Don't take your eyes off high-risk patients: ID sudden deterioration
Keep every patient in full view
(Editor's Note: This is a two-part series on keeping patients safe during lengthy waits in the ED. This month, we give practices to avoid missing a patient's deterioration in waiting areas, how to enlist the help of others in visualizing patients, and what to tell family members to watch for. Next month, we'll report on how to avoid blocked views of patients and which patients are at particularly high risk for sudden deterioration.)
It is an all-too familiar news headline: A patient was left unattended for hours in an ED and died of a life-threatening emergency before anyone noticed.
As an ED nurse, you know that there is undoubtedly more to the story than meets the eye, but the fact remains that a patient's deteriorating condition was not acted on in time. Presumably, no one saw it occurring.
"All patients that are in the triage area awaiting evaluation need to be kept within sight of the nurse," says John Provost, an ED nurse at St. Joseph's Hospital and Medical Center in Phoenix, AZ. "They felt the need to come to the emergency department. It is the nurse's duty to take that seriously."
ED patients are waiting longer than any time since reports were first made available in 2002, according to Press Ganey's 2010 Emergency Department Pulse Report: Patient Perspectives on American Health Care. The average wait time in 2009 was four hours and seven minutes 31 minutes more than in 2002.
"Across the country, wait times are routinely hours," says Cassondra Richard, RN, CEN, an ED nurse at Oregon Health and Science University in Portland. "In our department, we have experienced wait times up to eight hours to be seen."
Perform visual checks
Despite your best efforts, you might not immediately notice a patient's worsening condition. For this reason, triage technicians, registration representatives, security, and hospital volunteers all act as "eyes and ears" for triage nurses at Huntsville (AL) Hospital. (See related stories on enlisting the help of others in visualizing patients, and what to tell family members to watch for, below)
"They can assist by sitting with the patient, or notifying the triage nurses if a patient falls, begins to seize, is actively vomiting, slumps over in a chair, or just doesn't appear well," says LaGina May, RN, an ED nurse and triage coordinator at Huntsville Hospital. "I believe the use of ancillary staff is essential in the waiting room. No, they are not nurses, but they can notify the nurses that the patients need reassessment."
ED nurses also notify all personnel in the triage area about particular patients they're concerned about. "We identify those patients who present the greatest potential for a dangerous situation to erupt and monitor them closely," says May.
At Huntsville's ED, a "front desk nurse" is responsible for performing a visual check on patients. "Not only does the front desk nurse visualize the new patients signing in, but also those who have been triaged and are awaiting bed placement," says May.
At Christiana Care Health System in New Castle, DE, rotating waiting room checks are done every 15 to 30 minutes by ED nurses, technicians, or at times, even clerical staff. "The staff would make a walking round in the waiting room and address any concerns that come to their attention," says Karen Toulson, RN, MSN, CEN, NE-BC, ED nurse manager.
Continuous monitoring
At St. Joseph's Regional Medical Center's ED in Paterson, NJ, the first person patients see is a registration official who is "strategically seated to have full view of the waiting area," says Ramazan Bahar, RN, MSW, LSW, ED geriatric program coordinator.
Bahar adds that all waiting patients are visited by a patient care liaison periodically. "The liaison holds a roster of patients in the waiting area and makes rounds to identify any needs patients may have during their wait," he says. That person also alerts the triage nurse or charge nurse in the event of an emergency or change in status.
In between the patient care liaison's rounds, patients are continuously monitored by a security camera. "This is in view of the triage nurse, who also makes rounds in the waiting room," says Bahar.
A patient who doesn't hear his or her name called could potentially be overlooked in a crowded waiting area. In this case, ED nurses might mistakenly assume the patient left without being seen. "In order to make sure patients hear their names called while in the waiting room, the ED uses an overhead loud speaker system to call patients to the treatment area," says Bahar.
To avoid missing a patient's deterioration, imagine the worst case scenario that can happen when he or she goes to the waiting room. Mairead O'Regan, RN, an emergency nurse and administrative director of logistics at Newark (NJ) Beth Israel Medical Center, says, "For instance, what if a postictal seizes again? What if a dialysis patient codes from an unstable potassium level? What if an elderly patient has a syncopal episode and hits his head on the waiting room floor?"
Remember that your ED patient might not share all of the pertinent information needed to make an appropriate triage decision with you. Toulson says, "Patients may omit signs and symptoms, past medical history, or other relevant information due to stress, anxiety, or pain."
Sources
For more information on keeping patients in view during long waits:
- Ramazan Bahar, RN, MSW, LSW, Emergency Department, St. Joseph's Regional Medical Center in Paterson, NJ. Phone: (973) 754-2228. E-mail: [email protected].
- LaGina May, RN, Emergency Department, Huntsville (AL) Hospital. E-mail: [email protected].
- Mairead O'Regan, RN, Emergency Department, Newark (NJ) Beth Israel Medical Center. Phone: (973) 926-7288. E-mail: [email protected].
- Cassondra Richard, RN, CEN, Emergency Department, Oregon Health and Science University, Portland. E-mail: [email protected].
- Karen Toulson, RN, MSN, CEN, NE-BC, Emergency Department, Christiana Care Health System, New Castle, DE. Phone: (302) 733-1629. E-mail: [email protected].
Get others on your 'team' to view patients While waiting, any ED patient's condition might deteriorate, even those who you don't expect to. "Patients with medically complex histories can be unpredictable at times, even with a minor complaint," says Cassondra Richard, RN, CEN, an ED nurse at Oregon Health and Science University in Portland. Richard gives the example of a low-acuity patient with a wound infection, who is also diabetic. That patient could experience a drop in blood sugar that would require intervention if forced to wait for an extended time. "A patient may come in feeling weak and not know why, yet it could be an internal bleed," says John Provost, an ED nurse at St. Joseph's Hospital and Medical Center in Phoenix. "A patient may come in feeling short of breath, and it may be a myocardial infarction." To enlist the help of other ED staff in visualizing all waiting patients: Have a person stationed in the waiting room with emergency medical technician (EMT) and security skills. Karen Toulson, RN, MSN, CEN, NE-BC, ED nurse manager at Christiana Care Health System in New Castle, DE, says, "This person would have the background to recognize changes in patients that are in the waiting room and bring it to the triage nurse's attention. Patients will also have a staff member to approach should they begin to feel worse or experience different symptoms." Give all staff the responsibility to be your "eyes and ears." Mairead O'Regan, RN, an emergency nurse and administrative director of logistics at Newark (NJ) Beth Israel Medical Center, says, "Any patients who present as high-risk should be on the radar of every ED staff member. Every effort should be made to bring this patient in, and every effort should be made to keep this patient near the triage area." The ED has trained security officers stationed in the waiting room. "They are constantly scanning patients and visitors alike for changes in body language," says O'Regan. "How quickly the clinical staff respond to an employee's report of an escalation will make the difference in how quickly a situation can be deescalated." Regardless of an individual's role in the ED, he or she can interact with patients and report concerns to you, says Toulson. Provost says, "Ask for help, and offer up knowledge you have learned as a nurse to your team members. The more people that you can place on your team, the more likely it is that you will not find yourself in a bad situation." If something is brought to your attention, take it seriously. According to some news stories, other patients have alerted emergency nurses about a dying patient's need for help in ED waiting rooms, but they were ignored by staff. Toulson says, "Issues may be brought to you by other levels of staff, or even family members of patients that are in the waiting room." If the patient came with family or friends, you already have members on your "team" who are closely watching the patient, says Provost. "If they come to you concerned, listen to the complaints." |
Give family specific symptoms to look for You probably routinely tell family members to let you know if the patient is getting worse. Why not go a step further and tell them exactly what worsening symptoms to watch for that are relevant to the patient's outcome? With a head injury patient, for example, tell the family to watch for nausea, vomiting, visual changes, and loss of consciousness, says Tarah Grooms, RN, ED director at Methodist Richardson (TX) Medical Center. "A child with history of asthma that presents with wheezing is a [common] case for the triage nurse to pay close attention to," says Grooms. "A pediatric patient compensates very well until they get tired and crash." The pediatric patient might present with normal respiratory rate, heart rate, and oxygen saturation, and does not go straight back due to lack of open beds. In this case, says Grooms, tell the family to watch for an increase in respirations, nasal flaring, blue or gray color around lips, abdominal breathing, inability to speak in full sentences or unable to drink from a bottle, and increasing irritability. "Another example would be a patient that presents with a laceration with bleeding controlled by the triage nurse by pressure dressing," says Grooms. "The family needs to be instructed to inform the nurse of change in color of extremity, reoccurring bleeding, and loss of sensation of extremity." |
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