Triage standards in smaller rural ED's

[Sharon]

Could someone explain to me what is going on in some of the smaller, rural ED's. I just got a call from patient who is on two drugs that can cause infarct, acute renal failure, acute hemolytic anemia, suicide and other life threatening events. The patient reported that after his last dose of both drugs on Friday he had increased heart rate, chest pain, diaphoresis, urinary frequency q 10 minutes, lower back pain, dizziness when changing positions and lightheadedness with any length of sitting. This morning when he called his heart rate had fallen below 60 (patient's normal pre-treatment heart was an untreated rate of 100) and no chest discomfort but continuing lightheadedness while in a sitting position. Additionally a blizzard has just started in his area and he is two hours from the treating physician. I advised him to call 911 and he chose to have a friend drive him the one mile to the local ED. Once in the ED the nurse triaged him to a local doctor's office, in the hospital, which may or may not be able to see him some time today. She did not check his vital signs, EKG, or lab work. I even spoke to her and explained how life threatening the patient's medication can be. Her rational is that since he wasn't having chest pain at that moment he did not need to be seen in the ED. Are the only measures used in triaging possible cardiovascular events, pain? When has triage in the ED dropped any physical assessment? Do you think that the patient's Medicare to be a reason behind his transfer out of the ED? Does this constitute dumping?

[KRVRN, BSN, RN]

Was the person triaging him even a nurse? Sounds wrong to me.

[fab4fan]

This sounds like an EMTALA violation; pts. that present to the ED are to be given a medical screening. It is beyond her scope of practice to make the determination that the pt. did not need to be seen by the ED physician. There have been successful lawsuits under similar circumstances.

Someone needs to review EMTALA with her; she is putting the facility, her license, and the pt. well-being in jeopardy.

[Chiaramonte]

This has to be an isolated but never the less fluke of an incident.

I have worked in both a larger urban facility and a "small rural" facility. I find the triaging to be very similiar. If at all, we in the smaller rural facility are able to get our hands on and initiate care much quicker than the larger hospitals. Our time to door to stretcher is indeed just minutes.

We have unit clerks who first see the patients but they are quickly brought back through to the stretchers for any cardiac related problems be it pain, palpitations, lightheadedness, etc. or any other questionable scenerios.

Our times for initiating Reteplase, etc has been 5-10 minutes...

The truly sad part is generalizing about rural triaging protocols and not keeping this incident in focus and realizing that the same thing could and often does happen in a larger busier ER.

[Sharon]

Thank you for the responses. KVRN- The women identified herself as an RN. Fab4Fan I haven't done a legal case search in 6 months on EMTALA. NightMoonRN I have taught and worked in rural ED myself. If I had a student or employee triage the way my patients are triaged now, I would be writing a lot of disciplinary notices.

Unfortunately I am seeing a trend, especially in one area of the country, regarding rural ED's and how they handle (or don't) my patient's medical crises. As a group the urban and larger ED's are demonstrating involvement and commitment to resolving my patient's medical crises as quickly and safely as possible.

My feeling is this behavior is dumping. I will now research what information and who to report this behavior to.

My patient at the doctor's office had a rhythm strip done and a monospot test. No CBC, no enzymes, no chemistry, and no other lab work. His diagnosis was Mono (which can be a false positive due to his illness and medication.)

[SherRN]

Dear Sharon

Have I got a story for you. I live and work in a small rural setting. My Hospital is 120 beds inc. OB. Our ER is very good but sometimes I think that they just miss the boat on one while concentrating on another pt.

Case in point. I arrive for a 7am shift and am assigned to float. I am to do an admission on a pt that has arrived from ER about 20min ago. The man is admitted with abd. pain s/p choley 4 Jan. This is Jan 28th. I assess the pt. and find that ---1)He is majorly distended. 2) He has massive excoriation to peri-anal area. 3) He c/o bi-lat flank pain and frequency/incont. q 5 min since the surgery. He also tells me he has been taking a mail order med called "Prostata."

I called his surgeon and said the abd pain is not your surgery. This guy needs a foley bad!!! I put an 18 in threw away the kit washed up and asked 4 more questions. Looked down at the foley and had a FULL bag. 1900 ccs. Empytied and clamped for 1/2 hr. Then got 500. Came back in an hour only because I was curious and that guy had 1900 more. That poor guy had 6,000 out on my shift and 10,000 in 24 hours.

[Sharon]

The individual did have a cardiac problem has been withdrawn from the treatment that contributed to the episode and is having further evaluation by various specialist. He did not have mono.

This morning we had another case, in a different area in which the EMT's/Paramedics encouraged the individual to refuse transport.

[RMH]

Hi I work in a very small rural hospital. +/- 20 acute beds including OB. We have a full ER and are in the process of implementing true triage protocols. Our main goal has been and will always be patient care. Our basic policy is that every patient that checks in to ER is seen by an MD..No triaging "out" (whatever that means). So the above incident whould never have happened, I don't think..

[bhaysRNinKS]

[i work in a rural hospital in fact we are only a 15 bed facility and prior to this worked in a 45 bed facility. I have never seen anyone turned away as you described. It's been my experience that most of our patients receive treatment for more than they originally complain of. It sounds to me like this is an EMTALA violation. I understand your frustation!