A Neonatal Intensive Care Unit (NICU) is an intensive care unit specializing in
the care of ill or premature newborn infants.
A NICU is typically directed by one or more neonatologists and staffed
bynurses[, nurse practitioners, pharmacists, physician
assistants, residentphysicians, and respiratory therapists. Many other ancillary
disciplines and specialists are available at larger units. The term neonatalcomes
from neo, "new", and natal, "pertaining to birth or origin"
Nursing and neonatal populations
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A pediatric nurse checking recently-born triplets in an incubator at ECWA
Evangel Hospital, Jos, Nigeria
Healthcare institutions have varying entry-level requirements for neonatal
nurses. Neonatal nurses are Registered Nurses (RNs), and therefore must have
anAssociate of Science in Nursing (ASN) or Bachelor of Science in
Nursing (BSN) degree. Some countries or institutions may also require
amidwiferyqualification. Some institutions may accept newly-graduated RNs
who have passed the NCLEX exam; others may require additional experience
working in adult-health or medical/surgical nursing.
Some countries offer postgraduate degrees in neonatal nursing, such as
the Master of Science in Nursing (MSN) and various doctorates. Anurse
practitioner may be required to hold a postgraduate degree. The National
Association of Neonatal Nurses recommends two years' experience working in a
NICU before taking graduate classes.
As with any registered nurse, local licensing or certifying bodies as well as
employers may set requirements for continuing education.
There are no mandated requirements to becoming an RN in a NICU, although
neonatal nurses must have certification as a Neonatal ResuscitationProvider.
Some units prefer new graduates who do not have experience in other units, so
they may be trained in the specialty exclusively, while others prefer nurses with
more experience already under their belt.
Intensive care nurses endure intensive didactic and clinical orientation, in
addition to their general nursing knowledge, to provide highly specialized care for
critical patients. Their competencies include the administration of high-risk
medications, management of high-acuity patients requiring ventilator support,
surgical care, resuscitation, advanced interventions such as extracorporeal
membrane oxygenation or hypothermia therapy for neonatal
encephalopathyprocedures, as well as chronic-care management or lower acuity
cares associated with premature infants such as feeding
intolerance,phototherapy, or administering antibiotics. NICU RNs undergo
annual skills tests and are subject to additional training to maintain
contemporary practice.
History
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The problem of premature and congenitally ill infants is not a new one. There
were scholarly papers published as early as the 17th and 18th century that
attempted to share knowledge of interventions.[It was not until 1922, however,
that hospitals started grouping the newborn infants into one area, now called the
Neonatal Intensive Care Unit (NICU).
Stphane Tarnier
Before the industrial revolution, premature and ill infants were born and cared
for at home and either lived or died without medical intervention. In the mid-
nineteenth century, the infant incubator was first developed, based on the
incubators used for chicken eggs. Dr. Stephane Tarnier is generally considered to
be the father of the incubator (or isolette as it is now known), having developed it
to attempt to keep premature infants in a Paris maternity ward warm. Other
methods had been used before, but this was the first closed model, additionally,
he helped convince other physicians that the treatment helpedpremature infants.France became a forerunner in assisting premature infants, in part due to their
concerns about a falling birth rate.
Dr. Pierre Budin, followed in Tarniers footsteps after he retired, noting the
limitations of infants in incubators and the importance of breastmilk and the
mothers attachment to the child. Budin is known as the father of
modern perinatology, and his seminal workThe Nursling (Le Nourisson in
French) became the first major publication to deal with the care of the neonate.
Another factor that contributed to the development of modern neonatology was
thanks to Dr. Martin Couneyand his permanent installment of premature babies
in incubators at Coney Island. A more controversial figure, he studied under Dr.
Budin and brought attention to premature babies and their plight through his
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display of infants as sideshow attractions at Coney Island and the Worlds Fair in
New York and Chicago in 1933 and 1939, respectively.
Early years
Bundesarchiv Bild 183-1989-0712-025, Berlin, Krankenhaus "Oskar-Ziethen",
Kinderkrankenhaus
Doctors took an increasing role in childbirth from the eighteenth century
onwards. However, the care of newborn babies, sick or well, remained largely in
the hands of mothers and midwives. Some baby incubators, similar to those used
for hatching chicks, were devised in the late nineteenth century. In the United
States these were shown at commercial exhibitions, complete with babies inside,
until 1931. Dr A. Robert Bauer MD at Henry Ford Hospital in Detroit, MI
successfully combined oxygen, heat, humidity, ease of accessibility, and ease of
nursing care in 1931. It was not until after the Second World War that special care
baby units (SCBUs) were established in many hospitals. In Britain, early SCBUs
opened in Birmingham and Bristol. At Southmead Hospital, Bristol, initial
opposition from obstetricians lessened after quadruplets born there in 1948 were
successfully cared for in