Your patients are at risk after triage — wait times are unsafe for 59%
Dangerous delays are commonplace in the ED
You're worried about the patient standing in front of you, but you can clearly see that not only the patient care areas but also the waiting room is completely packed. How do you protect this person from deteriorating during a possible long wait?
The percentage of emergent patients who saw a physician within the recommended 14 minutes declined to 48% in 2006 from 59% in 1997, according to a study.1 Yale University researchers analyzed a nationally representative sample of 151,999 ED visits from 1997 to 2006 from the National Hospital Ambulatory and Medical Care Survey, conducted by the Centers for Disease Control and Prevention.
"Triage nurses hold a huge responsibility for larger patient volume in overflowing waiting rooms," says Bobbie Brothers, RN, BSN, an ED nurse at University of California — San Diego (UCSD) Thornton Hospital. "As the U.S. economy has plunged, more and more people are finding themselves out of work and without insurance, therefore making the ED their primary or only source of health care."
Patients are waiting longer to present and, therefore, are much sicker in many cases. "This means the triage nurse must continuously reassess patients in the waiting room and consult with the physician and charge nurses on the patients' status," says Brothers.
Dangerous delays might occur, even for patients who need be seen immediately, says Gabe Campos, RN, MSN, CEN, clinical nurse educator for the ED at The University of Chicago Medical Center. "If all the beds in the ED are occupied, and you receive someone who needs to be seen immediately, you then have to either move someone out of a room or find somewhere to place your new patient," says Campos. "This can take minutes." To avoid adverse outcomes in patients waiting to be seen, consider the following:
• Use triage protocols.
At UCSD Thornton, triage protocols are used "to ensure sick patients don't fall through the cracks," says Brothers. Triage nurses obtain EKGs for all patients with a potential cardiac issue or abdominal pain above the umbilicus for patients older than 40 years old, and they order chest X-rays for patients with suspected pneumonia and extremities fractures.
"We have implemented very clear guidelines and protocols for patients presenting with cardiac, abdominal, and pneumonia signs and symptoms," says Brothers. "Problematic diagnoses are being identified earlier."
In a single month, three "walk-in" ST-elevation myocardial infarctions were identified by ED nurses. "Activating the cath lab within minutes of arrival to the ED saved cardiac muscle and possibly even their life," says Brothers. "We even changed the layout of the triage room, to include a cardiac chair to perform EKGs, and purchased an additional EKG machine for use in triage."
• Constantly scan the waiting room.
"Each time the nurses open the door to bring back the next patient for triage, they must visually scan the waiting room, assessing for changes in patient status," says Brothers. Patients with any sign of declining status or abnormal findings are brought back to triage and reassessed at least every two hours.
"Red flags can be obvious, such as increased pain, decreased level of consciousness, and changes in vital signs. They can also be subtle: changes in the tone of voice, a change in posture, or changes in skin color or moisture," says Brothers. "The triage nurse must constantly listen to his or her gut instincts at all times."
• Be especially careful with patients at greatest risk.
Keep a close eye on patients with subtle symptoms and quiet patients who might be minimizing their condition. "Use your intuition and experience to obtain the entire story for their presentation," says Brothers. "Be persistent. You may need to reword or rephrase questions differently in order to obtain a thorough and accurate history."
An elderly woman seen at UCSD Thornton's ED complained of a headache that began that morning, but she said little else. "The nurse continued to probe to get more information, since the patient was just answering with brief explanations," says Brothers. The patient denied any recent injury or trauma, but when asked directly if she had fallen or hit her head, stated, "I did fall last night, but I was OK." After further probing about medications, it was determined that the patient was on aspirin therapy.
"The patient was taken directly to a room because the triage nurse was concerned for a potential head bleed, which in fact the patient did have," says Brothers.
Reference
- Horwitz L, Bradley EH. Percentage of US emergency department patients seen within the recommended triage time: 1997 to 2006. Arch Intern Med 2009; 169:1,857-1,865.
Sources
For more information on long wait times after triage, contact:
- Bobbie Brothers, RN, BSN, Emergency Department, University of California — San Diego Thornton Hospital. Phone: (858) 657-7600. E-mail: [email protected].
- Gabe Campos, RN, MSN, CEN, Clinical Nurse Educator, Emergency Department, The University of Chicago Medical Center. Phone: (773) 702-1927. Fax: (773) 702-2837. E-mail: gabriel. [email protected].
Tell patients to let you know if they worsen Give them specific instructions "You definitely need to instill in the patient the need to let the triage nurse or someone else know if their condition is worsening," says Gabe Campos, RN, MSN, CEN, clinical nurse educator for the ED at The University of Chicago Medical Center. "Upon reassessment, if the patient's condition has deteriorated, then their triage acuity score should be updated." Campos recommends telling patients exactly what to look for. For example, if you gave acetaminophen to a child with a fever, tell the parents to return in an hour so you can recheck the temperature. If you give ibuprofen to patients with extremity pain, tell them to come back in one hour so you can reassess their pain. At the University of California — San Diego (UCSD) Thornton Hospital, ED nurses use a standing script to tell each patient at triage that if he or she begins to feel worse or anything changes, to let the nurse know immediately, says Bobbie Brothers, RN, BSN, ED nurse. If at any time a patient appears to have a change in status after triage, they are reassessed immediately. If any patient waits longer than two hours, they are brought back to the triage room, reassessed, and vital signs are retaken. Recently, ED nurses cared for a middle-aged diabetic man who stated he was not sure if he took the wrong doses for his short- and long-acting insulins. The patient's blood glucose and vital signs were all normal. He was alert and oriented and said he was feeling fine. Thirty minutes later, however, the triage nurse was doing a visual scan of the waiting room when she went to bring back another patient. She noticed that the man was looking diaphoretic, and she brought him to a hallway bed for a thorough assessment. "His blood sugar was rechecked," says Brothers. "He was now hypoglycemic, and he required rapid interventions." |
Do a 'roll check' in the waiting room When your ED is crowded, walk out to the waiting area to ask if everyone has been signed in or has been triaged. This "roll check" can ensure that you haven't missed anyone who has arrived to your ED for evaluation, says Gabe Campos, RN, MSN, CEN, clinical nurse educator for the ED at the University of Chicago Medical Center. "When several people walk in at the same time, some will let you know they are there to be seen. Others may sit down in the waiting area," says Campos. "Unless you inquire, someone may be overlooked." Have nurses walk around answering questions or calling out simple instructions to be sure everyone in the waiting room is accounted for, she suggests. "Rounding helps ensure people are still present and there are no acute changes in their condition," says Campos. "If there is private information to be shared, having a second triage room or another private area to talk to the patient is ideal." |
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