Emergency Department Administration, Disaster Medicine and Prehospital Care
What the board tests
Operational judgement: triage accuracy, flow metrics, mass-casualty response, scene safety and the interface between prehospital and hospital teams.
Flow and administration
- Five-level triage (Emergency Severity Index) assigns resources as well as urgency; a level 1 needs immediate resuscitation.
- Key metrics: door-to-physician time, length of stay, left without being seen rate, ED occupancy and boarding time. Access block from admitted patients boarding in the ED is the dominant driver of crowding.
- Observation units shorten stay for chest pain, syncope and low-risk GI bleeding. Incident reporting should be non-punitive and separated from disciplinary processes.
- Design shifts and staffing against arrival patterns, not averages; monitor burnout.
Disaster and mass casualty
- Scene safety and triage precede treatment. Use START in adults: move the walking wounded first, then assess breathing, perfusion and mental status, assigning green, yellow, red and black categories.
- Overtriage consumes the resources needed by the salvageable; undertriage kills. Re-triage at each transfer point.
- Decontamination before entry for chemical exposure; personal protective equipment and an isolation zone for contaminated casualties.
- Surge capacity involves staff, stuff, space and systems; the hospital incident command system coordinates them.
Prehospital care
- Dispatch and response times, basic versus advanced life support scope, and destination selection by capability (trauma centre, PCI centre, stroke unit).
- Selective spinal immobilisation, early tourniquet for exsanguinating limb injury, and feedback CPR.
- Handover should use a structured format (ATMIST or SBAR) and include mechanism, vital signs trend and treatment given.
Worked example
A bus crash produces 20 casualties at a scene 15 km from hospital. First responders secure the scene, then apply START: the walking wounded are tagged green and moved to a collection point; those not breathing after airway repositioning are tagged black; a patient with respiratory rate 8 and no radial pulse is tagged red and evacuated first. Reasoning: in mass casualty, life-saving treatment at the scene is limited to airway and haemorrhage control, and transport priority follows triage category.
Traps
Treating before triage at a mass-casualty scene; over-triaging the worried well; allowing contaminated casualties into the department; using averages rather than peak arrival patterns to plan staffing; unstructured handover that omits vital sign trends.