Triage and ED Overcrowding: Two Cases of Unexpected Outcome

INTRODUCTION Overcrowding in emergency departments (EDs) has become a serious problem for many EDs in this country. As a result, patients may wait longer time periods after triage prior to evaluation by the ED physician. This places additional importance of initial “at the door” triage as potentially sick patients may be subject to very long waits. Minor misjudgments at triage are an expected part of the triage process, as medical assessments are done quickly, and with limited data. However, in overcrowded EDs, these triage misjudgments may subject some patients to increased risk of poor outcome as their condition may deteriorate during long waits. Therefore, during times of overcrowding, some patients may benefit by classification into a more acute category. Although triage of newly arriving patients in th ED is part of the daily routine operation of nearly every hospital ED in the country, very little research and resources have been allocated to this important and high-risk clinical activity. Furthermore, there are few national standards for triage and hospitals vary in the amount of time that should elapse prior to physician intervention. Even if patients are triaged into the appropriate category, unexpected outcomes may occur because of delays in physician availability. In large urban hospitals, two or three triage nurses may work simultaneously and have constant lines of incoming patients waiting to be triaged for care. In smaller community hospitals, triage may occur by nurses who have other duties, but are immediately available to perform triage for the two to three patients that arrive per hour. Patients who present to the triage nurse without cardinal signs of severe illness may be placed in non-emergent triage categories, but then deteriorate during long waits in the ED waiting room. Alternatively, triage nurses may be so rushed and pressured that they increase their error rate of under-triage. The following two cases were obtained from a large western US hospital and illustrate the critical importance of triage. Case 1: A 40 y/o man presented to ED triage with epigastric pain. Vital signs: blood pressure 145/95, pulse 116, respiratory rate 24, temperature 98.6. Because the patient’s pulse was 116, and his respiratory rate was 24, he was triaged as “urgent.” Since all ED beds were occupied, the patient was triaged to the waiting room. Two hours later, the patient’s friend complained that the patient continued to have pain. The triage nurse told the friend that the ED was busy, and the triage nurses overwhelmed, but that the patient would be called as soon as possible. Four hours after being seen at triage, the friend said that the patient had to be seen that he was now also having chest pain. While the friend was seeking assistance from the nurse, the patient collapsed in the waiting room and was brought into the ED and an ED physician was called to the scene. The patient was placed on a gurney and transported into a resuscitation area. A rhythm showed v-fibrillation and he received counter shock, ACLS drugs, and ACLS protocol. His rhythm deteriorated to asystole, and after 45 minutes of CPR efforts were terminated. A corner’s report showed an acute transmural myocardial infarction. Case 2: A 47 y/o male presented to the ED complaining of headache, fever, vomiting, and myalgias. At triage, the patient had vital signs of blood pressure 140/90, pulse 70, respiratory rate of 22, and temperature 101.2° and GCS of 15. The patient stated that the headache was not the worst headache of his life, and was vague as to the intensity of onset and duration and other historical fractures. The patient was triaged as urgent. The ED was overcrowded with patients, some even laying on gurneys placed in hallways. Since the triage nurse had seen many patients that day with URI symptoms and presumed that this patient had a URI no worse than others did, the patient was sent to the waiting room. Four hours after triage, the patient’s name was called as an examining space in the main ED had become available for him. He did not answer and it was presumed that he had left the ED without being seen. Four and one-half hours after triage, another patient in the waiting room came back to express concern that a man was slumped in his chair was sleeping. When approached, the patient was unarousable and was then quickly taken to the resuscitation room where he was found to have a Glasgow coma scale of five. At that time his blood pressure was 150/90, pulse 66, temperature 100.8° and the patient was bagged at a respiratory rate of 24. On physical examination the patient was found to have a laceration over the left parietal occipital area with encrusted blood. The patient was intubated with a rapid sequence technique and taken to have a head CT scan. The head CT scan revealed a large left-sided subdural hematoma with a substantial shift of structures in compression of ventricles. Neurosurgery was consulted and took the patient to the operating room where the subdural hematoma was evacuated. The patient survived neurosurgery, but developed cardiovascular instability and died 24 hours postoperatively. Family members contacted provided history of the patient being involved in an altercation the day before coming to the ED.