Novel ways to improve triage of elderly patients
Automatically give patients higher acuity
Triage often is extra challenging with elderly patients, says Korene Christianson, RN, CEN, ED clinical director at Methodist North Hospital in Memphis, TN. "We are seeing a growing number of patients over the age of 65 in our ED," she says. "Finding out the 'main reason they came today' is often the biggest challenge."
To improve triage of geriatric patients, do the following:
• Put patients right into a room.
An "immediate bedding" practice implemented in Methodist's ED has significantly reduced wait times for elderly patients, says Christianson. "Medical screening can be completed quickly, and the chance of a fall or incident in the lobby is gone," she says.
Now, if there is a bed open, a patient does not stop in triage. Marianne Fournie, RN, BSN, MBA, corporate director of system ED services for Memphis-based Methodist Healthcare, said, "We even pulled the triage nurse from 3 a.m. to 9 a.m. in most of our facilities. This practice helps keep a constant flow in triage and prevents back up after 10 a.m. You can stay ahead of the game, which allows the patient to be seen by a provider sooner. This decreases your risk and could save lives."
Either registration or security representatives escort the patients into the department, and ED nurses place them directly into a room. If delays in triage do occur, charge nurses, who usually do not have a patient assignment, can help until every patient is seen, says Fournie.
"The charge nurse can perform a brief triage by just speaking with the patient and documenting on paper," she says. "We want to make sure that the patient at the 'end of the line' isn't a seriously ill patient such as a chest pain patient."
• Address needs of hearing-impaired patients.
If the ED is full and your elderly patient is alone, patients who are hard of hearing may not hear their names re-called for rechecks, adds Christianson.
To address this, use restaurant pagers for patients in the waiting room, says Fournie. "They vibrate and they light up, so missing someone calling out your name is not a problem. This would be a perfect solution for anyone who has a hearing deficit," she says.
• Automatically increase acuity levels.
When triaging an elderly trauma patient, take increased risk of mortality into account, says Ann Bennett, RN, MSN, nurse educator for the ED at University of California — Davis Medical Center. "If a patient arrives with a critical trauma and is over 65, we increase the level of acuity based on age alone," she says.
The patient's age also is considered during the medical screening examination that is performed on all patients, says Bennett. Older patients have decreased resistance to infection, limited chest expansion, changes in ability to sense pain, and depressed temperature-regulating mechanisms, says Bennett.
"The elderly cannot compensate under stress, like children can," says Bennett. "Blood pressure medications may mask hypotension. Beta-blockers may keep tachycardia at bay until late in the compensation process."
• Keep medication issues in mind.
Elderly patients are at risk for drug interactions, irregular compliance, misunderstanding of directions, and liver and kidney changes that alter absorption rates, says Bennett.
"Many of the problems elder patients come in with are related to the polypharmacy they are taking, or they may not be taking medications as prescribed," she says. "When taking multiple drugs, drug reactions, interactions, and side effects can mask serious problems."
• Remember that patients may downplay symptoms.
Geriatric patients may minimize symptoms such as chest pain or abdominal pain, says Bennett.
"This could be a simple gastroenteritis, a cardiac event, abdominal aneurysm, or some other surgical emergency," she says. "General shortness of breath may be a full-blown pneumonia."
• Consider chronic problems, which can complicate even minor complaints.
Geriatric patients often put off coming to the ED until their reserves already are used up, which can be a dangerous situation, says Bennett. "The patients delay seeking care because of fear, lack of transportation, or they chalk aches and pains up to old age," she says.
Chronic conditions may override new, smaller symptoms such as a cough that escalates into pneumonia or the headache that is really a bleed, says Bennett.
Ask these questions at triage to ferret out potentially life-threatening conditions:
— How is the pain different from your usual pain? What is different today about your pain/cough/dizziness?
— Has this ever happened before, or have you ever felt like this before?
— Are you actually taking all the medications your doctor prescribed? How/when are you taking them?
"Getting a detailed, focused exam about the chief complaint is important for all patients. But with geriatric patients, the extraneous information is almost equally important," says Bennett. "Ask about chronic diseases, medications, allergies, past medical, and surgical history."
Sources
For more information on triage of elderly patients, contact:
- Ann Bennett, RN, MSN, Nurse Educator, Emergency Department, University of California — Davis Medical Center. Phone: (916) 734-5247. E-mail: [email protected].
- Korene Christianson, RN, CEN, Clinical Director, Emergency Department, Methodist North Hospital, Memphis, TN. Phone: (901) 516-5214. E-mail: [email protected].
- Marianne Fournie, RN, BSN, MBA, Corporate Director, System ED Services, Methodist Healthcare, Memphis, TN. Phone: (901) 516-2357. Fax: (901) 516-2676. E-mail: [email protected].
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