7 TRIAGE Triage The nature of ED work means that a sorting system is required to ensure that patient s with the most immediately life-threatening conditions are seen \201 rst. A triage proce ss aims to categorize patients based on their medical need and the available departmental r esources. One most commonly used process in the UK is the National Triage Scale (Table 1.1 ). Table 1.1 National Triage Scale Color Time to be seen by doctor 1 Immediate Red Immediately 2 Very urgent Orange Within 5 \200\22310 min 3 Urgent Yellow Within 1 hr 4 Standard Green Within 2 hr 5 Non-urgent Blue Within 4 hr As soon as a patient arrives in the ED he/she should be assessed by a dedicated triage nurs e (a senior, experienced individual with considerable common sense). This nurse should prov ide any immediate interventions needed (eg elevating injured limbs, applying ice packs or s plints, and giving analgesia) and initiate investigations to speed the patient \200\231s jo urney through the department (eg ordering appropriate X-rays). Patients should not have to wait to be triaged. It is a brief assessment which should take no more than a few minutes. Three points require emphasis: \200 Triage is a dynamic process. The urgency (and hence t riage category) with which a patient requires to be seen may change with time. For example a middle-aged man who hobbles in with an inversion ankle injury is likely to be placed in t riage category 4 (green). If in the waiting room he becomes pale, sweaty, and complains of chest discomfort, he would require prompt re-triage into category 2 (orange). Placement in a triage category does not imply a diagnosis, or even the lethality of a condi tion (eg an elderly patient with colicky abdominal discomfort, vomiting, and absolute const ipation would normally be placed in category 3 (yellow) and a possible diagnosis would be b owel obstruction). The cause may be a neoplasm which has already metastasized and is hence likely to be ultimately fatal. Triage has its own problems. In particular, patients in non-urgent categories may wait inor dinately long periods of time, whilst patients who have presented later, but with condition s perceived to be more urgent, are seen before them. Patients need to be aware of this and to be informed of likely waiting times. Uncomplaining elderly patients can often be poorly served by the process. 8 CHAPTER 1 General approach Discharge, referral, and handover Most patients seen in the ED are examined, investigated, treated, and discharged home, either with no follow-up, or advice to see their GP (for sutu re removal, wound checks, etc.). Give these patients (and/or attending relative/friend) cle ar instructions on when to attend the GP \200\231s surgery and an indication of the likely course of events, as well as any features that they should look out for to prompt them to s eek medical help prior to this. Formal written instructions are particularly useful for pat ients with minor head injury ( b p.367) and those with limbs in POP or other forms of cast immobilization ( b Casts and their problems, p.424). The referral of patients to an inpatie nt team can cause considerable anxiety, misunderstanding, and potential con \202 ict betwe en ED staff and other disciplines. Before making the referral the following should be consi dered. Is it appropriate to refer this patient to the inpatient team? Usually, this will be obviou s. For example, a middle-aged man with a history of crushing chest pain and an ECG showing an acute MI clearly requires urgent management in the ED, and rapid admission for further i nvestigation and treatment. Similarly, an elderly lady who has fallen, is unable to weight- bear and has a fractured neck of femur will require analgesia, inpatient care and surgery. However, dif \201 cult situations occur where the clinical situation is less clear; for ex ample, if a man experienced 4 \200\2235min of atypical chest pain, has a normal ECG and che st X-ray (CXR), and is anxious to go home. Or a lady has no apparent fracture on X-ray, but cannot weight-bear. Is there appropriate information to make this decision? This requires a balance between ava ilability, time, and appropriateness. In general, simple investigations which rapidly give the diagnosis, or clues to it, are all that are needed. These include electrocardiogram (EC Gs), arterial blood gas (ABG), and plain X-rays. It is relatively unusual to have to wait f or the results of investigations such as full blood count (FBC), urea & electrolytes (U&E), and liver function tests (LFTs) before referring a patient, since these rarely alter the i mmediate management. Simple trolley- side investigations are often of great value, for exam ple, stix estimations of blood glucose (BMG) and urinalysis. If complicated investigations are needed, then referral for inpatient or outpatient specialist care is often required. Has the patient had appropriate treatment pending the admission? Do not forget, or delay, a nalgesia. Treat every patient in pain appropriately as soon as possible. A patient does not have to \200\230earn \200\231 analgesia. Never delay analgesia to allow further examinati on or investigation. Concern regarding masking of signs or symptoms (for example, in a pati ent with an acute abdomen) is inhumane and incorrect. 9 DISCHARGE, REFERRAL, AND HANDOVER How to refer patients Referral is often by telephone, and this can create problems: \200 Introduce yourself and ask for the name and grade of the specialist. \200 Give a clear, c oncise summary of the history, investigations, and treatment that you have already undertaken. Early in the discussion say clearly whether you are making a referral for admission or a re quest for a specialist opinion. With ever increasing pressure on hospital beds, inpatient t eams can be reluctant to come and see patients, and may appear to be happier to give advice over the phone to avoid admission. If, in your view, the patient needs to be admitted, the n clearly indicate this. If, for whatever reason, this is declined, do not get cross, rude, or aggressive, but contact senior ED medical staff to speak to the specialist team. When the specialist team comes to see the patient, or the patient is admitted directly to a ward, the ED notes need to be complete and legible. Make sure that there is a list of the investigations already performed, together with the available results and crucially, a list of investigations whose results remain outstanding. The latter is essential to ensure cont inuity of care and to prevent an important result \200\230falling through the net \200\231 . Similarly, summarize treatment already given and the response. In an emergency, do not de lay referral or treatment merely to complete the notes, but complete them at the earliest o pportunity. \200 Encourage inpatient specialists who attend patients to write their \201 ndings and management plan in the notes, adding a signature and the time/date. Handing over patients Dangers of handing over Handing over a patient to a colleague, becaus e your shift has ended and you are going home, is fraught with danger. It is easy for patie nts to be neglected, or receive sub-optimal or delayed treatment. It is safest to complete to the point of discharge or referral to an inpatient team every patient that you are seein g at the end of a shift. Occasionally this may not be possible (eg if there is a delay in o btaining an X-ray or other investigation). In these situations, hand over the patient caref ully to the doctor who is taking over and inform the nursing staff of this. How to hand over Include in the handover relevant aspects of history and examination perfor med, the investigation results, and the treatment undertaken. Sign and aim to complete reco rds on the patient as soon as possible. Note the time of hand over, and the name of the doc tor or nurse handed over to. When accepting a \200\230handed-over patient \200\231 at the start of a shift, spend time establishing exactly what has happened so far. Finally, it is courteous (and will prevent problems) to tell the patient that their further care will be p erformed by another doctor or nurse. 10 CHAPTER 1 General approach Liaising with GPs Despite changes in the way that care (particularly out of hours) is deliv ered, GPs still have a pivotal role in co-ordinating medical care. Often the GP will know m ore than anyone about the past history, social and family situation, and recent events of t heir patient \200\231s management. Therefore, contact the GP when these aspects are relevan t to the patient \200\231s ED attendance, or where considerations of admission or discharge are concerned. Every attendance is followed routinely by a letter to the GP detailing the reason(s) for pr esentation, clinical \201 ndings and relevant investigations, treatment given, and follow -up arrangements. If a patient dies, contact the GP without delay \200\224 to provide a medical contact and assistance to the bereaved family, to prevent embarrassing experiences (eg letters requesti ng clinic attendances), and out of courtesy, because the GP is the patient \200\231s primar y medical attendant. Finally, the GP may be asked to issue a death certi \201 cate by the Coroner (in Scotland, the Procurator Fiscal) following further enquiries. Always contact the GP prior to the discharge of a patient where early follow-up (ie within the next 24 \200\22372hr) is required. This may occur with elderly patients where there is uncertainty about the home situation and their ability to manage. A typical example is an e lderly lady with a Colles \200\231 fracture of her dominant wrist who lives alone. The ED m anagement of this patient is relatively simple ( b p.444). However, merely manipulating a C olles \200\231 fracture into a good position, supporting it in an adequate cast, and provid ing analgesia, is only one facet of care. The GP may know that the lady has supportive rela tives or neighbors who will help with shopping and cooking, and will help her to bath and d ress. The GP and the primary care team may be able to supplement existing support and check that the patient is coping. Equally, the GP may indicate that with additional home support (eg home helps, meals, district nurses), the patient could manage. Alternatively, the GP m ay indicate that the Colles \200\231 fracture merely represents the \201 nal event in an increasingly fragile home situation and that the patient will require hospital admission, a t least in the short-term. For the same reasons, a GP who refers a patient to the ED and indicates that the patient re quires admission does so in the full knowledge of that patient \200\231s circumstances. Alw ays contact the GP if it is contemplated that the patient is to be discharged \200\224 pre ferably after senior medical consultation. Finally, remember that GPs are also under considerable pressure. Some situations may appear to re \202 ect the fact that a patient has been referred inappropriately or the patient m ay report that they have tried to contact their GP unsuccessfully. Rather than irately ring ing the practice and antagonizing them, inform the ED consultant who can raise this constru ctively and appropriately in a suitable environment. 11 TELEPHONE ADVICE Telephone advice Many departments receive calls from patients, parents, and other carers fo r advice. Approach these calls in exactly the same way as a face-to-face consultation. Form ally document details of the call, including: \200 Date and time of the call. \200 The caller \200\231s telephone number. \200 The caller \200\231s relationship to the patient. \200 The patient \200\231s name, age, and sex. \200 The nature of the problem. \200 The advice given. As with all notes, date, time, and sign these notes. NHS Direct In England and Wales NHS Direct provides a 24-hr, 7-day a week telephone service providing information and advice on health matters. It is staffed by nurses who respond ac cording to protocols. The telephone number for NHS Direct is 0845 4647. The equivalent service in Scotland is NHS24 tel. 08454 242424. These services have internet websites at www.nhsdirect.nhs.uk and www.nhs24.com Telephone advice calls from other health professionals Occasionally, other health professio nals request advice regarding the management of patients in their care. Such advice should be given by experienced ED staff. Telemedicine Increasingly, emergency health care is provided by integrated networks, which include EDs, minor injuries units, radiology departments, and GP surgeries connected by tel emedicine links. This has advantages in remote or rural settings, enabling a wide range of injuries and other emergencies to be diagnosed and treated locally. The combination of vide o and teleradiology may allow a decision to be made and explained directly to the patient. A typical example is whether a patient with an isolated Colles \200\231 fracture needs to h ave a manipulation of the fracture. Expertise is required to undertake telemedicine consult ations safely. This specialist advice should be given by senior ED staff, and careful docum entation is crucial. 12 CHAPTER 1 General approach Liaising with the ambulance crew Paramedics and ED staff have a close professional relation ship. Paramedics and ambulance staff are professionals who work in conditions that are ofte n dif \201 cult and sometimes dangerous. It is worth taking an off-duty day to accompany a crew during their shift to see the problems they face. A bene \201 t of paramedic training has been to bring ambulance staff into the ED to work with medical and nursing staff, and to foster the communication and rapport essential for g ood patient management. In the UK, a patient brought to an ED by ambulance will routinely have a patient report for m (PRF) (see Fig. 1.1 ). This is completed by the crew at the scene and in transit, and giv en to reception or nursing staff on arrival. The information on these forms can be invaluab le. In particular, the time intervals between the receipt of the 999 call, and arrival at t he scene and at hospital, provide a time framework within which changes in the patient \200 \231s clinical condition can be placed and interpreted. The initial at-scene assessment will include details of the use of seat belts, airbags, cra sh helmets, etc., and is particularly valuable when ampli \201 ed by speci \201 cally ask ing the crew about their interpretation of the event, likely speeds involved, types of vehi cle, etc. The clinical features of the Glasgow Coma Score (GCS) , pulse rate, blood pressure (BP), an d respiratory rate form baseline values from which trends and response to treatment can be judged. Useful aspects in the history/ comments section include previous complaints, curren t medications, etc., which the crew may have obtained from the patient, relatives, or frien ds. The PRF will also contain important information about oxygen, drugs, IV \202 uids adm inistered, and the response to these interventions. Before the crew leave the department, c on \201 rm that they have provided all relevant information. Do not be judgemental about the crew \200\231s performance. Remember the constraints under which they operate. Without the bene \201 ts of a warm environment, good lighting, and sop histicated equipment, it can be exceedingly dif \201 cult to make accurate assessments of illness or injury severity, or to perform otherwise simple tasks (eg airway management and intravenous (IV) cannulation). Do not dismiss the overall assessment of a patient made by an experienced crew. While the u ltimate diagnosis may not be clear (a situation which pertains equally in the ED), their ev aluation of the potential for life- threatening events is often extremely perceptive. Equal ly, take heed of their description of crash scenes. They will have seen far more than most ED staff, so accept their greater experience. Most ambulance staff are keen to obtain feedback, both about speci \201 c cases and genera l aspects of medical care. Like everyone, they are interested in their patients. A few word s as to what happened to Mrs Smith who was brought in last week and her subsequent clinical course is a friendly and easy way of providing informal feedback, and helps to cement the professional relationship between the ambulance service and the ED. 13 LIAISING WITH THE AMBULANCE CREW Fig. 1.1 An example of a patient reporting form. Reproduced with kind permission from the S cottish Ambulance Service. 14 CHAPTER 1 General approach Coping as a junior doctor Although many junior doctors coming to the ED have completed more than 12 months of work since quali \201 cation, the prospect of working at the \200\230s harp end \200\231 can be accompanied by trepidation. As with many potentially worrying situ ations in life, reality is not as terrifying as its anticipation. The number of hours worke d may not appear long in comparison with other posts, but do not assume that this makes an ED job \200\230easy \200\231. Being on duty inevitably involves much time standing, walkin g, working, thinking, and making decisions. It is unusual to come off-shift without feeling physically tired. Active young doctors can usually cope with these physical demands, but a demanding professi onal life and demanding social life are rarely compatible. Make the most of time off and tr y to relax from the pressures of the job. One function of relaxation is to enable you to fa ce work refreshed and invigorated. You are mistaken if you believe that you can stay out al l night and then work unimpaired the next day. Tired doctors make mistakes. They also tend to have less patience and, as a consequence, interpersonal con \202 icts are more likely. A greater problem is the mental aspect of the job. Doctors often \201 nd that the ED is t he \201 rst time in their careers when they have to make unequiv- ocal decisions based on their own assessment and investigations. This is one of the great challenges and excitemen ts of emergency medicine. It is also a worry. Decision-making is central to ED practice and , with experi- ence, the process becomes easier. Developing a structured approach can pre-e mpt many problems and simplify your life. After taking an appropriate history and completin g the relevant clinical examination of a patient, ask yourself a series of questions such a s: \200 Do I know what is likely to be wrong with this patient? \200 What investigation s are required to con \201 rm the diagnosis? \200 Do I know what treatment is needed and have I got the skills needed? \200 Does this patient require referral to an inpatient te am ( b p.8)? \200 If not, do they need to be reviewed in the ED or another specialist cli nic? The wide spectrum of problems with which ED patients can present means that no individ ual can be expert in every possible condition. It is therefore as important to recognize an d accept when you are out of your depth as it is to make decisions and treat patients whom you know you can manage. Seek help appropriately and do not just try to muddle through. Hel p may be readily available from senior ED staff, but in some departments direct contact wit h a specialist team is required. One of the most dif \201 cult situations is where a speci alist either refuses to come to see the patient or gives telephone advice that is clearly i nappropriate. You must always act as the patient \200\231s advocate. If you refer a patient with a fractured neck of femur, and the telephone message from the inpatient team is \200 \230bring him back to the Fracture Clinic in one week \200\231, it is clearly wrong to carr y this out. First, check that the doctor has understood the details of the patient \200\231 s condition and your concerns. More con \202 ict and aggravation is caused by communicatio n errors (usually involving second- hand telephone messages) than by anything else. If the situation remains unresolved, consult senior ED staff. Whatever happens, never lose your co ol in public and always put your patient \200\231s interests \201 rst. 15 COPING AS A JUNIOR DOCTOR Learning in the ED Try to learn something new every day. Keep a note of patients with inter esting or unusual problems, and later check what happened to them. Ask senior staff for adv ice. Use the ED reference books. Try to note all new conditions seen during a shift and rea d about them later. Staff interaction The nature of the job, the patients, and the diversity of staff involved means that a considerable degree of camaraderie exists. For an outsider, this can initially be daunting. Junior medical staff are likely to work for 4 \210\222 12 months in the depa rtment. Other staff may have spent a lifetime there with long-established friendships (or s ometimes animosities). Respect their position and experience, learn from them. The nub of this is an understanding that the role of one individual and that of other indiv iduals in the department are inextricably linked. Any junior (or senior) doctor who feels t hat they are the most important individual in their working environment will have an extrem ely uncomfortable professional existence. In the ED, every member of staff has a role. Your professionalism should dictate that you respect this. Only in this way will you gain recip rocal respect from other staff members. Never consider any job \200\230beneath you \200\231 or someone else \200\231s responsibili ty. Patients come before pride. So, if portering staff are rushed off their feet and you ar e unoccupied, wheel a patient to X-ray yourself \200\224 it will improve your standing wit h your colleagues and help the patient. Shifts Rule 1 Never be late for your shift. Rule 2 If, for whatever reason, you are unable to work a shift, let the senior staff in the ED know as soon as possible. Ensure that you take a break. Two or three short breaks in an 8-hr shift are better than on e long one. Remember to eat and maintain your \202 uid intake. Shift working may mean tha t you will work sometimes with familiar faces and perhaps occasionally with individuals wit h whom you \201 nd social contact uncomfortable. Put these considerations aside while you are at work, for the sake of the patients and your peace of mind. If you can \200\231t cope Finally, if you feel that you are unable to manage or that the pr essure of the job is too great \200\224 tell someone . Don \200\231t bottle it up, try to ignore it, or assume that it re \202 ects inadequacy. It doesn \200\231t. Everyone, at som e time, has feelings of inability to cope. Trying to disguise or deny the situation is unfa ir to yourself, your colleagues, and your patients. You need to tell someone and discuss th ings. Do it now. Talk to your consultant. If you cannot face him or her, talk to your GP or another senior member of staff \200\224 but talk to someone who can help you. The BMA Counseling Service for Doctors (tel: 08459 200169) provides a con \201 dential cou nseling service 24 hr a day, 365 days of the year to discuss personal, emotional, and work- related problems. The Doctors \200\231 Support Network ( www.dsn.org.uk ) and Doctors \200 \231 Support Line (tel: 0844 395 3010) are also useful resources. 16 CHAPTER 1 General approach Inappropriate attenders This is an emotive and ill-de \201 ned term. Depending upon the de partment, such patients could comprise 4 \200\22320 % of attendances. The perception as to whether it is appropriate to go to an ED or attend a GP will vary betw een the patient, GP, and ED staff. Appropriateness is not simply related to the symptoms, d iagnosis, or the time interval involved. It may not necessarily be related to the need for investigation. For example, not all patients who require an X-ray necessarily have to atten d an ED. Further blurring of \200\230appropriate \200\231 and \200\230inappropriate \200 \231 groups relates to the geographical location of the ED. In rural areas, GPs frequently perform procedures such as suturing. In urban areas, these arrangements are less common. Fo r ill-de \201 ned reasons, patients often perceive that they should only contact their GP during \200\230of \201 ce \200\231 hours, and outside these times may attend an ED with p rimary care complaints. It is clearly inappropriate to come to an ED simply because of a real or perceived dif \201 culty in accessing primary care. Nevertheless, the term \200\230inappropriate attenda nce \200\231 is a pejorative one \200\224 it is better to use the phrase \200\230primary care patients \200\231. It must be recognized that primary care problems are best dealed wi th by GPs. Many departments try to prevent this primary care workload presenting to the ED. Some departments tackle the problem by having GPs working alongside ED staff. Managing inappropriate attenders Only through a continual process of patient education will these problems be resolved. Initiatives include nurse practitioner minor injury units and hospital-based primary care services. Evaluations are underway but, to function effectively , such services require adequate funding and staf \201 ng. It can sometimes be dif \201 cult to deal with primary care problems in the ED. After an a ppropriate history and examination, it may be necessary to explain to patients that they wi ll have to attend their own GP. This may need direct contact between the ED and the practic e to facilitate this. Inappropriate referrals Sometimes, it may appear that another health professional (eg GP, e mergency nurse practitioner, nurse at NHS Direct) has referred a patient to the ED inapprop riately. Avoid making such judgements. Treat patients on their merits, but mention the issu e to your consultant. Remember that the information available to the referring clinician at the time of the prehospital consultation is likely to have been different to that availabl e at the time of ED attendance. 17 THE PATIENT WITH A LABEL The patient with a label Some patients will have been referred by another medical practitio ner, usually a GP. The accompanying letter may include a presumptive diagnosis. The details in the letter are often extremely helpful, but do not assume the diagnosis is necessarily correct. Take particular care with patients who re-attend following an earlier attendance. The situation may have changed since the previous doctor saw the patient. Clinical signs ma y have developed or regressed. The patient may have not given the referring doctor and ED s taff the same history. Do not pre-judge the problem: start with an open mind. Apply common sense, however. Keep any previous history in mind. For example, assume that a patient with a known abdominal aortic aneurysm who collapses with sudden, severe, abdominal pain, signs of hypovolaemic shock, and a tender pulsatile mass in the abdomen, to have a ruptured abdom inal aortic aneurysm, rather than intestinal obstruction. The patient \200\231s previous ED and hospital case notes are invaluable and will often give useful information and allow, f or example, ECG comparisons, aiding the diagnostic process. A call to the GP can also provi de useful background, which they may not have had time to include in their referral letter or may have excluded for con \201 dentiality or other reasons. Self-labeled patients Take care with patients who label themselves. Those with chronic or u nusual diseases often know signi \201 cantly more about their conditions than ED staff! In such situations, take special notice of comments and advice from the patient and/or their relatives. Do not resent this or see it as a professional affront \200\224 rapport with th e patient will increase markedly and management will usually be easier. Regular attenders Every ED has a group of \200\230regular \200\231 patients who , with tim e, become physically and sometimes emotionally attached to the department. Some have underl ying psychiatric illnesses, often with \200\230inadequate \200\231 personalities. Some are homeless. Regular attenders frequently use the ED as a source of primary care. As outlined above, make attempts to direct them to appropriate facilities, because the ED is unsuited to the management of chronic illness, and is unable to provide the continuing medical and n ursing support that these patients require. Repeated presentations with apparently trivial complaints or with the same complaint often tax the patience of ED staff. This is heightened if the presentations are provoked or aggra vated by alcohol intake. Remember, however, that these patients can and do suffer from the same acute events as everyone else. Keep an open mind, diagnostically and in attitude to th e patient. Just because he/she has returned for the third time in as many days complaining of chest pain, does not mean that on this occasion he does not have an acute MI! Maintain a dequate documentation for each attendance. Occasionally, especially with intractable re-att enders, a joint meeting between the social work team, GP, ED consultant and psychiatric ser vices is required to provide a de \201 nitive framework for both the patient and the medic al services. For some patients, it will be possible to follow a plan of action for ED prese ntations with a particular complaint. 18 CHAPTER 1 General approach The patient you dislike General approach Accept the patient as he or she is, regardless of behavior, class, religion, social lifestyle, or color. Given human nature, there will inevi tably be some patients whom you immediately dislike or \201 nd dif \201 cult. The feelin g is often mutual. Many factors that cause patients to present to the ED may aggravate the situation. These include their current medical condition, their past experiences in hospita ls, their social situation, and any concurrent use of alcohol and/or other drugs. Your appr oach and state of mind during the consultation play a major role. This will be in \202 uen ced by whether the department is busy, how much sleep you have had recently, and when you l ast had a break for coffee or food. Given the nature of ED workload and turnover, con \202 ict slows down the process and make s it more likely that you will make clinical errors. Many potential con \202 icts can be a voided by an open, pleasant approach. Introduce yourself politely to the patient. Use body language to reduce a potentially aggressive response. The patient \200\231s perspective Put yourself in the patient \200\231s position. Any patie nt marched up to by a doctor who has their hands on hips, a glaring expression, and the dem and \200\230Well, what \200\231s wrong with you now? \200\231 will retort aggressively. Defusing a volatile situation Most complaints and aggression occur when the department is b usy and waiting times are long. Patients understand the pressures medical and nursing staff have to work under, and a simple, \200\230I am sorry you have had to wait so long, but we have had a number of emergencies elsewhere in the department \200\231, does much to diffus e potential con \202 ict and will often mean that the patient starts to sympathize with yo u as a young, overworked practitioner! There is never any excuse for rude, abusive, or aggressive behavior to a patient. If you ar e rude, complaints will invariably follow and more importantly, the patient will not have r eceived the appropriate treatment for their condition. It may be necessary to hand care of a patient to a colleague if an unresolvable con \202 ict has arisen. Management of the vio lent patient is considered in detail on b p.610. 19 SPECIAL PATIENT GROUPS Special patient groups Attending the ED is dif \201 cult enough, but can be even more so f or certain \200\230special \200\231 patient groups. It is important that ED staff are sens itive to the needs of these groups and that there are systems in place to help them in what may be regarded as an intimidating atmosphere. The following list is far from exhaustive, but includes some important groups who require particular consideration: \200 Children : they are such an \200\230obvious \200\231 and large \200\230minority \200\231 group that they receive special attention to suit their particular needs (see b Pediatric emergencies, p.630). Pregnant women : see b Obstetrics and gynecology, p.563. \200 Those with mental health pr oblems : see b Psychiatry, p.601. \200 The elderly : who often have multiple medical prob lems and live in socially precarious circumstances. Patients with Alzheimer \200\231s disease and other states associated with chronic confusion. Those with learning dif \201 culties : b p.21. \200 Patients with hearing problems. \200 The visually impaired. \200 Those who do not speak or understand English : arrangem ents should be in place to enable the use of interpreters. Patients with certain cultural or religious beliefs (particularly amongst \200\230minority groups \200\231) : these can impact signi \201 cantly upon a variety of situations (eg af ter unsuccessful resuscitation for cardiac arrest \200\224 b Breaking bad news, p.24). Those who are homeless or are away from home, friends, and family (eg holiday makers). Those who have drug/alcohol dependency. Isn \200\231t everyone special? Taken at face value, the concept that certain groups of pat ients are \200\230special \200\231 and so require special attention does not meet with uni versal approval. There is a good argument that every patient deserves the best possible car e. Whilst this is true, it is also obvious that certain patients do have additional needs t hat need to be considered. Many of these additional needs relate to effective communication . There are some tremendous resources available that can help practitioners to overcome com munication dif \201 culties (eg www.communicationpeople.co.uk ). 20 CHAPTER 1 General approach Discharging the elderly patient There are no set predisposing factors that determine patien ts most at risk following discharge. Those that affect the chance of dif \201 culties at h ome include the current medical problem, underlying functional and social factors. Risk ind icators Multiple pathologies and atypical symptoms render this group more vulnerable to the physical, functional, and social effects of acute illness. Past medical history and pre-ad mission status are especially important determinants for patients with dementia or psychiat ric illness. There may be evidence of recently changed circumstances, a recent bereavement, a change in medical or physical condition, increasing confusion, or unusual behavior. The patient may not be able to afford adequate food or heating. Community services may not be a ware that support is needed or help may have been offered, but refused. Other important ind icators are: \200 Those living alone. \200 Absence of close family support or community services. \200 Unsuitable home circumstances (eg external or internal stairs). \200 Di f \201 culty with mobility. Determining those unable to cope Look for evidence of self-neg lect that suggests that the elderly person is having dif \201 culty coping at home (eg poo r personal hygiene, unclean or unsuitable clothing). Evidence of recent weight loss may sug gest dif \201 culties with food preparation or eating, unavailability of food, or may be d ue to serious pathology, such as a malignancy or tuberculosis. Signs of old bruising or oth er minor injuries may be consistent with frequent falls. Shortness of breath and any condit ion producing impaired mobility are important factors. Falls are a common problem of old ag e and require careful analysis, perhaps at a special \200\230Falls \200\231 clinic. Correc table factors include damaged walking aids, loose rugs, poor lighting, or unsuitable footwe ar or glasses. Common medical causes include cerebrovascular disease, arthritis, and side-e ffects of drugs. Many elderly people claim that they can cope at home when they are unable to do so. If in doubt, ask relatives, the GP, and community support agencies. They may give helpful insight into the patient \200\231s mental state, which can be investigated/assesse d further, whether it be a cognitive or reactive condition. The decision to discharge Hospital admission for an elderly person is a frightening experie nce and can lead to confusion and disorientation. If circumstances allow, discharge home is often a more appropriate outcome. If there are concerns regarding their functional ability and mobility, ask for an occupational therapy and/ or physiotherapy assessment with, if ap propriate, a home assessment. The elderly person is best seen in their home environment wit h familiar surroundings, especially if there is evidence of cognitive de \201 cit. The pro vision of equipment and recommendations for adaptations can be made at this point if requir ed. A wide range of community services including district nurse, health visitor, home help, crisis care, social work, hospital discharge, and rapid response therapy teams can be cont acted to provide immediate follow-up and support and play a crucial role in preventing late r breakdowns in home circumstances and unnecessary admissions for social reasons. 21 THE PATIENT WITH LEARNING DIFFICULTIES The patient with learning dif \201 culties Patients with learning dif \201 culties use th e healthcare system more than the general population. Unfortunately, many healthcare profes sionals have little experience with these patients. However, understanding common illness p atterns and using different techniques in communication can result in a successful consulta tion. Patients with learning dif \201 culties often have complex health needs. There are m any barriers to assessing health care, which may lead to later presentations of illness. Pa tients may have a high tolerance of pain \200\224 take this into consideration when examin ing them. Associated health problems Patients with learning dif \201 culties have a higher incidence of certain problems: \200 Visual and hearing impairment. \200 Poor dental health. \200 Swallowing problems. \200 Gastro-oesophageal re \202 ux disease. \200 Constipati on. \200 Urinary tract and other infections. \200 Epilepsy. \200 Mental health proble ms ( i incidence of depression, anxiety disorders, schizophrenia, delirium, and dementia), with speci \201 c syndromes having their own particular associations (eg Down \200\231s is associated with depression and dementia; Prader \200\223Willi with affective psychosis). Behavioral problems (eg Prader \200\223Willi, Angelman syndrome). Leading causes of death T hese include pneumonia (relating to re \202 ux, aspiration, swallowing, and feeding proble ms) and congenital heart disease. The patient \200\231s perspective Past experiences of hospital are likely to have a big imp act on the patient \200\231s reaction to his/her current situation. Most patients have prob lems with expression, comprehension, and social communication. They \201 nd it dif \201 cult to describe symptoms \200\224 behavioral change may the best indication that somethin g is wrong. Tips for communication \200 Explain the consultation process before starting. \200 Spea k \201 rst to the patient, then to the carer. \200 Use open questions, then re-phrase t o check again. \200 Aim to use language that the patient understands, modifying this according to comprehension. Patients may have dif \201 culties with time, so try to relate symptoms to real life temporal events (eg \200\230did the pain start before lunch? \200\231)