Is your 'low-acuity' patient at risk during long waits?
Impaired patients will need additional care
If a patient comes to your ED with a fractured wrist, you'd probably triage them as low acuity based solely on their chief complaint. But what if this patient is also confused, irrational, or mentally impaired? For these cases, there is a hidden danger: Your patient needs to be kept safe while waiting for treatment.
"Older patients with cognitive impairment, anxiety, or aphasia potentially strain nursing ratios in ways that are not fully captured by considering patient severity alone," says Mary Carter, PhD, an associate professor with the Center on Aging at the West Virginia University School of Medicine in Morgantown.
For example, an older adult with dementia who comes to your ED unattended and is able to ambulate "poses a significant challenge to patient care that currently is simply not captured by current staffing ratio estimates," she says.
This patient is put at risk while waiting for care as ED nurses turn their attention to more severe cases, notes Carter. Crowding adds to the risks, with only one-third of 3,562 emergency medicine clinicians surveyed reporting that patients in their ED's waiting rooms are monitored often, according to a study funded by the Agency for Healthcare Quality and Research.1
If a patient comes in for a cough, upper respiratory infection, urinary tract infection, or swelling of the ankles, but also is confused, elderly, mentally challenged, or has another condition that impedes rational behavior or judgment, then this patient requires special care, says Rosemary Lowry, MSN, APRN-BC, nurse practitioner/manager of the ED at Providence Hospital in Southfield, MI.
"We will bring them into the treatment area and have a patient advocate or clinical tech keep a special eye on them," says Lowry. "While clinically the condition might not warrant such attention, we are mindful that when treating patients holistically, one must take this into account."
Recently, a young man with an exacerbation of asthma was dropped off by the leaders of a group home for developmentally slow young adults. "The problem was the patient had lost his rescue inhaler and would not have had to seek treatment if he had the inhaler," says Lowry. "At first, he was not in any distress, and therefore was triaged as nonemergent."
After probing further, the triage nurse thought that the man should not be unsupervised while waiting for medical treatment. Lowry, who was the charge nurse at the time, put the patient right in front of the nurse's station. "We gave the patient 'busy work' such as folding washcloths and were able to keep him in one place."
Reference
- The safety of emergency care systems: Results of a national survey of clinicians in 65 U.S. emergency departments. Ann Emerg Med 2008. In press. doi:10.1016/j.annemergmed.2008. 10.007.
You may need to keep a patient in close proximity
If you are worried about a patient with a low acuity triage because he or she is impaired, put him or her close by and alert the clinical staff that you suspect the patient has some deficits.
"The worse that can happen is that you are wrong," says Rosemary Lowry, MSN, APRN-BC, nurse practitioner/manager of the ED at Providence Hospital in Southfield, MI. "In the meantime, you are advocating for that patient."
Here are three ways you can ensure the safety of these patients, says Herb Perry, RN, an ED nurse at Long Island College Hospital in Brooklyn, NY:
- Place the patient on a 1-to-1 observation to prevent elopement or further injury. "In many EDs, however, additional staffing for this purpose is not always available," notes Perry.
- Place the patient close to the nursing station for enhanced observation.
- Change the patient into a hospital gown so he or she is easily identifiable by security.
Perry gives the example of a patient with a minor laceration requiring sutures who would most likely be triaged as low acuity and have to wait to be seen. However, if the patient also is an insulin-dependent diabetic who took his insulin that morning, but didn't eat because of the laceration, that is a different situations.
"Such a patient has the potential to become critically hypoglycemic if unnoticed," says Perry. "It is hoped that the triage nurse would ask the appropriate questions while taking the patient's medical history. But the reality is that patients often omit crucial information until they are seen by the doctor."
Long Island College's ED has a policy that all patients go "inside" to be seen immediately after triage, instead of the waiting room. In the above patient's case, this would mean that the potential hypoglycemia would be "instantly noticeable," says Perry.
The policy also makes patients feel they are being seen more quickly. "If a lengthy wait is still required, he can see for himself that staff is busy taking care of patients truly more sick than he is," says Perry.
If a patient comes to your ED with a fractured wrist, you'd probably triage them as low acuity based solely on their chief complaint.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
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