Is My Clinic Prepared for Emergency Patients?
World Small Animal Veterinary Association World Congress Proceedings, 2015
A. Lopez Quintana, DMTV
Técnica Clínica Veterinaria, Uruguay

Time is one of the most important predictive factors on the outcome of emergency patients. The initial stabilization of the emergency patient is therefore the ethical obligation of any veterinary facility.

The effects of readiness and organized response on outcomes for patients receiving emergency care have been well studied and involves the accessibility of the equipment as well as the implementation of a proved method by a trained veterinary team. The combination of solid knowledge, regular team work training and readily accessible organized equipment is the formula for success.

Equipment Organization and Cognitive Aids

The emergency room should be ample enough with good illumination and electrical capacity and readily accessible from the street. It should contain a firm exam table that allows CPR, a sink with water supply, soap, antiseptic for proper hand hygiene, an oxygen source, Ambu bag and an emergency or crash cart.

The location, storage, and content of resuscitation equipment should be standardized and regularly audited. The presence of cognitive aids such as checklists, algorithm charts, and dosing charts has been shown to improve compliance with the ABC emergency method.

Access to readily accessible, organized and consistently audited crash carts have demonstrated improved outcomes. It should have 3 to 4 drawers containing all the elements that you need to use in the first five minutes (Table 1). The spaces for drugs should be clearly labeled with the name of the drugs and dose in mg/ml and in ml/kg to facilitate patient dosage.

Table 1

Crash cart distribution

Airway
- Endotracheal tubes numbers 3–11
- Laryngoscope
- Gauze to hold the tongue
- Rubber band
- Suction tip

IV catherization
- 14 a 25-G IV catheters
- 3-way stop lock
- Infusion sets
- Tape
- 3–20 ml syringes

Drugs
- CPR drugs (see CPR chart), diazepam
- Labeled space: drug name/concentration in mg/ml/dose in mg/ml and ml/kg
- Proper size syringes

Specific equipment
- Sterile gloves and surgical drapes
- Tracheostomy and thoracic tubes
- Surgical equipment/vascular clamps

Other drugs and materials like analgesics, corticoids, antihistamines, furosemide, vasopressors, hypertonic saline, mannitol, fluids, stethoscope, otoscope, ophthalmoscope, pointed light and reflex hammer, as well as equipment destined for secondary stabilization (e.g., urinary catheters, central venous lines) should be located in shelves or cabinets in the emergency room.

A list of all the contents of the cart should be available so that daily replacement and after each patient is warranty. The assignation of a person for daily cart replacement reduces the chances for overlooks. Another aid to warranty the proper replacement after patient care is to cross a tape with date, time and name of the responsible person on the front of the cart, every time the cart is open this tape will remain loose until the cart is checked.

In-hospital patients that develop an emergency situation should be treated in the emergency room or a second crash cart should be available in the hospitalization room, the crash cart should never abandon the emergency room.

All the possible aids to reduce the amount of time to deliver patient care should be in place. A bag of crystalloids connected to an infusion set and clippers should be hung over the table, precut tape of the proper length to secure an intravenous catheter should be taped to the lateral of the exam table or the top of the cart, a syringe fulfilled with air should be ready to use in the airway drawer, etc.

The availability of clearly visible ABC algorithms and dosing charts (Table 2) increases the compliance to the ABC method and time for implementation. Formal training of personnel in their use is crucial to effective utilization during a crisis.

An ECG monitor, a system to measure the arterial pressure, a pulse oximeter, a point of care lactate and glucose meter, a micro centrifuge, an aspiration system and if possible a defibrillator should also be present in the emergency room. The availability of other equipment like ultrasound and radiology would be of help for the primary evaluation of some trauma patients. Comprehensive, directed well-kept medical records are also very important.

Table 2. Adapted from the Veterinary Emergency and Critical Care Society

 

The Veterinary Team

Emergency medicine requires profound knowledge of physiology, physiopathology, internal medicine, toxicology, pharmacology and drug interactions to be able to readily diagnose the most important life threatening problems and basic principles of treatment for any emergency patient.

Ideally, the emergency team should have at least 3 trained members. Each member should have an assigned role (Table 3). It has been proved that the veterinary team that has received training in emergency care acts with more confidence, responsibility and reduced level of stress thus able to provide better patient care. In a rapid changing topic as emergency care continuing education is fundamental. The Veterinary Emergency and Critical Care Society recommends at least 40 hours of continuing education for specialized doctors and 24 hours for technicians over 2 years.

Table 3

Team tasks

1. Secretary
- Answer the phone (provides instructions for transport).
- Establishes the need of emergency triage.
- Keeps owners calm and calls for the doctor.
- Asks for owner information and starts anamnesis.
- Link between the owners and the veterinary team.
- Provides treatment costs and asks for signed consents and payment method.
- Explains what could be done in the case of cardiorespiratory arrest and obtain resuscitation orders.*
* The last 2 may be performed by the veterinary team but it should be clearly assigned.

2. Assistant
- Refill the emergency cart.
- Prepares the exam table, fluids and cage.

3. Technician
- IV catherization.
- Establishes vital signs.

4. Veterinary trained doctor
- Team leader. Strong knowledge and communication skills.
- Emergency and critical care training.
- Knows the ABC method.
- Establish the procedures and gives orders.
- Performs advanced maneuvers: endotracheal intubation, tracheostomy, arterial cauterization, etc.

Adherence to ABC protocol can only be accomplished if personnel receive effective, standardized training and regular opportunities to refresh their skills. Emergency training should include didactic components targeted at cognitive performance and opportunities to practice hands-on skills with quality feedback. Simulated situations and structured debriefing after real emergencies, allowing participants to review and critique their performance and the performance of the team as a whole is recommended. Open, honest discussion about opportunities for improvement immediately after an emergency and once a week scheduled discussions about the more complex cases can lead to significant enhancement in of the team dynamic, emergency performance and better patient outcomes.

The team leader should be a veterinary doctor with natural leadership capacity and specific training in emergency care. Specific leadership training is also recommended. Crucial roles include distributing tasks to other team members and enforcing rules and procedures to ensure a shared mental model among team members, actively soliciting input from team members to encourage situation awareness and identify issues and ideas from all members of the team, and assigning individual tasks to team members. Team performance can also be enhanced by using focused, clear communication directed at individuals when tasks are assigned. In order to reduce errors, misinterpretation and even the lack of performance of the required action, the receiving team member should repeat the order back to the requestor to verify the accuracy of the receiver's perception.

Conclusions

Probably one of the most important factors in the adequate and efficient functioning of the emergency room is the organization including the use of a labeled and audited crash cart, a standardized method and visual aids as algorithms and drugs charts.

Continuing education and regular training of the veterinary team has also demonstrated far better survival rates.

References

1.  Bliven MT. Animal health technicians in emergency hospital. Vet Clin North Am Small Anim Pract. 1981;11:9–22.

2.  Crowe DT Jr. Tomada de decisão para o paciente gravemente traumatizado con ênfase nas primeiras 24 horas de cuidado. En: Cardoso R, Crowe DT Jr, eds. Fundamentos de Terapia Intensiva Veterinária em Pequenos Animais. Rio de Janeiro, Brazil: L.F. Livros de Veterinária LTDA; 2005;16:149–162.

3.  Fletcher D, Boller M, Brainard B, et al. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: clinical guidelines. J Vet Emerg Crit Care. 2012;22(S1):S102–S131.

4.  Devey J, Cardoso RR. Estableciendo a clínica de emergencia En: Cardoso R, Crowe DT, eds. Fundamentos de Terapia Intensiva Veterinária em Pequenos Animais. Rio de Janeiro, Brazil: L.F. Livros de Veterinária LTDA; 2005;4:27–36.

5.  Kirby R. Critical care - the overview. Vet Clin North Am Small Anim Pract. 1989;19(6):1007–1019.

6.  Lacroix C, Noling D. Advanced directives and do-not-resuscitate orders. In: Wingfield W, Raffe M, ed. The Veterinary ICU Book. 1st ed. Jackson, WY: Teton NewMedia 2002:1217–1225.

7.  Osborne C. The problem oriented medical system. Improved knowledge, wisdom, and understanding of patient care. Vet Clin North Am Small Anim Pract. 1983;13(4):745–790.

8.  Rollin B. Ethics in veterinary critical care medicine. In: Wingfield W, Raffe M, ed. The Veterinary ICU Book. 1st ed. Jackson, WY: Teton NewMedia; 2002:1205–1216.

9.  Wingfield W. Equipping an emergency/critical care veterinary hospital. In: Wingfield W, Raffe M, ed. The Veterinary ICU Book. 1st ed. Jackson, WY: Teton NewMedia; 2002:1147–1167.

10. VECCS. Recommendations for Veterinary Emergency and Critical Care Facilities. http://veccs.org/guidelines.php (VIN editor: link could not be accessed as of 3/28/16).

  

Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Adriana López Quintana, DMTV
Técnica Clínica Veterinaria
Uruguay


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