By Mary Ann Hellinghausen
Illustration by Malcolm Garris/PhotoDisc
December 10, 1998

No one solution can fix all problems that plague today’s emergency departments, but many recent advances are now finding their way into the ER, making for a bright future in emergency medicine.

Some of the unpredictable factors in the ER—such as "feast or famine" patient loads and the threat of catastrophic accidents—may be inevitable. But advances in the diagnosis and treatment of certain ailments, the advent of more emergency nurse practitioners to relieve staffing pressure, and the use of computerized automation to help triage and chart patients will likely ease some of the strain, experts say.

Call to computerize

Computerization has helped ease the workload for many ER staffers, although some ER department heads are taking a wait-and-see attitude about the reliability of computer programs for bedside charting and triage. "Some of the computerized models don’t take into account certain patient variables that a nurse is able to pick up on," said Pam Baker, RN, director of trauma, pediatrics, and emergency management services with the Emergency Nurses Association, based in Park Ridge, Ill. "We still need that human element, that ability to make a judgment call."

Limited computerization is used at North Houston Medical Center, where outside physicians can link up to patient records to access data about a patient’s prior hospitalizations from their offices. But the hospital has not incorporated electronic bedside charting, because of difficulties in "back documenting"—going back into the system to insert information after new data has accrued in patient records. "We’ve taken a step back from that," said ER director Robin Garza, RN. "We’re waiting to see how it works in other ERs that have taken that on."

At Ben Taub General Hospital in Houston, which has one of the busiest ERs in the country that treats more than 300 people a day, computerized bedside charting is not used, because of the high patient volume and the high cost, said Lori Upton, RN, nurse manager.

Bedside laptops

Some hospitals have taken technological advances to the next level, finding that computers in patients’ rooms streamline care and increase efficiency. At Good Samaritan Hospital in San Jose, Calif., a laptop computer at bedside allows nurses to start an electronic patient chart without delaying care and has proved to be a time-saver, said Kathleen King-Davidson, RN, manager of the hospital’s ER department.

"We can interview the patient while we begin treatment, rather than delay the start of care for the registration process," she said. An automated tracking system helps healthcare providers keep track of which phase of treatment the patient is undergoing. "That’s one emerging technology that’s offering tremendous benefits for overall management of [patient] flow," King-Davidson said.

Diagnosis and treatment

The most gratifying progress in emergency medicine in the last few years is the ability to get quicker diagnoses and treatment for patients who have had cardiac events or stroke, experts say. "Time is of the essence in those cases," Garza said. "We can do an ECG in the ER and get the data quicker. It really helps with the diagnosis." Quicker diagnoses in combination with thrombolytic drugs provide for more positive outcomes for cardiac patients, experts say. These drugs dissolve blood clots in patients with cardiac problems or strokes, often resulting in more rapid recovery and fewer long-term effects for the patients.

Emergency nurse practitioners

But computers and new diagnostic techniques aren’t the only thing new in the ER these days. The future is likely to hold a shift in the way ERs are staffed, as emergency rooms are becoming more effective at treating patients through the use of emergency nurse practitioners. These ENPs often treat less acute patients, relieving physicians to handle more urgent cases. The University of Texas-Houston Health Science Center School of Nursing offers the nation’s only emergency nurse practitioner course and is expected to graduate 14 ENPs in May 1999 and 22 in May 2000, said certified emergency nurse Frank Cole, PhD, FNP, RN, the school’s director of ENP education.

"ENPs are having an impact," Cole said. "Turn around times are shorter and patients are happier." ENPs’ duties vary, depending on whether they are in a rural setting, where they may be needed for more acute services, or in an urban setting, where they usually treat less acute patients.

However, despite all the advances in care, there is little these new technologies can do to handle one of the most basic problems with ER work—unpredictability.

Lack of control over patient flow remains one of the biggest frustrations for ER staff. "I don’t know if there’s any technology that can ever assist with that," King-Davidson said. "But it’s also one of the most exciting things—always living on the edge, having to be prepared."

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