Are patients with life-threatening conditions in your waiting room?
Are patients with life-threatening conditions in your waiting room?
Lack of reassessment, increasing delays are dangerous combination
A man with a mild stomachache, a woman reporting neck pain days after a motor vehicle accident, and a teenager with an ankle injury. Would these patients be triaged as low acuity and sent to your ED’s waiting room?
What if an hour later it became apparent that these patients had a perforated ulcer, spinal injury, and potential loss of limb?
If you don’t reassess patients kept waiting, conditions can become life-threatening, especially if delays are long, warns Kathleen Emde, RN, MN, CEN, clinical services manager at Swedish Medical Center in Issaquah, WA. "Most EDs triage patients just once, then send the patient to the waiting room where they sit until their name is called, which can be hours later," Emde says. "There are no repeat vital signs, no rechecks, no reevaluation at all usually."
When a patient simply says something "doesn’t feel right" or downplays their pain score or symptoms, they probably will be placed in the waiting room if no treatment rooms are available, says Lori Pelham, RN, ED clinical nursing supervisor at University of Michigan in Ann Arbor. "If there is no one assigned to reassess this patient and they remain in the waiting room for hours, the potential for the patient’s condition to decline is great if they are indeed experiencing a medical emergency," she says.
If a patient isn’t reassessed and an adverse outcome occurs as a result, the triage nurse could be held liable in a malpractice lawsuit, warns Kathryn Eberhart, BSN, RN, CEN, a Santa Rosa, CA-based legal nurse consultant and ED nurse at Santa Rosa Memorial Hospital. "With overcrowding in EDs and fewer available resources, anything could happen," Eberhart says. "A patient with a subacute illness could potentially turn into an acute illness with a bad outcome if they wait too long."
To make sure patients are reassessed, do the following:
• Check in with patients regularly.
"It has to be part of the ED’s culture that repeat assessments will be done when waits are lengthy, or it won’t happen," says Emde. This repeat assessment could mean obtaining repeat vital signs, asking patients if pain has increased, or refilling ice bags, she adds.
Frequency of reassessment depends on the patient’s condition, presenting complaint, and comorbidities, says Emde. "We don’t even have a thorough baseline assessment documented when they are waiting, as most triage exams are very superficial," she says. "The patient’s true issues are really as yet unknown."
If a five-scale triage system is used, a patient with an acuity level of three should be reassessed every one to two hours depending on the complaint, advises Eberhart. "If a patient with an acuity of four to five waits for four hours, they should be reassessed for any change in symptoms," she says.
Liability risks increase when the triage nurse is overwhelmed and there is no available space in the ED, says Eberhart. "In this scenario, the triage nurse needs to inform the charge nurse of the situation, and an additional nurse should be available to reassess patients who are in the waiting room for an extended period of time," she says.
Document any action that you perform during reassessment, including obtaining vital signs and pain scores, providing comfort measures, giving medications, or providing education, says Pelham.
• Ask patients to report changes in symptoms.
To reduce liability risks, tell all patients to report worsening symptoms to the triage nurse, and document this in the patient’s chart, recommends Barbara J. Levin, BSN, RN, ONC, LNCC, president of the Chicago-based American Association of Legal Nurse Consultants. She suggests posting a sign in the ED stating "Contact a nurse immediately if your symptoms are getting worse."
• Perform procedures while patients are waiting.
At Deaconess Hospital’s ED in Evansville, IN, a "quick triage" process is used to obtain the patient’s name, complaint, full set of vital signs, allergies, and pain level assessment. If no treatment rooms are available, the patient is sent to "quick registration" that generates a patient number. Laboratory tests, an electrocardiogram, or X-rays are started as needed while the patient is waiting.
When the patient is called back for these procedures, it gives the nurse an opportunity to recheck vital signs as needed, says Melissa Brooks, RN, BSN, an ED nurse at Deaconess. "It is up to the triage nurse to use their discretion on whether a room must be found for that patient or if he or she can sit in the waiting room for a while longer," she says. "This process has helped our leave without being seen’ numbers go down because the patient doesn’t feel like we have forgotten them out in the waiting room."
• Have a specific nurse do reassessments.
At University of Michigan’s ED, a "waiting room" nurse documents hourly reassessment of patients from 11 a.m. to 3 a.m., which includes checking lab results and starting standing orders. "A nurse cannot work in this assignment until they have been with our department for six months and completed our triage course," says Pelham.
The reassessment may be as simple as comforting the patient, or it may involve taking a full set of vital signs including pain score or obtaining oral pain medications, says Pelham. "If the patient needs to be placed in a treatment room, the nurse works with the charge nurse to make this happen. The nurse will make the decision based on the chief complaint and pain score obtained on arrival and during the triage process."
If blood work or lab results come back abnormal, the waiting room nurse speeds intervention as needed, says Pelham. For example, a patient may complain of abdominal pain with a pain score of 5 and normal vital signs, but blood work reveals an extremely elevated white blood cell count. "Upon reassessment, the nurse finds the temperature has become elevated and the pain is increasing," says Pelham. "The potential for this patient to become sicker is great, and the priority level has changed."
Because patients have ongoing contact with the waiting room nurse during reassessments, they are less likely to leave without treatment, adds Pelham. "We all know that it is impossible to give an accurate time answer to a waiting patient due to the nature of our business, but letting patients and family members know they have not been forgotten is essential," she says.
Elderly patients often report multiple complaints without much specificity, says Pelham. "They may be very stoic and willing to wait, but when the reassessment is repeated each hour, the nurse catches any change in their condition quickly," she says.
Sources
For more information on reassessment of patients in waiting rooms, contact:
- Melissa Brooks, RN, BSN, Emergency Department, Deaconess Hospital, 600 Mary St., Evans-ville, IN 47747. Phone: (812) 450-3405. Fax: (812) 450-3996. E-mail: [email protected].
- Kathryn Eberhart, BSN, RN, CEN, Eberhart Medical Legal Consulting, 4706 Devonshire Place, Santa Rosa, CA 95405. Phone: (707) 538-7056. E-mail: [email protected].
- Kathleen Emde, RN, MN, CEN, Clinical Services Manager, Swedish Medical Center-Issaquah Campus, 2005 N.W. Sammamish Road, Issaquah, WA 98027. Phone: (425) 394-1646. Fax: (425) 396-1647. E-mail: [email protected].
- Barbara J. Levin, BSN, RN, ONC, LNCC, Eight Country Drive, Hingham, MA 02043. Phone: (781) 740-0254. Fax: (781) 740-1618. E-mail: [email protected].
- Lori Pelham, RN, Clinical Nursing Supervisor, Emergency Department, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109. Phone: (734) 647-7565. E-mail: [email protected].
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