Best approach to patients and relatives complaining about "long wait."

allnurses Guide · Jan 24, 2008

Is there a reason why non-emergent patients could be directed to an Urgent Care Center? It would make sense to have one next to the ER.

Lots of ERs have an urgent care or fast track attached, but they are overwhelmed too, with long waits.

As far as sending someone somewhere else, we are forbidden by federal law (EMTALA) from refusing to see someone or send somewhere else until they are certified not to have an emergent condition;and triage nurses except for very special circumstances set up with the regulatory bodies ahead of time, such as having an NP out there, CANNOT do that. Nor can EMS refuse to transport.

Once they've had the screening exam, you may as well treat, even when not an emergency. There are mutterings about once it is determined to not be emergent by a reasonable lay persons standards, insurance shouldn't pay and the person should be responsible for the costs. I have mixed feelings about that.

NYCRN16 · Jan 24, 2008

Beeee careful with the "directing" to other hospitals and facilities......
COBRA/EMTALA anyone?

I don't think anyone in their right mind tell someone that looks bad to go to another hospital, but I for one have had patients complaining that "XYZ" hospital has no wait time or they get in quicker, so I will then say, go ahead and go. They have freedom of choice, they can leave if they want. If someone asked me in triage what hospitals have peds or detox or whatever, I can tell them and if they do go there that is not an EMTALA violation. They are not already registered and admitted and then you are telling them to go to another hospital.

Altra, BSN, RN · Jan 24, 2008

I don't think anyone in their right mind tell someone that looks bad to go to another hospital, but I for one have had patients complaining that "XYZ" hospital has no wait time or they get in quicker, so I will then say, go ahead and go. They have freedom of choice, they can leave if they want. If someone asked me in triage what hospitals have peds or detox or whatever, I can tell them and if they do go there that is not an EMTALA violation. They are not already registered and admitted and then you are telling them to go to another hospital.

I mostly agree with you, but this can be stickier than you may think.

If the patient has signed in and completed the triage process but gets tired of waiting the triage nurse better well document thoroughly when they decide to leave, directly quoting anything the patient says, painting a clear picture of their condition as they are leaving, etc. Otherwise it can come back to bite you, because if they go 2 miles away to Hospital X and are found to have anything more pressing than a hangnail ... it's not pretty. Been there, seen the consequences.

Quite frankly, patients insist on freedom of choice until something unexpected is happening ... then it's someone else's fault.

Karl.Bishop · Jan 24, 2008

I mainly work fast track in our ED and the first thing I say when i go into the bay is thank you for being so patient. Then after they whine about how long they have had to hold their "blood drenched" 2x2 for 3 hours I say "oh my god have you really been out there for 3 hours?! Then the people comming in after you are relly going to be mad!" Kinda throws it back as a reminder that at least there in the ER and not in the waiting room.

ayla2004, ASN, RN · Jan 24, 2008

My idea, that will probably never happen is to have a large electronic display showing the average wait time for non-emergent care. People will still be upset if they haven't been seen in 2 hrs, but less likely to go off on the triage nurse if they can see that the average wait time is 5 hrs. It also, if displayed adequately enough, stop people from signing in if they understand from the start that they are looking at a long wait, thereby making the wait time less.

my local hospital in the UK used to do that as anyone who was critical or serioulsy ill would be taken care of sharpish and it was non urgent that were in the waiting room

NYCRN16 · Jan 25, 2008

I mostly agree with you, but this can be stickier than you may think.
If the patient has signed in and completed the triage process but gets tired of waiting the triage nurse better well document thoroughly when they decide to leave, directly quoting anything the patient says, painting a clear picture of their condition as they are leaving, etc. Otherwise it can come back to bite you, because if they go 2 miles away to Hospital X and are found to have anything more pressing than a hangnail ... it's not pretty. Been there, seen the consequences.
Quite frankly, patients insist on freedom of choice until something unexpected is happening ... then it's someone else's fault.

I understand what you are saying but I think we are talking about 2 different things. IF the patient has already been triaged I always document as you say because now they do have a record made.

What I was reffering to in the previous post is for example a patient walking in and asking the triage nurse before even signing in how long the wait is because they are here for *insert ridiculous problem*. I will then tell them what the wait time is the they will say to me, well I will go to XYZ hospital then because I am not waiting that long. Oh well, dont let the door hit ya! At that point the patient has not been triaged and they are making the choice not to be triaged. Its not much different from someone walking in and seeing a full waiting room and walking out.

**canoehead, BSN, RN** · Jan 26, 2008

Do any triage nurses answer questions, or assist with common sense stuff in the booth? I had a kid with popcorn up his nose and all mom really needed was a second person to help her hold the kid still. I took it out and they were done in a flash. Still offered to have them see the doc, but they declined.

Some people ask if a wound needs stitches- if I can answer confidently that they will get a fancy Bandaid and antibiotic cream- should I?

I know policy is to have everyone seen, but I want to know about what you actually do.

ERRNTraveler, RN · Jan 27, 2008

I had a guy in triage for a kidney stone, when giving his urine specimen, he passed the stone into the cup... He instantly felt better, I offered for him to still be seen by the doc, but he declined. I would be careful about telling people their cut doesn't need stitches- even if you know for sure it doesn't. If it gets infected it could come back to bite you in the butt.....

elthia · Jan 27, 2008

The only time I have complained about about an ER wait was when I went to the ED, I arrived with sharp chest pain 8/10, was diaphoretic, tachypneic, my husband pulled the car up to the door and ran in yelling for help. The clerk shoved a w/c at him and said the nurses were to busy to be disturbed, he pushed me in, I was still diaphoretic, with dry heaves, clutching my chest, crying in pain, unable to catch my breath. After sitting through the entire registration process, waiting over 15 minutes, my husband caused a scene, asked for the nursing supervisor, and was getting ready to take me AMA from the ED when I finally was seen. My husband was threatened with being forcibly removed from the ED. When they came to do the EKG my pajamas were so soaked with sweat they had to towel me off to get the leads to stick.

Next time...I'll call an ambulance.

CritterLover, BSN, RN · Jan 27, 2008

do any triage nurses answer questions, or assist with common sense stuff in the booth? i had a kid with popcorn up his nose and all mom really needed was a second person to help her hold the kid still. i took it out and they were done in a flash. still offered to have them see the doc, but they declined.
some people ask if a wound needs stitches- if i can answer confidently that they will get a fancy bandaid and antibiotic cream- should i?
i know policy is to have everyone seen, but i want to know about what you actually do.

the hospital where i used to work triage had gotten into some emtala-related trouble, so we were very careful about that kind of stuff.

i can think of two patients that didn't need to be in the er (one an adult with an "abscess" on her back -- it was a pimple; the other a child with a "spider bite" -- of the non-toxic, non-infected variety). i knew they didn't need to be there, but kept my mouth shut. both waited a very long time to be seen, and both were furious that i hadn't told them they didn't need er treatment.

would i do it the same way again? yeah, i would. emtala states that anyone presenting to triage is entitled to an mse, and that hospital policy didn't allow for rns to do the mse. further, emtala has been extended to mean that we can't say anything that would cause the patient to leave before getting the mse (though that might just be that particular hospital's interpretation of it).

anytime someone asked me if i thought they needed to be seen, and i didn't think they needed to be seen, i'd give them a general "well, you came here to see a doctor, so if you are willing to wait, a doctor will see you."

some manage to read between the lines and leave, but that isn't often.

a couple of times i managed to snag one of the docs and get the mse done quickly in triage, but that didn't usually happen.

the only time i told a patient that she didn't need to be seen was a lady that came in early one morning wanting an hiv test. she had found out her husband was cheating on her, and she was scared. she didn't have any physical complaints, so i knew she wasn't going to get an hiv test. since our health department does them for free, and the er visit was going to cost her a bundle (for nothing), i suggested she go to the health department on monday, and told her why. according to that hospital policy, what i did was wrong, and i could have been disciplined for it. but i thought that it was (ethically) the right thing to do. i talked to her for a long time about it (we were slow that night), and thought it was in her best interest. after i explained, she agreed with me.

**canoehead, BSN, RN** · Jan 27, 2008

Next time...I'll call an ambulance.

Please do, it's worth it. You get treatment faster, and registration will come to you. The scene when you come in the ER is more organized as we know you are coming and have the equipment and room ready. (Calling ahead isn't the same thing because 70% of the time call ins don't show up or have a totally different issue than what they called about.) EMT's get a great start on the assessment, and we can take over with less time and pain on your part.

MAISY, RN-ER, BSN, RN · Jan 27, 2008

Whether she walked in or was brought in by EMS. Based on HER presentation, Elthia would have been brought straight to a room or to our triage area(beds and monitors there) right away-registration is done at bedside-patient quick registered as soon as a name/complaint is received.

The myth of ambulance still exists and I am not sure why....anyone can call an ambulance, but unless they have the top 3-worst HA of life, SOB, CP(symptomatic).....they will not necessarily get a room right away, will be sent to triage area......then determined whether emergent OR going out to waiting room. I'd say 50% end up in waiting room.

We just lost two more hospitals in our area, of course they serve the poor in one of our largest cities. Where will these people go? Long bus rides to other city hospitals, or to us. More wait times....more sick people....more people that need care that is not emergent, but they can't get anywhere else.

How much longer can we survive without a national healthcare plan?

Maisy