Much like British naval vessels once considered noon the start of their day, 7 am is the start of the day in the Paterson ER (150,000 visits per year). During the next 24 hours an average of 415 patients will seek care (Monday and Tuesday always being the busiest). They will be cared for by 17 emergency physicians, 4 nurse practicioners, and 45 nurses supported by three dozen scribes, techs, transporters and registration personnel.
But for now only about 30 patients are in the department. It is a busy time of transition. The night shift physicians and most of the nurses have been here since 7pm. When they came in nine zones were humming along at full power. Now they are turning over only four areas to the day shift.
Before the new team can begin caring for patients the off-going Team must sign out. Physician to physician. Clinical nurse to clinical nurse. Charge nurse (See Inset) to charge nurse. All patients in the emergency department proper are “owned” by someone. This ownership (responsibility) forms the basis of the complex systems that provide medical care.
“Ownership” in the Paterson ER is geographical. This very large ER (88 beds with 15-20 additional spaces for overflow) is broken down into nine zones (excluding the Resuscitation bays and Psych area). Each zone is staffed by a set team of one physician and two nurses for 8-10 beds. They are supplemented with a scribe for the doctor, trainees (residents, medical students) and pull from a pool of transporters, registrars and techs.
Because of this scale areas have specialties. Zones 1-3 (Main ER) care for adults, are open 24 hours a day and receive the most critical patients. Zones 8 and 9 are pediatric and also never close. Zone 4 (also known as Supertrack) is a hybrid unit taking care of ambulatory patients with low to moderate intensity complaints. Zones 5 and 6 make up the SrED (Senior ED) and specializes in the care of those 65 and older. Finally Zone 7 is an area in transition currently taking care of the excess demand the other units can’t handle.
At 7 am with only four zones open (3 in Main ER and one in Peds along with the Psych and Trauma areas), the department can comfortably handle the roughly 8 patients an hour that are arriving. Beginning at 9 am that rate will sharply increase until 20 patients are presenting for care per hour. As demand increases more zones with more beds will come on-line.
The pattern will be much the same for each of those 415 patients. 1)Come in, 2) get triaged (sorted), 3) go into a treatment area (bed), 4) be seen by the doctor and nurse, 5) receive ordered tests and treatments, 6) receive a disposition and 7) leave. Some patients will require this faster, others slower.
Some will require very intensive care and others just an xray or a prescription. Frequently those who are dying will be saved. Sometimes though a patient will die. All will be touched by multiple people and their care will require the close cooperation of multiple departments and systems during their stay. Compassion amongst organized chaos will be the order of the day.
Technology plays a big role in modern healthcare but particularly in a SuperER. Without electronic medical record system (EMR) that integrates bed management, medication/test ordering, charting, and disposition planning there is no way this complex system could function. Though paper certainly exists in the ER more and more information is transmitted electronically. It is not unusual for physicians to have 4-5 different program running in order to access their patients’ current information, previous history, lab results, and digital images of radiology tests (CTs, ultraounds, etc).
Next week Anatomy of a SuperER – Part Two will highlight some of the important innovations at PatersonER including Pivot Triage, the SuperTrack, and our astounding evolution of the emergency care of geriatric patients. We will also get in depth into the care of some of the most critical patients including those with major trauma and life threatening heart and brain emergencies. Stay tuned!
David Adinaro MD, FACEP
Dr. Adinaro is the president of NJ-ACEP for 2013-14 and is the Chief of the Adult Emergency Medicine at St. Joseph’s Regional Medical Center in Paterson, NJ. He is also the current editor of the “Year of Confusion…Year of Opportunity: 20 Things Changing Emergency Medicine” blog. Dr. Adinaro can be reached via @PatersonER .
This publication represents the personal opinion of the author and does not reflect NJ-ACEP or his employer.