Don't allow 'stable' elders to deteriorate during long waits
Potential for catastrophe is 'very high'
General malaise is the only complaint of a 77-year-old man and, other than a low-grade fever, his vital signs are within normal limits. But while waiting to be seen, he becomes mildly disoriented, tachycardic, and hypotensive, and he is diagnosed with urosepsis. If the changes in this patient's status go unnoticed, he could suffer circulatory collapse.
This is just one example of how an elderly patient suddenly can deteriorate in your crowded ED waiting room. The rate of ED visits by elderly patients increased 26% from 1993 through 2003, and those patients use the most resources and stay the longest, says a new study. The researchers conclude that ED visits by patients between 65 and 74 years of age could nearly double from 6.4 million in 2003 to 11.7 million by 2013.1
"Nursing ratios in the ED are not the same as on the floor, and patients are a lot less comfortable, too," says Mary Pat McKay, MD, one of the study's authors and associate professor of emergency medicine at the George Washington University Medical Center in Washington, DC. "The potential for a catastrophe is very high."
Patients older than 65 are more likely to get admitted than other patients (33% vs. 14% overall), and they often are boarded in the ED for hours or even days, says McKay. "This clogs up the system and puts all patients in danger," she says. "They wait unattended for hours in the waiting room, and some of them get tired of waiting and leave without any care."
Elderly patients are an increasing challenge for ED nurses at Emory University Hospital in Atlanta, says Sam Shartar, RN, CEN, ED nurse manager. "This group of patients is growing in numbers, which adds stress to the ED's resources," he says.
Burden is on triage
The burden placed on the triage nurse when the waiting room is full is tremendous, says Margaret Miller, RN, an ED nurse at Swedish Medical Center in Seattle. "You are responsible for looking after not only the new patients entering the department, but also all of the other patients who continue to wait — a potentially unsafe situation, to say the least."
To avoid sudden deterioration of elderly patients, do the following:
• Reassess frequently.
Elderly patients have more comorbid diseases and require a more complicated work-up, says Shartar. "They are susceptible to sepsis and pneumonia," he says. "In both of these cases, the patient can present in triage with stable vital signs and subsequently deteriorate later during their visit," Shartar says.
Reassess vital signs, mental status, hydration, and functional ability to identify trends and changes in the patient's condition, says Shartar.
Hypovolemia is one condition that can change rapidly in your elderly patient, says Miller. "A younger person's cardiovascular system is usually pretty intact and can maintain a tolerable blood pressure for a longer period of time than the elderly patient with heart problems or peripheral vascular disease," she says.
When reassessing, look for changes in blood pressure, pulse, and respirations and speech, says Miller. "Depending on the patient's condition at initial triage, they should have vital signs taken at least every hour that they spend in the waiting room," she says.
Work closely with the charge nurse or the nurse determining placement of patients in ED rooms to move less ill patients to the hallway or holding area, advises Miller. "This can help expedite treatment of the patient whose condition is deteriorating in the waiting room," she says.
• Have a high index of suspicion.
If an elderly patient reports dizziness or weakness with no history of cardiac problems, for example, this is a situation that can deteriorate quickly. "If a quick look at the patient in triage doesn't tell the story, an ECG or cardiac monitor will tell," says Miller.
When taking the patient's vital signs, look at the heart rate, whether the rhythm is regular; and whether the pulse is bounding, full, weak, or thready; and correlate this with blood pressure, respiratory rate, and effort, says Miller. If the triage nurse has any concern due to irregularities with the patient's vital signs, he or she needs to have the patient placed on a cardiac monitor and have an ECG taken promptly to be reviewed by the ED physician, she says.
Use critical thinking along with your assessment to determine the severity of the elderly patient's illness, says Miller. "The acuity level for the elderly patient with fever is usually higher due to age and the knowledge that the patient can deteriorate rapidly," she adds.
If fever is present, suspect pneumonia or urinary tract infections that can progress to pyelonephritis and sepsis, says Miller. "These patients have a faster recovery rate when treated quickly with antibiotics," she says.
• Use observation to assess severity of symptoms.
"Elderly patients also tend to downplay their symptoms, so you may need to observe them a little more closely," says Shartar. For example, your patient may deny that they are having difficulty breathing, yet as you observe them, they are tachypneic and demonstrate increased work of breath, he says.
Body positioning, skin color, capillary refill, the manner in which patients answer questions, and whether they have an inability to look directly at you all play a part in your assessment, says Miller. For example, the patient may give a low pain scale number that doesn't coincide with their body language, says Miller. "In this case, probe further with different questions and correlate the physical assessment findings with what the patient is saying," she advises. "Decide if your findings warrant moving the patient's acuity level higher."
When asking patients about their current illness, their answers may be vague and incomplete, says Miller. "Ask patients if they have ever had anything like this before. Listen to what the family member or friend that comes in with the patient has to say. Do they contradict the patient's story? Do they give you more information than the patient?"
• Remember that patients may have multiple problems.
Because many older patients wait longer than they should to seek medical care, by the time they do reach the ED, they have "multisystem" problems going on, says Miller. These may include hypertension, cardiac problems, hypertension, renal problems, diabetes, vascular insufficiency, and stroke, she says.
• Don't assume that others will alert you.
Elderly patients often come to the ED accompanied by family, friends, neighbors, or care workers, notes Miller. "This can give you some comfort knowing that if the patient turns for the worse, someone will make the triage nurse aware," she says. "But this 'comfort' also can work like a trap."
Many elderly patients don't want to appear "pushy," says Miller. "Before the patient leaves the triage booth, tell them or anyone with them to let the triage nurse know if their condition changes," she advises.
Reference
- Roberts DC, McKay MP, Shaffer A. Increasing rates of emergency department visits for elderly patients in the United States, 1993 to 2003. Ann Emerg Med; in press.
Sources
For more information on care of elderly patients in the ED, contact:
- Mary Pat McKay, MD, MPH, Associate Professor, Emergency Medicine and Public Health, The George Washington University Medical Center, Washington, DC. Phone: (202) 741-2947. Fax: (202) 741-2921. E-mail: [email protected].
- Margaret Miller, RN, Emergency Department — First Hill Campus, Swedish Medical Center, Seattle. Phone: (206) 215-2583. E-mail: [email protected].
- Sam Shartar, RN, CEN, Nurse Manager, Emergency Department, Emory University Hospital, Atlanta. Phone: (404) 712-7576. E-mail: [email protected].
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