Additional Requirements : Emergencies

• Objectives:
• Expected additional requirements in the context of an emergencies.
  
• Scenarios:
• Scenarios before the hospital:
• First aid on site::
• In general anybody should have a minimum of knowledge about what to do as first aid and at least how and where to call for urgent help. 
  
• Emergency call:
  
• First person at the site of the accident:
• Should know how and where to call for support.  
• In general anybody could be the witness of a cardiac emergency and should have a minimum of basic knowledge. Hopefully there is a nurse nearby or even a doctor.
  
• Basic "case" information:
• A minimum of information should be communicated to the call center:
  
• The exact location of the patient and the context of did happen.
  
• The main symptoms. A predefined checlist of questions could help here.
• Observations as pulse rate, blood pressure, consciensiouness level, if a cardiac condition is suspected an ECG record, a picture of a wonded patient, etc....
  
• Assuming that an electronic network is available, the  new case should be immediately recorded once in the computer network and made available to several involved actors as alocal doctor nearby, ambulance staff, cardiologic center.
  
• Identification:
• A case has immediately a provisional "case iidentification" and can be retrieved by time, location, calling person, and maybe exact patient identity if available.  
• However the exact patient identification is perhaps not yet available:
• If possible one will seek for an existing patient record.  If any an overview of known health problems could be important for the current care.
  
• Otherwise a new patient record will be created and will keep archive of the current emergency event.
• Usually the initial recording will be initiated in the network by the call center , but anybody else could occasionally initiate an emergency case record.  The other actors will continue to extend the information about the case.
  
• Role of the regional call center:
• Provisional rough evaluation of the situation.  Which type of problem? Which kinds of resources should be alerted first? Of course an overview of possible care services should be always available.
  
• First aid recommendations.
• Coordination of the care, as sending an ambulance, notification to the most nearby cardiologic center. who will try to make a more precise assesment of the situation and recommendation for the initial treatment e.g. defribrillation, etc...
• A very temporary role before taken over by a medical center.
  
• Medical center:
• When receiving notification of the call:
• The medical center could already try to get more information in order to make a more precise assessment, for example is an ECG record can be transmitted.
  
• Could try to provide advices about what to do, for example to use a defibrillator.
   
  
• Scenario of the emergency unit at the intrance of the hospital:
  
• Introduction:
• If not yet anticipated in the above scenarion, the case registration is done here in a similar way as above.  The common software requirement of level "A" are assumed to be already available in the hospital and the scenario focus now on specific requirements related to an emergency department at the entrance of a hospital.
• Missions:
• First aid in case of life threatening situations:
• A challenging medical situation: any kind of medical problem can appear at any time, as well road accidents as well any disease. 
  
• Moreover during night and week-ends the emergency department is also one of the few units inside the hospital, remaining fully operational 24 hours a day.
• Very variable workload, hours with nothing to do but sometimes at once several emergencies.  A first look at the arrival define priorities.  Patients with obviouly relatively minor problems may have to wait several hours.
• Evaluation:
• Patient examination The emergency unit has a priority access to technical services
  
• The doctor move between several patients, and come back when the results of the first test become available, as lab, images, etc .
  
• Triage:
• Decision about where the patient should go:
• Admission:
• Either admitted in the hospital after urgent measures if necessary.  For example trasferred to the surgery department.
• Discharge:
• Or reassurance of the patient advised to go back at home and to be followed in the next days, by the GP and maybe at the consultation of a specialist.
• At the same time simple care is provided here, e.g. a prescription to be get in an external pharmacy, immobilisation of a simple fracture, etc....
  
• The trend is that this kind of basic care is increasing to more than 80 %.  Indeed GP become less available out of working hours and patients hope better care in hospital.  The latest point is not necessarily true.  Anyhow patient going to hospital get as a mean much more expensive technical examinations, lab, XRays, etc... while a GP with common sense and well knowing the patient can solve many problems.
• Patient should leave the emergency unit as soon as possible, in principle within less the 2 hours.
  
• Report:
• In all cases a report need to be available when tha patient leave the emergency unit, as well in case of transfert to a hospital department as well if the patient is discharged as non urgent and referred to external consultations.  This mean that the information should be recorded directly on site, step by step, in such a way that the record should always be closed when the patient leave, as far as possible.
   
  
• Specific additional requirement for emergencies:
• Reuse of the common platform:
• The common software requirement of level "A" are assumed to be already available. 
  
• From the "Problem List" point of view an emergency call is a new "Health Issue".  The problem will have an evolution from a rough "reason for calling" to a more precise medical definition.  For example the initial version could something like "patient in bad condition found by the police", while the medical department will later identify a precise diagnose, moreover which can be classified with an ICD code from the WHO.
  
• Patient group:
• The patients and the cases the emergency unit is currently in charge of.  The patients actually present in the emergency unit, as well new cases just known via a call and expected to arrive soon.
• The common Patient Group module should be extended as a kind of dashboard. Indeed an emergency unit need to follow several cases in parallel.  Therefore they need a kind of dashboard showing the current patient list with a short presentation of the most important information.  
  The list should usually be sorted on emrgency level and secondarily on time of arrival.
  
• The emergency unit must remain operational 24 hours a day:
• For many hours there are nearly no real emergency patient.  However there is always some work, but mostly as primary care.
  
• In case of a catrastrophic event there could be far too many.  The question is then to identify qhickly the most urgent ones and to sort the list according to urgency level.
  
• Dashboard:
• Motivation:
• The dashboard is used as a way to follow the evolution of the group of emergency patients.  The elements of this list contain a short summary of every patient.  
• It make easy to move from one case to the next one.  A click on this short summary provide a zoom into the full patient record.
  
• Content of a dashboard entry:
• A few essential informations intended to the coordination of the emergency unit.  Typically:
• Identification:  patient ID number or at least a case number, patient name,
• Primary responsible staff member taking charge of this particular patient.
  
• Location of the patient:  box number, and my be currently moved to radiology,
• Urgency level, optional alarm icon and sound, in case a monitoring device would raise an alarm, for example if a cardiac arrect.
  
• Summary ogf the main current problems.
• Summary of the currensituation of the action plan:  for example lab requested and waiting for results.
• ....
• Collaboration issues:
• Nearly all patients are of course new and not known in advance in the emergency unit:
• Access to a previouly well maintained up to date patient record should be very desirable.  An overview of the already known problems can help to make safer and more quickly decisions.
  
• Required reports:
  
• Normally all patients are transferred within less than about 2 hours.  When the patient arrive by a new colleague it is critical to have a report of all what was observed and done during the stay in the emergency department.  It is particularly critical if the patient is admitted in a depetment of the hospital.  If the patient is discharged th GP should have access to the report the same day.
• Other documents are less urgents, but it is efficient to close a case completly when the patient is leaving.  There is not always time to do it immediately, but doing that work a few days later would be more difficult and more time consuming.
  
• Approaches:
• The idea is to register the information once immediatly at the source by the person getting the information.  Having the information in the computer it can be reused several time in order to produce the various reports, as electronic messages and/or printer documents.
  
• Most usual reports:
• Medical summary intended for the colleagues where the patient is transferred.
• optional prescriptions if the patient may be discharged.
  
• Optional certificates for an employer or a school,
  
• Administrative declaration,
• Insurance documents,
• Classification code intended for the statistics. 
• Access rigths:
• Normally the rule is that in order to get get access to any personal patient record, one must be an agreed member of the care team of the patient, with his/her explicit agreement.
  
• In practice emergency units need an exception, allowing the doctor to declare himself to be a member of the care team of the patient.  However as a preventive measure, the list of such forced accesses can be reviewed later for justification. Moreover the patient should be informed afterwards of any forced access.