This chapter was reproduced from the Emergency Medicine Clerkship Primer, 2008, Chapter 5, with the permission of the Editor, for ease of viewing on mobile devices.
Throughout medical school, you will encounter patients in many clinical arenas: the inpatient wards, the public health clinic, the private office, the hospital outpatient clinic, and of course the emergency department. Although medicine at its core involves taking care of patients, the approach and sequence of steps involved in caring for patients will be different depending on the health care setting in which they are encountered. When evaluating a patient, the health care provider (nurse, medical student, resident, or attending) needs to develop an approach tailored to the specific health care setting and available resources.
Think of the ambulatory care and hospital outpatient clinic setting. In this clinical venue, unexpected emergencies occur; however, they are few and far between. The acuity level is low, with 1% of patient encounters requiring referral to the emergency department or for hospital admission (Middleton et al., 2007, Cherry et al., 2007). Some patients will require diagnostic studies (laboratory tests or diagnostic imaging). Fortunately in this setting, the majority of these are routine, and most are obtained electively.
Many patients requiring diagnostic studies will need to be referred to an off-site laboratory, diagnostic imaging center, or hospital to undergo testing. Therefore, the results of many of these diagnostic studies are not available to the ordering physician for days. Although many private offices and outpatient clinics have a system in place allowing unscheduled walk-in visits, the overwhelming majority of patient visits are scheduled, and patients are cared for on a first-come-first-served basis. When patients are sick, or when the office is closed, patients are referred to the emergency department. In addition, the majority of patients seeking medical care in an ambulatory care or outpatient clinic setting are established patients compared with the emergency department, where the overwhelming number of physician–patient encounters are new visits.
Consider the patient with an elevated blood pressure measurement who is referred to the emergency department for evaluation from a local health clinic. The patient is asymptomatic, without complaints of headache, chest pain, or shortness of breath. His repeat blood pressure measurement in the emergency department is 186/98 mmHg. In such a case, a targeted H&PE and selected diagnostic work up will be needed to exclude any acute complications of elevated blood pressure such as the involvement of key target organs (i.e., eyes, brain, heart, lungs, and kidneys). The goal is not necessarily to establish baseline laboratory values, to obtain diagnostic studies for future comparison or even to necessarily normalize the blood pressure at this time.
Traditionally, approximately half of all outpatient encounters are made to primary care physicians, with many of these visits being for preventive care. The most common reasons for a patient to visit an outpatient clinic include progress visit, general medical examination, routine prenatal care, cough, and sore throat. Together, these types of patient visits account for 20% of all outpatient clinic visits (Middleton et al., 2007). By contrast, the emergency department provides care to the acutely ill or injured. In the emergency department, nursing triage guidelines are designed to ensure that more seriously ill patients are cared for first. The acuity level is also much greater than the ambulatory care or outpatient clinic setting.
Across the country, approximately 12% of all emergency department patient encounters require hospital admission (Nawar et al., 2007), with 16% of patients admitted to a critical care bed. Anecdotally, high-acuity, high-volume emergency departments will admit 20% to 25% of cases to the hospital. Compared with the outpatient setting, a greater number of emergency department patient encounters require a diagnostic workup. This may include laboratory tests or advanced imaging techniques such as CT scans and magnetic resonance imaging (MITI). The majority of diagnostic tests performed in the emergency department by design provide results to the ordering physician within minutes to hours. Although some patients will present to the emergency department with complaints that could otherwise be cared for in an ambulatory care setting, many unexpected emergencies such as trauma, myocardial infarction, stroke, pneumonia, anaphylaxis, and others come through the doors at all hours of the day and night. Some of these cases require emergency subspecialty consultation, a service that is often difficult to provide in an ambulatory care setting.
In addition, the emergency department has both an ethical and legal obligation to evaluate every patient who presents for care to determine whether he or she has a medical emergency, regardless of ability to pay for health care (Emergency Medical Treatment and Active Labor Act or EMTALA). One third of the nation’s emergency departments are considered high safety net sites. These institutions serve a disproportionately high number of Medicaid and uninsured patients, a dramatically different payer mix than that of the routine ambulatory care population.
In the inpatient setting, patient encounters often occur after a preliminary or definitive diagnosis has been made by another health care provider, many times by the emergency physician. Across the country, emergency departments are responsible for approximately 55% of all hospital admissions (Owens et al., 2006). Physicians caring for inpatients face legitimate challenges, some diagnostic, others therapeutic or social, such as short- or long-term placement issues. We all know that medical emergencies occur in the inpatient population; luckily they are not as common as in the emergency department. When they do occur, the health care team often has the benefit of prior rapport with the patient and family, along with some understanding of the patient’s medical condition before the event at hand. This is in stark contrast to unexpected emergencies that present to the emergency department requiring prompt resuscitation and stabilization without the benefit of an adequate history of present illness (HPI) or knowledge of the patient’s medical history, prenatal care, medications, and the like.
The emergency department also differs dramatically from both the inpatient and ambulatory care setting in a few other areas. First and foremost, the emergency department never closes, and the volume of patients cared for is not limited by the number of patient care spaces. Although it is foreseeable that patients with nonurgent complaints will need to wait until an appropriate patient care area is available before they will be evaluated, the sick or unexpected emergencies are at times cared for in less-than-optimal patient care areas, such as a hallway. In the emergency department, the spectrum of patients ranges from the young to the very old, representing disease states of the newborn to the various complications seen in the elderly nursing home resident. The clinical scenarios encountered are also unique to this setting and can range from routine medical and surgical pathology to environmental emergencies, toxic exposures, substance abuse, trauma, psychiatric emergencies, and more.
It is also necessary to realize that patient-specific goals are different in the emergency department from other health care settings. This can directly translate into a better understanding of the specialty-specific approach to a particular clinical scenario or chief complaint. Understanding how emergency physicians approach particular clinical problems will allow students to better place the educational and patient care objectives of their rotation in perspective. See the case study shown in this chapter an example.
Focusing on the problem at hand is key to managing most cases in the emergency department. Whether we are talking about a complaint-directed H&PE, case presentation skills, or a case-specific differential diagnosis, the art of focusing—that is, being able to see the forest through the trees, identifying and relaying pertinent positive or negative case specific information—is crucial to understanding the role of the emergency physician and providing excellent patient care. Remember, the focus of the emergency department is different from other health care settings. Therefore, your approach to certain chief complaints or patient presentations may need to be modified to keep in line with providing optimal and efficient care in the emergency department.
|Comparison of the Three Patient Care Settings|
|Emergency Department||Inpatient Setting||Office/Outpatient Setting|
12% of patients require hospitaladmission
Undifferentiated patients with complaint-based presentations
No prior rapport with patient and family
Most diagnostic studies ordered are urgent or emergent
Results of diagnostic studies available within minutes to hours
No scheduled visits; patients are evaluated in order of acuity
Admitted patients have a preliminary diagnosis
After initial evaluation, will develop rapport with patient and family
Diagnostic studies ordered can be nonurgent, urgent, or emergent
Results of diagnostic studies available within hours to days
Most admissions are unscheduled
1% of patients require hospital admission
Routine medical and follow-up care account for a majority of patient visits
Usually have established rapport with patient and family
Most diagnostic studies ordered are nonurgent
Results of diagnostic studies available within days
Scheduled visits on a first-come-first-served basis, occasional unscheduled visits
One final point that deserves mentioning is that the patient presenting to the emergency department must be considered at higher risk for potential serious illness than a similar patient presenting to an office or other outpatient clinic setting. Many patients presenting to the emergency department have acute symptoms. These complaints may reflect more serious underlying pathology when compared with the patient who is willing or able to wait several days for an outpatient appointment. In addition, patients choosing to come to an emergency department for an evaluation rather than going to an outpatient office should alert the caregiver that the patient may believe he or she is too sick to wait for a scheduled appointment; at times, they are right.
Thus, patient care in the emergency department is quite different from other health care settings. It is important to be aware of these differences so that, as a medical student, you understand that the clinical and bedside skills needed to succeed in the emergency department are different from skills needed to succeed in other settings. Understanding and embracing these differences will allow for a more educational and enjoyable experience.
- Cherry DK, Woodwell DA, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2005 summary. Advance Data From Vital Health and Statistics. 2007,387;1–40. Available at:http://www.cdc.gov/nchs/data/ad/ad387.pdf. Accessed March 25, 2008.
- This article reviews nationally representative data on ambulatory care visits in the United States. Data are from the 2005 National Ambulatory Medical Care Survey (NAMCS).
- Middleton K, Hing E, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 outpatient department summary. Advance Data From Vi-tal Health and Statistics. 2007,389;1–35. Available at:http://www.cdc.gov/nchs/data/ad/ad389.pdf. Accessed March 25, 2008.
- This article reviews nationally representative data on ambulatory care visits in the United States. Data are from the 2005 National Hospital Ambulatory Medical Care Survey (NHAMCS).
- Owens P, Elixhauser A. Hospital Admissions That Began in the Emergency Department, 2003. Rockville, MD: Healthcare Cost and Utilization Project, Agency for Healthcare Quality and Research; 2006. Available at:http://www.hcup-us.ahrq.gov/reports/statbriefs/sb1.pdf. Accessed March 25, 2008.
- This document uses data from the Healthcare Cost and Utilization Project to identify hospital admissions that began in the emergency department.
Hospitals are ready for almost anything: Although equipped to treat minor injuries or sickness, emergency departments are best suited for the bigger stuff. “They can generally respond to just about any emergency within the capabilities of that hospital — 24/7,” Uren says.What is the difference between inpatient and outpatient? ›
What's the main difference between inpatient and outpatient care? Generally speaking, inpatient care requires you to stay in a hospital and outpatient care does not. The big difference is whether you need to be hospitalized or not.What is the difference between acute care and the emergency room? ›
One type of acute care is the emergency room, which is typically reserved for life-threatening situations that require advanced medical intervention, like injuries after a car accident. Other acute care takes place on a non-emergency basis, like the services available at Healthy Life Family Medicine.What is IP and OP in hospital? ›
The difference between an inpatient and outpatient care is how long a patient must remain in the facility where they have the procedure done. Inpatient care requires overnight hospitalization. Patients must stay at the medical facility where their procedure was done (which is usually a hospital) for at least one night.Is the emergency room inpatient or outpatient? ›
You're an outpatient if you're getting emergency department services, observation services, outpatient surgery, lab tests, or X-rays, or any other hospital services, and the doctor hasn't written an order to admit you to a hospital as an inpatient.What is the difference between in the hospital and at the hospital? ›
A person is at the hospital when he is physically on the premises of the hospital. A person who is in the hospital is a patient at that facility.What are the similarities and differences between inpatient and outpatient coding? ›
Outpatient coding refers to a detailed diagnosis report in which the patient is generally treated in one visit, whereas an inpatient coding system is used to report a patient's diagnosis and services based on his duration of stay.What are examples of inpatient services? ›
- Complex surgeries, as well as some routine ones.
- Serious illnesses or medical issues that require substantial monitoring.
- Childbirth, even in cases that don't require a cesarean section.
- Rehabilitation services for psychiatric illnesses, substance misuse, or severe injuries.
Inpatient nurses care for patients who require long-term care, and outpatient nurses care for patients who need immediate care. However, a patient may see both kinds of nurses for the same issues. For example, a patient may initially receive treatment from an outpatient nurse in an emergency room.What are the key differences between a hospital based and a free standing emergency room? ›
Freestanding ERs can be owned by a hospital or they may be privately owned, but all have one key difference – they are not attached to a hospital, so if a higher level of care is required, such as immediate surgery or cardiac procedure, patients will be transferred to the nearest hospital, potentially losing valuable ...
Triage is a sorting process for patients coming to the emergency department. The triage nurse, who receives additional triage training, assesses the severity of a patient's symptoms using a standard set of guidelines called the Canadian Triage and Acuity Scale (CTAS).Is acute care the same as inpatient care? ›
Simply put, acute refers to inpatient care while ambulatory refers to outpatient care. An acute setting is a medical facility in which patients remain under constant care.What is inpatient department? ›
Indoor Patients Department (IPD) refers to the areas of the hospital where patients are accommodated after being admitted, based on doctor's/specialist's assessment, from the Out-Patient Department, Emergency Services and Ambulatory Care.What is the definition of inpatient facility? ›
Inpatient care is designed to treat conditions that require the patient to stay at least one night in a care-related facility. Several facility types fall under this category, including acute care facilities, rehabilitation centers, addiction treatment facilities, psychiatric hospitals, and long-term care facilities.What are IP rooms in hospital? ›
In-Patient Services are provided by the Hospital in wards which are spaciously designed along with Duty Doctors , Nurses stations and other facilities . All patients admitted in various wards of the hospital are treated as per the hospital policy.What is the difference between outpatient and emergency? ›
You are classified as an inpatient as soon as you are formally admitted. For example, if you visit the Emergency Room (ER), you are initially considered an outpatient. However, if your visit results in a doctor's order to be formally admitted to the hospital, then your status is transitioned to inpatient care.What is the purpose of an emergency department? ›
Emergency departments' number one purpose is to be ready to deal with emerging, life-threatening situations. While they are there for non-life threatening problems, they have to stay prepared and operate as if an emergency exists.What is the difference between an inpatient admission and observation status? ›
As the terms imply, “admitted” means the patient is in the hospital under the care of a doctor, and “under observation” means the patient is staying in the hospital but as an outpatient. Even though they spend the night, no admissions papers have been signed making them an admitted inpatient in the hospital.What is the difference between a hospital and a health system? ›
The Dartmouth College Center of Excellence defines a health system as an organization that consists of either at least one hospital plus at least one group of physicians or more than one group of physicians.What is the difference between hospital and healthcare? ›
Hospital managers engage with frontline physicians while healthcare managers are confined only to the administration and business.
The different levels (ie. Level I, II, III, IV or V) refer to the kinds of resources available in a trauma center and the number of patients admitted yearly. These are categories that define national standards for trauma care in hospitals. Categorization is unique to both Adult and Pediatric facilities.What is the difference between inpatient and outpatient services quizlet? ›
What is the difference between inpatient and outpatient services? An inpatient services involves the patient being admitted the hospital so that they can be closely monitored after they've done their procedure. An outpatient service involves a patient not staying over night.What are the different coding systems used for inpatient versus outpatient physician office billing? ›
Inpatient coding utilizes ICD-10-CM and ICD-10-PCS codes to transcribe the details of a patient's visit and stay, while outpatient coding on the other hand utilizes ICD-10-CM and HCPCS Level II codes to report healthcare services.What is the difference between inpatient and outpatient in Medicare? ›
The day before you're discharged is your last inpatient day. You're an outpatient if you're getting emergency department services, observation services, outpatient surgery, lab tests, X-rays, or any other hospital services, and the doctor hasn't written an order to admit you to a hospital as an inpatient.What are the functions of inpatient services? ›
Patient are admitted in Inpatient Ward for short and long term depending on severity of their disease. 3. Inpatient Department consists of a wards with Nursing Station, Beds, and all other facility & services necessary for good patient care.What is the function of inpatient care? ›
Inpatient care starts with admission to the hospital for medical treatment. Most patients enter inpatient care from a hospital's Emergency Room (ER) or through a pre-booked surgery or treatment. In most cases, the treatment must be serious and require in-depth observation and monitoring.What is another word for inpatient? ›
|sick person||hospital case|
For example, when you go to the emergency room, you receive outpatient care until the medical team decides that you must be admitted to get the care you need. Once you are formally admitted, you are registered as an inpatient, and your care continues on an inpatient basis until you leave the hospital.What problems arise in an acute facility in distinguishing between an outpatient and an inpatient? ›
What problems can arise in an acute care facility in distinguishing between an outpatient and an inpatient? The problems that may arise can vary between the type of treatments they are providing the patient and medicines they give them.What is the role of a nurse in an inpatient setting? ›
Inpatient nurse duties
Develop a connection between patients and their families. Determine patient care requirements through patient interviews. Maintain a safe and clean working environment. Monitor vital signs.
- Immediately life threatening.
- Urgent, but not immediately life threatening.
- Less urgent.
While community hospitals exist to serve the short-term acute care needs of the general public, non-community hospitals often provide for specific groups such as veterans or Native American populations.What are the differences between public and private hospitals write any three point? ›
Private hospitals are hospitals that are owned by an individual or a group of people. Public Hospitals are hospitals owned and funded by the government. Private hospitals provide the best healthcare facilities. Public hospitals offer healthcare services but the quality is not up to the mark.
- Immediate category. These casualties require immediate life-saving treatment.
- Urgent category. These casualties require significant intervention as soon as possible.
- Delayed category. These patients will require medical intervention, but not with any urgency.
- Expectant category.
The injured people are placed in four urgent (red), emergency (yellow), delayed (green) and non-salvageable (black) classes.What are the 5 levels of triage? ›
The triage categories used in both systems are: Red (immediate evaluation by physician), Orange (emergent, evaluation within 15 min), Yellow (potentially unstable, evaluation within 60 min), Green (non-urgent, re-evaluation every 180 min), and Blue (minor injuries or complaints, re-evaluation every 240 min).Does er count as acute care? ›
Acute care settings include emergency department, intensive care, coronary care, cardiology, neonatal intensive care, and many general areas where the patient could become acutely unwell and require stabilization and transfer to another higher dependency unit for further treatment.What is the most expensive type of healthcare setting? ›
Cost: Because of their more complex and intensive medical services, long-term acute care hospitals are the most expensive of the three options.Why is it called acute care? ›
Acute care describes a level of healthcare wherein a patient needs immediate yet brief treatment. This treatment could be in response to a severe episode related to a chronic condition, trauma, or during recovery from surgery, among others. Acute is considered short-term; the opposite of chronic care or long-term care.What is inpatient and example? ›
/ˈɪnˌpeɪ·ʃənt/ a person who stays one or more nights in a hospital in order to receive medical care: His insurance company is unwilling to pay for inpatient treatment.
Often, one may hear the terms outpatient or inpatient used when referring to a type of diagnostic or therapeutic procedure. “Inpatient” means that the procedure requires the patient to be admitted to the hospital, primarily so that he or she can be closely monitored during the procedure and afterward, during recovery.What are the four 4 main departments in a hospital? ›
Hospitals may have acute services such as an emergency department or specialist trauma center, burn unit, surgery, or urgent care.What is the difference between an inpatient facility and an outpatient facility? ›
Generally speaking, inpatient care requires you to stay in a hospital and outpatient care does not. The big difference is whether you need to be hospitalized or not.What is the difference between inpatient and outpatient settings and services? ›
Generally, inpatient care refers to medical care that occurs when a patient is admitted into the hospital, while outpatient refers to medical care that is received while a patient is not admitted into the hospital.What is considered inpatient hospitalization? ›
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.What is the 4th floor in a hospital? ›
4th Floor Medical/Surgical Unit
The complexity of med-surg training provides our nurses with the skills to oversee the care of many levels of care, from post-surgical care to medical care for the variety of illnesses that require the specialized care only a hospital can provide.
A Transitional Care Unit is short-term stay in a skilled nursing facility where people can receive further physical and occupational therapy.What is the 3rd floor in a hospital? ›
Third Floor - Critical Care at Medical City Alliance
Critical Care Nurses make sure critically ill patients get optimal care for their illnesses and injuries. To do that, they use their specialized skills as well as their in-depth knowledge of the human body and the latest technology in the field.
- The patient in serious medical condition. ...
- The “Pain All Over” person. ...
- The Second-Opinion seeker. ...
- The Frequentist. ...
- The person who is diagnosed by Google and comes for medicine. ...
- The forgetful. ...
- The Narcotics seeker. ...
- The Impatient patient.
The doctor will examine you as soon as possible and order tests as needed. Your tests, such as X-rays, blood analysis or CT scans, will be performed and then evaluated by a specialist. Your ER doctor will review your test results with you and explain next steps in your care.
: a hospital room or area staffed and equipped for the reception and treatment of persons with conditions (as illness or trauma) requiring immediate medical care.What is the point of an emergency room? ›
Life-threatening emergencies, such as a heart attack or serious head injury, require a visit to the emergency department, also called the emergency room (ER). An illness or injury that does not appear to be life threatening but can't wait until the next day should be treated at an urgent care center.What are 3 typical reasons for a patient to be admitted to emergency department? ›
The most common specific reasons for treat-and-release ED visits were abdominal pain, acute upper respiratory infection, and nonspecific chest pain.What are 4 common medical emergencies? ›
- Heart attack symptoms.
- Stroke symptoms.
- Infections such as pneumonia, kidney and skin infections.
- Problems associated with diabetes, obstructive lung disease and heart disease, and chronic medical problems.
Injury management is a key component of emergency department services.What rooms does the emergency department of the hospital consist of? ›
- A full fledged emergency department has the following areas of care: EMS (Ambulance) Coordination Center. ...
- EMS (Ambulance) Coordination Center. ...
- Triage. ...
- Resuscitation Area. ...
- Major Trauma / Medical Area. ...
- Consultation Rooms. ...
- Minor Procedure Room.
The triage registered nurse might assign you a priority level based on your medical history and current condition according to the following scale: Level 1 – Resuscitation (immediate life-saving intervention); Level 2 – Emergency; Level 3 – Urgent; Level 4 – Semi-urgent; Level 5 – Non-urgent.What procedures can be done in emergency room? ›
- Abscess Incision and Drainage (I&D)
- Closed Fracture Reductions.
- Digital Block.
- Fishhook Removal.
- Laceration Repair.
- Lumbar Puncture.
- Peritonsilar Abscess Drainage.
Globally prearranged emergency services
EMS can be provided in two forms—treatment to in-patients and pre-hospital services. Pre-hospital medical services include ambulatory services, transportation of the patients to or from places of treatment and acute medical care (also called first aid).
Type 1 departments are what most people might traditionally think of as an A&E service. They are major emergency departments that provide a consultant-led 24-hour service with full facilities for resuscitating patients, for example patients in cardiac arrest.
When capacity is reached, it can mean that all their beds are full, and/or that their staff and physicians are caring for the maximum number of patients recommended.Why are ER rooms cold? ›
Hospitals combat bacteria growth with cold temperatures. Keeping cold temperatures help slow bacterial and viral growth because bacteria and viruses thrive in warm temperatures. Operating rooms are usually the coldest areas in a hospital to keep the risk of infection at a minimum.Why do patients leave the ER without being seen? ›
A long wait time is a common reason for patients choosing to leave. Patients who leave the ER before being seen by a health care provider may delay care that is important to their health.How many patients does an ER see a day? ›
Depends if you are in triage, fast track, non emergent or emergent, are the trauma/Code stroke/code blue designated RN for the day. Depends on the trauma level of the facility. Trauma 1's are typically 60-100 beds. Trauma 4's can be as small as 6-8 beds.