The ER: Stuff You Need to Know. Part 1: Triage

I recently wrote an article describing a variety of examples of poor behavior demonstrated by patients in the Triage section of my Emergency Department. While the article was written primarily to introduce the reader to some of the actual (rather than media-generated) challenges encountered by an ER nurse in a humorous vein (which is the modus operandi for all of my writing), my article evoked a tremendous negative response with regard to the readers' personal ER experiences. A majority of responders related their unpleasant experiences when they or a loved one was treated in an ER.

The most common complaint was that an extraordinarily long time was spent simply waiting: waiting to get back to a room while others who arrived in Triage later were brought back first; after arrival in a room, waiting for the nurse to come in and perform an assessment; waiting for the MD to come in; waiting for medication; waiting for tests to be performed; waiting for test results to come back; waiting for diagnosis or treatment; waiting for transfer up to a unit bed; or waiting for discharge instructions and prescriptions. Furthermore, more deeply entrenched in these woes was a complaint common to all: not being informed about what was going on with the process. These people were simply never told what was happening at any point throughout their ER experiences. (It is perfectly understandable that a person in that situation would feel forgotten and ignored, and thus become upset.)

After considering these problems, and at the suggestion of a colleague, I have determined to do something about it. I hope that this series of articles will inform and enlighten the reader regarding the challenges and intricacies of emergency medicine. I hold the firm belief that a well- and accurately- informed public makes for a great patient, because a better-informed patient is far better equipped to actively participate in the care process and is able to more effectively advocate for oneself. I have found that patients treated in this manner nearly always described a far more positive and satisfactory experience, even if an extended wait was involved. Thus, when I teach new nurses (and students), I pound into their minds the following adage:

Keep them SAFE, Keep them WARM, Keep them COMFORTABLE, and Keep them INFORMED. When a nurse does this, it goes a very long way towards making the patient feel cared for- which is the whole point of nursing, if memory serves me correctly.

Returning to the issue at hand, I begin this series where the ER process begins: Triage.

In the civilian sector, triage was adopted by emergency departments in the early 1960s when the demand for emergency services grew beyond capacity to provide everything to everyone at the same time. The process enabled overloaded emergency departments to quickly identify and treat the "super-sick" patient from among the crowds. (Interestingly, it also proved a useful tool in identifying malingerers who were inappropriately using the ER.)

With the advent of government-subsidized medical entitlement programs, emergency departments were rapidly overwhelmed with non-emergent and non-urgent cases that slowed the entire emergency care process down. The need for, and value of, an effective triage system became immediately evident. As a result, four-tier and 5-tier triage systems were developed. With either system, patients are classified by level of acuity (how sick they appear based on objective data such as vital signs, obvious trauma, or body system affected).

Level I: LIFE-THREATENING condition requiring immediate care. Not stable. Examples: CPR or intubation in progress, acute MI, acute stroke, major trauma, acute respiratory distress, or major burn;

Level II: EMERGENT but stable. Seen ASAP (within 30 minutes); Examples: Stroke when patient was last observed without symptoms more than three hours ago, Open fracture, kidney stone, testicular torsion, possible ectopic pregnancy, "hot" (surgical) abdomen, sickle cell crisis, frankly-ill child, neonate with fever, fever (with headache, stiff neck, and rash), traumatic eye injury, acute narrow-angle glaucoma, suicidal ideation.

Level III: URGENT. Stable, no distress. Seen ASAP if no Level I or II patients ahead of them. Can wait up to one hour before being seen. Examples: Closed fractures, laceration without bleeding, Drug ingestion > 3 hours prior to visit with no signs or symptoms.

Level IV: NON-URGENT. Stable, no distress, can wait at least one hour before being seen. Examples: Typical migraine, rash (without fever), abrasion, anxiety, cough/cold.

Level V: DELAYED. Can wait four or more hours before being seen. Examples: out of medications, routine exams.

The patient is classified according to objective findings (abnormal vital signs, obvious distress, etc.) The experienced and astute triage nurse also develops a "sick sense" (being able to quickly visually assess a patient for a genuine life-threatening illness, as opposed to the fakers who pretend to have seizures or who feign unconsciousness as they come through the door).

It is absolutely essential that the reader understand this system because it governs the entire flow of the emergency medical process. The patient is not merely classified randomly and arbitrarily by the triage nurse. It also provides the inarguable reason why one person may arrive first but be seen later than another person who comes in after them. While one person my have a migraine and be completely and undeniably miserable, if another person arrives with signs and symptoms of a higher-acuity condition, that person is going in first, and no amount of complaining is going to change this fact. Furthermore, screaming, crying, or otherwise acting out will never qualify a patient to receive a higher acuity "just to shut them up." It just upsets everyone else who has to endure the childish, selfish and obnoxious behavior.)

Triage is one of the trickiest, most challenging functions for the ER nurse. Symptoms of a potentially life-threatening condition can be subtle, and can even be discovered "accidentally" when a patient is complaining of a problem that would itself provide for a lower acuity assignment. In my career, I have had at least six patients who complained of abdominal pain without vomiting or diarrhea (which at face value, merits an acuity of II to IV, depending on vital signs). But every single one of those six made a seemingly-offhand remark, or described their pain in a particular way, that caused my "suspicion index" to send up massive red flares. In each case, acting merely on my suspicion through the simple act of looking at and feeling both legs revealed one being colder and paler than the other- and that the patient's pain was not gastrointestinal at all, but that he or she was suffering from a dissecting abdominal aortic aneurism, which merits an acuity level of I with an exclamation point. (Only one of those patients died, and that was because his aorta completely tore within moments of sitting down in my triage booth. When the aorta blows out, there is nothing anyone can do; death occurs in ten seconds or less- there often isn't even enough time for the patient to say more than a startled, "Oh!" before the lights go out forever (It happened once). He just said, "I can't breathe," and he was gone. But had I been less experienced, I might have missed all six.)

The effective and safe triage nurse demonstrates experience, awareness, astuteness, coolness under pressure, and razor-sharp critical thinking skills. Where I work, no nurse with less than two full years as a full-time ER nurse is allowed to go anywhere near triage- even if only to give the triage nurse a 30-minute break. It is no place for the neophyte or any nurse who is still in the process of gaining confidence of his or her abilities. As illustrated above, people live and die on the quality of the triage nurse's assessment. When a waiting room is packed and more people are coming in, and just when three rooms are opening up the charge nurse informs triage that three medics have arrived with Level I patients, the triage nurse has no choice but to hold the line.

I have had many nights like that in Triage. In some ways, it is more difficult than working in a Level I thrash. Instead of one patient, I have thirty or forty with variable levels of acuity. This, again, is where experience and calm is an absolute requirement. Nobody likes to be stared at; and the awkwardness is amplified when every one of the people staring at the triage nurse is not feeling well and has been waiting for hours. How does one cope with this potentially-volatile situation? The question introduces two more equally-vital traits of the triage nurse: empathy and compassion.

In my experience, it really does not take much effort to help even a miserably uncomfortable person endure a long wait. It is amazing how calming to a room full of patients it is to simply circulate around the waiting room periodically, offer a blanket or pillow, and say "I know you've waited a long time. Has anything changed? We are working as fast as we can. We haven't forgotten about you. As long as you are out here, you are my patient and I will look out for you."

When people see you actively following up on them and looking after them, they feel cared for. All it requires is one minute of time to infuse calm into a crowded, highly-charged waiting room. Granted, there are times when it may not help (a demented patient with "sundowner's syndrome," a belligerent drunk or drug user, for example). But otherwise, I have never, in all my experience, known this approach to have failed me in calming down a room full of upset patients.

In fact, the triage nurse is required to re-assess everybody waiting on a regular basis. Making rounds is a quick and efficient means of doing that.

I cannot speak for the practices of every nurse, hospital, or emergency department. Many factors not mentioned here can create a positive or negative experience for the patient. But I strongly encourage you, the reader, to advocate for yourself or your loved one. This is not Cuba; our medical system is still driven by a free-market economy. That means if enough patients get upset, they can tell their friends not to go to that hospital, and so on. People will start avoiding that hospital. The hospital is a business. No patients means no revenue. State agencies will begin to wonder what is going on at that hospital. The hospital will either change, lose accreditation, go bankrupt, or lapse into backwater obscurity.

Here is what you can do: If there is a problem, speak up! If more than an hour has passed since you have been informed or have seen your nurse, speak up! If you have not been seen, gone to a diagnostic test, received results, been treated for the diagnosis, or received your discharge instruction more than an hour after being informed of the step, speak up! And if you feel that you are not being informed about any part of the care process, speak up!

You, the patient, do not exist for us; We, the Emergency Department, exist for you. If we work together as a team, we both will be the more satisfied and enriched for it.

Our healthcare system has some similarities to both Canada and the UK, and some similarities to yours in the US.

We have “socialized” public healthcare, funded and operated by the state (read: taxpayers). It is excellent, but there are waiting lists if you are chronic, which are triaged and prioritized. If you are acute you get seen right away.

We also have private healthcare, where you can either pay yourself or more typically have your health insurer pay. It too is excellent, and there is never a wait.

I have used both systems in New Zealand: it is quite common for Kiwis to have health insurance. The public system, as often as not, uses the same surgeons and nurses as the private system, the facilities are quite good and the food is superb (I often ask for seconds or thirds when I’m in).

The private hospitals are like five-star hotels: they even serve wine with your meal.

Socialized medicine isn’t the same thing as Socialism: it’s actually a very good thing and quite efficient if it is done properly. Of course, that’s a really big IF.

Typically, Emergency medicine is done in the Public system: they are geared for acute cases. Once admitted, the patient will either stay in the public system or be transferred to the private system if he wants to. I have never transferred when I’ve been acute: there’s no point. The standard of care is just as good in the public system, and while the public hospitals look more like high schools than hotels, if you’re sick enough to be in hospital you’re not going to notice the plush carpets and tasteful decor.

I usually have surgery in the private system, just because I can. Some of the best vacations I’ve ever had have been in the Southern Cross Hospital, recovering from surgery.

Now that I've had my surgery and am recovering well I don't want to start anything. Its a new(ish) Hospital.

I will comment on a couple of things here.

It looked to me, like the waiting area covered not only emergency, but a clinic as well. Those that were there for little things ended up coming out a different set of doors. There were a bunch of people that fell into that category the last time I was in ER. Might be the way to go.

I would only add that people be persistent. You know your body better than anyone else. My first visit to ER for severe abdominal pain, vomiting, got me a total stay of 4 hours and an antibiotic for a bladder infection. I told them I was concerned about a hernia was diagnosed with back in December. They did take an xray but said everything was fine.

Two days later 9am I was right back there with the same symptoms except that the vomiting is dark green, so green it looked black. This visit lasted 8 hours. CT scan and xrays. No blockage. Prescription for pain and anti nausea.

8pm vomiting the contrast, 11pm right back to ER carrying my trusty bucket and still vomiting the dark green fluid. Total stay about 5 hours with new prescription for different anti nausea and instructions to call a particular Dr in the morning for an appt.

Vomiting in the Dr's office gets me placed in the hospital. Surgery at 8 that night. The hernia had twisted and a section of the intestines had turned purple.

I told them on each visit about the hernia. The first two visits they didn't even palpate the abdomen. What's up with that? Why do not listen to the patient? Sometimes we might actually know what is happening. ok rant over,

The two biggest problems I have ever encountered in my many years on Planet Earth can be split in half as one problem is the hospital being irresponsible and the other as the patients’ irresponsibility, as follows:

1. Patients who choose to use the ER in lieu of a family physician or urgicare center - sprained ankle, minor burn, a simple cold, cough, sore throat, and so on.

2. Hospital personnel who want us to believe they are busy and overwhelmed but stand around shooting the breeze. Now THAT really annoys me. I’ve seen it on several occasions, though admittedly not in the past couple of years.

I disagree that it makes it better to have someone show they “care.”

It makes it better, but it’s not sufficient. The ER is broken and it’s because it is full of non-emergency cases.

I don’t want someone to “care.” I want to be efficiently screened for an emergency, told the results and then released if I don’t want to hang around for hours until some doctor or nurse tells me to “rest, drink plenty of fluids, and take motrin as needed.”

When I take my child in because he possibly has a broken arm, I don’t care if one person there “cares.” It’s very easy to determine if he has a broken bone. If he does, then we’ll wait for treatment. If he doesn’t, we’re out of there. An x-ray and reading the x-ray takes five minutes-—in five minutes, we could be in and out of there-—because, if his bone is not broken, I don’t need anyone to tell me how to take care of my child’s boo-boo.

Yet we wait and wait for hours and hours, while people who have nonspecific complaints, for which the doctor may “want” to do zillions of tests, languish in the back.

Anyway, I ranted on the original thread, so will step off here.

People don’t need to understand triage better. They understand triage very well. They understand the reason for the delays in the ER. THEY JUST DON’T AGREE THAT WE CANNOT DO BETTER.

No way our medical system is influenced at all by a free-market economy-—wish it were so, but it isn’t.

To try to cut down on ER abuse in the military, there was once a push to charge people $25 per visit. All hell broke loose and the proposal was quickly abandoned.

I have repeatedly said I would willingly pay a surcharge to be able to go to a “private” ER where we didn’t have to put up with the usual crappola at the ER.

Hey Gunner!

Excellent post as always!

Sorry about the rant last week. Sounds like everyone else unloaded too. :)

I wish I hadn’t been so stressed/had known more when hubby was in the hosps. If you don’t go, you don’t know what’s normal/to be expected. Whether it’s due to a fear of not being able to pay the bills or a nearly pathological fear of drs/hosps...we just don’t go.

Had to go to my gp the other day and he asked me about a lifelong bout with anemia/asked me how long. I told him since my first real dr visit—when I was in my mid teens. The only other time I remember going to the dr as a child was when I almost died from chicken pox.

Wow, I’m sorry you went through that. Hope you’re feeling better now! (And better tomorrow ;).)

Here’s one thing I’m picking up from this discussion:

On the original thread I touched on it, but now I see a better way to articulate it.

The ER really should serve two purposes. Screening (is *emergency* care needed?) and treatment (if *emergency* care is needed).

If the ER screened and then turned away people who did not need *emergency* treatment, they would have a lot more time and resources to do better screening.

Hells Bells, most of the time I can pick out several patients in the waiting room who are going to end up receiving NO TREATMENT WHATSOEVER, yet are clogging up the system for many, many hours. The biggest example of this is the baby brought in because she has a cough, a runny nose, or “can’t breath” (excuse me?), yet while in the waiting room, she sits there playing happily with the magazines, crawling around, laughing at Grandma, making faces at bystanders, etc. In short, the baby that most parents realize is is NO WAY in an emergency situation.

That baby should have been screened and released immediately in one fell swoop. There is nothing that is going to happen in the back beyond what the intake nurse with temperature and other vitals. Give mom a flier that says give your baby TLC, plenty of fluids, rest and a warm bath if fussy. Please.

Because the ER starts with the assumption that EVERY PATIENT will get some kind of examination by a doctor (add four hours) and then some kind of “treatment” (even if it’s “rest, fluids, etc.”) and some kind of prescription (for OTC pain relivers or Pepto Bismal . . . basic Dr. Mom stuff), no patient ever gets bumped out of line without completing a often worthless 8-10 hour stint.

ERs should screen and release if no emergency is found and there is no indication of the need for additional tests.

This, I think, would allow ERs to improve their screening process for everyone.

New Zealand has much titghter controls on immigration (both legal and illegal) than the US, and given its geography it’s got a huge built-in advantage in that respect. No way can any kind of socialized medicine work here unless access to it is tightly restricted — as in if you don’t have a biometric ID registration that identifies you via a national database as an authorized user, you get no service. As long as unlimited hordes of people who have never paid into the system are using it, the quality of care will be lousy. The problem is more severe in parts of the country with more illegal immigrants and more welfare addicts, but it’s worsening everywhere.

> New Zealand has much titghter controls on immigration (both legal and illegal) than the US, and given its geography it’s got a huge built-in advantage in that respect. No way can any kind of socialized medicine work here unless access to it is tightly restricted

I agree completely. Because health would probably be state-administered (rather than Federal) it would be exceedingly difficult to implement anything like what we have here. Or more likely impossibly expensive and infeasible.

Even if it were implemented by Washington DC, it would take many years, if not decades, for you to get your infrastructures tuned to suit our model.

What we have in New Zealand has been the product of decades of building: aside from a few philosophical differences it has been done with bilateral support in Parliament. That would probably never happen in the USA.

Step one would have to be to get a handle on your illegal migration problem. Sort that first, and many of your other problems diminish greatly.

That baby should have been screened and released immediately in one fell swoop.

Naaaahhhh, it's better if the tyke continues to '...sit there play happily with the magazines, crawl around, laugh at Grandma, make faces at bystanders...'

That way when she catches the galloping-never-get-overs from someone actually sick enough to need to be in an ER, her next emergency trip won't be a total waste....

Joe: "I, personally, would like to see ERs go back to treating emergencies and turn away the petty."

Conservative: "Can't do it...for a number of reasons.Perhaps the most important of which is that the 1 of 500 "heartburn" patients that you might turn away would turn out to be having an MI (heart attack)...would die....and the family would sue,sue,SUE."

There is another reason that ERs cannot turn petty complaints away and that actually forces ERs to screen every single patient for life-threatening conditions: Federal law.

The Emergency Medical Treatment and Active Labor Act (EMTALA) mandates that no person shall be turned away for any reason without first being screened for a life-threatening condition. This law, while perhaps well-intended, is the primary reason for the logjam on our emergency medical system. It places the cost of screening (including CT scans and MRIs) on the backs of the hospitals, and has caused the cost of emergency care to skyrocket.

And of course, the people who genuinely need our services the most are the ones who end up being forced to carry the weight of those who abuse the system and the law.

If you really want to attack the culprit and improve healthcare, attack the entitlements system and lobby for an amendment to the EMTALA law that allows for abusers to be punished if they are caught.

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